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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
mechanical fall
Major Surgical or Invasive Procedure:
Right Hip Hemiarthroplasty (___)
History of Present Illness:
___ W/ PMH of IDDM, CKD (Cr 1.6), MGUS, Crohns (s/p
iliocolectomy), CAD s/p stents, CVAx2 with residual right sided
weakness who presents s/p mechanical fall. Patient states he was
standing next to his car when a dog was being walked by and
began barking aggressively at him. He was trying to get away and
fell on his hip. He denies HS/LOC. He denies any pre-syncopal
symptoms and had no preceding hip pain on that side.
Of note, he was hospitalized in ___ for an illeocectomy.
This hospitalization was complicated by pneumonia, sepsis, a fib
with rvr, and ___, with creatinine rising to 4.3 during but
eventually recovered to 1.3 upon discharge. Cr has since risen
to 1.6.
Mr. ___ is able to ambulate at baseline with a Cane. He
states he can walk ___, but stops after a block ___ to back
pain. He is able to walk up one flight of stairs without
difficulty. He denies DOE, Orthopnea, or PND.
Patient endorses slight nonproductive cough and occasional ___
edema but denies fevers, chills, sweats, nausea, Vomiting, SOB,
PND, Orthopnea, numbness, paresthesias and pain in other
extremities.
Past Medical History:
CARDIAC HISTORY:
CAD, w/ 2 VD and NSTEMI ___ with DES to major pOM1, and DES to
dOM1.
Atrial Fibrillation
OTHER PAST MEDICAL HISTORY:
- Multiple past CVA, ___ L pontine infarct, ___ L pontine
infarct, history of cerebellar infarcts, chronic L ICA occlusion
with residual R sided weakness
- HTN
- HLD
- DM II
- PVD
- Chronic Kidney Disease (baseline Cr 1.6)
- Crohns Disease - Last flare ___ per patient
- Left parotid mass resection
- Pyodermal gangrenosum.
- Hypothyroidism.
- Depression
- MGUS
PAST SURGICAL HISTORY:
- s/p open ileocecectomy secondary to stricture ___
Social History:
___
Family History:
Father - rectal cancer
Mother- DM, CAD
Sister- cancer
Sister- ___
Physical Exam:
ADMISSION PHYSICAL:
=======================
Vitals: 98.1 75 176/68 16 97% 2L Nasal Cannula
General: A&Ox3, NAD
CAM/MINICOG: Negative
Heart: Regular rate and rhythm peripherally
Lungs: Breathing comfortably on room air.
Abdomen: soft, non-distended, non-tender. Well healed surgical
scars.
Right/ Left upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless active/passive ROM of shoulder, elbow, wrist,
and digits
- EPL/FPL/DIO (index) fire
- Sensation intact to light touch in
axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, fingers warm and well perfused
Right Lower extremity:
- Skin intact, leg slightly shortened, externally rotated.
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and lower leg
- Pain with any ROM of hip. Full, painless active/passive ROM of
knee, and ankle
- ___ fire
- Sensation intact to light touch in
SPN/DPN/Tibial/saphenous/Sural distributions
- 1+ ___ pulses, foot warm and well perfused
DISCHARGE PHYSICAL:
=======================
Vitals: T:98 ___ 80 20 96%RA
General: Alert, oriented, no acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Mildly decreased breath sounds on LLL.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, 1+ Pitting edema up to knee
(confirmed with ortho this is a normal finding s/p right hip
arthroplasty)
Pertinent Results:
ADMISSION LABS:
====================
___ 09:00AM BLOOD WBC-12.7* RBC-3.86* Hgb-9.9* Hct-34.1*
MCV-88 MCH-25.6* MCHC-29.0* RDW-21.1* RDWSD-65.4* Plt ___
___ 09:00AM BLOOD Neuts-82.6* Lymphs-8.0* Monos-7.3
Eos-0.9* Baso-0.6 Im ___ AbsNeut-10.45* AbsLymp-1.01*
AbsMono-0.92* AbsEos-0.11 AbsBaso-0.08
___ 09:00AM BLOOD ___ PTT-39.6* ___
___ 09:00AM BLOOD Glucose-138* UreaN-24* Creat-1.5* Na-139
K-4.3 Cl-108 HCO3-22 AnGap-13
___ 04:40AM BLOOD Calcium-8.0* Phos-4.2 Mg-1.6
PERTINENT LABS:
====================
___ 02:20AM BLOOD CK-MB-5 cTropnT-0.18* ___
___ 08:30AM BLOOD CK-MB-4 cTropnT-0.16*
___ 01:10AM BLOOD ALT-9 AST-22 LD(LDH)-213 AlkPhos-58
TotBili-0.2
___ 02:20AM BLOOD CK(CPK)-136
DISCHARGE LABS:
====================
___ 06:20AM BLOOD WBC-17.0* RBC-3.11* Hgb-8.0* Hct-27.6*
MCV-89 MCH-25.7* MCHC-29.0* RDW-20.9* RDWSD-67.7* Plt ___
___ 06:20AM BLOOD Glucose-146* UreaN-34* Creat-1.3* Na-136
K-4.9 Cl-105 HCO3-21* AnGap-15
MICROBIOLOGY:
====================
Urine Cultures x 2 - Negative
Blood Cultures x 4 - Negative
C. Diff (___) - Negative
STUDIES:
====================
CXR ___:
IMPRESSION:
Left basilar opacity could be any combination of atelectasis,
infection, or effusion. Consider PA/lateral chest radiograph if
patient is amenable.
R HIP X-RAY ___:
IMPRESSION:
There is a a right hemiarthroplasty in place that appears well
seated. Further information can be gathered from the procedure
report.
CTA CHEST ___:
IMPRESSION:
1. Eccentric, nonocclusive filling defects in the right upper
lobe subsegmental arteries may be due to subacute or chronic
pulmonary emboli. No pulmonary emboli identified elsewhere.
Right upper lobe opacity distal to the pulmonary emboli is
concerning for pulmonary infarction, although this may represent
infection given that it appears similar to heterotogenous
opacity in the left upper lobe which is concerning for
infection.
2. Left lower lobe collapse with small to moderate left pleural
effusion. No obstructing lesion seen in the left lower lobe
bronchus.
3. Partial right lower lobe collapse with small right pleural
effusion.
4. Mild mediastinal lymphadenopathy without axillary
lymphadenopathy is likely reactive to the intrathoracic
findings. Recommend repeat chest CT after treatment of acute
issues to evaluate for resolution.
5. 11 mm left thyroid nodule could be evaluated by non-urgent
thyroid ultrasound, if clinically warranted.
BILATERAL ___ ULTRASOUND ___:
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
ECHOCARDIOGRAM ___:
Conclusions:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate mitral regurgitation with mild leaflet
thickening. Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild pulmonary artery hypertension.
Compared with the prior study (images reviewed) of ___,
the severity of mitral regurgitation is increased and pulmonary
artery hypertension is now identified. However, the prior study
was of suboptimal technical quality and this may account for
some of the differences.
Foot/Ankle XRay ___:
There are mild degenerative changes with some well-defined
osteophytes off the talus vascular calcifications are noted
there is patchy osteopenia involving the distal fibula. Soft
tissue swelling is noted about the distal fifth toe. The
alignment is normal there is no fracture or dislocation.
___: Doppler of LEs
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Dipyridamole-Aspirin 1 CAP PO BID
3. Atorvastatin 20 mg PO QPM
4. Fenofibrate 134 mg PO DAILY
5. Gabapentin 100 mg PO BID
6. Hydrochlorothiazide 25 mg PO DAILY
7. Aspart (NovoLog) 5 Units Breakfast
Aspart (NovoLog) 6 Units Dinner
Glargine 8 Units Bedtime
8. Levothyroxine Sodium 125 mcg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. TraMADOL (Ultram) 100 mg PO BID
12. Venlafaxine 75 mg PO BID
13. Zolpidem Tartrate 5 mg PO QHS insomnia
14. Aspirin 81 mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. LOPERamide 2 mg PO TID:PRN diarrhea
17. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Gabapentin 100 mg PO BID
3. Aspart (NovoLog) 5 Units Breakfast
Aspart (NovoLog) 6 Units Dinner
Glargine 8 Units Bedtime
4. Levothyroxine Sodium 125 mcg PO 6X/WEEK (___)
5. Multivitamins 1 TAB PO DAILY
6. Venlafaxine 75 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 Puffs Inhaled
twice a day Disp #*1 Inhaler Refills:*0
10. OxycoDONE (Immediate Release) 2.5-5 mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*24 Tablet Refills:*0
11. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
12. Diltiazem Extended-Release 360 mg PO DAILY
RX *diltiazem HCl 360 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
13. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
Capsule(s) Inhaled Daily Disp #*30 Capsule Refills:*0
14. Lisinopril 20 mg PO DAILY
15. Levofloxacin 500 mg PO Q24H CAP Duration: 7 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
fall with right femoral neck fracture
hypoxemia
atrial fibrillation with rapid ventricular response
pneumonia
SECONDARY:
acute kidney injury on chronic kidney disease
insulin dependent diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with hip frx. Evaluate for acute process.
TECHNIQUE: Single portable supine AP view of the chest.
COMPARISON: Chest radiograph from ___ and ___.
FINDINGS:
Previously described right basilar focal opacity has resolved. There is
decreased aeration at the left lung base, which could be due to a combination
of atelectasis, effusion, or consolidation. Accounting for patient
positioning, the cardiomediastinal contours are unchanged. No pneumothorax.
Old healed left upper posterior rib fractures are unchanged.
IMPRESSION:
Left basilar opacity could be any combination of atelectasis, infection, or
effusion. Consider PA/lateral chest radiograph if patient is amenable.
Radiology Report
EXAMINATION: HIP 1 VIEW
INDICATION: HEMIARTHROPLASTY
IMPRESSION:
There is a a right hemiarthroplasty in place that appears well seated.
Further information can be gathered from the procedure report.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ yoM with DM, CKD, MGUS, Crohns (s/p iliocolectomy), CAD s/p
stents, ___ s/p R hip arthoplasty c/o hypoxia // Any evidence of
effusion/atelectasis/PNA? Any evidence of effusion/atelectasis/PNA?
IMPRESSION:
In comparison with the study of ___, there is again enlargement of the
cardiac silhouette without definite vascular congestion. Retrocardiac
opacification with blunting of the costophrenic angle is again seen, most
likely consistent with some combination of pleural effusion and volume loss in
the left lower lobe. In the appropriate clinical setting, superimposed
pneumonia could also be considered
Radiology Report
EXAMINATION:
DX ANKLE AND FOOT
INDICATION:
___ year old man with IDDM, CKD and CVAx2 residual right sided weakness s/p
mechanical fall and r hip arthroplasty ___ c/o right ankle pain // eval
for fracture
TECHNIQUE: Right ankle three views and right foot three views
COMPARISON: None.
IMPRESSION:
There are mild degenerative changes with some well-defined osteophytes off the
talus vascular calcifications are noted there is patchy osteopenia involving
the distal fibula. Soft tissue swelling is noted about the distal fifth toe.
The alignment is normal there is no fracture or dislocation.
Radiology Report
EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY
INDICATION: ___ year old man with hypoxia, tachycardia // eval for PE or PNA
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Visipaque intravenous
contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique
maximal intensity projection images were submitted to PACS and reviewed. The
patient received intravenous hydration before and after the study.
DOSE: 289 mgy-cm
COMPARISON: CXR ___, CT abdomen ___
FINDINGS:
The thoracic aorta is normal in caliber with moderate atherosclerotic
calcifications along its course. There is no evidence of dissection. There
is a normal three vessel takeoff from the aortic arch with atherosclerotic
calcifications at the origins of the brachiocephalic and left subclavian
arteries without apparent narrowing.
The main pulmonary artery is normal in caliber. Evaluation of the
subsegmental arteries is limited by respiratory motion and bilateral lower
lobe pulmonary opacities. Nonocclusive, eccentric filling defects in the
right upper lobe subsegmental arteries (7:80, 81) are compatible with
pulmonary emboli, which may be subacute or chronic. No other filling defects
are identified in the pulmonary arterial tree. There is no evidence of right
heart strain.
No enlarged axillary lymph nodes are identified. An 1.1 x 2.5 cm right upper
paratracheal lymph node is seen. Mediastinal and hilar lymph nodes are mildly
enlarged measuring up to 11 mm in the prevascular space, 11 mm in the right
lower paratracheal station and 22 mm in the subcarinal station. A right hilar
lymph node is 1.4 x 2.0 cm in aggregate. A left hilar lymph node is 1.4 cm.
An 11 mm left thyroid nodule is noted (06:18).
There is no pericardial effusion.
Mild emphysema has an upper lobe predominance. The left lower lobe is
collapsed with moderate pleural effusion layering dependently as well as in
the left fissure. No obstructing lesion is seen in the left lower lobe
bronchus. Heterogenous opacity adjacent to the fissure in the left upper lobe
is concerning for infection more than atelectasis.
A wedge-shaped heterogeneous opacity in the right lower lobe distal to the
pulmonary emboli may represent a pulmonary infarct. However, it appears
similar to the heterogeneous opacity in the left upper lobe and may be
infectious. The right lower lobe is partially collapsed with small pleural
effusion, predominantly with a subpulmonic component (9b:44).
Central airways are patent.
Evaluation of the upper abdomen demonstrates calcifications in the spleen
suggesting prior exposure to granulomatous disease. Atherosclerotic
calcifications are seen in the celiac axis and at the origin of the SMA. A 10
mm porta hepatic lymph node (6:94) is unchanged from ___.
Multilevel degenerative change is seen in the thoracic spine. No bone finding
suspicious for infection or malignancy is identified.
IMPRESSION:
1. Eccentric, nonocclusive filling defects in the right upper lobe
subsegmental arteries may be due to subacute or chronic pulmonary emboli. No
pulmonary emboli identified elsewhere. Right upper lobe opacity distal to the
pulmonary emboli is concerning for pulmonary infarction, although this may
represent infection given that it appears similar to heterotogenous opacity in
the left upper lobe which is concerning for infection.
2. Left lower lobe collapse with small to moderate left pleural effusion. No
obstructing lesion seen in the left lower lobe bronchus.
3. Partial right lower lobe collapse with small right pleural effusion.
4. Mild mediastinal lymphadenopathy without axillary lymphadenopathy is
likely reactive to the intrathoracic findings. Recommend repeat chest CT
after treatment of acute issues to evaluate for resolution.
5. 11 mm left thyroid nodule could be evaluated by non-urgent thyroid
ultrasound, if clinically warranted.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephone on ___ at 5:30 ___, 60 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with IDDM, CKD (Cr 1.6), CVAx2 with residual
right sided weakness who presents s/p mechanical fall now s/p R hip
hemiarthroplasty with new O2 requirement. Patient currently requiring
increased O2 tonight, please assess for increased pulm edema. // look for
increased pulmonary edema
TECHNIQUE: Portable chest
COMPARISON: ___
FINDINGS:
The heart is moderately enlarged, similar to prior. There small bilateral
effusions, left greater than right. There bilateral lower lobe infiltrates
that have increased compared to the prior exam. There is mild pulmonary
vascular redistribution
IMPRESSION:
Bilateral lower lobe infiltrates. It is unclear if these are due to infection
or pulmonary edema. They have increased compared to prior
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with recent r hip arthroplasty, now hypoxemia,
off anticoagulation. Evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, femoral, and popliteal veins. Normal compressibility is demonstrated
in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ man with possible pneumonia. Assess left lower lobe
atelectasis and bilateral effusions for interval change.
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs, most recent from ___.
FINDINGS:
Markedly improved aeration of left lower lobe. Improvement in bilateral
perihilar and right infrahilar opacities with residual heterogeneous opacities
remaining. Small, residual bilateral pleural effusions. Normal
cardiomediastinal and hilar contours.
IMPRESSION:
Improving multifocal pneumonia.
Small, residual bilateral pleural effusions.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Hip fracture, Transfer
Diagnosed with FX NECK OF FEMUR NOS-CL, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.1
heartrate: 75.0
resprate: 16.0
o2sat: 97.0
sbp: 176.0
dbp: 68.0
level of pain: 0
level of acuity: 3.0 | ___ W/ PMH of IDDM, CKD (Cr 1.6), CVAx2 with residual right
sided weakness who presented with a mechanical fall now s/p R
hip hemiarthroplasty. After his surgery, he was transferred to
the medicine service for a new oxygen requirement where his
course was complicated by AF with RVR.
# Hypoxia: Patient was s/p R hip hemiarthroplasty when new O2
requirement developed and was transferred to medicine service.
Most likely this was due to multiple factors including moderate
left sided pleural effusion with LLL collapse, atelectasis
possibly ___ operation, chronic upper lobe emphysematous
changes, and pneumonia. CTA also showed concern for areas of
infection and subacute or chronic pulmonary emboli. Patient
continued to have improved oxygenation with aggressive chest ___
and standing atrovent and fluticasone. He is being discharged on
Levofloxacin to complete a 10 day course given his persistent
leukocytosis. Last day is ___.
#A-fib with RVR: Has hx of afib with RVR after prior operations.
He was transferred to the MICU for a dilt gtt with stabilization
of his tachycardia and was transitioned to dilt 90 mg PO/NG QID.
Will initiate diltiazem 360 ER prior to discharge. Patient was
started on apixiban 5 mg BID for AF with RVR and
chronic/subacute PEs noted on CTA.
#s/p Mechanical Fall with displaced femoral neck fracture. Right
hip hemiarthroplasty on ___. Pain control with oxycodone 2.5-5
mg Q3H PRN. WBAT on RLE. On apixaban as above.
#CKD: (baseline 1.5) being followed by renal as outpatient.
Increased to 2.0 following contrast for CT but returned to
baseline prior to discharge.
#IDDM: Continued Lantus w/ Humalog Sliding scale while in
house.
#CAD: patient w/ 2VD s/p DES x2 in ___. Currently stable.
Continued home atorvastatin, metoprolol succinate 50 mg daily
stopped for diltiazem. Dipyridamole-Aspirin stopped.
#HTN: stable. Held home HCTZ, amlodipine. Pressures controlled
with diltiazem and lisinopril. Home antihypertensives can be
restarted as needed as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Worse headache of life
Major Surgical or Invasive Procedure:
___ Cerebral Angiogram and Coiling of ACOM aneurysm
___ Right External Ventricular Drain
___ Replacement of Right External Ventricular Drain
___ Cerebral Angiogram with Verapamil
___ Right External Ventricualr Drain
___ Cerebral Angiogram with coiling to ACOMM
___ Tracheostomy and PEG tube placement
___ Cerebral Angiogram with Verapamil
___ cerebral angiogram
History of Present Illness:
This is a ___ year old male with no known medical history who
drove himself to ___ tonight at
approximately 7 pm after developing headache in the shower. The
patient developed the worst headache of life, nausea, and became
obtunded and at approximately 10:20 pm was intubated at ___. ___ was consistent with ___ and the
patient
was transferred here for further evaluation and treatment. The
patient was medflighted here and in route the patient became
bradycardic and hypotensive.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
Gen: intubated fisher grade 4, ___ grade 5, GCS 3T
HEENT: Pupils: 2 NR EOMs: poor mental status unable to test
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: GCS 3T
Cranial Nerves:
I: Not tested
II: Pupils 2 NR
III, IV, VI: Extraocular movements unable to test
V, VII,VIII,IX, X, XI, XII: due to poor mental status unable to
test at this time
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors.
Sensation: unable to test
Toes mute
PHYSICAL EXAMINATION ON DISCHARGE:
EO spontaneously
pupils equal and reactive to light
trach
full strength except AT2/5 ___ ___ on left plantar flexion ___
right plantar flex ___ AT ___
sensation intact
Pertinent Results:
CTA Head: ___
Multilobulated anterior communicating artery aneurysm measuring
approximately 8 x 6 mm. Diffuse subarachnoid and
intraparenchymal hemorrhage as detailed above.
CT Head: ___
Stable diffuse subarachnoid hemorrhage. New right approach
ventriculostomy catheter with tip near foramen ___.
Interventional Angiography: ___
The patient underwent cerebral angiography and coil embolization
of an anterior cerebral artery aneurysm that was uneventful.
The patient
tolerated the procedure well and there were no complications.
CT Head: ___
1. Stable appearance of diffuse subarachnoid and
intraventricular hemorrhage.
2. Right frontal ventriculostomy catheter in place with a small
amount of
hemorrhage along the catheter tract.
CT Head: ___
Stable appearance of diffuse subarachnoid hemorrhage.
CT head ___
1. Interval revision of the ventriculostomy catheter with the
tip likely
within the frontal horn of the right lateral ventricle. The
ventricle size is unchanged. There is no evidence of
hydrocephalus.
2. No change in the right frontal parenchymal hematoma with
intraventricular extension and diffuse subarachnoid hemorrhage.
No new foci of hemorrhage are identified.
CT Head ___
1. Unchanged size of ventricles from yesterday which are
decreased in size
from initial presentation. Again, this raises the concern for
"over
shunting." There are no findings to suggest that this could be
secondary from increasing edema.
2. Unchanged right frontal intraparenchymal hemorrhage with
intraventricular extension and subarachnoid hemorrhage.
CT Head: ___:
IMPRESSION:
1. Over the 11 hour interval, there is no apparent significant
change in the ventricular size or shape, or the position of the
right frontal approach ventriculostomy catheter, which
terminates in the frontal horn of the right lateral ventricle.
Once again, the imaging appearance raises concern for
"over-shunting," given the marked decrease in ventricular size
since the patient's initial
presentation; however, per given history the catheter is not
draining.
2. Stable intraparenchymal hemorrhage with intraventricular
extension and
surrounding vasogenic edema, subarachnoid hemorrhage, and
artifact from the coiled anterior communicating artery aneurysm.
CT Head: ___: Post-EVD Replacement
1. Interval replacement of right transfrontal ventriculostomy
catheter, with newly-placed catheter traversing both foramina of
___ and the cavum septum pellucidum, to terminate in the
frontal horn of the left lateral ventricle.
2. No significant change in ventricular size or shape.
3. No change in the right frontal parenchymal hemorrhage with
intraventricular extension and surrounding vasogenic edema,
subarachnoid
hemorrhage, and metallic artifact from the coiled anterior
communicating
artery aneurysm.
___ ECHO
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal study. Normal
biventricular cavity sizes with preserved global biventricular
systolic function. No valvular pathology or pathologic flow
identified. Dilated aortic sinus.
___ HCT
1. Stable appearing right frontal parenchymal hemorrhage,
ventricular size, and vasogenic edema.
1. Stable appearing right trans frontal ventriculostomy catheter
which
terminates just above the ___ ventricle.
___: HCT s/p clamping trial
Patient is status post right frontal approach craniotomy with
EVD placement terminating just above the foramen of ___.
Stable appearing ventricular size as well as intraparenchymal
hemorrhage. No new hemorrhage or mass effect.
___: Carot/Cereb Angiogram
IMPRESSION:
Administration of 5 mg of intra-arterial verapamil was performed
via slow hand infusion into each of the right internal carotid,
left internal carotid, and vertebral arteries.
The procedure was uneventful and the patient tolerated the
procedure well. No complications were encountered. The patient
was sent to the unit with orders.
___ CT HEAD
IMPRESSION:
1) No evidence of new hemorrhage or edema.
2) Slighty larger ventricular size, especially the frontal horn
of right
lateral ventricle.
2) Stable right frontal intraparenchymal hemorrhage with
surrounding vasogenic edema and intraventricular extension.
Status post ACOM aneurysm coiling and right frontal approach
EVD.
___ CTA
IMPRESSION:
1. Residual blood products and edema is redemonstrated in the
right frontal lobe involving the gyrus rectus.
2. Residual intraventricular hemorrhage identified in the
occipital
ventricular horns.
3. The CTA demonstrates minimal vasospasm in the middle
cerebral arteries with no evidence of critical stenosis,
residual anterior communicating artery aneurysm as described
above, measuring approximately 5.9 mm in coronal projection.
___ PORTABLE HEAD CT
IMPRESSION:
Stable appearance of intraparenchymal hemorrhage with
surrounding unchanged edema. Patient is status post ACOM
coiling in and EVD removal without evidence of ventricular
enlargement.
___ CXR
Cardiomediastinal contours are normal. Aside from faint
opacities in the left lower lobe, the lungs are grossly clear.
The aeration of the lungs has markedly improved from prior
study. These remaining opacities could be due to improved
infection. Minimal atelectasis in the right lower lobe is still
present. There is no pneumothorax or large effusions.
Tracheostomy tube is in standard position. Right PICC tip is in
the mid SVC.
___ Angio
IMPRESSION: ___ underwent cerebral angiography and coil
embolization of
an aneurysm that was unvevntful.
___ EMG:
Complex, abnormal study, somewhat limited due to factors
detailed
above. There is electrophysiologic evidence for myopathy with
denervating features, as seen in acute quadriplegic myopathy
(i.e. due to critical illness). In addition, there is evidence
for a significant upper motor neuron contribution to the
patient's weakness, as evidenced by the absence of activation of
distal lower extremity muscles in the setting of normal nerve
conduction studies. There is no electrophysiologic evidence for
a
generalized polyneuropathy.
___ LENIs
IMPRESSION:
No evidence of deep vein thrombosis in either leg.
___ CT ABD/PELVIS
IMPRESSION:
1. No CT findings to explain the patient's fever of unknown
origin.
2. Multiple pulmonary nodules measuring up to 7 mm. If this
patient has high risk for primary lung malignancy, followup
chest CT is recommended in ___ months. Otherwise, this can be
followed in ___ months.
3. Cholelithiasis.
___ CT CHEST
IMPRESSION:
1. No CT findings to explain the patient's fever of unknown
origin.
2. Multiple pulmonary nodules measuring up to 7 mm. If this
patient has high risk for primary lung malignancy, followup
chest CT is recommended in ___ months. Otherwise, this can be
followed in ___ months.
3. Cholelithiasis.
___ CXR
FINDINGS: The tracheostomy tube is again seen. There is no
focal infiltrate or effusion. Residual contrast is noted in the
colon. Gastric tube is visualized.
Medications on Admission:
None
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough/wheezing
2. Bisacodyl 10 mg PO/PR DAILY
3. CefePIME 2 g IV Q12H
4. Dextromethorphan Poly Complex ___ mg PO Q12H:PRN cough
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC TID
7. HydrALAzine 10 mg IV Q8H:PRN for SBP > 200
8. LeVETiracetam Oral Solution 1000 mg PO BID
9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
10. Miconazole Powder 2% 1 Appl TP TID:PRN skin irritation
11. Nystatin Oral Suspension 5 mL PO QID
12. Senna 5 mL PO BID
13. Vancomycin 1000 mg IV Q 8H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subarachnoid Hemorrhage; Intraventricular Hemorrhage; ACOM
Aneurysm
Respiratory failure
protien/calorie malnutrition
Elevated intracranial pressure
Fevers of unknown etiology
Ventilator associated Pneumonia
Discharge Condition:
oriented to person, place, time- trach, soft speech
strength full except bilateral AT 3 on right and AT ___ on left
___ on left ___ gastrocs right5/5 gastrocs on left 4
patient able to ambulate with assist x 1
angio site is clean/dry/intact no hematoma or eccymosis
Followup Instructions:
___
Radiology Report
TECHNIQUE: CTA of the head.
HISTORY: Subarachnoid hemorrhage.
COMPARISON: ___.
FINDINGS: There is diffuse subarachnoid hemorrhage with intraventricular
extension. There is also focal intraparenchymal hemorrhage in the right
frontal lobe. The ventricles are enlarged compatible with hydrocephalus.
Basal cisterns are effaced. There is suggestion of inferior tonsillar
herniation. Low density in the brainstem is concerning for edema. CTA
demonstrates a multilobed 8X6 mm ACOM aneurysm. The right A1 segment is
hypoplastic. There is a right fetal PCA. No additional aneurysms are seen.
Visualized soft tissues of the neck are unremarkable.
IMPRESSION: Multilobulated anterior communicating artery aneurysm measuring
approximately 8 x 6 mm. Diffuse subarachnoid and intraparenchymal hemorrhage
as detailed above
Radiology Report
HISTORY: Subarachnoid hemorrhage. Now intubated.
COMPARISON: None.
TECHNIQUE: Single AP view of the chest.
FINDINGS: There is an endotracheal tube which terminates approximately 5.5 cm
from the carina. An NG tube is seen curling into the fundus of the stomach.
The lungs are clear. Cardiac silhouette is normal. No pleural effusion or
pneumothorax.
IMPRESSION: Appropriate placement of ET tube and NG tube. No acute chest
process.
Radiology Report
AP CHEST, 3:59 A.M., ___
HISTORY: ___ man after central venous line placement.
IMPRESSION: AP chest compared to ___.
ET tube, left subclavian line, upper enteric drainage tube are all in standard
placements. Lungs are clear and there is no pneumothorax or appreciable
pleural effusion. Vascular engorgement is probably a function of supine
positioning. Heart size, mediastinal and hilar contours are all normal.
Radiology Report
HISTORY: Subarachnoid hemorrhage, evaluate interval change.
COMPARISON: CT from ___ at 23:30.
TECHNIQUE: Non-contrast head CT.
FINDINGS: Once again, there is diffuse subarachnoid hemorrhage with blood
within virtually all the sulci of the brain as well as the blood within the
perimesencephalic cisterns, ventricles, along the right frontal horn. The
ventricular _size remains stable. There is a new right approach
ventriculostomy catheter terminating in the third ventricle.
IMPRESSION: Stable diffuse subarachnoid hemorrhage. New right approach
ventriculostomy catheter with tip near foramen ___.
Radiology Report
ANGIO REPORT
PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage from ruptured anterior
communicating artery aneurysm.
INDICATIONS: Secure aneurysm to prevent rehemorrhage.
ATTENDING PHYSICIAN: ___, M.D.
ASSISTANT: ___, M.D.
ANESTHESIA: General.
PROCEDURES PERFORMED: Right vertebral artery arteriogram, right internal
carotid artery arteriogram, left internal carotid artery arteriogram.
INTERVENTIONAL PROCEDURE PERFORMED: Coil embolization of anterior
communicating artery aneurysm with Target coils.
DETAILS OF THE PROCEDURE: The patient was brought to the angiography suite.
Anesthesia was given. Following this, both groins were prepped and draped in
a sterile fashion. Access was gained to the right common femoral artery using
a Seldinger technique. A 5 ___ vascular sheath was placed in the right
common femoral artery. We now catheterized the above-mentioned vessels and
AP, lateral filming was done. This demonstrated aneurysms in the left
paraclinoid area and in the left anterior communicating segment. The anterior
communicating segment was seen to be dysplastic and was essentially a part of
the A2 complex from a dominant left A1. There was, however, a discrete
aneurysm pointing superiorly measuring 2.5 mm. This was responsible for the
hemorrhage since the hemorrhage was predominantly in the gyrus rectus. We now
exchanged out the catheter in the left internal carotid artery for ___
catheter following which the aneurysm was catheterized with a Synchro wire and
an SL-10 microcatheter. Following this, multiple coils were placed within the
aneurysm, first starting with a 360 coil and with 360 UltraSoft Target coils
and finishing with 1.5 mm coils. The first coil transgressed the wall of the
aneurysm. However additional coils were placed to obliterate the aneurysm and
there were no significant changes in the vitals. At the end of the procedure,
the aneurysm was completely obliterated and the parent vessels were patent.
FINDINGS: Right internal carotid artery arteriogram shows that the A1 is
hypoplastic on the right side. The middle cerebral artery is seen normally.
The PCA is seen to be fetal in origin.
Left internal carotid artery arteriogram shows filling of the left internal
carotid artery along the cervical, petrous, cavernous and supraclinoid
portion. There is a 2.5 x 3 mm aneurysm of the superior hypophyseal artery
origin, pointing medially. There is a 2.5 x 2.5 mm aneurysm of the anterior
communicating segment, predominantly arising from the right A2 pointing
superiorly.
The A2 on the right side is seen to be very dysplastic at the origin and seems
to have aneurysmal areas. Right vertebral artery arteriogram shows filling of
the basilar artery and the left PCA. The right PCA is not visualized as it is
hypoplastic. There is no stenosis and there are no aneurysms or arteriovenous
malformation.
Left internal carotid artery arteriogram status post coil embolization shows
that the anterior communicating artery aneurysm does not fill.
IMPRESSION: The patient underwent cerebral angiography and coil embolization
of an anterior cerebral artery aneurysm that was uneventful. The patient
tolerated the procedure well and there were no complications.
Radiology Report
HISTORY: ___ male with subarachnoid hemorrhage. Evaluate for
interval change.
TECHNIQUE: Contiguous axial multi detector CT images were obtained through
the brain without administration of IV contrast.
Total exam DLP: ___ mGy/cm
CTDIvol: 70.73 mGy
COMPARISON: Nonenhanced CT of the head dated ___.
FINDINGS:
The there is a right frontal ventriculostomy catheter in place, with a small
amount of hemorrhage along the catheter tract, which terminates in the mid
portion of the right lateral ventricle. Again noted is diffuse subarachnoid
hemorrhage with blood within virtually all the sulci of the brain as well as
blood within the perimesencephalic cisterns, ventricles, and the right frontal
lobe. There has been interval decrease in size of the bilateral lateral
ventricles. Hypodensity within the brain stem likely represents edema.
No fracture is identified. The visualized paranasal sinuses. There is a
small amount of fluid within the left maxillary sinus. The remaining
visualized paranasal sinuses, mastoid air cells, middle ear cavities are
clear, accounting for patient movement during the scan.
The globes are unremarkable.
IMPRESSION:
1. Stable appearance of diffuse subarachnoid and intraventricular hemorrhage.
2. Right frontal ventriculostomy catheter in place with a small amount of
hemorrhage along the catheter tract.
Radiology Report
AP CHEST, 5:12 A.M. ON ___
HISTORY: Subarachnoid hemorrhage.
IMPRESSION: AP chest compared to ___:
Heterogeneous opacification in the left lower lobe is most readily explained
by aspiration pneumonia. More uniform opacification in the right lower chest
could be moderate right pleural effusion or even right lower lobe atelectasis.
Upright radiographs would be helpful in distinguishing between these
possibilities. ET tube and left subclavian line are in standard placements
and the upper enteric drainage tube coiled in the stomach. No pneumothorax.
Heart size normal.
Radiology Report
HISTORY: ___ male with subarachnoid hemorrhage and anterior
communicating artery aneurysm s/p coiling. Evaluate for interval change.
TECHNIQUE: Contiguous axial multi detector CT images were obtained through
the brain without administration of IV contrast.
Total exam DLP: 1343.83 mGy/cm
CTDIvol: 70.73 mGy
COMPARISON: Nonenhanced CT of the head dated ___.
FINDINGS:
Again noted is a right frontal approach ventriculostomy catheter which is
terminating at the mid right lateral ventricle. There is a stable amount of
hemorrhage along the catheter tract. Stable appearance of diffuse
subarachnoid hemorrhage, with blood in virtually all sulci of the brain, as
well as the perimesencephalic cisterns, ventricles and right frontal lobes.
There is a stable appearance of the bilateral lateral ventricles. Again noted
is hypodensity of the brainstem which is likely consistent with edema. There
are no new areas of hemorrhage seen.
There is a small amount of fluid in the left maxillary sinus. The remaining
visualized paranasal sinuses, mastoid air cells, middle ear cavities are
clear. There is an oral enteric tube coiled within the oropharynx.
IMPRESSION:
Stable appearance of diffuse subarachnoid hemorrhage.
Radiology Report
HISTORY: ___ man with subarachnoid hemorrhage status post coiling.
Evaluate interval change.
TECHNIQUE: Portable AP semi-erect chest radiograph was obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
The previous left basilar opacity initially seen on ___ has cleared, and
the right lower lobe opacification initially seen on ___ has worsened.
The ET tube is in appropriate position, and the gastric tube appropriately
coils in the stomach. The left PICC line ends in the mid SVC. The heart,
mediastinal and hilar contours are normal.
IMPRESSION:
Right lower lobe opacification initially seen on ___ has increased
suggesting volume loss and possible pleural effusion.
Radiology Report
HISTORY: Status post coiling of an ACOM aneurysm. Assess for interval
change.
TECHNIQUE: Contiguous axial sections were acquired through the brain without
the administration of IV contrast.
DLP: 1343.83 mGy/cm.
COMPARISON: Head CT ___ 8:46.
FINDINGS: The patient is status post coiling of an ACOM aneurysm. There is
persistent intraparenchymal hemorrhage within the right frontal lobe, diffuse
subarachnoid hemorrhage and hemorrhage throughout the ventricular system. The
right frontal approach ventriculostomy catheter terminates near the foramen of
___. There is a stable amount of hemorrhage along the catheter tract.
Edema persists within the brainstem, although, there is no evidence of
downward herniation. There is no shift of the midline structures.
A small amount of fluid is again seen within the maxillary sinuses. An
enteric tube is coiled within the nasopharynx, although, the recent chest
radiograph demonstrates termination of the catheter within the stomach.
IMPRESSION: Unchanged distribution and quantity of hemorrhage with no new foci
of hemorrhage identified.
Radiology Report
HISTORY: ___ man with right lower lobe opacity. Please evaluate for
pneumonia.
TECHNIQUE: Portable AP supine chest radiograph was obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
The previous right lower lobe opacity has significantly improved since ___. The lungs are otherwise clear of consolidation, pleural effusion or
pulmonary edema. The heart, mediastinal, and hilar contours are normal. Left
subclavian central venous line ends at the mid SVC. The ET tube and gastric
tube are in appropriate position.
IMPRESSION:
Significant improvement in right lower lobe opacity since ___ likely to be
improved lower lobe volume loss.
Radiology Report
HISTORY: Subarachnoid hemorrhage status post ventricular drain placement for
hydrocephalus and intraventricular hemorrhage. Evaluate for interval changes.
TECHNIQUE: Continuous axial sections were acquired through the brain without
the administration of IV contrast.
DLP: 1273.10 mGy/cm.
CTDIvol: 70.73 mGy.
COMPARISON: Head CT ___ and ___.
FINDINGS: Again, the patient is status post coiling of ACOM aneurysm. There
is persistence of intraparenchymal hemorrhage within the right frontal lobe
with surrounding edema and intraventricular extension. The amount of
hemorrhage seen layering within the ventricles is unchanged from prior. There
is no evidence of hydrocephalus. Diffuse subarachnoid hemorrhage is
unchanged. A right frontal ventriculostomy catheter again terminates near the
foramen of ___. Hemorrhage along the course of the catheter is again
appreciated. There are no new areas of hemorrhage.
There is no shift of midline structures and the basal cisterns are patent.
The gray-white matter differentiation is preserved, without evidence for an
acute territorial vascular infarction. Small amount of mucous is seen within
the maxillary sinuses. Again, the enteric tube is coiled within the
nasopharynx but was noted to be properly positioned on the recent chest
radiograph.
IMPRESSION: Unchanged right frontal intraparenchymal hematoma with
intraventricular extension and diffuse subarachnoid hemorrhage. No
hydrocephalus or new blood.
Radiology Report
CLINICAL HISTORY: Status post coiling of the anterior communicating artery
aneurysm. The patient is here for a cerebral angiogram to rule out vasospasm.
TECHNIQUE: Informed consent was obtained from the patient after explaining the
risks, indications, and alternative management. Risks explained included
stroke, loss of vision and speech, temporary or permanent, with possible
treatment with stent and coils if needed.
The patient was brought to the Interventional Neuroradiology Theater and
placed on the biplane table in supine position. Both groins were prepped and
draped in the usual sterile fashion. Access to the right common femoral
artery was obtained using a 19 gauge single wall needle, under local
anesthesia using 1% lidocaine mixed with sodium bicarbonate and with aseptic
precautions. Through the needle, a 0.35 ___ wire was introduced and the
needle was taken out. Over the wire, a ___ Fr vascular sheath was placed and
connected to a saline infusion (mixed with heparin 500 units in 500 cc of
saline) with a continuous drip. Through the sheath, a ___ Fr ___
catheter with introduced and connected to continuous saline infusion (with
mixture of 1000 units of heparin in 1000 cc of saline).
The following blood vessels were selectively catheterized and arteriograms
were performed from:
Right internal carotid artery.
Left internal carotid artery.
Left vertebral artery.
RIGHT INTERNAL CAROTID ARTERY: Evaluation of the right internal carotid
artery demonstrates no significant vasospasm in the branches. Good flow is
noted in the proximal and distal right internal carotid artery, right anterior
and middle cerebral artery branches. 5 mg of intra-arterial verapamil was
given by slow hand infusion.
LEFT INTERNAL CAROTID ARTERY: Evaluation of the left internal carotid artery
demonstrates good flow in the proximal and distal left internal carotid
artery, anterior and middle cerebral artery branches on the left. The
previously coiled aneurysm appears to be well excluded with no residual
aneurysm. 5 mg of intra-arterial verapamil was given by slow hand infusion.
LEFT VERTEBRAL ARTERY: Evaluation of the left vertebral artery demonstrates
good flow in the proximal and distal right vertebral artery and the left
vertebral artery. Incidental note is of left occipital artery arising from
the left extracranial portion of the left vertebral artery. 5 mg of
intra-arterial verapamil was given by slow hand infusion.
IMPRESSION:
1. No evidence of significant vasospasm noted.
2. No evidence of vasospasm noted in the right anterior, right middle, left
anterior, left middle and posterior cerebral arteries bilaterally.
3. Fetal right posterior cerebral artery noted.
4. The right A1 segment is hypoplastic.
Radiology Report
INDICATION: Evaluate after ventricular drain placement.
COMPARISONS: CT of head from ___ at 10:18. CT of the head from
___. CT of the head from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Sagittal, coronal, and thin
section bone reformations were obtained and reviewed.
FINDINGS: Since the exam of roughly 14 hours earlier, there has been revision
of the right frontal ventriculostomy catheter. Tip now appears to be within
the frontal horn of the right lateral ventricle, though the exact location of
the tip is somewhat difficult to determine due to surrounding metal artifacts.
Hemorrhage along the course of the catheter is not significantly changed from
prior exam. The ventricles appear similar in size. There is no evidence of
hydrocephalus. The amount of layering intraventricular blood appears similar.
The patient is status post coiling of an ACom aneurysm. Persistence of
parenchymal hemorrhage within the right lobe with surrounding edema. This is
unchanged in size. Widespread subarachnoid hemorrhage is not significantly
changed. There are no new foci of hemorrhage. The degree of surrounding mass
effect is stable. There is no shift of the normally midline structures. The
basal cisterns are patent.
No fracture is identified. Mild mucosal thickening is noted in the paranasal
sinuses. A small amount of fluid is noted in bilateral mastoid air cells.
This is unchanged from the prior exam. Post-surgical changes in the scalp at
the site of the ventriculostomy catheter are stable. The soft tissues are
otherwise unremarkable.
IMPRESSION:
1. Interval revision of the ventriculostomy catheter with the tip likely
within the frontal horn of the right lateral ventricle. The ventricle size is
unchanged. There is no evidence of hydrocephalus.
2. No change in the right frontal parenchymal hematoma with intraventricular
extension and diffuse subarachnoid hemorrhage. No new foci of hemorrhage are
identified.
Radiology Report
HISTORY: ___ male with large subarachnoid hemorrhage and aneurysm of
the ACOM, status post coiling. Lots of secretions. Evaluate.
TECHNIQUE: Portable AP upright chest radiograph was obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
ET tube is 8 cm above the carina, and the left subclavian central venous line
is in the mid to upper SVC. The gastric tube curls in the stomach
appropriately. An increased heterogeneous opacity is in the right mid to
lower lung. The heart, mediastinal and hilar contours are normal.
IMPRESSION:
Increasing heterogeneous right lower lung opacity concerning for pneumonia.
Recommend advancing ET tube by 2-3 cm.
Radiology Report
HISTORY: ___ male with subarachnoid hemorrhage, status post anterior
communicating artery aneurysm coiling and replacement of right ventriculostomy
drain; evaluate for interval change.
TECHNIQUE: Contiguous axial multidetector CT images were obtained through the
brain without the administration of IV contrast.
Total exam DLP: 1373.10 mGy/cm
CTDIvol: 70.73 mGy
COMPARISON: Non-enhanced CT of the head dated ___ and ___.
FINDINGS:
Again the patient is status post coiling of the right ACom aneurysm. The
right transfrontal ventriculostomy catheter terminates adjacent to the foramen
of ___. There is a stable amount of hemorrhage with associated edema along
the catheter tract. There has been progressive reduction in size of the
bilateral lateral ventricles, which is concerning for over-shunting. Also
noted is commensurate interval decrease in size of the cavum septum
pellucidum.
There is persistence of intraparenchymal hemorrhage in the right frontal lobe
with a stable degree of surrounding edema and intraventricular extension. The
intraventricular extension of the previously noted hemorrhage extends within
the bilateral occipital horns, ___ ventricle, cerebral aqueduct, and ___
ventricle. The subarachnoid hemorrhage is less conspicuous, but there
continues to be blood diffusely within the sulci bilaterally and the anterior
interhemispheric fissure. There are no new foci of hemorrhage identified.
There is minimal thickening of the bilateral sphenoid sinuses. The remaining
visualized paranasal sinuses, mastoid air cells, and middle ear cavities are
clear. The globes are unremarkable.
IMPRESSION:
1. Stable appearance of right frontal parenchymal hemorrhage with
intraventricular extension and diffuse subarachnoid hemorrhage. No new focus
of hemorrhage identified.
2. Continued interval decrease in size of bilateral lateral ventricles raisese
concern for early "over-shunting"; correlate with functional assessment of the
ventriculostomy.
Radiology Report
HISTORY: Subarachnoid hemorrhage with pneumonia.
FINDINGS: In comparison with the study of ___, there is little overall
change. Monitoring and support devices remain in place. Areas of patchy
opacification in the lower portions of both lungs are consistent with
multifocal pneumonia as suggested in the clinical history.
Radiology Report
HISTORY: Subarachnoid hemorrhage status post coiling, bed rest, assess for
DVTs.
COMPARISON: None available.
FINDINGS:
There is normal phasicity in the common femoral veins bilaterally. There is
normal compression, augmentation and flow in the common femoral, superficial
femoral, popliteal, peroneal, and posterior tibial veins of the right and left
leg.
IMPRESSION:
No evidence of DVT in the right or left leg.
Radiology Report
HISTORY: Anterior communicating artery aneurysm, now with increasing
intracranial pressure and ventricular drain non-functioning; evaluate for
interval change.
COMPARISON: Head CT ___ and ___.
TECHNIQUE: Continuous axial sections were acquired through the brain without
administration IV contrast. Coronal and sagittal reformations were provided
and reviewed.
FINDINGS: The patient is status post coiling of a right anterior communicating
artery aneurysm which results in streak artifact and limits full evaluation.
A right frontal approach ventriculostomy catheter terminates within the
frontal horn of the right lateral ventricle. Allowing for differences in
plane of scanning, the right frontal intraparenchymal hematoma with associated
edema is unchanged in size. Scattered foci subarachnoid blood are also
unchanged. Blood is again seen layering within the occipital horns of the
lateral ventricles, within the ___ ventricle and, to a lesser extent than
prior, within the ___ ventricle.
The size of the ventricles is unchanged from yesterday but decreased in size
from ___, at the time of presentation. There is no evidence for
downward herniation. There is no shift of the midline structures. The
gray-white matter differentiation persists, without evidence for acute
infarction or edema.
IMPRESSION:
1. Unchanged size of ventricles from yesterday which are decreased in size
from initial presentation. Again, this raises the concern for "over-
shunting." There is no finding to specifically suggest that this is the
result of increasing cerebral edema.
2. Unchanged right frontal intraparenchymal hemorrhage with intraventricular
extension and subarachnoid hemorrhage.
Radiology Report
HISTORY: ___ man with subarachnoid hemorrhage. EVD not functioning.
COMPARISON: ___ and multiple more remote CTs.
TECHNIQUE: CT of the head without IV contrast.
FINDINGS: Allowing for slight differences in plane of scanning, the right
frontal intraparenchymal hemorrhage with intraventricular extension and
surrounding vasogenic edema is stable. The patient is status post coiling of
an anterior communicating artery aneurysm. Foci of subarachnoid hemorrhage
are evolving in density, but overall unchanged in distribution and extent.
There are no new foci of hemorrhage. There is no shift of the normally
midline structures. The basal cisterns are patent.
A right frontal approach ventriculostomy catheter appears to be in the frontal
horn of the right lateral ventricle, unchanged from the prior study, but
smaller than on the patient's initial presentation on ___.
Hemorrhage along the course of the catheter tract is not significantly
changed. Compared to the two most recent prior studies over the course of 48
hours, there is no change in ventricular size.
Mucosal thickening in the paranasal sinuses is also unchanged. Post-surgical
changes of the scalp at the ventriculostomy catheter insertion site are
stable. Soft tissues are otherwise unremarkable.
IMPRESSION:
1. Over the 11 hour interval, there is no apparent significant change in the
ventricular size or shape, or the position of the right frontal approach
ventriculostomy catheter, which terminates in the frontal horn of the right
lateral ventricle.
Once again, the imaging appearance raises concern for "over-shunting," given
the marked decrease in ventricular size since the patient's initial
presentation; however, per given history the catheter is not draining.
2. Stable intraparenchymal hemorrhage with intraventricular extension and
surrounding vasogenic edema, subarachnoid hemorrhage, and artifact from the
coiled anterior communicating artery aneurysm.
Radiology Report
HISTORY: SAH with pneumonia.
FINDINGS: In comparison with the study of ___, there is little overall change
in the bibasilar patchy opacification consistent with multifocal pneumonia.
Monitoring and support devices are unchanged.
Radiology Report
HISTORY: PICC placement.
FINDINGS: In comparison with the earlier study of this date, there has been
placement of a right subclavian PICC line that extends to the mid-to-lower
portion of the SVC. Other monitoring and support devices are unchanged.
There is little change in the appearance of the heart and lungs.
The information regarding the PICC line has been telephoned to ___, the
venous access nurse.
Radiology Report
HISTORY: ___ man with EVD replacement.
COMPARISON: CT performed 6 hours prior to this exam.
TECHNIQUE: Axial contiguous MDCT images of the head without IV contrast were
obtained. Coronal and sagittal reformates were generated.
DLP: 917 mGy-cm
CTDI: 52.40 mGy
FINDINGS: Since the most recent exam, the right frontal intraparenchymal
hemorrhage with intraventricular extension and surrounding vasogenic edema are
stable. The patient is status post coiling of an anterior communicating
artery aneurysm. Foci of subarachnoid hemorrhage are evolving in density, but
overall unchanged in distribution and extent. There are no new foci of
hemorrhage. There is no shift of the normally midline structures. The basal
cisterns are patent.
A right frontal approach ventriculostomy catheter has been replaced in the 6
hour interval, with the new catheter entering the right lateral ventricle and
crossing the midline just above the foramen ___ to end in the left
lateral ventricle. There is no significant change in ventricular size. Minimal
air layering antidependently in the frontal horn of the right lateral
ventricle is post-procedural. Hyperdense blood along the catheter tract in the
right frontal lobe is not significantly changed from prior exam.
Mucosal thickening in the paranasal sinuses is also unchanged. Post-surgical
changes of the scalp at the ventriculostomy catheter insertion site are
stable. Soft tissues are otherwise unremarkable.
IMPRESSION:
1. Interval replacement of right transfrontal ventriculostomy catheter, with
newly-placed catheter traversing both foramina ___ and the cavum septum
pellucidum, to terminate in the frontal horn of the left lateral ventricle.
2. No significant change in ventricular size or shape.
3. No change in the right frontal parenchymal hemorrhage with
intraventricular extension and surrounding vasogenic edema, subarachnoid
hemorrhage, and metallic artifact from the coiled anterior communicating
artery aneurysm.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Aneurysm, status post coiling, evaluation for chest findings.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. The monitoring and support devices are constant. Bilateral areas of
parenchymal opacities are seen at the lung bases, left more than right.
Normal size of the cardiac silhouette. No pleural effusions. No
pneumothorax.
Radiology Report
HISTORY: Subarachnoid hemorrhage with possible pneumonia.
FINDINGS: In comparison with the study of ___, the monitoring and support
devices remain in place. There are bibasilar opacifications, increasing and
now more prominent on the right, consistent with bilateral consolidations.
Radiology Report
CLINICAL HISTORY:
Patient with known anterior communicating artery aneurysm which was coiled.
Patient is here for vasospasm check.
TECHNIQUE: Informed consent was obtained from the patient after explaining
the risks, indications, and alternative management. Risks explained included
stroke, loss of vision and speech, temporary or permanent, with possible
treatment with stent and coils if needed.
The patient was brought to the Interventional Neuroradiology Theater and
placed on the biplane table in supine position. Both groins were prepped and
draped in the usual sterile fashion. Access to the right common femoral
artery was obtained using a 19 gauge single wall needle, under local
anesthesia using 1% lidocaine mixed with sodium bicarbonate and with aseptic
precautions. Through the needle, a 0.035 ___ wire was introduced and the
needle was taken out. Over the wire, a ___ Fr vascular sheath was placed and
connected to a saline infusion (mixed with heparin 500 units in 500 cc of
saline) with a continuous drip. Through the sheath, a ___ Fr Beren___
catheter was introduced and connected to continuous saline infusion (with
mixture of 1000 units of heparin in 1000 cc of saline).
The following blood vessels were selectively catheterized and arteriograms
were performed from the:
1. Right internal carotid artery.
2. Left internal carotid artery.
3. Left vertebral artery.
EVALUATION OF THE RIGHT INTERNAL CAROTID ARTERY:
Evaluation of the right internal carotid artery demonstrates good flow in the
proximal and distal right internal carotid artery, anterior inferior middle
cerebral arteries. Mild vasospasm noted in the posterior communicating
artery. 5 mg of intra-arterial verapamil was given by slow hand infusion.
LEFT INTERNAL CAROTID ARTERY:
Evaluation of the left internal carotid artery demonstrates good flow in the
proximal and distal left internal carotid artery. Good flow is noted in the
left middle cerebral artery. Moderate spasm is noted in the left A1 segment.
Good flow is noted in the distal anterior cerebral artery branches. There is
a residual filling of the previously coiled aneurysm noted which now measures
approximately 3 x 3 mm in size.
LEFT VERTEBRAL ARTERY:
Evaluation of the left vertebral artery demonstrates good flow in the proximal
and distal left vertebral artery, basilar artery and posterior cerebral
arteries bilaterally. 5 mg of intra-arterial verapamil was given by slow
infusion.
At this time findings were discussed with Dr. ___ referring
neurosurgeon, who suggested we treat the recurrent aneurysm in the anterior
communicating artery.
The system was upgraded to a ___ system and a 6 ___ ___ catheter
was introduced and the left internal carotid artery was selectively
catheterized. Using SL-10 microcatheter and a Synchro wire the aneurysm was
catheterized and multiple coils were placed. The following coils were placed:
Target helical 2 mm x 2 cm coil and two 2 mm x 1 cm coils were placed.
The aneurysm was well coiled. Later, the microcatheter was withdrawn into the
A1 segment and approximately 100 mcg of nitroglycerin was introduced.
Post-procedure angiogram demonstrates minimal spasm at the left A1 segment. 5
mg of intra-arterial verapamil was administered via slow hand infusion into
the left internal carotid artery.
IMPRESSION:
Successful coiling of the recurrent aneurysm at the anterior communicating
artery on the left.
Intra-arterial verapamil was given into right internal carotid artery and left
internal carotid artery via slow hand infusion.
100 mcg of nitroglycerin was given into the left A1 segment by using a
microcatheter in the left A1 segment.
The procedure was uneventful and the patient tolerated the procedure well.
The patient was sent to the unit with orders.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Assessment for pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is an improvement of
the pre-existing parenchymal opacities, notably at the right lung bases. No
new parenchymal opacities. The mild hilar enlargement on the right persists
and is slightly more obvious than on the previous image. Unchanged monitoring
and support devices. Unchanged size and shape of the cardiac silhouette.
Radiology Report
HISTORY: ___ male with right frontal intraparenchymal hemorrhage and
intraventricular extension.
TECHNIQUE: Contiguous multi detector CT images of the head without
intravenous contrast were obtained. DLP 1073mGy-cm. CTDIvol: 70.73mGy
COMPARISON: Noncontrast head CT ___.
FINDINGS:
The patient is status post right frontal intraparenchymal hemorrhage with
intraventricular extension and surrounding vasogenic edema. The area of the
right frontal hemorrhage is unchanged in size and there is no evidence of new
hemorrhage. There is redemonstration of surrounding stable vasogenic edema.
The patient is status post right frontal ventriculostomy catheter which
terminates just above the ___ ventricle. There is resolution of prior seen
blood along the catheter track within the right frontal lobe. Patient is
status post coiling of anterior communicating artery aneurysm which appears
stable since prior examination. There is no shift of the normal in midline
structures. The basal cisterns are patent.
Redemonstration of mucosal thickening within the maxillary sinus as well as
partial opacification within the mastoid air cells bilaterally, unchanged
since prior examination.
IMPRESSION:
1. Stable appearing right frontal parenchymal hemorrhage, ventricular size,
and vasogenic edema.
1. Stable appearing right trans frontal ventriculostomy catheter which
terminates just above the ___ ventricle.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Aneurysm, evaluation for pneumonia.
COMPARISON: ___.
As compared to the previous examination, there is a further improvement with
reduction and regression of the pre-existing parenchymal opacities, notably at
the right lung bases. No new opacities. No pleural effusions. No pulmonary
edema. The endotracheal tube has been exchanged against a tracheostomy tube.
The nasogastric tube has been removed. The right PICC line is in unchanged
position and shows an unchanged course.
Radiology Report
HISTORY: ___ year old man with SAH and pna
COMPARISON: Exam is ocmpared with ___
FINDINGS:
The right subclavian central line has been pushed down over 2 cm, tip ending
in inferior SVC. Heart size is unchanged.
Lung are less inflated and there are no changes in the bibasilar opacities.
There is no pleural effusion. ET tube is in standard position.
IMPRESSION:
Exam is overall unchanged
Radiology Report
HISTORY:
___ male with history of ruptured anterior communicating artery
aneurysm status post coil embolization for vasospasm check.
TECHNIQUE:
Informed consent was obtained after explaining the risks, indications, and
alternative management. Risks explained included stroke, loss of vision and
speech, temporary or prominent, with possible treatment with stent and coils
as needed.
The patient was brought to the Interventional Neuroradiology Theater and
placed on the biplane table in supine position. Both groins were prepped and
draped in the usual sterile fashion. Access to the right common femoral
artery was obtained using a 19 gauge single wall needle, under local
anesthesia using 1% lidocaine mixed with sodium bicarbonate and aseptic
precautions. Through the needle, a 0.035 ___ wire was introduced and the
needle was taken out. Over the wire, a 5 ___ vascular sheath was placed
and connected to a saline infusion (mixed with heparin 500 units in 500 cc of
saline) with a continuous drip. Through this sheath, a 4 ___ Berenstein
catheter was introduced and connected to continuous saline infusion (with
mixture of 1000 units of heparin in 1000 cc of saline). The following blood
vessels were selectively catheterized and arteriograms were performed:
1. Right internal carotid artery.
2. Left internal carotid artery.
3. Left vertebral artery.
COMPARISON: Cerebral angiogram dated ___.
FINDINGS:
Right internal carotid artery:
Evaluation of the right internal carotid artery demonstrates good flow in the
proximal and distal right internal carotid artery, and right middle cerebral
artery. Administration of 5 mg of intra-arterial verapamil was performed via
slow hand infusion.
Left internal carotid artery:
Evaluation of the left internal carotid artery demonstrates good flow in the
proximal and distal left internal carotid the, and left middle cerebral
artery. Mild-to-moderate spasm is noted in the left A1 segment, slightly
improved from prior examination. Good flow was noted in the distal anterior
cerebral artery branches. Once again identified are coils from prior
embolization with some mild residual filling. Administration of 5 mg of
intra-arterial verapamil was performed via slow hand infusion.
Left vertebral artery:
Evaluation of the left vertebral artery demonstrates blood flow in the
proximal and distal left vertebral artery, basilar artery, and posterior
cerebral arteries bilaterally. Administration of 5 mg of intra-arterial
verapamil was performed via slow hand infusion.
IMPRESSION:
Administration of 5 mg of intra-arterial verapamil was performed via slow hand
infusion into each of the right internal carotid, left internal carotid, and
vertebral arteries.
The procedure was uneventful and the patient tolerated the procedure well. No
complications were encountered. The patient was sent to the unit with orders.
Radiology Report
HISTORY: ___ male with large subarachnoid hemorrhage, status post
coiling of ACom aneurysm; evaluate after EVD clamping.
TECHNIQUE: Contiguous axial multi detector CT images were obtained through
the brain without administration of IV contrast. DLP 1273 mGy-cm. CTDI
140mGy.
COMPARISON: Nonenhanced head CT ___, 48 hours prior.
FINDINGS: The study is limited by bedside acquisition technique,
Patient is status post right frontal approach craniotomy with EVD placement.
EVD terminates just superior to the right foramen of ___. The ventricles
are unchanged in size from most recent examination. Patient is status post
aneurysm coiling with beam-hardening artifact, limiting evaluation of adjacent
structures. The organizing hematoma within the right frontal lobe anterior to
the right lateral ventricle, with surrounding vasogenic edema are unchanged.
No evidence of new hemorrhage.
The sulci are somewhat poorly-visualized; however, this appearance is
unchanged over the entire series of examinations, and there is preservation of
gray-white matter differentiation, both superficial and deep, throughout. The
basal cisterns are patent.
The mastoid air cells and middle ear cavities, bilaterally, are fluid
opacified unchanged since most recent studies, likely due to prolonged supine
positioning and intubation. A mucus-retention cyst is noted within the right
maxillary sinus.
IMPRESSION: Status post right frontal craniotomy with EVD placement, with
ventriculostomy catheter terminating just superior to the right foramen of
___. The ventricular size is unchanged, as as the right frontal parenchymal
hemorrhage. No new hemorrhage is seen.
Radiology Report
PORTABLE AP CHEST, ___ AT 4:48
CLINICAL INDICATION: ___ with subarachnoid hemorrhage, evaluate for
interval change.
Comparison to previous studies dated ___ at 4:14.
Portable semi-erect chest film, ___ at 4:49 is submitted.
IMPRESSION:
1. Tracheostomy tube and right subclavian PICC line are unchanged in
position. Cardiac and mediastinal contours are stable, being upper limits of
normal given portable technique. Subtle bibasilar patchy opacities are again
seen, suggestive of patchy atelectasis, although pneumonia or aspiration
cannot be entirely excluded. No large pneumothorax. No evidence of pleural
effusions. No pulmonary edema.
Radiology Report
HISTORY: Subarachnoid hemorrhage. Evaluate for interval change.
TECHNIQUE: CT of the head without IV contrast.
TOTAL DLP: 1029 mGy-cm.
CTDIvol: 52.4 mGy.
COMPARISON: Multiple prior studies, most recently ___.
FINDINGS: The patient is status post right frontal approach EVD placement
with EVD terminating in the foramen of ___. The ventricles are slightly
larger size compared to the prior study, particularly the frontal horn of
theright lateral ventricle. Organizing hematoma within the right frontal lobe
with surrounding vasogenic edema is unchanged. Intraventricular hemorrhagic
extension bilaterally remains. There is no evidence of new edema or
hemorrhage or change in the ventricular size. The basal cisterns are patent.
Artifact in the region of the ACOM coling is stable.
IMPRESSION:
1) No evidence of new hemorrhage or edema.
2) Slighty larger ventricular size, especially the frontal horn of right
lateral ventricle.
2) Stable right frontal intraparenchymal hemorrhage with surrounding vasogenic
edema and intraventricular extension. Status post ACOM aneurysm coiling and
right frontal approach EVD.
Radiology Report
STUDY: CTA of the head.
CLINICAL INDICATION: ___ man, with history of subarachnoid
hemorrhage, EVD clamped, worsening lower extremity exam, rule out vasospasm.
COMPARISON: Prior cerebral angiogram dated ___.
TECHNIQUE: Pre-contrast axial MDCT images were obtained through the brain,
the images were reviewed using soft tissue and bone window algorithms. After
the administration of intravenous contrast material, axial MDCT images were
obtained through the brain. The images were reviewed using soft tissue and
bone window algorithms. Sagittal and coronal reformations were reviewed.
FINDINGS: Residual blood products are redemonstrated in the gyrus rectus of
the right frontal lobe with associated edema, there is no significant shifting
of the normally midline structures. Again a right ventricular shunt is in
place with tip terminating at the level of the third ventricle. Residual
blood products are visualized in the occipital ventricular horn with no
evidence of hydrocephalus. There is no evidence of hemorrhage throughout the
course of the right ventricular shunt. Post-surgical changes consistent with
burr hole are noted in the frontal lobe and staples in the soft tissues.
CTA OF THE HEAD:
There is vascular enhancement in the major arterial vascular structures.
Again hypoplasia of the A1 segment on the right is redemonstrated. There is
minimal narrowing of the right middle cerebral artery as well as the left
middle cerebral artery, with no evidence of critical stenosis. The patient is
status post coiling of a anterior communicating artery aneurysm (ACOM).
Residual anterior communicating artery aneurysmal sac is redemonstrated and
unchanged since the prior angiogram in the ventral aspect of the anterior
cerebral artery (image #19, series 400b), measuring approximately 5.9 mm in
coronal projection. The orbits are unremarkable, and mucosal thickening is
noted in the lateral recess of the left sphenoid sinus and bilateral patchy
mucosal thickening in the mastoid air cells.
IMPRESSION:
1. Residual blood products and edema is redemonstrated in the right frontal
lobe involving the gyrus rectus.
2. Residual intraventricular hemorrhage identified in the occipital
ventricular horns.
3. The CTA demonstrates minimal vasospasm in the middle cerebral arteries
with no evidence of critical stenosis, residual anterior communicating artery
aneurysm as described above, measuring approximately 5.9 mm in coronal
projection.
These findings were communicated to ___ by Dr. ___ at
12:05 hours on ___ via phone call.
Radiology Report
HISTORY: ___ male with ACOM aneurysm rupture. Evaluate for interval
change.
TECHNIQUE: Contiguous axial multi detector CT images were obtained through
the brain without administration of intravenous contrast. DLP 1273 mGy-cm.
CTDI 138 mGy.
COMPARISON: CTA of the Head ___.
FINDINGS:
The patient is status post ACOM coiling and EVD removal. There is no evidence
of ventricular enlargement when compared to prior examination. Prior seen
intraparenchymal hemorrhage within the right frontal lobe anterior to the
lateral ventricle less hyperdense indicating appropriate evolution.
Surrounding hypodensity most consistent with edema unchanged. Mild effacement
of adjacent sulci without shift of midline structures is seen. The cisterns
are patent. There is resolution of prior seen intraventricular blood
products. No evidence to suggest new hemorrhage or infarction.
Re- demonstration of partial opacification of the mastoid air cells
bilaterally most likely consistent with prolonged supine positioning. The
paranasal sinuses are clear. The patient is status post surgical changes
within the right frontal region with staples in the soft tissue. The
remainder of the bones are unremarkable.
IMPRESSION:
Stable appearance of intraparenchymal hemorrhage with surrounding unchanged
edema. Patient is status post ACOM coiling in and EVD removal without
evidence of ventricular enlargement.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: SAH with increased secretions.
Comparison is made with prior study ___.
Cardiomediastinal contours are normal. Aside from faint opacities in the left
lower lobe, the lungs are grossly clear. The aeration of the lungs has
markedly improved from prior study. These remaining opacities could be due to
improved infection. Minimal atelectasis in the right lower lobe is still
present. There is no pneumothorax or large effusions. Tracheostomy tube is
in standard position. Right PICC tip is in the mid SVC.
Radiology Report
HISTORY: ___ man with anterior communicating artery aneurysm status
post rupture and subarachnoid hemorrhage. The patient is status post coil
embolization. Exam is done to evaluate for vasospasm, new aneurysm or
recanalization of coiled aneurysm.
ATTENDING PHYSICIAN: ___, M.D.
ASSISTANT: ___, M.D.
COMPARISON: Cerebral angiogram ___
and ___, CTA head with and without contrast and reconstructions ___.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
Fentanyl (total 50 mg) and Versed (total 0.5 mg) for a total intra-service
time of 75 minutes, during which the patient's hemodynamic parameters were
continuously monitored.
TECHNIQUE: Informed consent was obtained from the patient's wife after
explaining the risks, indications, and alternative management. Risks
explained included stroke, loss of vision and speech, temporary or permanent,
with possible treatment with stent and coils if needed.
The patient was brought to the Interventional Neuroradiology Theater and
placed on the biplane table in supine position. Both groins were prepped and
draped in the usual sterile fashion. Access to the right common femoral
artery was obtained using a 19 gauge single wall needle, under local
anesthesia using 1% lidocaine mixed with sodium bicarbonate and with aseptic
precautions. Through the needle, a 0.035 ___ wire was introduced and the
needle was taken out. Over the wire, a ___ Fr vascular sheath was placed and
connected to a saline infusion (mixed with heparin 500 units in 500 cc of
saline) with a continuous drip. Through the sheath, a ___ Fr Berenstein
catheter was introduced and connected to continuous saline infusion (with
mixture of 1000 units of heparin in 1000 cc of saline).
The following blood vessels were selectively catheterized and arteriograms
were performed from the:
1. Right internal carotid artery.
2. Left internal carotid artery.
3. Left vertebral artery.
FINDINGS:
EVALUATION OF THE RIGHT INTERNAL CAROTID ARTERY:
Evaluation of the right internal carotid artery demonstrates good flow in the
proximal and distal right internal carotid artery, anterior and middle
cerebral arteries. The right A1 branch is hypoplastic, as seen on prior
studies. No evidence of vasospasm was seen.
LEFT VERTEBRAL ARTERY:
Evaluation of the left vertebral artery demonstrates good flow in the proximal
and distal left vertebral artery, basilar artery and posterior cerebral
arteries bilaterally. There was no evidence of significant vasospasm.
LEFT INTERNAL CAROTID ARTERY:
Evaluation of the left internal carotid artery demonstrates good flow in the
proximal and distal left internal carotid artery. Good flow is noted in the
left middle cerebral artery. No significant vasospasm is seen. Good flow is
noted in the distal anterior cerebral artery branches. There is a new small
aneurysm projecting superiorly and medially, and originating from the dome of
the previously coiled anterior communicating artery aneurysm. It measures
approximately 2.3 x 2.3 mm in size.
At this point, the catheter was withdrawn, the sheath was removed and manual
compression was applied for closure of the common femoral artery puncture
site.
IMPRESSION:
___ underwent cerebral angiogram which demonstrate status post coiling
of anterior communicating artery aneurysm with new small aneurysm projecting
superomedially and measuring approximately 2.3 x 2.3 mm. There was no evidence
of vasospasm. Coil embolization of this aneurysm is recommended as further
treatment.
The procedure was uneventful and the patient tolerated the procedure well.
The patient was sent to the floor with orders.
Radiology Report
PREOPERATIVE DIAGNOSIS: Recanalized anterior communicating artery aneurysm.
INDICATION: The patient had presented with a subarachnoid hemorrhage from a
ruptured anterior communicating artery aneurysm - from a daughter sac. This
daughter sac was coiled, however, the aneurysm continued to enlarge and had
recanalized; therefore, he was brought back for further coiling.
PROCEDURES PERFORMED: Left common carotid artery arteriogram, left internal
carotid artery arteriogram.
INTERVENTIONAL PROCEDURE PERFORMED: Coiling of anterior communicating artery
aneurysm.
ATTENDING PHYSICIAN: ___, M.D.
ASSISTANT: ___, M.D.
ANESTHESIA: General.
DETAILS OF THE PROCEDURE: The patient was brought to the angiography suite.
Anesthesia was induced in the supine position. Following this, both groins
were prepped and draped in a sterile fashion. Access was gained to the right
common femoral artery using a Seldinger technique and a 6 ___ vascular
sheath was placed in the right common femoral artery. We now catheterized the
left common carotid artery and AP, lateral filming was done. Under
roadmapping guidance, Neuron catheter was placed in the left distal internal
carotid artery. We now catheterized the anterior communicating artery
aneurysm with a Synchro wire and an SL-10 microcatheter. Multiple coils of 2
mm helical UltraSoft Target coils were placed. Following this, the aneurysmal
daugther sac of the anterior communicating segment obliterated. The sheath
was removed and manual compression applied for closure of the femoral artery
puncture site.
FINDINGS: Left common carotid artery arteriogram shows persistent filling of
daughter sac of the anterior communicating artery aneurysm.
Left internal carotid artery arteriogram status post coil embolization shows
that the previously recanalized anterior communicating artery aneurysm
daughter sac is now completely obliterated. There is no filling of the
aneurysm.
IMPRESSION: ___ underwent cerebral angiography and coil embolization of
an aneurysm that was unvevntful.
Radiology Report
HISTORY: Fever with increased sputum.
FINDINGS: In comparison with the study of ___, the tracheostomy tube remains
in place and the central catheter has been removed. Minimal areas of
increased opacification are again seen at the bases, most likely reflecting
streaks of atelectasis. No vascular congestion or acute focal pneumonia.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Fevers, sputum production, rule out pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, no relevant change is seen.
Tracheostomy tube in situ. Borderline size of the cardiac silhouette without
overt pulmonary edema. No pleural effusions. No pneumonia. No pneumothorax.
Radiology Report
HISTORY: ___ man with prolonged bed rest and fevers, evaluate for
DVT.
COMPARISON: Bilateral leg ultrasound ___.
FINDINGS:
Grayscale, color and Doppler images were obtained of bilateral common femoral,
femoral, popliteal and tibial veins. Normal flow, compression and
augmentation is seen in all of the vessels.
IMPRESSION:
No evidence of deep vein thrombosis in either leg.
Radiology Report
INDICATION: Fever of unknown origin.
TECHNIQUE: MDCT images were obtained from the thoracic inlet to the lesser
trochanters after the administration of oral and intravenous contrast.
Coronal and sagittal reformations were prepared.
COMPARISON: None available.
FINDINGS: Tracheostomy tube is in satisfactory position. There are no
pathologically enlarged supraclavicular, axillary, mediastinal, or hilar lymph
nodes by size criteria. The heart and great vessels are normal. There is a
7-mm nodule in the right middle lobe and two other nodules in the right lower
lobe measuring up to 6 mm (2:31, 40). There is also a 5 mm subpleural nodule
adjacent to the right minor fissure (2:28). The airways are patent to the
subsegmental level. There is no focal consolidation or pleural effusion.
CT ABDOMEN: 11-mm hypodensity in the right lobe of liver probably represents
a simple cyst. Smaller hypodensity in segment IVb is too small to
characterize (2:62). The liver otherwise enhances homogeneously. The hepatic
and portal veins are patent. Dependent hyperdensity in the gallbladder is
probably a stone (2:66). The pancreas, spleen, and adrenals are normal. The
kidneys enhance symmetrically and excrete contrast without evidence of
hydronephrosis or mass. Gastrostomy tube is in satisfactory position. Oral
contrast passes freely through the stomach and small bowel without evidence of
obstruction. There is no portacaval, mesenteric, or retroperitoneal
lymphadenopathy. There is no free air or free fluid.
CT PELVIS: The colon, rectum, seminal vesicles are normal. The urinary
bladder contains a Foley catheter. The prostate is mildly enlarged.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for
malignancy.
IMPRESSION:
1. No CT findings to explain the patient's fever of unknown origin.
2. Multiple pulmonary nodules measuring up to 7 mm. If this patient has high
risk for primary lung malignancy, followup chest CT is recommended in ___
months. Otherwise, this can be followed in ___ months.
3. Cholelithiasis.
Radiology Report
CHEST ON ___
HISTORY: Fever, question infection.
REFERENCE EXAM: ___.
FINDINGS: The tracheostomy tube is again seen. There is no focal infiltrate
or effusion. Residual contrast is noted in the colon. Gastric tube is
visualized.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: SAH
Diagnosed with SUBARACHNOID HEMORRHAGE, NONRUPT CEREBRAL ANEURYM
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ was intubated at ___ and was
transported to ___ via Medflight. During Medflight, the
patient became hypertensive and bradycardic. Upon arrival, his
___ score was 3. He underwent an emergent CTA which showed
extensive SAH with IVH x4 with ACOMM aneurysm. He received 750mg
Keppra x1. An EVD was placed and he was admitted to the ICU for
close monitoring. He was started on Nimodipine, and an A-line
and central line were placed.
On ___, he underwent a non-contrast head CT with good placement
of the EVD. He underwent a cerebral angiogram with 4-coils
placed in the ACOM. The EVD was set at 5.
On ___, the patient's ICPs were elevated to ___ in the
morning. He underwent a STAT non-contrast head CT which showed a
small amount of hemmorhage along the EVD tract and cerebral
edema. He received 2mg tPA at 11:30 AM to help dissolve the
clot. He was started on 23%. An Alsius catheter was started to
decrease ICPs with a temperature goal of 35 Celsius.
On ___, Mr. ___ underwent a head CT which showed a stable SAH
& stable hemorrhage along EVD tract. Continuous EGG showing low
voltage and no indication of seizure activity. Sodium elevated
to 153, 23% was discontinued and started on normal saline at
80cc/hr.
On ___, head CT was repeated and showed an unchanged
distribution and quantity of hemorrhage in the ventricle and
EVD tract. Patient is now being maintained normothermic,
presently temp is ___. Prelim EEG showed low voltage and no
indication of seizure activity. CSF culture showed 2+ PMN with
no microorganisms. Blood cultures are still pending. Urinalysis
is negative, but urine culture is pending. Sputum culture
prelimi showed 4+ gram negative rods, 1+ gram positive cocci,
amd 1+ gram positive rods. Sodium is trending down, this morning
sodium was 150.
On ___, there was a slight decrease on exam. A repeat head CT
showed no changes from previous head CT. His temperature on the
alsius continued to rise. Presently, his temp is 100.2F on the
alsius cooling system, all cultures were resent including CSF cx
and alsius catheter tip. The alsius cooling system was d/c'ed,
he continued on tylenol PRN for his fevers. He was placed on
both vancomycin and cefepime for a presumed HAP. TCDs showed no
vasospasm. EGG was positive seizure activity overnight around
the left temporal lobe, the longest lasting over ___ minutes.
Keppra IV was increased to 1500mg bid from 750mg bid and
neurology was consulted.
Overnight, patient was seen to have low output from EVD. On
further investigation, it was noted that the EVD was pulled out
and catheter was then replaced. He had good drainage from EVD
throughout the rest of the night. On ___, patient's exam was
poor, repeat head CT confirmed placement of EVD and no new
hemorrhage was seen. EEG leads were replaced and neurology
evaluated the patient for seizures and at this time no changes
were made to his keppra dosing. He appeared to have jaundice in
his face, LFTs were sent in which his ALT and AST were slightly
elevated. He was taken to angiogram where slight vasospasm was
seen and he was treated with intra-arterial verapamil to
bilateral ICAs and L VA. He continues to be febrile despite
antibiotic treatment. Overnight into ___ his EVD was flushed
distally for slow flow and ICP of 18. In the mornign he recieved
a 500cc bolus of normal saline in order to maintain euvolemia.
He was subsequently febrile to 103 and LENIS were ordered which
were negative, cultures were deffered given positive cultures
with sensisitivites from prior fever episodes.
On ___, the right frontal EVD stopped working. It was replaced
by Dr. ___. A post-procedure non-contrast head CT was
obtained and showed good placement of the catheter. He spiked a
fever to 102. He was pan cultured,ID was consulted for input on
the ongoing fever.
___: the patient was putting out large amounts of dilute looking
urine, sometimes a liter at time. Serum and urine labs were
obtained every six hours which all remained within normal
limits. The patient was likely mobalizing his fluids. He had
TCDs which were concerning for high velocities in his L PCA. He
was consented for angio.
On ___ patient returned to ___, had a few more coils placed in
the Acom aneurysm and some intra-arterial Verapamil for mild to
moderate vasospasm. Fevers persist at 102.6 with no definitive
source.
___ the patient's EVD was raised to 20. He was peristently
febrile and started on florinef. He went to the operating room
where a trach and a peg were placed.
___ Vancomycin was discontinued due to concerns that he might be
having drug related fevers. In the morning, his EVD was clamped
and his intracranial pressures remained stable throughout the
day.
___ A NCHCT was obtained to evaluate the ventricles following
his clamping trial which showed they were stable in size. He was
taken to angio again which showed mild vasospasm in the left A1
for which he was given verapamil. His angiogram was otherwise
unremarkable.
On ___ He had a head CT with right frontal lateral horn
enlargement and the decision was made to leave the EVD in for
another day given the fact his exam was stable. On ___ he
underwent a CTA of the head which showed persistent outpouching
to the M2 segment. His EVD was discontinued as his ICP's were
stable and his exam remained improved. On ___ he was doing well
and on trach mask, he had a trial of a PMV. On ___ his
guardianship paperwork was complted and submitted. He continued
to do well on ___ and was deemed fit for transfer to the floor
with telemetry and was awaitign a bed. He also underwent CT scan
of teh brain which was stable. On ___ he was transferred to the
floor with tele and ___ was ordered. On ___ the patient
experienced respiratory difficulties, chest x-ray showed mild
atelectasis, no pneumothorax. On ___ the patient remained
stable. On ___ Nimodipine was discontinued. Staples were
removed from EVD site. Incision was clean, dry and intact.
On ___ Na was 152, free water flushes were increased. K was
repleted. Neuromedicine was consulted for evaluation for
bilateral foot drop. EMG was recommended and arranged to be
performed on ___. TSH, B12, folate and SPES labs were checked.
The patient was consented and pre oped for angio to be performed
on ___.
On ___ he underwent EMG which showed no evidence of
polyneuropathy and diagnostic angiogram which showed a 2mm ACOMM
segment that would be amenable to re-coiling. In the evening he
pulled out his PICC line and as a result he was placed in mitt
restraints. Later on he was found out of bed sitting on the
floor without signs of trauma.
On ___ he underwent a cerebral angiogram for coiling of the 2mm
ACOMM aneurysm recannalization under general anesthesia. He
tolerated the procedure well. He remained flat for 6 hours post
procedure. Postoperatively he remained neurologically stable at
baseline.
On ___ he was stable and transferred to the Step Down Unit; he
remained stable on ___ and ___ with daily lab checks and
potassium repletion as needed. Patient spiked a fever to 101.2
on ___ and was pan cultured. On ___, patient was afebrile in
the AM. His u/a was negative but urine cx grew out staph coag
negative. A repeat u/a and urine culture was sent. He remains
stable on exam. ___ continues to evaluate. His potassium remains
low at 3.1 and he was given supplement. Labs were also resent.
Early on ___, the patient once again spiked a fever to 103. CXR
performed the next morning was normal. After discussion with ID,
it was decided to remove the foley, though the patient failed to
void subsequently and the foley was re-inserted. New UA and
urine culture were sent following insertion of the new foley, as
was a new sputum culture. On ___ he was offered a rehab bed
hwoever it was not taken as he continued to be febrile. ID was
contacted to assist with his care. LENIS were done which were
negative and he was pancultured with blood, urine, and sputum..
On ___ he was started on vancomycin and cefepime and he
underwent a CT of the torso which showed no acute abnormalities.
Also a PPD was placed.
On ___ a CXR and labs were WNL, UA was negative, culture showed
no growth. Blood cultures were pending.
On ___ Vanc trough was 7.2, dose was adjusted. Blood cultures
were still pending. Trach was downsized.
On ___, Infectious Disease provided final recommendations which
included continuing intravenous antibiotics for a otal of 8 days
and repeating a vancomycin trough at rehab. There is no need
for further follow up with infectious Disease. The patient was
neurologially stable and was able to ambulate to the bathroom
with assist x 1. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abnormal eye movements
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo man with a history of a pituitary
macroadenoma s/p resection via craniotomy and radiation
complicated by intracranial hemorrhage in ___, hypopituitarism,
bilateral ACA ischemic strokes, seizure disorder, and diabetes
insipidus who presents as a transfer from ___ for concern
for INO.
The history is extremely limited. Per note from ___, the
patient has had right eye deviation and right eye blurry vision
for anywhere from 1 day to 1 month. Exam was concerning for an
INO lesion, and the patient was transferred to ___.
On interview, the patient states that he is here for a letter
for
work because he went to the ___ office today because he hasn't
been in contact with them for a while and they won't let him
work
(NB: he lives at a ___ and is not working and this information
is
likely not correct). When prompted about any eye symptoms, he
states that his right eye has been blurry, for anywhere from 1
week to 1 month. He says that it also feels scratchy.
He denies double vision, headache, hearing loss, focal
weakness/numbness, problems walking. He denies recent fever,
chills, cough, cold, flu, nausea, vomiting or diarrhea.
Further history could not be obtained.
Past Medical History:
pituitary macroadenoma s/p resection via craniotomy and
radiation completed 2 weeks prior to admission c/b ICH w/
residual cortical encephalomacia; hypothyroidism; adrenal
insufficiency; diabetes insipidus; psychosis; s/p falls x2
Social History:
___
Family History:
unable ot obtain
Physical Exam:
ADMISSION EXAM:
98.0 59 145/82 16 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple, 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 to name. Thinks he is at ___.
States month is ___ and year is ___. Unable to relate
history. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name high frequency objects only. Speech was
not
dysarthric. Able to follow both midline and appendicular
commands. Attentive, able to name ___ backward without
difficulty. Pt. was able to register 3 objects and recall ___
at
5 minutes.
-Cranial Nerves:
I: Olfaction not tested.
II: L pupil 2.5 mm, briskly reactive, R pupil reactive but not
brisk, with hippus, no RAPD. No red color desaturation. Visual
acuity OD finger counting, OS ___. Left visual field cut,
tested by blink to threat.
III, IV, VI: R eye down and out at rest. R eye full EOM. L eye
can cross midline but not fully adduct, otherwise full EOM. Exam
complicated by field cut.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-snap bilaterally - mild hearing
loss 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 4+ ___ 5 5 5
R ___ ___ 5 4+ ___ 5 5 5
-DTRs:
- Plantar response was equivocal bilaterally.
-Sensory: No deficits to light touch, pinprick, proprioception
(large movements) throughout.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally.
-Gait: per ED nurse, slightly unsteady but does not fall to one
side.
DISCHARGE EXAM:
alert and awake, lying comfortably in bed.
Slightly inattentive, with flat affect. Confabulatory. Fluent
speech and follows commands. No hemisensory or visual neglect.
On
cranial nerve exam, PERLL 3-->2mm, although R less brisk than L,
no APD. Reports blurriness out of R eye and "brown" color when
shown red ID badge. Vision is ___ -1 in the right eye and
___
+2 in the left eye. At rest, he has alternating exotropia, more
prominent in the right eye. Both eyes have full movements, with
the exception of incomplete adduction of the left eye. He
reports
no double vision at any point in gaze although eyes are
dysconjugate. He has a dense left homonymous hemianopsia. Other
CN are intact including V. He does have conjuntival injection
(slight) in the left eye. On motor exam he has no drift, tone is
symmetric. He has poor effort in the left deltoid and left IP
(?pain related), reflexes are symmetric and toes are downgoing
with a large withdrawal component.
Pertinent Results:
___ 05:35AM GLUCOSE-98 UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16
___ 05:35AM estGFR-Using this
___ 05:35AM CALCIUM-9.5 PHOSPHATE-2.9 MAGNESIUM-2.1
___ 05:35AM WBC-5.8 RBC-4.82# HGB-11.6* HCT-36.7*#
MCV-76*# MCH-24.1*# MCHC-31.6* RDW-15.9* RDWSD-43.3
___ 05:35AM NEUTS-48.9 ___ MONOS-7.6 EOS-1.0
BASOS-0.2 IM ___ AbsNeut-2.82 AbsLymp-2.41 AbsMono-0.44
AbsEos-0.06 AbsBaso-0.01
___ 05:35AM PLT COUNT-205#
___ 03:12AM URINE HOURS-RANDOM
___ 03:12AM URINE HOURS-RANDOM
___ 03:12AM URINE UHOLD-HOLD
___ 03:12AM URINE GR HOLD-HOLD
___ 03:12AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:12AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
MRI BRAIN:
FINDINGS:
The examination is moderately to severely degraded by motion.
The patient is status post left frontoparietal craniotomy and
resection of a
mass in the sella turcica. The sella turcica remains expanded.
There is
nodular enhancement along the floor of the sella turcica. A
lobulated
enhancing lesion encases the right cavernous and supra clinoid
internal
carotid artery, decreased in size and bulk in comparison to the
MRI ___. The flow void of the right internal carotid artery is
maintained.
No new enhancing lesions are identified. There is no enhancement
along the
course of the visualized cranial nerves.
The encephalomalacia in the bilateral frontal lobes, right
greater than left,
with ex vacuo dilatation of the frontal horns of the lateral
ventricles is
unchanged. There is no evidence of hemorrhage, midline shift or
acute
infarction.
There is a mildly mucosal thickening in the bilateral frontal,
sphenoid, and
maxillary sinuses. The mastoid air cells are clear.
IMPRESSION:
1. Limited examination due to motion.
2. Postsurgical changes with residual neoplasm in the floor of
the sella
turcica and encasing the right cavernous and supra clinoid
internal carotid
artery common decreased in comparison to the prior examination.
3. No new enhancing lesions.
4. No enhancement along the visualized cranial nerves.
5. Chronic infarctions in the bilateral ACA distribution.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Desmopressin Nasal 2 mcg NAS BID
2. Ferrous Sulfate 325 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. LeVETiracetam 750 mg PO BID
6. Metoprolol Tartrate 75 mg PO BID
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
8. Multivitamins 1 TAB PO DAILY
9. Acetaminophen 325-650 mg PO Q6H:PRN pain
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Hydrocortisone 20 mg PO QAM
12. Hydrocortisone 10 mg PO QPM
13. Bisacodyl 10 mg PO DAILY:PRN constipation
14. Milk of Magnesia 30 mL PO Q6H:PRN constipation
15. Senna 8.6 mg PO BID:PRN constipation
16. MetFORMIN (Glucophage) 750 mg PO BID
17. Docusate Sodium 100 mg PO BID
18. Metoprolol Succinate XL 75 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Desmopressin Nasal 2 mcg NAS BID
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Hydrocortisone 20 mg PO QAM
6. Hydrocortisone 10 mg PO QPM
7. LeVETiracetam 750 mg PO BID
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
10. Acetaminophen 325-650 mg PO Q6H:PRN pain
11. Bisacodyl 10 mg PO DAILY:PRN constipation
12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
13. MetFORMIN (Glucophage) 750 mg PO BID
14. Metoprolol Tartrate 75 mg PO BID
15. Milk of Magnesia 30 mL PO Q6H:PRN constipation
16. Multivitamins 1 TAB PO DAILY
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Metoprolol Succinate XL 75 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Pituitary tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with prior pituitary macroadenoma status
resection, prior ACA infarcts, now with multiple CNII-VI findings. Evaluate
for intracranial mass, particularly in cavernous sinus and midbrain.
TECHNIQUE: 11 ml of Gadavist was administered. T1, and post-contrast
sagittal and coronal T1 weighted sequences of the sella turcica were obtained.
Precontrast axial T2, axial FLAIR, and post-contrast axial T1 and sagittal
MPRAGE with axial and coronal reformatted sequences of the brain were
obtained. Axial Fiesta sequence through the cavernous sinus was obtained.
COMPARISON: ___ noncontrast head MRI
___ noncontrast head CT.
___ outside noncontrast head CT.
FINDINGS:
Study is moderately degraded by motion, especially on postcontrast imaging.
Within these confines:
The patient is status post left frontoparietal craniotomy and resection of a
mass in the sella turcica. The sella turcica remains expanded. There is
nodular enhancement along the floor of the sella turcica. A lobulated
enhancing lesion encases the right cavernous and supra clinoid internal
carotid artery, decreased in size and bulk in comparison to the MRI ___. The flow void of the right internal carotid artery is maintained.
No new enhancing lesions are identified. There is no enhancement along the
course of the visualized cranial nerves.
The encephalomalacia in the bilateral frontal lobes, right greater than left,
with ex vacuo dilatation of the frontal horns of the lateral ventricles is
unchanged. There is no evidence of hemorrhage, midline shift or acute
infarction.
There is a mildly mucosal thickening in the bilateral frontal, sphenoid, and
maxillary sinuses. The mastoid air cells are clear.
IMPRESSION:
1. Study is moderately degraded by motion.
2. Postsurgical changes with residual neoplasm in the floor of the sella
turcica and encasing the right cavernous and supra clinoid internal carotid
artery common decreased in comparison to the prior examination.
3. Within limits of study, no definite new enhancing lesions.
4. Within limits of study, no definite enhancement along the visualized
cranial nerves.
5. Chronic infarctions in the bilateral ACA distribution.
6. Paranasal sinus disease as described.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Visual changes, Altered mental status, Transfer
Diagnosed with Altered mental status, unspecified
temperature: 97.5
heartrate: 61.0
resprate: 16.0
o2sat: 97.0
sbp: 176.0
dbp: 86.0
level of pain: unable
level of acuity: 2.0 | Mr. ___ is a ___ year old man with a past medical history of
pituitary
macroadenoma s/p resection via craniotomy and radiation
complicated by intracranial hemorrhage in ___, hypopituitarism,
bilateral ACA ischemic strokes, seizure disorder, and diabetes
insipidus who presented as above with EOM abnormalities and left
visual field cut, both of unknown chronicity and possibly
related to old pituitary adenoma.
MRI brain was performed, which showed stable residual tumor in
the sella turcica, and old bilateral ACA strokes with frontal
encephalomalacia. There was no stroke or new expanding lesion to
explain his exam. It remains unclear what eye findings are new
vs old findings, however, given MRI findings and that he
reported no new diplopia, the likelihood of new dysconjugate
gaze is less. Therefore, it was determined that outpatient
follow up regarding his eye findings and tumor, in specialized
clinics as below, is the best course of action as it seems he
has been somewhat lost to follow up in this regard recently.
His mental status remained stable, notable only for severe
amnesia likely related to prior strokes, and his electrolytes
were stable as well.
No medication changes were made during this admission.
OUTSTANDING ISSUES
[ ] Neuro-ophthalmology follow up
[ ] Brain tumor clinic follow up
[ ] Should follow with endocrinologist as outpatient
* Please make sure to include paperwork with baseline exam for
any future transfers to the emergency room. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
topiramate
Attending: ___.
Chief Complaint:
Feeling "out of out" and left sided sensory changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ states that he has been in his usual state of health
with no recent illnesses or unplanned medication changes (see
below for description of rotating schedule of AEDs). He has
been
getting good sleep and not experiencing any increased stress.
For the last 4 weeks however, he states that he has been feeling
progressively "out of it" and "confused". He reports that some
days are better than others, though the overall trend is one of
worsening. He has difficulty giving concrete examples, and when
prompted says that maybe he is having more difficulty in his job
as an ___. However, no network has raised concerns about
his performance. He then states "I feel disoriented at home...
But I know I am home... I do not know... ___ I get confused
about what my schedule is." He states that he sees his parents
weekly and talks to them often by text message, and they have
not
noticed any changes in his behavior. Similarly his girlfriend
has not noticed any changes in his behavior. When prompted, he
states that the sensation is similar to feeling post-ictal --
but
says "that feeling usually goes away after an hour".
Mr. ___ also reports some associated left facial numbness
that
he believes has been going on over the same time. In addition
he
reports headache, which is unusual for him, but is unable to
describe it further. He states that he has some subtle "verbal
memory" difficulties and visual field deficits following his
temporal lobe surgery, though that these are usually only
perceptible with formal testing.
As stated below, Mr. ___ reports that his last seizure was
one
year ago. His seizure semiology is generalized tonic-clonic
seizures, and prior to a year ago they had been happening
several
times per year. He cannot identify any reason for this longer
period of seizure freedom. His epilepsy neurologist has not
begun to down titrate any of his AEDs. He has seen several
different neurologists and currently follows with Dr. ___ at
___.
Patient notes that he has (intentionally) lost 50 pounds since
___ with exercise (cardio, weights) and dieting (eats 5
small meals per day instead of 3 large ones). He sometimes
supplements workouts with protein powder, but does not endorse
use of performance-enhancing or stimulant drugs. He notes that
he has had slight difficulty with word-finding that is baseline
s/p left medial temporal lobe resection. Mother has noted that
it may have gotten worse in the past few weeks.
Past Medical History:
PAST MEDICAL HISTORY:
- seizures since birth -> complex partial
- patient reports: "difficulty talking, sudden fear, and HA"
- prior notes document semiology of staring with RUE shaking
- prior notes document diagnosis of K+ channel defect, patient
is unaware of this
- underwent L medial temporal lobe resection at age ___ at ___
- subsequently had GTCs, "a few per year"
- GTCs stopped ___ year ago, unclear why
*above is given by patient though he is having some difficulty
recalling precise history*
Social History:
___
Family History:
Father with same potassium channel mutation, no
seizures. Two cousins paternal side with seizures, Mom has a
slew
of cousins ___ seizures and negative genetic workup.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS T:98.1 HR:73 BP:132/69 RR:20 SaO2:97
GEN - well appearing, well developed
HEENT - NC/AT, MMM
NECK - full ROM, no meningismus
CV - RRR
RESP - normal WOB
ABD - soft, NT, ND
EXTR - atraumatic, WWP
NEUROLOGICAL EXAMINATION:
MS - Awake, alert, oriented x 3. Concentration maintained when
recalling months backwards. Some difficulty recalling history.
Speaks vaguely regarding his deficits, difficult providing
concrete examples. At times, appears to be searching for words.
Structure of speech demonstrates fluency with full sentences,
and
normal prosody. No paraphasic errors. Intact repetition, naming,
reading, and comprehension. No evidence of apraxia or neglect.
CN - [II] PERRL 5->2 brisk. VF full to number counting. [III,
IV,
VI] EOMI, no nystagmus. [V] Reports decrement to LT and PP over
L
V1-3, ~70% of normal. [VII] No facial movement asymmetry with
forced eyelid closure or volitional smile. [VIII] Hearing intact
to finger rub bilaterally. [IX, X] Palate elevation symmetric.
No
dysarthria. [XI] SCM/Trapezius strength ___ bilaterally. [XII]
Tongue midline with full ROM.
MOTOR - Normal bulk and tone. No pronation, no drift. No
orbiting
with arm roll. No tremor or asterixis.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
SENSORY - Reports decrement to LT and PP over left hemibody
~70-80% of normal.
REFLEXES -
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 3 3 3 3 2
R 3 3 3 3 2
Plantar response flexor bilaterally.
COORD - No dysmetria with finger to nose or heel-shin testing.
Mild intention tremor L>R. Good speed and intact cadence with
rapid alternating movements. Negative Romberg.
GAIT - Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Able to tandem with mild
difficulty at the beginning, but improves.
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 98.2, HR 60-72, BP 102-122/63-70, RR ___, >96%RA
General: young man sitting up in bed, NAD
HEENT: NC/AT, no conjunctival injection, MMM
Pulmonary: Breathing comfortably, no tachypnea or increased WOB
Cardiac: skim warm, well-perfused, no pallor or diaphoresis
Abdomen: soft, ND
Extremities: symmetric, no edema
Skin: large tattoo on left shoulder and upper arm
Neurologic:
Mental status: Awake, alert, oriented to person, place, time and
situation. Language is fluent, intermittent pauses while
thinking of response, very concrete, no paraphasias. Able to
perform ___ backwards and intact calculations. Able to recount
history of recent events.
Cranial Nerves: PERRL (4 to3mm), EOMI without nystagmus, facial
sensation decreased on left (80%) in V1, V2 and V3, face
symmetric, hearing grossly intact, palate elevates
symmetrically,
trapezius full strength, tongue midline
Motor (tone/bulk): Normal bulk, tone throughout. No adventitious
movements, such as tremor, noted.
Strength: ___ throughout
Sensory: Decreased sensation on left arm (90% compared to
right), now improved on leg. Temperature sensation intact
bilaterally. Vibration sense intact bilaterally. Proprioception
intact.
Coordination: normal FNF bilaterally
Gait: normal based
Pertinent Results:
___ 12:34PM WBC-5.5 RBC-5.30 HGB-16.2 HCT-46.1 MCV-87
MCH-30.6 MCHC-35.1 RDW-13.2 RDWSD-42.0
___ 12:34PM NEUTS-54.3 ___ MONOS-5.8 EOS-1.8
BASOS-0.9 IM ___ AbsNeut-3.01 AbsLymp-2.04 AbsMono-0.32
AbsEos-0.10 AbsBaso-0.05
___ 12:34PM PLT COUNT-190
___ 12:34PM GLUCOSE-87 UREA N-15 CREAT-1.0 SODIUM-134
POTASSIUM-7.4* CHLORIDE-101 TOTAL CO2-22 ANION GAP-18
___ 12:34PM ALBUMIN-4.8 CALCIUM-9.3 PHOSPHATE-3.6
MAGNESIUM-2.4
___ 12:34PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:13PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 12:34PM PHENYTOIN-19.1
___ 01:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:13PM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
IMAGING:
MRI Brain ___:
Final Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old man with PMHx of L medial temporal lobe
resection;
now w ?subclinical seizures and left hemibody numbness, R
hemispheric focus?
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: ___ noncontrast head CT
FINDINGS:
There is no abnormal focus of slow diffusion. Postsurgical
changes related to
reported history of left medial temporal lobectomy are noted.
There is no
evidence of hemorrhage, edema, mass, mass effect, or infarction.
The
ventricles and sulci are age-appropriate principal intracranial
vascular flow
voids are preserved. Images of the right hemisphere appear
normal with no
evidence of mesial temporal sclerosis or focal cortical
dysplasias.
The dural venous sinuses are patent. There is no abnormal
parenchymal or
meningeal enhancement. Mucous retention cysts are noted in
bilateral
maxillary sinuses. There is also mild mucosal thickening in the
ethmoid air
cells.
IMPRESSION:
Postsurgical changes of medial left temporal lobectomy.
Otherwise,
unremarkable contrast-enhanced brain MRI.
EEG ___:
IMPRESSION: This is an abnormal continuous monitoring study
because of
occasional ___ second bursts of generalized, ___ Hz generalized
sharp activity
with a frontal predominance, with no clinical correlate. The
findings suggest
generalized or frontal regions of potential epileptogenesis.
Sharply contoured
10 Hz activity in the left anterior temporal region during sleep
is likely due
to breach artifact, consistent with the patient's history of a
left temporal
craniotomy. There were no electrographic seizures in this
recording. Compared
to the previous day's recording, there was no significant
change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam ___ mg PO BID
2. Phenytoin Sodium Extended 400 mg PO QAM
3. Phenytoin Sodium Extended 300 mg PO QPM
4. ClonazePAM 1 mg PO BID
Discharge Medications:
1. ClonazePAM 1 mg PO BID
2. LevETIRAcetam ___ mg PO BID
3. Phenytoin Sodium Extended 400 mg PO QAM
4. Phenytoin Sodium Extended 300 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
epilepsy, anxiety, medication side effects
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with more frequent confusion/?seizures.// pneumonia?
COMPARISON: ___
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old man with PMHx of L medial temporal lobe resection;
now w ?subclinical seizures and left hemibody numbness, R hemispheric focus?
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: ___ noncontrast head CT
FINDINGS:
There is no abnormal focus of slow diffusion. Postsurgical changes related to
reported history of left medial temporal lobectomy are noted. There is no
evidence of hemorrhage, edema, mass, mass effect, or infarction. The
ventricles and sulci are age-appropriate principal intracranial vascular flow
voids are preserved. Images of the right hemisphere appear normal with no
evidence of mesial temporal sclerosis or focal cortical dysplasias.
The dural venous sinuses are patent. There is no abnormal parenchymal or
meningeal enhancement. Mucous retention cysts are noted in bilateral
maxillary sinuses. There is also mild mucosal thickening in the ethmoid air
cells.
IMPRESSION:
Postsurgical changes of medial left temporal lobectomy. Otherwise,
unremarkable contrast-enhanced brain MRI.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Confusion
Diagnosed with Altered mental status, unspecified
temperature: 99.4
heartrate: 92.0
resprate: 18.0
o2sat: 100.0
sbp: 158.0
dbp: 98.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ ___ male with h/o complex partial
seizures s/p medial temporal lobe resection with subsequent
GTCs, seizure-free for the past ___ year, who presented to the ED
on ___ with 4 weeks of vague neurocognitive complaints and
left hemibody numbness, most prominent on left face.
Medical workup (CBC, BMP, TSH, lipid panel, liver enzymes, lyme
titer, urinanalysis, CXR, tox screen) showed no abnormalities.
MRI brain with and without contrast showed no evidence of
hemorrhage, edema, mass, mass effect, or infarction; it provided
no explanation for his symptoms. Phenytoin levels were in the
therapeutic range (trough 15.4). Given history of epilepsy, Mr.
___ was monitored on cvEEG from ___ to ___ which revealed
intermittent generalized epileptiform discharges, but no seizure
activity sufficient to explain his symptoms. During this
hospitalization, Mr. ___ was started on his home rotating AED
regimen, which involved starting tiagabine 2mg daily with plan
to down-titrate phenytoin. No adverse drug reaction was noted.
On the morning of ___, Mr. ___ reported feeling better
overall, with mild left facial sensory deficits to pinprick
only, improved from admission. The cause of Mr. ___ vague
neurocognitive and sensory symptoms remains unclear, though
possibilities include change in AED metabolism in the context of
intentional 50lb weight loss, or anxiety in the context of
recent psychosocial stressors. He agreed with plan for
discharge and close neurology follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Simvastatin /
Hydrochlorothiazide
Attending: ___.
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ with history of atrial fibrillation on Coumadin, CKD,
Hyperlipidemia presenting from a restaurant status post a
syncopal event. At lunch with friends, pt reports having a few
seconds of crampy abdominal pain, standing up to head toward the
bathroom and feeling as if she would pass out. On standing, she
felt lightheaded, but that the room was not spinning. She says
her friends said she sat down and that for a few moments she did
not respond to their questions, but was back to normal a minute
or two later. She did not have any bowel or bladder incontinence
surrounding the event, and nobody saw any convulsive activity.
She felt very hot and diaphoretic for a few seconds during her
abdominal cramping. She denies any chest pain or shortness of
breath, changes in vision, decreased dietary intake or diarrhea.
She reports feeling light headed on occasion in the past upon
standing from a seated position. She did have a mild headache
earlier this morning consistent with prior headaches. She repots
having one prior episode of syncope, but it was ___ ago.
She remembers wearing a holter monitor in the past but believed
the result to be negative or inconclusive.
In the ED, Vitals were T 97, HR 62, BP 122/67, RR 16, O2Sat
100%RA, EKG was notable for T wave inversions V3 through V6,
without prior for comparison. CXR was unremarkable. Labs were
notable for ___ set troponin <.1, CBC 6.1>35.6<224, coags 33.6,
35.4, 3.1, cr. 1.2. She was transferred to the floor for
presyncope in the setting of abnormal EKG without comparison.
Currently she is doing well, reclining comfortably. She reports
having walked over to bed without precipitating lightheadedness.
She is accompanied by her daughter and grandson.
Past Medical History:
Mild Aortic Reguritation
Atrial Fibrillation
Hyperlipidemia
Osteopenia
Prediabetes
Chronic kidney disease ___ diuretic use.
Social History:
___
Family History:
Lung cancer in brother, HTN in distant family.
Physical Exam:
Admission:
Vitals: 98.8, 65 112/65 laying, 62 130/78 standing, 17 98%RA
General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Dry, intact, no rashes
Back: no midline tenderness
Neuro: CN II-XII intact. ___ Strength in both upper and lower
extremities, intact sensation to fine touch throughout. 2+
patellar reflexes bilaterally, 1+ achilles reflexes bilaterally,
toes downgoing. Normal gait, normal finger-nose, no pronater
drift.
Discharge: Exam unchanged from admission. Orthostatics negative
on day of discharge as well.
Pertinent Results:
___ 09:37PM CK(CPK)-60
___ 05:45AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:37PM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:03PM BLOOD cTropnT-<0.01
___ 03:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 02:03PM WBC-6.1 RBC-3.76* HGB-11.7* HCT-35.6* MCV-95
MCH-31.1 MCHC-32.8 RDW-12.4
___ 12:00PM BLOOD Glucose-126* UreaN-20 Creat-1.0 Na-142
K-4.0 Cl-108 HCO3-29 AnGap-9
___ 1:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending)
___ CXR: IMPRESSION: No acute intrathoracic process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 20 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Warfarin 3 mg PO DAILY16
4. Acetaminophen Dose is Unknown PO Q6H:PRN pain
5. Calcium Citrate + D *NF* (calcium citrate-vitamin D3) unknown
Oral unknown
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain
2. Atenolol 50 mg PO DAILY
3. Pravastatin 20 mg PO DAILY
4. Warfarin 2 mg PO DAILY16
5. Calcium Citrate + D *NF* (calcium citrate-vitamin D3) 315 mg
ORAL Frequency is Unknown
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope
Atrial fibrillation
CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Syncope.
COMPARISON: ___.
TECHNIQUE: PA and lateral chest radiograph, two views.
FINDINGS: Heart size is top normal. Cardiomediastinal silhouette and hilar
contours are unremarkable. Lungs are clear. A punctate sclerotic focus
projecting over the intersection of the left fifth posterior and third
anterior rib is unchanged from prior study and likely represents a calcified
bone island or granuloma. Lungs are otherwise clear. There is no pleural
effusion or pneumothorax.
IMPRESSION: No acute intrathoracic process.
Gender: F
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: NEAR SYNCOPE
Diagnosed with SYNCOPE AND COLLAPSE
temperature: 97.0
heartrate: 62.0
resprate: 16.0
o2sat: 100.0
sbp: 122.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | #Syncope: Pt presented after syncopal event at restaurant upon
standing that was consistent with orthostatic hypotension as
etiology. Although EKG showed t-wave inversions in precordial
leads (without prior for comparison), Troponins x3 ruled her out
for ischemia. Orthostatic BPs were obtained on day of admission
and on day of discharge and were normal, but her labs were
notable for a cr that improved from 1.2 to 0.9, and mild
hypernatremia to 146 that would be consistent with mild
dehydration as a factor in her syncopal episode, corrected with
PO intake.. Holter monitoring in place overnight showed no
arrythmia. Per witness report she had no convulsive motion or
postictal bowel/bladder incontince or prolonged AMS.
#Dyspnea on exertion/chest pain: Pt reports having about 1.5
months of gradually increasing DOE noticed occasionally at the
end of her daily 30min walks that she did not have in the past
but also does not significantly limit her exercise capacity. She
also does endorse some intermittent rib/L chest pain over a
similar time period, occuring sometimes at rest, sometimes with
exercising, lasting about ___ minutes. Given current rule out
by enzymes for cardiac ischemia, this was not thought to be an
active issue at discharge, but PCP was notified and an
outpatient stress test was scheduled within the next week.
#Hyperlipidemia: home statin continued.
#Hypertension: home atenolol was continued, however outpt care
may consider changing to metoprolol as atenolol is generally not
first line for patients with CKD given its renal clearance.
#CKD: Admission Cr of 1.2 came down to 0.9 with 1L of IVF, and
was 1.0 at discharge. Left on home atenolol but consider
changing to metoprolol as mentioned above given CKD. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with CAD s/p NSTEMI ___, DES
to LAD (c/b ICU stay with Impella, vaspopressors, and
intubation), HFrEF (EF 45% ___, HTN, DM2, who presents for
fever and vomiting for 2 days.
He was in his usual state of health until ___ when he had
NBNB emesis x5, poor PO tolerance, and low grade temperature of
100.9. He presented to an outpatient provider who suspected
symptoms were likely viral. The patient took acetaminophen but
had worsening fever to 101s the following day in addition to new
rigors, chills, diaphoresis, diarrhea, and productive cough with
yellow sputum. He had minimal PO intake and reported continued
vomiting, though less frequent. He denied chest pain, SOB,
palpitations, headache, lightheadedness, dizziness, vision
changes, abdominal pain, or urinary symptoms.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes (diet-managed)
- Hypertension
2. CARDIAC HISTORY
- None
3. OTHER PAST MEDICAL HISTORY
- Possible Polymyalgia rhematica
- DJD of hands and narrowing of MCP joints
- Spinal stenosis, lumbar
- Osteoporosis
- Colonic adenoma
- Irregular heart rhythm- EKG ___ with bigemeny and premature
atrial beats
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathy,
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: T 97.8, 123/61, HR 83, RR 18, 97% RA
GENERAL: well-appearing, NAD, intermittent cough
HEENT: NC/AT, EOMI, mucous membranes dry
NECK: supple, no JVD appreciated
CARDIAC: rrr, normal s1 s2, no murmurs/rubs/gallops
LUNGS: decreased breath sounds at right base with crackles and
egophony, no increased WOB, no wheezes
ABDOMEN: normoactive bowel sounds, soft, nontender,
nondistended, no masses appreciated
EXTREMITIES: wwp, no ___ edema
NEUROLOGIC: A&Ox3, gross motor and sensation intact
SKIN: wwp, diaphoretic, slightly flushed, no rashes appreciated
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: ___ 0749 Temp: 98.4 PO BP: 113/64 HR: 90 RR:
20 O2 sat: 91% O2 delivery: RA FSBG: 186
GENERAL: well-appearing, NAD, intermittent cough with blood
tinge
HEENT: NC/AT, EOMI, mucous membranes dry
NECK: supple, no JVD appreciated
CARDIAC: rrr, normal s1 s2, no murmurs/rubs/gallops
LUNGS: egophony sounds heard during expiration, no increased
WOB, no wheezes
ABDOMEN: normoactive bowel sounds, soft, nontender, nondistended
EXTREMITIES: wwp, no ___ edema
NEUROLOGIC: A&Ox3, gross motor and sensation intact
SKIN: wwp, diaphoretic, no rashes appreciated
Pertinent Results:
ADMISSION LABS:
___ 03:52AM BLOOD WBC-8.3 RBC-4.99 Hgb-15.2 Hct-44.2 MCV-89
MCH-30.5 MCHC-34.4 RDW-14.1 RDWSD-45.9 Plt ___
___ 03:52AM BLOOD Neuts-87.7* Lymphs-4.6* Monos-7.2
Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.32* AbsLymp-0.38*
AbsMono-0.60 AbsEos-0.00* AbsBaso-0.01
___ 03:52AM BLOOD Glucose-198* UreaN-36* Creat-1.2 Na-129*
K-4.2 Cl-92* HCO3-22 AnGap-15
___ 03:52AM BLOOD ALT-156* AST-143* AlkPhos-56 TotBili-1.9*
___ 03:52AM BLOOD Albumin-3.5
___ 10:20AM BLOOD Calcium-7.9* Phos-4.1 Mg-1.9
MICRO:
___ Blood cultures: no growth to date
___ Urine legionella: negative
___ Urine culture: no growth
IMAGING:
___ Liver US:
1. Status post cholecystectomy without evidence of biliary
ductal dilatation.
2. Mild splenomegaly, measuring up to 13.1 cm.
3. Probable hemangioma in the right lobe of the liver.
___ Chest XRAY:
New focal consolidation within the right lower lobe is likely
compatible with right lower lobe pneumonia. Follow-up to
complete resolution after course of antibiotics is ___ weeks is
recommended
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-5.7 RBC-4.82 Hgb-14.8 Hct-43.7 MCV-91
MCH-30.7 MCHC-33.9 RDW-14.4 RDWSD-48.1* Plt ___
___ 06:15AM BLOOD Glucose-121* UreaN-24* Creat-0.9 Na-134*
K-4.1 Cl-98 HCO3-25 AnGap-11
___ 06:15AM BLOOD ALT-239* AST-218* AlkPhos-52 TotBili-1.1
___ 06:15AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Lisinopril 2.5 mg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. TiCAGRELOR 90 mg PO BID
6. Sertraline 37.5 mg PO DAILY
7. glimepiride 1 mg oral DAILY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 2 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
2. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #*8
Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. glimepiride 1 mg oral DAILY
6. Sertraline 37.5 mg PO DAILY
7. TiCAGRELOR 90 mg PO BID
8. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
Do not restart Lisinopril until seen by primary care provider
9. HELD- Metoprolol Succinate XL 12.5 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until seen by primary care provider
___:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
COMMUNITY-ACQUIRED PNEUMONIA
SECONDARY DIAGNOSES:
HYPONATREMIA
CORONARY ARTERY DISEASE
CHRONIC DIASTOLIC HEART FAILURE
HYPERLIPIDEMIA
TYPE II DIABETES MELLITUS
ACUTE KIDNEY INJURY
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 vomiting, cough, fever. Evaluation for PNA,
aspiration
TECHNIQUE: Chest PA and lateral
COMPARISON: Comparison to prior radiograph from ___.
FINDINGS:
New focal consolidation within the right lower lobe is likely compatible with
pneumonia. Cardiomediastinal silhouette is within normal limits. The
pulmonary vasculature is normal. No pleural effusion or pneumothorax is seen.
IMPRESSION:
New focal consolidation within the right lower lobe is likely compatible with
right lower lobe pneumonia. Follow-up to complete resolution after course of
antibiotics is ___ weeks is recommended
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with fever, pain, lft abnormality. Evaluation for
stone, obstruction.
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 a small focal echogenic area of calcification in
the left hepatic lobe measuring 4 mm, possibly compatible with calcified
granuloma. There is an echogenic lesion within the right hepatic lobe
measuring 1.8 x 1.8 x 1.2 cm, likely compatible with hemangioma. The main
portal vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 5 mm
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 13.1 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.There is a
simple appearing cyst within the right midpole measuring 2.6 x 2.3 x 2.4 cm.
There is a simple appearing cyst within the left upper pole measuring 1.7 x
1.9 x 1.8 cm.
Right kidney: 12.2 cm
Left kidney: 11.9 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Status post cholecystectomy without evidence of biliary ductal dilatation.
2. Mild splenomegaly, measuring up to 13.1 cm.
3. Probable hemangioma in the right lobe of the liver.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Other pneumonia, unspecified organism, Abn lev hormones in specimens from female genital organs, Acute and subacute hepatic failure without coma, Nausea, Essential (primary) hypertension
temperature: 98.6
heartrate: 88.0
resprate: 18.0
o2sat: 98.0
sbp: 139.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old man with CAD s/p NSTEMI ___, DES
to LAD (c/b ICU stay with Impella, vaspopressors, and
intubation), HFrEF (EF 45% ___, HTN, DM2, who presented for
fever and vomiting for 2 days and found to have right lower lobe
consolidation on CXR concerning for community-acquired
pneumonia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Erythromycin Base / Amoxicillin / ciprofloxacin /
Crestor / Tamiflu / ragweed pollen
Attending: ___.
Chief Complaint:
nausea and chest pain.
Major Surgical or Invasive Procedure:
Cardiac catheterization (___)
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of UC s/p
colectomy, PSC c/b recurrent bacterial cholangitis, who
presented with 1 week of nausea and RLQ.
Patient reports she has been having nausea and abdominal pain
that has progressively gotten worse over the last week and 1
episode of chest pain leading to her presentation to the ED. She
reports progressive RLQ pain that is consistent with previous
episodes of cholangitis. She also reports 1 episode of chest
pain
that she describes as sharp, localized over the left chest
without radiation, not associated dyspnea or palpitation.
Reports
that the pain has resolved by the time she presented to the
emergency room. Denies PND, orthopnea, peripheral edema,
pre-syncope or syncope.
In the ED initial vitals were: 98.3 91 123/73 18 98% RA
Exam notable for abdomen diffusely tender with most prominent
tenderness over the right upper quadrant, positive ___
sign,
no peripheral edema.
Labs/studies notable for:
Labs remarkable for leukocytosis (WBC 14.5, normal electrolytes
and renal function, elevated AST of 54, elevated total bili of
1.8, elevated lipase 69, troponin T 0.23, CK-MB 8.2, lactate
2.7).
EKG showed normal sinus rhythm at 80 82 bpm, left axis
dimension,
LVH, T-wave inversion in leads V3 through V6 (left bundle branch
block as well as T-wave inversions are new compared to EKG from
___.
CT abdomen pelvis with contrast showed mildly distended
fluid-filled loops of small bowel distal collapse of the
terminal
ileum which may be compatible with early small bowel obstruction
or possibly due to distention from the oral contrast. The
appearance of round, arterially enhancing focus measuring 9 x 5
mm in the left lower lobe of the liver which is not seen on
previous studies.
Cardiology was consulted and recommended:
- ASA 81 mg daily, status post ASA 325 mg in the ED.
- Start heparin GTT
- Start metoprolol 6.25 mg every 6 hours
- Please obtain transthoracic echocardiogram
- Repeat EKG if the patient has recurrence of chest pain
- Serial cardiac enzymes until they peak and start to down
trend
- Surgery and hepatology consult for management of possible
SBO/intra-abdominal infection. Would recommend broad infectious
workup including right upper quadrant ultrasound to evaluate for
cholecystitis or cholangitis.
Patient was given: 4mg of ondansetron, 1L NS and aspirin 324mg
Vitals on transfer: 88 129/68 15 96% RA
On the floor, patient reports abdominal pain and nausea is much
improved currently. Reports she had a fever of 100 at home
during
the past week. States she took ciprofloxacin a few days ago
since
she has had her abdominal pain again. No current chest pain.
Past Medical History:
PAST MEDICAL HISTORY:
1. Ulcerative colitis.
2. Primary sclerosing cholangitis c/b recurrent cholangitis
3. COPD: not on home O2
4. PE/DVT diagnosed in ___
5. Glaucoma.
6. GERD.
7. Osteopenia.
PAST SURGICAL HISTORY:
1. Hysterectomy.
2. Cholecystectomy.
3. Hemicolectomy.
4. Cataracts.
5. Parotid tumor.
6. Small-bowel obstruction.
Social History:
___
Family History:
Mother with colon cancer diagnosed in her ___. Brother with
pancreatic ca at age ___. Brother with liver cancer at age ___.
Maternal uncle with colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
VITALS: 99.3 118/72 90 18 93% RA
GENERAL: well appearing in no acute distress
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: JVP not elevated
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: Resp were unlabored, no accessory muscle use. No
crackles,
wheezes or rhonchi.
ABDOMEN: Soft, nondistended. Tenderness on RLQ, +BS.
EXTREMITIES: No ___ edema
========================
DISCHARGE PHYSICAL EXAM
========================
Vitals: 98.6PO 105/66L Lying 100 16 90 Ra
GENERAL: Lying in bed, well appearing, in no acute distress
HEENT: PERRL, EOMI, dry moist mucous
NECK: JVP not elevated
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: CTAB, no w/r/r
ABDOMEN: Soft, nondistended. mildly tender to palpation in RLQ
and RUQ, +BS.
EXTREMITIES: No ___ edema
Pertinent Results:
================
ADMISSION LABS
================
___ 05:15PM CK-MB-8 cTropnT-0.20*
___ 02:11PM URINE HOURS-RANDOM
___ 02:11PM URINE UHOLD-HOLD
___ 02:11PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:11PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR*
___ 02:11PM URINE RBC-5* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0 TRANS EPI-<1
___ 02:11PM URINE MUCOUS-RARE*
___ 10:56AM ___ COMMENTS-GREEN TOP
___ 10:56AM LACTATE-2.7*
___ 10:44AM GLUCOSE-107* UREA N-15 CREAT-0.6 SODIUM-135
POTASSIUM-5.0 CHLORIDE-96 TOTAL CO2-21* ANION GAP-18
___ 10:44AM estGFR-Using this
___ 10:44AM ALT(SGPT)-37 AST(SGOT)-54* CK(CPK)-122 ALK
PHOS-84 TOT BILI-1.8*
___ 10:44AM LIPASE-69*
___ 10:44AM CK-MB-10 MB INDX-8.2* cTropnT-0.23*
___ 10:44AM ALBUMIN-4.2
___ 10:44AM WBC-14.5*# RBC-4.48 HGB-14.8 HCT-45.1*
MCV-101* MCH-33.0* MCHC-32.8 RDW-13.2 RDWSD-48.7*
___ 10:44AM NEUTS-79.2* LYMPHS-11.9* MONOS-8.1 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-11.49*# AbsLymp-1.73 AbsMono-1.17*
AbsEos-0.01* AbsBaso-0.02
___ 10:44AM PLT COUNT-200
================
PERTINENT IMAGES
================
___ CXR
IMPRESSION:
Medial right mid to lower lung opacities most likely due to
atelectasis and vascular structures, underlying pneumonia is
difficult to exclude.
Persistent mild prominence of the main pulmonary artery may
relate to
pulmonary arterial hypertension.
___ CT ABD & PELVIS WITH CO
IMPRESSION:
1. Mildly distended fluid-filled loops of small bowel with
distal collapse of the terminal ileum, which may be compatible
with early small bowel obstruction or possibly due to distension
from oral contrast.
2. 6 mm calcification located distally within the tail of the
pancreas, with distal ductal dilatation measuring approximately
3-4 mm. No evidence of peripancreatic fat stranding or fluid
collection.
3. New appearance of a round, arterially-enhancing focus
measuring 9 x 5 mm in the left lobe of the liver, which was not
seen on previous studies. For further characterization, a
multiphasic CT or MRI is recommended when
clinically appropriate.
4. Mild diffuse intrahepatic biliary ductal dilatation is
minimally improved from prior study.
___ Cardiovascular ECHO
IMPRESSION: Severe regional left ventricular systolic
dysfunction. Moderate regional right ventricular systolic
dysfunction. Mild mitral regurgitation. Moderate tricuspid
regurgitation. Moderate pulmonary hypertension.
These findings are most suggestive of biventricular takotsubo
cardiomyopathy, although a large LAD-territory myocardial
infarction cannot be excluded.
Compared with the prior study (images reviewed) of ___, LV
function has substantially deteriorated.
___ Imaging MRCP (MR ___
IMPRESSION:
1. No large hepatic lesions meeting OPTN 5 criteria for HCC.
Specifically, segment 2 enhancing lesion identified on prior CT
is not clearly depicted on the current MR examination however
study is slightly limited due to non breath hold sequencing.
2. Cholangitis within the hepatic dome.
3. Findings consistent with primary sclerosing cholangitis,
unchanged since ___. No mass forming cholangiocarcinoma.
4. Atelectasis/consolidation at the lung bases bilaterally.
5. Sequelae of chronic pancreatitis involving pancreatic tail
with 0.6 cm
intraductal stone.
___ Cardiovascular STRESS
IMPRESSION: No anginal type symptoms or significant ST segment
changes.
Nuclear report sent separately.
___ Imaging CARDIAC PERFUSION PHARM
IMPRESSION: 1. Moderate fixed defect in the distal anterior and
apical walls and in the inferior and inferolateral walls. There
is hypokinesis in the areas of the defects. 2. Mild left
ventricular cavity enlargement with an ejection fraction of 27%.
___ Cardiovascular Cath Physician ___
___: No angiographically apparent coronary artery
disease
================
DISCHARGE LABS
================
___ 06:22AM BLOOD WBC-6.5 RBC-3.67* Hgb-12.1 Hct-37.9
MCV-103* MCH-33.0* MCHC-31.9* RDW-14.0 RDWSD-53.1* Plt ___
___ 06:22AM BLOOD Plt ___
___ 06:22AM BLOOD Glucose-101* UreaN-8 Creat-0.6 Na-139
K-4.9 Cl-104 HCO3-26 AnGap-9*
___ 05:56AM BLOOD ALT-17 AST-30 LD(LDH)-194 AlkPhos-77
TotBili-0.5
___ 06:22AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DICYCLOMine 10 mg PO TID:PRN abdominal pain
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. Tiotropium Bromide 1 CAP IH DAILY
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
7. Lumigan (bimatoprost) .03% ___ DAILY
8. Omeprazole 10 mg PO DAILY
9. SulfaSALAzine_ 1000 mg PO DAILY
10. Colchicine 0.6 mg PO DAILY:PRN gout
11. Ciprofloxacin HCl 250 mg PO DAILY:PRN concern fo
rcholangitis
12. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN diarrhea
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
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. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*1
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth At bedtime Disp #*30
Tablet Refills:*1
4. Metoprolol Succinate XL 12.5 mg PO BID
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
Twice a day Disp #*30 Tablet Refills:*1
5. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth Twice a day
Disp #*5 Tablet Refills:*0
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
7. Colchicine 0.6 mg PO DAILY:PRN gout
8. DICYCLOMine 10 mg PO TID:PRN abdominal pain
9. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN diarrhea
10. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
11. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
12. Lumigan (bimatoprost) .03% ___ DAILY
13. Omeprazole 10 mg PO DAILY
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. ProAir HFA (albuterol sulfate) 90 mcg inhalation Q6H:PRN
SOB
16. SulfaSALAzine_ 1000 mg PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
- Bacterial cholangitis
- Stress cardiomyopathy
SECONDARY:
- Liver mass
- Primary sclerosing cholangitis
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 chest pain// ?pna
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
There is basilar and possible right middle lobe atelectasis. Opacity
projecting over the right hemidiaphragm thought represent atelectasis, appears
decreased/resolved compared the prior study. Prominence of the hila is
stable. Perihilar bronchial wall thickening is noted. There is prominence of
the main pulmonary artery which may be due to underlying pulmonary
hypertension. The cardiac silhouette is mildly enlarged. The aorta is
tortuous. No pulmonary edema or pleural effusion is seen. There is no
evidence of pneumothorax. Evidence of DISH is seen along the thoracic spine.
IMPRESSION:
Medial right mid to lower lung opacities most likely due to atelectasis and
vascular structures, underlying pneumonia is difficult to exclude.
Persistent mild prominence of the main pulmonary artery may relate to
pulmonary arterial hypertension.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast.
INDICATION: ___ female with h/o PSC, s/p cholecystectomy, UC s/p
partial colectomy, p/w RLQ abd pain + nausea. Evaluation for SBO,
diverticulitis, cholangitis, colitis, other intraabdominal pathology.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
2) Spiral Acquisition 6.9 s, 54.6 cm; CTDIvol = 20.8 mGy (Body) DLP =
1,132.4 mGy-cm.
Total DLP (Body) = 1,146 mGy-cm.
COMPARISON: Multiple prior studies, most recently CT abdomen and pelvis from
___.
FINDINGS:
LOWER CHEST: Stable appearance of linear atelectasis or scarring in the
bilateral lower lung lobes, with an adjacent thin-walled cyst or bulla noted
in the left lung base. An 8 mm nodule in the right middle lobe is unchanged
since ___. There is trace bilateral pleural effusions. There is no
evidence of pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is a round, arterially-enhancing focus measuring 9 x 5 mm in the left
lobe of the liver (02:21), which was not seen on previous studies. Mild
diffuse intrahepatic biliary ductal dilatation is minimally improved from
prior study. The gallbladder is surgically absent.
PANCREAS: The pancreas is atrophic. There is a 6 mm calcification located
distally within the tail of the pancreas (02:31), with distal ductal
dilatation measuring approximately 3-4 mm. There is no peripancreatic fat
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout. Tiny
hypodensities in the spleen are stable in appearance and too small to
characterize.
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 a stable 1.5 cm hypodensity in the upper pole of the left kidney,
consistent with simple renal cyst. There is no evidence of hydronephrosis.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. There are mildly distended
fluid-filled loops of small bowel with distal collapse of the terminal ileum,
which may be compatible with early small-bowel obstruction or possibly due to
distension from oral contrast. The patient is status post right colectomy.
Diverticulosis of the sigmoid colon is noted, without evidence of wall
thickening and fat stranding. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
RETROPERITONEUM: There is stable appearance of a 2.4 cm cystic lesion adjacent
to the left psoas muscle anteriorly (02:56).
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.
There is moderate multilevel degenerative change noted in the spine, including
anterior osteophytosis and endplate sclerosis with vacuum disc phenomenon.
SOFT TISSUES: Calcified granulomas are again noted in the subcutaneous tissues
over the gluteal regions. The abdominal and pelvic wall is otherwise within
normal limits.
IMPRESSION:
1. Mildly distended fluid-filled loops of small bowel with distal collapse of
the terminal ileum, which may be compatible with early small bowel obstruction
or possibly due to distension from oral contrast.
2. 6 mm calcification located distally within the tail of the pancreas, with
distal ductal dilatation measuring approximately 3-4 mm. No evidence of
peripancreatic fat stranding or fluid collection.
3. New appearance of a round, arterially-enhancing focus measuring 9 x 5 mm in
the left lobe of the liver, which was not seen on previous studies. For
further characterization, a multiphasic CT or MRI is recommended when
clinically appropriate.
4. Mild diffuse intrahepatic biliary ductal dilatation is minimally improved
from prior study.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman w/ hx of UC s/p colectomy, PSC c/b recurrent
bacterial cholangitis presents for 1 wk nausea and RLQ pain. Delayed ___
protocol to evaluation liver lesion; please also comment on bile ducts
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: CT abdomen with contrast ___
MRCP ___.
FINDINGS:
Limited evaluation due to respiratory motion.
Lower Thorax: Limited evaluation of the lung bases are notable for bibasilar
atelectasis with trace pleural effusions.
Liver: Mild T2 hyperintense signal is seen within the hepatic dome with
associated intraductal biliary duct dilatation. Assessment for hyper
enhancement is limited due to non breath hold sequencing, however given the
edema findings are most consistent with cholangitis. Liver is otherwise
homogeneous in signal intensity without suspicious mass. Specifically, the
previously noted segment 2 enhancing lesion identified on prior CT is not
clearly depicted on the current MR examination. No signal drop on out of
phase imaging to suggest hepatic steatosis. No ascites.
Biliary: Irregular appearance of the biliary tree with dilated common bile
duct and right posterior intrahepatic ducts keeping with history of primary
sclerosing cholangitis. The right posterior intrahepatic biliary ductal
dilatation demonstrates a transition point near the hepatic hilum which is
unchanged since ___.
Pancreas: Multiple T2 hyperintense tubular dilated cystic structures in the
pancreatic tail are sequelae of chronic pancreatitis given the 0.6 cm
intraductal pancreatic tail stone seen on ___ CT. No
peripancreatic fat stranding. No pancreatic duct dilatation.
Spleen: Spleen is normal in size without suspicious mass.
Adrenal Glands: Unremarkable.
Kidneys: 1.2 cm left upper pole renal cyst noted. Kidneys are otherwise
homogeneous in signal intensity without suspicious mass. No hydronephrosis
perinephric fat stranding.
Gastrointestinal Tract: Distal esophagus, stomach, visualized small and large
bowel are unremarkable. No obstruction.
Lymph Nodes: Retroperitoneal or mesenteric lymph nodes are nonenlarged.
Vasculature: Limited evaluation due to non breath hold sequence. No abdominal
aortic aneurysm. Celiac axis, SMA, and bilateral renal arteries are patent.
Hepatic anatomy is conventional. Hepatic veins, main portal vein, SMV, and
splenic vein are patent. Mild susceptibility artifact along the right portal
vein due to cholecystectomy clips.
Osseous and Soft Tissue Structures: 1 cm mildly T2 hyperintense lesion is seen
within T2 vertebral body, most consistent with a hemangioma, unchanged since
___. No suspicious osseous lesions. Soft tissues are unremarkable.
IMPRESSION:
1. No large hepatic lesions meeting OPTN 5 criteria for HCC. Specifically,
segment 2 enhancing lesion identified on prior CT is not clearly depicted on
the current MR examination however study is slightly limited due to non breath
hold sequencing.
2. Cholangitis within the hepatic dome.
3. Findings consistent with primary sclerosing cholangitis, unchanged since
___. No mass forming cholangiocarcinoma.
4. Atelectasis/consolidation at the lung bases bilaterally.
5. Sequelae of chronic pancreatitis involving pancreatic tail with 0.6 cm
intraductal stone.
RECOMMENDATION(S): Recommend short-term follow-up multiphasic CT for further
evaluation of segment 2 hepatic lesion given motion degradation.
NOTIFICATION: The findings were discussed with ___, ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:20 am, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new R PICC// R DL Power PICC 38cm ___
___ Contact name: ___: ___
TECHNIQUE: Chest, single AP portable view
COMPARISON: Chest x-ray from ___ and ___
FINDINGS:
A right subclavian PICC line is present. The distal tip is not well
delineated, but appears to lie near the cavoatrial junction. No pneumothorax
is detected.
Inspiratory volumes are low, considerably lower than on ___.
Cardiomediastinal silhouette is probably unchanged allowing for technique.
There is diffuse vascular plethora, and bronchial all thickening, consistent
with CHF and interstitial edema. There is increased retrocardiac density,
with new obscuration of the left hemidiaphragm, consistent with left lower
lobe collapse and/or consolidation, probably with a small left effusion.
There is atelectasis at the right base, with suspected partial collapse of the
right middle lobe.
IMPRESSION:
Right subclavian PICC line tip not optimally delineated, but likely at the
cavoatrial junction. No pneumothorax detected.
Low inspiratory volumes. Suspect interval development of CHF, though this
appearance can be accentuated by low lung volumes.
New left lower lobe collapse and/or consolidation, probably with a small
effusion.
Partial right middle lobe collapse, which appears to be a chronic finding. If
this has not been previously characterized, then chest CT could help for
further assessment.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction, Right lower quadrant pain
temperature: 98.3
heartrate: 91.0
resprate: 18.0
o2sat: 98.0
sbp: 123.0
dbp: 73.0
level of pain: 7
level of acuity: 3.0 | Ms. ___ is a ___ woman with a history of UC s/p
colectomy, PSC c/b recurrent bacterial cholangitis, who
presented with 1 week of nausea and abdominal pain and was found
to have recurrent bacterial cholangitis and stress
cardiomyopathy likely triggered by cholangitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ultram / Seroquel / ketorolac
Attending: ___.
Chief Complaint:
Diarrhea, hallucinations, alcoholism, failure to thrive, SI
Major Surgical or Invasive Procedure:
Paracentesis on ___
History of Present Illness:
Mrs ___ is a ___ with HCV, cirrhosis, alcoholism (1L vodka
daily, history of withdrawal), neuropathy, hiatal hernia
depression, prior suicide attempt, and recent admission for
alcohol withdrawal and C difficile diarrhea, who presented today
with multiple issues: diarrhea, weakness, alcohol intoxication,
SI, hallucinations.
She tells me that she has had a very difficult time this year,
with multiple family members/significant others/pets passing
away. She was here relatively recently for alcohol detox and
treatment of c difficile diarrhea. She endorses fairly prompt
relapse to 1L vodka daily along with incorrect use of oral
vancomycin (taking it only daily rather than QID). In this
context, she has had progressively worsening diarrhea with urge
fecal incontinence along with increasing fatigue and subjective
weakness, difficulty caring for herself. She noted onset of
hallucinations -- said a man who wasn't really there was
standing over her bed yesterday evening.
She was found by ___ today, who called EMS and had her brought
to ___ ED. In the ED, she had mild tachycardia but otherwise
stable vitals. Labs showed hypokalemia, hypomagnesemia, stable
anemia, and pyuria. She endorsed SI and psychiatry was
consulted, recommending medical admission, detox, treatment of c
diff, consideration of rehab placement. She was given CTX,
Valium, electrolytes, IVF, home medications. Admission was
requested.
She currently endorses a passive death wish, no clear SI at this
point. ROS is negative in 10 points except as noted.
Past Medical History:
MEDICAL HISTORY:
- Peripheral neuropathy
- Hepatitis C
- Hiatal hernia
- Hx of melena
- Hx of cervical cancer
- Anemia
- C diff
- Appendectomy
- Child A/B alcoholic and hepatitis C cirrhosis (complicated by
varices and ascites)
PSYCHIATRIC HISTORY:
Hospitalizations: Numerous past ED consults for similar
presentations (SI in setting of EtOH intoxication) ___,
___
Current treaters and treatment: No current therapist; PCP ___.
___ (___ prescribes Psych medications: Sertraline
100mg daily and trazodone 150mg daily.
Self-injury: Patient denied; collateral revealed recent suicide
attempt in ___ by overdosing on gabapentin, trazodone
and alcohol.
Harm to others: Denies
Social History:
Currently lives in apartment in ___. Son lives in ___ and sister lives in ___. Does not work at this time,
has SSI.She has 4 children and 4 grandchildren. She is currently
single. She previously went to ___ school and also worked as
a ___ which she was arrested for. She is Catholic but not
practicing. She has a history of rape as a teenager.
FORENSIC HISTORY:
Arrests: once for assault in ___ during bar fight, previous
note states she was arrested for prostitution
Convictions and jail terms: served 6 months for above incident
SUBSTANCE USE:
Illicits: denies currently, years ago had heroin IVDU; Remote
history of MJ abuse; found with a crack pipe on premises per
___
Alcohol: Chronic alcohol abuse since age ___. Drinks 1 pint vodka
per day.
Longest period of sobriety was ___ years ago for ___ years.
Family History:
Younger brother - ___ abuse, died of liver cancer.
Parents - alcohol abuse. Denies other family history of mental
illness or suicide attempts.
Physical Exam:
Vitals AVSS
Gen NAD, quite pleasant
Abd soft, NT, mildly distended, bs+
CV RRR, no MRG
Lungs CTA ___
Ext WWP, no edema
Skin no rash, anicteric
GU no foley
Eyes EOMI
HENT MMM, OP clear
Neuro nonfocal, moves all extremities, generalized weakness
noted
Psych flat affect
98.7 108 / 70 73 18 93 RA
Gen: Somewhat pale, NAD, alert
Lung: CTA B
CV: RRR
Abd: Distended, cannot appreciate liver edge, + fluid wave but
not taut
Ext: No edema
Psych: Oriented to person, date off by one, oriented to
___, his policies, oriented to year, details of this
hospitalization but cannot tell me about other hospitalizations
in detail "there have been so many"
Pertinent Results:
Labs on admission:
Heme
___ 12:59AM BLOOD WBC-6.9 RBC-3.55* Hgb-8.7* Hct-29.2*
MCV-82 MCH-24.5* MCHC-29.8* RDW-24.9* RDWSD-71.4* Plt Ct-75*
___ 12:59AM BLOOD Neuts-59.2 ___ Monos-3.4*
Eos-0.1* Baso-0.1 NRBC-0.6* Im ___ AbsNeut-4.06#
AbsLymp-2.49 AbsMono-0.23 AbsEos-0.01* AbsBaso-0.01
Chem
___ 12:59AM BLOOD Glucose-100 UreaN-7 Creat-0.6 Na-138
K-2.6* Cl-99 HCO3-23 AnGap-19
___ 07:15AM BLOOD Glucose-73 UreaN-6 Creat-0.4 Na-140 K-3.8
Cl-108 HCO3-22 AnGap-14
___ 12:59AM BLOOD Calcium-7.9* Phos-2.2* Mg-1.4*
___ 07:15AM BLOOD Calcium-7.6* Phos-1.9* Mg-2.0
___ 12:59AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS
___ 07:10AM BLOOD WBC-5.2 RBC-2.87* Hgb-7.3* Hct-24.5*
MCV-85 MCH-25.4* MCHC-29.8* RDW-25.4* RDWSD-77.8* Plt Ct-99*
___ 07:35AM BLOOD ___ PTT-37.9* ___
___ 07:25AM BLOOD Glucose-97 UreaN-5* Creat-0.4 Na-137
K-4.0 Cl-105 HCO3-23 AnGap-13
___ 07:35AM BLOOD TotBili-1.4
___ VItamin b12
Vitamin B12 ___ Ferritin 60
Imaging on admission:
KUB ___:
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are notable for degenerative changes
There are no unexplained soft tissue calcifications or
radiopaque foreign
bodies apart from surgical clips in the right upper quadrant and
rounded
radiodensities projecting over the stomach.
IMPRESSION:
Nonspecific, nonobstructive bowel gas pattern. No evidence of
free air.
___
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ year old woman with abd pain, distension, c.
diff// ?Colitis
TECHNIQUE: Multidetector CT images of the abdomen and pelvis
were acquired
without intravenous contrast. Non-contrast scan has several
limitations in
detecting vascular and parenchymal organ abnormalities,
including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
DOSE: Total DLP (Body) = 363 mGy-cm.
COMPARISON: CT abdomen and pelvis with contrast ___
FINDINGS:
LOWER CHEST: Large hiatal hernia exerts compressive effect with
atelectasis in the left lower lobe. Coronary artery
atherosclerotic calcifications noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation
throughout. The contours of the liver is nodular, consistent
with cirrhosis. 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 surgically absent. There is moderate volume
intra-abdominal
ascites.
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. Stranding and fluid about the
pancreas is
nonspecific in the setting of ascites.
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. 1.1 cm
hemorrhagic
cyst again noted projecting laterally from the midpole of the
left kidney.
There is no hydronephrosis. There is no nephrolithiasis. There
is no
perinephric abnormality.
GASTROINTESTINAL: Majority of the stomach in the patient's large
hiatal
hernia. No evidence for obstruction. Small bowel loops
demonstrate normal
caliber and wall thickness throughout. The colon and rectum are
within normal limits. The appendix measures 8 mm.
PELVIS: The urinary bladder and distal ureters are unremarkable.
Foley
catheter noted.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within
normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. 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. Moderate volume ascites, most likely secondary to portal
hypertension in
the setting of cirrhosis.
2. Limited non-contrast examination demonstrates no evidence for
colitis.
3. The appendix measures at the upper limits of normal, similar
to the prior
CT examination.
Liver US ___
FINDINGS:
Liver: The hepatic parenchyma is coarsened and nodular.. No
focal liver
lesions are identified. There is mild ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation.
The common
hepatic duct measures 3 mm.
Gallbladder: Patient is status post cholecystectomy.
Pancreas: The pancreas is obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and
measures 11.1 cm.
Kidneys: The right kidney measures 10.4 cm. The left kidney
measures 11.2
cm.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate
direction.
Main portal vein velocity is 29.1 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.
Splenic vein and superior mesenteric vein are patent, with
antegrade flow.
IMPRESSION:
1. Patent hepatic vasculature.
2. Coarsened and nodular liver echo texture, consistent with
cirrhosis.
3. Small ascites.
cxr:
IMPRESSION:
1. Possible developing right lower lobe pneumonia. Continued
follow-up is
recommended.
2. Unchanged large hiatal hernia.
___ 4:14 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
___ 11:59 am URINE Site: NOT SPECIFIED Source:
___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- 8 I
VANCOMYCIN------------ =>32 R
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Sertraline 100 mg PO DAILY
6. TraZODone 100 mg PO QHS
7. Vancomycin Oral Liquid ___ mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
c.diff diarrhea
alcoholism
PNA
Discharge Condition:
Mental Status: Clear and coherent but forgetful of prior details
of care
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with HCV, ETOH abuse, C.diff, now with abd
pain// eval for obstruction, free air
TECHNIQUE: Supine and left lateral decubitus abdominal radiographs were
obtained
COMPARISON: ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are notable for degenerative changes
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies apart from surgical clips in the right upper quadrant and rounded
radiodensities projecting over the stomach.
IMPRESSION:
Nonspecific, nonobstructive bowel gas pattern. No evidence of free air.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ year old woman with abd pain, distension, c. diff// ?Colitis
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 363 mGy-cm.
COMPARISON: CT abdomen and pelvis with contrast ___
FINDINGS:
LOWER CHEST: Large hiatal hernia exerts compressive effect with atelectasis in
the left lower lobe. Coronary artery atherosclerotic calcifications noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. The
contours of the liver is nodular, consistent with cirrhosis. 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 surgically absent. There is moderate volume intra-abdominal
ascites.
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. Stranding and fluid about the pancreas is
nonspecific in the setting of ascites.
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. 1.1 cm hemorrhagic
cyst again noted projecting laterally from the midpole of the left kidney.
There is no hydronephrosis. There is no nephrolithiasis. There is no
perinephric abnormality.
GASTROINTESTINAL: Majority of the stomach in the patient's large hiatal
hernia. No evidence for obstruction. Small bowel loops demonstrate normal
caliber and wall thickness throughout. The colon and rectum are within normal
limits. The appendix measures 8 mm.
PELVIS: The urinary bladder and distal ureters are unremarkable. Foley
catheter noted.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. 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. Moderate volume ascites, most likely secondary to portal hypertension in
the setting of cirrhosis.
2. Limited non-contrast examination demonstrates no evidence for colitis.
3. The appendix measures at the upper limits of normal, similar to the prior
CT examination.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: RUQ US w doppler
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Liver gallbladder ultrasound from ___.
FINDINGS:
Liver: The hepatic parenchyma is coarsened and nodular.. No focal liver
lesions are identified. There is mild ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 3 mm.
Gallbladder: Patient is status post cholecystectomy.
Pancreas: The pancreas is obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 11.1 cm.
Kidneys: The right kidney measures 10.4 cm. The left kidney measures 11.2
cm.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 29.1 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.
Splenic vein and superior mesenteric vein are patent, with antegrade flow.
IMPRESSION:
1. Patent hepatic vasculature.
2. Coarsened and nodular liver echo texture, consistent with cirrhosis.
3. Small ascites.
Radiology Report
EXAMINATION: Ultrasound-guided paracentesis
INDICATION: ___ year old woman with ascites// para
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: CT abdomen and pelvis from the day prior
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites. A suitable target in the deepest pocket in the left lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the left
lower quadrant and 2.5 L of clear, straw-colored fluid were removed. Fluid
samples were submitted to the laboratory for cell count, differential, and
culture.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Postprocedure sonographic images demonstrate no residual ascites.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 2.5 L of fluid were removed.
Radiology Report
INDICATION: ___ year old woman with fever and mild hypoxia// Assess for PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Compared to the prior radiograph, there is a new heterogeneous airspace
opacity involving the right lower lobe. The large hiatal hernia results in
compression of the lingula and left lower lobe, with resultant atelectasis,
but the left lung appears clear. Heart size and mediastinal contours are
otherwise normal.
IMPRESSION:
1. Possible developing right lower lobe pneumonia. Continued follow-up is
recommended.
2. Unchanged large hiatal hernia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Diarrhea, ETOH
Diagnosed with Urinary tract infection, site not specified
temperature: 97.8
heartrate: 106.0
resprate: 16.0
o2sat: 99.0
sbp: 105.0
dbp: 56.0
level of pain: 10
level of acuity: 3.0 | ___ with PMHx of HCV and etoh cirrhosis, neuropathy,
depression, prior SI, sp recent admission for EtOH withdrawal
and c.diff who presented ___ w diarrhea, weakness, alcohol
intoxication, SI, hallucinations.
# C.diff infection:
sp recent admission ___ and ___ for c. difficile
and etoh use/dcompensated cirrhosis. Pt presented w diarrhea and
abd pain; found to have c. diff PCR + in stool. Likely
recurrent/poorly treated in the setting of medication
non-adherence. Pt with poor social support structure and w
ongoing etoh use likely did not complete therapy. Pt rx with PO
vancomycin (d1 = ___ with plan for 2w therapy sp completion of
rx for UTI/PNA. COMPLETION DATE FOR ORAL VANCOMYCIN IS ___.
# UTI:
Pt received 3d CTX completed on ___. Pt with lower abd pain on
___. Re-started on CTX given +UA on ___, converted to PO
levoflox given concern for PNA. Plan for 7 day total course.
Initial UCX with klebsiella. however, repeat ucx ___ with VRE
which was suspected to be a contaminant given that UTI symptoms
had resolved by that time and did not recur.
#PNA/ fever on ___ with new cough and CXR infiltrate. Finished
five day course of levaquin and had no additional fevers or
cough. PCP should obtain ___ CXR to document resolution.
# Low UOP:
Likely in setting of diarrhea and poor po intake noted on
___ Albumin 50g on ___ with improvement in UOP. No further
problems with low urine output.
# ETOH intoxication
# h/o ETOH withdrawal
Pt had minimal signs of etoh withdrawal.
# Resolved hallucinations
# Depression with SI
Likely ___ ETOH use/withdrawal vs. ___ encephalopathy from acute
illness vs. psychiatric disorder. Denies currently. Psychiatry
opined that pt was safe without direct supervision. Social work
followed during admission. Psych did not think pt required inpt
psych upon discharge.
Once patient's encephalopathy cleared, she demonstrated
significant insight into her alcoholism, need to complete c diff
treatment and noted that she cannot return home under present
conditions. She demonstrated capacity to make medical decisions
at the time of her discharge. She could tell me clearly that if
she resumes alcohol use "I will die" and that if she fails to
complete C diff treatment she will also "die".
# HCV 1b
# ETOH cirrhosis:
# Coagulopathy:
# Thrombocytopenia:
MELD 17. Recent HCV VL 1.3million. sp therapeutic paracentesis
on ___ w 2.5L removed. No evidence of SBP. Tbili elevated
likely ___ decompensated cirrhosis vs. mild alk hep. MDF 45->33.
Steroids were deferred in setting of infection and poor
adherence. Her bilirubin normalized during her hospital stay.
Pt will need hepatology ___ upon discharge. She was given 3
doses of vitamin K but her INR remained at 1.6 on discharge,
consistent with coagulopathy from her liver disease. She has
hepatology ___ scheduled at which point they can discuss
initiation of lasix and aldactone. Also, she needs EGD to
assess for varices and consideration of initation of
propranolol. Hepatology ___ scheduled. She had a large volume
paracentesis (2.5 liters) on ___ with no rapid reaccumulation
of fluid - stable abdominal exam over past several days.
# Hiatal hernia:
Continued PPI
# Neuropathy:
Continued Neurontin
# Anemia: Hct 24.5 on discharge. Normocytic anemia. hct
24.5-31.5 range this hospitalization and prior one in ___
as well. No melena. Low Ferritin seen in ___ does argue
for some element of iron deficiency. Hepatology will need to
arrange for outpatient endoscopy. Vitamin B12 replete in ___.
Likely has multifactorial anemia - iron deficient and anemia of
chronic disease given her cirrhosis. Started on oral iron prior
to discharge.
# Housing: ___ investigated the details of her
housing in great depth.
Social Worker "called the patient's Elder ___ Services
worker
___, ___. Ms. ___ provided an
outline of the patient's home/housing situation. The patient
has
an open voucher for housing that ends on ___.
However,
Ms. ___ stated that this voucher will allow her to stay in
the
housing she currently has at ___ in the
___; the patient would like to live on the ___
and Ms. ___ has continued to help her to find housing on the
___ without success. Ms. ___ feels that her current
residence will keep her on there, in spite of the fact that the
patient has violations there (being half-dressed in the public
spaces and falling down)."
Patient's apartment is also reportedly covered in feces and has
a toilet that is not functioning. EPS is aware, and is working
on sending a HAZMAT crew for completion of the work. SW called
Ms ___ on ___ to confirm date of HAZMAT crew, but Ms ___
was not in the office on ___, and stated that she would return
on ___. Rehab should reach out to Ms ___ to confirm that
the HAZMAT crew has disinfected the home and that the toilet is
functional prior to the patient returning 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:
chest and abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ ___ speaking M w/ afib on
coumadin, dCHF, CKD, rectal CA s/p ___, colonic anastomotic
strictures s/p multiple endoscopic dilations (last in ___
and recent admission in ___ for small bowel obstruction
secondary to umbilical hernia, who presents with chest and abd
pain. Initial history limited by language barrier.
On exam patient was warm and dry. Fever reported. Home health
aide was with patient on scene. Pain mid upper abdomen started
last night. Similar pain as last admission, mid upper abdomen,
when he was admitted for SBO, but not as bad. No cough, fever,
chills, vomiting. Overall feeling unwell. Reports pain in
shoulders, ___ old arthritis pain. Pain in upper abdomen
relieved after using the bathroom. Having normal output from
ostomy. Last BM this morning. Takes lactulose. Daughter states
that he always has upper abdomen pain from multiple hernias.
In the ED, initial VS were 100.3 90 110/55 20 94%. Exam notable
for no abdominal pain after BM. Labs showed lactate 2.4, wbc
11.7, hct 36, cr 1.2, k 3.1, trop t <0.01, inr 2.5, ast/alt
77/67, tbili 0.5. EKG showed RBBB with LAD, CWP, QRS 152.
Imaging showed new larger area of consolidation involving the
right lung and smaller area of opacity at the left lung base
concerning for multifocal pneumonia on CXR. CT abd/pelvis showed
"No evidence of bowel obstruction. Bowel containing umbilical
and right lower quadrant peristomal hernias without evidence of
bowel obstruction. No free fluid." Received vanc, cefepime and
KCL 40meq. Transfer VS were 99.5 74 135/54 26 97% RA. Decision
was made to admit to medicine for further management.
On arrival to the floor, patient denies ongoing pain, and feels
hungry, requesting his home meds (eg lactulose, warfarin). He
denies SOB, cough, fever.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
1. CARDIAC RISK FACTORS: no Diabetes, +Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
CAD s/p MI in ___ in ___. Cardiac cath in ___ and ___
without obstructive CAD. Echo in ___ with mild symmetric LVH
with LVEF 60-65%. Exercise MIBI ___ with normal perfusion and
LVEF 66% with no wall motion abnormality, unchanged from ___.
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-H/o prostate cancer s/p XRT in ___, now on monthly Lupron
injections after his PSA was elevated from 0.6 in ___ to 26 in
___
-H/o rectal cancer s/p colostomy in ___, anastomotic strictures
s/p multiple dilations (___) and SBO (___)
-Multiple abdominal hernias
-Atypical chest pain with normal coronary arteries, normal pMIBI
stress in ___
-Mild mitral regurgitation
-Dilated thoracic aorta (moderate) thought ___ longstanding HTN,
normal EF on ___ TTE
-Seronegative rheumatoid arthritis
-GERD
-Colon polyps
-Anemia
-Pulmonary embolism ___ years ago
-Stasis dermatitis
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 99.3 76 114/84 20 97% RA
General: resting comfortably, NAD, son at the bedside
HEENT: nc, atraumatic, MMM
Neck: no LAD
CV: rrr, s1, s2, no mrg
Lungs: crackles in right middle lobe and left lower lung base,
expiratory wheezes bilaterally
Abdomen: nontender, nd, no guarding or rebound tenderness,
colostomy present, umbilical hernia present
GU: deferred, no foley
Ext: warm well perfused, no edema
Neuro: grossly normal
Skin: scattered seborrheic keratoses
DISCHARGE PHYSICAL EXAM:
VS - 98.7 98.6 64 131/56 18 99% RA
General: resting comfortably, NAD
HEENT: nc, atraumatic, MMM
Neck: no LAD
CV: rrr, s1, s2, no mrg
Lungs: crackles in right middle lobe, no wheezing
Abdomen: slight ttp periumbilically, without guarding or rebound
tenderness, colostomy present, umbilical hernia present
GU: deferred, no foley
Ext: warm well perfused, no edema
Neuro: grossly normal
Skin: scattered seborrheic keratoses
Pertinent Results:
LABS ON ADMISSION:
==================
___ 01:03PM BLOOD WBC-11.7*# RBC-3.97* Hgb-11.9* Hct-36.0*
MCV-91 MCH-30.0 MCHC-33.1 RDW-14.1 Plt ___
___ 01:03PM BLOOD ___ PTT-35.8 ___
___ 01:03PM BLOOD Glucose-103* UreaN-21* Creat-1.2 Na-135
K-3.1* Cl-94* HCO3-29 AnGap-15
___ 01:03PM BLOOD ALT-67* AST-77* AlkPhos-75 TotBili-0.5
___ 01:03PM BLOOD cTropnT-<0.01
___ 01:03PM BLOOD Albumin-3.6
___ 02:04PM BLOOD Lactate-2.4*
LABS ON DISCHARGE:
==================
___ 07:45AM BLOOD WBC-7.6 RBC-3.45* Hgb-10.5* Hct-31.4*
MCV-91 MCH-30.2 MCHC-33.2 RDW-14.0 Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-104* UreaN-17 Creat-1.0 Na-132*
K-4.6 Cl-96 HCO3-27 AnGap-14
___ 07:45AM BLOOD ALT-34 AST-26 AlkPhos-69 TotBili-0.5
___ 07:45AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.4* (repleted
prior to discharge)
MICRO:
======
Blood cultures with no growth to date.
IMAGING:
========
CTA chest: No evidence of central pulmonary embolism.
Evaluation of the segmental and subsegmental pulmonary arteries
is limited by respiratory motion. Opacity in the right upper
lobe most consistent with pneumonia.
CT abd: No evidence of bowel obstruction. Bowel containing
umbilical and right lower quadrant peristomal hernias without
evidence of bowel obstruction. No free fluid.
CXR: New large area of consolidation involving the right lung
and smaller area of opacity at the left lung base concerning for
multifocal pneumonia. Recommend followup to resolution.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Lactulose 60 mL PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QPM back pain
7. Lorazepam 0.5 mg PO Q4H:PRN anxiety or insomnia
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Tamsulosin 0.4 mg PO HS
12. Valsartan 80 mg PO BID
13. Warfarin 2 mg PO DAILY16
14. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
15. Nitroglycerin Patch 0.3 mg/hr TD Q24H
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Citalopram 10 mg PO DAILY
3. Lactulose 60 mL PO DAILY
4. Lidocaine 5% Patch 1 PTCH TD QPM back pain
5. Omeprazole 40 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Warfarin 2 mg PO DAILY16
8. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
9. Amlodipine 10 mg PO DAILY
10. Hydrochlorothiazide 25 mg PO DAILY
11. Lorazepam 0.5 mg PO Q4H:PRN anxiety or insomnia
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Nitroglycerin Patch 0.3 mg/hr TD Q24H
14. Tamsulosin 0.4 mg PO HS
15. Valsartan 80 mg PO BID
16. Levofloxacin 500 mg PO Q24H Duration: 3 Days
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth once a
day Disp #*3 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with chest pain // Eval for widened mediastinum or
infiltrate
TECHNIQUE: Chest Frontal and Lateral
COMPARISON: ___
FINDINGS:
Since the prior study, there has been development of large area of
consolidation involving the right upper and lower lobes. There is also patchy
lateral left base opacity. No large pleural effusions are seen. There is no
evidence of pneumothorax. The cardiac silhouette is top-normal to mildly
enlarged. The aorta is calcified.
IMPRESSION:
New large area of consolidation involving the right lung and smaller area of
opacity at the left lung base concerning for multifocal pneumonia. Recommend
followup to resolution.
Radiology Report
EXAMINATION: Contrast enhanced CT of the abdomen and pelvis
INDICATION: NO_PO contrast; History: ___ with abdominal pain, prior SBOs,
colostomyNO_PO contrast // Eval for SBO
TECHNIQUE: Contrast enhanced MDCT images of the abdomen and pelvis were
obtained following the administration of intravenous contrast. Reformatted
coronal and sagittal images were also obtained.
Total exam DLP: 580.12 mGY per cm.
COMPARISON: ___
FINDINGS:
Lung bases: There is mild bibasilar atelectasis. There is no pleural
effusion.
Abdomen: The liver, gallbladder, and spleen are unremarkable. The pancreatic
body and tail, particularly tail, remain atrophic. No pancreatic ductal
dilatation is seen. The adrenal glands are unremarkable. There are bilateral
renal cysts, measuring up to 6 cm on the right and 5.7 cm on the left. No
frank hydronephrosis is seen. The kidneys uptake and excrete contrast
symmetrically bilaterally. The stomach is relatively collapsed.
Atherosclerotic changes are seen along the aorta and bilateral iliac arteries.
There is an umbilical hernia containing nonobstructed loops of small bowel.
There is a fat containing ventral hernia more superiorly, measuring 7.9 cm in
transverse dimension, 2.4 cm craniocaudal, by 2.3 cm AP, present on the prior
study.
Pelvis: The appendix is seen in the right lower quadrant and is within normal
limits. Right lower quadrant stoma is seen with large peristomal hernia
containing nonobstructed bowel. The patient is status post resection of the
distal colon with the descending colon extending to the stoma in the right
lower quadrant. The bladder is unremarkable. The prostate gland contains
several coarse calcifications. There is a small fat containing right inguinal
hernia. Atherosclerotic changes are seen along the aorta and bilateral iliac
arteries. No pelvic free fluid, free air, or lymphadenopathy. No bowel
obstruction is seen.
Osseous structures: No concerning lytic or blastic lesions are seen.
Degenerative changes are seen along the spine.
IMPRESSION:
No evidence of bowel obstruction. Bowel containing umbilical and right lower
quadrant peristomal hernias without evidence of bowel obstruction. No free
fluid.
NOTIFICATION: No evidence of bowel obstruction. Bowel containing umbilical
and right lower quadrant peristomal hernias without evidence of bowel
obstruction. No free fluid.
Radiology Report
EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY
INDICATION: ___ year old man with new lung infiltrate // Assess for acute
pulmonary process; assess for infection vs PE vs other process
TECHNIQUE: MDCT axial images were acquired through the chest following
intravenous administration of 100cc of Omnipaque scanning in the early
arterial phase. Coronal, sagittal and oblique reformations were performed.
DOSE: DLP: 539 mGy-cm.
COMPARISON: CT torso dated ___
FINDINGS:
Although this study is not designed for assessment of intra-abdominal
structures, the visualized upper abdomen is unremarkable.
CHEST:
The thyroid is unremarkable and there is no supraclavicular lymph node
enlargement. The airways are patent to the subsegmental level. There is no
mediastinal, hilar or axillary lymph node enlargement by CT size criteria. The
heart, pericardium and great vessels are within normal limits. No hiatal
hernia is present.
Bronchiectasis in the right upper lobe is again seen with increased peripheral
consolidation. There is new opacification in the inferior posterior segment of
the right lower lobe. A trace right pleural effusion is present. There is
bibasilar atelectasis. Evaluation of the lung parenchyma somewhat limited by
respiratory motion.
CTA CHEST:
The aorta and main thoracic vessels are well opacified. The aorta demonstrates
normal caliber throughout thorax without intramural hematoma or dissection.
The pulmonary arteries are opacified to the segmental level. There is no
filling defect in the main, right, left, or lobar pulmonary arteries.
Evaluation of the segmental and subsegmental pulmonary arteries is limited by
respiratory motion.
OSSEOUS STRUCTURES: No lytic or sclerotic lesion concerning for malignancy is
present.
IMPRESSION:
1. No evidence of central pulmonary embolism. Evaluation of the segmental and
subsegmental pulmonary arteries is limited by respiratory motion.
2. Opacity in the right upper lobe most consistent with pneumonia.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, ATRIAL FIBRILLATION
temperature: 100.3
heartrate: 90.0
resprate: 20.0
o2sat: 94.0
sbp: 110.0
dbp: 55.0
level of pain: 13
level of acuity: 3.0 | HOSPITAL COURSE: Mr. ___ is a ___ yo ___ M w/ afib
on coumadin, ___, CKD, rectal CA s/p ___, colonic
anastomotic strictures s/p multiple endoscopic dilations (last
___ and recent admission in ___ for small bowel obstruction
secondary to umbilical hernia, who presents with chest and abd
pain, admitted for management of pneumonia, with R chest
consolidation on both chest x-ray and CT, and found to be
without fever, cough, SOB, or diminished o2 sat during this
hospitalization. He will completed a five-day course of
antibiotics with PO levofloxacin (to stop on ___. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Erythromycin
Base / Clindamycin / Zithromax / Keflex / Cipro Cystitis /
Plaquenil / Benadryl
Attending: ___.
Chief Complaint:
joint pain and "freezing"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMHX psoriatic arthritis, HLD, Migraines, IDDMT2 p/w right
sided joint pain that began last night at 22:00 and awoke her
from sleep. Pain is constant and ongoing and feels "like i got
hit by a 2x4". No trauma or inciting event. On ROS pt notes
Chills, sweats, fever, HA, nausea, 1x emesis, neck pain, right
sided joint pain and denies CP, SOB, PCP, ___, VC, abdominal
pain, recent travel, photophobia, confusion.
Pt actually went to ___ ED today ___, at 4.30am when she
felt severe pain and a "locking" sensation and couldn't move her
R joints. Pt reports having had a similar episode of "locking"
of her whole body when she stopped taking etanercept earlier
this year. She reports that this sensation resolved once she
started a prednisone taper (5mg daily x 1 wk, then 4mg x 1 wk
etc). She was evaluated and instructed to call her own
rheumatologist at ___ because ___ does not have a
rheumatologist on staff over this weekend. Pt's rheumatologist
instructed her to go to ___ ED.
In the ___ ED, initial vitals: 99.1 90 137/68 16 100%. The
patient was evaluated by rheumatology who recommended PO
steroids. They will continue to follow as an inpatient. She was
admitted for pain control and inability to ambulate; she
received dilaudid and toradol in the ED. Her CRP was elevated to
108.
Vitals prior to transfer: 100 138/70 18 99%
Currently, Pt's VS: 98.3, 104/48, 100, 16, 100% RA.
Pt denies any trauma, strain, or other injury. States that she
recently transitioned from etanercept to infliximab in ___ due
to excessive infections with the former. Reports that her pain
is much better controlled and that she was able to walk slowly
to the bathroom.
ROS: per HPI
Past Medical History:
Hypertension, essential
Hypercholesterolemia
OSTEOPENIA
MITRAL VALVE INSUFFIC
ABSCESS / CELLULITIS - FACE
Psoriatic arthritis
Vulvitis
DM (diabetes mellitus) type II controlled, neurological
manifestation
Diabetic sensorimotor neuropathy
Hypothyroidism
Morbid obesity
Social History:
___
Family History:
Her daughter has "SLE of the skin". No other family memebers
with autoimmune conditions, arthritis, IBD or psoriasis.
Physical Exam:
PHYSICAL EXAM:
98.3, 104/48, 100, 16, 100% RA.
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, ___ systolic murmur
LUNGS - CTAB auscultated anteriorly
ABDOMEN - obese, ABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
Admission labs:
___ 04:40PM BLOOD WBC-13.3* RBC-4.00* Hgb-11.7* Hct-33.0*
MCV-83 MCH-29.3 MCHC-35.5* RDW-15.2 Plt ___
___ 04:40PM BLOOD Neuts-79.4* Lymphs-15.5* Monos-4.1
Eos-0.5 Baso-0.6
___ 05:00AM BLOOD ___ PTT-32.1 ___
___ 10:39PM BLOOD ___
___ 04:40PM BLOOD Ret Aut-1.4
___ 04:40PM BLOOD Glucose-110* UreaN-19 Creat-1.2* Na-140
K-3.5 Cl-101 HCO3-26 AnGap-17
___ 04:40PM BLOOD ALT-55* AST-40 LD(LDH)-273* AlkPhos-98
TotBili-0.6
___ 04:40PM BLOOD Albumin-3.9 Calcium-9.2 Phos-1.7* Mg-1.8
UricAcd-7.1* Iron-16*
___ 04:40PM BLOOD calTIBC-376 Hapto-305* Ferritn-75 TRF-289
___ 04:57PM BLOOD Lactate-2.0
___ 04:40PM BLOOD CRP-108.6*
___ 05:00AM BLOOD CRP-237.8*
___ 05:00AM BLOOD ESR-67*
IMAGING:
___ RadiologyPELVIS (AP ONLY)
No fracture nor significant degenerative change identified.
___ RadiologyHIP UNILAT MIN 2 VIEWS
No fracture nor significant degenerative change identified.
___ RadiologyCHEST (PA & LAT)
Low lung volumes which limit the assessment of the lung bases.
Probable bibasilar atelectasis. Elevation of the right
hemidiaphragm.
___ RadiologySHOULDER ___ VIEWS NON
On the right, a small soft tissue calcification is seen at the
insertion site of the rotator cuff. There is a slight decrease
in the acromiohumeral space. The gleohumeral articulation on the
right is unremarkable. On the left, no pathological soft tissue
calcifications are visible. The glenohumeral joint is normal.
Bilaterally, there currently is no evidence of erosions or other
changes suggesting the presence of a chronic inflammatory
condition. There are no posttraumatic changes.
Micro:
___ CULTUREBlood Culture, Routine-PENDING
- no growth to date
___ 04:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Discharge labs:
___ 05:00AM BLOOD WBC-10.7 RBC-3.79* Hgb-10.5* Hct-32.0*
MCV-84 MCH-27.8 MCHC-32.9 RDW-15.4 Plt ___
___ 05:00AM BLOOD Glucose-193* UreaN-24* Creat-1.3* Na-140
K-3.6 Cl-104 HCO3-25 AnGap-15
___ 05:00AM BLOOD Calcium-8.7 Phos-2.4* Mg-1.9
___ 05:00AM BLOOD CRP-237.8*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. exenatide *NF* 10 mcg/0.04 mL Subcutaneous twice daily before
morning and evening meals
Pt has been using 5mcg
2. losartan-hydrochlorothiazide *NF* 100-25 mg Oral qam
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Halobetasol Propionate *NF* 0.05 % Topical M W F vulvitis
5. Glargine 78 Units Bedtime
6. Atorvastatin 40 mg PO DAILY
7. Infliximab Dose is Unknown IV Q6-8 WKS
8. Atenolol 75 mg PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO TID
10. Vitamin D 1000 UNIT PO DAILY
11. Ascorbic Acid ___ mg PO DAILY
12. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 75 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO TID
6. Glargine 78 Units Bedtime
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. exenatide *NF* 10 mcg/0.04 mL Subcutaneous twice daily before
morning and evening meals
Pt has been using 5mcg
10. Halobetasol Propionate *NF* 0.05 % Topical M W F vulvitis
11. Infliximab 300 mg IV Q6-8 WKS
12. losartan-hydrochlorothiazide *NF* 100-25 mg Oral qam
13. PredniSONE 40 mg PO DAILY
Tapered dose - DOWN
RX *prednisone 5 mg ___ tablet(s) by mouth daily as instructed
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
acute flare of psoriatic arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Fever.
TECHNIQUE: Upright AP and lateral views of the chest.
COMPARISON: None.
FINDINGS:
The heart size is mildly enlarged. The mediastinal contours are unremarkable.
There is crowding of the bronchovascular structures, likely the result of low
lung volumes. Additionally, patchy bibasilar airspace opacities likely
reflect atelectasis. Elevation of the right hemidiaphragm is noted. There is
no focal consolidation, pleural effusion or pneumothorax. No acute osseous
abnormalities identified.
IMPRESSION:
Low lung volumes which limit the assessment of the lung bases. Probable
bibasilar atelectasis. Elevation of the right hemidiaphragm.
Radiology Report
HISTORY: ___ female with pain. Question osteoarthritis or fracture.
COMPARISON: None.
FINDINGS:
AP view of the pelvis. AP and frogleg views of the right hip. Exam is
somewhat limited to overlying soft tissues. There is no visualized fracture.
No significant degenerative changes are noted. Pubic symphysis and SI joints
are grossly preserved. Right femoroacetabular joint is anatomically aligned.
Phleboliths seen within the pelvis.
IMPRESSION:
No fracture nor significant degenerative change identified.
Radiology Report
LEFT AND RIGHT SHOULDERS
INDICATION: Pain.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: On the right, a small soft tissue calcification is seen at the
insertion site of the rotator cuff. There is a slight decrease in the
acromiohumeral space. The gleohumeral articulation on the right is
unremarkable. On the left, no pathological soft tissue calcifications are
visible. The glenohumeral joint is normal. Bilaterally, there currently is
no evidence of erosions or other changes suggesting the presence of a chronic
inflammatory condition. There are no posttraumatic changes.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RIGHT SIDE BODY PAIN
Diagnosed with PSORIATIC ARTHROPATHY
temperature: 99.1
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 137.0
dbp: 68.0
level of pain: 4
level of acuity: 3.0 | ___ PMHX psoriatic arthritis, HLD, Migraines, IDDMT2 p/w right
sided severe joint pain and locking sensation.
#. joint pain and locking sensation: no history of trauma or
strain. Based on presentation, which seems very similar to her
prior episode when she stopped etanercept, Pt most likely has a
psoriatiac arthritis flare. Pt was examined by rheumatology, who
recommended oral steroids. Plain XRs have not shown any
significant degenerative changes in her legs, hips, or
shoulders. Presentation was unusual for inflammatory arthritis
since her symptoms appeared very rapidly (hours), she seemed to
improve markedly with just opiates for pain control (she was
able to walk to the bathroom by the time she arrived on the
medical floor), and she was nearly entirely back to baseline
function only 8 hours after receiving one dose of oral
prednisone 50mg. Pt was seen by her rheumatologist and inpatient
rheum consult team, who agreed that her presentation was odd,
but likely due to acute inflammation since her CRP was 109 on
admission and increased to 238 the following morning. She had a
mild leukocytosis to 11.4 on admission but no other evidence of
infection (no fever, no localizing symptoms, normal chest XR,
bland UA), and negative blood cultures to date. Pt was started
on oral prednisone, 50x1, then 40mg daily w/ daily 5mg
decreasing taper but plateau at 5mg with instructions to
follow-up w/ outpt rheumatologist. Pt did not require any pain
medications aside from acetaminophen x 1 on medical ward and did
not want pain meds on discharge.
# normocytic anemia: Hct 33, down from 36 on ___ and prior
baseline of 38 in ___, 41 in ___ and 42 in ___. Per atrius
records, baseline has been stable at ~ 35 for the last year.
Suspect some component of hemodilution, but concerning trend
over the years. Iron low at 16, ferritin normal at 75, MCV 84.
No evidence of hemolysis, haptoglobin 305. Retic count is low
for degree of anemia in this post menopausal woman. Labs
suggestive of anemia of chronic disease, but would recommend
continued outpatient workup.
# diabetes: home glargine 78U qhs and humalog sliding scale.
Holding home exenatide while inpatient.
# ARF: baseline Cr per atrius records ~0.9 to 1.0. Mildly
elevated over the last ___ wks at 1.2-1.3. Suspect dehydration.
Remained 1.3 after IV fluids.
# hypertension: currently normotensive. Held lisinopril and
hctz given normal pressures and mild ARF. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Non-fluent aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with history of type 1
diabetes mellitus on insulin, otherwise no significant past
medical history who presents after waking up this morning with
expressive aphasia. History provided by patient and parents via
collateral.
Mr. ___ was in his usual state of health until this morning.
Prior to that, he went out last night with a few friends to play
darts. He said he had two beers, otherwise denies any drug use,
denies marijuana, denies the possibility of an accidental
ingestion. His girlfriend was not with him at the time, but
reports that there was no mention of unusual behavior by his
friends. He returned home at 11:30PM and went to sleep in his
usual state of health.
The patient woke up this morning at 0530, and recalls checking
his glucose which was 76. He recalls reporting a generalized,
holocephalic headache. He then has minimal recollection of the
events that followed. His mother woke up when he did at ___,
and
notes that this was earlier than he usually wakes up. He walked
into the kitchen and started eating a donut, which was unusual
for him as he does not like donuts. She was concerned that he
was
hypoglycemic and gave him two glasses of orange juice to drink.
She checked his glucose after and it was 176. She tried to talk
to him and noted that he was minimally verbal. He answered "I
___ go back" to all questions asked. He seemed to attend to
her
but was either nonverbal or saying "I ___ go back" in response
to questions. Concerned, EMS was called and patient presented to
___ for further evaluation.
Parents note that he has never exhibited this behavior before.
His sugars generally run in the 100 to 200 range, as far as they
are aware. When he does run high or low, he complains of fatigue
and does not have issues with language or speech.
At ___, NIHSS was 5, scoring predominantly for
expressive aphasia (minimal verbal output, followed simple
commands only). He was out of the window for tPA given he woke
up
with symptoms. He was then transferred to ___ urgently, before
more thorough evaluation could be completed, for consideration
of
thrombectomy. At ___ was 2, scoring for moderate
aphasia
only. He underwent STAT CTA Head/Neck and CT perfusion which did
not reveal any large vessel occlusion, and CT perfusion also did
not reveal evidence of infarct.
His symptoms have overall gradually improved since this morning.
He is now able to string together several words at a time, which
he could not do before, and relate some history.
Prior to this morning, parents report the patient has been
stressed over the last week. He works allocating money for a
___, and it is the end of the fiscal year, where
he has had increased pressure and demands at work. In addition,
his diabetes was recently found to be poorly controlled at his
routine endocrinology checkup this summer (A1c 9.7). Otherwise,
family denies any recent changes to his health. Denies recent
illness including no recent fevers or chills. No medication
changes. They report he has never done drugs to their knowledge,
and his alcohol use is minimal.
Past Medical History:
Type 1 Diabetes Mellitus, on insulin, poorly controlled (A1c
9.7)
History of lyme disease remotely
Social History:
___
Family History:
Denies family history of early stroke or
premature CAD. No history of seizures in family.
Physical Exam:
Admission Physical Examination:
Vitals:
Tm 98.9F/ Tc 98.6F, HR 110s-130s (sinus tachycardia), BP
120s-140s/70s-80s, RR 14, O2 99% RA
General: Awake, alert, in no acute distress
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm, well perfused; regular on telemetry
Pulmonary: breathing non labored on room air
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert. Expressive aphasia; When
answering
questions, strings together up to ___ words in a sentence. Often
says "I think it was a lot of nervous...this morning" and
perseverates on this phrase throughout the interview. When asked
orientation questions, says "This morning, this morning."
Attentive to examiner, unable to complete attention tasks. Can
repeat very simple, brief phrases only (i.e. "Today is a sunny
day") but cannot repeat longer ("The cat always hid under the
couch") or more grammatically complex ("No ifs ands or buts")
phrases. Naming intact to all objects on stroke card except
"hammock". No paraphasias. No dysarthria. Normal prosody. No
apraxia; can pantomime brushing teeth, combing hair and using a
nail and hammer. He can read sentences on stroke card. He
struggles with writing. When asked to write "Today is a sunny
day", writes 'Today" and then is unable to proceed further. No
evidence of hemineglect. No left-right confusion. He is able to
follow one step midline and appendicular commands, but not more
complex commands. When asked about recent events in news,
perseverates on "this morning."
- Cranial Nerves: Mydriasis; pupils 6>4mm and briskly reactive.
VF full to finger wiggling. EOMI, no nystagmus. Funduscopic exam
reveals crisp disc margins bilaterally. V1-V3 without deficits
to
light touch bilaterally. No facial movement asymmetry. Hearing
intact to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Negative Romberg.
Discharge Physical Examination:
Vitals:
T 98.5F, HR 101, BP 116/73, RR 20, O2 97% RA
General: Awake, alert, in no acute distress
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm, well perfused; regular on telemetry
Pulmonary: breathing non labored on room air
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Alert and oriented to person, place, and date.
Attentive and able to name ___ backwards and correctly spell
"world" backwards. Registered ___ words and able to retrieve ___
after 5 min. Speech was fluent, but perhaps a little slower than
usual with mild word finding difficulty that manifested in
patient having to contemplate the occasional word choice.
Patient was able to talk in full, grammatically correct
sentences. Normal prosody and no paraphasic errors. Intact
repetition of "no ifs and or buts" and "Today is a sunny day in
___. Intact comprehension. He was able to name all objects
on the stroke card, but took a few seconds to find the word for
"hammock". In general, patient was able to relate the events of
the day, but seemed to have limited insight into what might have
caused it. He kept emphasizing that he was nervous this morning
and that he thought his state may have been due to his diabetes.
He remembered being unable to communicate clearly this AM and
endorsed feeling frustrated. Able to copy a rectangle but not to
draw a cube from memory (loss of 3D features). Able to put the
numbers on a clock face and draw the hands at ten past eleven.
When asked how a "ruler" and a "watch" are similar, he said
"they both have the same numbers"; asked to clarify, he said
"they both have numbers like 4, 6, and 12". When asked how a
train and a bicycle are similar, he said "they both go in the
same direction".
- Cranial Nerves: Mydriasis; pupils 6>4mm and briskly reactive.
VF full to finger wiggling. EOMI, no nystagmus. Funduscopic exam
reveals crisp disc margins bilaterally. V1-V3 without deficits
to
light touch bilaterally. No facial movement asymmetry. Hearing
intact to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Negative Romberg.
Pertinent Results:
___ 07:20AM BLOOD WBC-7.4 RBC-5.20 Hgb-14.8 Hct-45.8 MCV-88
MCH-28.5 MCHC-32.3 RDW-13.7 RDWSD-43.8 Plt ___
___ 10:24AM BLOOD WBC-12.0* RBC-5.18 Hgb-14.5 Hct-44.7
MCV-86 MCH-28.0 MCHC-32.4 RDW-13.4 RDWSD-42.3 Plt ___
___ 10:24AM BLOOD Neuts-85.4* Lymphs-9.3* Monos-4.5*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-10.10* AbsLymp-1.10*
AbsMono-0.53 AbsEos-0.01* AbsBaso-0.05
___ 07:20AM BLOOD Plt ___
___ 10:24AM BLOOD Plt ___
___ 10:24AM BLOOD ___ PTT-30.0 ___
___ 07:20AM BLOOD Glucose-67* UreaN-13 Creat-0.8 Na-141
K-4.8 Cl-102 HCO3-23 AnGap-16
___ 10:24AM BLOOD Creat-0.8
___ 10:24AM BLOOD Glucose-266* UreaN-10 Creat-1.0 Na-137
K-4.9 Cl-96 HCO3-22 AnGap-19*
___ 10:24AM BLOOD ALT-14 AST-22 AlkPhos-59 TotBili-0.3
___ 10:24AM BLOOD Lipase-15
___ 07:20AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.1
___ 10:24AM BLOOD Albumin-4.5 Calcium-10.2 Phos-3.4 Mg-1.9
___ 10:24AM BLOOD TSH-2.5
___ 10:24AM BLOOD Free T4-1.1
___ 10:29AM BLOOD Glucose-258* Na-135 K-4.5 Cl-97
calHCO3-25
IMAGES:
MRI Brain w/wo contrast ___:
IMPRESSION:
1. No intracranial abnormality.
2. Mild paranasal sinus disease, as above.
XR Chest ___:
IMPRESSION:
No acute cardiopulmonary process. No focal consolidation to
suggest
pneumonia.
CTA Head and Neck ___:
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage,
edema, or mass. The ventricles and sulci are normal in size and
configuration.
There is a mucous retention cyst and mild mucosal thickening in
the left
maxillary sinus. The visualized portion of the remaining
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are
unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches appear normal without stenosis, occlusion,
or aneurysm formation. The left PCA is diminutive in comparison
to the right, likely congenital. The left A1 segment is also
diminutive compared to the right, likely congenital. 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. No acute intracranial abnormalities identified.
2. Patent Circle of ___ without evidence of aneurysm or
stenosis.
3. No evidence of internal carotid artery stenosis by NASCET
criteria.
4. No asymmetric perfusion abnormalities identified.
Medications on Admission:
insulin regular human 100 unit/mL injection ___ID
insulin lispro 100 unit/mL subcutaneous PRN
Discharge Medications:
1. Humalog ___ 55 Units Breakfast
Humalog ___ 50 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. HumaLOG Mix ___ (insulin lispro protamin-lispro) 50
subcutaneous BID
Discharge Disposition:
Home
Discharge Diagnosis:
Transient aphasia
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 NECK WITH PERFUSION PQ149 CT HEADNECK
INDICATION: ___ with aphasia. Please evaluate for ischemic process.
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. Additional CT
perfusion maps were generated and reviewed. 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) Sequenced Acquisition 19.2 s, 8.0 cm; CTDIvol = 314.2 mGy (Head) DLP =
2,513.8 mGy-cm.
3) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 21.8 mGy (Head) DLP =
10.9 mGy-cm.
4) Spiral Acquisition 4.9 s, 38.9 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,240.1 mGy-cm.
Total DLP (Head) = 4,568 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
There is a mucous retention cyst and mild mucosal thickening in the left
maxillary sinus. The visualized portion of the remaining paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation. The left
PCA is diminutive in comparison to the right, likely congenital. The left A1
segment is also diminutive compared to the right, likely congenital. 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. No acute intracranial abnormalities identified.
2. Patent Circle of ___ without evidence of aneurysm or stenosis.
3. No evidence of internal carotid artery stenosis by NASCET criteria.
4. No asymmetric perfusion abnormalities identified.
Radiology Report
INDICATION: ___ man with altered mental status, aphasia, clinical
concern for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: None available.
FINDINGS:
The cardiomediastinal contours are within normal limits. The bilateral hila
are unremarkable. The lungs are clear without focal consolidation. There is
no evidence of pulmonary vascular congestion. There is no pneumothorax or
pleural effusion.
IMPRESSION:
No acute cardiopulmonary process. No focal consolidation to suggest
pneumonia.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with acute onset aphasia after a period of
unresponsiveness and hypoglycemia // eval for etiology of aphasia
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 7 mL 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 ___
FINDINGS:
There is no evidence of acute infarction. No intracranial hemorrhage. No
mass, mass effect, edema or midline shift. There are no subtle areas of FLAIR
or diffusion abnormality involving cortical or deep gray structures.
The ventricles and sulci are normal, without evidence of hydrocephalus. The
basal cisterns are patent. There is gross preservation of the principal
intracranial vascular flow voids.
Following the administration of intravenous contrast material, there is no
abnormal enhancement. The dural venous sinuses appear patent on MP-RAGE
imagine sequences.
Mucosal thickening is seen involving the left maxillary and left sphenoid
sinuses, in addition to scattered bilateral ethmoid air cells. A small mucous
retention cyst is noted in the left maxillary sinus. The remainder of the
visualized paranasal sinuses, middle ear cavities, and mastoid air cells are
well aerated and clear. The orbits are within normal limits bilaterally.
IMPRESSION:
1. No intracranial abnormality.
2. Mild paranasal sinus disease, as above.
Gender: M
Race: WHITE
Arrive by HELICOPTER
Chief complaint: Aphasia, Transfer
Diagnosed with Aphasia
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: pre-hosp
level of acuity: 1.0 | Mr. ___ is a ___ year old man with history of type 1 DM insulin
dependent who presents after waking up this morning with
expressive aphasia. Initial NIHSS at OSH 5, scoring
predominantly for expressive aphasia. Patient transferred here
for possible endovascular intervention. On imaging, NCHCT is
unremarkable, no vessel occlusion on CTA H/N. Not tPA candidate
given out of window. Not endovascular candidate given no vessel
occlusion noted. Admission exam notable for expressive aphasia
(but improved from OSH), able to string only ___ words together,
quite perseverative, can read but not write; can follow only
simple commands. General exam notable for pupillary dilation and
tachycardia. On discharge exam, his expressive aphasia has
resolved, his speech fluent with comprehension, repetition, and
naming intact.
# Expressive (non-fluent) aphasia
Presented with expressive aphasia and was evaluated for stroke.
___ stroke scale at admission was 2 (down from 5 at ___). tPA
was not administered because out of window (last well 11:30 ___
on ___. Overall low suspicion for stroke given improving
deficits, minimal stroke risk factors apart from diabetes. His
TSH, free T4 were WNL. Head MRI with and without contrast showed
no intracranial abnormality. CTA of head and neck with and
without contrast showed no acute intracranial abnormalities, a
patent Circle of ___ without evidence of aneurysm or
stenosis, no evidence of internal carotid artery stenosis by
NASCET criteria, and no asymmetric perfusion abnormalities.
Urine toxicology negative. Preliminary EEG report showed
left-sided slowing. Final EEG report pending.
# Type 1 diabetes
Mr. ___ T1DM is poorly controlled (A1c 9.7). Blood glucose on
admission was elevated at 266. We administered fixed dose
insulin (Humalog ___ 40 units BID at breakfast and at dinner)
and sliding scale insulin. He should follow up with his diabetes
care provider to discuss diet, exercise, and insulin regimen.
# Initial concern for pneumonia
Chest X-ray was done because of clinical concern for pneumonia.
CXR however shows no acute cardiopulmonary process and no focal
consolidation to suggest pneumonia. Patient was not tachypneic,
afebrile, therefore not treated.
# Transitional issues
Counseled to abstain from driving for 6 months because of
abnormal sensorium as per EEG. Patient instructed to follow up
with neurology to monitor seizure activity. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Subtherapeutic INR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male s/p Bentall for Type A dissection
___. He had an uneventful postoperative course and was
discharged on postoperative day six with an INR of 2.3. Coumadin
being managed by Dr. ___. His INR was checked today and found
to be 1.6. He was subsequently sent to ED and readmitted back to
the cardiac surgical service for intravenous Heparin.
Past Medical History:
History of Type A Aortic Dissection, s/p Repair
Hypertension
Hyperlipidemia
s/p cholecystectomy
s/p Achilles tendon repair
Social History:
___
Family History:
Father had a Type A dissection
Physical Exam:
Admission Exam:
Pulse: 78 Resp: 14 O2 sat: 99
BP Right: 156/80 Left: 157/82
General: WDWN in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA x[x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - crisp click
Abdomen: Soft [xx] non-distended x[] non-tender x[] bowel
sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
___ Right:2 Left:2
Radial Right:2 Left:2
Pertinent Results:
___ WBC-9.1 RBC-3.94* Hgb-11.3* Hct-34.6* RDW-14.0 Plt
___
___ WBC-10.4 RBC-3.60* Hgb-10.4* Hct-31.5* RDW-14.3 Plt
___
___ WBC-10.4 RBC-3.61* Hgb-10.3* Hct-32.7* RDW-13.8 Plt
___
___ ___ PTT-109.8* ___
___ ___ PTT-43.9* ___
___ ___ PTT-31.6 ___
___ ___ PTT-35.5 ___
___ ___ PTT-34.3 ___
___ UreaN-21* Creat-1.1 Na-140 K-4.6 Cl-102
___ Glucose-97 UreaN-13 Creat-1.1 Na-142 K-3.9 Cl-101
___ Glucose-149* UreaN-14 Creat-1.0 Na-138 K-3.9 Cl-101
HCO3-30
.
___ Chest x-ray:
There is an unchanged minor left retrocardiac opacity likely
representing atelectasis. There is mild pleural thickening
bilaterally. Mild cardiomegaly, but no pulmonary edema. Status
post aortic valve replacement. No evidence of pneumonia.
Medications on Admission:
Lisinopril 5mg daily, Coumadin 5mg daily, ASA 81 mg daily,
Percocet prn, Simvastatin 10mg daily, Lopressor 25mg TID,
Amiodarone 400mg BID
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days: then drop to one tablet(200mg) daily .
Disp:*60 Tablet(s)* Refills:*1*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
8. warfarin 2.5 mg Tablet Sig: Four (4) Tablet PO once a day:
Take as directed by Dr. ___. Daily dose may vary according to
INR. Goal INR 2.5 - 3.0.
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
- Subtherapeutic INR, s/p Bentall procedure with a ___
21-mm mechanical composite valve graft secondary to Type A
Aortic Dissection
- Hypertension
- Hyperlipidemia
- History of Postop Atrial Fibrillation, currently in sinus
rhythm
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions: Sternal - healing well, no erythema or drainage
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with fever.
TECHNIQUE: Frontal and lateral radiographs of the chest were obtained.
COMPARISON: Chest radiograph from ___ and CTA of the chest from
___.
FINDINGS: There is an unchanged minor left retrocardiac opacity likely
representing atelectasis. There is mild pleural thickening bilaterally. Mild
cardiomegaly, but no pulmonary edema. Status post mitral valve replacement.
IMPRESSION: Unchanged mild retrocardiac opacity likely representing
atelectasis. No evidence of pneumonia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER S/P DISSECTION AND AVR
Diagnosed with FEVER, UNSPECIFIED, ABNORMAL COAGULATION PROFILE, HEART VALVE REPLAC NEC, HYPERTENSION NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT
temperature: 100.3
heartrate: 68.0
resprate: 18.0
o2sat: 98.0
sbp: 157.0
dbp: 85.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ was admitted back to the cardiac surgical service
with subtherapeutic INR for his mechanical aortic valve. He was
subsequently started on intravenous Heparin. Warfarin was
increased to 10mg daily. Over several days his blood pressure
medications were optimized. He was maintained on intravenous
Heparin for several days until INR reached 2.3. Heparin was
subsequently stopped and he was discharged on hospital day four.
Prior to discharge, outpatient Warfarin management was arranged
with primary care physician ___. He will have an INR
checked on ___. His discharge Warfarin dose remained at 10
mg daily. His goal INR is between 2.5 to 3.0. At discharge, he
remained in a normal sinus rhythm. All surgical incisions were
clean, dry and intact. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Plasma-Lyte 148 / Mexiletine / Amiodarone
Attending: ___.
Chief Complaint:
Worsening confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ gentleman with PMH of CAD s/p CABG/PCI, AF
c/b LV thrombus (on coumadin), CHF (EF ___ s/p BiV ICD, PVD,
HTN, HLD, dementia/delerium presenting with worsening confusion.
Was seen in clinic today for routine visit, CT head was ordered
and was at baseline (global atrophic changes). After clinic,
went home and tried to leave the house to get to his real home,
doesn't recognize his wife as being who she is. Also recently
seen by Neurology who thought the patient suffers from Capgras
delusion who recommended repeat CT, EEG, carotid evaluation (pt
cannot get MRI/MRA given ICD), and workup for infection.
In the ED intial vitals were: T98.3 P76 BP140/75 RR16 O2 sat
99%. Labs were significant for Cr 1.3 (baseline 1.0-1.2),
Chloride 109, u/a was unremarkable. CXR and CT head were w/o
acute process. Patient was given nothing. He was admitted to
gerentology for monitoring and full evaluation for placement.
Unable to obtain quickly in the ED due to holidays. Vitals prior
to transfer were: T97.5 P61 BP155/80 RR16 O2 sat 96% RA.
On the floor, patient's son corroborates above story. Says that
Father's confusion all started ___ year ago, but since early this
month pt has not been recognizing his wife. Has been trying to
run out of the house to fin her. Thinks his wife who lives with
him is some random woman, not his real wife. Son says that his
father still recognizes him. They are not looking to place him
in a NH at this point, but rather want to find out if there is a
solution for this worsening confusion, such as a pill that would
keep him calm and allow him to stay at home. But he does admitt
that if his father continues to decline and become combative at
home, that he is too much for his mother to take of on her own.
Past Medical History:
- Coronary artery disease: CABG (___) (SVG Y graft to D1 and
OM1, SVG->RPDA, SVG->LAD), PCI (200) (DES to RCA), stress MIBI
(___) with fixed defects.
- ICD ___, upgrade to BiV in ___: For primary prevention of
sudden cardiac death
- Ventricular tachycardia: S/p ablation ___ and ICD placement
as above. Last episode: ___.
- Left ventricular thrombus: On chronic warfarin therapy
- Atrial fibrillation
- Cerebrovascular accident (___)
- Peripheral vascular disease: Multiple interventions, followed
by Dr. ___. Most recently in ___.
- Lightheadedness: Multiple admissions/ER visits without obvious
organic cause. No orthostasis, hypovolemia, malignant
arrhythmias on telemetry, vertigo, nor dysequilibrium when
ambulating.
- Hypertension
- Dyslipidemia
- Benign prostatic hyperplasia
Social History:
___
Family History:
- Mother: ___ from ___ age ___.
- Father: CVA at around age ___.
- Sister: some kind of dementia, but not as severe as patient's
(per son)
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- T97.7 P64 BP145/79 RR16 O2 sats 98%RA
General- alert, knows his name, but refuses to answer further
orientation questions. Thin male, sitting up in bed, appears
slightly anxious, but NAD
HEENT- OP clear, MMM, PERRLA
Neck- JVP flat, no LAD
Lungs- CTAB no wheezing, rales, rhonchi
CV- Irregularly, irregular, normal S1/S2 no M/R/G
Abdomen- Soft, NT/ND, +BS, no hepatomegaly or splenomegaly
GU- No foley
Ext- WWP, no clubbing or edema, pulses dopplerable
Neuro- CN II-XII intact, ___ strength ___, sensation grossly
normal
DISCHARGE PHYSICAL EXAM
Vitals- T 98.1 P 58 (58-68) BP 141/68 (63-141/58-68) RR 18 O2
sats 100%RA
General- Awake, alert. Knows ___ but unable to answer date
or more specific location.
HEENT- OP clear, MMM, PERRLA
Lungs- CTAB no wheezing, rales, rhonchi
CV- RRR normal S1/S2 no M/R/G
Abdomen- Soft, NT/ND, +BS, no hepatomegaly or splenomegaly
GU- No foley
Ext- WWP, no clubbing or edema
Pertinent Results:
ADMISSION LABS
___ 07:30PM BLOOD WBC-6.1 RBC-3.90* Hgb-12.5* Hct-38.0*
MCV-98 MCH-32.0 MCHC-32.8 RDW-16.6* Plt ___
___ 07:47PM BLOOD ___ PTT-42.9* ___
___ 07:30PM BLOOD Glucose-123* UreaN-26* Creat-1.3* Na-145
K-4.1 Cl-109* HCO3-24 AnGap-16
___ 06:30AM BLOOD ALT-20 AST-25 AlkPhos-72 TotBili-1.0
___ 06:30AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.1
___ 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS
___ 06:40AM BLOOD ___ PTT-41.4* ___
___ 06:35AM BLOOD Glucose-90 UreaN-20 Creat-0.9 Na-144
K-3.8 Cl-109* HCO3-25 AnGap-14
___ 06:30AM BLOOD ALT-20 AST-25 AlkPhos-72 TotBili-1.0
___ 06:30AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.1
MICRO
___ URINE CULTURE (Final ___: NO GROWTH
IMAGING
___ CT HEAD W/O CONTRAST: No acute intracranial abnormality
with unchanged appearance to encephalomalacia and volume loss
related to chronic left MCA infarct. Likely age-related global
atrophy.
___ CHEST (PA & LAT): Cardiomegaly. No acute
cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 100 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Lorazepam 0.25 mg PO HS:PRN sleep
7. Meclizine 12.5 mg PO BID:PRN dizziness
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL PRN chest pain
10. Omeprazole 20 mg PO DAILY
11. Pravastatin 40 mg PO DAILY
12. Tamsulosin 0.4 mg PO HS
13. Warfarin 5 mg PO 2X/WEEK (___)
14. Acetaminophen ___ mg PO Q8H:PRN pain
15. Aspirin 81 mg PO DAILY
16. Carbamide Peroxide 6.5% ___ DROP AD BID:PRN cerumen
impaction
17. Docusate Sodium 100 mg PO TID
18. Ferrous Sulfate 325 mg PO DAILY
19. Senna 1 TAB PO BID
20. Warfarin 2.5 mg PO 5X/WEEK (___)
21. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
22. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic BID
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic BID
4. Docusate Sodium 100 mg PO TID
5. Ferrous Sulfate 325 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
10. Lisinopril 5 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Pravastatin 40 mg PO DAILY
13. Senna 1 TAB PO BID
14. Tamsulosin 0.4 mg PO HS
15. Warfarin 5 mg PO 2X/WEEK (___)
16. Warfarin 2.5 mg PO 5X/WEEK (___)
17. Carbamide Peroxide 6.5% ___ DROP AD BID:PRN cerumen
impaction
18. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Altered mental status
Secondary Diagnosis
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Progressive dementia. Assess for ischemia.
TECHNIQUE: Contiguous axial images were obtained through the brain without
intravenous contrast. Multiplanar reformations were prepared.
COMPARISON: ___.
FINDINGS: There is no acute intracranial hemorrhage, edema, or mass effect.
There is no finding to specifically suggest acute or subacute vascular
territorial infarction. Encephalomalacia in the left MCA distribution is
unchanged in appearance with accompanying ex vacuo dilatation of the left
lateral ventricle and Wallerian degeneration along the ipsilateral
corticospinal tracts. Global ventricular and sulcal enlargement is stable and
compatible with age-related atrophy. Periventricular and subcortical white
matter hypodensities reflect chronic small vessel ischemic disease.
Hypodensities in the bilateral basal ganglia are compatible chronic lacunar
infarcts. Extensive calcification is seen of the bilateral cavernous carotid
arteries. Imaged paranasal sinuses and mastoid air cells are well aerated.
There is no fracture.
IMPRESSION: No acute intracranial abnormality with unchanged appearance to
encephalomalacia and volume loss related to chronic left MCA infarct. Likely
age-related global atrophy.
Radiology Report
EXAM: CHEST, FRONTAL AND LATERAL VIEWS.
CLINICAL INFORMATION: Confusion.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. Left-sided
AICD is stable in position. The cardiac silhouette remains mild to moderately
enlarged. The aorta and mediastinal contours are unremarkable. The patient
is status post median sternotomy and CABG. Subtle linear left basilar
opacities are improved since the prior study and likely represent chronic
changes. No new focal consolidation is seen. There is no pleural effusion or
pneumothorax. The lungs are relatively hyperinflated with flattening of the
diaphragms, suggesting chronic obstructive pulmonary disease.
IMPRESSION: Cardiomegaly. No acute cardiopulmonary process.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: CONFUSION
Diagnosed with SENILE DEMENTIA UNCOMP
temperature: 98.3
heartrate: 76.0
resprate: 16.0
o2sat: 99.0
sbp: 140.0
dbp: 75.0
level of pain: 0
level of acuity: 3.0 | ___ with history CAD s/p CABG/PCI, AF c/b LV thrombus (on
coumadin), PVD, HTN, HLD, dementia/delerium presenting with
worsening confusion.
# Confusion: Pt presented confused with stuttering speech and
inability to answer questions coherently with an interpretor. No
clear organic etiology to explain his worsening confusion,
though seems as though these symptoms have been more progressive
over the last year and last month. No source of infection was
found and his labs were unremarkable as well, making
toxic/metabolic derrangements the likely culprit. It was felt
that it could be secondary to his worsening baseline dementia,
especially if he has vascular dementia (given his PVD and CAD
s/p CABG) especially if he had another event, or could be from
medication effect. His medications were reviewed and medications
that could possibly be contributing were discontinued
(amiodarone, meclizine, and lorazepam). Pt was seen by neurology
recently as an outpatient who recommended EEG, CT head, and
infectious work-up. EEG was obtained and demonstrated mild
diffuse encephalopathy, implying widespread cerebral dysfunction
but is nonspecific as to etiology. No focal or epileptiform
features were seen. CT head showed no acute change and
infectious work-up was negative. ___ saw the pt and it was
felt that he would benefit from a stay in a dementia unit.
# Hypotension - On the night of ___, pt developed
hypotension to ___ systolic. He was asymptomatic and
improved with PO intake and 500cc IVF. Over nigth and the next
day, his blood pressures recovered and were in the 140s on
___ AM. Therefore, his anti-hypertensives (lisinopril,
lasix, imdur, metoprolol) were held and should be re-started as
indicated. Please assess blood pressure and start lisinopril if
BP can tolerate it (can start at 2.5mg, then titrate up to home
dose of 5mg if needed). Please assess fluid status and re-start
furosemide as clinically indicated for fluid overload.
Metoprolol and Imdur were also held, but can re-start Imdur if
blood pressures can tolerate (would start lisionpril as above,
first), and can lastly add metoprolol if needed.
# AF: CHADS-Vasc = 6 (yearly stroke rate 9.8%), complicated by
LV thrombus in the past. He was continued on warfarin and INR
was therapeutic throughout the hospitalization. His home
amiodarone was discontinued as above. He should have his INR
checked next on ___.
# CHF: On admission he was euvolemic with no signs of acute
exacerbation and remained this way throughout the
hospitalization. Because of the hypotension noted above, his
lisinopril, furosemide, toprol, and imdur were discontinued, but
should be re-started if blood pressures can tolerate it, as
above. Please assess fluid status and re-start furosemide as
clinically indicated for fluid overload.
# CAD: s/p CABG and PCI. He was continued on his aspirin, but as
above, his toprol, lisinopril, and imdur were discontinued.
# HTN: Was well-controled, but had hypotension as noted above,
and so his anti-hypertensives were held as above, and should be
re-started, as above. Please assess blood pressure and start
lisinopril if BP can tolerate it (can start at 2.5mg, then
titrate up to home dose of 5mg if needed). Please assess fluid
status and re-start furosemide as clinically indicated for fluid
overload. Metoprolol and Imdur were also held, but can re-start
Imdur if blood pressures can tolerate (would start lisionpril as
above, first), and can lastly add metoprolol if needed.
# BPH: Pt was continued on tamsulosin and finasteride
# HLD: Pt home Pravastatin
# Vertigo: Meclizine was discontinued.
TRANSITIONAL ISSUES
- Pt's mental status should be monitored while OFF amiodarone,
meclizine, and ativan - and be assessed for any improvement
- Please assess blood pressure and start lisinopril if BP can
tolerate it (can start at 2.5mg, then titrate up to home dose of
5mg if needed)
- Please assess fluid status and re-start furosemide as
clinically indicated for fluid overload
- Metoprolol and Imdur were also held, but can re-start Imdur if
blood pressures can tolerate (would start lisionpril as above,
first), and can lastly add metoprolol if needed
- Pt should not take any ___ herbal medications |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left ___ toe ulcer
Major Surgical or Invasive Procedure:
___: L ___ toe debridement
___: Left leg angiogram via right femoral access;
Angioplasty of the left tibial peroneal trunk and peroneal
artery.
___: L ___ toe debridement and wound closure
History of Present Illness:
___ w/DM and CKD presents from the ___ with
L foot infection. Pt presented to Dr. ___ podiatry at the
___ with ulcerations to his L ___ distal
toe and sub met 1 (both pre-existing). He was referred to BI for
erythema and swelling to the digit. Of note, he also has an
abscess on his back that just opened today. Denies n/v/c/f.
ROS:+ per HPI
Past Medical History:
1. Diabetes mellitus, type 2 adult onset with complications.
He
has retinopathy and neuropathy resulting.
2. Chronic kidney disease, stage III, due to microvascular
changes of hypertension and diabetes, presumably.
3. Coronary artery disease status post stent placements in
___.
4. Peripheral vascular disease status post angioplasty of his
left leg and chronic foot ulcers. The current one being on the
plantar aspect of his foot underneath the first metatarsal,
improving according to him.
5. Obesity with current weight of 330 pounds and what he
believes to be a goal weight of about 240 pounds.
6. Hypertension.
7. Chronic low back pain with treatment using narcotic pain
relievers.
8. Lower extremity edema.
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.4 82 128/85 18 100% ra
Gen - NAD
Lower extremity - ___ pulses nonpalpable, though both
dopplerable. Erythema and edema to L ___ toe with ulceration
distally that probes to bone. No prurulent drainage or malodor.
R
sub met 1 ulcer with serous drainage and no fluctuance or
prurulence.
DISCHARGE PHYSICAL EXAM:
VSS, afebrile
Gen - NAD
Cardio - RRR
Pulm - no respiratory distress
Abd - s, ___ - L ___ toe with sutures intact, minimal sanguinous drainage,
no erythema or prurulence
Pertinent Results:
ADMISSION LABS:
___ 07:53PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:53PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 07:53PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 07:53PM URINE MUCOUS-RARE
___ 04:13PM LACTATE-1.5
___ 04:00PM GLUCOSE-73 UREA N-76* CREAT-2.1* SODIUM-136
POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-24 ANION GAP-22*
___ 04:00PM WBC-13.2*# RBC-3.94* HGB-11.2* HCT-33.5*
MCV-85 MCH-28.5 MCHC-33.6 RDW-14.7
___ 04:00PM NEUTS-82.2* LYMPHS-9.9* MONOS-5.4 EOS-2.2
BASOS-0.3
___ 04:00PM PLT COUNT-307
___ 04:00PM ___ PTT-32.7 ___
DISCHARGE LABS:
___ 09:15AM BLOOD WBC-9.3 RBC-3.92* Hgb-11.1* Hct-33.9*
MCV-87 MCH-28.4 MCHC-32.9 RDW-15.3 Plt ___
___ 09:15AM BLOOD Glucose-242* UreaN-42* Creat-1.6* Na-135
K-4.3 Cl-100 HCO3-23 AnGap-16
___ 09:15AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.9
IMAGING:
L foot x-rays (___) -
Cortical irregularity and erosions involving the head of the ___
metatarsal and base of the ___ proximal phalanx as well as the
medial aspect of the head of the ___ metatarsal and base of the
___ proximal phalanx appear relatively unchanged. No new areas
of cortical destruction are demonstrated. No acute fracture or
dislocation is present. There is no subcutaneous gas. Moderate
size dorsal and small plantar calcaneal spurs are re-
demonstrated. There scattered vascular calcifications. Hallux
valgus/metatarsus varus deformity is re- demonstrated.
IMPRESSION:
No new areas of cortical destruction to suggest osteomyelitis.
Please note that MRI is more sensitive for the detection of
osteomyelitis.
L foot x-rays (___) -
Dressing overlies the distal digits making assessment
suboptimal. That hallux valgus and degenerative changes are
again seen. The region of the distal phalanx ectomy in the ___
digit is visualized but cannot be completely assessed due to the
overlying dressing.
Arterial duplex (___) -
Grayscale and Doppler images of the left superficial femoral,
common femoral, popliteal and posterior tibial arteries was
obtained. All arteries are patent. The left common femoral
artery has peak systolic velocities of 97.8 centimeters/second,
due to proximal left superficial femoral artery has peak
systolic velocities of 88.2 centimeters/second, the mid left
superficial femoral artery has peak so systolic velocities of
151 centimeters/second and the distal left superficial femoral
artery has peak systolic velocities of 157 centimeters/second.
The left popliteal artery has peak systolic velocities of 66
centimeters/second and the left posterior tibial artery has peak
systolic velocities of 104 centimeters/second.
IMPRESSION: Change in velocities at the level of the distal left
SFA stent and a monophasic waveform in the left popliteal artery
may suggest some stenosis in the distal stent.
NIAS (___) -
On the right side, triphasic Doppler waveforms are seen in the
femoral and popliteal arteries. Monophasic waveforms are seen
in the right posterior tibial, dorsalis pedis and digital
arteries.
On the left side, triphasic Doppler waveforms are seen in the
femoral,
popliteal and posterior tibialarteries. Monophasic waveforms
are seen in the dorsalis pedis and digital arteries.
The right ABI is 0.75 and the left ABI is 0.97. Pulse volume
recordings
demonstrate symmetric waves in both lower extremities.
There are new monophasic waveforms in the right posterior tibial
artery.
IMPRESSION:
Moderate posterior tibial artery disease on the right and
anterior tibial
artery disease bilaterally.
MICROBIOLOGY:
___ 4:57 pm SWAB Source: L ___ toe wound.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT in
this culture..
STAPH AUREUS COAG +. RARE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 8:15 am TISSUE
WOUND CULTURE,DEEP LEFT DISTAL PHALANYX 2 ND TOE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT in
this culture..
Work-up of organism(s) listed below discontinued
(excepted
screened organisms) due to the presence of mixed
bacterial flora
detected after further incubation.
ENTEROCOCCUS SP.. RARE GROWTH.
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___-___ ___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Glargine 50 Units Breakfast
Glargine 50 Units Bedtime
3. Clopidogrel 75 mg PO DAILY
4. alpha lipoic acid ___ mg oral bid
5. Atorvastatin 80 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Furosemide 40 mg PO DAILY
8. Gabapentin 800 mg PO QAM
9. Gabapentin 1600 mg PO HS
10. Lisinopril 40 mg PO DAILY
11. Metolazone 2.5 mg PO QD PRN increased leg swelling
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth
every twelve (12) hours Disp #*14 Tablet Refills:*0
2. alpha lipoic acid ___ mg oral bid
3. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6h Disp #*30 Tablet
Refills:*0
4. Aspirin 81 mg PO DAILY
5. Gabapentin 800 mg PO QAM
6. Lisinopril 40 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Metolazone 2.5 mg PO QD PRN increased leg swelling
9. Gabapentin 1600 mg PO HS
10. Furosemide 40 mg PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. Atorvastatin 80 mg PO DAILY
13. Glargine 65 Units Breakfast
Glargine 65 Units Bedtime
Humalog 40 Units Breakfast
Humalog 40 Units Lunch
Humalog 40 Units Dinner
Humalog 40 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left second toe infection, back wound
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY:
Left ___ digit wound probing to bone.
TECHNIQUE: Left foot, 3 views.
COMPARISON: Left foot radiographs ___.
FINDINGS:
Cortical irregularity and erosions involving the head of the ___ metatarsal
and base of the ___ proximal phalanx as well as the medial aspect of the head
of the ___ metatarsal and base of the ___ proximal phalanx appear relatively
unchanged. No new areas of cortical destruction are demonstrated. No acute
fracture or dislocation is present. There is no subcutaneous gas. Moderate
size dorsal and small plantar calcaneal spurs are re- demonstrated. There
scattered vascular calcifications. Hallux valgus/metatarsus varus deformity
is re- demonstrated.
IMPRESSION:
No new areas of cortical destruction to suggest osteomyelitis. Please note
that MRI is more sensitive for the detection of osteomyelitis.
Radiology Report
HISTORY: Left ___ digit infection status post distal phalanxxectomy.
___
FINDINGS:
dressing overlies the distal digits making assessment suboptimal. That hallux
valgus and degenerative changes are again seen. The region of the distal
phalanx ectomy in the ___ digit is visualized but cannot be completely
assessed due to the overlying dressing
Radiology Report
HISTORY: Left ___ toe ulceration at the distal aspect.
COMPARISON: ABI study from ___.
FINDINGS:
On the right side, triphasic Doppler waveforms are seen in the femoral and
popliteal arteries. Monophasic waveforms are seen in the right posterior
tibial, dorsalis pedis and digital arteries.
On the left side, triphasic Doppler waveforms are seen in the femoral,
popliteal and posterior tibialarteries. Monophasic waveforms are seen in the
dorsalis pedis and digital arteries.
The right ABI is 0.75 and the left ABI is 0.97. Pulse volume recordings
demonstrate symmetric waves in both lower extremities.
There are new monophasic waveforms in the right posterior tibial artery.
IMPRESSION:
Moderate posterior tibial artery disease on the right and anterior tibial
artery disease bilaterally.
Radiology Report
HISTORY: Please assess arteries of the left lower extremity given recent
ulcer. The patient is status post left superficial femoral artery stenting
and left balloon angioplasty.
COMPARISON: Lower extremity ultrasound study from ___.
FINDINGS:
Grayscale and Doppler images of the left superficial femoral, common femoral,
popliteal and posterior tibial arteries was obtained. All arteries are
patent. The left common femoral artery has peak systolic velocities of 97.8
centimeters/second, due to proximal left superficial femoral artery has peak
systolic velocities of 88.2 centimeters/second, the mid left superficial
femoral artery has peak so systolic velocities of 151 centimeters/second and
the distal left superficial femoral artery has peak systolic velocities of 157
centimeters/second. The left popliteal artery has peak systolic velocities of
66 centimeters/second and the left posterior tibial artery has peak systolic
velocities of 104 centimeters/second.
IMPRESSION: Change in velocities at the level of the distal left SFA stent and
a monophasic waveform in the left popliteal artery may suggest some stenosis
in the distal stent.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L FOOT INFECTION
Diagnosed with ULCER OF OTHER PART OF FOOT, SEBACEOUS CYST, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS
temperature: 99.4
heartrate: 82.0
resprate: 18.0
o2sat: 100.0
sbp: 128.0
dbp: 85.0
level of pain: 8
level of acuity: 3.0 | Pt was admitted to the podiatry service on ___ after being
transferred from the ___ with a L ___ toe
infection. Upon arrival to the floor, all home meds were resumed
and IV antibiotics were initiated. X-rays showed osteo to the L
___ toe distal phalanx. He was taken to the OR on ___ for a
distal phalangectomy and left packed open (please see op note
for details). Upon recovery in the PACU he was transferred back
to the floor and suffered no complications from the procedure.
On ___, vanc trough was 11.8 and no dose adjustments were
made. On ___, his K+ was slightly elevated at 5.3 and
kayexalate was given, normalizing it the following day. Pt
remained in house through the weekend in order to get NIAS,
which was not obtainable until ___ given the long holiday
weekend. Pt was scheduled for angio with vascular and went to
the OR for L PTA of ___ on ___ (see op note for details).
He went to the OR for ___ toe wound closure on ___ with
podiatry (see op note) and the following morning the surgical
site was in good condition. He was discharged home on oral
antibiotics and pain medication and will follow up with Dr.
___ in ___ days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Respiratory Distress, COPD exacerbation
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation ___ to ___
History of Present Illness:
Ms. ___ is a ___ with h/o COPD on 2L supplemental oxygen who
initially presented to ___ with progressive dyspnea x3
days, was found to be in hypercarbic respiratory failure,
transferred following intubation with mechanical ventilation for
further management. History is obtained from outside hospital
records as she is intubated on arrival. She reportedly called
EMS due to progressive shortness of breath in the 3 days
preceding admission. On EMS arrival, she was found to be
wheezing and in tripod position, speaking in ___ sentences.
EMS administered nebulizers, which she did not tolerate.
At ___, initial vital signs were: 99.7, 103, 90/62, 15,
100% on uncertain supplemental oxygen. Labs were notable for CBC
of 11.9/41.6/387, Na of 125, normal LFTs, BNP of 64, and TnI
<0.01. She received levofloxacin 750mg IV, methylprednisolone
125mg IV, and albuterol nebulizers. In the setting of tachypnea
to ___ and respiratory distress, she was placed on BiPAP soon
after arrival. She reportedly became lethargic to lorazepam 1mg
IV x1 for anxiety. When her respiratory status did not improve
with BiPAP, she was was intubated and sedated with propofol,
which caused hypotension to ___, which normalized to
130s/90s following IVNS bolus of uncertain quantity. She was
transferred to ___ for further care due to lack of ICU bed
availability.
In the ___ ED, initial vital signs were as follows: 92,
108/79, on uncertain ventilator settings. Admission labs were
notable for Na of 127, normal CBC, lactate of 1.1, and UA
without evidence of infection. ABG on arrival was ___
on uncertain ventilator settings. Blood Cx x2 were obtained. EKG
was reportedly negative for acute ischemic changes. CXR
revealed... She received fentanyl 2.5mg, propofol 1g, and
midazolam 100mg, as well as albuterol inhaler. Vital signs were
not available prior to transfer.
On arrival to the MICU, she is intubated and lightly sedated,
opening her eyes to voice. She nods 'yes' when asked if she is
breathing comfortably and 'no' when asked if she is in pain.
Past Medical History:
COPD
Hypertension
Hyperlipidemia
Anxiety
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
=====================
Vitals- T98.5 HR 88 BP 107/63 RR 18 93% on CMV FIO4 40%
GENERAL: intubated and sedated, but responds to commands
HEENT: Pupils small, ET tube in place
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, nontender/nondistended
EXT: trace pedal edema
DISCHARGE PHYSICAL EXAM:
=====================
VS - 97.6 146/69 80 18 97% on 2L
General: Pt breathing comfortably when speaking, AAOx3
HEENT: PERRL, EOMI, OP clear, MMM
Neck: JVP flat
CV: S1 S2 RRR no m/r/g
Lungs: Scattered expiratory wheezes with improved air movement.
Prolonged expiratory phase throughout all lung fields.
Abdomen: Soft, non-tender, non-distended, normoactive BS
GU: Foley in place
Ext: No edema, clubbing, cyanosis
Neuro: Non-focal
Skin: Chronic venous stasis changes ___ bilaterally
Pertinent Results:
ADMISSION LABS:
==============
___ 07:00AM BLOOD WBC-8.0 RBC-3.92* Hgb-12.5 Hct-37.5
MCV-96 MCH-32.0 MCHC-33.4 RDW-15.3 Plt ___
___ 07:00AM BLOOD Glucose-139* UreaN-7 Creat-0.4 Na-127*
K-4.8 Cl-92* HCO3-30 AnGap-10
___ 03:02PM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8
___ 11:30AM BLOOD Phenoba-8.9*
___ 07:44AM BLOOD Type-ART pO2-76* pCO2-64* pH-7.29*
calTCO2-32* Base XS-1
___ 07:44AM BLOOD Lactate-1.1
DISCHARGE LABS:
===============
___ 07:00AM BLOOD WBC-7.8 RBC-3.73* Hgb-12.1 Hct-36.3
MCV-97 MCH-32.4* MCHC-33.4 RDW-15.2 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-78 UreaN-11 Creat-0.4 Na-136
K-3.6 Cl-93* HCO3-35* AnGap-12
___ 07:00AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.9
MICRO:
========
___ 8:15 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ ___
10:40AM.
GRAM POSITIVE COCCI IN CLUSTERS.
___ 11:14 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
___ 5:06 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING:
==========
Chest X-Ray AP ___
Chest, single AP view, portable which excludes a large portion
of the left
hemidiaphragm. No previous chest x-rays on PACS record for
comparison.
An ET tube is present -- the tip lies approximately 5.1 cm above
the carina.
An NG tube is present -- the tip extends to the inferior edge of
the film,
though this plane lies above the GE junction.
Probable background hyperinflation/COPD. Moderate cardiomegaly,
with a
calcified aorta. Upper zone redistribution and probable mild
vascular
plethora, but no overt CHF. Bibasilar patchy opacities are not
fully
evaluated on this view. Minimal linear atelectasis or scarring
noted in both
mid zones. No gross effusion, though small effusions would be
excluded from
the film.
Chest X-Ray AP ___
An ET tube is present -- the tip lies approximately 3.1 cm above
the carina.
An NG or OG type tube is present. The tip extends beneath the
diaphragm and
overlies the gastric fundus. The side port lies at the very
upper medial edge
of the gastric fundus, likely just beyond the GE junction.
Background COPD, cardiomegaly, vascular plethora, and bibasilar
atelectasis
are similar to the earlier film. Focal opacity in the right
cardiophrenic
region could reflect some pleural fluid and/or parenchymal
opacity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 240 mg PO DAILY
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheeze
3. Atorvastatin 20 mg PO HS
4. Calcium 500 + D (calcium carbonate-vitamin D3) Dose is
Unknown mg oral BID
5. Magnesium Oxide 400 mg PO DAILY
6. Lorazepam 0.5 mg PO DAILY:PRN anxiety
7. Metoprolol Tartrate 25 mg PO BID
8. Potassium Chloride 20 mEq PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Discharge Medications:
1. Supplemental O2
Patient will require 3L supplemental O2 to be worn at all times,
as SaO2 decreased to <88% with ambulation on RA.
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheeze
3. Atorvastatin 20 mg PO HS
4. Diltiazem Extended-Release 240 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Calcium 500 + D (calcium carbonate-vitamin D3) 0 mg ORAL BID
7. Lorazepam 0.5 mg PO DAILY:PRN anxiety
8. Magnesium Oxide 400 mg PO DAILY
9. Potassium Chloride 20 mEq PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose 1
INH PO twice a day Disp #*1 Disk Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
# Hypercarbic respiratory failure
# Chronic obstructive pulmonary disease exacerbation
# Hypovolemic hyponatremia
SECONDARY DIAGNOSES:
# Hypertension
# Hyperlipidemia
# History of alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Intubated, check tube placement.
Chest, single AP view, portable which excludes a large portion of the left
hemidiaphragm. No previous chest x-rays on PACS record for comparison.
An ET tube is present -- the tip lies approximately 5.1 cm above the carina.
An NG tube is present -- the tip extends to the inferior edge of the film,
though this plane lies above the GE junction.
Probable background hyperinflation/COPD. Moderate cardiomegaly, with a
calcified aorta. Upper zone redistribution and probable mild vascular
plethora, but no overt CHF. Bibasilar patchy opacities are not fully
evaluated on this view. Minimal linear atelectasis or scarring noted in both
mid zones. No gross effusion, though small effusions would be excluded from
the film.
Radiology Report
HISTORY: Intubated with OG tube, assess tube position.
CHEST, SINGLE AP VIEW.
COMPARISON: Chest x-ray from ___ at 6:53 a.m.
An ET tube is present -- the tip lies approximately 3.1 cm above the carina.
An NG or OG type tube is present. The tip extends beneath the diaphragm and
overlies the gastric fundus. The side port lies at the very upper medial edge
of the gastric fundus, likely just beyond the GE junction.
Background COPD, cardiomegaly, vascular plethora, and bibasilar atelectasis
are similar to the earlier film. Focal opacity in the right cardiophrenic
region could reflect some pleural fluid and/or parenchymal opacity.
Gender: F
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: SOB
Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Ms. ___ is a ___ with h/o COPD on 2L supplemental oxygen who
initially presented to ___ with progressive dyspnea x3
days, was found to be in hypercarbic respiratory failure
secondary to COPD exacerbation, transferred to ___ following
intubation with mechanical ventilation for further management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Mental status change
Major Surgical or Invasive Procedure:
___: Left burr hole evacuation of a chronic subdural
hematoma
History of Present Illness:
This is a ___ year old female well known to this service who
presents today from ___ after a fall in
the bathroom. She denies hitting her head. Following the fall
she was reported to have slurred speech and was slightly
confused. The patient had a Head Ct which revealed stable left
sided subdural hematoma and was transferred here for further
evaluation and treatment. The patient has a new skin tear on
her
anterior shin from the fall. The family is at the patient's
bedside and reports that the patient is now back at her baseline
mental status.
The patient denies, weakness, numbness, tingling sensation,
hearing or vision disturbance, bowel or bladder dysfunction.
Past Medical History:
PMH: frequent falls, dementia w/ dysarthria/broca's aphasia,
lyme
disease, L hand contracture, hypothyroid
PSH: C3 laminectomy, C5 and C6 fusion/laminectomy from fall and
MVC
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAM (on Admission)
O: T: 97.6 BP: 173/85 HR:71 R:18 O2Sats96% 2 liters
Gen: comfortable
HEENT: Pupils: ___ EOMs:intact
Neck: Supple.
Extrem: Warm and well-perfused.new large skin tear on left
anterior shin
Neuro:
Mental status: Awake and alert, cooperative and pleasant but
does
not follow all aspects of the exam,slightly vague affect
Orientation: Oriented to person only
Recall: unable to perform
Language: Speech fluent
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength patient is antigravity and appears, very
pleasant but does not fully participate in motor exam. No
pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: patient does not participate
Upon discharge:
PERRL, Moves all extremities spontaneously, confused
Pertinent Results:
Blood
___ 03:05AM BLOOD WBC-4.7 RBC-4.20 Hgb-12.9 Hct-38.6 MCV-92
MCH-30.7 MCHC-33.4 RDW-13.4 Plt ___
___ 03:05AM BLOOD Glucose-124* UreaN-11 Creat-0.7 Na-139
K-3.6 Cl-107 HCO3-25 AnGap-11
___ 03:05AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1
Urine
___ 12:30AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 12:30AM URINE RBC-2 WBC-115* Bacteri-NONE Yeast-NONE
Epi-4
Imaging studies:
CXR ___
FINDINGS: There is an irregularity along the base of the fifth
metacarpal,
suspected to represent a tug lesion associated with enthesopathy
rather than trauma. There is also a bridging osteophyte at the
joint between the medial cuneiform and first metatarsal. A tug
lesion is also noted along the lateral malleolus. Spurring is
likewise noted along the superior margin of the patella. The
bones appear demineralized.
IMPRESSION: Bony demineralization. No evidence of fracture.
Head CT ___
IMPRESSION:
1. Decrease in size of left subdural hematoma with slight
decrease in
rightward shift of the normal midline structures.
2. Expected postoperative pneumocephalus.
3. No evidence of new hemorrhage.
Head CT ___
IMPRESSION: Interval craniotomy with partial evacuation of
subdural
collection, now significantly decreased in size with improved
mass effect and
shift of midline structures.
Medications on Admission:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. memantine 10 mg Tablet Sig: One (1) Tablet PO daily ().
6. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
7. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
8. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Continue as previously prescribed.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. memantine 10 mg Tablet Sig: One (1) Tablet PO QD ().
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. levothyroxine 88 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO four times
a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left chronic subdural hematoma with compression
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
PREOP AP AND LATERAL CHEST, ___
HISTORY: Preop for a burr hole removal.
IMPRESSION: AP and lateral chest compared to ___:
Lungs are low in volume but clear. Heart is moderately enlarged, but
pulmonary vasculature is not engorged and there is no edema or pleural
effusion. Thoracic aorta is mildly enlarged throughout, but not focally
aneurysmal.
Radiology Report
INDICATION: History of left subdural hematoma, status post burr hole.
Evaluate for interval change.
COMPARISONS: CT head, ___. CT head, ___. CT
head, ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast.
FINDINGS: Since the previous study, a new left parietal burr hole is noted.
The mixed attenuation extra-axial collection in the left frontal and parietal
convexity has decreased in size with a maximum transverse dimension of 8 mm as
compared to 10.6 mm in the prior exam predominantly due to decrease in the
clear fluid component. The small regions of high attenuation in the parietal
convexity are unchanged and likely reflect the mild hemorrhagic component of
the subdural hematoma. A hyperdense focus along the left side of tentorium (
se 3, im 9) is less dense in comparison to the prior study, suggesting there
has been a decrease in the size of this component of the subdural hematoma. A
collection of extra-axial pneumocephalus is present, which is an expected
postoperative finding. It measures 4.7 x 2.1 cm (3, 21). There is mild mass
effect on the adjacent sulci. A second smaller pocket of air is present
posteriorly (3, 18). Overall, there has been a slight decrease in the mild
rightward shift of the normal midline structures since placement of the burr
hole.
Prominence of the sulci and ventricles suggests age-related volume loss and is
unchanged from prior exams. There is no evidence of new hemorrhage, edema, or
mass effect. The basal cisterns are patent.
The visualized paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. Cutaneous clips are seen in the soft tissues adjacent to the left
parietal burr hole.
IMPRESSION:
1. Decrease in size of left subdural hematoma with slight decrease in
rightward shift of the normal midline structures; persistent mild displacement
of the left cerebral hemisphere.
2. Expected postoperative pneumocephalus.
3. No evidence of new hemorrhage.
Radiology Report
INDICATION: Left-sided subdural hematoma status post burr hole evacuation.
TECHNIQUE: Multidetector CT scan of the head was obtained without the
administration of contrast. Coronal and sagittal reformations were prepared.
COMPARISON: Multiple prior examinations, most recent dated ___.
FINDINGS: There has been an interval left-sided craniotomy at the vertex with
partial evacuation of previously seen subdural collection. There remains both
some hypodense and hyperdense fluid as well as post-procedure pneumocephalus.
At the level of the foramen of ___, the maximal thickness of the collection
is now 7 mm, previously 11 mm on a similar image. The degree of midline shift
is also decreased, currently measuring 3 mm to the right, previously 5 mm.
Mass effect on the occipital horn of the left lateral ventricle is also
slightly improved. No new concerning hemorrhage is seen. Hyperdensity along
the burr hole track likely represents expected procedure-related hemorrhage.
There is a moderate degree of age-related global atrophy. Areas of
periventricular and subcortical white matter hypodensity likely reflect
sequelae of chronic small vessel ischemic disease. No concerning osseous
lesion is seen. The visualized paranasal sinuses and mastoid air cells are
grossly clear.
IMPRESSION: Interval craniotomy with partial evacuation of subdural
collection, now significantly decreased in size with improved mass effect and
shift of midline structures.
Radiology Report
RADIOGRAPHS OF THE LEFT TIBIA AND FIBULA
HISTORY: Trauma.
COMPARISONS: None.
TECHNIQUE: Left tibia and fibula, four views.
FINDINGS: There is an irregularity along the base of the fifth metacarpal,
suspected to represent a tug lesion associated with enthesopathy rather than
trauma. There is also a bridging osteophyte at the joint between the medial
cuneiform and first metatarsal. A tug lesion is also noted along the lateral
malleolus. Spurring is likewise noted along the superior margin of the
patella. The bones appear demineralized.
IMPRESSION: Bony demineralization. No evidence of fracture.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SDH
Diagnosed with TRAUMATIC SUBDURAL HEM, OPEN WND KNEE/LEG/ANKLE, UNSPECIFIED FALL, HYPERTENSION NOS, HYPOTHYROIDISM NOS, ALZHEIMER'S DISEASE
temperature: 97.6
heartrate: 71.0
resprate: 18.0
o2sat: 96.0
sbp: 173.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | ___ year old female with recent admission/discharge for ___
(without intervention at that time) who presented on ___ from
___ after a fall in the bathroom and
question seizure activity. Head CT was stable in comparison to
the Head CT from ___.
#Neuro:
- started Keppra 500mg BID for question seizure. She was made
NPO on ___ and underwent burr hole for subdural hematoma
evacuation on ___. Post-op exam remained stable. Repeat head
CT on day of discharge on ___ was stable with some expected
pneumocephalus, but decreased midline shift.
# ID:
- U/A showing increased WBC, patient placed on Cipro. Culture
showed alpha streptococcus or Lactobacillus sp. She should
continue on this medicaition for 7 days.
# Cardiac:
- patient is being discharged on home doses of Digoxin and
Diltiazem.
# Nutrition:
- Patient takes an adequate oral diet with assistance.
# s/p Fall:
- tib/fib xray not showing Fx.
Patient is being discharged with instructions to follow up with
us in two weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Midline placement
History of Present Illness:
The pt is a ___ yo F with RRMS (pt of Dr. ___ who presents
with chronic progressive fatigue, weakness and possible UTI.
Pt was last seen in clinic with Dr. ___ week. At that
time she was noted to have had a worsening of her MS symptoms,
specifically her weakness in the R lower extremity. She had
missed two Tysabri doses over the preceding months because of
hospitalization including an admission with UTI/pyelonephritis
and a fifth metarsal fracture in the right foot. Dr. ___ debated treating these symptoms with a course high
dose steroids but opted to give her the scheduled Tysabri
infusion.
Since her appointment last week, the patient has noticed
progression of all her symptoms including fatigue, gait,
weakness, (generalized as well as more specifically in the RLE
and RUE as well). She is unable to walk unassisted at this point
given the weakness and an overall sense of imbalance.
She has a chronic headache which is nothing new. She has nausea
though and is unable to tolerate being in the car because of the
back and forth movement.
Of note, she has recently completed two Abx courses for
recurrent UTI/pyelonephritis and has felt the recurrence of
frequency and
burning and believes she might have a repeat UTI.
She notes that tysabri infusions have always been well tolerated
in the past and that she would typically get a "boost" in her
energy. However this time she did not experience any beneficial
effects.
Past Medical History:
- MS, dx ___
- GERD
- Lumbar disc disease L3-5
Social History:
___
Family History:
NC, no CVA, Sz, CA, MS.
___ Exam:
Vitals: T: 98 P: 70 R: 16 BP: 118/77 SaO2: 100%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 but with some memory lapses that must be
filled in by husband. ___, 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. Verbal memory not tested, 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. No
diplopia.
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 was spastic but more so in the legs
than arms b/l. Pronator drift on the right with pseudoathetosis
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 4+ 4+ 4+ 5 4 5 5 5 5
R 4 4+ ___ 4+ 4- 4 4+ 4 4
-Sensory: Decreased to vibration/pinprick/temperature over right
leg to just above the knee and R arm to elbow. Proprioception
impaired at great toes on the right. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 2 0
R 3 3 3 2 0
Plantar response was extensor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: defered
Discharge Physical Exam:
Pertinent Results:
___ 11:40PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 11:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
___ 11:40PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-10
___ 11:40PM URINE CA OXAL-RARE
___ 11:40PM URINE MUCOUS-RARE
___ 09:10PM GLUCOSE-131* UREA N-15 CREAT-0.7 SODIUM-136
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-22 ANION GAP-15
___ 09:10PM estGFR-Using this
___ 09:10PM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-38 TOT
BILI-0.2
___ 09:10PM ALBUMIN-4.2 CALCIUM-9.0 PHOSPHATE-3.7
MAGNESIUM-2.2
___ 09:10PM LACTATE-2.3*
___ 09:10PM WBC-8.4 RBC-4.80 HGB-13.9 HCT-41.9 MCV-87
MCH-29.0 MCHC-33.2 RDW-15.1
___ 09:10PM NEUTS-56.0 ___ MONOS-4.4 EOS-2.3
BASOS-0.6
___ 09:10PM PLT COUNT-234
___ 09:10PM ___ PTT-28.3 ___
Medications on Admission:
Adderall 20 mg p.o. q.a.m., 10 mg p.o. noon.
Desonide lotion to chest rash as needed,
Vicodin 7.5/750 taken about once a day or less for back pain,
Tysabri infusions q6weeks
pantoprazole 40 mg one p.o. daily,
sertraline 150 mg p.o. q.a.m. (interaction with both amphetamine
salts and sumatriptan underscored with the patient),
sumatriptan succinate 100 mg at onset of migraine.
Discharge Medications:
1. Adderall *NF* (amphetamine-dextroamphetamine) 10 mg Oral BID
Reason for Ordering: Wish to maintain preadmission medication
while hospitalized, as there is no acceptable substitute drug
product available on formulary.
2. Desonide 0.05% Cream 1 Appl TP DAILY apply to chest as needed
3. Sertraline 150 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. MethylPREDNISolone Sodium Succ 500 mg IV Q24H Duration: 3
Days
RX *Solu-Medrol 500 mg 1 dose over 8 hours daily Disp #*3 Each
Refills:*0
6. MethylPREDNISolone Sodium Succ 250 mg IV Q24H Duration: 3
Days
RX *Solu-Medrol 500 mg 250 mg over 8 hours daily Disp #*3 Each
Refills:*0
7. MethylPREDNISolone Sodium Succ 1000 mg IV Q24H Duration: 1
Doses
If discharged ___ patient can receive 3rd dose at home.
RX *methylprednisolone sodium succ 1,000 mg 1 dose over 8 hours
daily Disp #*1 Each Refills:*0
8. Quetiapine Fumarate ___ mg PO HS insomnia
RX *quetiapine 25 mg ___ Tablet(s) by mouth at bedtime Disp #*10
Each Refills:*0
9. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q4H:PRN pain
1. Adderall *NF* (amphetamine-dextroamphetamine) 10 mg Oral BID
Reason for Ordering: Wish to maintain preadmission medication
while hospitalized, as there is no acceptable substitute drug
product available on formulary.
2. Desonide 0.05% Cream 1 Appl TP DAILY apply to chest as needed
3. Sertraline 150 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. MethylPREDNISolone Sodium Succ 500 mg IV Q24H Duration: 3
Days
RX *Solu-Medrol 500 mg 1 dose over 8 hours daily Disp #*3 Each
Refills:*0
6. MethylPREDNISolone Sodium Succ 250 mg IV Q24H Duration: 3
Days
RX *Solu-Medrol 500 mg 250 mg over 8 hours daily Disp #*3 Each
Refills:*0
7. MethylPREDNISolone Sodium Succ 1000 mg IV Q24H Duration: 1
Doses
If discharged ___ patient can receive 3rd dose at home.
RX *methylprednisolone sodium succ 1,000 mg 1 dose over 8 hours
daily Disp #*1 Each Refills:*0
8. Quetiapine Fumarate ___ mg PO HS insomnia
RX *quetiapine 25 mg ___ Tablet(s) by mouth at bedtime Disp #*10
Each Refills:*0
RX *quetiapine 25 mg ___ Tablet(s) by mouth at bedtime Disp #*14
Each Refills:*0
9. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q4H:PRN pain
10. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
RX *potassium chloride 20 mEq 20 mEq by mouth Daily Disp #*6
Each Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. MS ___ VS ___
___ Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro Exam: AOx3, right hemiparesis, ___ weaker than UE.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with MS and worsening symptoms in the setting
of missing two doses of Tysabri. Assess for ___ versus MS flare.
COMPARISON: Old studies going back to ___.
TECHNIQUE: Sagittal FLAIR and axial FLAIR, T1, T2, gradient echo and
diffusion with ADC map images were obtained without contrast. Following IV
administration of gadolinium, sagittal MP-RAGE and axial T1 spin echo
sequences were acquired.
FINDINGS: There are several callosal, pericallosal, periventricular, deep
white matter and subcortical FLAIR/T2 hyperintense white matter lesions. A few
lesions are also noted in the cervicomedullary region and upper cervical cord.
Subtle hyperintensities are moreover identified in the left middle cerebellar
peduncle and mesencephalon. Several of these lesions
demonstrate focal enhancement - incomplete ring-enhancing pattern/ovoid/oblong
and a some as punctate lesions. There is no new diffuse FLAIR/T2 signal
abnormality involving the cortex or subcortical white matter. Hyperintensity
on DWI most likely represents T2 shine-through effect.
The cerebral sulci, ventricles and extra-axial CSF-containing spaces are
enlarged for age, likely representing mild diffuse cerebral volume loss. Flow
voids of the major intracranial vessels are preserved. Mild mucosal
thickening is noted in ethmoid air cells and mastoid air cells.
IMPRESSION: Several supra- and infratentorial enhancing lesions and in the
cervicomedullary region and upper cervical cord.Several are new since ___ (
no recent studies are available for comparison)- varying patterns of
enhancement; no mass effect. The nature of these lesions is uncertain; these
can relate to new MS lesions/ ___/ other etiology/combination. Correlate
clinically and with labs for better assessment and close followup.
Comments: The findings were discussed with Dr. ___ by Dr. ___ 3
pm, ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FATIGUED, UNABLE TO WALK
Diagnosed with MULTIPLE SCLEROSIS
temperature: 99.0
heartrate: 70.0
resprate: 16.0
o2sat: 100.0
sbp: 118.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | The pt is a ___ yo F w RRMS with progressive worsening of MS
symptoms in the setting of 2 missed tysabri infusions over past
months. Etiologies include ___, MS flare and patient found to
have multiple small enhancing lesions on MRI imaging. Patient
was admitted and following MRI results was started on 9 day IV
steroid regiment. The patient slowly did better over the weekend
and was followed by ___. She has excellent home services and was
reluctant to got to an ___ rehab setting. She was followed
by ___ inpatient and tolerated the steroids well. She was
discharged home to continue the steroids and home ___.
She will have follow-up with Dr. ___ to contact her
office with questions or concerns. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
small bowel obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ history of appendectomy and multiple ovarian
surgeries p/w abdominal pain x 1 day found to have SBO. Patient
started having mid abdominal pain around 6pm yesterday, which
gradually worsened to the point where the patient was unable to
move. No nausea but had emesis due to the feeling of abdominal
pressure. No fevers, no dysuria, but did endorse decreased
appetite. Last BM was 2pm and last passed gas yesterday am. Of
note has had intermittently cramping and constipation the last
few months. Has had multiple abdominal surgeries, mostly ovarian
surgeries, last was a salpingoophrectomy ___ years ago. No
history
of previous bowel obstructions. Had history of alcohol
dependence. Last drink was 6 months ago. Does use xanax
regularly, now once every three days and uses naloxone prn. WBC
11.4, Cr 1.0, labs from ___. CT shows SBO with
transition point in the pelvis. NGT was placed in the ED with
100cc clear liquid output. +urinary frequency but no dysuria.
ECG
with inverted P waves and ST changes in II
Past Medical History:
ASEPTIC MENINGITIS
DEPRESSION
MELANOMA
ALCOHOL ABUSE
Social History:
___
Family History:
pancreatic and liver cancer
Physical Exam:
General-AAOx3, NAD
HEENT-AT, NC, sclerae anicteric
Heart-RRR, normal S1, S2
Lungs-CTA B/L
Abd-soft, NT, ND
extr.-no edema or cyanosis
Pertinent Results:
___ 01:30PM GLUCOSE-93 UREA N-12 CREAT-0.8 SODIUM-140
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
___ 01:30PM estGFR-Using this
___ 01:30PM CK(CPK)-114
___ 01:30PM CK-MB-3 cTropnT-<0.01
___ 01:30PM CALCIUM-8.8 PHOSPHATE-3.9 MAGNESIUM-2.1
___ 01:30PM WBC-6.0# RBC-4.44 HGB-14.0 HCT-42.1 MCV-95
MCH-31.5 MCHC-33.2 RDW-13.3
___ 01:30PM PLT COUNT-221
___ 01:30PM ___ PTT-35.4 ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Citalopram 40 mg PO DAILY
2. ALPRAZolam 0.25 mg PO TID:PRN anxiety
3. TraZODone 50 mg PO HS
Discharge Medications:
1. TraZODone 50 mg PO HS
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. ALPRAZolam 0.25 mg PO TID:PRN anxiety
4. Citalopram 40 mg PO DAILY
Discharge Disposition:
Home
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
CHEST RADIOGRAPH
INDICATION: Nasogastric tube placement.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: The lung volumes are normal. Normal size of the cardiac
silhouette. Normal appearance of the lung parenchyma and the pleura. The
patient has received a nasogastric tube, the course of the tube is
unremarkable, the tip of the tube projects over the upper parts of the
stomach, with the sidehole at the gastroesophageal junction. The tube should
be advanced by approximately 5 cm. No evidence of complications, notably no
pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.7
heartrate: 100.0
resprate: 18.0
o2sat: 98.0
sbp: 136.0
dbp: 72.0
level of pain: 6
level of acuity: 3.0 | Ms. ___ was transferred from outside hospital to ___ on
___ for further management of her small bowel obstruction
diagnosed on CT abd/pelvis. nasogastric tube was placed in the
emergency department which only drained 100cc of clear liquid.
The patient was admitted to acute care surgery service for
further management. She was kept NPO for diet and received
intravenous fluids. The NG tube was later removed. On HD2 she
was given regular diet which she tolerated well without nausea
and vomiting. Her INS and Outs as well as vital signs were
recorded adnn remained adequate.
The patient was discharged home with instructions to follow up
in ___ clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodinated Contrast Media - Oral and IV Dye / Cipro / Flagyl /
Zantac / ondansetron / Keflex
Attending: ___.
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
celiac plexus neurolysis performed ___
History of Present Illness:
___ yo female with a history of pancreatic cancer who is admitted
with nausea, vomiting, and abdominal pain. The patient states
she
has been having ongoing abdominal pain but it has been worse
since ___. She also has been having nausea and vomiting since
___. She is unable to keep anything down. She has been
loosing
weight. She has gone to ___ when she reports she
was given a dose of Zofran one time and a dose of Compazine
another time without relief. She denies any fevers. She denies
any shortness of breath, diarrhea, dysuria, urinary frequency,
urinary urgency, or rashes. She does have some sores in her
mouth. Of note she received chemotherapy with nab-paclitaxel and
gemcitabine on ___.
In the ED a CT was done which showed her known pancreatic cancer
invading her stomach. She was given oxycodone and clonazepam.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
Locally advanced unresectable stage III pancreatic cancer
- Presented in ___ with several months of intermittent severe
postprandial abdominal pain. The pain is most prominent in the
left lower quadrant and was accompanied by a ___ pound weight
loss over the proceeding 3 months. She was referred for CT,
MRI, and eventually ultrasound performed ___ which
identified a 3.6 cm pancreatic body mass. This was confirmed on
MRI, which showed involvement of the SMV, splenic vein, and
portal splenic confluence. She underwent endoscopic ultrasound
___. Biopsy of the pancreatic mass returned atypical.
She
underwent repeat endoscopic ultrasound ___ and biopsy,
which
showed adenocarcinoma. She began nab-paclitaxel/gemcitabine
___.
PAST MEDICAL HISTORY:
1. Thyroid cancer status post thyroidectomy ___
2. History of colon polyps
3. History of benign breast nodules status post lumpectomy ___
4. COPD
5. Status post incarcerated inguinal hernia repair
6. History of anxiety and panic attacks, depression
7. History of frequent urinary tract infections
Social History:
___
Family History:
The patient's mother was treated for breast cancer at ___ years
and is alive in her ___. Her father died of suicide at ___
years.
Her sister is alive and was reportedly treated for brain cancer
in her ___ as well as colon cancer at ___ years. A brother died
at ___ years with hepatocellular carcinoma and schizophrenia.
Another brother was treated for lung cancer at ___ years. Two
other brothers, 1 sister, and 2 children are without health
concerns.
Physical Exam:
ADMISSION EXAM:
VITAL SIGNS: 98.2 PO 125 / 72 63 18 96 Ra
General: NAD
HEENT: MMM
CV: RR, NL S1S2 no S3S4, no MRG
PULM: CTAB, respirations unlabored
ABD: BS+, soft, NTND
LIMBS: No ___
SKIN: No rashes on extremities, L chest port intact
NEURO: Grossly WNL
DISCHARGE EXAM:
VITAL SIGNS: I/O: 654 (400 po + 254 IV) / Void
General: Anxious woman, appears chronically ill but in NAD.
Standing up at side of her bed.
HEENT: MMM, PERLL, EOMI
CV: RR, NL S1S2 no S3S4, no MRG
PULM: Non-labored appearing on RA. CTAB.
ABD: Non-distended. Soft without any guarding. No rebound.
NABS. No ___ sign. Reports TTP in LUQ and LLQ.
LIMBS: No ___. Normal bulk.
SKIN: No rashes on extremities, L chest port intact
NEURO: AAOx3. CNIII-XII intact. Strength grossly intact in all
extremities.
Pertinent Results:
ADMISSION LABS:
==============
___ 10:10PM BLOOD WBC-9.2# RBC-3.44* Hgb-11.1* Hct-31.6*
MCV-92 MCH-32.3* MCHC-35.1 RDW-14.7 RDWSD-49.4* Plt ___
___ 10:10PM BLOOD ___ PTT-29.6 ___
___ 10:10PM BLOOD Glucose-110* UreaN-14 Creat-0.7 Na-136
K-4.1 Cl-99 HCO3-22 AnGap-19
___ 10:10PM BLOOD ALT-8 AST-21 AlkPhos-50 TotBili-1.2
___ 05:40AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.8
___ 10:21PM BLOOD Lactate-1.6
DISCHARGE LABS:
==============
___ 05:03AM BLOOD WBC-3.2* RBC-3.33* Hgb-10.4* Hct-30.2*
MCV-91 MCH-31.2 MCHC-34.4 RDW-13.8 RDWSD-46.4* Plt Ct-89*
___ 05:03AM BLOOD Glucose-91 UreaN-8 Creat-0.7 Na-129*
K-3.8 Cl-95* HCO3-22 AnGap-16
___ 05:03AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0
IMAGING:
========
___BD & PELVIS W/O CON
Limited assessment without intravenous contrast.
1. Invasion of the 4.2 cm pancreatic mass into the stomach
antrum is better seen on the prior exam from ___.
Otherwise, unremarkable small and large bowel.
2. Vascular compromise, including attenuation of the portal vein
due to the pancreatic mass is better seen on the prior contrast
exam from ___.
3. Stable trace ascites.
MICRO:
======
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ URINE URINE CULTURE-FINAL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO QID
2. Levothyroxine Sodium 137 mcg PO DAILY
3. Morphine SR (MS ___ 30 mg PO Q12H
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
5. Sertraline 50 mg PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN Constipation
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4
hours Disp #*30 Tablet 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. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
4. Sucralfate 1 gm PO QID
RX *sucralfate [Carafate] 1 gram/10 mL 10 mL by mouth four times
a day Refills:*0
5. ClonazePAM 0.5 mg PO QID
6. Docusate Sodium 100 mg PO BID:PRN Constipation
7. Levothyroxine Sodium 137 mcg PO DAILY
8. Morphine SR (MS ___ 30 mg PO Q12H
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
10. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: NO_PO contrast; History: ___ with abdominal pain NO_PO contrast//
evaluate for intraabdominal infection, bowel obstruction. Allergic to oral and
IV contrast
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.3 s, 47.4 cm; CTDIvol = 7.0 mGy (Body) DLP = 332.9
mGy-cm.
Total DLP (Body) = 333 mGy-cm.
COMPARISON: CTA from ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion. Relative hypo dense appearance
of the blood pool with respect to the interventricular septum likely reflects
anemic state.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: Evaluation of the known pancreatic mass is limited on this
noncontrast exam. There is overall unchanged appearance of the hypodense
pancreatic body lesion measuring 3.9 x 2.2 cm, better seen on the contrast
exam from ___. Pancreatic tail atrophy and upstream pancreatic
ductal dilation is overall similar, allowing for differences in technique.
Punctate calcification near the distal body of the pancreas is unchanged from
prior exam (02:17). Vascular involvement with the known pancreatic mass is
better seen on the prior study. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right adrenal gland is unremarkable. Thickened appearance of
the left adrenal gland is unchanged from prior exam.
URINARY: The kidneys are of normal and symmetric size. Multiple renal cysts
are better seen on the prior exam from ___. There is no evidence of
focal renal lesions within the limitations of an unenhanced scan. There is no
hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: Invasion of the pancreatic mass into the antrum of the
stomach is not well visualized on today's exam due to lack of contrast. Small
bowel loops demonstrate normal caliber and wall thickness throughout. Patient
is status post partial right colectomy with surgical sutures in the right
lower quadrant. The appendix is normal (601b:27).
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
small amount of free fluid in the pelvis. Hyperdense focus near the presacral
space was present on prior exam, possibly reflecting calcifications (2:60).
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. Encasement and attenuation of the portal vein is not well
demonstrated on today's exam due to lack of contrast.
BONES: Multilevel degenerative changes of the lower lumbar spine, worst at
L5-S1 is unchanged. Calcific density in the spinal canal at S5 is unchanged
from prior exam (02:50).
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Limited assessment without intravenous contrast.
1. Invasion of the 4.2 cm pancreatic mass into the stomach antrum is better
seen on the prior exam from ___. Otherwise, unremarkable small and
large bowel.
2. Vascular compromise, including attenuation of the portal vein due to the
pancreatic mass is better seen on the prior contrast exam from ___.
3. Stable trace ascites.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, N/V
Diagnosed with Unspecified abdominal pain, Urinary tract infection, site not specified
temperature: 96.5
heartrate: 68.0
resprate: 16.0
o2sat: 98.0
sbp: 129.0
dbp: 75.0
level of pain: 8
level of acuity: 3.0 | PRINCIPLE REASON FOR ADMISSION:
___ w/ COPD, anxiety, depression, and locally advanced
unresectable stage III pancreatic cancer presenting on C1D3
Paclitaxel/gemcitabine w/ exacerbation of her underlying
nausea/vomiting/abd pain.
# Nausea/Vomiting
# Abdominal Pain
# Severe protein calorie malnutrition
# Locally advanced pancreatic ductal carcinoma: Symptoms most
likely due to the invasive pancreatic ca, exacerbated by chemo,
as seen on admission CT scan. Labs and remainder of imaging
unremarkable. She underwent a celiac plexus neurolysis on ___.
Procedure also notable for marked esophagitis. She had slowly
improvinig abdominal pain, nausea, and vomiting after the
procedure. She was also started on IV pantoprazole and
sucralfate before transitioning to omeprazole 40mg daily.
Palliative care saw her and recommended transitioning off
morphine to hydromorphone which she tolerates best. She will
likely need aggressive antiemetics w/ further chemotherapy. She
also received IV thiamine, folate, and was started on MVI for
malnutrition.
# Hyponatremia - Mild. Recommend repeating on outpatient labs.
# Depression/Anxiety: Continued sertraline, clonazepam
# Hypothyroid: Continued synthroid
# COPD: No e/o flare this admission.
# Hypokalemia: Likely due to n/v, she was repleted on scales
this admission.
# Hypophosphatemia: Likely in setting of advancing diet,
received po neutraphos while in house
# Anemia/Thrombocytopenia: most likely due to antineoplastic
therapy. Monitored daily.
FEN: Regular diet
ACCESS: PORT
CODE STATUS: DNR/DNI (confirmed on admission and w/ pal care)
DISPO: Home w/o services
BILLING: >30 min spent coordinating care for discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Clindamycin / Aspirin /
Gentamicin / Penicillins
Attending: ___.
Chief Complaint:
jaw pain, poor oral intake
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH of MS, trigeminal neuralgia, suprapubic catheter
and prior UTIs p/w increased jaw pain over the last ~10 days
limiting his PO intake. He is unable to speak except to make
dysarthric noises and attempts to write responses but has a
significant tremor which results in only scribble. He is able to
answer focused yes/no questions for the interview.
He states the pain has been constant and is similar to his prior
trigeminal neuralgia pain. The pain has significantly limited
his ability to take PO so he was brought to ___ from his
long-term care facility. He has had no fevers, chills, ear pain,
changes in vision, dysphagia, neck pain, CP, SOB, abdominal
pain, nausea or vomiting.
In the ED initial vitals were: 98.6 104 135/80 16 97% RA
- Labs were significant for +UA, anion gap of 25 with
bicarbonate of 21, WBC of 10.6. Patient was given 1LNS and 5mg
PO oxycodone and admitted.
Review of Systems:
(+) per HPI
Past Medical History:
1) Secondary progressive MS (___): Failed steroids
2) Paraplegia
3) T9-T11 discitis / osteomyelitis / phlegmon / intraosseus
abscess
- s/p ___mpiric Vanco/Zosyn/Flagyl ending ___
4) Dementia
5) GERD
6) Chronic constipation
7) Seizure disorder
8) Trigeminal neuralgia
9) Urinary retention due to neurogenic bladder and urethral
stricture
- s/p suprapubic catheter ___
- Recurrent UTI, urosepsis with VRE, ESBL Klebsiella, Proteus,
E. coli
10) Central line infection ___ with Proteus
11) Decubitus ulcers: extremities, thoracic spine
12) Temporomandibular joint pain
13) Cholecystitis (s/p cholesystostomy tube placement)
14) Decreased visual acuity
Social History:
___
Family History:
# Mother, alive: ___, macular degeneration
# Father, died at ___: Unknown, possibly had MI's
# Siblings (two sisters): One with MS
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T: 99.4 BP: 180/90 HR: 110 RR: 20 02 sat: 96%RA
GENERAL: Elderly man in NAD
HEENT: AT/NC, EOMI, PEERL, anicteric sclera, poor dentition,
pooling secretions in mouth which patient drools forward, hold
tongue in back of mouth, poor dentition and blood oozing from
left lower teeth, no visible airway obstruction, tenderness of
lower jaw and maxilla L>R
NECK: nontender supple neck, no LAD, no JVD, trache midline,
able to make dysarthric vocaliations, no stridor
CARDIAC: Regular, tachycardic, S1/S2, no murmurs, gallops, or
rubs
LUNG: Decreased BS in left base, bibasilar crackles, no
increased work of breathing
ABDOMEN: nondistended, +BS, nontender in all quadrants,
suprapubic catheter in place
EXTREMITIES: no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN notable for poor vision bilaterally, decreased right
sided facial strength, saccadic intrusions in smooth pursuit,
dysarthria as above, paraplegic with increased tone and
spacicity throughout, bilateral upper extremities held in flexed
position, UE strength R>L with significant rest and action
tremor, minimal ___ movement.
SKIN: warm and well perfused, RLE protective dressing, no rashes
DISCHARGE PHYSICAL EXAM:
VS - Tm 98.5, Tc 98.5, HR 85 (80s-90s), BP 138/84
(130s-160s/70s-80), RR 18, O2 96%RA
I's & O's: not recorded
General: Elderly man, no apparent distress, forearms chronically
flexed, watching the news.
HEENT: Poor dentition, MMM w/o pooled saliva, minimal to no
white plaque on tongue, no visible airway obstruction,
tenderness of lower jaw and maxilla variable.
Neck: No stridor.
CV: Regular, tachycardic, S1/S2, no m/r/g
Lungs: Limited by exam, clear to auscultation anteriorly,
breathing comfortably
Abdomen: +BS, nontender to palpation without guarding, mildly
distended.
GU: suprapubic catheter covered with clean dry bandage
Ext: Bilateral lower extremities cool to knee, difficult to feel
DP pulse bilaterally, pale but no cyanosis, clubbing, edema
Neuro: paraplegic with increased tone and spacicity throughout,
bilateral upper extremities mostly in flexed position, can be
extended, minimal ___ movement, no ___ sensation
Pertinent Results:
LABS ON ADMISSION:
___ 06:45PM BLOOD WBC-10.6# RBC-5.01# Hgb-14.2# Hct-44.9#
MCV-90 MCH-28.3 MCHC-31.6 RDW-15.4 Plt ___
___ 06:45PM BLOOD Neuts-75.6* Lymphs-13.8* Monos-8.1
Eos-1.8 Baso-0.6
___ 06:45PM BLOOD Plt ___
___ 06:45PM BLOOD Glucose-82 UreaN-23* Creat-0.9 Na-141
K-4.6 Cl-100 HCO3-21* AnGap-25*
___ 06:45PM BLOOD ALT-12 AST-23 AlkPhos-101 TotBili-0.2
___ 06:45PM BLOOD Calcium-9.9
___ 07:40AM BLOOD Calcium-9.3 Phos-2.1* Mg-2.0
___ 06:45PM BLOOD CRP-90.2*
___ 07:40AM BLOOD Carbamz-3.0*
___ 08:36AM BLOOD ___ pO2-103 pCO2-34* pH-7.35
calTCO2-20* Base XS--5
___ 08:36AM BLOOD Lactate-2.1*
___ 06:45PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 06:45PM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 06:45PM URINE RBC->182* WBC->182* Bacteri-FEW
Yeast-MANY Epi-0
___ 06:45PM URINE Mucous-FEW
LABS ON DISCHARGE:
___ 07:00AM BLOOD WBC-8.5 RBC-4.16* Hgb-12.1* Hct-37.4*
MCV-90 MCH-29.0 MCHC-32.3 RDW-16.0* Plt ___
___ 07:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-87 UreaN-10 Creat-0.7 Na-139
K-4.0 Cl-102 HCO3-24 AnGap-17
___ 07:00AM BLOOD CK(CPK)-194
___ 06:00AM BLOOD Calcium-8.7 Phos-4.6*# Mg-2.0
___ 07:00AM BLOOD CRP-28.0*
___ 06:30AM BLOOD CRP-38.2*
___ 07:00AM BLOOD Carbamz-8.3
___ 06:25AM BLOOD Carbamz-3.6*
___ 07:40AM BLOOD Carbamz-3.0*
___ 06:33AM BLOOD Lactate-2.5*
MICRO:
___ 5:30 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
___ 7:40 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:25 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
IMAGING:
___: Arterial resting study left lower extremity: Normal right
lower extremity flow. Significant left tibial sludge pedal
disease affecting the anterior circulation only.
___ CT Chest IMPRESSION: The lesion incidentally detected on
the neck CT performed today corresponds rounded atelectasis in
the left upper lobe. Left more than right pleural effusions.
Severe asymmetry of the rib cage due to severe scoliosis.
___ Mandible: Study is somewhat limited due to difficulty in
positioning patient for standard views. Allowing for this, there
is no bony destruction or signs for acute fractures. The
mandibular condyles appear well seated. There is normal osseous
mineralization.There are degenerative changes of the cervical
spine.
___ CT neck with contrast: No evidence of abnormal fluid
collection.
Left pleural effusion with rounded atelectasis in the left lung
apex. Please refer to subsequently performed chest CT for
further detail.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 10 mg PO TID
2. Carbamazepine Suspension 200 mg PO TID
3. cefdinir 600 mg oral daily
4. Gabapentin 300 mg PO HS
5. LeVETiracetam Oral Solution 250 mg PO BID
6. Misoprostol 200 mcg PO QIDPCHS
7. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
8. OxycoDONE Liquid 5 mg PO BID
9. Acetaminophen 650 mg PO Q6H
10. Calcium Carbonate Suspension 750 mg PO BID
11. Docusate Sodium (Liquid) 100 mg PO BID
12. Famotidine 10 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Baclofen 10 mg PO TID
3. Calcium Carbonate Suspension 750 mg PO BID
4. Carbamazepine Suspension 200 mg PO TID
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Famotidine 10 mg PO DAILY
7. Gabapentin 300 mg PO HS
8. LeVETiracetam Oral Solution 250 mg PO BID
9. Misoprostol 200 mcg PO QIDPCHS
10. Multivitamins 1 TAB PO DAILY
11. Senna 8.6 mg PO BID:PRN constipation
12. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
Duration: 1 Week
13. cefdinir 600 mg oral daily
14. OxycoDONE (Concentrated Oral Soln) ___ mg PO Q6H:PRN pain
hold for sedation or RR<12, do not take within 2 hours of
oxycontin
15. OxyCODONE SR (OxyconTIN) 15 mg PO Q12H
hold for sedation or RR<12 do not give within 2 hours of
oxycodone
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagoses:
Trigeminal neuralgia
Advanced multiple sclerosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive most of the time,
occasionally confused
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS)
INDICATION: ___ year old man with multiple sclerosis, trigeminal neuralgia,
difficulty managing secretions with facial pain and bleeding // ?dental or
pharyngeal infectious fluid collection
TECHNIQUE: Routine enhanced CT study of the neck was performed with images
obtained from the skull base to the thoracic inlet. Sagittal and coronal
reconstructions were performed.
DOSE: DLP: 494 mGy-cm; CTDI: 18 mGy
COMPARISON: None available
FINDINGS:
There are no fluid collections. The pharyngeal mucosa is within normal limits
without evidence of focal mass. Evaluation of the cervical lymph chains
demonstrate no pathologic lymphadenopathy by imaging criteria. The visualized
salivary glands are unremarkable in appearance. No thyroid mass is seen. Neck
vessels are patent. There is a left-sided pleural effusion and atelectasis. A
rounded mass in the left upper lobe represents rounded atelectasis. There are
multilevel degenerative changes in the spine.
IMPRESSION:
No evidence of abnormal fluid collection.
Left pleural effusion with rounded atelectasis in the left lung apex. Please
refer to subsequently performed chest CT for further detail.
Radiology Report
INDICATION: ___ year old man with MS, trigeminal neuralgia, p/w increased jaw
pain for 10 days limiting PO intake // ?abscess
COMPARISON: CT scan of the neck from ___
IMPRESSION:
Study is somewhat limited due to difficulty in positioning patient for
standard views. Allowing for this, there is no bony destruction or signs for
acute fractures. The mandibular condyles appear well seated. There is normal
osseous mineralization.There are degenerative changes of the cervical spine.
Radiology Report
COMPUTED TOMOGRAPHY OF THE THORAX
INDICATION: Upper lobe structure on the left that is unclear in origin.
COMPARISON: No comparison available at the time of dictation.
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
administration of intravenous contrast material, multiplanar reconstructions.
FINDINGS: The examination is limited by respiratory motion artifacts as well
as by the position of the patient.
No incidental thyroid findings. No abnormalities at the level of the large
mediastinal vessels. Moderate cardiomegaly. No pericardial effusion. Fatty
liver. Elongation of the descending aorta. No relevant abnormalities at the
level of the upper abdominal organs.
Moderate-to-severe degenerative changes at the level of the vertebral bodies.
No evidence of osteolytic lesions.
The patient displays substantial bilateral pleural effusions, left more than
right. In addition, in the dependent lung regions, areas of atelectasis,
again left more than right, are visualized. Finally, the patient shows a
rounded approximately 2 cm in diameter pleural-based structure in the left
upper lobe adjacent to pleural thickening, reflecting a rounded atelectasis.
No evidence of malignancy is present.
No evidence of airways disease. No other relevant findings.
IMPRESSION: The lesion incidentally detected on the neck CT performed today
corresponds rounded atelectasis in the left upper lobe. Left more than right
pleural effusions. Severe asymmetry of the rib cage due to severe scoliosis.
Radiology Report
STUDY: Lower extremity arterial noninvasives at rest.
REASON: Cold left foot.
FINDINGS: Doppler waveform analysis reveals normal waveforms throughout the
right lower extremity. Right ABI is 1.0. On the left there are triphasic
waveforms at the common femoral, superficial femoral, popliteal and posterior
tibial. The dorsalis pedis is absent. There is a flat trace in the digit.
The left ABI is 1.0.
Pulse volume recordings show essentially normal waveforms throughout the right
lower extremity. On the left there is dampening at the level of the
metatarsal with a nearly flat trace here.
IMPRESSION: Normal right lower extremity flow. Significant left tibial
sludge pedal disease affecting the anterior circulation only.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MOUTH PAIN
Diagnosed with JAW PAIN, ABN URINE FINDINGS NEC
temperature: 98.6
heartrate: 104.0
resprate: 16.0
o2sat: 97.0
sbp: 135.0
dbp: 80.0
level of pain: 5
level of acuity: 3.0 | HOSPITAL COURSE: Mr. ___ is a ___ with secondary progressive
MS and trigeminal neuralgia p/w decreased PO intake in the
setting of an exacerbation of pain likely due to trigeminal
neuralgia, which was controlled with increased carbamazapine
dosing for three days (with return to his home dose by the time
of discharge), as well as oxycontin and oxycodone, with dosing
managed by palliative care doctors in the hospital. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Endocet / Demerol
Attending: ___
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
___ s/p left craniotomy for tumor resection
History of Present Illness:
___ is a ___ male who presents after a
witnessed seizure with fall today. Patient reports he was taking
a walk today with fiancé along the river when he developed a
headache and nausea. He reports that both headache and nausea
worsened as he walked up stairs to a bridge, and then doesn't
remember anything until being in the ambulance. His fiancé,
___,
is at bedside and describes that when they reached the top of
the
stairs, the patient suddenly stopped, grabbed his arm and made
an
"ahhhh" noise before falling backwards. As he fell, he hit his
face on the railing. He then started to convulse for ~30 seconds
and was then unconscious for ~1 minute. When he regained
consciousness he was drooling and had garbled speech. EMS was
called and brought him to ___ ED. Per EMS report, the patient
was displaying expressive aphasia and confusion on their
arrival.
In the ED, ___ showed a large area of edema in the left
temporal lobe extending to left frontal lobe, concerning for
underlying lesion. Neurosurgery was consulted for evaluation.
Patient denies any prior seizure history. Denies any difficulty
with speech or confusion prior to this episode. Denies any other
neurological symptoms including weakness, vision changes, or
difficulty ambulating.
Past Medical History:
Wisdom teeth extraction
Social History:
___
Family History:
Father - seizures from ___
Sister - sarcoma
___ grandmother - brain tumor
___ uncle - leukemia
Physical ___:
On Admission
--------------
PHYSICAL EXAM:
O: T:not recorded, HR 98, BP 102/69, RR 16, O2 96% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm EOMs full
Neck: C-collar in place
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 3-2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
--------------
On Discharge
--------------
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL 3-2mm bilaterlly
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
R sided ecchymosis and swelling
Tongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
___
IPQuadHamATEHLGast
___
Left5 5 5 5 5 5
[x]Sensation intact to light touch
Wound:
[x]Clean, dry, intact
[x]Staples
Pertinent Results:
See OMR for pertinent lab/imaging studies.
Medications on Admission:
Vitamin D
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache
Do not exceed 6 tablets/day
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ tab-cap
by mouth every eight hours as needed Disp #*30 Tablet Refills:*0
2. Dexamethasone 4 mg PO Q8H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice per day
Disp #*60 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
Left temporal brain lesion
Cerebral edema
Brain compression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ male with new seizures, brain mass on CT. Brain
tumor?
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CT head without contrast dated ___.
FINDINGS:
There is an expansile T2 and FLAIR hyperintense mass involving the majority of
the left anterior temporal lobe. The mass measures approximately 7.2 cm AP x
4 cm TV x 5.5 cm SI in maximal ___. There is no nodular or irregular
enhancement involving the mass. GRE hypointense foci within the mass
correlate to calcific densities on the prior CT head without contrast. There
is minimal restricted diffusion (image 20 of series 6) along the
posterolateral aspect of the mass. There is associated mild mass effect on
the left cerebral peduncle and partial effacement of the ambient cisterns and
near complete effacement of the left sylvian fissure and left lateral
ventricle. There is approximately 3 mm of left-to-right midline shift at the
level of the septum pellucidum. There is displacement and mass effect on the
left middle cerebral artery and M2 segments.
No additional masses are seen. Otherwise, the major arterial flow voids are
preserved. The dural venous sinuses are patent.
There is no evidence of acute infarction or intracranial hemorrhage.
Mild-to-moderate mucosal thickening of the ethmoid air cells. Mild mucosal
thickening of the remaining sinuses. The mastoid air cells are clear.
Unremarkable intraorbital contents.
IMPRESSION:
1. Expansile left anterior temporal lobe mass with effacement of the ambient
cisterns, left lateral ventricle, and left sylvian fissure and 3 mm leftward
midline shift. Differential considerations include a low-grade astrocytoma,
especially given the lack of enhancement. An oligodendroglioma is possible
given the presence of calcifications. A ganglioglioma is a consideration
given the clinical presentation of epilepsy and temporal lobe location.
2. No acute infarction or intracranial hemorrhage.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with brain lesion, seizure on presentation.
Evaluate for primary lesion.
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 79.7 cm; CTDIvol = 18.3 mGy (Body) DLP =
1,456.1 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.9 mGy (Body) DLP =
18.4 mGy-cm.
Total DLP (Body) = 1,476 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal (2:103).
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: Scattered retroperitoneal and mesenteric lymph nodes are not
pathologically enlarged by CT size criteria. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: Small sclerotic focus in the right sacrum likely reflects a bone island
(2:108). 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 abdominopelvic abnormality.
2. Please refer to separately reported CT chest for description of the
intrathoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with brain lesion, seizure on presentation.
Evaluate for primary lesion.
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
contiguous 5 mm and 1.25 mm thick axial, 2.5 mm thick coronal and
parasagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 79.7 cm; CTDIvol = 18.3 mGy (Body) DLP =
1,456.1 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.9 mGy (Body) DLP =
18.4 mGy-cm.
Total DLP (Body) = 1,476 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: None.
FINDINGS:
NECK, THORACIC INLET, AXILLAE: The visualized thyroid is normal. Small
left-sided supraclavicular lymph nodes are not pathologically enlarged by CT
size criteria measure up to 6 mm (2:5, 7).
MEDIASTINUM: Mediastinal lymph nodes are not enlarged.
HILA: Hilar lymph nodes are not enlarged.
HEART: The heart is not enlarged and there is no coronary arterial
calcification. There is no pericardial effusion.
VESSELS: Vascular configuration is conventional. Aortic caliber is normal.
The main, right, and left pulmonary arteries are normal caliber.
PULMONARY PARENCHYMA: Mild bibasilar dependent atelectasis. There is no
evidence of emphysema. No evidence of abnormal pulmonary opacification or
pulmonary masses. There are multiple small right-sided pulmonary nodules.
For example, there is a 4 mm right lower lobe pulmonary nodule (02:31). 3 mm
right middle lobe pulmonary nodule (02:32). 2 mm subpleural right lower lobe
pulmonary nodule (02:36).
AIRWAYS: The airways are patent to the subsegmental level bilaterally.
PLEURA: There is no pleural effusion.
CHEST WALL AND BONES: There is no aggressive lytic or sclerotic lesion.
UPPER ABDOMEN: Please see separately submitted Abdomen and Pelvis CT report
for subdiaphragmatic findings.
IMPRESSION:
1. Small right-sided pulmonary nodules measure up to 4 mm.
2. No acute intrathoracic process.
3. Please refer to separately dictated CT abdomen pelvis for description of
the subdiaphragmatic findings.
Radiology Report
EXAMINATION: Functional MRI.
INDICATION: ___ male with no significant past medical history,
presents with seizures, MRI finding of expansile left anterior temporal lobe
mass with effacement of the ambient cisterns, left lateral ventricle, and left
sylvian fissure and 3 mm leftward midline shift. please evaluate speech, for
pre-operative planning.
TECHNIQUE: The examination was performed using a 3.0T MRI scanner. After the
uneventful administration of 10 mL of Gadavist intravenous contrast agent,
axial FSPGR, axial Arterial Spin Labeled (ASL), diffusion tensor images (DTI)
using 36 directions and task based functional imaging paradigms were obtained.
Functional imaging was performed using Echo Planar/BOLD (blood oxygen level
dependent) technique using block design functional paradigms.
The functional paradigms include analysis of the motor areas during the
alternating movement of the hands, feet, tongue, and language areas during the
mental process of generating words with different letters. Post processing of
functional images, DTI fiber tractography and reference image skull stripping
was performed using a dedicated workstation. All obtained and derived images
were used to generate this report.
COMPARISON: MRI head with and without contrast dated ___.
CT head without contrast dated ___.
FINDINGS:
There is redemonstration of an expansile FLAIR hyperintense masses involving
the majority of the left anterior temporal lobe. The mass measures 7.1 cm AP
x 4 cm TV x 6 cm SI, unchanged. Again there is no definite nodular or
irregular enhancement involving the mass. There is mass-effect on the left
cerebral peduncle and partial effacement of the ambient cisterns and near
complete effacement of the left sylvian fissure and left lateral ventricle. 3
mm of left-to-right midline shift persists.
Again, there is displacement and mass-effect on the left middle cerebral
artery and M2 branches.
The arterial spin labeled sequence is notable for a 1.5 cm AP x 0.8 cm TV area
of elevated cerebral blood flow within the mid to posterior aspect of the
mass. The tractography color maps demonstrate mild to moderate medial
deviation of the left inferior longitudinal fasciculus and left corticospinal
tracts.
The functional MRI demonstrates BOLD activation areas during the movement of
the tongue along the superior aspect of the mass. The functional MRI
demonstrates an additional activation area during the word generation paradigm
in the mid to posterior aspect of the mass (image 29 of series 21), which is
favored to reflect flow related artifact as demonstrated on the ASL images
versus an additional area of BOLD activation.
The language paradigm demonstrates the propagation of activation in the
convexity with the majority of the BOLD activity in the left cerebral
hemisphere, likely related with dominance.
IMPRESSION:
1. Stable expansile left anterior temporal lobe Mass with effacement of the
ambient cisterns, left lateral ventricle, and left sylvian fissure and 3 mm of
leftward midline shift. Differential considerations include oligodendroglioma
or low-grade astrocytoma.
2. Small area of increased ASL perfusion and probable flow related artifact in
the mid to posterior aspect of the mass, which is also evidenced on the word
generation paradigm as an area of BOLD activation versus an additional area of
BOLD activity.
3. Mild to moderate medial deviation of the left corticospinal and inferior
longitudinal fasciculus.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. in person on ___ at 4:17 pm.
Radiology Report
EXAMINATION: PRE-SURGICAL WAND OR THERAPY PLANNING T7___ MR HEAD
INDICATION: ___ year old man with left frontotemporal brain lesion, going to
OR ___ for left craniotomy for resection. Please complete by 0500 AM on ___.
OR TIME 0700 on ___// Please perform by 0500 on ___. Please place fiducials
for OR planning. Pre-op exam- left crani for resection left frontotemporal
lesion.
TECHNIQUE: After administration of 10 mL of Gadavist intravenous contrast,
axial imaging was performed with MPRAGE and T1 technique. Sagittal and coronal
orientation reformatted images of the MPRAGE acquisition was then produced.
COMPARISON: MRI with and without contrast ___
FINDINGS:
The patient's previously noted left frontotemporal mass is again seen. There
is 3 mm leftward midline shift and effacement of the ambient cisterns, left
lateral ventricle and left sylvian fissure.
IMPRESSION:
1. Limited imaging for the purposes of pre-surgical planning demonstrate
grossly stable large left frontotemporal mass with significant mass effect and
3 mm leftward midline shift.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old man with brain lesion, pre-op// pre-op Surg: ___
(Crani for tumor resection) SEIZURE
IMPRESSION:
Comparison to ___. No relevant change is seen. The lung volumes
are normal. Normal size of the cardiac silhouette. Normal hilar and
mediastinal contours. No pneumonia, no pulmonary edema, no pleural effusions.
No pneumothorax.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man s/p left craniotomy for tumor resection. Post-op
scan to be done at 1400.// Postop scan to be done at 1400.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: Brain MRI ___. head CT ___.
FINDINGS:
Left frontotemporal, parietal craniotomy, anterior left temporal lobectomy for
tumor resection. Minimal blood products marginating surgical cavity. Mild
pneumocephalus. Small volume hyperdense extra-axial hemorrhage at the
cisterna magna, anterior to pons, foramina magnum, likely subdural, new since
prior. Extracranial surgical bed drain in place.
No acute infarct, no hydrocephalus. Minimal midline shift to the right,
improved. No hydrocephalus. Clear paranasal sinuses, mastoids.
IMPRESSION:
New small volume extra-axial hemorrhage posterior fossa, likely subdural.
Interval tumor resection left temporal lobe, postsurgical change.
RECOMMENDATION(S): Follow-up head CT.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with left temporal brain lesion s/p left crani
for tumor resection// Post-op MRI. Evaluate for residual tumor.
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: ___ contrast brain MRI.
FINDINGS:
Study is mildly degraded by motion.
Postsurgical changes related to interval left frontal mass resection,
including blood products and probable pneumocephalus are seen. Minimal slow
diffusion along the posteromedial surgical bed is noted (see 5, 06:15). There
is interval decreased mass effect on the left lateral ventricle. There is
interval resolution of previously noted left right midline shift. Minimal
nonspecific T2 and FLAIR hyperintensity within the left frontal and temporal
lobes and left insula adjacent to the surgical bed are noted. Minimal
nonspecific enhancement is noted along the resection cavity, not definitely
seen on preoperative imaging of mass, and likely postoperative.
There is no evidence of mass effect or midline shift. The ventricles and
sulci are grossly preserved in caliber and configuration. Minimal mucosal
thickening of all paranasal sinuses noted.
IMPRESSION:
1. Study is mildly degraded by motion.
2. Postoperative changes related interval left frontotemporal mass resection
as described.
3. Minimal nonspecific parenchymal signal intensity abnormalities within
residual tissue surrounding surgical bed, as described. While findings may
represent postoperative changes, residual tumor is not excluded on the basis
of this examination. Recommend attention on follow-up imaging.
4. Interval decreased mass effect on left lateral ventricle with no definite
evidence of midline shift.
RECOMMENDATION(S): Minimal nonspecific parenchymal signal intensity
abnormalities within residual tissue surrounding surgical bed, as described.
While findings may represent postoperative changes, residual tumor is not
excluded on the basis of this examination. Recommend attention on follow-up
imaging.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with Disorder of brain, unspecified, Unspecified convulsions, Laceration w/o fb of left eyelid and periocular area, init, Fall on same level, unspecified, initial encounter
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: ua
level of acuity: 2.0 | #Brain lesion
Mr. ___ was admitted to the neurosurgical floor for ongoing
neurological monitoring and workup of suspected brain lesion as
seen on noncontrasted head CT. He was started on Keppra 1000mg
BID and Dexamethasone 4mg Q6hrs. MRI brain with and without
contrast was performed on ___, which better characterized the
lesion, suggesting a primary brain lesion. CT Torso was negative
for overt malignancy, see below for minor findings. The patient
was discussed at ___ and evaluated by Neuro-Oncology, who
recommended total gross surgical resection. Functional MRI to
evaluate speech was done on ___ and showed the lesion pushing
on the speech center. Patient was booked for surgical tumor
resection and was taken to the OR on ___ for left craniotomy
for tumor resection with Dr. ___ a subgaleal drain was
placed. Please see separate operative report in OMR for more
information. Postop CT showed expected post-operative changes.
On POD#1, ___, the patient continued with post-operative
expressive and receptive aphasia. The subgaleal drain was
removed on ___. The patient underwent a post-operative MRI
which showed postoperative changes and minimal nonspecific
parenchymal signal intensity abnormalities within
residual tissue surrounding surgical bed; residual tumor not
excluded. He maintained on Keppra 1000mg BID and Dexamethasone
4mg Q6hr until ___. At that time, Dr ___
decreasing the Dexamethasone dose to 4mg Q8hr until follow up
with Brain Tumor Clinic outpatient. His speech progressively
improved alittle each day. Physical therapy and occupational
therapy deferred consults per nursing assessment - as patient
was independently ambulating the hallways and independent with
his ADL's. Upon day of discharge, patient had very minimal
expressive aphasia, able to have full conversation and states
that occasionally he "just has to slow down and think about the
specific words he wants to say". He remained neurologically
intact and was deemed stable for discharge. He will follow up
with Dr ___ staple removal and with Dr ___ Brain
___ Clinic appointment.
#Multiple small right sided pulmonary nodules
CT Chest was notable for multiple small right pulmonary nodules,
measauring up to 4mm. Radiology deferred to oncology for planned
follow-up. Dr ___ was emailed to refer to oncologist
outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness, Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with recently
diagnosed metastatic RCC complicated by left malignant pleural
effusion who presents s/p TPC, PE/DVT on Xarelto, paroxysmal
atrial fibrillation, and hypertension who presents with weakness
and shortness of breath.
Patient was recently ___ to ___ with acute dyspnea and found
to
have PE/DVT started on Xarelto. Her dyspnea was thought to be
multifactorial to malignant pleural effusion, PE, lymphangitic
carcinomatosis, and pulmonary nodules. Plan was made to start
cabozantinib urgently. She was discharged to rehab.
She reports that she had been recovering slowly in rehab and
ambulating with a walker since her recent discharge. She reports
that she was having her baseline dyspnea on exertion until this
morning when she was taken to the restroom without her oxygen
(the tubing did not reach far enough). When returning she had
sudden onset of shortness of breath. She had O2 increased to 5L
from ___ at baseline. She was told that her heart rate was fast
and blood pressure was low. She denies any chest pain or
palpitations.
Her husband reports that her Cabozantinib will be delivered in
afternoon of ___ and then he will bring it into the hospital.
On arrival to the ED, initial vitals were 97.7 83 97/59 18 97%
RA. Exam was notable for tachycardia and peripheral edema. Labs
were notable for WBC 11.1, H/H 8.0/27.8, Plt 275, INR 2.5, Na
132, K 5.5 -> 4.7, BUN/Cr ___, tropT < 0.01, BNP 797, lactate
3.0 -> 1.9, and UA negative. Blood and urine cultures were sent.
CXR showed bilateral pleural effusions and persistent moderate
interstitial abnormality. Patient went into rapid afib with
hypotension and was cardioverted 200J x 2 (sedated with fentanyl
25mcg IV and versed 2mg IV) with return to sinus rhythm. She was
seen by IP and left TPC was attached to pleurovac and
recommended
to place to -20 wall suction. Patient was given zosyn 4.5g IV,
vancomycin 1g IV, and 500cc NS. Prior to transfer vitals were
98.1 97 101/54 27 94% 2L.
On arrival to the floor, patient reports her breathing is
improved and back to baseline. She notes some difficulty
urinating as well as some discharge from her right eye that is
not painful or itchy. She denies fevers/chills, night sweats,
headache, vision changes, dizziness/lightheadedness,
weakness/numbness, cough, hemoptysis, chest pain, palpitations,
abdominal pain, nausea/vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
Past Medical History:
-Hypertension
-Colonic polyps
-Hyperlipidemia
-Bradycardia (first-degree AV block, asymptomatic)
-Dermatofibroma, seborrheic keratoses, actinic keratosis
-Ovarian cystectomy
-Recurrent malignant left pleural effusion s/p pleurX
-Metastatic RCC
Social History:
___
Family History:
History of lung cancer in brother and sister
(both smokers). Colon cancer (father). History of gastric ulcers
in siblings.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.3, BP 104/67, HR 91, RR 22, O2 sat 92% 2L.
GENERAL: Pleasant fatigued-appearing woman, in no distress,
lying
in bed comfortably.
HEENT: Anicteric, yellow discharge from right eye without
conjunctive erythema, PERLL, OP clear.
CARDIAC: RRR, no murmurs.
LUNG: Appears in no respiratory distress, decreased sounds at
bilateral bases, left TPC in place.
ABD: Soft, non-tender, non-distended, positive bowel sounds.
EXT: Warm, well perfused, trace bilateral lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
==============================
Discharge physical exam:
GENERAL: sitting up in bed, NAD. appears comfortable
CV: regular rate, rhythm. no m/r/g
PULM: chest tube in place, capped. lung fields with bl crackles
at bases. no wheezing
ABD: soft, ND. +BS. no TTP
Extremities: WWP, no ___ edema
Pertinent Results:
ADMISSION LABS:
___ 10:38AM BLOOD WBC-11.1* RBC-3.09* Hgb-8.0* Hct-27.8*
MCV-90 MCH-25.9* MCHC-28.8* RDW-17.2* RDWSD-56.3* Plt ___
___ 10:38AM BLOOD Glucose-249* UreaN-19 Creat-0.7 Na-132*
K-5.5* Cl-97 HCO3-15* AnGap-20*
___ 10:38AM BLOOD ALT-32 AST-52* AlkPhos-411* TotBili-0.3
___ 03:48PM BLOOD Albumin-1.5* Calcium-7.3* Phos-3.6 Mg-1.9
___ 11:56AM BLOOD pO2-38* pCO2-46* pH-7.37 calTCO2-28 Base
XS-0 Comment-GREEN TOP
___ 11:56AM BLOOD Lactate-3.0* K-4.6
CXR:
Very similar appearance of the chest with persistent moderate
interstitial
abnormality in bilateral pleural effusions. Prior studies
suggested that at least for the most part the interstitial
abnormality is due to lymphangitic carcinomatosis.
Pelvic Ultrasound
TECHNIQUE: Grayscale ultrasound images of the pelvis were
obtained with transabdominal approach followed by transvaginal
approach for further delineation of uterine and ovarian anatomy.
FINDINGS:
The uterus is anteverted and measures 8.0 cm x 4.1 cm x 4.5 cm.
The endometrium is heterogenous and measures 26 mm. Equivocal
vascularity demonstrated in the thickened endometrium.
The ovaries are normal. There is minimal free fluid.
IMPRESSION: Heterogenous thickened endometrium with equivocal
internal vascularity. Correlation with endometrial biopsy
advised
DISCHARGE LABS
Hgb 9.0, wbc 6.9, plt 188
BMP: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Ferrous Sulfate 325 mg PO DAILY
3. Milk of Magnesia 30 mL PO DAILY:PRN constipation
4. Ondansetron ODT 4 mg PO BID:PRN nausea/vomiting
5. Vitamin D ___ UNIT PO DAILY
6. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety/insomnia
7. Mirtazapine 15 mg PO QHS
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Rivaroxaban 15 mg PO BID
10. Benzonatate 100 mg PO TID:PRN cough
11. guaiFENesin 200 mg oral Q4H:PRN cough
Discharge Medications:
1. cabozantinib 40 mg oral DAILY
2. Docusate Sodium 100 mg PO BID
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Polyethylene Glycol 17 g PO BID
5. Benzonatate 100 mg PO TID:PRN cough
6. Bisacodyl 10 mg PO DAILY:PRN constipation
7. Ferrous Sulfate 325 mg PO DAILY
8. guaiFENesin 200 mg oral Q4H:PRN cough
9. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety/insomnia
10. Milk of Magnesia 30 mL PO DAILY:PRN constipation
11. Mirtazapine 15 mg PO QHS
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Ondansetron ODT 4 mg PO BID:PRN nausea/vomiting
14. Rivaroxaban 15 mg PO BID 15mg BID until ___ and then start
20mg
QD on ___. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Metastatic renal cell carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright view.
INDICATION: Rapid atrial fibrillation and dyspnea.
COMPARISON: Chest radiograph and CT from ___.
FINDINGS:
Chest tube at the base of the left hemithorax appears unchanged. Heart is
again enlarged. Mediastinal and hilar contours appear stable. Moderate
interstitial abnormality is unchanged since the prior radiographs and CT.
Prior CT had shown that this abnormality is probably, at least for the most
part, due to lymphangitic carcinomatosis.. There is a small pleural effusion
on the right and a larger one on the left, probably unchanged. The prior CT
showed that the left pleural effusion was largely loculated. Loculated
component is visible along the left lateral apex, as seen previously. There
is no visible pneumothorax.
IMPRESSION:
Very similar appearance of the chest with persistent moderate interstitial
abnormality in bilateral pleural effusions. Prior studies suggested that at
least for the most part the interstitial abnormality is due to lymphangitic
carcinomatosis.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright view.
INDICATION: Malignant left pleural effusion. Renal cell carcinoma. Status
post pigtail drainage with worsening hypoxia and tachypnea.
COMPARISON: ___.
FINDINGS:
Basilar chest tube appears unchanged on the left. A loculated pleural
effusion is largely resolved along the lateral left lung apex. Small to
medium size right-sided pleural effusion appears possibly increased. Probable
persistent a pleural effusion on the left which is hard to distinguish from
parenchymal opacities that probably reflect moderate worsening pulmonary edema
in addition to retrocardiac atelectasis. No visible pneumothorax.
RECOMMENDATION(S): Worsening, now moderate, pulmonary edema. Possible
increase in right pleural effusion. Resolution of loculated left apical
pleural effusion. Any remaining left-sided pleural effusion is difficult to
quantify but would not be expected to be large.
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: metastatic RCC with vaginal bleeding// vaginal bleeding
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: Abdominal CT done ___
FINDINGS:
The uterus is anteverted and measures 8.0 cm x 4.1 cm x 4.5 cm. The
endometrium is heterogenous and measures 26 mm. Equivocal vascularity
demonstrated in the thickened endometrium.
The ovaries are normal. There is minimal free fluid.
IMPRESSION:
Heterogenous thickened endometrium with equivocal internal vascularity.
Correlation with endometrial biopsy advised
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old woman with metastatic RCC c/b L malignant pleural
effusion s/p TPC, PE/DVT on Xarelto, now with worsened hypoxia and dyspnea//
Interval change in pleural effusion? Pulmonary edema? Interval change in
pleural effusion? Pulmonary edema?
IMPRESSION:
Compared to chest radiographs ___ through ___.
Increasing, moderate to large pleural effusions, exaggerate the severity of
pulmonary edema. Cardiac silhouette is obscured, but probably enlarged.
Stable, dense left lower lobe consolidation could be atelectasis alone or in
combination with pneumonia. Moderate right lower lobe atelectasis has
increased.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with Paroxysmal atrial fibrillation
temperature: 97.7
heartrate: 83.0
resprate: 18.0
o2sat: 97.0
sbp: 97.0
dbp: 59.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ was admitted to the hospital and immediately
transfused one unit of PRBCs. She was started on cabozanatib
that evening. Her course was complicated by worsening hypoxic
respiratory failure -- likely driven by enlarging left pleural
effusion, perhaps in the setting of starting cabozanatib, which
resolved with two doses of IV furosemide, as well as severe
constipation requiring manual disimpaction. Her carbozanatib
was increased on ___ to 40 mg daily and she was monitored for
side effects without any. Her course was complicated by vaginal
bleeding on ___. Workup with a pelvic ultrasound showed a
thickened endometrium. Gynecology was consulted and discussed
endometrial biopsy with patient. After discussion, pt decided to
not pursue biopsy as she does not wish to pursue hysterectomy in
the case that biopsy positive for endometrial cancer (no
chemotherapy options). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chronic cough and night sweats
Major Surgical or Invasive Procedure:
Induced sputum x3
History of Present Illness:
___ with hx depression, UGIB, hyperprolactinemia presenting
with cough for over one year, night sweats, and 26 lb
unintentional weight loss, as well as recent trip to ___. The
patient reports that she develoepd a dry cough over one year ago
which has not improved. She was recently traveling to ___
where she was treated for bronchitis with a course of
antibiotics, with no clinical improvement. This has been a
mostly dry cough although sometimes is productive of clear
sputum. Over the past few months it has gotten continually
worse. She also notes 26 lb unintentional weight loss and
drenching night sweats for the last year. She reports that she
has never been tested for TB. Recently her PCP chest ___ which
showed some hyperinflation and that pulmonary function tests
which were normal. Denies hematemesis, sore throat, rashes,
diarrhea, n/v.
Past Medical History:
DEPRESSION
DUODENAL ULCER :EGD ___, ___
HYPOGONADISM
HYPERPROLACTINEMIA
INSOMNIA
POSSIBLE SEIZURE HISTORY
Social History:
___
Family History:
No family history of neurologic or autoimmune disease known.
Physical Exam:
ADMISSION PHYSICAL:
Vital Signs: 98.2 PO 118 / 87 67 18 100 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, 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
Neuro: CNII-XII intact, ___ strength upper/lower extremities
DICHARGE PHYSICAL:
Vitals: 98.4 90/51 59 16 100%RA
General: Alert, oriented x4, nontoxic, flat mood and affect
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
INITIAL LABS:
___ 05:05PM BLOOD WBC-5.1 RBC-4.11 Hgb-11.8 Hct-35.5 MCV-86
MCH-28.7 MCHC-33.2 RDW-13.6 RDWSD-42.7 Plt ___
___ 05:05PM BLOOD Neuts-53.0 ___ Monos-8.3 Eos-0.8*
Baso-1.0 Im ___ AbsNeut-2.70 AbsLymp-1.86 AbsMono-0.42
AbsEos-0.04 AbsBaso-0.05
___ 05:05PM BLOOD Plt ___
___ 05:05PM BLOOD Glucose-91 UreaN-15 Creat-0.8 Na-140
K-4.0 Cl-108 HCO3-23 AnGap-13
___ 05:24PM BLOOD Lactate-0.8
DISCHARGE LABS:
___ 07:40AM BLOOD WBC-4.2 RBC-4.23 Hgb-12.1 Hct-36.9 MCV-87
MCH-28.6 MCHC-32.8 RDW-13.7 RDWSD-43.4 Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-83 UreaN-9 Creat-0.8 Na-139 K-4.1
Cl-105 HCO3-25 AnGap-13
___ 07:40AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.2
MICROBIOLOGY:
Acid fast smear and culture x3 (___): negative
Blood culture (___): no growth
MTB direct amplification (___): M. TUBERCULOSIS DNA NOT
DETECTED BY NAAT
STUDIES:
CT CHEST W/O CONTRAST (___): 1.Trace bilateral pleural
effusions. 2. No evidence of tuberculosis or pulmonary mass.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LamoTRIgine 100 mg PO BID
2. QUEtiapine Fumarate 50 mg PO QHS
3. LORazepam 0.5 mg PO BID:PRN anxiety
4. cabergoline 0.5 mg oral 2X/WEEK
5. linaclotide 145 mcg oral DAILY
6. FLUoxetine 30 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY as needed
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
9. Amantadine 100 mg PO DAILY
10. Benzonatate 100 mg PO TID:PRN cough
11. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
2. cabergoline 0.5 mg oral 2X/WEEK
3. FLUoxetine 30 mg PO DAILY
4. LamoTRIgine 100 mg PO BID
5. linaclotide 145 mcg oral DAILY
6. QUEtiapine Fumarate 50 mg PO QHS
7. Omeprazole 40 mg PO QAM
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
9. Amantadine 100 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY as needed
12. LORazepam 0.5 mg PO BID:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Gastroesophageal reflux disease
- Constipation
- Depression
- Insomnia
SECONDARY DIAGNOSES:
- DUODENAL ULCER:EGD ___, ___
- HYPOGONADISM
- HYPERPROLACTINEMIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ female with chronic cough, weight loss, night sweats.
The patient denies hemoptysis. Evaluate for tuberculosis or mass.
TECHNIQUE: Axial MDCT images were obtained through the chest without
intravenous contrast material. Reformatted coronal and sagittal axis images
were obtained and reviewed.
DOSE: Total DLP (Body) = 244 mGy-cm.
COMPARISON: Chest radiograph from ___ and ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: There is no axillary or
supraclavicular lymphadenopathy. The thyroid is homogeneous and unremarkable.
MEDIASTINUM: There is no mediastinal mass. There is no mediastinal
lymphadenopathy. The esophagus is normal in caliber and course, and there is
no hiatal hernia.
HILA: No hilar lymphadenopathy is noted.
HEART and PERICARDIUM: The heart is normal in size, there is no significant
coronary artery calcifications. There is no significant pericardial effusion.
The thoracic aorta is normal in caliber and course, with no significant
atherosclerotic disease noted.
PLEURA: There are trace bilateral pleural effusions. There is no
pneumothorax.
LUNG:
-PARENCHYMA: Bilateral dependent atelectasis is noted. The lungs are clear
without focal consolidation to suggest pneumonia. There is no suspicious
pulmonary is nodules or masses.
-AIRWAYS: The airways are patent to the subsegmental level.
-VESSELS: The pulmonary artery is normal in caliber.
CHEST CAGE: There is no suspicious osseous lesion, and there is no acute
fracture.
UPPER ABDOMEN: The visualized aspects of the upper abdomen are within normal
limits.
IMPRESSION:
1. Trace bilateral pleural effusions.
2. No evidence of tuberculosis or pulmonary mass.
Gender: F
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Cough
Diagnosed with Cough
temperature: 98.6
heartrate: 70.0
resprate: 20.0
o2sat: 99.0
sbp: 116.0
dbp: 71.0
level of pain: 5
level of acuity: 3.0 | BRIEF SUMMARY:
Ms. ___ is a ___ F with a Hx significant for depression
and travel to ___ who presents with persistent dry cough and
night sweats who was admitted for a TB work-up. Patient is in
stable condition with improving cough and pending AFB smears.
ACUTE ISSUES:
# Cough: Dry cough for over a year now. Initially only in the
mornings but not persists throughout the day and has worsened
over the past couple months. TB work up with AFB smears x3 and
MTB Direct amplification were negative. CT chest did not reveal
any masses or signs of TB. CT did reveal small bilateral pleural
effusions. On further questioning, patient confirms having
history of acid reflux symptoms such as retrosternal burning and
acid taste in mouth. She also confirms that her cough is worse
after eating. Patient was started on omeprazole in the hospital,
and in the subsequent days, her cough significantly improved.
Will continue omeprazole after discharge.
# GERD: has a history of acid reflux with associated
retrosternal burning and acid taste in mouth. Will send home
with omeprazole 40mg QAM.
# Depression: Patient's psychiatrist passed away earlier this
years and has not been able to get an appointment with another
psychiatrist. Concerned that the fluoxetine is not working for
her. Denies suicidal or homicidal ideations throughout hospital
course. Was seen by social work who will look into options for
outpatient mental health services (psychiatry & psychotherapy),
and will f/u w/ pt after discharge.
# Chronic constipation: was on home medication of linaclotide
which according to her causes diarrhea. We begun senna and
bisacodyl instead which also caused diarrhea. We switched all
constipation medications to PRN and will not be discharged on
any new constipation medications. |
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, leg swelling
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ y/o man with h/o prior R MCA stroke, prior LV thrombus on
chronic anticoagulation, IDDM II, HTN, dyslipidemia, HFrEF
(EF35-40%), and recent admission (discharged ___ for R
parietal stroke, presenting with worsening ___ edema.
Patient recently was released from rehab following this recent
admission. On follow-up 6 days prior to this presentation,
recently had labs indicating ___ (Cr from baseline 1.6-1.8 up to
2.2) and per OMR notes, PCP recommended stopping HCTZ,
increasing fluid intake, and starting amlodipine.
One day PTA, patient began noticing lower extremity edema left
worse than right, beyond baseline. He denies pain, motor or
sensory deficits. He also endorses increased SOB as well as some
lightheadedness with minimal exertion on morning of
presentation. No palpitations, chest pain, chest pressure, PND,
orthopnea. For these sx, came into ED for further evaluation.
ROS otherwise + for diarrhea.
He currently feels well apart from swollen legs.
In the ED initial vitals were: 98.6 78 162/90 18 99%RA
EKG: new TWI in I, LVH with repol changes, otherwise unchanged
from prior
Labs/studies notable for: SCr 2.7 from baseline in mid 1's,
proBNP 1886, WBC 4.8, H/H 10.6/33.1
CXR on my read notable for increased pulmonary vascular
congestion, no focal PNA, no pleural effusions. ___ negative
for DVT.
Patient was given 20mg IV Lasix
Vitals upon transfer 97.2 75 155/100 18 99% RA
On the floor pt is accompanied by his daughters. Pt is
currently living alone, and they attempted to get him a home
health aid for medication teaching, but that person has not been
to the house yet. Mr. ___ currently lives alone. Additionally
he reports x1 episode of nausea today. His daughters report that
he frequently has numbness and tingling in his extremities. They
also report he was converted to 24U of lantus with lunch because
doing sliding scale insulin was becoming to difficult for their
father.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia,
+diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Hypertension
- type 2 diabetes
- hx CVA ___: thought to have been embolic in nature (see
neuro note from ___ in the setting of having stopped the
warfarin he was taking for LV thrombus. Neurology recommended
ASA/warfarin long-term. Pt with residual L sided weakness
- cardiomyopathy: followed by Dr. ___ ___, no
thrombus noted at that time
- BPH
- chronic kidney disease: creatinine baseline ~1.5 since ___
Social History:
___
Family History:
one brother with type 2 diabetes. Mother died of CVA at ___,
father died of CVA at ___.
Physical Exam:
On admission:
VS: T= 98.1 BP= 150/72 HR= 74 RR= 14 O2 sat= 98% RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
Becomes winded when asked to sit up for examination
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. ___ systolic murmur heard best LLSB. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Soft end-expiratory
wheezing particularly in lower lobes with decreased breath
sounds at bilateral bases.
ABDOMEN: Firm, NTND. No HSM or tenderness.
EXTREMITIES: 1+ RLE, 2+ LLE edema, no cyanosis or clubbing,
warm and well perfused. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
On discharge:
Vitals: 98 ___ 100/RA
GENERAL: WDWN in NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with flat JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. ___ systolic murmur heard best LLSB. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use.
ABDOMEN: soft NT, no longer any distension. No HSM or
tenderness.
EXTREMITIES: trace L>R edema, no cyanosis or clubbing, warm and
well perfused. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
On admission:
___ 12:45PM BLOOD WBC-4.8 RBC-3.83* Hgb-10.6* Hct-33.1*
MCV-86 MCH-27.7 MCHC-32.0 RDW-15.0 RDWSD-47.1* Plt ___
___ 12:45PM BLOOD Neuts-76.1* Lymphs-13.4* Monos-8.2
Eos-1.5 Baso-0.6 Im ___ AbsNeut-3.63 AbsLymp-0.64*
AbsMono-0.39 AbsEos-0.07 AbsBaso-0.03
___ 05:54PM BLOOD ___
___ 12:45PM BLOOD Glucose-81 UreaN-45* Creat-2.7* Na-141
K-4.3 Cl-104 HCO3-23 AnGap-18
___ 12:45PM BLOOD ALT-15 AST-24 LD(LDH)-296* AlkPhos-70
TotBili-0.3
___ 12:45PM BLOOD CK-MB-5 cTropnT-0.02* proBNP-1886*
___ 12:45PM BLOOD Calcium-8.8 Phos-4.2 Mg-2.5
___ 07:08AM BLOOD TSH-1.8
___ 07:08AM BLOOD T4-7.8
On discharge:
___ 05:55AM BLOOD WBC-5.4 RBC-3.35* Hgb-9.3* Hct-29.1*
MCV-87 MCH-27.8 MCHC-32.0 RDW-14.7 RDWSD-46.3 Plt ___
___ 05:55AM BLOOD ___ PTT-37.7* ___
___ 05:55AM BLOOD Glucose-234* UreaN-33* Creat-2.1* Na-138
K-3.6 Cl-100 HCO3-28 AnGap-14
___ 05:55AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.1
Pertinent labs:
___ 12:45PM BLOOD CK-MB-5 cTropnT-0.02* proBNP-1886*
___ 07:08AM BLOOD CK-MB-4 cTropnT-0.02*
Micro:
___ 10:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. >100,000 ORGANISMS/ML..
PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION.
Reports:
CHEST (PA & LAT) Study Date of ___ 2:21 ___
IMPRESSION:
Mild cardiomegaly with pulmonary vascular congestion. No frank
pulmonary
edema or consolidation.
UNILAT LOWER EXT VEINS LEFT Study Date of ___ 4:21 ___
IMPRESSION:
1. No evidence of deep venous thrombosis in the left lower
extremity veins.
2. Sluggish blood flow is identified in the bilateral common
femoral veins.
RENAL U.S. Study Date of ___ 11:43 AM
IMPRESSION:
1. Bilateral hydronephrosis is moderate in severity.
2. Bladder is distended with coarse wall trabeculation.
Partially imaged
prostate appear enlarged and bulges into the bladder neck.
Findings may
reflect bladder outlet obstruction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Carvedilol 25 mg PO BID
3. Doxazosin 8 mg PO HS
4. HydrALAZINE 25 mg PO Q8H
5. Warfarin 5 mg PO/NG 5X/WEEK (___)
6. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
7. Docusate Sodium 100 mg PO BID:PRN Constipation
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
9. Senna 8.6 mg PO BID:PRN Constipation
10. Warfarin 7.5 mg PO 2X/WEEK (MO,FR)
11. amLODIPine 10 mg PO DAILY
12. Glargine 24 Units Lunch
Discharge Medications:
1. Potassium Chloride 20 mEq PO DAILY
Hold for K >
RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Atorvastatin 20 mg PO QPM
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Carvedilol 25 mg PO BID
5. Docusate Sodium 100 mg PO BID:PRN Constipation
6. HydrALAZINE 25 mg PO Q8H
7. Glargine 15 Units Lunch
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
9. Senna 8.6 mg PO BID:PRN Constipation
10. Warfarin 5 mg PO DAILY16
11. Finasteride 5 mg PO DAILY
RX *finasteride 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Obstructive nephropathy
___ on CKD
Acute on chronic HFrEF
Hypertension
Insulin dependent diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with multiple prio rstrokes, EF25%, recent
changes in diuretic medications, presenting with worsening ___ from baseline
1.8 to 2.7, increasing SOB, increased ___ edema, elevated BNP, evaluate for
etiology of shortness of breath.
TECHNIQUE: Chest PA and lateral
COMPARISON: Prior chest radiographs dating back to ___.
FINDINGS:
Moderate cardiomegaly is unchanged from prior studies. There is mild
pulmonary vascular congestion with vascular redistribution to the upper lungs.
There is no frank pulmonary edema. There is no focal consolidation,
pneumothorax, or pleural effusion. The cardiomediastinal contour is normal.
IMPRESSION:
Mild cardiomegaly with pulmonary vascular congestion. No frank pulmonary
edema or consolidation.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old man with CHF, multiple CVA's, presenting with L>R ___
swelling. Also with ___. Assess for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the tibial and peroneal veins.
Sluggish flow is identified in the bilateral common femoral veins.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
1. No evidence of deep venous thrombosis in the left lower extremity veins.
2. Sluggish blood flow is identified in the bilateral common femoral veins.
Radiology Report
EXAMINATION: RENAL U.S. PORT
INDICATION: ___ year old man with ___ on CKD, CKD thought to be d/t DM and HTN
// c/f hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 10.8 cm. The left kidney measures 11.9 cm. There
are moderate bilateral hydronephrosis. There is no stones, or masses
bilaterally. Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally.
The bladder is distended with irregular posterior wall which may reflect
coarse trabeculation. Partially imaged prostate appear enlarged and bulges
into the bladder neck. Bilateral urinary jets could not be demonstrated.
IMPRESSION:
1. Bilateral hydronephrosis is moderate in severity.
2. Bladder is distended with coarse wall trabeculation. Partially imaged
prostate appear enlarged and bulges into the bladder neck. Findings may
reflect bladder outlet obstruction.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea, Leg swelling
Diagnosed with Acute kidney failure, unspecified, Localized edema
temperature: 98.6
heartrate: 75.0
resprate: 18.0
o2sat: 100.0
sbp: 139.0
dbp: 89.0
level of pain: 0
level of acuity: 2.0 | Mr ___ is a ___ y/o man with h/o prior R MCA stroke, prior LV
thrombus on chronic anticoagulation, IDDM II, HTN, dyslipidemia,
HFrEF (EF35-40%), and recent admission (discharged ___ for
R parietal stroke, who presented with worsening ___ edema and ___
on CKD.
#Acute on chronic kidney disease: Pt presented with dyspnea,
orthopnea, ___ edema and pulmonary congestion on CXR with
elevated proBNP. He additionally had worsening creatinine, which
was concerning for worsening cardiac function. The patient was
trialed on diuresis with improvement in his ___ edema and
dyspnea, but worsened his renal function. He had a renal
ultrasound which showed bilateral moderate hydronephrosis,
distended bladder and probable bladder outlet obstruction from
his prostate. The patient was thus diagnosed with
post-obstructive nephropathy. However, he declined catheter
placement for several days until convinced by family om ___.
After placement, he drained > 9L the first day with improvement
in swelling and renal function. Foley trauma resulted in clots
requiring manual irrigation that resolved prior to discharge. He
will keep the foley in place until follow up in ___
for voiding trial.
#HTN: Continued on home doxazosin, hydralazine, and carvedilol.
Amlodipine was d/c'd for ___ swelling. ACE-I was held in the
setting of ___, but should be re-evaluated as an outpatient.
#Anemia: Pt with new onset anemia, no evidence of blood loss on
exam or history. Guaiac negative in the ED. Continued to
downtrend in the setting of supratx INR.
#IDDM: Pt placed on reduced dose QHS lantus and ISS QACHS.
#H/o LV thrombus: Patient presented with an INR that was
supratherapeutic on admission and Coumadin was held until within
goal range ___. Patient was restarted on Coumadin prior to
discharge.
#Constipation: Patient had multiple days without bowel movement.
He was given an aggressive bowel regimen with senna, docusate,
and miralax and was able to have regular bowel movements. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Keflex
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with PMHx of TIA, HIV, inclusion body
myositis, PFO, afib (s/p ablation) who presents with L-sided
pleuritic sharp localized CP, starting at 5:30am on the morning
of admission. He was sitting on his computer this morning when
he
suddenly started to feel sharp pains on his left lateral ribcage
that were intermittent and exacerbate with deep inspiration. He
denies any trauma. He denies any shortness of breath or
palpitations. He denies any recent fever, cough, or sore throat.
Otherwise denies any abdominal pain, urinary symptoms, or stool
changes. He denies any personal or family history of blood
clots.
He also denies any recent long travel.
Of note, he started taking "Spartagen XT" and a "caffeine" pill
(name unknown) for erectile dysfunction last week. He also notes
a lump in the muscle on the left side of his neck, associated
with pain, that started 3 days ago, but has gotten better with
massage.
In the ED, initial vitals: 98.0, 72, 160/84, 19, 94% on RA. His
labs were notable for troponin of 0.09 (repeat 0.06), D-dimer
2240, CK 1232, MB 30, proBNP 71, H/H 13.5/38.4. He had a CT-A
that showed bilateral segmental and subsegmental pulmonary
embolism most notably in the lower lobes.
EKG FINDINGS: NSR, unchanged from prior EKG
In the ED, he was given 4mg IV morphine, 325mg aspirin.
Past Medical History:
- HIV (last CD4 count 967 in ___, VL undetectable)
- Stroke in ___
- Hypertension
- Inclusion body myositis in bilateral thighs
- HIV related sensory polyneuropathy
- Cerebral microvascular disease, status post infarction
posterior limb of the left carpus internal capsule, left corona
radiata, right basal ganglia and left thalamus.
- Probable inclusion body myositis (never biopsied)-uses
Rollator
walker at baseline for gait assistance. Has a frame toilet seat
and shower stool at home.
- Hypogonadism on replacement therapy
- Hyperlipidemia
- Atrial fibrillation: s/p ablation
- S/P cholecystectomy
- History of anal dyplasia
- Restless leg syndrome
- Episodes of vertigo: intermittent for years
Social History:
___
Family History:
Heart disease. no family with myopathies, strokes, or other
neurologic disease
Physical Exam:
VS: 98.1F, 155/85, 75, 22, 96% on RA
GEN: Alert, lying in bed, no acute distress. Temporal wasting
present.
HEENT: Dry MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema, no erythema or palpable
cords. Muscle wasting at the thighs bilaterally.
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
===============
___ 06:25AM BLOOD WBC-9.8 RBC-4.00* Hgb-13.5* Hct-38.4*
MCV-96 MCH-33.8* MCHC-35.2 RDW-12.7 RDWSD-45.0 Plt ___
___ 06:25AM BLOOD Neuts-55.6 ___ Monos-11.3 Eos-3.9
Baso-0.4 Im ___ AbsNeut-5.46 AbsLymp-2.75 AbsMono-1.11*
AbsEos-0.38 AbsBaso-0.04
___ 10:00PM BLOOD PTT-72.9*
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-99 UreaN-14 Creat-0.8 Na-141
K-4.4 Cl-105 HCO3-21* AnGap-15
___ 12:31PM BLOOD CK(CPK)-1232*
___ 06:25AM BLOOD cTropnT-0.09*
___ 12:31PM BLOOD CK-MB-30* MB Indx-2.4
___ 12:31PM BLOOD cTropnT-0.06*
___ 06:25AM BLOOD D-Dimer-2240*
NOTABLE ADMISSION LABS
=======================
___ 07:03AM BLOOD CK(CPK)-711*
___ 07:03AM BLOOD CK-MB-12* MB Indx-1.7 cTropnT-0.09*
DISCHARGE LABS
===============
___ 07:20AM BLOOD WBC-9.4 RBC-4.16* Hgb-13.9 Hct-39.5*
MCV-95 MCH-33.4* MCHC-35.2 RDW-12.3 RDWSD-42.8 Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD PTT-61.8*
___ 07:20AM BLOOD Glucose-111* UreaN-14 Creat-0.7 Na-142
K-4.0 Cl-103 HCO3-25 AnGap-14
___ 07:20AM BLOOD CK(CPK)-372*
___ 07:20AM BLOOD CK-MB-9 MB Indx-2.4 cTropnT-0.07*
___ 07:20AM BLOOD Calcium-10.3 Phos-3.3 Mg-2.0
IMAGING
=========
___: CXR:
FINDINGS:
Low lung volumes with bibasilar atelectasis noted. No
convincing evidence for
pneumonia or edema. Cardiomediastinal silhouette appears
stable. No
pneumothorax or large effusion. Bony structures are intact.
IMPRESSION:
Bibasilar atelectasis.
___: CTA CHEST:
IMPRESSION:
Bilateral segmental and subsegmental pulmonary emboli most
notable in the
lower lobes with areas of lower lobe infarction and atelectasis.
No signs of
right heart strain.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY
2. Acyclovir 400 mg PO Q8H
3. Atorvastatin 10 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Diazepam 5 mg PO QHS:PRN anxiety
6. Gabapentin 600 mg PO QAM
7. Nevirapine 400 mg PO DAILY
8. Pramipexole 0.125 mg PO QHS
9. omeprazole 20 mg oral DAILY
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
2. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth twice a day
Disp #*42 Tablet Refills:*0
3. Acyclovir 400 mg PO Q8H
4. Atorvastatin 10 mg PO QPM
5. Diazepam 5 mg PO QHS:PRN anxiety
6. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY
7. Gabapentin 600 mg PO QAM
8. Nevirapine 400 mg PO DAILY
9. omeprazole 20 mg oral DAILY
10. Pramipexole 0.125 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with left sided chest pain// please evaluate for evidence of
musculoskeletal injury, infectious process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___ and ___.
FINDINGS:
Low lung volumes with bibasilar atelectasis noted. No convincing evidence for
pneumonia or edema. Cardiomediastinal silhouette appears stable. No
pneumothorax or large effusion. Bony structures are intact.
IMPRESSION:
Bibasilar atelectasis.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ with chest pain and elevated D dimer// PE
TECHNIQUE: Multidetector CT through the chest performed with IV contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DLP: Total DLP (Body) = 221 mGy-cm.
COMPARISON: Prior exam is dated ___
FINDINGS:
The imaged base of neck including the thyroid is unremarkable aside from a
punctate calcification in the inferior left thyroid lobe. Thoracic aorta is
normal in course and caliber without significant atherosclerotic
calcification. The main pulmonary artery and central branches are patent.
Extensive segmental and subsegmental pulmonary emboli seen bilaterally most
notably involving the lower lobes with associated consolidation concerning for
a component of infarction and probable atelectasis. No evidence of right
heart strain. The heart is within normal limits of size without pericardial
effusion. No lymphadenopathy. No pleural effusion. No worrisome nodule or
mass. No signs of pneumonia. Airways centrally patent.
Within the upper abdomen, no abnormalities are detected.
Bones: Bony structures appear intact without worrisome lytic or blastic
osseous lesion.
IMPRESSION:
Bilateral segmental and subsegmental pulmonary emboli most notable in the
lower lobes with areas of lower lobe infarction and atelectasis. No signs of
right heart strain.
NOTIFICATION: D/W ___ (MED STUDENT)
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 99.3
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 157.0
dbp: 95.0
level of pain: 1
level of acuity: 3.0 | ___ year old male with history of HIV, TIA, inclusion body
myositis, PFO, afib s/p ablation who presented with left sided
pleuritic chest pain, found to have bilateral segmental and
subsegmental pulmonary emboli with elevated troponins. He was
started on a heparin drip then transitioned to rivaroxaban prior
to discharge. He has had elevated troponins on prior admissions,
and he had no EKG changes on this admission, so the elevated
troponin was attributed to his inclusion body myositis, which
can cause this abnormality. Neurology was consulted to comment
on the elevated troponin in the context of inclusion body
myositis and advised that he stop his clopidogrel in the setting
of starting rivaroxaban. The cause of his PE remains unclear:
chronic inflammation from inclusion body myositis, testosterone
augmenting herbal supplements, and decreased activity ___ hip OA
and inclusion body myositis may have contributed. He will get
outpatient hematology ___ for hypercoagulability and an
outpatient PCP malignancy ___.
#Submassive pulmonary embolism
#Chest pain
The patient presented with chest pain, found on CTA to be a
bilateral PE. He had elevated trops, but no EKG changes, in the
ED, but these were consistent with prior elevated trops and were
attributed to his inclusion body myositis, which can cause
elevated troponins (it was resassuring that his CK and CK-MB
were both elevated and trended together). Thus, his PE was
determined not to be submassive. The cause of the PE remains
unclear: the patient denied any recent travel and had no signs
of DVT on physical exam. Other possible causes of the PE include
starting herbal testosterone enhancing supplements, occult
malignancy, chronic inflammatory state from inclusion body
myositis, decreased mobility ___ OA and myositis, or baseline
hypercoagulability.
The patient was started on a heparin drip then transitioned to
rivaroxaban prior to discharge. He was seen by neurology who
recommended that his clopidogrel be stopped in the setting of
starting rivaroxaban (patient was getting clopidogrel because of
a stroke in ___ and confirmed that inclusion body myositis can
cause both hypercoagulability and elevated troponins, he also
appeared to be in a flare of his myositis upon admission
secondary to his clinical symptoms and elevated CK level. The
risks and benefits of starting on an anticoagulant, especially
given that the patient has some fall risk, were discussed with
the patient. He stated understanding of risks and benefits and
stated that he did want to continue anticoagulation therapy at
this time. He will have follow up with Hematology as well as
Neurology, and close follow up with his PCP to pursue any
further age-appropriate cancer screening needed.
# Elevated troponin: The patient presented with trops x3 0.09,
0.07, 0.09, but no chest pain or EKG changes. This is consistent
with elevated troponins that patient has had on prior
admissions. Furthermore, Neurology saw the patient and confirmed
that this elevation can occur in the context of inclusion body
myositis, per above, and is less concerning for cardiac
ischemia. His elevated CK and CKMB are consistent with this as
well.
# Erectile dysfunction: Patient expresses considerable distress
around erectile dysfunction, which prompted him to take an
herbal testosterone enhancing supplement, which may have
contributed to the development of his PE. He should avoid these
in future. He has seen a urologist for this in the past and has
tried Viagra without resolution of symptoms. He can follow-up
with urology as an outpatient.We discussed importance of
stopping herbal testosterone supplements at this time.
# Hypertension - Patient was admitted with no known history of
hypertension and on no antihypertensive medications. However in
review of previous ___ records it was noted that he has had
elevated BP readings during his past few output. appointments.
His BP was elevated to the 130s-160s SBP during this admission,
and he was started on amlodipine 2.5mg. He will have follow up
with his PCP next week and can taper up on his medications as
needed. |
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 appendectomy
History of Present Illness:
This patient is a ___ year old male who complains of ABD
PAIN, ABNL LABS. This is a male with a remote history of
ruptured cerebral aneurysm presenting with abdominal pain
starting at midnight last night, kept him up, worsening
through the day with poor appetite. Vomited tonight several
times. Found to have an elevated WBC and referred to the ED
for imaging. No diarrhea. No swelling in groin.
Past Medical History:
cerebral aneurysm ___ years ago
Social History:
___
Family History:
non-contributory
Physical Exam:
Temp: 98.5 HR: 85 BP: 101/84 O(2)Sat: 97 Normal
Constitutional: The set, pleasant, in no acute distress
Chest: Normal
Cardiovascular: Normal
Abdominal: Soft, obese, tender to palpation in the right
lower quadrant without rigidity, positive guarding
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry
Neuro: Normal
Psych: Normal mentation
T99.4 HR 102 BP 117/66 RR 20 92% on RA
Gen: alert, pleasant, nontoxic, appears comfortable
HEENT: mmm
CV: RRR no m/r/g
Pulm: ctab nonlabored breathing
Abd: soft, appropriately tender, nondistended. port sites with
gauze/tegaderm in place.
Ext: no ___, wwp
Gait: nml
Pertinent Results:
WBC 15.6, 80% neutrophils
HCT 46.0
CT Abd ___
1. Acute tip appendicitis with dilated distal appendix
measuring 14 mm with surrounding inflammatory stranding and
fluid in the right lower quadrant. Microperforation cannot be
excluded.
2. Cholelithiasis without evidence of cholecystitis.
3. Fatty liver.
4. Right duplex kidney with duplicated collecting systems but
no evidence of obstruction.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Ciprofloxacin HCl 500 mg PO/NG Q12H Duration: 2 Weeks
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth Two times a day
Disp #*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
Please take as needed
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours as needed
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute nonperforated appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right lower quadrant pain with nausea and vomiting, here to
evaluate for appendicitis.
COMPARISON: No prior studies available.
TECHNIQUE: MDCT-acquired axial images were obtained from the lung bases to
the pubic symphysis following the uneventful administration of 150 mL
Omnipaque intravenous contrast. No enteric contrast was administered.
Coronally and sagittally reformatted images were generated and reviewed.
FINDINGS:
LUNG BASES: The visualized lung bases are clear. Limited imaging of the
heart shows normal size without pericardial effusion. The distal esophagus
and descending thoracic aorta are within normal limits.
ABDOMEN: The liver is diffusely hypoattenuating, compatible with hepatic
steatosis. Relative ___ at the gallbladder fossa is compatible
with focal fatty sparing. No focal hepatic lesion is detected. The portal
venous system is satisfactorily opacified with intravenous contrast. No
biliary dilation is seen. The gallbladder contains at least one radiopaque
gallstone in the neck of the gallbladder. The gallbladder is mildly distended
without gallbladder wall thickening, edema or pericholecystic fluid to suggest
cholecystitis. The pancreas, spleen and bilateral adrenal glands are within
normal limits. Both kidneys enhance symmetrically and excrete contrast
normally without evidence of hydronephrosis. Note is made of a duplex right
kidney with duplicated collecting system to the level of the urinary bladder.
A subcentimeter hypodensity in the lower pole of the left kidney is too small
to fully characterize, but most likely represents a renal cyst. No suspicious
renal lesion is detected.
The stomach and intra-abdominal loops of small and large bowel are normal in
caliber without evidence of wall thickening or obstruction. There is a
tubular, fluid-filled and rim-enhancing structure in the right lower quadrant
contiguous with a normal caliber proximal appendix, which is thought to
represent dilation of the appendiceal tip, measuring 14 mm in maximum diameter
(601B:36). There is surrounding fat stranding and fluid, but no focal air.
No free air or ascites is present. Multiple retroperitoneal lymph nodes do
not meet CT size criteria for lymphadenopathy. No mesenteric lymphadenopathy
is seen.
The abdominal aorta is normal in caliber throughout.
PELVIS: The urinary bladder, seminal vesicles, rectum and sigmoid colon are
within normal limits. The prostate is mildly enlarged. Note is made of a
small fat-containing right inguinal hernia. There is no free pelvic fluid or
inguinal/pelvic lymphadenopathy.
OSSEOUS STRUCTURES: No osseous destructive lesion concerning for malignancy
is detected.
IMPRESSION:
1. Acute tip appendicitis with dilated distal appendix measuring 14 mm with
surrounding inflammatory stranding and fluid in the right lower quadrant.
Microperforation cannot be excluded.
2. Cholelithiasis without evidence of cholecystitis.
3. Fatty liver.
4. Right duplex kidney with duplicated collecting systems but no evidence of
obstruction.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN, ABNL LABS
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 98.5
heartrate: 85.0
resprate: nan
o2sat: 97.0
sbp: 101.0
dbp: 84.0
level of pain: 3
level of acuity: 3.0 | Mr. ___ was admitted to the ACS service on ___ for acute
appendicitis and was taken to the OR for laparoscopic
appendectomy. He was started on IV ciprofloxacin/metronidazole
in the ER prior to the operation. The appendix was found to be
non-perforated during the operation and there were no
complications. He was sent to the floor and his diet was
advanced to regular which he tolerated well. His antibiotics
and IV fluids were stopped. His foley was discontinued, and 6
hours later he had not voided. A bladder scan was performed
which revealed only 250cc of fluid. A 500cc bolus of fluid was
then given. He then voided several hours later, however at this
point it was late into the night and thus he stayed for an
additional day. At this time the laboratory reported that one
of his blood cultures taken in the emergency department had
grown gram-negative rods. He had been afebrile for >24 hours
and on exam was non-toxic and appeared comfortable.
Nonetheless, we restarted ciprofloxacin for a two week course.
Sensitivities for the blood culture are still pending and may
need to be changed if they are found to be resistant to
ciprofloxacin. He was ambulating without assistance and taking
oral pain medication. He will follow up in the ___ clinic in
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:
fever, cough, dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ h/o Hodgkin's lymphoma s/p C6 ABVD (___) who presents
to
the ED with cough, dysuria and fever. States his symptoms
started
on ___ with rigors, a new dry cough, and dysuria. +DOE that
is
chronic and unchanged. Denied CP. Admits to runny nose that is
chronic. No sore throat. No myalgias/arthalgias/rash. No abd
pain, no changes in bowel habits. Admits to new RUE swelling.
In the ED, initial VS were: 99.8 108 103/59 20 94% RA.
Labs were notable for: Cr bump, lactate 3.3
Imaging included: CXR; results as below
Treatments received:
NS bolus 500cc, LR bolus 500-1000cc; foley for acute urinary
retention, Acetaminophen 650 mg PO ONCE for fever, and
Ciprofloxacin 400 mg IV ONCE for presumed cystitis.
VS prior to transfer were: 102.9 102 133/68 15 97% RA.
REVIEW OF SYSTEMS:
As per HPI, otherwise 10 point ROS negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___: weight loss (~12lbs) and fatigue, -CXR at that time,
mild anemia with hgb 11.8, ferritin 583, alb 2.9
-___: CT-abd showed mild RP adenopathy and hilar prominence
-___: CT-chest showed marked axillary and right hilar
adenopathy
-___: Right axillary LN biopsy showed classical Hodgkin's.
-___: PET-CT showed extensive 1. FDG avid supraclavicular,
axillary, hilar, portal, retroperitoneal, and mesenteric
lymphadenopathy, all consistent with malignancy. 2. Extensive
splenic involvement of disease. 3. Possible renal involvement of
disease; an MRI of the kidneys is recommended 4. Compression
fracture of L1, is of indeterminate chronicity. Recommend
clinical correlation. No FDG avidity is associated with this.
-___: ABVD C1
-___: ABVD C3
-___: ABVD C5
-___: PET confirms response
-___: ABVD C6
-___: Hospitalized at ___ for syncope thought
possibly ___ vinblastine toxicity causing autonomic neuropathy
PAST MEDICAL HISTORY:
HTN
Hypothyroidism
Hyperlipdemia
Nephrolithiasis
Colonic adenoma
Colon cancer, sigmoid
Coronary artery disease S/P coronary artery stent placement
CKD (chronic kidney disease) stage 3, GFR ___ ml/min
Hodgkin lymphoma
___
Social History:
___
Family History:
Denies IBD/CRC.
Mother: ? ovarian v uterine CA
Father: healthy, died at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 100.0 110/60 82 24 95% on 0.5L NC
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MM very dry difficult to assess OP
well but there may be some stomatitis
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi but
diminished
sounds on left, + dry cough
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: Significant RUE edema extending from proximal humerus to
digits
GU: No suprapubic tenderness, no CVAT, prostate non-tender and
enlarged in caliber
PULSES: 2+DP pulses bilaterally
NEURO: A&O x 3, CN III-XII intact
SKIN: Warm and dry, diffuse seborrheic keratosis
DISCHARGE PHYSICAL EXAM:
VS: 97.4 140/74 70 20 93RA
GENERAL: Laying in bed, in NAD, breathing non-labored
HEENT: NC/AT, EOMI, PERRL, MMM; L eye without any lesions,
scleral injection
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: decreased BS in RLL, mild L basilar rales
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: RUE with significant swelling that is somewhat improved
from yesterday. No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: grossly intact, flat affect.
SKIN: Warm and dry, without rashes; numerous seborrheic
keratoses scattered throughout
Pertinent Results:
ADMISSION LABS
==============
___ 02:45PM BLOOD WBC-6.4 RBC-3.03* Hgb-8.8* Hct-28.1*
MCV-93 MCH-29.0 MCHC-31.3* RDW-14.6 RDWSD-49.8* Plt ___
___ 02:45PM BLOOD Neuts-83.8* Lymphs-6.8* Monos-6.8
Eos-0.3* Baso-0.6 Im ___ AbsNeut-5.33 AbsLymp-0.43*
AbsMono-0.43 AbsEos-0.02* AbsBaso-0.04
___ 03:49AM BLOOD ___ PTT-119.6* ___
___ 02:45PM BLOOD Glucose-119* UreaN-21* Creat-2.0* Na-140
K-3.4 Cl-102 HCO3-25 AnGap-16
___ 06:04AM BLOOD ALT-79* AST-76* LD(LDH)-250 AlkPhos-79
TotBili-0.2
___ 03:49AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.7
___ 04:48PM BLOOD ___ pO2-19* pCO2-46* pH-7.46*
calTCO2-34* Base XS-6
___ 02:56PM BLOOD Lactate-3.3*
___ 04:48PM BLOOD O2 Sat-26
OTHER PERTINENT LABS
=====================
___ 04:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 04:50AM BLOOD HCV Ab-NEGATIVE
IMAGING
=======
___ V/Q LUNG SCAN:
Very low likelihood ratio of acute pulmonary embolism.
___ CHEST X-RAY:
Mild pulmonary edema which developed on ___ has
improved. Small bilateral pleural effusions remain. Heart size
has returned to normal. Right subclavian central venous
infusion port catheter ends in the low SVC. No pneumothorax.
___ CHEST X-RAY (PA AND LATERAL)
IMPRESSION:
In comparison with the study of ___, there is increasing
opacification at the bases. Although this most likely
represents atelectatic change with small pleural effusions, more
prominent on the left, in the appropriate clinical setting the
possibility of superimposed pneumonia would have to be
considered, especially on the left.
___ RUQ U/S:
1. Cholelithiasis without evidence of cholecystitis.
2. Small hepatic echogenic focus, with features compatible with
hemangioma.
___ CXR: No acute cardiopulmonary process.
___ RUE US: Thrombus is seen within the right subclavian and
axillary veins. These veins are noncompressible, show diminished
flow, and lack of waveforms. The right brachial, basilic, and
cephalic veins are patent, compressible and show normal color
flow and augmentation.
MICRO
=====
___ BLOOD CULTURE - negative
___ URINE Legionella Antigen - Negative
___ URINE CX - Negative
___ BLOOD CULTURE - negative
___ 3:20 pm URINE
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
DISCHARGE LABS
==============
___ 05:05AM BLOOD WBC-7.2 RBC-2.96* Hgb-8.6* Hct-28.0*
MCV-95 MCH-29.1 MCHC-30.7* RDW-14.8 RDWSD-51.1* Plt ___
___ 05:05AM BLOOD Plt ___
___ 05:05AM BLOOD Glucose-81 UreaN-17 Creat-1.7* Na-142
K-3.4 Cl-107 HCO3-29 AnGap-9
___ 05:15AM BLOOD ALT-136* AST-34 LD(LDH)-165 AlkPhos-122
TotBili-0.2
___ 05:05AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.9
Radiology Report
INDICATION: ___ with Hodgkins lymphoma with new cough and dyspnea // any
PNA
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Right-sided Port-A-Cath is seen with catheter tip in the mid to lower SVC.
The lungs remain clear of focal consolidation, effusion, or edema.
Cardiomediastinal silhouette is stable. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: History: ___ with incidentally noted swelling right arm distal to
elbow
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
Thrombus is seen within the right subclavian and axillary veins. These veins
are noncompressible, show diminished flow, and lack of waveforms.
The right brachial, basilic, and cephalic veins are patent, compressible and
show normal color flow and augmentation.
IMPRESSION:
Deep venous thrombus within the right subclavian and axillary veins.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with DVT, malignancy
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territorial infarction, hemorrhage, edema,
or mass effect. Focal encephalomalacia in the right frontal lobe and rounded
hypodensities in the left frontal lobe white matter likely reflect the sequela
of prior infarcts. Prominence of the sulci is compatible with age-related
cortical volume loss. Mild periventricular, subcortical and deep white matter
hypodensities are noted, most consistent with the sequela of chronic small
vessel ischemic disease.
No osseous abnormalities seen. Mucous retention cysts are seen in the
maxillary sinuses. There is minimal mucosal thickening of the ethmoid air
cells with complete opacification of the left frontal sinus. The mastoid air
cells and middle ear cavities are patent. The orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with history of Hodgkin's lymphoma, with
increased oxygen requirement, fever, and cough. // Please evaluate for
cardiopulmonary process. Please evaluate for cardiopulmonary process.
IMPRESSION:
In comparison with the study of ___, there is increasing opacification
at the bases. Although this most likely represents atelectatic change with
small pleural effusions, more prominent on the left, in the appropriate
clinical setting the possibility of superimposed pneumonia would have to be
considered, especially on the left.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with history of Hodgkin lymphoma, presenting with
fever and elevated transaminases. // Please evaluate for hepatic process.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis without contrast dated ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. 10 x 7 x 7 mm right liver lobe echogenic focus near the
liver dome is consistent with a small hemangioma. The main portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm.
GALLBLADDER: There is a 1.5 cm gallstone without evidence of acute
cholecystitis. There is no wall edema, hydropic gallbladder distension or
pericholecystic fluid.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity. The spleen measures 13.1 cm, top-normal.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cholelithiasis without evidence of cholecystitis.
2. Small hepatic echogenic focus, with features compatible with hemangioma.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new/worsening O2 requirement, has decreased
breath sounds on right side // effusion? edema effusion? edema
COMPARISON: Chest radiographs since ___, most recently ___
IMPRESSION:
Mild pulmonary edema which developed on ___ has improved. Small
bilateral pleural effusions remain. Heart size has returned to normal. Right
subclavian central venous infusion port catheter ends in the low SVC. No
pneumothorax.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dysuria, Dyspnea
Diagnosed with Urinary tract infection, site not specified, Acute kidney failure, unspecified, Dehydration
temperature: 99.8
heartrate: 108.0
resprate: 20.0
o2sat: 94.0
sbp: 103.0
dbp: 59.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old man with a history of Hodgkin's
lymphoma s/p C6 ABVD (___) who presented to the ED with cough,
dysuria and fever. Ucx/CXR/Flu/CMV/EBV/Hepatitis/CDiff negative.
Pt was initially treated with IV antibiotics but they were
discontinued once infectious study returned negative.
#Viral illness:
Patient initially received treatment with vancomycin and
cefepime for possible HCAP given lung exam with decreased breath
sounds and presence of fevers and cough. However, after 48
hours, patient defervesced and remained afebrile for the
remainder of hospitalization. His fevers were thought to be
secondary to a viral process. Workup included negative flu
swab, negative legionella ag, negative strep pneumo, and
negative urine culture and blood cultures. Given resolution of
fevers and negative infectious workup, vancomycin and cefepime
were discontinued ___.
#Hypoxia:
Of note, patient temporarily had oxygen requirement of unknown
etiology. Had CXR which was negative, V/Q scan with low
probability of PE. Concern for bleomycin toxicity so PFTs
completed but DLCO measurement was only of fair test quality.
#Elevated LFTs:
Notably LFTs began to increase after starting
vancomycin/cefepime and downtrended after discontinuing. At
discharge, LFTs were downtrending but had not normalized.
Unclear if drug related effect.
#RUE DVT:
Patient was found to have right upper extremity DVT, which was
provoked in setting of active chemotherapy, malignancy, and
right sided port. He was initially started on heparin gtt and
then transitioned to lovenox, which he will need to continue as
an outpatient, with final course to be determined by primary
hematologist/oncologist. Given limited kidney function and
baseline Cr of 1.7, was discharged on once daily dosing 80mg SC
q24h. Xa level was drawn incorrectly so was not helpful in
dosing but may be repeated as outpatient.
# Anemia:
Patient had anemia during admission, requiring 2 units during
the hospitalization. Workup showed hypoproliferative anemia
with no evidence of hemolysis. Likely related to bone marrow
suppression possibly secondary to viral process.
#Hodgkin Lymphoma: s/p "cycle 6" ABVD ___ per outpatient
oncologist patient has been unable to complete his ABVD cycles
___ complications. Should be due for next cycle on ___,
although she does not feel that he will be able to tolerate this
from home. Notes that she feels that he needs more supports at
home for successful completion of ABVD. Will reconsider chemo
once patient is stronger.
#Urinary Retention:
Has long h/o BPH. Follows with urology as an outpatient. Foley
placed in ED (___) for urinary retention. Continued home
finasteride. Held tamsulosin initially given possibility for
sepsis, then restarted once vital signs remained stable. Was
provided pyridium for symptom relief.
#CAD:
Continued home plavix, simvastatin, and aspirin.
#Orthostatic hypotension:
Continued home Fludrocortisone Acetate 0.3 mg PO QD.
#Constipation:
Continued home Magnesium Citrate 150 mL PO 2X/WEEK PRN
constipation, home Senna 8.6 mg PO BID:PRN constipation. Added
on BID miralax, lactulose PRN, and bisacodyl PR PRN per
patient's request.
#Hypothyroidism:
Continued home synthroid.
TRANSITIONAL ISSUES
===================
1. Given concern for bleomycin toxicity PFTs completed by time
of discharge, but report not finalized and will need to be
followed up.
2. Would re-check LFTs in 1 week. If they normalize, would
consider restarting patient's home dose statin.
3. Would re-check patient's Cr in 1 week. If it continues to
improve may need increased Lovenox dosing as he is currently at
a reduced dose for limited GFR. Xa level was drawn incorrectly
so was not helpful in dosing but may be repeated as outpatient.
4. Would recheck CBC in 1 week to assess Hgb. Pt had anemia
during hospitalization requiring pRBC which was attributed to BM
suppression during acute illness.
5. Pt needs UA as outpt to re-evaluate for hematuria seen during
stay.
6. Pt was Hepatitis B non-immune and may benefit from
vaccination as outpatient.
7. Pt needs continued physical therapy to regain prior
functional status.
CODE: Full
EMERGENCY CONTACT HCP:
Name of health care proxy: ___ Relationship: son Phone
number: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Tachypnea
Major Surgical or Invasive Procedure:
Tracheostomy
History of Present Illness:
Mr. ___ is an ___ yo M with h/o recent ex lap with repair of
bile leak/duodenal enterotomy now with PEG tube and several
percutaneous biliary drains who presented from rehab with
tachypnea and respiratory distress. Before arrival, EMS placed
him on BiPAP.
According to the rehab note, patient was getting chest therapy
at nursing home, and during this he became acutely short of
breath. Also, he had altered mental status today worse than
baseline.
In the ED, he continued to be tachypneic but was unable to
answer further history questions. His ABG showed respiratory
acidosis so he was intubated. After intubation, he became
hypotensive with pressures nadiring at 67/37. He was started on
norepinephrine for this hypotension and right IJ CVL was placed.
Because of concern for sepsis, he underwent CT C/A/P which
showed left lower lobe collapse and no acute intra-abdominal
process. His vital signs prior to transfer were 119 129/68 22
100%, CMV fi02 100%, Vt 460, RR 22, PEEP 5.
On arrival to the MICU, he is intubated and sedated. He does
not grimace to abdominal exam. He was suctioned for large
amounts of mucus.
Review of systems:
unable to obtain
Past Medical History:
Medical History: HTN, prostate CA, duodenal ulcer
Surgical History: lap cholecystectomy c/b bile leak and
duodenal injury, B II recontruction, prostatectomy with
bilateral
inguinal node dissection, lateral duodenostomy tube, T-tube,
PTBD, feeding jejunostomy tube
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMIT:
Vitals: T: 98.8, BP: 111/36, P: 125, R: 22, O2: 100% CMV
General: intubated, sedated, opens eyes to voice but does not
follow commands, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL but pupils
2 mm bilaterally
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: firm on the midline and left side with involuntary
muscle contraction, right side soft, non-distended, bowel sounds
present, no organomegaly
GU: foley
Ext: cool, well perfused, 2+ pulses DP and radial, no clubbing,
cyanosis or edema
Neuro: intubated, sedated, opens eyes to voice but does not
follow commands
Discharge:
General: trached, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, edentuolus,
PERRL
Neck: supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: clear bilaterally
Abdomen: non-tender/distended. J tube present, as are JP drain,
along with biliary drain
GU: foley
Ext: 2+ pulses DP and radial, no clubbing, cyanosis or edema
Neuro: following commands
Pertinent Results:
Admit labs:
___ 08:50PM LIPASE-39
___ 09:02PM freeCa-1.19
___ 09:02PM GLUCOSE-113* LACTATE-1.9 NA+-143 K+-4.5
CL--108 TCO2-28
___ 09:02PM ___ PH-7.33* COMMENTS-GREEN TOP
___ 09:30PM URINE AMORPH-RARE
___ 09:30PM URINE HYALINE-34*
___ 09:30PM URINE RBC-12* WBC-76* BACTERIA-FEW YEAST-FEW
EPI-<1
___ 09:30PM URINE UHOLD-HOLD
___ 09:30PM URINE HOURS-RANDOM
___ 09:35PM PLT COUNT-906*
___ 09:35PM PLT COUNT-906*
___ 10:58PM O2 SAT-99
___ 10:58PM TYPE-ART TEMP-38.3 RATES-18/ TIDAL VOL-400
PEEP-5 O2-100 PO2-252* PCO2-69* PH-7.19* TOTAL CO2-28 BASE XS--3
AADO2-397 REQ O2-69 INTUBATED-INTUBATED
___ 03:00AM CORTISOL-23.9*
___ 03:00AM ALT(SGPT)-47* AST(SGOT)-42* LD(___)-206 ALK
PHOS-579* TOT BILI-0.6
___ 03:00AM ALT(SGPT)-47* AST(SGOT)-42* LD(LDH)-206 ALK
PHOS-579* TOT BILI-0.6
___ 03:50AM ___ 03:50AM ___
Discharge labs:
___ 03:56AM BLOOD WBC-10.3 RBC-2.70* Hgb-8.4* Hct-25.9*
MCV-96 MCH-31.1 MCHC-32.5 RDW-14.2 Plt ___
___ 03:56AM BLOOD Glucose-104* UreaN-32* Creat-1.3* Na-142
K-4.3 Cl-108 HCO3-28 AnGap-10
___ 03:56AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.1
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 9:53 ___
IMPRESSION:
1. Bilateral lower lobe pneumonia, with necrotic consolidation
of the left lower lobe, and fluid versus soft tissue attenuation
of the left lower lobe bronchus. This may represent mucus
plugging, or an obstructive lesion. There is marked mediastinal
lymph node enlargement in all visualized stations.
2. Small bilateral non-hemorrhagic pleural effusions.
3. Calcified pleural plaques reflect prior asbestos exposure.
4. Multiple abdominal drains, with no residual fluid collection
or acute
intra-abdominal pathology noted.
___ Change of drains
IMPRESSION:
Successful exchange and repositioning of a 10 ___ PTBD,
internal/external drain.
___ Chest X-ray:
IMPRESSION:
1. Left subclavian PICC line and tracheostomy tube remain in
satisfactory
position. Overall, cardiac and mediastinal contour is difficult
to assess
given patient rotation on the current examination. There
continues to be
bilateral patchy airspace opacities with a more confluent
opacity at the left base, which may reflect multifocal
pneumonia. An element of superimposed edema cannot be entirely
excluded as the pulmonary vasculature appears somewhat
indistinct. There is a layering left effusion and a smaller
right effusion. No pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO TID
3. Pantoprazole 40 mg PO Q24H
4. Metoprolol Tartrate 25 mg PO TID
5. Lorazepam 0.5 mg PO Q8H:PRN anxiety
6. Acetaminophen 650 mg PO Q6H:PRN pain
7. Heparin 5000 UNIT SC TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Carbidopa-Levodopa (___) 1 TAB PO TID
3. Heparin 5000 UNIT SC TID
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
5. Aspirin 325 mg PO DAILY
6. Lorazepam 0.5 mg PO Q8H:PRN anxiety
7. Metoprolol Tartrate 25 mg PO TID
8. Pantoprazole 40 mg PO Q24H
9. CefePIME 1 g IV Q12H
10. Vancomycin 1000 mg IV Q 24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
aspiration pneumonia
septic shock
Secondary:
___ disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: Hypercarbic respiratory failure, question interval change.
CHEST, SINGLE AP PORTABLE VIEW.
An ET tube is present, tip in satisfactory position 5.4 cm above the carina.
An NG tube is present, tip extending beneath the diaphragm off the film.
Right IJ central line is present, tip over distal SVC. A right-sided PICC line
is present, tip is not optimally visualized, but likely overlies the distal
SVC. No pneumothorax is detected.
There is mild-to-moderate cardiomegaly. There is upper zone redistribution
and mild vascular plethora. There are patchy alveolar opacities in the left
mid and lower zones and in the right cardiophrenic region. There are small
left greater than right effusions. There is a rounded 9-mm lucency abutting
the upper right chest wall adjacent to the right third posterior rib whoch
apparently represents a small bleb.An old right fifth posterior rib fracture
is again noted.
IMPRESSION: Compared with ___, overall appearance is similar.
Radiology Report
AP CHEST, 4:26 A.M., ___
HISTORY: ___ man with pneumonia and possible left lung collapse.
IMPRESSION: AP chest compared to ___ through ___:
Mild pulmonary edema has worsened since ___ and this asymmetric
deposition of edema could explain the apparent worsening of the right lower
lobe pneumonia, but it may have progressed as well. Small bilateral pleural
effusions are presumed. Heart is normal size. ET tube, right internal
jugular line, enteric tube, are all in standard placements. No pneumothorax.
Asbestos-related calcified pleural plaques noted.
Radiology Report
AP CHEST, 4:22 A.M. ON ___
HISTORY: ___ male with pneumonia.
IMPRESSION: AP chest compared to ___ through ___:
Variations day-to-day in the intensity of diffuse infiltrative pulmonary
abnormality are more likely due to changes in ventilator settings and
hemodynamics than real changes. For example, today, there has been mild
clearing in the right upper lung, but both lower lungs are as densely
consolidated as before. Overall, I doubt that there has been any change in
pneumonia over the past several days. Small bilateral pleural effusions are
also stable. Heart size is normal. ET tube, right internal jugular lines are
in standard placements and an upper elementary tube passes into the stomach
and out of view. No pneumothorax.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Severe pneumonia in followup.
Comparison is made to prior study ___.
Cardiomediastinal contours are unchanged. Diffuse bilateral lung
consolidations larger in the lower lobes and in the left perihilar region are
grossly unchanged. Small right pleural effusion is stable. Moderate left
pleural effusion has minimally increased. Lines and tubes are in standard
position.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Assess line.
Comparison is made to prior study performed five hours earlier.
Left PICC tip is malpositioned, loops in the mediastinum and its tip goes back
and ends in the mid left subclavian vein. There are no other interval
changes.
IV nurse ___ was paged regarding this finding at the time of discovery.
Radiology Report
INDICATION: Patient with pneumonia, intubated, interval change.
COMPARISON: Multiple chest x-rays from ___ to ___. CT
torso of ___.
FINDINGS:
Widespread bilateral pneumonia, more predominant in lower lung is unchanged.
Bilateral small pleural effusions are also stable. There is no pneumothorax.
ET tube ends 6.4 cm above carina. Left-sided PICC line has been repositioned
and now ends in mid SVC. NG tube is below the diaphragm.
CONCLUSION:
There is no significant change since yesterday of the bilateral widespread
pneumonia, more predominant in lower lobe.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: Study of earlier the same date.
FINDINGS: Endotracheal tube has been exchanged for a tracheostomy tube, which
terminates within the trachea about 3 cm above the carina. Moderate to large
left pleural effusion has apparently increased in size since the recent study,
although positional differences limit comparison. Small to moderate right
pleural effusion with intrafissural component appears unchanged, however.
Cardiomediastinal contours are stable in appearance. Slight worsening of
multifocal heterogeneous lung opacities, likely representing multifocal
infection considering the appearance on prior CT of ___.
Co-existing pulmonary edema is also possible.
Radiology Report
PORTABLE CHEST ___
COMPARISON: ___ radiograph.
FINDINGS: Improving bilateral asymmetrical alveolar opacities involving the
left lung to a greater degree than the right. The rapid degree of improvement
in some of the opacities suggests a component of pulmonary edema superimposed
upon underlying multifocal pneumonia. Moderate left and small right pleural
effusions are again demonstrated.
Radiology Report
PORTABLE AP CHEST FROM ___ AT 3:16 A.M.
CLINICAL INDICATION: ___ with trach, repeated aspiration, necrotizing
pneumonia, question assess for interval change.
Comparison is made to the patient's prior study dated ___ at 11:16.
Portable AP semi-erect chest film ___ at 3:16 is submitted.
IMPRESSION:
1. Left subclavian PICC line and tracheostomy tube remain in satisfactory
position. Overall, cardiac and mediastinal contour is difficult to assess
given patient rotation on the current examination. There continues to be
bilateral patchy airspace opacities with a more confluent opacity at the left
base, which may reflect multifocal pneumonia. An element of superimposed
edema cannot be entirely excluded as the pulmonary vasculature appears
somewhat indistinct. There is a layering left effusion and a smaller right
effusion. No pneumothorax.
Radiology Report
INDICATION: ___ man with PTBD after ex-lap, now falling out, alkaline
phosphatase rising, concern the drain is not working.
PHYSICIANS: Dr. ___ (radiology fellow) and Dr. ___
___ (radiology attending) who was present throughout and supervised the
procedure.
RADIATION: 4.2 minutes fluoroscopy time, 26 mGy.
PROCEDURE DETAILS:
Following discussion of the risks, benefits and alternatives to the procedure,
informed telephone consent was obtained from the patient's daughter, who is
next of kin. Patient was brought to the angiographic suite and placed supine
on the table. A preprocedure timeout was performed using three patient
identifiers. The skin of the right abdomen including the indwelling 10 ___
biliary drain was prepped and draped in the usual sterile fashion. An initial
scout image demonstrated that the drain had been pulled back significantly.
The catheter was cut and ___ wire was initially used in an attempt to get
access to the common bile duct; however, this would not advance readily, so
this was exchanged for a 035 glidewire. This was manipulated into the common
bile duct without difficulty and down into the duodenum. The existing 10
___ drain was removed and a Kumpe catheter was advanced over the wire. The
wire was removed and an injection of small amount of contrast confirmed
position within the duodenum, which in addition opacified the nondilated
intrahepatic ducts. At this point, contrast was seen to enter the JP drain in
the upper quadrant, suggestive of an ongoing biliary leak. The ___ wire
was advanced through the Kumpe catheter which was then removed and exchanged
for a new 10 ___ internal-external biliary drain. The catheter was then
secured to the skin with an 0 silk suture and a StatLock device. The catheter
has been attached to a bag for free drainage. A sterile dressing was applied.
There were no immediate post-procedure complications.
IMPRESSION:
Successful exchange and repositioning of a 10 ___ PTBD, internal/external
drain.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RESP DISTRESS
Diagnosed with SEPTICEMIA NOS, PNEUMONIA,ORGANISM UNSPECIFIED, SEPSIS , ACCIDENT NOS, URIN TRACT INFECTION NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ yo M with recent ex lap with repair of bile leak/enterotomy
and placement of PTCB and PEG tube who presented from rehab with
hypercarbic respiratory failure and altered mental status.
.
# Hypercarbic respiratory failure/septic shock: CT compatible
with necrotizing pneumonia, enterobacter growing from the sputum
as well as MRSA. Due to witnessed aspiration event at rehab.
Low compliance/high resistance on the vent. Started on
vanc/zosyn for HCAP coverage now switched to vanc/cefepime and
transiently on pressors. Pt underwent tracheostomy on ___.
Patient will go out on ID recommendations vanco for 21 days and
cefepime for a total of 8 days. The patient should have weekly
Chem7, vancomycin troughs, CBC, LFTs.
.
# Hypernatremia: Given free water replacement with D5W and
corrected quickly.
.
# Eosinophilia: Was up to 5.3% of 6.8 wbc. Question remained as
to if this is medication-related due to zosyn, so this was
exchanged for cefepime on ___.
.
# Recent bile leak s/p surgery: PTBD (percutaneous biliary drain
and JP drain also in place) replaced by ___ ___ with
improvement in alkaline phosphotase today. Surgery team
continued to follow with no additional recommendations.
# CKD: His admission Cr is 1.3 which is at his recent baseline
1.4
# Nutrition: Continued on TPN, as tube feeds not viable at this
time given aspiration occurred shortly after tubefeed
initiation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with history of stiff person syndrome
(functional quadriplegia) c/b constipation and muscle spasm,
HFpEF, CAD, hypothyroidism, obesity presenting with altered
mental status.
Per patient's son, she was behaving normally last night and then
became more confused later in the evening. She slept fine
overnight, but her O2 sat was noted to be in the mid to low ___
in the morning, which improved with nasal canula and sitting
upright. She was then brought to the ___ ED for evaluation.
Notably, patient was admitted from ___ - ___ for
altered mental status at ___. AMS was of unclear etiology at
that time, but she had a negative workup that included normal
EEG, negative MRI, and normal prolactin and CK. She was also
found to have hypoxia with ___ O2 requirement of unclear
etiology. She was weaned of oxygen and started on home
torsemide. Patient was found to have hypercapnea during this
admission and was not adherent to home BiPAP regimen. Her blood
gases were trended and hypercapnea improved. She was found to
have elevated Anti-GAD antibodies, but neurology did not feel
that IVIG or plasmapheresis was indicated.
In ED initial VS: 97.2 81 111/71 18 99% 3L NC
Labs significant for:
148|100|13
----------< 146
3.3|35|0.5
12.9
8.9 >---< 271
40.6
INR 1.0
Trop: 0.06 -> 0.05
VBG: 7.45|50|36 -> 7.36|72|42
Patient was given: No medications. She was started on Bipap for
worsening somnolence and hypercarbia.
Imaging notable for:
- Negative head CT
- CXR with mild cardiomegaly and otherwise normal
Consults:
- Neurology requested
VS prior to transfer: 97 116/77 21 97% RA
On arrival to the MICU, patient notes that she feels slightly
better. Denies shortness of breath or pleuritic chest pain.
Denies PND, orthopnea, palpitations, syncope, or pre-syncope.
Denies fevers, chills, or night sweats.
REVIEW OF SYSTEMS:
All other ROS negative.
Past Medical History:
- chronic Diastolic CHF w preserved EF/Stress-Induced
Cardiomyopathy
- NSTEMI (___)
- small pericardial effusion
- Hypothyroidism
- OSA
- Stiff person syndrome (for ___ years)
- functional quadriplegia
- DM2 (now diet controlled)
- Hypertension
- Hyperlipidemia
- Frequent ventricular ectopy
- Urge incontinence s/p sacral neurostimulator ___
- s/p cholecystectomy ___ ago)
- s/p hysterectomy ___ for fibroids)
- s/p rectocele repair ___
- s/p R TKR ___
- Urinary tract infection
Social History:
___
Family History:
Father: Died at age ___ from MI
Mother: ___ cancer
Sister: Died of MI at age ___
Son: Had a stroke at age ___, and has had several seizures
Physical Exam:
Admission Physical
==================
Neuro: somnolent, aaox3
HEENT: No scleral icterus, Left pupil with coloboma and no
visual acuity, can only see shapes
Cardiovascular: tachy
Pulmonary: Clear to auscultation bilaterally, decreased at RLB
with mild crackles
Abdominal: Soft, nontender, nondistended, no masses
Extremities: lower legs with Dopplerable pulses, violet colored
up to mid shins, with bullae at shins, right dorsal aspect of
foot with open bullae 4cm
Discharge Physical
==================
Vitals: Temp 97.4 BP 122/86 HR 90 SpO2 93% on CPAP
General: Awake, eyes open, no acute distress, answers in full
sentences
HEENT: Slightly dry mucous membranes, oropharynx clear
Neck: Supple, JVD at angle of clavicle
Resp: Soft breath sounds, faint bibasilar crackles
CV: RRR, S1/S2 normal but distant, no murmurs
GI: Slightly firm, non-tender, distended, hypoactive bowel
sounds
MSK: Warm, well-perfused, 1+ pulses, no peripheral edema
Neuro: Squeezes fingers, wiggles toes, opens eyes and mouth to
command, oriented to name/date/hospital, conversant, speaking in
full sentences (monosyllabic answers on ___, UE held in slight
contraction, no visible spasms
Pertinent Results:
Admission Labs
==============
___ 04:35PM BLOOD WBC-8.9 RBC-4.66 Hgb-12.9 Hct-40.6 MCV-87
MCH-27.7 MCHC-31.8* RDW-15.3 RDWSD-48.5* Plt ___
___ 04:35PM BLOOD ___ PTT-25.4 ___
___ 04:35PM BLOOD Glucose-146* UreaN-13 Creat-0.5 Na-148*
K-3.3* Cl-100 HCO3-35* AnGap-13
___ 02:52AM BLOOD Albumin-3.7 Calcium-8.9 Phos-3.4 Mg-2.2
___ 04:48PM BLOOD Lactate-1.4
Discharge Labs
==============
___ 06:15AM BLOOD WBC-10.2* RBC-4.41 Hgb-12.2 Hct-38.0
MCV-86 MCH-27.7 MCHC-32.1 RDW-15.2 RDWSD-47.9* Plt ___
___:04AM BLOOD Glucose-130* UreaN-11 Creat-0.5 Na-140
K-3.8 Cl-94* HCO___* AnGap-12
___ 06:04AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.0
___ 11:01AM BLOOD ___ pO2-90 pCO2-53* pH-7.40
calTCO2-34* Base XS-5 Comment-GREEN TOP
Microbiology
============
Blood cultures pending- no growth to date
Urine culture- no growth
C.diff negative
Imaging
=======
___ CXR: PA and lateral views of the chest provided. Lung
volumes are markedly low limiting assessment. Lung for this,
lungs are clear without focal consolidation, large effusion or
pneumothorax. The heart remains mildly enlarged. Mediastinal
contour is stable and normal. Imaged bony structures are
intact. No free air below the right hemidiaphragm.
___ CT Head:
There is no evidence of infarction, hemorrhage, edema,or mass
effect.
Periventricular white-matter hypodensities are nonspecific,
could represent sequela of chronic small vessel disease. There
is prominence of the ventricles and sulci suggestive of
involutional changes.
There is no evidence of acute fracture. The visualized portion
of the
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
Patient is status post bilateral cataract surgery. Otherwise,
the orbits are unremarkable.
___ Portable Abdomen:
Dilation of the sigmoid colon, could be secondary to redundant
sigmoid but cannot exclude volvulus. Given the clinical
symptoms, CT abdomen and pelvis is recommended.
___ CT abdomen:
LOWER CHEST: Slight bibasilar atelectasis is noted. There is
cardiomegaly. A metallic clip is noted within the partially
visualized left breast.
HEPATOBILIARY: Evaluation of the patent parenchyma is mildly
limited by beam hardening artifact from the patient's adjacent
extremities. Within this limitation, no focal hepatic lesion is
identified. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is not
visualized.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. There is no evidence of focal renal lesions
or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The sigmoid colon is markedly redundant
and distended measuring up to 10.3 cm. However, no evidence of
a volvulus. Mild wall thickening is noted at the recto sigmoid
junction. Large amount of gas and stool is seen throughout the
colon which can be seen with constipation. A normal appendix is
visualized. No free air.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The patient is status post hysterectomy.
No adnexal mass is seen.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture. Chronic, healed fracture deformities are noted
of multiple left ribs.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Dilated and redundant sigmoid colon. No evidence of
obstruction or
volvulus.
2. Mild wall thickening is noted at the rectosigmoid junction
suggesting mild proctocolitis. No free air. No ascites.
3. Cardiomegaly.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Artificial Tears ___ DROP BOTH EYES PRN dryness
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Baclofen 20 mg PO QID
6. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
7. Calcium Carbonate 500 mg PO QID:PRN indigestion
8. Diazepam 10 mg PO Q8H
9. Fish Oil (Omega 3) 1000 mg PO BID
10. LevETIRAcetam 500 mg PO BID
11. Levothyroxine Sodium 62.5 mcg PO DAILY
12. Torsemide 10 mg PO DAILY
13. LOPERamide 2 mg PO QID:PRN diarrhea
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. Ondansetron 4 mg PO Q6H:PRN nausea
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Potassium Chloride 10 mEq PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Artificial Tears ___ DROP BOTH EYES PRN dryness
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Baclofen 20 mg PO QID
6. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
7. Calcium Carbonate 500 mg PO QID:PRN indigestion
8. Diazepam 10 mg PO Q8H
9. Fish Oil (Omega 3) 1000 mg PO BID
10. LevETIRAcetam 500 mg PO BID
11. Levothyroxine Sodium 62.5 mcg PO DAILY
12. LOPERamide 2 mg PO QID:PRN diarrhea
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. Ondansetron 4 mg PO Q6H:PRN nausea
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Potassium Chloride 10 mEq PO DAILY
17. Torsemide 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
-Hypercarbic respiratory failure
-Encephalopathy
Secondary:
-Stiff Person Syndrome
-Hypothyroidism
-Heart failure with preserved EF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with dyspnea// acute process
COMPARISON: Prior study from ___
FINDINGS:
PA and lateral views of the chest provided. Lung volumes are markedly low
limiting assessment. Lung for this, lungs are clear without focal
consolidation, large effusion or pneumothorax. The heart remains mildly
enlarged. Mediastinal contour is stable and normal. Imaged bony structures
are intact. No free air below the right hemidiaphragm.
IMPRESSION:
Limited exam due to low lung volumes. Stable mild cardiomegaly. Otherwise
unremarkable exam.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: 75 head CT of ___ woman on anticoagulation
with acute ams. Evaluate for intracranial hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
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: Head CT study of ___. Head MR study of ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema,or mass effect.
Periventricular white-matter hypodensities are nonspecific, could represent
sequela of chronic small vessel disease. There is prominence of the
ventricles and sulci suggestive of involutional changes.
There is no evidence of acute fracture. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
Patient is status post bilateral cataract surgery. Otherwise, the orbits are
unremarkable.
IMPRESSION:
No evidence of acute intracranial process. No significant interval change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old female with history of stiff person syndrome
(functional quadriplegia) c/b constipation and muscle spasm, HFpEF, CAD,
hypothyroidism, and obesity, who presented with altered mental status, found
to have hypercarbia and AMS, needing CPAP titration.// evaluate interval
change- consolidation or edema
COMPARISON: Prior chest radiographs ___
FINDINGS:
AP view of the chest provided.
Lung volumes are low resulting in bronchovascular crowding. There is no focal
consolidation. Left lung base is better aerated. No pulmonary vascular
engorgement. No large pleural effusion or pneumothorax. Aorta is tortuous
and there are calcifications of the aortic knob. Moderate cardiomegaly is
unchanged. Cardiomediastinal silhouette is otherwise within normal limits.
IMPRESSION:
Low lung volumes. No definite focal consolidation.
Radiology Report
INDICATION: ___ year old woman admitted with altered mental status, now with
abdominal distention, leukocytosis, liquid stool, and persistent altered
mental status. Stool sent for c diff, abdominal exam and patient report
unreliable given AMS.// Concern for megacolon iso of possible C. difficile
colitis
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: No recent abdominal imaging for comparison.
FINDINGS:
Dilation of the sigmoid without distal air in the rectum, unclear if it is
simply air distended redundant sigmoid colon, cannot exclude volvulus in the
appropriate clinical setting. Small bowel loops are not dilated. Large amount
of fecal content in the ascending colon.
There is radiograph is limited to evaluate pneumoperitoneum.
IMPRESSION:
Dilation of the sigmoid colon, could be secondary to redundant sigmoid but
cannot exclude volvulus. Given the clinical symptoms, CT abdomen and pelvis
is recommended.
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast
INDICATION: ___ year old woman with AMS and leukocytosis, unable to exclude
volvulus on KUB// R/O volvulus, obstruction- CT abd/pelvis with IV contrast
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 5.0 s, 1.0 cm; CTDIvol = 11.6 mGy (Body) DLP =
11.6 mGy-cm.
3) Spiral Acquisition 14.7 s, 50.6 cm; CTDIvol = 21.9 mGy (Body) DLP =
1,074.0 mGy-cm.
Total DLP (Body) = 1,099 mGy-cm.
COMPARISON: Abdomen pelvis CT dated ___
FINDINGS:
LOWER CHEST: Slight bibasilar atelectasis is noted. There is cardiomegaly. A
metallic clip is noted within the partially visualized left breast.
ABDOMEN:
HEPATOBILIARY: Evaluation of the patent parenchyma is mildly limited by beam
hardening artifact from the patient's adjacent extremities. Within this
limitation, no focal hepatic lesion is identified. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is not
visualized.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The sigmoid colon
is markedly redundant and distended measuring up to 10.3 cm. However, no
evidence of a volvulus. Mild wall thickening is noted at the recto sigmoid
junction. Large amount of gas and stool is seen throughout the colon which
can be seen with constipation. A normal appendix is visualized. No free air.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The patient is status post hysterectomy. No adnexal mass
is seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Chronic, healed fracture deformities are noted of multiple left ribs.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Dilated and redundant sigmoid colon. No evidence of obstruction or
volvulus.
2. Mild wall thickening is noted at the rectosigmoid junction suggesting mild
proctocolitis. No free air. No ascites.
3. Cardiomegaly.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Hypoxia
Diagnosed with Acute respiratory failure with hypercapnia, Altered mental status, unspecified, Dyspnea, unspecified
temperature: 97.2
heartrate: 81.0
resprate: 18.0
o2sat: 99.0
sbp: 111.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | ___ year old female with history of stiff person
syndrome(functional quadriplegia) c/b constipation and muscle
spasm, CHF with preserved EF, CAD, hypothyroidism, OSA, possible
seizure disorder, and obesity admitted ___ with hypercapnia and
somnolence attributed to CPAP non-compliance, transferred from
MICU to medicine, now with improved mental status.
ICU Course ___
========================
# Acute on chronic hypercapneic respiratory failure
# Acute hypoxic respiratory failure:
OSA likely with component of obesity hypoventilation syndrome,
baseline CO2 according to bicarb calculation is in low ___ c/w
diagnosis. Sleep consulted and rec CPAP 14cm at night, which she
tolerated well. She will be continued on CPAP at night, and CPAP
setting increase to 14cm was communicated to her nursing home
care team.
# Hypernatremia: Patient initially with hypernatremia to 148.
Likely in the setting of decreased free water intake. Improved
with D5.
# Diarrhea: Chronic and likely related to autonomic dysfunction
in setting of long-standing stiff person syndrome. She was
continued on loperamide.
FLOOR COURSE: ___
==========================
# Encephalopathy
Somnolence and lethargy on presentation initially attributed to
hypercapnia. Somewhat unclear baseline mental status, but much
more interactive/conversant and oriented over the course of the
hospitalization. Given extensive prior evaluations, suspect
baseline early dementia exacerbated by occult inflammation/pain
secondary to mild proctocolitis in the setting of constipation.
TSH returned as normal, WBC down-trended, daily electrolytes and
glucose remained normal. Afebrile throughout duration of
hospital course and no acute infectious process was found. There
was no clinical concern for seizure given her stability on her
current regimen, unclear if true history of seizures, and recent
unrevealing EEG on ___ admission for same clinical
presentation. Ddx does include worsening depression as well,
given fluctuating and chronic course, possibly with early
dementia underlying. On review of her records, she appears to
have been on lithium, lamotragine, and venlafaxine in the past,
but does not seem to be on any of these medications currently.
Neurology was consulted inpatient with no acute changes
recommended to current regimen. Recommend outpatient psychiatry
follow-up which the patient is agreeable with.
# Proctocolitis
# Constipation and Diarrhea
# Sterocolitis
Abdominal distention and hypoactive bowel sounds on exam, KUB
and CT abdomen with evidence of large stool and gas throughout
colon, and mild proctocolitis on CT abd, consistent with mild
sterocolitis. Constipation treated with regular enemas per
conversation with nursing home. She had down-trending
leukocytosis but continued with diarrhea in the setting of
background severe constipation, likely secondary to stool
impaction. C difficile testing was negative. Symptoms and
abdominal exam improved with the addition of oral bisacodyl.
Consider outpatient antibiotics if fever or clinical worsening.
# Chronic hypercapneic respiratory failure:
Venous blood gas on floor consistent with chronic hypercapnia
(pH 7.40, pCO2 stably in low ___. Attributed to known OSA
likely with component of obesity hypoventilation syndrome.
Stiff person syndrome can contribute to impaired ventilation,
but neurology was consulted inpatient with no acute changes
recommended to current regimen. Sleep was consulted while in the
ICU and recommended CPAP 14cm at night. CPAP up-titration was
started ___ ___, tolerated well, with repeat venous blood gases
demonstrating normal pH and cPO2 stably in low ___. Outpatient
sleep follow-up has been scheduled.
CHRONIC ISSUES
================
# Stiff person syndrome:
Anti-GAD antibodies found to be elevated to >250 during prior
admission. Previously neurology advised against IVIG or
plasmapheresis. Initial concern for progression in symptoms
given family's report of declining mental status and potentially
worsening pulmonary ventilation. Stabilized, kept on home
regimen in consultation with neurology.
# HFpEF:
Stress-induced cardiomyopathy with recovered EF per record
review, EF 55% no RVH echo ___. No evidence of volume
overload on exam. Home torsemide was resumed when infection
ruled out. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
Abdominal pain; admitted to ICU for hypotension and anemia with
guaiac positive stool
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ with HTN, HLD, GERD who presented for
colonosopy and EGD on ___ (for workup of recurrent abdominal
pain). She had a 9mm cecal polyp removed via hot snare. EGD
showed erythema in entire stomach and irregular Z-line (biopsy
taken). After returning home, she began having severe diffuse
lower abdominal pain, vomited x 1 and felt weak and lightheaded
prompting her to present to the ED.
Initial ED vitals, T97.8 P83 BP 91/50 RR16 O2 sat 100%. She
denied fevers, chills, CP, SOB. Exam notable for diffuse
abdominal tenderness, guaic positive with dark brown stool, but
no gross blood. Labs were significant for WBC 11.4, HCT 39.1,
Lactate 1.2 and were otherwise normal. CT abd/pelvis showed no
perforation but shows stranding/edema consistent with
postpolypectomy electrocautery syndrome. FAST exam was negative.
GI was consulted and recommended NPO, Abx and IVF. Patient was
given 2L IVF, Cipro/Flagyl, Percocet, omeprazole PO and Zofran.
She continued to have episodes of hypotension, responsive to IVF
while in the ED. Patient appeared pale, diaphoretic on one
occasion, prompting repeat HCT which was 31. She was then
admitted to the ICU for further monitoring and management for
possible lower GIB.
Vitals prior to transfer: T98.7 P90 BP106/64 RR13 O2 sat 99% RA.
She reported that after she went home she drank tea, ate pita
bread and took her BP meds which she did not take prior to the
procedure. She then started having worsening abdominal pain and
vomited prompting her to present to the ED. In the ED, she at
some broth which she tolerated ok and she says she felt better
after eating something and keeping it down.
In the ICU, fluid resuscitation was continued. She was continued
on cipro/flagyl. Her BPs stabilized. Her abdominal pain
improved, and her diet was advanced. She was then called out to
the floor.
She currently has no complaints except for persistent abdominal
pain and tenderness on exam. She denied fevers, chills, sweats,
dysphagia, cough, shortness of breath, chest pain, palpitations,
trouble with hot or cold, skin changes, rash, arthralgias.
Remainder of 10 point ROS was negative.
Past Medical History:
HTN
GERD
IBS / recurrent epigastric abdominal pain of unclear etiology
Anxiety
Hyperlipidemia
Raynaud's
OA, hip pain
Cervicalgia
Denies prior surgery
Social History:
___
Family History:
No family history of colon cancer.
Mom deceased, had hx CVA and HTN, brother with HTN and sister
with PMR.
Physical Exam:
ON ADMISSION TO THE ICU
=======================
Vitals- T:99.1 BP:113/63 P:96 R:26 O2:100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, flat JVP, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, soft ___ SEM, no rubs, gallops
Abdomen: soft, non-distended, TTP over lower abdomen, +BS, no
rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
ON TRANSFER FROM ICU
====================
Vitals T:Afebrile/99.1 BP:90s-110s/60s P:70s-90s ___
O2:99%RA
General: Alert, oriented, no acute distress; sitting up in a
chair
Eyes: Sclera anicteric, EOMI
HENT: MMM, OP clear
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, soft ___ SEM, no rubs, gallops
Abdomen: soft, non-distended, TTP over lower abdomen worst in
LLQ, +BS, no rebound tenderness, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rash
GU: no foley
ON DISCHARGE
====================
Vitals: Afebrile, max 99.0, 110s-150s/50s-80s, 80s-130, ___,
99%RA
General: Alert, oriented, no acute distress; sitting up at her
bedside
Eyes: Sclera anicteric, EOMI
HENT: MMM, OP clear
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, soft ___ SEM, no rubs, gallops
Abdomen: soft, non-distended, very minimal tenderness in LLQ,
+BS, no rebound tenderness, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rash
GU: no foley
Pertinent Results:
ON ADMISSION/TRANSFER:
======================
Labs ___ 10:59PM: WBC-13.6* HGB-10.0* HCT-30.1* PLT
COUNT-275 GLUCOSE-124* UREA N-15 CREAT-0.9 SODIUM-138
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14 LACTATE-1.0
CT abd/pelvis w/contrast ___: Cecal wall edema and minimal
adjacent simple fluid and fat stranding at the site of patient's
polypectomy. Consistent with postpolypectomy electrocautery
syndrome. No evidence of perforation. Multiple uterine fibroids.
AFTER ADMISSION/TRANSFER:
=========================
CBC remained stable.
No additional imaging was performed.
GI consult assessment ___: ___ yo F w/ h/o HTN p/w abdominal
pain, n/v after colonoscopy, noted to have leukocytosis, anemia
and cecal wall edema and fat stranding at the site of patient's
polypectomy c/w postpolypectomy electrocautery syndrome. There
is no evidence of perforation on the CT scan read. She has a
new anemia, with a risk of post-polypectomy bleed, but no
evidence of overt blood loss. Therefore, at this time we
recommend ongoing supportive management, monitoring of labs,
signs of overt GI bleed and emperic antibiotics for
post-polypectomy syndrome." Verbal recommendations were for 5
days of antibiotics (given limited evidence of benefit), advance
diet as tolerated, discharge OK if patient able to advance diet
and no evidence of ongoing GI bleeding.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 50 mg PO BID
2. Valsartan 320 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 5 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Aspirin 81 mg PO DAILY
7. BusPIRone 10 mg PO DAILY:PRN anxiety
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Simvastatin 5 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice
daily Disp #*6 Tablet Refills:*0
4. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 3 Days
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hours Disp #*9 Tablet Refills:*0
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. BusPIRone 10 mg PO DAILY:PRN anxiety
8. Metoprolol Tartrate 50 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, nausea and vomiting, likely post-polypectomy
syndrome
Fluid responsive hypotension, likely dehydration and
inflammation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ woman with abdominal pain and hypotension after
undergoing screening colonoscopy earlier today.
TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were obtained
after administration of 130 mL Omnipaque intravenous contrast. Enteric
contrast was not given. Coronal and sagittal reformats prepared and reviewed.
DOSE: DLP: 430.73 mGy-cm.
COMPARISON: CT from ___.
FINDINGS:
CHEST:
There is left lower lobe atelectasis, a small hiatal hernia, and trace,
physiologic pericardial effusion.
ABDOMEN:
The liver enhances homogeneously, without concerning focal lesion. There is
a sub cm hypodensity in the right lobe of the liver which is too small to
characterize but stable from ___ (2:6). The gallbladder and biliary tree are
normal. The pancreas is normal, without focal lesion or duct dilation. The
spleen is normal in size, without focal lesion. The adrenal glands are normal.
The kidneys enhance normally and excrete contrast briskly. There are no solid
renal lesions or hydronephrosis.
There is cecal mural edema with minimal adjacent mesenteric fat stranding and
simple fluid (___). Otherwise, the small bowel and remainder large bowel
are normal in caliber.
There is no intra- or retroperitoneal lymphadenopathy. There is no ascites,
fluid collection, or pneumoperitoneum. The abdominal aorta is normal caliber,
with patent main branches. The portal vein and IVC are patent.
PELVIS:
The urinary bladder is without wall thickening or mass. The rectum is
unremarkable. There is no free fluid. There is no pelvic or inguinal
lymphadenopathy. There are multiple uterine fibroids with coarse
calcifications, likely in the process of involution, with areas of hypodensity
which may reflect degeneration. Rounded hypodensities in the region of the
cervix may relate to nabothian cysts. There is no adnexal abnormality.
BONES AND SOFT TISSUES:
There is no acute fracture. There is severe scoliosis of the spine with
associated degenerative change.
IMPRESSION:
1. Cecal wall edema and small amount of adjacent simple fluid and fat
stranding at the site of patient's reported polypectomy, most c onsistent with
postpolypectomy electrocautery syndrome. No evidence of perforation.
2. Multiple uterine fibroids, some of which may be degenerating.Rounded
hypodensities in the region of the cervix may relate to nabothian cysts.
Findings could be confirmed on nonurgent pelvic ultrasound.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: N/V, Weakness
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 97.8
heartrate: 83.0
resprate: 16.0
o2sat: 100.0
sbp: 91.0
dbp: 50.0
level of pain: 9
level of acuity: 2.0 | ISSUES ADDRESSED THIS HOSPITAL STAY:
[Active]
# Abdominal pain: postpolypectomy electrocautery syndrome vs
microperforation. No free air on CT, which was reassuring
perforation; LFTs and lipase normal made cholecystitis,
cholangitis, pancreatitis unlikely; no diverticula on CT to
suggest diverticulitis; she was low risk for ischemic colitis,
though was an initial consideration, lactates unremarkable.
Improved with IVF, pain medication, cipro/flagyl, and bowel
rest. Diet advanced on day of discharge, tolerated well. Had
normal BM morning of DC. Plan for 3 more days of cipro/flagyl
after DC.
# Anemia: Probably acute blood loss anemia in setting of GI
biospies given guaiac positive stool, but there was also
probably a component of dilution. CBC remained stable on serial
checks, and she had a normal stool without melena or gross blood
prior to discharge.
# Hypotension: Resolved with IVF. Likely SIRS and acute blood
loss. Cultures negative (though asymptomatic bacteriuria).
# GERD with EGD evidence of gastritis: Continued PPI, but
transitioned to high dose BID.
[Stable/Chronic/Minor]
# HTN: Held home anti-hypertensives while here. Resumed BB at
___, but instructed her to monitor her BPs at home and resume her
valsartan only if BPs >140/90.
# Anxiety: Continued home buspar. She had a mild anxiety attack
on the night prior to discharge with tachycardia and mild
hypertension, which resolved with a single dose of Ativan.
# HLD: Continued home simvastatin.
# Hypothyroidism: Continued home levothyroxine. TSH was 1.7. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Status-Post Fall
Major Surgical or Invasive Procedure:
None (Suturing/Stapling performed as ___
History of Present Illness:
PCP: Dr. ___
CC: Fall
HISTORY OF PRESENT ILLNESS:
___ yo M PMHx T2DM/HLD presents from ___ due to
post-concussive syndrome. On ___ @ 12:15, patient was climbing
up ladder to roof to take pictures for insurance company to
document damage to his roof. What happened next was unwitnessed
and patient cannot recall but his wife found him on his back
having fall ?___ feet backwards after ___ minutes out of the
house. Wife was unable to arouse patient and called EMS.
Paramedics aroused patient with voice, noticed lots of blood
from scalp, and brought patient to ___. At OSH, he was
evaluated and stitched but his CT-Head (negative C-Spine) had
findings concerning for ICH and transferred to ___ for
Neurosurgery evaluation.
In the ED, initial vitals were: 3 98.1 89 150/81 18 99. ab: CBC
and chem were unremarkable. Imaging: Repeat CT showed a stable
puncate hyperdensity along the septum pellucidum unlikely to
represent hemorrhage and CT torso showed no acute pathology. He
was seen by neurosurgery in the ED who felt the patient was
neurologically intact an no need for neurological intervention
at this time. He was also seen by trauma surgery. Tertiary exam
was negative, with no further need for trauma evaluation. He was
seen by ___ in the ED who recommended inpatient admission for
2 inpatient OT sessions. He received APAP 1g, metformin 1.5g,
simvastatin 80, and omeprazole 40.
On CC7, patient has ___ neck pain from occiput wrapping forward
palliated by APAP. He still endorses other complaints per ROS
and above (with assistance from wife).
Review of Systems: Positive for memory loss, nausea, dizziness
(unable to walk yesterday, today can walk with assistance),
disorientation, headache, word slurring (when talking >1
hour), nausea without emesis, neck pain all improved since
yesterday. Negative for fever/chills, pain, prodromal symptoms,
numbness or paresthesias, continued hemorrhage. 9-Point ROS
otherwise negative.
Past Medical History:
Type II Diabetes on metformin
Rheumatic Fever as a child
GERD
HLD
Bankart Procedure for Right Shoulder Dislocation
Right Knee Arthroscopy
Testicular Torsion s/p Orchiectomy
Social History:
___
Family History:
Twin has T2DM, another brother has RA, mother had stroke at ___.
No family history premature coronary artery disease,
arrhythmias, or sudden death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.8, 93, 124/66, 18, 96% on RA, ___ Pain/Dyspnea
General: Alert, oriented, no acute distress
HEENT: Y-shaped laceration on right occiput with 13 scalp
staples and 13 scalp sutures. Sclera anicteric, MMM, oropharynx
clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, no dysmetria,
positive Romberg sign without challenge, gait unsteady upon a
few steps and thus deferred. ___ recall at 5 minutes, ___ with
category clues. Able to recite months of year backwards. 11:10
clock significant for need for repeated instructions and sloppy
writing.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.6, 72-83, 129-151/64-85, ___, 96-99% on RA, ___
Pain, Ins 1820, Outs BRP
General: Alert, oriented, no acute distress
HEENT: Y-shaped laceration on right occiput with 13 scalp
staples and 13 scalp sutures. Sclera anicteric, MMM, oropharynx
clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, no dysmetria,
negative Romberg, gait wide-based but able to walk outside room
without active assistance.
Pertinent Results:
ADMISSION LABS:
___ 05:30PM BLOOD WBC-7.5 RBC-4.30* Hgb-13.0* Hct-37.4*
MCV-87 MCH-30.3 MCHC-34.8 RDW-14.0 Plt ___
___ 05:30PM BLOOD ___ PTT-28.2 ___
___ 05:30PM BLOOD Glucose-168* UreaN-21* Creat-0.9 Na-137
K-3.8 Cl-101 HCO3-27 AnGap-13
___ 07:20AM BLOOD Calcium-9.5 Phos-3.9 Mg-1.8
___ 12:30AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:30AM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
CT Head ___ = Stable 4mm punctate hyperdensity along the
septum pellucidum, highly unlikely to represent hemorrhage given
lack of other intracranial traumatic findings
CT Torso ___ = No evidence of an acute injury. Essentially
normal CT Torso. A 3 mm right lower lobe pulmonary nodule. If
patient has no risk factors, no additional imaging is necessary,
otherwise ___ year followup is suggested if long-term stability
cannot be documented from prior scan performed elsewhere
EKG ___ = Sinus @ 77 with borderline 1st Degree AVB, PR
218ms, QTc 409ms, normal axis, no ST-T changes
MRI Brain ___ =
1. Possible subacute 2-mm are in the splenium verses artifact as
described. No hemorrhage noted in this region. Recommend
clinical correlation.
2. Probable old punctate hemorrhages abutting the right lateral
ventricle.
3. No cerebellar mass or hemorrhage.
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-5.4 RBC-3.72* Hgb-11.9* Hct-32.5*
MCV-88 MCH-31.9 MCHC-36.5* RDW-14.6 Plt ___
___ 07:20AM BLOOD Glucose-179* UreaN-18 Creat-0.9 Na-136
K-4.2 Cl-101 HCO3-24 AnGap-15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO QPM
2. MetFORMIN (Glucophage) 1000 mg PO QAM
3. Simvastatin 80 mg PO QPM
4. Omeprazole 40 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. MetFORMIN (Glucophage) 500 mg PO QPM
2. MetFORMIN (Glucophage) 1000 mg PO QAM
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Simvastatin 80 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. Durable Medical Equipment
Standard Cane
IC9: ___.2 Unstable Gait
Prognosis: Good
Duration: 13 Months
8. Outpatient Physical Therapy
ICD 310.2
Evaluate and Treat
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Status-Post Fall
Post-Concussive Syndrome
Occipital Laceration status-post Suture/Laceration
SECONDARY:
Type II Diabetes Mellitus on oral agents
Lung Nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ male with fall off ladder.
TECHNIQUE: Multi detector CT images through the abdomen pelvis and chest were
obtained after the administration of intravenous contrast. No oral contrast
was administered. Coronal and sagittal reformations were generated and
reviewed.
DOSE: DLP: 1028 mGy cm.
COMPARISON: None available.
FINDINGS:
CT chest: The included thyroid gland appears within normal limits. There is no
axillary, supraclavicular, mediastinal or hilar adenopathy. The heart appears
within normal limits in size. No appreciable coronary artery calcifications
are identified. The aorta and pulmonary artery are wall within normal limits
in caliber. Trace pericardial fluid is physiologic. No esophageal abnormality
is detected.
The airways are patent to the subsegmental level. Trace bibasilar atelectasis
is noted. There is no pleural effusion. No pneumothorax is identified. No
focal consolidation is identified. There is a 3 mm right lower lobe pulmonary
nodule (02:37)
CT abdomen: The liver appears homogeneous in attenuation with no focal lesion
identified. There is no intrahepatic biliary ductal dilatation. The portal
vein is patent. The gallbladder is without radiopaque cholelithiasis. The
pancreas, spleen, and bilateral adrenal glands are within normal limits. Two
small accessory spleens are noted within the splenic hilum. Bilateral kidneys
present symmetric nephrograms and excretion of contrast. Renal sinus cysts
are identified on the left. There is no perinephric fluid stranding or
hydronephrosis.
The stomach, duodenum, and loops of small bowel are grossly unremarkable. The
appendix is visualized, within normal limits. The colon is unremarkable.
The abdominal aorta demonstrates moderate to severe atherosclerotic
calcifications without aneurysmal dilatation. There is no retroperitoneal or
mesenteric adenopathy. No abdominal free fluid or air is identified.
A small umbilical fat containing hernia is noted.
Pelvis: The bladder is moderately well distended and grossly unremarkable.
Prostate gland and seminal vesicles appear within normal limits. There is no
pelvic free fluid. There is no inguinal or pelvic sidewall adenopathy.
Osseous structures: No suspicious lytic or blastic lesion is identified. No
acute fracture is identified.
IMPRESSION:
No evidence of an acute injury. Essentially normal CT Torso.
A 3 mm right lower lobe pulmonary nodule. If patient has no risk factors, no
additional imaging is necessary, otherwise ___ year followup is suggested if
long-term stability cannot be documented from prior scan performed elsewhere.
NOTIFICATION: Updated finding paged to Dr. ___ at 930pm on ___.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: Status post fall off ladder from 10 feet with impact on the right
posterior head with loss of consciousness found to have possible hemorrhage on
outside CT.
TECHNIQUE: Contiguous axial images images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 1003.42 mGy-cm
CTDI: 51.31 mGy
COMPARISON: Prior head CT from an outside institution ___),
dated ___.
FINDINGS:
Punctate hyperdensity along the septum pellucidum is unchanged (02:21). There
is otherwise no evidence of infarction, hemorrhage, edema, or mass. Prominent
ventricles and sulci is suggest age related involution.
Right posterior scalp hematoma and laceration with overlying skin staples. No
underlying fracture. No osseous abnormalities seen. The paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The orbits are
unremarkable.
IMPRESSION:
Stable punctate hyperdensity along the septum pellucidum, highly unlikely to
represent hemorrhage given lack of other intracranial traumatic findings.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ man who is status-post fall off an ___ foot ladder
with approximately 15 min of LOC and trauma to his right occiput who presented
to outside hospital with neck pain, mild headache, and right posterior scalp
laceration (status-post repair) and transfered to ___ on ___ for
evaluation of possible ICH. Patient has continued poor gait. Evaluate for
cerebellar/posterior fossa pathology.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 9 cc of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CT head non-contrast dated ___.
No prior brain MRI is available.
FINDINGS:
There is a 2-mm focus the splenium that appears to show restricted diffusion
(Series 6; Image 17; Series 5, Image 11), is hyperintense on FLAIR sequence
(Series 11, Image 14) but without clear corresponding hemorrhage on GRE(Series
10, Image 15). This may represent a subacute injury that is evolving verses
an artifact. There is no evidence of hemorrhage in this region. There are
several punctate hypointense foci on GRE just lateral to the right lateral
ventricle that may represent prior punctate hemorrhage since prior CT did not
identify calcifications in this region (Series 10, Images ___. There is no
focal infarct or hemorrhage in the cerebellum. Post-contrast imaging is
limited by artifact, but there is no enhancing lesion. There is no evidence
of mass effect. The ventricles and sulci are prominent but within the normal
limits for age.
IMPRESSION:
1. Possible subacute 2-mm are in the splenium verses artifact as described.
No hemorrhage noted in this region. Recommend clinical correlation.
2. Probable old punctate hemorrhages abutting the right lateral ventricle.
3. No cerebellar mass or hemorrhage.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___, the referring provider, on the telephone on ___ at 4:16
___, 2 minutes after discovery of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Head injury
Diagnosed with BRAIN HEM NEC-COMA NOS, FALL-1 LEVEL TO OTH NEC, DIABETES UNCOMPL ADULT
temperature: 98.1
heartrate: 89.0
resprate: 18.0
o2sat: 99.0
sbp: 150.0
dbp: 81.0
level of pain: 3
level of acuity: 2.0 | ___, a ___ yo M PMHx T2DM presents with concussion
status-post fall. Patient fell backwards from 10 feet with 15
minute LOC and no memory of prodrome or witnesses. He had
CT-Head showing 4mm punctate hyperdensity in septum pellucidum
inconsistent with intracranial hemorrhage and CT-Torso also
inconsistent with anatomic trauma. Patient was evaluated by
Neurosurgery who recommended ED Observation and OT who wanted
Medicine Inpatient Admission for 2 sessions. Neurosurgery did
not want admission to there service since neurologically intact.
Trauma Surgery found no indication for admission to there
service. Although patient did not remember what happened exactly
at the time of fall due to retrograde amnesia; he did not recall
prodromal chest pain or palpitations or lightheadedness and has
not felt these symptoms before. EKG significant only for ___
degree AV Block. MRI Brain did not show any acute injury beyond
the laceration and concussion; they noted a small foci of
abnormal signal in the splenium (noted on CT) and lateral
ventricle that did not seem acute not did they explain patient's
presentation. Patient was discharged after clearance by ___
and Brain MRI to 24-hour observation and ___ prescription.
# Post-Concussive Syndrome / Status-Post Fall / Occipital
Laceration: Patient fell backwards from 10 feet with 15 minute
LOC and no memory of prodrome or witnesses. He had CT-Head
showing 4mm punctate hyperdensity in septum pellucidum
inconsistent with intracranial hemorrhage and CT-Torso also
inconsistent with anatomic trauma. Patient was evaluated by
Neurosurgery who recommended ED Observation and OT who wanted
Medicine Inpatient Admission for 2 sessions. Neurosurgery did
not want admission to there service since neurologically intact.
Trauma Surgery found no indication for admission to there
service. EKG significant only for 1st degree AV Block. Over
the course of his hospitalization under OT's care, his gait
significantly improved and his dizziness and nausea improved
although he had continued memory/cognitive dysfunction. MRI
Brain showed subacute findings but these are not acute and ___
explain patients presentation. On late ___, patient was
cleared by ___ to go home with 24-hour supervision and likely
___nd OT. His staples are to be removed after ___
days and his aspirin was restarted after discharge.
# T2DM: Stable on home metformin in house (continued as
inpatient given clinical stability). FSBG 176-196 and insulin
sliding scale could be used if patient were to be inpatient for
longer.
# Lung Nodule: Transitional issue to repeat CT-Chest in ___ year
to evaluate 3 mm right lower lobe pulmonary nodule.
# HLD: Continued on home simvastatin
# GERD: Continued on home omeprazole |
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 VF cut
Major Surgical or Invasive Procedure:
na
History of Present Illness:
___ is a ___ right-handed man
w/PMH of AFib on dabigatran recent ___ Stroke admission ___
with embolic strokes of the left parietal, occipital, cerebellum
presents now with 30 min right hand clumsiness and right VF
loss.
The patient noted acute onset clumsiness of right-hand
clumsiness
while typing on the computer. He could not press the correct
buttons and was making mistakes. He feels like there was
weakness of the muscles of the hand, but symptoms did not
clearly
affect the whole arm. There was no involvement of the face or
right leg. A few minutes later he walked to a door that has a
latch on the right hand side and when he went to open it, he
realized he could not see the doorknob. He sat back down and
realized that he had poor vision on the right side of visual
field with either eye. He could not see the computer mouse at
his
desk and says "it was like it disappeared". There was no
headache, blurry vision, paresthesias, or speech difficulty.
The
whole episode lasted about 30 minutes in total. He lives with a
friend who alerted EMS and was taken to the ED. By the time he
arrived, deficits had resolved but was sent for an urgent CT
head
that showed a new area of hypodensity in the right
parieto-occipital region, consistent with an recent infarct.
During his recent Stroke Admission in ___ he had MRI/MRA and
the MRA was notable for irregularity towards the end of the M1
segment from prior embolic stroke or in-situ atherosclerotic
disease. The etiology of the strokes was believe due ischemia in
the setting of in situ atherosclerosis or recurrent embolism.
EEG was obtained which showed slowing but no frank seizures. The
patient unfortunately left the hospital AMA before echo could be
obtained.
He claims he has continued his home dabigatran and we
recommended
he start atorvastatin 20mg daily.
Past Medical History:
Afib
HTN
Hyperlipidemia
Chronic Kidney Disease
Anemia likely due to iron deficiency and chronic disease
Recent L parietal, occipital
hypothyroid
Social History:
___
Family History:
Brother died of lung cancer. No FH of CAD or Diabetes. Nil
neurological
Physical Exam:
Vitals: T: 98.0 P:58 R: 16 BP: 140/66 SaO2:100%
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: irregular. 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 self, hospital date= ___.
Able to relate history without difficulty. Attentive, but some
difficulty with ___ 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 spontaneously.There was no evidence of
neglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF appears full to confrontation
to finger count and motion with a few mistakes on both sides.
There is not a right hemifield cut. Fundoscopic exam revealed no
papilledema, exudates, or hemorrhages.
Without glasses OS ___, OD ___
III, IV, VI: EOMI with ___ saccadic intrusions but no 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 0 0
R 2 2 2 2 0
Plantar response was upgoing on left, equivocal right.
-Coordination: Slight intention tremor, some slowness with fine
motor movements bilaterally (right worse than left). No
dysmetria
on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
admit labs
___ 08:46PM BLOOD WBC-5.3 RBC-3.86* Hgb-11.1* Hct-35.5*
MCV-92 MCH-28.7 MCHC-31.2 RDW-17.3* Plt ___
___ 08:46PM BLOOD Neuts-65.7 ___ Monos-5.3 Eos-1.0
Baso-0.3
___ 08:46PM BLOOD Plt ___
___ 09:15PM BLOOD PTT-74.6*
___ 08:46PM BLOOD Glucose-98 UreaN-27* Creat-1.7* Na-136
K-4.6 Cl-99 HCO3-29 AnGap-13
___ 08:46PM BLOOD ALT-31 AST-52* AlkPhos-65 TotBili-0.6
___ 05:10AM BLOOD Calcium-8.9 Phos-2.5* Mg-1.7
___ 08:46PM BLOOD Albumin-3.9
stroke labs
___ 08:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:40AM BLOOD T3-102 Free T4-1.1
___ 08:46PM BLOOD Ammonia-22
___ 06:40AM BLOOD Triglyc-89 HDL-39 CHOL/HD-3.5 LDLcalc-79
Studies:
___ ___
Acute infarct in the right parieto-occipital region without
acute hemorrhage. Old left parietal infarct.
MRI/MRA head/neck ___. New areas of slow diffusion within the bilateral parietal
lobes, right
greater than left, compatible with acute ischemia. Pattern, in
combination with prior findings, is suggestive of central
source.
2. No pathologic large vessel occlusion or vascular malformation
within the head or neck.
3. Distal intracranial vessels are not well visualized which is
potentially an artifactual basis although atheromatous narrowing
is possible.
ECHO ___
No atrial septal defect or patent foramen ovale. Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function. Mildly dilated aortic root with
mild aortic regurgitaion. Mild mitral regurgitation. Pulmonary
hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atenolol 50 mg PO BID
3. Dabigatran Etexilate 150 mg PO BID
4. Levothyroxine Sodium 37.5 mcg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
7. Ferrous Sulfate 150 mg PO DAILY
8. Citalopram 20 mg PO DAILY
9. Spironolactone 25 mg PO DAILY
10. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Atenolol 50 mg PO BID
2. Citalopram 20 mg PO DAILY
3. Ferrous Sulfate 150 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
6. Spironolactone 25 mg PO DAILY
7. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily at 4pm
Disp #*30 Tablet Refills:*1
9. Amlodipine 5 mg PO DAILY
10. Lisinopril 20 mg PO DAILY
11. Levothyroxine Sodium 88 mcg PO DAILY
RX *levothyroxine 88 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. Outpatient Lab Work
Please have INR drawn on ___ and ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ACUTE ISCHEMIC STROKE, atrial fibrilation, HTN, HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ year old man with new suacute occipital infarct // assess
ischemic lesion
TECHNIQUE: MRI of the brain without contrast. Three dimensional noncontrast
time of flight MR arteriography was performed with rotational reconstructions.
2D time-of-flight noncontrast MRA of the neck was also performed.
COMPARISON: MRI ___.
FINDINGS:
New areas of slow diffusion predominantly involving the right posterior
parietal cortex with additional punctate focus of slow diffusion within the
left posterior parietal cortex. Previously described infarct within left
parietal region again shows increased diffusion signal and is compatible with
now subacute to chronic infarct. Given distribution, findings are suggestive
of a central source.
There is no evidence of acute intracranial hemorrhage or mass effect. White
matter signal abnormality is presumably on the basis of chronic small vessel
ischemic disease, in combination with multiple bilateral lacunar infarcts.
The orbits and paranasal sinuses are unremarkable.
Evaluation of the intracranial vasculature demonstrates no large vessel
occlusion, aneurysm, or vascular malformation. The distal intracranial vessels
are not well-visualized which is potentially on an artifactual basis although
atheromatous narrowing is also possible. Incidental note is made of fetal
origin of right PCA.
Evaluation of vasculature within the neck on 2D time-of-flight images
demonstrates no large vessel occlusion or vascular malformation.
IMPRESSION:
1. New areas of slow diffusion within the bilateral parietal lobes, right
greater than left, compatible with acute ischemia. Pattern, in combination
with prior findings, is suggestive of central source.
2. No pathologic large vessel occlusion or vascular malformation within the
head or neck.
3. Distal intracranial vessels are not well visualized which is potentially an
artifactual basis although atheromatous narrowing is possible.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Vision changes, Headache
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, MUSCSKEL SYMPT LIMB NEC, VISUAL DISTURBANCES NEC, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, HYPOTHYROIDISM NOS
temperature: 98.0
heartrate: 58.0
resprate: 16.0
o2sat: 100.0
sbp: 140.0
dbp: 66.0
level of pain: 3
level of acuity: 2.0 | ___ is a ___ right-handed man w/ PMH
significant for AFib on dabigatran and a recent ___ Stroke
admission ___ with embolic strokes of the left parietal,
occipital and cerebellum who presented this time with 30 min
right hand clumsiness and right VF loss. His exam was notable
for left-right confusion, finger agnosia, dycalculia and
dysgraphia, in addition to his VF loss on the right and some
neglect on the left. MRI showed a new right inf MCA territory
acute infarct along with a small left post punctate infarct. The
etiology of the strokes were again thought to be cardioembolic
source. The patient was switched from dabigatran to warfarin
given his mulitple strokes on dabigatran. He was eventually DCed
home with services. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
vomiting
Abdominal pain
Major Surgical or Invasive Procedure:
Incisional hernia reduction
History of Present Illness:
Ms. ___ is a ___ woman with history of HTN, HLD,
CKD, hypothyroidism, prior abdominal surgeries with incision
hernia s/p repair who presents with abdominal pain.
History is taken from the patient and her daughter, who also
provides assistance with translation at the bedside. The patient
reports that she was in her usual state of health until ___,
when she developed the acute onset of abdominal pain associated
with nausea and five episodes of emesis. The pain is in the
middle of her abdomen/right lower quadrant, and was made worse
by
drinking and eating. She also noted a large bulge in her abdomen
that was new. On ___, she felt that the pain was somewhat
better, and she had bowel movement. She denies any other
complaints such as fever, chills, chest pain, shortness of
breath, flank pain, or dysuria. She presented to urgent care for
evaluation, and was referred to the ED for further evaluation.
In the ED, vitals: 97.6 58 149/62 18 99% RA
Exam notable for: quiet bowel sounds, no rebound or guarding,
there is a ~5cm round firm hernia in the RLQ that crosses the
midline that is tender to palpation.
Labs notable for: CBC wnl, BUN/Cr 50/1.7, lactate 1.0
Imaging: CT A/P
Consults: ACS, reduced hernia
Patient given: 1L LR
On arrival to the floor, the patient reports that she feels much
better. She denies any abdominal pain. She reports feeling
thirsty.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
- HTN
- HLD
- CKD
- Hypothyroidism
- Osteoporosis
- S/p bilateral cataract surgery
- S/p TAH/?BSO for fibroids
- Incisional hernia s/p repair ___, ___)
Social History:
___
Family History:
FAMILY HISTORY: No known family history of hernia.
Physical Exam:
VITALS: Afebrile and vital signs within normal limits
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: normocephalic, atraumatic
CV: Heart regular, I/VI systolic murmur at LSB, no S3, no S4.
No
JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Trace crackles that resolved on further breaths
GI: Abdomen soft, mildly distended, non-tender to palpation.
Bowel sounds present. abdominal wall defect to the R of the
umbilicus and superior to old surgical incision with soft hernia
contents, easily reduced
MSK: Neck supple, moves all extremities
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: delightful and pleasant, appropriate affect
Pertinent Results:
___ 02:55PM NEUTS-70.6 ___ MONOS-8.5 EOS-0.2*
BASOS-0.2 IM ___ AbsNeut-3.76 AbsLymp-1.08* AbsMono-0.45
AbsEos-0.01* AbsBaso-0.01
___ 03:50PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-20*
GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NORMAL PH-6.0
LEUK-LG*
___ 06:20AM BLOOD WBC-3.5* RBC-3.36* Hgb-10.0* Hct-32.1*
MCV-96 MCH-29.8 MCHC-31.2* RDW-13.5 RDWSD-47.8* Plt ___
___ 02:55PM BLOOD Glucose-80 UreaN-50* Creat-1.7* Na-142
K-4.6 Cl-104 HCO3-20* AnGap-18
___ 06:20AM BLOOD Glucose-84 UreaN-48* Creat-1.3* Na-143
K-3.8 Cl-110* HCO3-19* AnGap-14
___ 02:55PM LIPASE-116*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Gemfibrozil 600 mg PO BID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
8. Denosumab (Prolia) 60 mg SC Q6MONTHS
Discharge Medications:
1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW ___. Gemfibrozil 300 mg PO QAM
RX *gemfibrozil 600 mg 0.5 (One half) tablet(s) by mouth every
morning Disp #*15 Tablet Refills:*0
3. Gemfibrozil 600 mg PO QPM
4. Denosumab (Prolia) 60 mg SC Q6MONTHS
5. FoLIC Acid 1 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. HELD- Atenolol 50 mg PO DAILY This medication was held. Do
not restart Atenolol until instructed by your primary care
doctor.
10. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until instructed by your primary care
physician.
Discharge Disposition:
Home
Discharge Diagnosis:
Incarcerated ___ hernia, reduced
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ yo F with PMH of HTN, CKD, HLD, OA here with abdominal
pain.+PO contrast // eval for evidence of obstruction, hernia
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.8 s, 45.6 cm; CTDIvol = 9.3 mGy (Body) DLP = 423.4
mGy-cm.
Total DLP (Body) = 423 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Focal opacity with some bronchiectasis changes in the right
middle lobe (2:1). There is a 0.4 cm nodule in the right lower lobe (2:3).
These changes are seen on a background of bibasilar and lingular atelectasis.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout
without evidence of focal lesion within limitation of a unenhanced study.
There is no definite evidence of intrahepatic or extrahepatic biliary ductal
dilatation. The gallbladder is markedly distended with multiple intraluminal
gallstones. There is no wall thickening or definite pericholecystic
stranding.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. A 0.8 cm hyperdense
lesion in the upper pole left kidney is nonspecific, possibly hemorrhagic
cyst. There is no nephrolithiasis. There is no perinephric abnormality.
GASTROINTESTINAL: A ventral abdominal wall hernia is noted which contains a
significantly distended loop of small bowel which measures up to 5.4 cm in
axial diameter and contains fluid and fecalized material (2:49). There is some
stranding surrounding this loop of bowel within the hernia. The small bowel is
distended and fluid-filled proximally measuring up to 3.4 cm (602:30). The
small bowel distal to the hernia is entirely collapsed (602:43) after
returning in the abdominal cavity. There is no substantial free fluid within
the abdomen or pelvis. There is diffuse colonic diverticulosis, predominantly
involving the sigmoid colon and without evidence of diverticulitis. The
appendix is unremarkable. Note is made of a prominent duodenal diverticulum.
PELVIS: The urinary bladder and distal ureters are unremarkable. No free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: No intra-abdominal or intrapelvic lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted including at the ostia of the right and left renal arteries.
BONES: The bones are diffusely demineralized. A compression deformity of the
superior endplate of T12 is favored to be chronic (602:36). Multifocal
cortical sclerotic foci are seen, for example in the left iliac bone, most
consistent with bone islands.
SOFT TISSUES: Mild soft tissue stranding in the soft tissues of the abdominal
wall as described above. A nonspecific calcification is noted in the left
breast.
IMPRESSION:
1. High-grade small-bowel obstruction due to an obstructive ventral wall
hernia containing a 10 cm segment of markedly dilated small bowel measuring up
to 5.4 cm and containing fluid and fecalized material. The obstruction is
centered at the point where the small bowel re-entered the abdomen (602:43).
2. Largely distended gallbladder with multiple gallstones but no wall
thickening or pericholecystic fluid.
3. Airspace opacity in the visualized right middle lobe with some
bronchiectatic changes, possibly chronic however correlation for pneumonia is
recommended.
4. Compression deformity of the T12 superior endplate, favored to be chronic.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unsp intestnl obst, unsp as to partial versus complete obst
temperature: 97.6
heartrate: 58.0
resprate: 18.0
o2sat: 99.0
sbp: 149.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman with history of HTN, HLD,
CKD, hypothyroidism, prior abdominal surgeries with incision
hernia s/p repair who presented with abdominal pain, found to
have SBO due to obstructing ventral hernia. The hernia was
reduced by surgery in the ED and she was admitted to be sure of
tolerance of PO and passage of stool. She was able to tolerate
PO and passed stool the afternoon of ___ and so was discharged
home to recover, and to follow up with surgery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lower abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
LAPAROSCOPIC APPENDECTOMY
History of Present Illness:
Ms. ___ is a ___ presenting with 16 hours of dull pain in
lower abdomen associated with persistent nausea and vomiting x
2. The pain started yesterday evening after dinner. No sick
contacts. Denies fevers, diarrhea, similar episodes of pain in
the past.
Past Medical History:
PMH
None
PSH
Laparoscopic left dermoid ovarian cyst resection ___
IUD
Social History:
___
Family History:
Non-contributory
Physical Exam:
V/S: T98.4, HR52, BP101/61, RR16, Sat98%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, non-distended, appropriately tender to palpation,
tender at ___, incisions with small gauze covering
incision sites.
Ext: No ___ edema, ___ warm and well perfused
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Mild
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every four (4)
hours Disp #*18 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
ACUTE APPENDICITIS status post laparoscopic appendectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US APPENDIX
INDICATION: History: ___ with rt LQ pain// appendicitis?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the right lower
quadrant in the region of the pain were obtained.
COMPARISON: None.
FINDINGS:
Targeted ultrasound of the right lower quadrant was obtained for evaluation of
the appendix. There is a blind ending loop of bowel measuring 7 mm in
diameter. The appendix is slightly thickened and noncompressible. In
addition, there is mild inflammatory changes around the tip of the appendix
with small amount of fluid, concerning for acute appendicitis.
IMPRESSION:
Findings concerning for acute appendicitis with small amount of fluid in the
right lower quadrant.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ woman with right lower quadrant pain. Evaluate for
appendicitis. NO_PO contrast.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP =
7.2 mGy-cm.
2) Spiral Acquisition 5.5 s, 43.6 cm; CTDIvol = 9.2 mGy (Body) DLP = 399.1
mGy-cm.
Total DLP (Body) = 406 mGy-cm.
COMPARISON: Abdominal ultrasound dated ___, earlier on the same
day at 11:37.
FINDINGS:
LOWER CHEST: The partially imaged lower lungs are clear other than minimal
bibasilar atelectasis.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. No
evidence of focal lesions. No evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is within normal limits. Periportal
edema is mild, likely related to intravenous hydration.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. No peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A few renal cortical hypodensities are too small to accurately characterize on
CT. No evidence of focal renal lesions or hydronephrosis. No perinephric
abnormality.
GASTROINTESTINAL: Detailed evaluation of bowel loops is limited secondary to
the patient's thin body habitus and lack mesenteric fat as well as lack of
oral contrast administration.
The terminal ileum at the ileocecal valve is decompressed. Loops terminal and
distal ileum centered in the pelvis are mildly dilated up to 3.1 cm with
fecalized material and mild wall hyperenhancement (e.g. Series 601, image 14,
22). Most of the free fluid in the abdomen and pelvis is centered in the
pelvis around these mildly dilated loops of small bowel. There appears to be
a transition point several cm from the ileocecal valve in the right lower
abdomen (e.g. Series 601, image 19). The colon and rectum are decompressed.
These findings are concerning for an early small bowel obstruction. No
evidence of pneumatosis or free air. More proximal loops of small bowel are
decompressed. The stomach is not distended.
The appendix is not definitely visualized in its entirety and appears to be
retrocecal. Visualized portions of the appendix measure up to 5-6 mm (E.g.
Series 601, image 19; series 2, image 45). There is minimal fat stranding and
fluid around the visualized portions of the appendix.
PELVIS: The urinary bladder is moderately distended and unremarkable. The
distal ureters are unremarkable. There is moderate free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus has an intrauterine device in the endometrium.
The ovaries have normal follicular activity bilaterally.
LYMPH NODES: No retroperitoneal or mesenteric lymphadenopathy. No pelvic or
inguinal lymphadenopathy.
VASCULAR: No abdominal aortic aneurysm. No atherosclerotic disease is noted.
The main portal vein, splenic vein, SMV are patent.
BONES: No evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Mildly dilated segment of small bowel terminal and distal ileum centered in
the pelvis and lower abdomen with fecalized material, wall hyperemia,
surrounding free fluid, and transition point in the right lower abdomen,
concerning for early small bowel obstruction.
2. The appendix is not seen in its entirety as assessment is limited by
patient's thin body habitus and lack of oral contrast. Where seen, the
appendix is normal in caliber (measuring up to 6 mm) with minimal fat
stranding, suggesting that the primary etiology of the patient's pain may be
from the small-bowel obstruction rather than from acute appendicitis.
3. Mild periportal edema, likely from hydration status.
NOTIFICATION: Findings and impression were discussed with ___ at 545
pm on ___ on the telephone immediately after discovery of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified acute appendicitis
temperature: 97.6
heartrate: 90.0
resprate: 20.0
o2sat: 100.0
sbp: 136.0
dbp: 78.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ is a ___ year old Female who presented to the ___
___ on ___ with dull pain in
lower abdomen associated with persistent nausea and vomiting x
2. She was tender at ___. Her WBC was 10.6.
Ultrasound of Right lower quadrant of abdomen was obtained for
evaluation of the appendix which showed a blind ending loop of
bowel measuring 7 mm in diameter. The appendix was slightly
thickened and noncompressible. In addition, there was mild
inflammatory changes around the tip of the appendix with small
amount of fluid, concerning for acute appendicitis. CT scan of
abdomen was obtained to confirm diagnosis and demonstrated
mildly dilated segment of small bowel terminal and distal ileum
centered in the pelvis and lower abdomen with fecalized
material, wall hyperemia, surrounding free fluid, and transition
point in the right lower abdomen, concerning for early small
bowel obstruction. The appendix was not seen in its entirety as
assessment was limited by patient's thin body habitus and lack
of oral contrast. Where seen, the appendix was normal in caliber
(measuring up to 6 mm) with minimal fat stranding.
It was concluded to have acute appendicitis. She was placed NPO
and IVF were given. She was placed on antibiotics ciprofloxacin
and flagyl and was taken to the operating room and underwent
laparoscopic appendectomy. For details of the procedure, please
see the surgeon's operative note. The patient tolerated the
procedure well without complications and was brought to the
post-anesthesia care unit in stable condition. After a brief
stay, the patient was transferred to the surgery floor where she
remained through the rest of the hospitalization.
Post-operatively, she was able to tolerate a regular diet, get
out of bed and ambulate without assistance, void without issues,
and pain was controlled on oral medications alone. She was
deemed ready for discharge, and was given the appropriate
discharge and follow-up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Fosamax / Myrbetriq / ciprofloxacin
Attending: ___.
Chief Complaint:
R ankle pain
Major Surgical or Invasive Procedure:
ORIF R trimalleolar ankle fx ___, ___
History of Present Illness:
___ female w/ HTN, HLD, prior episode of pneumonia ___
who presents with the above fracture s/p mechanical fall. She
slipped while walking and sustained the above injury. She
normally uses a walker and walks minimally. She resides at a
retirement community in ___ for the past couple years.
Past Medical History:
Compression fractures
Low back pain
Hyperlipidemia
Hypertension
Coronary artery disease (s/p ___ 2)
Pulmonary arterial hypertension (noted on ECHO ___
RBBB
Transient ischemic attack
Hypothyroidism
GERD
Esophagitis (EGD ___, thought ___ fosfomax)
Vitamin B12 deficiency
Diverticulitis (s/p colostomy with reversal)
GI bleeding
Urge incontinence
Depression
C. diff. colitis
S/p tracheostomy tube placement and PEG placement (___) d/t
hypoxemic respiratory failure, since removed
Cholecystectomy
Tonsillectomy
Social History:
___
Family History:
Brother & mother - leukemia
Father - heart disease
Sister - diabetes
Physical ___:
General: Well-appearing female in no acute distress.
Right lower extremity:
- Skin intact
- short leg splint in place
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Pertinent Results:
___ 07:30AM BLOOD WBC-9.8 RBC-3.21* Hgb-9.3* Hct-30.1*
MCV-94 MCH-29.0 MCHC-30.9* RDW-14.9 RDWSD-50.1* Plt ___
Radiology Report
INDICATION: History: ___ with concern for pneumonia, hypoxia// Pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple chest radiographs, most recent dated ___.
FINDINGS:
Right lung is fully expanded. The left lung is slightly under ventilated.
Linear opacities in the left mid lung likely represents linear atelectasis.
There is mild cardiomegaly with mild interstitial edema and small left pleural
effusion. No pneumothorax.
IMPRESSION:
Mild cardiomegaly with mild interstitial edema and small left pleural
effusion. No definite focal consolidation. Bibasilar atelectasis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with concern for bleed or fracture// Bleed or
Fracture
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.3 cm; CTDIvol = 49.3 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 3.0 s, 6.1 cm; CTDIvol = 49.3 mGy (Head) DLP =
301.0 mGy-cm.
Total DLP (Head) = 1,104 mGy-cm.
COMPARISON: Noncontrast head CT ___.
FINDINGS:
There is no evidence of acute large territorial infarction, intracranial
hemorrhage, edema, or mass.
There is prominence of the ventricles and sulci suggestive of age-related
cerebral volume loss. Periventricular and subcortical white matter
hypodensities are nonspecific, though likely sequelae of chronic small vessel
ischemic disease. Atherosclerotic vascular calcifications are noted of
bilateral vertebral and cavernous portions of internal carotid arteries.
No acute osseous abnormalities seen. The partially imaged paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The orbits demonstrate
no acute abnormalities.
IMPRESSION:
No evidence of acute intracranial process. No evidence of intracranial
hemorrhage or fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with concern for bleed or fracture// Bleed or
Fracture
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.8 s, 22.8 cm; CTDIvol = 22.7 mGy (Body) DLP = 517.8
mGy-cm.
2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
30.0 mGy-cm.
3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
30.0 mGy-cm.
Total DLP (Body) = 578 mGy-cm.
COMPARISON: CT C-spine ___.
FINDINGS:
There is stable minimal retrolisthesis of C5 on C6. Otherwise, the remaining
alignment is normal. No fractures are identified.Multilevel degenerative
changes are seen, not significantly changed since ___. There is no
prevertebral edema.
The upper neck and included lung apices are unremarkable.
IMPRESSION:
No acute fracture or traumatic malalignment.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: History: ___ with right ankle pain after a fall// Fracture
Fracture
TECHNIQUE: AP and lateral views of the right ankle.
COMPARISON: Right ankle radiograph ___
FINDINGS:
There is a oblique displaced, minimally comminuted fracture of the distal
fibular diaphysis, with mild lateral displacement of the distal fracture
component. Additionally, there is a minimally displaced, possibly comminuted,
fracture of the medial malleolus with intra-articular extension. There is
likely a small vertically oriented posterior malleolar fracture. Tiny focus
of mineralization along the dorsal neck of the talus may represent a small
avulsion fracture, age indeterminate and seen on prior exam. Achilles
enthesophytes. There is moderate surrounding soft tissue swelling.
IMPRESSION:
Trimalleolar fracture of the right ankle.
Surrounding soft tissue swelling.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with shortness of breath, hypoxia, tachycardia//
Pulmonary Embolism
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE:
Total DLP (Body) = 503 mGy-cm.
COMPARISON: CTA chest ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The 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: Lung volumes are slightly low. There is bibasilar dependent
atelectasis. Mosaic attenuation of the lungs is likely due to expiratory
phase. Otherwise, lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES/soft tissues: No suspicious osseous abnormality is seen.? There is no
acute fracture. There post treatment changes in the right breast.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. No evidence of traumatic injury.
3. Scattered atelectasis.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: History: ___ with fracture s/p splinting. Evaluate
post-reduction.
TECHNIQUE: Frontal, lateral, and oblique views of the ankle.
COMPARISON: Ankle x-ray ___.
FINDINGS:
Interval placement of overlying splint/cast obscures fine bony detail.
Compared to the most recent prior study, the obliquely oriented, displaced
fracture of the distal fibula appears similar to prior. The minimally
displaced fracture of the medial malleolus also appears similar to prior. The
probable posterior malleolar fracture is obscured by the splint material. No
definite new fracture is seen. The ankle mortise does not appear widened.
IMPRESSION:
Status post splint/cast placement, which obscures bony detail. Grossly with
unchanged appearance of the distal fibular and medial malleolar fractures.
Radiology Report
EXAMINATION: ANKLE CT
INDICATION: ___ year old woman with right ankle fracture// operative planning
TECHNIQUE: Multidetector axial CT images of the right ankle were obtained
without the administration of intravenous contrast. Coronal and sagittal
reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 11.6 s, 24.6 cm; CTDIvol = 14.1 mGy (Body) DLP =
348.2 mGy-cm.
Total DLP (Body) = 348 mGy-cm.
COMPARISON: Ankle radiographs performed on ___
FINDINGS:
There is patchy demineralization throughout the imaged osseous structures.
There is a comminuted fracture of the distal tibia, with extension into the
tibiotalar joint space. Fracture of the anterior tibial plafond at the level
of the syndesmotic ligament, is seen with 3 mm lateral displacement of the
fracture fragment (401:35). There is also an obliquely oriented fracture of
the medial tibial plafond, with 2 mm lateral displacement of the fracture
fragment (401:45). Obliquely oriented posterior malleolar fracture, with
approximately 3 mm superior displacement of the fracture fragment, resulting
in cortical step-off at the posterior tibiotalar joint space (400:55).
Highly comminuted fracture of the distal fibular metadiaphysis, with multiple
small osseous fragments and a 2.4 cm butterfly fragment located posteriorly
(400:37). A few tiny ossific densities in the distal tibiofibular joint space
most likely represent fracture fragments (2:69). There is also suggestion of
slight cortical irregularity along the inferior tip of the malleolus (401:50),
which may represent either a small injury or a sequela of remote injury.
No other fractures are identified. There are no suspicious lytic or sclerotic
lesions. Mild subchondral cystic changes are noted at the fourth
tarsometatarsal joint (2:145).
There is thickening of the Achilles tendon measuring up to 7 mm (3:79), with
calcifications are noted at the calcaneal insertion, compatible with
underlying tendinopathy. Peroneal tendons are grossly unremarkable in
appearance. The posterior tibialis tendon is partly entrapped by adjacent
tibial fracture fragments (3:72). Slightly more distally, note is made of a
fat-fluid level in the posterior tibialis tendon sheath (3:104), suggesting
tendon sheath communication with the fracture. Remainder of the flexor and
extensor tendons are otherwise unremarkable in appearance.
Incidental note is made of atrophy in the abductor digiti minimi muscle.
Evaluation of the soft tissues is notable for a small locule of gas along the
dorsal aspect of the talus, slightly anterior to the tibiotalar joint space
(2:93). Additional smaller locule of gas is seen along the dorsal
talonavicular joint (2:103). There is soft tissue edema, predominantly around
the medial and lateral malleoli.
IMPRESSION:
1. Comminuted intra-articular distal tibial fracture, with involvement of the
anterior, medial, and posterior tibial plafond. The anterior tibial plafond
fracture is located at the level of the syndesmotic ligament attachment.
2. Highly comminuted fracture of the distal fibular metadiaphysis, with a 2.4
cm posterior butterfly fragment. Additional focus of nonspecific cortical
irregularity along the inferior margin of the lateral malleolus, may represent
a small injury versus sequela of remote trauma.
3. Posterior tibialis tendon is partially entrapped by adjacent tibial
fracture fragments, with suggestion of tendon sheath injury as evidenced by
associated fat-fluid levels.
4. Two tiny locules of air in close proximity to the tibiotalar and
talonavicular joints, which may represent either vacuum phenomena or sequela
of penetrating injury. Clinical correlation is recommended.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: RT ANKLE FX. ORIF
TECHNIQUE: Multiple intraoperative fluoroscopic images of the right ankle
were obtained without a radiologist present.
COMPARISON: CT ___.
FINDINGS:
Multiple intraoperative fluoroscopic images of the right ankle were obtained
without a radiologist present demonstrate steps toward its ORIF of
trimalleolar fracture.
IMPRESSION:
Images obtained during ORIF of right ankle fracture. Please refer to
operative report for further details.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Unspecified abdominal pain
temperature: 97.7
heartrate: 99.0
resprate: 18.0
o2sat: 87.0
sbp: 100.0
dbp: 52.0
level of pain: 5
level of acuity: 1.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF R ankle fx, 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 aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Hemodialysis ___
History of Present Illness:
___ year old gentleman with history of hypertension,
calciphylaxis, paroxysmal atrial fibrillation not on warfarin,
and ESRD on HD (___) who presents with 2 days of worsening
dyspnea after skipping HD on ___.
Despite being on a ___ HD schedule, Mr. ___ stopped going to
dialysis after his ___ appointment because they "stuck the
living daylights out of me." This morning, five days after his
last HD appointment, Mr. ___ felt dizzy, so he added a
generous amount of salt to his breakfast to increase his blood
pressure. He also endorsed a ___ dyspnea, bilateral peripheral
edema, and ___ back pain that began a few weeks ago during his
previous hospitalization.
His dizziness and dyspnea did not improve, so Mr. ___ came to
___ for dialysis. On the way to the hospital, he bought
himself a roast beef sandwich.
In the ED, initial vital signs were: T(96.7) P(83) BP(157/95),
R(20) O2 sat (98% RA). Exam notable for AOx3, denies chest pain,
dizziness, palpitations or n/v/d. Labs were notable for K+
(5.5), BUN (78), Cr (17.3), Ca (6.3), P(6.8), H/H (12.4/36.9),
Platelets (134).
CXR: "mild pulmonary congestion, no pleural effusion, no focal
consolidation"
EKG: "90 bpm nsr occasional PAC qtc 511 nl QRS and nl PR, LAD no
peaked Ts no acute ST changes
- QTc is .460 fridericia which is consistent with prior"
On Transfer Vitals were: 98.4 ___ 97RA. At the time of
our meeting, he requests that his low-sodium dietary
restrictions be removed, since "you can't go cold ___ when
reduing sodium intake.
He has approx. 20 salt/pepper packets in his room, which he
brought to season his hospital food.
Past Medical History:
-ESRD
-Paroxysmal atrial fibrillation
-Hypertension
-Calciphylaxis
-Parathyroidectomy
Social History:
___
Family History:
-Mother: HTN
Mother died of natural causes. Does not know father. Brothers
healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4 ___ 97RA
General: Mr. ___ is an obese, well-appearing gentleman who is
AOx3 and in NAD.
HEENT: NCAT, EOMI, MMM
Lymph: JVP not ascertained due to redundant tissue.
CV: soft S1/S2 with no murmurs, rubs, or gallops. RRR.
Lungs: Distant lung sounds. Otherwise, CTAB with no WRR.
Tachypneic with no accessory muscle use.
Abdomen: soft, non-tender abdomen with reducible midline hernia
on valsalva. Bowel sounds present. No ascites.
Ext: WWP, 1+ pittind edema up to mid-shin bilaterally. No C/C,
1+ peripheral pulses.
Neuro: CNII-XII. no appreciable sensory/motor deficits
Skin: healed black necrotic lesions on posteior aspect of LLE,
just anterior to the ankle, approximately 4-5cm in diameter.
DISCHARGE PHYSICAL EXAM:
Vitals: 97.8 176/115 86 24 98RA
General: Mr. ___ is an ___, well-appearing gentleman who
was sleeping during HD.
Weight: 114.3 kg from new dry weight of 107.8kg
Ext: healed black necrotic lesions on posteior aspect of LLE,
just anterior to the ankle, approximately 4-5cm in diameter.
Pertinent Results:
ADMISSION LABS:
___ 02:25PM BLOOD WBC-6.6 RBC-4.30* Hgb-12.4* Hct-36.9*
MCV-86 MCH-28.8 MCHC-33.6 RDW-20.6* Plt ___
___ 02:25PM BLOOD Plt ___
___ 02:25PM BLOOD Neuts-70.8* Lymphs-17.4* Monos-7.5
Eos-3.2 Baso-1.0
___ 02:25PM BLOOD Glucose-109* UreaN-78* Creat-17.3*#
Na-142 K-5.5* Cl-99 HCO3-21* AnGap-28*
___ 02:25PM BLOOD Calcium-6.3* Phos-6.8* Mg-2.3
___ 02:35PM BLOOD K-5.5*
.
CXR PA/LAT ___: FINDINGS: PA and lateral views of the chest
provided. Cardiomegaly and mild-to-moderate pulmonary edema
noted. No large effusions or pneumothorax. Mediastinal contour
appears grossly unchanged. Bony structures are intact.
Striated sclerotic appearance of the vertebrae likely reflects
renal osteodystrophy as clearly seen on the prior CT chest.
IMPRESSION:
1. Cardiomegaly and mild to moderate pulmonary edema.
2. Bony changes consistent with renal osteodystrophy.
.
DISCHARGE LABS (PRE-DIALYSIS)
___ 07:26AM BLOOD WBC-7.6 RBC-4.18* Hgb-12.6* Hct-35.4*
MCV-85 MCH-30.2 MCHC-35.6* RDW-20.6* Plt ___
___ 07:26AM BLOOD Plt ___
___ 07:26AM BLOOD Glucose-90 UreaN-93* Creat-19.3*# Na-143
K-6.4* Cl-104 HCO3-17* AnGap-28*
___ 07:26AM BLOOD Calcium-6.1* Phos-7.1* Mg-2.2 Iron-PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 0.25 mcg PO DAILY
2. Nephrocaps 1 CAP PO DAILY
3. sevelamer CARBONATE 2400 mg PO TID W/MEALS
4. Aspirin 81 mg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QPM
6. Lidocaine-Prilocaine 1 Appl TP DAILY:PRN as directed pre HD
Discharge Medications:
1. sevelamer CARBONATE 2400 mg PO TID W/MEALS
2. Nephrocaps 1 CAP PO DAILY
3. Lidocaine-Prilocaine 1 Appl TP DAILY:PRN as directed pre HD
4. Lidocaine 5% Patch 1 PTCH TD QPM
5. Calcitriol 0.25 mcg PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
Dyspnea
End-Stage Renal Disease
Therapy and Dietary Non-Compliance
SECONDARY DIAGNOSES:
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: ___ with dyspnea, ESRD // PNA?
COMPARISON: ___.
FINDINGS:
PA and lateral views of the chest provided. Cardiomegaly and
mild-to-moderate pulmonary edema noted. No large effusions or pneumothorax.
Mediastinal contour appears grossly unchanged. Bony structures are intact.
Striated sclerotic appearance of the vertebrae likely reflects renal
osteodystrophy as clearly seen on the prior CT chest.
IMPRESSION:
1. Cardiomegaly and mild to moderate pulmonary edema.
2. Bony changes consistent with renal osteodystrophy.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, RENAL DIALYSIS STATUS
temperature: 96.7
heartrate: 97.0
resprate: 20.0
o2sat: 98.0
sbp: 157.0
dbp: 95.0
level of pain: 0
level of acuity: 2.0 | PATIENT: ___ year old gentleman with history of hypertension,
calciphylaxis, paroxysmal atrial fibrillation not on warfarin,
and ESRD on HD (___) who presents with 2 days of worsening
dyspnea after skipping HD on ___.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cellulitis, AMS
Major Surgical or Invasive Procedure:
Intubation ___, Extubation ___
PICC placement
EGD ___
History of Present Illness:
___ M hx of EtOH abuse, elevated transaminases, DM2, ?COPD, AFib
recently on coumadin who presents as a transfer from ___ after a
fall.
The patient himself is a poor historian and the history is
mainly gathtered from notes and from his primary care
Physician's assistant. He was brought to his PCP by his wife on
___ because he had been fatigued for about three weeks and
had reportedly had multiple falls. Felt "not himself" and was
weak and unable to walk much in the last week. No fevers/chills.
Unclear how much or how frequently he was drinking, he says ___
drinks daily. In his PCP's office, he was sleepy and hypoxic to
86%, so he was sent to the ED at ___.
In the ED at ___ he had labs, notable for elevated AST/ALT,
EToH of 467, ammonia 53, PLTs 53, INR 2.4, negative UA. He had
a non-con CT head which showed (read by our neuroradiologists) a
chronic subdural hematoma without acute blood. A non-con CT of
the abdomen from OSH informally read by our radiologists as
fatty, shrunken, nodular, increased venous collaterals
(umbilical vein) in the abdomen suggestive of portal
hypertension, presence of IVC filter, a partial splenectomy, and
findings concerning for lower abdominal/upper pelvic superficial
cellulitis. He was given lactulose, 1g of Vancomyin IV and
transfered to ___ for further management. Of note he was being
treated for bilateral lower extremity cellulitis with
doxycycline as an outpatient.
In the ED at ___, he was sleepy but arousable, vitals were
unremarkable. Labs notable for ETOH >300, INR 2.3, PLTs 31, HCT
31, MCV 122, albumin 2.7, and lactate of 3.0. He was evaluated
by neurosurgery who, as above, felt that the OSH CT was c/w a
chronic, not acute, subdural hematoma, and recommended no
intervention.
On transfer to the floor he was in AF, Afebrile, HR 83, 103/57
93% on 3L.
===================MICU
TRANSFER====================================
Mr. ___ is a ___ year old gentleman with a history of ETOH
abuse, afib recently on coumadin who initially presented ___ as
a transfer from ___ after a fall. At ___ he was somnolent and
hypoxemic to 86%, found to have elevated LFTs, ETOH 467. NCCT
revealed chronic subdural hematoma. A non-con CT of the abdomen
from ___ showed fatty, shrunken, nodular liver with increased
venous collaterals (umbilical vein) in the abdomen suggestive of
portal hypertension, presence of IVC filter, a partial
splenectomy. He was given lactulose for AMS and vancomycin given
concern for cellulitis prior to transfer.
He was transferred to the MICU on ___ for escalating nursing
needs in the setting of encephalopathy and increasing 02
requirement. He was treated for hepatic encephalopathy and EtOH
withdrawal with phenobarb protocol. Hypoxemic respiratory
failure was attributed to aspiration pneumonia and he was
treated with Unasyn. He was diuresed ~2L and TTE did not show
reduced EF. He was transferred back to the floor ___ with
somewhat improved mental status.
Since going back to the floor ___ his mental status has
worsened, now responsive only to sternal rub. He has been
persistently febrile to 102 despite APAP and was broadened to
vanc/cefepime/metronidazole for possible GI source given
abdominal pain. He has been getting 100g 25% albumin for the
past 2 days for volume. Over the past 3 days his 02 requirement
has been increasing with RR in the ___ now on
non-rebreather. ABG this morning 7.35 44 78. Given concern for
volume overload as a component of his worsening respiratory
status, he was given 80 mg IV lasix with 600-800cc UOP prior to
ICU transfer.
On arrival to the MICU, the patient is minimally responsive to
sternal rub, tachypneic, saturating 88% on 100 non-rebreather.
Given AMS and hypoxemia he was intubated shortly after arrival.
Review of systems: Unable to obtain given AMS
Past Medical History:
PAST MEDICAL HISTORY:
- HCV/ETOH cirrhosis
- Alcohol abuse
- Transaminitis since ___ as above
- Atrial fibrillation - on warfarin recently, has sparse cards
followup. Report of a recent TTE that looked "OK"
- DM2
- COPD: no PFTs
- OSA: On 2L home oxygen for the last year.
PSurgical Hx:
- Tracheostomy in ___
- Partial splenectomy ___
- Partial prostatectomy for prostate Ca
- IVC filter ___ after MVA and inability to anticoagulate for
AFib in setting of polytrauma and abdominal surgery
Social History:
___
Family History:
Father died of lung cancer
Mother died of neck cancer
Physical Exam:
ADMISSION:
Vitals - 98.1 HR 84 AF, 111/47 RR 14 93% on 3L
GENERAL: coughing, appears uncomfortable, tremulous, disheveled,
obese, poor hygeine, smells of alcohol.
NEURO: AOX2, knows year, knows president. Unable to recount much
of his history. Follows commands appropriately.
HEENT: AT/NC, conjunctiva red, sclera slightly icteric. Tongue
tremor. Significant lacrimation.
CARDIAC: irregular rhythm, S1/S2, no murmurs.
LUNG: very poor air movement throughout, inspiratory and
expiratory wheezes.
ABDOMEN: obese, NT. 10-20 cm violaceous patch in RLQ of abdomen.
Not warm, non-tender. Flaky skin beneath pannus.
EXTREMITIES: Anasarcic, pitting edema in hands and to the knee
bilaterally. Woody skin changes in bilateral lower extreities.
Bilateral warm erythema with scabs and some dry ulcers in
bilateral lower extremities.
PULSES: 2+ DP pulses bilaterally
NEURO: No pronator drift. Coarse resting tremor bilaterally. +
Asterexis.
SKIN: small spider angiomata over torso with central flushing
under neck. Armpits and chest hairless.
DISCHARGE:
VS Tmax 98.7 Tc 98.4 HR 75-104 BP 104/57-134/76 RR ___ SpO2
93-96% RA, I/O 24h 520/850+BMx2, 8h 120/300+BMx1,
General: Appears well, NAD. AOx2 (not to date). Unable to spell
world backwards. Interacting appropriately. Less interactive
today.
Neck: Unable to appreciate JVD. No supraclavicular adenopathy.
CV: No murmurs, irregular.
Lungs: clear anteriorly.
Abdomen: Soft, obese, large ecchymosis RLQ. No evidence of
fluid wave suggestive of ascites.
GU: Scrotal edema. Foley in place.
Ext: Trace pitting edema.
Skin: Spider angiomas on chest, no jaundice.
Neuro: Mild asterixis. Otherwise, cranial nerves II-XII grossly
intact. Normal UE and ___ strength and sensation bilaterally.
Unable to assess gait.
Pertinent Results:
ADMISSION
___ 05:30PM CK(CPK)-223
___ 05:30PM IRON-113
___ 05:30PM calTIBC-192* VIT B12-1680* FERRITIN-1849*
TRF-148*
___ 05:30PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE
___ 05:30PM HCV Ab-POSITIVE*
___ 05:30PM ___
___ 01:10PM LACTATE-3.2*
___ 12:46PM LIPASE-421*
___ 02:38AM ___ PTT-42.7* ___
___ 01:59AM COMMENTS-GREEN TOP
___ 01:59AM LACTATE-3.4*
___ 01:49AM GLUCOSE-100 UREA N-18 CREAT-1.0 SODIUM-140
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-27 ANION GAP-18
___ 01:49AM estGFR-Using this
___ 01:49AM ALT(SGPT)-39 AST(SGOT)-184* ALK PHOS-215* TOT
BILI-3.0*
___ 01:49AM ALBUMIN-2.7*
___ 01:49AM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:49AM WBC-8.2 RBC-2.61* HGB-10.1* HCT-31.9*
MCV-122* MCH-38.7* MCHC-31.7 RDW-17.6*
___ 01:49AM NEUTS-75* BANDS-0 LYMPHS-10* MONOS-14* EOS-1
BASOS-0 ___ MYELOS-0 NUC RBCS-2*
___ 01:49AM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-2+
MACROCYT-3+ MICROCYT-1+ POLYCHROM-OCCASIONAL TARGET-2+
HOW-JOL-OCCASIONAL PAPPENHEI-OCCASIONAL ENVELOP-1+
___ 01:49AM PLT SMR-VERY LOW PLT COUNT-31*
___ 01:49AM RET AUT-2.9
=
=
=
=
=
=
=
======================Imaging===================================
Liver US ___
IMPRESSION:
1. Coarsened liver echogenicity and nodular hepatic contour
consistent with cirrhosis.
2. Sequela of portal hypertension including recanalization of
paraumbilical vein. Patent hepatic and portal venous
vasculature.
3. Dilated common bile duct measuring up to 12 mm without
evidence of filling defect or intrahepatic biliary dilatation,
however the distal aspect of the duct is not visualized. Sludge
in GB also noted. MRCP may be considered if further imaging
evaluation is indicated.
TTE ___
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thicknesses and cavity size are normal. Left ventricular
systolic function is hyperdynamic (EF>75%). Doppler parameters
are indeterminate for left ventricular diastolic function. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Hyperdynamic left ventricular systolic function
without outflow tract obstruction. Mild mitral regurgitation.
Normal pulmonary artery systolic pressure. Diastolic function
indices are equivocal.
CT Head
IMPRESSION:
1. Chronic right frontal subdural hematoma causing mild sulcal
effacement. No shift of midline structures.
2. Large posterior fossa hypodensity, which may represent an
arachnoid cyst ___ cisterna magna.
CT Chest
IMPRESSION:
1. Right lower lobe bronchi filled with secretions leading to
atelectasis. Multifocal bilateral patchy ground-glass and
nodular opacities with upper lobe predominance, the possibility
of aspiration pneumonia has to be considered.
2. moderate left and small right pleural effusions.
3. Mild dilatation of the main pulmonary trunk and its major
branches suggests pulmonary arterial hypertension.
4. Please refer to separately dictated CT abdomen and pelvis
report from the same day for full description of
subdiaphragmatic findings.
CT A/P
IMPRESSION:
1. No organized fluid collection to suggest an intra-abdominal
abscess.
2. Mild central intrahepatic and mild extrahepatic biliary
dilatation without evidence of obstruction.
3. A 2.7 cm round soft tissue mass abutting the tail of the
pancreas at the splenectomy bed is thought to represent an
accessory spleen. If further confirmation is needed MRI or a
nuclear medicine sulfur colloid scan may be obtained.
4. Please refer to separately dictated CT chest report from the
same day for full description of intrathoracic findings.
CTA CHEST ___:
1. No evidence of pulmonary embolism.
2. Improvement in bibasilar atelectasis.
3. Right lung base ___ nodules are most likely due to
aspiration or infection. Mucous plugs are present in the
segmental bronchi to the right upper lobe and nonobstructing
secretions in the trachea and right main bronchus. Right upper
lobe airspace ground-glass infiltrate has increased from
previous.
4. Nonspecific lucent lesion in T5 vertebral body which could
represent
hemangioma but is not specific. MRI can be performed for further
characterization as indicated.
EGD
___
no varices
=
=
=
=
===========================Micro================================
___ fungal and mycobacterial isolator culture negative to
date.
C. Diff ___ negative.
BAL ___: HSV-1 grew out of culture, CMV antigen detected.
BAL ___: yeast
___ 10:10 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
Multiple negative blood cxs
Multiple negative urine cxs
Negative c diff
DISCHARGE:
___ 05:22AM BLOOD WBC-13.0* RBC-2.44* Hgb-9.6* Hct-30.9*
MCV-127* MCH-39.3* MCHC-31.1 RDW-15.9* Plt Ct-84*
___ 05:22AM BLOOD Plt Ct-84*
___ 05:22AM BLOOD ___ PTT-67.4* ___
___ 05:22AM BLOOD Glucose-89 UreaN-13 Creat-0.8 Na-137
K-4.2 Cl-110* HCO3-21* AnGap-10
___ 05:22AM BLOOD ALT-30 AST-76* LD(LDH)-421* AlkPhos-113
TotBili-2.4*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation
inhalation qd dyspnea
2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q6H wheeze
3. Digoxin 0.125 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. OxyCODONE SR (OxyconTIN) 60 mg PO Q8H
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
9. Doxycycline Hyclate 50 mg PO Q12H
10. TraZODone 100 mg PO HS
11. Warfarin 3 mg PO DAILY16
12. potassium chloride 10 mEq oral daily
13. Zovirax Ointment 5% 1 appl Other qd
14. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Furosemide 40 mg PO DAILY
2. Lisinopril 2.5 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Cyanocobalamin 50 mcg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Lactulose 30 mL PO QID
8. Multivitamins 1 TAB PO DAILY
9. Rifaximin 550 mg PO BID
10. Thiamine 100 mg PO DAILY
11. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation qd dyspnea
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q6H wheeze
13. Tiotropium Bromide 1 CAP IH DAILY
14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q8H:PRN Disp #*20 Tablet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Cirrhosis
___
hospital acquire pneumonia
Secondary:
atrial fibrillation
alcoholic hepatitis
diabetes
Discharge Condition:
Alert and oriented x2 (not to date)
Clear and coherent
Deconditioned and weak. Unable to stand without assistance.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with PICC. Pt had a right ___ ___
Contact name: ___: ___
TECHNIQUE: Portable AP radiograph of the chest from ___.
COMPARISON: Plain radiograph from earlier the same day.
FINDINGS:
The tip of the newly placed right-sided PIC line projects over the superior
SVC. A new interstitial abnormality accompanied by congestion of the pulmonary
vessels and mediastinal veins is probably edema. New severe opacification in
the right lower lobe is probably asymmetric edema, given the rapid, two hour,
onset. There is stable cardiomegaly despite the projection. No pneumothorax
is identified. Multiple metallic surgical clips are incidentally noted in the
left upper quadrant.
IMPRESSION:
Tip of newly placed right PICC line projects over superior SVC.
New moderate pulmonary edema.
Stable cardiomegaly.
NOTIFICATION: The findings were discussed by Dr. ___ with Nurse ___ on
the telephone on ___ at 11:28 AM, 3 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new Dobhoff. Confirm placement.
TECHNIQUE: Portable AP radiograph of the chest from ___.
COMPARISON: ___.
FINDINGS:
The bilateral lung apices and left costophrenic angle have been excluded from
the field of view. There has been interval placement of a feeding tube with
its tip projecting over the stomach. Metallic right upper quadrant surgical
clips from are in place. The tip of a right-sided PICC line is not well seen,
but appears to extend to at least the level of the mid SVC. Small bilateral
layering pleural effusions are unchanged. Mild pulmonary edema is unchanged.
IMPRESSION:
No appreciable interval change and mild pulmonary edema with small bilateral
pleural effusions.
Tip of Dobbhoff catheter projects over stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hepatic encephalopathy, NG placed for
lactulose given dysphagia // NG placement.
TECHNIQUE: Portable AP radiograph of the chest from ___.
COMPARISON: ___.
FINDINGS:
Right PICC line and feeding tubes are unchanged in position. There is no
pneumothorax. Mild pulmonary vascular congestion and small bilateral pleural
effusions are unchanged. Metallic right upper quadrant surgical clips are
again incidentally noted.
IMPRESSION:
No appreciable interval change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p NG tube palcement. (Dobhov) // confirm
placement
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the nasogastric tube was replaced. The
course of the tube is unremarkable, the tip of the tube is not included on the
image. Unchanged position of the right PICC line. No complications, notably
no pneumothorax. The appearance of the cardiac silhouette and the lung
parenchyma is constant.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ongoing hypoxemia now febrile to 102.
Concern for HAP. // r.o lobar infiltrate
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, there is unchanged evidence of mild
pulmonary edema. No new focal parenchymal opacities. But blunting of the
costophrenic sinuses could suggest the presence of small pleural effusions.
No new focal parenchymal opacities. Moderate cardiomegaly. The Dobbhoff
catheter and the right PICC line are constant.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with cirrhosis, fevers, dilated proximal CBD. //
assess for ascites, distal CBD diameter
TECHNIQUE: Grayscale and color and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: Comparison is made with abdominal ultrasound from ___ and CT abdomen from ___.
FINDINGS:
LIVER: The liver shows no evidence of focal lesions or textural abnormality.
Doppler assessment of the main portal vein shows patency and hepatopetal flow.
There is no ascites.
BILE DUCTS: There is no evidence of intrahepatic biliary dilatation. The CBD
is mildly ectatic to 8 mm.
GALLBLADDER: The gallbladder is again demonstrated to be distended and
sludge-filled, similar to prior exam. There is trace gallbladder wall edema,
which is nonspecific in this patient with cirrhosis and documented
hypoalbuminemia. There is no sonographic ___ sign.
PANCREAS: The tail of the pancreas is not well visualized, but the visualized
portions of the pancreas are unremarkable.
KIDNEYS: Limited views of the right kidney are unremarkable.
IMPRESSION:
1. Distended, sludge-filled gallbladder with trace wall edema, which is
nonspecific in this patient with cirrhosis and documented hypoalbuminemia.
Stable appearance of gallbladder compared with prior CT. If clinical concern
remains high for acute cholecystitis, a HIDA scan could be performed.
2. CBD is mildly ectatic to 8 mm, but there is no intrahepatic biliary
dilatation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with a prior right-sided SDH, increasingly
sleepy, mild anisocoria // r/o SDH expansion
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal, sagittal and
thin-section bone algorithm-reconstructed images were acquired.
DOSE: DLP: 1449 mGy-cm
CTDI: 106 mGy
COMPARISON: Outside Hospital CT Head without IV contrast ___
FINDINGS:
This study is slightly limited by motion.
There is a right frontal extra-axial collection of intermediate density
measuring 9mm in thickness (2b:49), representing an old subdural hematoma.
This is unchanged in appearance since the outside hospital CT dated ___.
It causes minimal mass effect on the adjacent frontal lobe. There is no shift
of midline structures. No acute hemorrhage, edema, or infarction. Prominent
ventricles and sulci suggest cortical volume loss. Basal cisterns are patent.
Gray-white matter differentiation is preserved. A large hypodense region is
seen in the mid-posterior fossa (602b:46), which may represent an arachnoid
cyst ___ cisterna magna.
No fracture is identified. Other than mild mucosal thickening in the right
maxillary sinus, remainder the visualized paranasal sinuses are clear.
Bilateral orbits are unremarkable.
IMPRESSION:
1. Chronic right frontal subdural hematoma causing mild sulcal effacement. No
shift of midline structures.
2. Large posterior fossa hypodensity, which may represent an arachnoid cyst
___ cisterna magna.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with fever and tachypnea // evaluation
evaluation
IMPRESSION:
In comparison with the study of ___, there is little overall change.
Again there is enlargement of the cardiac silhouette with moderate pulmonary
edema. Bibasilar opacification is consistent with pleural effusions and volume
loss, especially in the left lower lung
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure, s/p intubation //
please confirm ETT placement
COMPARISON: ___, 06:51
IMPRESSION:
As compared to the previous radiograph, the patient has been intubated. The
tip of the endotracheal tube projects 5 cm above the carinal. The tube could
be advanced by 1 cm. The nasogastric tube is in unchanged position. Mild 2
moderate pulmonary edema persists. Mild right pleural effusion. Moderate
retrocardiac atelectasis. Moderate cardiomegaly.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with known chronic SDH, now hypertensive
emergency, altered mental status, intubated // worsened or new intracranial
bleed
TECHNIQUE: Contiguous axial MDCT images were obtained from the skull base
through the vertex, without IV administration of contrast. Reformatted coronal
and sagittal and thin-section bone algorithm-reconstructed images were
acquired, and all images are viewed in brain and bone window on the
workstation.
DOSE: DLP (mGy-cm): 892
CTDIvol (mGy): 55
COMPARISON: CT head from ___
FINDINGS:
A small chronic subdural collection layering along the right frontoparietal
convexity (2:14, 601b:66) measuring 8 mm in maximum thickness from the inner
table is a stable compared to the prior examination. There is minimal mass
effect on adjacent sulci similar to the prior examination but no shift of
normally midline structures. No new hemorrhage is identified. Ventricles are
stable in size and configuration. Basal cisterns are patent. Mild to moderate
global atrophy is again noted. Gray-white matter differentiation is preserved.
A large hypodense region is seen in the mid-posterior fossa, which may
represent an arachnoid cyst ___ cisterna magna.
Partially imaged paranasal sinuses are notable for mild mucosal thickening of
the ethmoid air cells. The mastoids with exception of a few air cells are
clear. There is no fluid in the inner ear cavity. The nasogastric tube is
partially imaged.
IMPRESSION:
Stable small chronic right frontoparietal subdural collection.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with known chronic SDH, now hypertensive
emergency, altered mental status, intubated, persistent high fever, cirrhosis,
hyperbilirubinemia // intra-abdominal process to explain persistent fevers
TECHNIQUE: Contiguous axial multidetector CT images through the abdomen and
pelvis with intravenous and oral contrast. Multiplanar reformations. CT
scanning through the chest was performed concurrently but will be reported
separately.
Total DLP: 1273 mGy-cm
COMPARISON: Noncontrast CT abdomen and pelvis from ___
FINDINGS:
CT abdomen: The liver enhances homogeneously. A 7 mm hypodensity in the right
lobe of the liver is too small to characterize. There is mild central
intrahepatic and mild extrahepatic biliary dilatation however the CBD tapers
normally to the ampulla. Gallbladder and adrenal glands are within normal
limits. The pancreas is mildly atrophic but enhances homogeneously. Patient is
status post a splenectomy. A 2.7 cm round soft tissue densities adjacent to
the splenectomy clips and abutting the tail of the pancreas is felt to
represent an accessory spleen and not likely a pancreatic tail mass (2:52).
The kidneys enhance symmetrically without focal lesions. There is no
hydronephrosis.
NG tube terminates in the body of the stomach which is collapsed. Contrast
opacifies loops of small bowel do not show wall thickening or signs of
obstruction. Colon is unremarkable. Oral contrast reaches the rectum. A
rectal tube is in place. There is no intra-abdominal free air or fluid.
Heavy calcifications are noted in the infrarenal abdominal aorta and common
iliac arteries without aneurysmal dilatation. An IVC filter is in place just
inferior to the renal veins. There is no mesenteric or retroperitoneal
lymphadenopathy. Multiple varices are noted.
CT pelvis: Bladder is collapsed around a Foley catheter. Prostatectomy clips
are noted. There is no pelvic free fluid or lymphadenopathy. Bilateral fat
containing inguinal hernias are present. A fat containing umbilical hernia is
also noted.
Bone window: No suspicious lytic or sclerotic osseous lesion is identified.
IMPRESSION:
1. No organized fluid collection to suggest an intra-abdominal abscess.
2. Mild central intrahepatic and mild extrahepatic biliary dilatation without
evidence of obstruction.
3. A 2.7 cm round soft tissue mass abutting the tail of the pancreas at the
splenectomy bed is thought to represent an accessory spleen. If further
confirmation is needed MRI or a nuclear medicine sulfur colloid scan may be
obtained.
4. Please refer to separately dictated CT chest report from the same day for
full description of intrathoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with persisent fevers, hypoxia // Please
evaluate for pulmonary process
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.
CT scanning through the abdomen and pelvis was performed concurrently but will
be reported separately.
DOSE: Total DLP: 1273 mGy-cm
COMPARISON: None
FINDINGS:
There is no axillary, mediastinal, or hilar lymphadenopathy. A prominent right
lower paratracheal lymph node measures 9 mm on the short axis. Endotracheal
and enteric tubes are appropriately positioned. Heart is mildly enlarged and
coronary artery calcifications are noted. There is no pericardial effusion.
The thoracic aorta is notable for calcifications along the arch without
evidence of aneurysm or dissection. Pulmonary trunk and its major branches are
mildly enlarged.
The airways are patent to subsegmental level, except for the right lower lobe
where the bronchi are filled with secretions.. Bilateral patchy areas of
ground-glass opacification with upper lobe predominance, right more than left,
are likely infectious or inflammatory in etiology. A solid irregular
subpleural nodule at the left apex measures 12 x 15 mm (4:30). An 8 mm solid
nodule is also present amongst the ground-glass opacities in the right apex
(4:29). Additional smaller nodules are also seen in the periphery of the right
upper lobe (4:113) and along the minor fissure (4:125). There is a moderate
left and small right pleural effusion with adjacent opacities, atelectasis on
the left, and probably a combination of atelectasis and consolidation on the
right. There is no pneumothorax.
No suspicious lytic or sclerotic osseous lesion is identified.
IMPRESSION:
1. Right lower lobe bronchi filled with secretions leading to atelectasis.
Multifocal bilateral patchy ground-glass and nodular opacities with upper lobe
predominance, the possibility of aspiration pneumonia has to be considered.
2. moderate left and small right pleural effusions.
3. Mild dilatation of the main pulmonary trunk and its major branches suggests
pulmonary arterial hypertension.
4. Please refer to separately dictated CT abdomen and pelvis report from the
same day for full description of subdiaphragmatic findings.
NOTIFICATION: Additional finding regarding concern for aspiration pneumonia
was discussed with Dr. ___ by Dr. ___ by telephone on ___ at
4:45PM.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man, intubated, previous hypoxia, fever without
source // interval change
TECHNIQUE: Portable chest
COMPARISON: ___.
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure, aspiration pneumonia
// Please eval for interval change
TECHNIQUE: Portable chest
COMPARISON: ___.
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)
INDICATION: ___ year old man with ETT. // please assess for interval change
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
ET tube at the thoracic inlet common standard placement. Right PIC line ends
at the origin of the right brachiocephalic vein. Feeding tube passes into the
lower esophagus and out of view. No recent interval change, including
persistent right lower lobe atelectasis small bilateral pleural effusions.
Moderate enlarged of the cardiac silhouette, and mediastinal vascular
engorgement. There is no pneumothorax.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old man with persistent fever, tachycardia,
immobilization in ICU, bilat leg edema // DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial veins. There was
normal color flow and compressibility of the peroneal veins on the left
however the peroneal veins are not well seen on the right.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with persistent fevers, aspiration pneumonia,
increasing O2 and PEEP requirement on vent // worsening pneumonia or other
cause for worsening oxygenation worsening pneumonia or other cause for
worsening oxygenation
IMPRESSION:
In comparison with the earlier study of this date, the tip of the endotracheal
tube lies above the clavicles, approximately 9 cm above the carina. It could
be advanced about 4-5 cm. Other monitoring and support devices are unchanged.
There is continued enlargement of cardiac silhouette with bilateral effusions,
much more prominent on the right, and basilar atelectatic changes. No
definite pulmonary vascular congestion.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with aspiration pneumonia, persistent fevers //
ETT placement, interval change Contact name: ___ , ___: ___
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the endotracheal tube has been
advanced. The tip of the tube is not projecting approximately 4.3 cm above the
carinal. The course of the feeding tube and of the right as well PICC line. As
the position are unchanged. The known bilateral parenchymal opacities, right
more than left, as well as the small pleural effusions, are constant in extent
and severity. No new parenchymal opacities have occurred.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with cirrhosis with pneumonia and persistent
fevers // please eval for interval change for liver pathology, ? increase in
duct dilation
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON:
Ultrasound ___ and CT on ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. Main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 6 mm.
GALLBLADDER: The gallbladder is minimally distended and sludge/gravel filled,
similar in appearance to the prior exam. Trace gallbladder wall edema is again
demonstrated and is nonspecific in this patient with known cirrhosis.
PANCREAS: The pancreas is not well visualized due to overlying bowel gas.
SPLEEN: The spleen is surgically absent.
KIDNEYS: Limited views of the right kidney are unremarkable.
Note is made of a small right pleural effusion.
IMPRESSION:
Mildly distended, sludge filled gallbladder with trace wall edema is unchanged
from the prior examination and is nonspecific in this patient with cirrhosis.
There is no evidence of intrahepatic biliary ductal dilatation. No significant
change from the prior examination and on ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with worsening 02 requirement. Please assess for
interval change
TECHNIQUE: Portable AP radiograph of the chest from ___.
COMPARISON: ___.
FINDINGS:
The endotracheal tube ends at the level of the clavicles. An NG tube
terminates in the stomach. A right PICC line is unchanged in position, ending
in the mid SVC. Moderate right has slightly increased, but the small left
layering pleural effusion is unchanged. There is no pneumothorax. Heart size
appears slightly larger, which may be due to a combination of poor inspiration
and pleural fluid.
IMPRESSION:
Slightly increased moderate right and stable small left pleural effusions.
Lines and tubes in satisfactory position.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with history of prostate cancer, now with
abdominal cellulitis and chronic subdural hematomas concern for aspiration
pneumonia, ongoing fevers, worsening leukocytosis, positive apergillis in BAL.
Evaluate for evidence of empyema, aspergillosis.
TECHNIQUE: Non-contrast chest CT was performed acquiring sequential axial
images from the thoracic inlet through the adrenal glands. Thin section axial,
coronal, sagittal and axial MIP's were also obtained.
DOSE: Total DLP = 812.58mGy-cm
COMPARISON: Chest CT dated ___. Correlation made to imported CT
abdomen/pelvis dated ___.
FINDINGS:
An endotracheal tube ends in the lower trachea. A right subclavian central
venous catheter ends in the upper SVC. The thyroid gland is unremarkable.
There is no supraclavicular, mediastinal, hilar or axillary lymphadenopathy.
A borderline right lower paratracheal lymph node appears slightly smaller
measuring 6 mm in short axis, previously 9 mm (2, 21).
Moderate cardiomegaly with multichamber enlargement is stable. Extensive
coronary artery and minimal aortic valvular calcifications are present.
Diffuse low attenuation of the blood in the heart suggests mild anemia. There
is stable dilatation of the main pulmonary artery to 3.4 cm. The thoracic
aorta is normal caliber.
Multiple images are partially degraded by respiratory motion artifact.
However, there is increased near-complete bilateral lower lobe atelectasis,
left greater than right. No endobronchial lesion is identified. Stable trace
right and decreased trace left pleural effusions are present. Bilateral
pleural plaques, many of which are calcified, are re- demonstrated. Upper
lobe predominant bilateral subsegmental ground-glass opacities and
interlobular septal thickening are not appreciably changed. New extensive
right middle lobe bronchiolar nodules are likely due to aspiration or
infection.
There is a new small amount of upper abdominal perihepatic ascites. A
nasogastric tube ends in the stomach. The patient has had prior splenectomy
with presence of a rounded soft tissue mass lateral to several surgical clips,
which likely reflects a residual splenule. This lesion is inseparable from the
pancreatic tail.
There is moderate bilateral gynecomastia, right greater than left.
Old bilateral rib fractures are unchanged.
IMPRESSION:
Increased near-complete bilateral lower lobe atelectasis, left greater than
right. No endobronchial lesion identified.
New extensive right middle lobe bronchiolar nodules are most likely due to
aspiration or infection.
Unchanged subsegmental ground-glass opacities and interlobular septal
thickening which may be due to edema or infection.
Stable trace right and decreased trace left pleural effusions. No evidence of
empyema.
New small upper abdominal perihepatic ascites.
Stable dilatation of the main pulmonary artery suggests pulmonary arterial
hypertension.
Bilateral pleural plaques suggest prior asbestos exposure.
Mild anemia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: please eval for interval change in hematoma ___ year old man
with chronic subdural hematoma, cirhosis, pneumonia with worsening mental
status changes // please eval for interval change in hematoma
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
CTDIvol: ___ MGy
DLP: 936 mGy-cm
COMPARISON: CT head ___.
FINDINGS:
A chronic subdural collection layering along the right frontoparietal
convexity has slightly decreased in both size and attenuation compared to the
prior examination performed ___, consistent with the expected
evolution of blood products. Although the overall size of the collection
appears decreased, the maximum thickness of the collection has only minimally
changed, currently measuring 7 mm and previously measuring 8 mm. Correlation
with MRI of the brain with and without contrast is recommended for further
characterization.
There is no evidence of new hemorrhage, edema, mass effect, midline shift, or
mass. The ventricles and sulci are prominent consistent with atrophy.
Confluent periventricular and subcortical white matter hypodensities likely
represent the sequela of chronic small vessel ischemic disease. A large
hypodense area in the mid posterior fossa may represent an arachnoid cyst or
___ cisterna magna.
No bony abnormalities seen. Aerosolized secretions in the ethmoid air cells,
sphenoid sinuses and maxillary sinuses as well as opacification of a few
bilateral mastoid air cells is consistent with supine positioning and
intubation. The orbits are unremarkable.
IMPRESSION:
A chronic subdural collection layering along the right frontoparietal
convexity has slightly decreased in both size and attenuation compared to the
prior examination performed ___, consistent with expected evolution of
blood products. No new hemorrhage.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure // please assess for
interval change
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Dobhoff tube tip isin the stomach. Right lower lobe collapse has resolved. .
There is a consolidation in the right lower hemi thorax consistent with
pneumonia. There is no pneumothorax. Mild cardiomegaly is stable. Right PICC
tip is in the confluence of the brachiocephalic veins. ET tube is in standard
position. Small left effusion and left lower lobe atelectasis are unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)
INDICATION: ___ year old man with worsened hypoxia // interval change
COMPARISON:
Chest radiographs ___ through ___ at 9:28 a.m.
IMPRESSION:
Left lower lobe collapse has improved, but small to moderate left pleural
effusion has developed. Right lower lobe atelectasis has improved as well,
but both lower lungs remain partially consolidated. Heart size is
substantially smaller even since earlier in the day. Has this patient had a
pericardial centesis?
Feeding tube passes as far as the lower esophagus and out of view. Right PIC
line ends proximal to the origin of the SVC. ET tube ends at the thoracic
inlet.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pneumonia, concern for aspergillus //
please eval for interval change please eval for interval change
TECHNIQUE: Single portable AP view radiograph of the chest.
COMPARISON: Prior chest radiographs from ___ to ___.
FINDINGS:
Compared with the immediate prior study, the left lower lobe consolidation or
collapse has slightly improved, and the left pleural effusion and mild
cardiomegaly are unchanged. The ill-defined opacity at the right base appears
improved compared with the morning of ___, and likely unchanged
from the evening of ___. All lines and tubes are in standard
position. There is no pneumothorax or pulmonary edema.
IMPRESSION:
1. Slight interval improvement in left lower lobe consolidation or collapse.
2. Unchanged ill-defined right base opacity.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure. // Please assess for
interval change
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
Heart size and mediastinum are stable. A right PICC line tip is at the level
of superior SVC. Bibasal consolidations are present. There is no appreciable
pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cirrhosis and worsening hypoxia // please
eval for worsening lung collapse
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
Right PICC line tip is at the confluence of the brachiocephalic veins. Heart
size and mediastinum are unchanged. Lungs are essentially clear with no
interval development of consolidation or pulmonary edema. No atelectasis is
seen as well as no interval increase in pleural effusion demonstrated.
Radiology Report
EXAMINATION: CT angiography of the chest.
INDICATION: ___ year old man with cirrhosis, intubated with worsening hypoxia
// please eval for pe, avm
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: DLP: 828 mGy-cm
COMPARISON: CT of the chest from ___
FINDINGS:
An endotracheal tube ends in the midtrachea. A right subclavian central venous
catheter ends in the superior SVC.
The thyroid gland is unremarkable.
Paratracheal lymph nodes measure up to 6 mm in short-axis (2:37). There is no
axillary or hilar lymphadenopathy.
Previously visualized right lower lobe and left lower lobe atelectasis
improved. Right middle lobe ___ nodules have cleared, but there are
right lower lobe ___ nodules which were not previously demonstrated
because of atelectasis. Upper lobe bilateral ground-glass opacities and
interlobular septal thickening improved on the left and worsened on the right.
Mucous plugs are seen in the segmental and subsegmental bronchi to the right
upper lobe (2:40). Secretions are seen in the trachea and in the right main
bronchus.
Stable minimal amount of pleural effusion is present bilaterally.
No pulmonary embolism is present. The pulmonary trunk is mildly dilated to 3.5
cm, suggesting mild pulmonary hypertension.
The aorta is normal in caliber. Calcifications are present in the aortic arch
and the descending aorta.
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence
of penetrating atherosclerotic ulcer or aortic arch atheroma present.
Pleural plaques with calcifications are redemonstrated.
Moderate cardiomegaly with multichamber enlargement is stable. Extensive
coronary artery calcifications present.
Nasogastric tube ends in the stomach. The liver demonstrates cirrhotic
morphology with nodular border, relative atrophy of the right lobe and
hypertrophy of the left and caudate lobes. 8 mm hypodense lesion in segment V
(2:116) is indeterminate. The patient is status post splenectomy. Presumed
regenerated splenic tissue seen in the splenic bed. The visualized portions of
the pancreas, right kidney and adrenals are unremarkable. Small amount of
perihepatic ascites is present.
Bilateral gynecomastia is present, right more than left.
Bilateral old rib fractures are seen. There is nonspecific lucent lesion in
T5 vertebral body which could be representing hemangioma. MRI can be performed
for further characterization as indicated.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Improvement in bibasilar atelectasis.
3. Right lung base ___ nodules are most likely due to aspiration or
infection. Mucous plugs are present in the segmental bronchi to the right
upper lobe and nonobstructing secretions in the trachea and right main
bronchus. Right upper lobe airspace ground-glass infiltrate has increased
from previous.
4. Nonspecific lucent lesion in T5 vertebral body which could represent
hemangioma but is not specific. MRI can be performed for further
characterization as indicated.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure // Please assess for
interval change
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
ET tube tip is 7 cm above the carinal. Feeding tube passes below the diaphragm
terminating in the stomach. Cardiomediastinal silhouette is unchanged
including mild cardiomegaly but there is interval development of pulmonary
edema associated with left retrocardiac consolidation. There is no
pneumothorax. Right PICC line tip is not clearly seen, most likely within the
same location at the very superior SVC
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p extubation, please eval ng placement //
please eval ng placement
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the patient was extubated. The
nasogastric tube shows a normal course. The tip is incompletely visualized but
appears to project over the middle parts of the stomach. The right PICC line
is in unchanged position, the tip projects over the mid SVC. Unchanged
moderate cardiomegaly. Retrocardiac atelectasis and small left pleural
effusion, combined to mild fluid overload.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with etoh abuse, newly diagnosed cirrhosis,
hypoxemic resp failure thought ___ pna, now extubated. // evaluate pleural
effusion seen on previous CXR evaluate pleural effusion seen on previous
CXR
IMPRESSION:
In comparison with the study of ___, the intestinal tube has been
removed. The right PICC line remains in place.
The lateral view is somewhat limited. Nevertheless, there is a left pleural
effusion that appears quite similar to the prior examination. Volume loss in
the left lower lung is again seen. The pulmonary vascularity appears
essentially within normal limits.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with EtOH and Hep C cirrhosis // Please evaluate
for pneumonia
IMPRESSION:
Since ___, mild pulmonary vascular congestion has developed as
well as worsening left retrocardiac opacity, probably a combination of
atelectasis and small to moderate left pleural effusion. Underlying pneumonia
in this region is not excluded.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with unknown cardiopulmonary history with severe
cough wheezing. // assess for infiltrate, pulmonary edema, hyperinfilation
IMPRESSION:
As compared to the prior radiograph from 1 day earlier, there has not been a
substantial change in the appearance of the chest. A small poorly defined
nodular opacity lateral to the left hilum is unchanged considering positional
differences between the exams. When the patient's condition allows, standard
PA and lateral views of the chest would be helpful for further
characterization.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with transaminitis, concern for decompensating
liver function. // eval for cirrhotic liver morophology, size of CBD, patency
of hepatic and portal veins
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained. Spectral Doppler interrogation of hepatic arterial and venous
vasculature was performed.
COMPARISON: Outside facility CT abdomen and pelvis ___.
FINDINGS:
LIVER: There is diffusely increased and coarsened echogenicity of hepatic
parenchyma. The contour of the liver is nodular. There is no focal liver mass,
however coarsened echogenicity limits ultrasound sensitivity for mass. Main
and right portal veins are patent with hepatopetal flow. The left portal vein
is patent with to and fro flow. The paraumbilical vein is recannulized with
hepatofugal. The middle, right, and left hepatic veins are patent with
appropriate flow direction and venous waveforms. The IVC is patent. There is
no ascites.
Hepatic artery has brisk systolic upstroke and antegrade diastolic flow.
Hepatic artery resistive index is 0.63.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD is dilated
measuring up to 12 mm.
GALLBLADDER: Dependent echogenic debris within the gallbladder is consistent
with sludge or small stones.
PANCREAS: The pancreas is not visualized due to artifact from overlying bowel
gas.
SPLEEN: Spleen is not visualized.
IMPRESSION:
1. Coarsened liver echogenicity and nodular hepatic contour consistent with
cirrhosis.
2. Sequela of portal hypertension including recanalization of paraumbilical
vein. Patent hepatic and portal venous vasculature.
3. Dilated common bile duct measuring up to 12 mm without evidence of filling
defect or intrahepatic biliary dilatation, however the distal aspect of the
duct is not visualized. Sludge in GB also noted. MRCP may be considered if
further imaging evaluation is indicated.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)
INDICATION: ___ year old man with altered mental status, hypoxemia. // r/o
aspiration, infiltrate
COMPARISON: Chest radiographs ___
IMPRESSION:
Previously questioned left lung nodules are no longer visible. They were
either transient or are now obscured by increasing mild pulmonary edema.
Moderate cardiomegaly and mediastinal venous engorgement have also worsened.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)
INDICATION: ___ year old man with recently diagnosed cirrhosis, who now has
new dyspnea and increased O2 requirement. // fluid overload? pna?
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
Interstitial edema has improved, pulmonary and mediastinal vascular
engorgement slightly diminished as well. Moderate cardiomegaly improved.
Previously questioned lung nodules are not apparent. When feasible
conventional chest radiograph should be obtained.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cirrhosis, hypoxemia, and e/o volume
overload on CXR. // ? interval change in pulmonary edema
TECHNIQUE: Single portable AP view radiograph of the chest.
COMPARISON: Prior chest radiographs dating back ___.
FINDINGS:
Compared with the immediate prior study of ___, pulmonary edema
and pulmonary vascular congestion have improved, both now mild. The right
hilum is persistently enlarged, but looks arterial perhaps due to left heart
failure. The previous left-sided nodule is not appreciated on the present
study. Conventional PA and lateral radiographs will be helpful for further
assessment when clinically feasible. There may be a small left pleural
effusion. There is no focal consolidation or pneumothorax. The heart is
stably top-normal in size.
IMPRESSION:
1. Interval improvement in pulmonary edema and pulmonary vascular congestion,
now mild.
2. Persistent enlargement of the right hilum, could be arterial enlargement
due to left heart failure.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with CELLULITIS/ABSCESS OF TRUNK, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, LONG TERM USE ANTIGOAGULANT
temperature: 97.1
heartrate: 68.0
resprate: 16.0
o2sat: 100.0
sbp: 112.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | ___ yo M with PMH of alcohol abuse who presented with
encephalopathy, new cirrhosis, and alcohol withdrawal whose
hospital course was complicated by slow-to-clear encephalopathy,
hypoxemic respiratory failure, and prolonged intubation. Treated
for hepatic encephalopathy, alcohol withdrwal, and
aspiration/hospital acquired pneumonia. At time of discharge
mental status had cleared and he was breathing comfortably on
room air. Etiology of the cirrhosis is either alcoholic, ___
HCV, or NAFLD. He will follow up in the ___.
# Encephalopathy: Initially thought due to alcohol withdrawal
and hepatic encephalopathy. Treated with aggresive lactulose and
rifaximina nd a phenobarbitol taper. His encephalopathy,
however, was slow to clear and he remained delerious and
intermittently agitated, in spite of appropriate treatment for
the above conditions. Systemic illness was likely also causing
decreased level of arousal. Hypernatremia may also have been
contributing. Head CT revealed stable subdural hematoma.
Repeated on admission to MICU given dilated pupils, though
revealed no change from prior. He was continued on
lactulose/rifaximin. His mental status improved significantly on
___. Given his long history of alcohol use, started on oral
thiamine supplementation.
# Hypoxemic respiratory failure: Concern for possible aspiration
in the setting of worsening mental status given productive
cough, elevated WBC, and high fevers. VOlume overload may also
have contributed in the setting of IVF resuscitation on
admission with low albumin and multiple CXRs with vascular
congestion. Did not improve with diuresis. TTE with normal LVEF
and he remained in persistent Afib with rates in low 100s. Low
suspicion for cardiogenic etiologies given absence of valvular
disease and adequate rate control. Initially treated with
Vanc/Zosyn given concern for aspiration pneumonia in the setting
of AMS. He was intubated and remained so for > 7 days given high
PEEP requirements and in the setting of persistent altered
mental status. Once he was more arousable he still required high
levels of PEEP, particularly when sitting upright, though
improved while lying flat. Given concern for intrapulmonary
shunting, a bubble study was performed, though revealed no
evidence of shunt physiology. His respiratory status improved
and he was extubated on ___. No microbiologic soure was
identified. He had GNRs on a sputum gram stain that did not grow
in the culture. He had a BAL that grew HSV-1 and was positive
for CMV antigen, but these were not felt to be respiratoy
pathogens in his case. He had a positive galactomannan and was
briefly treated with voriconazole, but no pathogenic fungi grew
from his blood or respiratory cultures. He completed a 14 day
course of Meropenem on ___.
# Cirrhosis: Diagnosed by labs and OSH CT abdomen/pelvis showing
a nodular liver. Chronicity unclear. RUQUS confirmed cirrhotic
liver appearance. HCV positive and has an extensive drinking
history. HAV negative. HBV non-immune. Started on Lactulose and
Rifaximin. Hepatology followed throughout hospital stay. They
will see him in the ___ as an outpatient for ongoing
monitoring (regular RUQUS, ? treatment of HCV, HBV
immunization). EGD on ___ showed no varices.
# ___: Presented with creatinine of 1.3 from baseline 0.9-1.
Likely secondary to volume depletion. Given history of
cirrhosis, important to consider HRS. His renal function
improved with albumin resuscitation.
# Hypernatremia: Intermittently hypernatremic during hospital
stay. Likely from minimal POs (while without NG access) and
ongoing loose stools from the lactulose.
# Chronic right frontal SDH: Stable on Repeat CT head ___ and
___.
# Afib: CHADS2 of 2. INR was 2.4 despite holding Coumadin, most
likely representing coagulopathy of liver disease. Will continue
to hold Coumadin given this, thrombocytopenia, and SDH. Also, on
discussion with wife, coumadin was initiated for planned
cardioversion, but patient decided not to undergo cardioversion
later, so doesn't really need to be anticoagulated. Rate
controlling with metoprolol. Stopped digoxin given fluctuating
renal function. In discussion with PCP, decision was made to
continue to hold Warfarin at discharge given elevated INR, and
no plans for cardioversion (had been off coumadin for years
before that). Patient started on Aspirin 81 mg PO QDaily at
discharge.
# Macrocytic anemia: Most likely due to a combination of alcohol
use and splenectomy. B12 normal. Will monitor. Started on
B12/folate.
# Thrombocytopenia: Likely cirrhosis. He is s/p partial
splenectomy. No DIC or TTP based on initial labs. Held heparin
for Plt < 50.
# Hypoalbuminemia: Likely due to cirrhosis and poor oral intake.
Was on TF as he failed initial swallow evaluation. However
swallow improved as mental status cleared, pand patient was able
to take adequate PO by time of discharge, and TFs were
discontinued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
___ scan
TEE
History of Present Illness:
___ with history of DM2, who on ___ was seen at ___
for left index finger infection with pus for which he had I & D
and was discharged on bactrim and keflex with instructions to
keep wound covered. Per report this was improving. However 2
weeks ago his finger redness and swelling worsened when he was
in ___. He was admitted given that he was looking sick and
potentially septic. Per report, blood cultures showed no growth
and wound culture showed MRSA susceptible to minocycline and
vancomycin. Per Cardiology note in OMR, An ECG showed possible
inferior and/or lateral MI and his cardiac enzymes were positive
with a positive CK-MB in the 28 range and a troponin of up to
11. He had coronary cath done which normal normal coronaries but
LVEF per report was 45% with anterior, apical and inferior
hypokinesis more towards apex. He subsequently had two ECHOs
which showed the LVEF to be normal with normal wall motion and
valvular function. Impression at ___ was that he had viral
myocarditis (per Dr ___ cardiomyopathy).
While at ___ in ___, given worsening redness
and swelling of his left index finger, he had another I & D and
was on vancomycin for 2 days and was discharged on minocycline
for 12 day course ___ is day 6). Pt says his left index
finger redness and swelling is much better and improving.
He had been short of breath at that time per ___ notes
though pt denied to me any SOB or CP at anytime. A chest x-ray
and CTA at ___ showed mild interstitial edema with a
elevated BNP. CTA also showed mild axillary and mediastinal
LN's. Since then, he was started on Coreg and his dyspnea has
resolved. He has no chest pain. Recently pt was not able to take
coreg on time so this was switched to metoprolol after
discussing with his cardiologist Dr ___ he did not start
it yet.
Pt presents to ___ with 2 days of fevers to 101. He
denies cough, but feels intermittently short of breath (he has
felt this way since his ___ admission). Again, he denied
this to me. No pleuritic pain or chest pain. No URI symptoms. No
vomiting or diarrhea. No abdominal pain. No urinary symptoms. No
rash other than the persistent redness on his finger which is
improved from previous. No headache, no neck stiffess, no
photophobia. Exam was notable for tachycardia, Left index finger
with some residual erythema. Minimal swelling. Full range of
motion of the finger and hand. Few lesions on toes and fingers
possibly splinter hemorrhages per ___ exam but no murmur was
appreciated and o2 sa 92-94%RA. After 3 blood cultures were
drawn, pt was given tylenol, Normal saline IVF, iv vancomycin 1
gram x1 out of concern for endocarditis as well as iv levaquin
750 mg x1 (unclear why). At ___, CXR performed which showed
no obvious PNA. Trop trending down to 0.318 (compared to levels
from ___ per ___ notes). CK MB 4.9 BNP 941. Labs were
notable for WBC 14.8 PMN 79.5, Lactate 1.9, normal UA, Cr 1, BUN
21, EKG HR 113 q wave III. Otherwise no STE.
In the ED at ___, initial vs were: 97.2 96 134/80 20 94%.
Vitals on Transfer: 96 112/71 22 99%
On the floor, pt says he feels tired but no complaints.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
1. Constipation
2. Hypothyroidism
3. Hyperelipidemia
4. DMII with HgA1c% of 6.8 in FL.
5. Palpitations in the past.
Social History:
___
Family History:
Father ___ PROSTATE CANCER Father developed
prostate cancer at
___, died at ___
Mother ___ ___ BREAST CANCER
Sister Living ___ ELEVATED CHOLESTEROL
Sister Living ___ ULCERATIVE COLITIS
ELEVATED CHOLESTEROL
Sister Living ___ IRRITABLE BOWEL
SYNDROME
DEPRESSION
ELEVATED CHOLESTEROL
Sister Living ___ INTRACRANIAL
HEMORRHAGE
ELEVATED CHOLESTEROL
MGF Deceased ___ MYOCARDIAL
INFARCTION
Uncle ___ ___ STROKE
PGF Deceased ___ COLON CANCER
Son Living ___
Daughter Living 12
Physical Exam:
Vitals: 98.5 125/85 93 12 93%RA
General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. possible splinter hemorrhages on toes and fingers. left
index finger lateral blanching erythema, no fluctuation, mild
tenderness
Skin: nevi
Neuro: Cn2-12 intact. power ___ bilaterally in all limbs
DISCHARGE PE:
97.8 126/80 76 18 97RA Tm 98.1
General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: rare bibasilar rales R>L, no wheezes/rhonchi
CV: RRR, nl S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Left index finger cellulitis stable indurated area, no
drainage collection. Warm, well perfused, 2+ pulses, several
fingers w/ distal splinter hemorrhages
Pertinent Results:
ADMIT LABS:
=============================
___ 09:34AM BLOOD WBC-13.2*# RBC-4.39* Hgb-12.9*# Hct-38.7*
MCV-88 MCH-29.5 MCHC-33.4 RDW-13.0 Plt ___
___ 09:34AM BLOOD Neuts-77.0* Lymphs-14.2* Monos-5.9
Eos-2.7 Baso-0.3
___ 09:34AM BLOOD Plt ___
___ 09:34AM BLOOD ESR-62*
___ 09:34AM BLOOD Glucose-101* UreaN-14 Creat-0.7 Na-140
K-3.8 Cl-103 HCO3-24 AnGap-17
___ 09:34AM BLOOD ALT-16 AST-19 LD(LDH)-183 CK(CPK)-124
AlkPhos-86 TotBili-0.7
___ 09:34AM BLOOD CK-MB-7 cTropnT-0.23*
___ 09:34AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.9
___ 09:34AM BLOOD CRP-114.8*
DISCHARGE LABS:
=================================
___ 08:00AM BLOOD WBC-7.2 RBC-4.56* Hgb-13.4* Hct-40.3
MCV-88 MCH-29.3 MCHC-33.2 RDW-13.1 Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-111* UreaN-12 Creat-0.9 Na-141
K-4.4 Cl-102 HCO3-29 AnGap-14
___ 08:00AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.2
___ 08:00AM BLOOD Vanco-14.9
MICRO:
=================================
___ BCx x3 no growth to date
___ UCx negative final
___ BCx x2 No growth to date
IMAGING:
=================================
___
Sinus rhythm. Low limb lead voltage. No diagnostic change
compared to the
previous tracing of ___.
Read by: ___.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
98 162 94 342/408 71 19 61
___ TEE
GENERAL COMMENTS: Written informed consent was obtained from the
patient. A TEE was performed in the location listed above. I
certify I was present in compliance with ___ regulations. The
patient was monitored by a nurse in ___ throughout the
procedure. The patient was monitored by a nurse in ___
throughout the procedure. The patient was sedated for the TEE.
Medications and dosages are listed above (see Test Information
section). Local anesthesia was provided by benzocaine topical
spray. The posterior pharynx was anesthetized with 2% viscous
lidocaine. 0.2 mg of IV glycopyrrolate was given as an
antisialogogue prior to TEE probe insertion. No TEE related
complications.
Conclusions
The left atrium is dilated. No atrial septal defect is seen by
2D or color Doppler. Overall left ventricular systolic function
is mildly depressed (LVEF= 45 %). Right ventricular chamber size
is normal with mildly depressed free wall contractility. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque to 37 cm from the
incisors. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: No 2D echocardiographic evidence of endocarditis.
Mildly depressed global biventricular systolic function.
___ CXR
As compared to the previous radiograph, the pre-described left
lower lobe opacity is almost completely resolved. The
structures of increased density seen on the lateral radiograph
likely to represent vessels. No pleural effusions. 4 mm
calcified granuloma in the right apex. Borderline size of the
cardiac silhouette with mild tortuosity of the thoracic aorta.
___ XR Lef tindex finger
IMPRESSION: Soft tissue swelling of the left index finger. No
radiographic evidence of osteomyelitis. Incidental old post
traumatic deformity fifth finger.
___
___ scan
INTERPRETATION: Following the injection of autologous white
blood cells labeled with In-111, images of the hands obtained.
Transmission images were also obtained.
These images show a linear focus in the region of the mid to
lateral carpal bones of the left hand, however, there is no
uptake within the left second finger or elsewhere.
IMPRESSION: Linear focus in the region of the mid to lateral
carpal bones which can be due to inflammatory changes. No
evidence of uptake within the left second finger.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
hold for SBP<100 and HR<55
2. Atorvastatin 20 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. ClomiPRAMINE 50 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Linezolid ___ mg PO Q12H
complete the last dose on ___
RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*19 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: Fever, recent finger abscess, evaluation for pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the pre-described left
lower lobe opacity is almost completely resolved. The structures of increased
density seen on the lateral radiograph likely to represent vessels. No
pleural effusions. 4 mm calcified granuloma in the right apex. Borderline
size of the cardiac silhouette with mild tortuosity of the thoracic aorta.
Radiology Report
HISTORY: Left index finger cellulitis. Incision and drainage of two prior
abscesses. ? osteomyelitis.
Three views of the left hand centered on the index finger with no prior
studies available. There is mild joint space narrowing with osseous spurring
of the first carpometacarpal and metacarpophalangeal joints. There is
generalized thinning of articular spaces of metacarpophalangeal and
interphalangeal joint space narrowing. Incidnetally noted is moderate joint
space narrowing & subchondral sclerosis of the proximal interphalangeal joint
of the left little finger. There is soft tissue swelling of the left index
finger. There is no periosteal reaction or cortical disruption of the index
finger.
IMPRESSION: Soft tissue swelling of the left index finger. No radiographic
evidence of osteomyelitis. Incidental old post traumatic deformity fifth
finger.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R/O ENDOCARDITIS
Diagnosed with FEVER, UNSPECIFIED, DIABETES UNCOMPL ADULT
temperature: 97.2
heartrate: 96.0
resprate: 20.0
o2sat: 94.0
sbp: 134.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | ___, DM2, hypothyroidism, HLD presenting after left index finger
abscess drainaged with recurrent abscess and ?sepsis, and
?myocarditis with transient systolic heart failure 2 weeks ago
presenting for ongoing fevers, chills, sob concerning for
infection endocarditis vs. PNA vs. cellulitis. Ultimately, pt
was treated for 5d for PNA on levo, and treated with IV vanc for
MRSA cellulitis and transitioned to 10d PO linezolid after ___
scan did not show e/o foci of infection.
# Fever/leukocytosis: Pt presented from OSH with fevers, chills
s/p treatment of MRSA cellulitis on left index finger. Initial
presentation of fevers, known MRSA cellulitis, without adequate
resolution s/p bactrim/keflex and s/p minocycline was concerning
for endocarditis. CXR also showed retrocardiac opacity. Thus, pt
was treated with vanc (for MRSA cellulitis) and levo. Pt
teachnically should have been covered for HCAP with cefepime or
zosyn with vanc but bc there was low suspicion for PNA ad low
suspicion for pseudomonas and pt was improving ___ allergy to
PCN (which confers 10% cross reactivity to cephalosporins), pt
was treated with levo. Clinically, rales on initial exam
improved. As there was concern despite neg TEE for occult
infection, a WBC scan was pursued to help determine choice and
course of abx. Pt completed 5d of levo for CAP. Blood cultures
from ___, and at ___ were all negative / no
growth to date. ___ scan did not show any e/o infection, there
was tracer uptake in the area of the left wrist which was not
clinically infected, and oddly no tracer uptake at the left
index finger, which has a known resolving cellulitis. Per ID
recommendations, given the lack of endovascular infection and
soft tissue infection, ID recommended 10d of linezolid. While on
linezolid, he should not take clomipramine due to high risk of
serotonin syndrome with linezolid.
# SOB / Pneumonia: Initially SOB was thought to be related to
CHF given rales on exam, elevated JVD, no peripheral edema vs.
pneumonia. Pt was treated for PNA, and was not diuresed. TEE
showed EF 45%, which is consistent with range of prior echo from
___. Pt was started on toprol 25 xl per outpatient cards
plan, though pt was resistant as did not like how he felt on
coreg and self dc-ed it. Outpatient team should consider ACEi as
well for depressed EF.
# CHF: Pt had elevated BNP at ___. EF 45% at ___ and resolved
s/p subsequent Echos from OSH in ___. At ___, ___ revealed
depressed EF 45% which was consistent wtih prior. Pt has clean
coronaries per ___ summary and cath. He likely has
Takatsubo. Started toprol 25 XL. Per outpatient cards hold off
on ACEi for now, as pt is already reluctant to start BB.
# Left index finger cellulitis: MRSA cellulitis from ___
records, gave IV vanc. No drainable collection during
hospitalization, though area of erythema initially improved and
then remained somewhat stable.
# DM-II: held metformin and placed on HISS, resumed on
metformin at discharge.
# Hypothyroidism: continue Levothroid 50 mcg tablet daily. Pt
was not taking and TSH was mildly elevated adn FT4 was WNL.
# Depression: continue clomipramine 50 mg capsule. daily
Clomipramine was stopped while linezolid was started to avoid
serotonin syndrome.
# HL/CAD: continue lipitor and ASA 81mg
# CODE: full - confirmed
# CONTACT: ___ , wife, H ___, ___
TRANSITION ISSUES
# Consider starting ACEi for cardiomyopathy
# F/u pending blood cx ___ BCx x3, ___ BCx x2
# f/u left wrist and left hand MRI given nuc med uptake in that
region without clinical e/o infection
# f/u blood cultures ___ x3 and ___ x2 (no growth to date) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Plavix / atorvastatin
Attending: ___.
Chief Complaint:
Hypertension, visual disturbance
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ M w PMHx of CABG x4 and significant
PAD who presents to the ___ ED after his blood pressure at
home
was sBP>200. He also reported a visual disturbance and headache
earlier in the morning.
Mr. ___ states that he was awoken from sleep early this
morning with a headache located at the crown of his head. He
does
not typically get headaches so this was somewhat odd for him.
When he sat up in bed, he felt "lightheaded" and when he went to
get up his legs felt "wobbly." He looked over at his digital
clock and reports that although the time was 05:16, he was only
able to see the xx:16. He denies a frank visual field cut and
states that he was able to see everything else on his left side.
He was then able to get up and go about his usual morning
routine. He felt a little lightheaded but was able to drink a
cup
of coffee and walk two blocks to the store. He walked back home
and ate a light breakfast without difficulty. He still
complained
of a mild headache so his wife took his blood pressure which was
sBP>200. Given his significantly elevated sBP, his son called
EMS, and Mr. ___ was taken to ___ ED. He reports that his
HA
resolved as soon as he was given oxygen by EMS.
Currently, Mr. ___ reports that he feels quite well. He
denies
any headache or visual difficulties. He denies any weakness,
sensory loss, language difficulties, dysphagia, N/V, or CP
associated with his recent event - or in the recent past.
Past Medical History:
PMH: AAA, HLD, asbestosis, CAD s/p CABG ___, HTN, duputyren's
contracture, PAD, elevated LFT's, EtOH dependence
PSH: CABGx4, L SFA stent ___, L SFA stent PTA and re-stenting,
diagnostic RLE angiogram (___), repeat RLE angiogram, SFA
stent x2/angioplasty peroneal art. (___), AngioJet
thrombectomy/stenting of distal SFA/PTA of SFA stent (___)
Social History:
___
Family History:
Mr. ___ has 12 siblings, most of whom are deceased from
non-vascular causes.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VS T98.1 HR86 BP181/70-(spontaneous x8hrs)->150/82 RR20 Sat100%
GEN - elderly male, pleasant and cooperative
HEENT - NC/AT, MMM
NECK - supple, no meningismus
CV - RRR
RESP - normal WOB
ABD - soft, NT, ND
EXTR - B/L ___ digits with contractures
NEUROLOGICAL EXAMINATION:
MS - brightly awake and alert; attentive to examination but
makes
several errors with MOYB; oriented to self, place, date, and
situation; language is fluent with normal prosody and no
paraphasias; naming, comprehension, and repetition intact; omits
the first word when reading sentences off the stroke card;
appropriate fund of knowledge; no evidence of apraxia
CN - PERRL 3 to 2mm and brisk; ?decreased BTT over L hemifield;
EOMI without nystagmus; facial sensation intact to light touch;
no facial droop, facial musculature symmetric; hearing intact to
voice; palate elevates symmetrically; ___ strength in trapezii
and SCM bilaterally; tongue protrudes in midline with full ROM
MOTOR - Normal bulk and tone throughout. No pronator drift. B/L
intention tremor. No asterixis.
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 throughout.
REFLEXES -
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response was flexor bilaterally.
+Pectoral jerks bilaterally.
COORD - mild intention tremor bilaterally; no gross dysmetria or
ataxia on FNF B/L
GAIT - deferred
DISCHARGE PHYSICAL EXAM
Neuro Exam
MS - Alert, oriented to hospital and details of admission
CN - EOMI, PERRL, Endorsed seeing finger movement in all four
quadrants but unable to count fingers in left lower quadrant.
Facial sensaion intact. Face symmetric.
Motor - Full strength in b/l deltoid, biceps, triceps, IP,
hamstring, ___ and TA. No drift.
Coordination - mild intention tremor noted bilaterally.
Pertinent Results:
PERTINENT LAB RESULTS
___ 05:35AM BLOOD WBC-9.2 RBC-3.60* Hgb-9.2* Hct-29.4*
MCV-82 MCH-25.6* MCHC-31.3* RDW-17.0* RDWSD-50.1* Plt ___
___ 05:35AM BLOOD Glucose-88 UreaN-17 Creat-1.1 Na-137
K-4.5 Cl-107 HCO3-21* AnGap-14
___ 05:45AM BLOOD ALT-43* AST-42* LD(LDH)-159 CK(CPK)-171
AlkPhos-552* TotBili-0.5
___ 05:45AM BLOOD GGT-990*
___ 05:45AM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:45AM BLOOD Albumin-3.7 Calcium-9.2 Phos-3.3 Mg-2.0
Cholest-213*
___ 10:02PM BLOOD %HbA1c-4.9 eAG-94
___ 05:45AM BLOOD Triglyc-91 HDL-67 CHOL/HD-3.2 LDLcalc-128
___ 04:35PM BLOOD TSH-5.2*
___ 05:45AM BLOOD Free T4-0.90*
___ 04:35PM BLOOD CRP-5.8*
IMAGES
HEAD CT
1. Right occipital hypodensity concerning for an infarct which
is at least
subacute in time course.
2. No acute intracranial hemorrhage.
3. Moderate cortical atrophy with chronic small vessel ischemic
disease.
.
ECHOCARDIOGRAM
The left atrium is normal in size. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
focal severe hypokinesis of the inferior wall and hypokinesis of
the basal to mid inferoseptum. Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
arch is mildly dilated. The number of aortic valve leaflets
cannot be determined. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
estimated pulmonary artery systolic pressure is normal.
IMPRESSION: No cardiac source of embolism identified. Regional
left ventricular systolic dysfunction c/w CAD. Normal right
ventricular cavity size and systolic function. Mild aortic
stenosis.
.
CHEST PA/LAT
In comparison with the study of ___, there is again
extensive
pleural plaquing and hemidiaphragmatic calcification, consistent
with
asbestos-related disease. Little change in the opacification in
the right
apex, which most likely relates to previous surgery.
No evidence of acute focal pneumonia or aspiration.
.
MRI/MRA BRAIN
Preliminary Report1. Acute infarct involving the right occipital
lobe in the right posterior
Preliminary Reportcerebral artery distribution.
Preliminary Report2. Decreased flow related enhancement and
arborization of distal right
Preliminary Reportposterior cerebral artery corresponding to the
site of infarct.
Preliminary Report3. No aneurysm greater than 4 mm.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO BID
3. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
stroke, right posterior cerebral artery
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with new acute onset headache, dizziness, visual
disturbance
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 18.0 s, 20.2 cm; CTDIvol = 49.7 mGy (Head) DLP =
1,003.4 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of intracranial hemorrhage or mass. Hypodensity in the
right occipital lobe is concerning for a subacute to early chronic infarct.
The ventricles and sulci are prominent, consistent with age-related atrophy.
Periventricular and subcortical white matter hypodensities are compatible with
chronic small vessel ischemic disease.
No acute osseous abnormalities seen. Calcifications of the carotid siphons
and distal left vertebral artery are noted. Minimal mucosal thickening of the
maxillary sinuses is noted as well as opacification of bilateral anterior
ethmoid air cells. The mastoid air cells and middle ear cavities are clear.
The orbits are unremarkable.
IMPRESSION:
1. Right occipital hypodensity concerning for an infarct which is at least
subacute in time course.
2. No acute intracranial hemorrhage.
3. Moderate cortical atrophy with chronic small vessel ischemic disease.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with stroke // r/o aspiration r/o
aspiration
IMPRESSION:
In comparison with the study of ___, there is again extensive
pleural plaquing and hemidiaphragmatic calcification, consistent with
asbestos-related disease. Little change in the opacification in the right
apex, which most likely relates to previous surgery.
No evidence of acute focal pneumonia or aspiration.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: ___ year old man with new R PCA infarct on CT. Stroke eval for
acquity of stroke.
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of 11 mL of
Multihance intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: Head CT from ___.
FINDINGS:
MRI Brain:
Again seen is an acute infarct in the right PCA territory involving the right
occipital lobe with slow diffusion. No hemorrhagic conversion of the infarct
is seen.
The ventricles and sulci are patent and prominent in keeping with age-related
volume loss. There is no abnormal enhancement after contrast administration.
There are confluent areas of T2/FLAIR hyperintensity in the periventricular
and subcortical white matter, nonspecific, likely secondary to small vessel
ischemic changes.
There has been prior bilateral lens replacement. Mucosal thickening in
bilateral ethmoid air cells, left maxillary sinus and partial opacification of
left sphenoid sinus. Nonspecific partial fluid opacification of left mastoid
air cells.
MRA brain: There is decreased in arborization and flow related enhancement
involving the right distal posterior cerebral artery (see 8: 41-42). This
corresponds to acute infarct and right posterior cerebral artery distribution.
There is some luminal irregularity and luminal narrowing of the intracranial
vasculature suggestive of atherosclerosis. The remaining intracranial
vertebral and internal carotid arteries and their major branches appear
unremarkable without evidence of stenosis, occlusion, or aneurysm formation.
MRA neck: There is some luminal irregularity involving bilateral common and
internal carotid arteries, likely secondary to atherosclerosis. The neck
arteries otherwise appear normal. There is no evidence of internal carotid
artery stenosis by NASCET criteria. The origins of the great vessels,
subclavian and vertebral arteries appear normal bilaterally.
IMPRESSION:
1. Acute infarct involving the right occipital lobe in the right posterior
cerebral artery distribution.
2. Decreased flow related enhancement and arborization of distal right
posterior cerebral artery corresponding to the site of infarct.
3. No aneurysm greater than 4 mm.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache, Visual changes
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, HYPERTENSION NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT
temperature: 98.1
heartrate: 86.0
resprate: 20.0
o2sat: 100.0
sbp: 181.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ M w PMHx of CABG x4, significant PVD
s/p stenting who presented with hypertension and headache and
was found to have subacute R PCA infarct on noncontrast head CT,
admitted for workup for this stroke. His admission exam was
notable for L inferior quadrantinopia.
His symptoms were stable during his admission. He had MRI
confirmed his R PCA infarct and his MRA showed severe
atherosclerotic disease of the right A1 segment of the ACA,
right MCA, left vertebral V4 segment, bilateral vertebral artery
origin. There was a cutoff of the P2 segment of the right PCA.
Therefore, this makes us most suspicious for artery to artery
embolism as the etiology for his stroke. His telemetry was
significant for several episodes of short SVT but no atrial
fibrillation. He had an echocardiogram that showed hypokinesis
that was expected given his significant history of CAD. His LDL
was 128 and we would recommend starting a statin, however, upon
review of PCP records, the patient had previously been on a
statin that was stopped becuase of elevated Alk Phos. AP was in
500s here with GGT in 900s. His primary care provider office was
called regarding this and the need for follow up regarding his
liver disease and the hyperlipidemia. In the meantime, he was
started on 1000mg Fish oil BID. He was continued on aspirin 81mg
daily. Because we feel that his etiology was likely artery to
artery embolus, he was not set up with ___
monitoring.
TSH was 5.2 which was slightly high with FT4 0.9 which was
slightly low. This is likely subclinical and should be followed
by primary care.
OT evaluated him and suggested home with OT services. ___ was
consulted but felt that he was at his functional baseline and
since his only deficit was visual, he did not need any ___ follow
up.
Transitional issues
- Alk Phos elevation with GGT
- SVT on telemetry
- LDL 128 need for lowering
- Subclinical hypothyroidism monitoring |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine / Vicodin
Attending: ___.
Chief Complaint:
R Vancouver B3 periprosthetic femur fx
Major Surgical or Invasive Procedure:
R periprosthetic femur ORIF
History of Present Illness:
___ is a ___ year old female who presents to the
ED as a transfer from ___ for management of a
right
periprosthetic hip fracture. Patient says she was in her
bedroom, putting on clothes yesterday morning when she tripped
and fell. She landed on her left hip and had immediate pain.
She was unable to stand and was discovered 2 hours later by her
son. She reports having her right total hip performed at ___ for a fracture in ___. Denies having pain
prior
to her fall. She denies having pain in any other location.
Past Medical History:
Cirrhosis
Hypertension
Hypothyroidism.
Social History:
___
Family History:
N/C
Physical Exam:
RLE:
Dsg c/d/I
Thigh soft and compressible
Toes wwp
motor and sensory exam deferred ___ sleep and delirium
precautions
Pertinent Results:
___ 10:02AM BLOOD WBC-13.1* RBC-2.93* Hgb-9.3* Hct-28.6*
MCV-98 MCH-31.7 MCHC-32.5 RDW-14.5 RDWSD-51.9* Plt ___
Medications on Admission:
Medications - Prescription
ALENDRONATE [FOSAMAX] - Dosage uncertain - (Prescribed by Other
Provider)
ATENOLOL - Dosage uncertain - (Prescribed by Other Provider)
CELECOXIB [CELEBREX] - Dosage uncertain - (Prescribed by Other
Provider)
LEVOTHYROXINE - Dosage uncertain - (Prescribed by Other
Provider)
OMEPRAZOLE - Dosage uncertain - (Prescribed by Other Provider)
PROPOXYPHENE - propoxyphene 65 mg capsule. ___ Capsule(s) by
mouth q4-6 as needed for pain
VALSARTAN-HYDROCHLOROTHIAZIDE [DIOVAN HCT] - Dosage uncertain -
(Prescribed by Other Provider)
Medications - OTC
CALCIUM CARBONATE - Dosage uncertain - (Prescribed by Other
Provider)
DOCUSATE SODIUM - docusate sodium 100 mg capsule. 2 Capsule(s)
by
mouth twice a day
GLUCOSAMINE SULFATE 2KCL - Dosage uncertain - (Prescribed by
Other Provider)
MULTIVITAMIN, STRESS FORMULA - Dosage uncertain - (Prescribed
by
Other Provider)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
4. QUEtiapine Fumarate 12.5 mg PO BID PRN agitation
5. Ramelteon 8 mg PO QHS
6. Senna 8.6 mg PO BID
7. TraMADol ___ mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*20 Tablet Refills:*0
8. Atenolol 25 mg PO DAILY
9. Levothyroxine Sodium 100 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R ___ B3 periprosthetic femur fracture
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: Right femur fracture.
TECHNIQUE: CT scan of the right femur was obtained without the IV
administration of contrast material. Sagittal, axial, and coronal reformats
were provided for image interpretation.
COMPARISON: X-ray ___.
FINDINGS:
Bones:
The patient is status post right total hip arthroplasty. Arthroplasty appears
well aligned.
There is a proximal right femur periprosthetic fracture. Fracture line is
oriented obliquely in the subtrochanteric region with a vertical component
extending along the posterior shaft to the mid to distal diaphysis
approximately 6 cm distal to the distal tip of the femoral component.
Mild right SI joint degeneration mild cartilage space narrowing of the
patellofemoral compartment.
Soft tissues: Stranding, high density, and apparent fat within the vastus
medialis and intermedius muscles is likely consistent with a component of
hematoma as well as intramedullary fat.
Lobular fluid deep to the distal sartorius tendon is most consistent with pes
anserine bursitis. Mineralization at the proximal femoral insertion of the
medial collateral ligament likely represents sequela of prior injury. Foley
catheter is seen within the bladder.
There is a 4.7 x 4.5 cm cystic structure of the right lower quadrant of the
abdomen which is incompletely visualized. This is separate from the
normal-appearing appendix. Visualized loops of small bowel appear collapsed.
There is dense aortic vascular calcifications.
IMPRESSION:
Proximal right femur periprosthetic fracture. Fracture line is oriented
obliquely in the subtrochanteric region with a vertical component extending
along the posterior shaft to the mid to distal diaphysis approximately 6 cm
distal to the distal tip of the femoral component.
4.7 x 4.5 cm cystic structure of the right lower quadrant of the abdomen which
is incompletely visualized. This should be correlated with any prior
abdominal imaging. If no prior abdominal imaging is available, a contrast
enhanced CT of the abdomen pelvis is recommended for further evaluation.
Pes anserine bursitis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:11 am, 15 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) RIGHT IN O.R.
IMPRESSION:
Fluoroscopic images show placement of a fixation device about periprosthetic
fracture. Further information can be gathered from the operative report.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Hip fracture, s/p Fall, Transfer
Diagnosed with Periprosth fracture around internal prosth r hip jt, init, Other fall on same level, initial encounter
temperature: 98.1
heartrate: 70.0
resprate: 13.0
o2sat: 95.0
sbp: 127.0
dbp: 65.0
level of pain: 8
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a R Vancouver B3 periprosthetic femur fx and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for R periprosthetic
femur ORIF, 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 was co-managed by the Medicine
service for intermittent agitation, most consistent with
hospital-acquired delirium She required IV Haldol on POD1 but
otherwise was managed by PRN Seroquel and frequent
reorientation. The Medicine team also decided to hold the
patients home Diovan until her follow-up appointment with her
PCP because of relatively low blood pressures. 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
protected weight bearing in the right lower extremity, and will
be discharged on subcutaneous heparin twice daily for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
aspirin
Attending: ___
Chief Complaint:
abdominal distention
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ gentleman with cognitive impairment whose past
surgical history is suggestive of a subtotal gastrectomy and
gastrojejunostomy some years ago with prior SBO managed
non-operatively now presents with approximately 1 day of
anorexia, abdominal distention, and constipation.
Her the patient's health aide, who helps to take care of him at
the group home in which she resides, Mr. ___ was in his
usual, good state of health until one day ago. At this time, he
reported not feeling well, with limited appetite and gradual
development of worsening abdominal distention. Over the same
time interval, he developed mild constipation, which is new for
him. He additionally complained of nausea without vomiting.
While his last bowel movement was earlier yesterday, he cannot
remember when he last passed gas. In light of his prior history
of bowel obstruction, is helped a elected to bring him to the
emergency department this evening for further workup and
evaluation.
Since arrival in the emergency department, Mr. ___ abdomen
has become less distended and softer her is assistant. He is
remained afebrile and hemodynamically normal since arrival. He
has had no nausea or vomiting, and currently does not have a
nasogastric tube in place. Since receiving the oral contrast
for
his CT scan, Mr. ___ has had one, gray colored bowel
movement, with some improvement in symptoms.
Past Medical History:
PMHx: Hypertension, cognitive impairment, anxiety, history of
colon polyps, BPH.
PSHx: By the patient nor his aide are aware of his prior
surgical
history. Per the scant records available in our system and from
radiologic images, it appears he may have had a subtotal
gastrectomy and gastrojejunostomy.
Social History:
___
Family History:
unknown
Physical Exam:
Physical Exam at Admission:
Temp: 98.7 HR: 105 BP: 101/84 Resp: 19 O(2)Sat: 100
Gen: In no acute distress, well-nourished man who appears his
stated age.
CV: Regular rate and rhythm
R: Clear to auscultation bilaterally
Abd: Softly distended, with no focal tenderness appreciated
although patient is uncomfortable to deep palpation. There are
no masses noted, there are no hernias noted on the abdomen or
groin. Patient is tympanitic. There is no evidence of ascites.
There is no voluntary guarding or rebound. There is a
well-healed midline surgical incision within the upper abdomen.
Ext: No cyanosis, clubbing, or edema
Physical Exam at Discharge:
VS: 99.2, 132/83, 82, 18, 96% Ra
Gen: no acute distress, back at baseline
CV: regular rate and rhythm
Resp: breathing comfortably on room air
Abd: soft, non-distended, non-tender
Ext: warm, well perfused
Pertinent Results:
___ 04:50AM BLOOD WBC-7.8 RBC-4.31* Hgb-11.5* Hct-34.8*
MCV-81* MCH-26.7 MCHC-33.0 RDW-15.3 RDWSD-44.2 Plt ___
___ 03:45PM BLOOD WBC-2.9* RBC-4.09* Hgb-11.0* Hct-33.3*
MCV-81* MCH-26.9 MCHC-33.0 RDW-14.8 RDWSD-43.3 Plt ___
___ 11:10PM BLOOD WBC-4.0 RBC-4.54* Hgb-12.0* Hct-36.7*
MCV-81* MCH-26.4 MCHC-32.7 RDW-14.8 RDWSD-43.0 Plt ___
___ 04:50AM BLOOD Glucose-107* UreaN-7 Creat-0.9 Na-141
K-4.4 Cl-105 HCO3-24 AnGap-12
___ 11:10PM BLOOD Glucose-121* UreaN-22* Creat-1.2 Na-140
K-4.4 Cl-103 HCO3-24 AnGap-13
___ 04:50AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.9
___: CT ___
IMPRESSION:
1. There is a partial small bowel obstruction with multiple
dilated loops,
measuring up to 4.7 cm. No evidence of ischemia. The
transition point is
likely in the right lower quadrant as the terminal ileum is
normal in caliber.
2. Hepatic steatosis.
3. Mild splenomegaly, measuring 13.2 cm.
4. Trace left pleural effusion.
5. There is a 4.1 cm loop of small bowel with thickened wall,
concerning for chronic inflammatory disease. Recommend CT
enterography after resolution of acute issues.
___ CXR:
IMPRESSION:
No previous images. Nasogastric tube extends well into the
stomach with the side port distal to the esophagogastric
junction. Low lung volumes accentuate the transverse diameter
of the heart. No vascular congestion or acute focal
consolidation.
___ KUB:
IMPRESSION:
Oral contrast from prior abdominal CT scan is now within the
colon.
Nonspecific bowel gas pattern with persistent mildly dilated
loops of small
bowel in the left mid abdomen.
___ CXR:
IMPRESSION:
NG tube is within the stomach. Atelectatic changes right lung
base.
___ KUB
IMPRESSION:
1. Several dilated loops of small bowel concerning for small
bowel obstruction appears worse compared to most recent
abdominal radiograph performed ___ and unchanged
compared to prior CT abdomen pelvis performed ___.
2. Enteric tube is visualized with its side port projecting over
the expected position of the stomach.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. BusPIRone 15 mg PO TID
3. Clozapine 200 mg PO DAILY:PRN agitation
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. BusPIRone 15 mg PO TID
3. Clozapine 200 mg PO DAILY:PRN agitation
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction
Discharge Condition:
Mental Status: Back at baseline- very pleasant
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: +PO contrast; History: ___ with hx SBO with abd distension and
anorexia. +PO contrast// SBO?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 54.9 cm; CTDIvol = 13.6 mGy (Body) DLP = 748.6
mGy-cm.
Total DLP (Body) = 749 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
LOWER CHEST: Trace left pleural effusion. There is bibasilar atelectasis.
Visualized lung fields are within normal limits. There is no evidence of
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver is diffusely hypodense, consistent with hepatic
steatosis. There is no evidence of focal lesions. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: There is diffuse fatty infiltration of the pancreas, without
evidence of focal lesions or pancreatic ductal dilatation. There is no
peripancreatic stranding.
SPLEEN: Mildly enlarged, measuring 13.2 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 kidneys are of normal and symmetric size with normal nephrogram.
There is a 0.9 cm hypodensity in the midpole of the right kidney, too small to
characterize (___). No hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The patient is status post subtotal gastrectomy and
gastrojejunal anastomosis, as before. There are multiple dilated loops of
small bowel, measuring up to 4.7 cm with decompressed distal loops. The
transition point is likely in the right lower quadrant. The terminal ileum is
normal in caliber. There is no evidence of ischemia. There is a 4.1 cm loop
of small bowel with thickened wall in the mid pelvis, concerning for chronic
inflammatory disease. The colon is also mildly dilated The rectum is within
normal limits. The appendix is normal.
PELVIS: The urinary bladder is mildly distended. The distal ureters are
unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged and the seminal vesicles are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There are multilevel degenerative changes of the visualized spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. There is a partial small bowel obstruction with multiple dilated loops,
measuring up to 4.7 cm. No evidence of ischemia. The transition point is
likely in the right lower quadrant as the terminal ileum is normal in caliber.
2. Hepatic steatosis.
3. Mild splenomegaly, measuring 13.2 cm.
4. Trace left pleural effusion.
5. There is a 4.1 cm loop of small bowel with thickened wall, concerning for
chronic inflammatory disease. Recommend CT enterography after resolution of
acute issues.
RECOMMENDATION(S): After resolution of acute issues, recommend CT
enterography for further evaluation of a 4.1 cm loop of small bowel in the mid
pelvis with thickened wall.
NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on
the telephone on ___ at 3:21 am, 4 minutes after discovery of the
findings.
The updated findings and recommendations were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 9:49 am, 10 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ prior subtotal gastrectomy and GJ now here with SBO//
Confirmation of NGT
IMPRESSION:
No previous images. Nasogastric tube extends well into the stomach with the
side port distal to the esophagogastric junction. Low lung volumes accentuate
the transverse diameter of the heart. No vascular congestion or acute focal
consolidation.
Radiology Report
INDICATION: ___ w/ cognitive impairment, prior subtotal gastrectomy and GJ
now here with SBO// Interval x-ray with regards to SBO
TECHNIQUE: Portable views of the abdomen.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
Oral contrast from prior CT is noted within the:. Bowel gas pattern is
nonspecific with a few mildly dilated loops of small bowel in the left mid
abdomen measuring up to 3.8 cm. There are no large pockets of free air.
Excreted contrast is noted within the bladder. There is multilevel
degenerative change in the lumbar spine. There is no suspicious bony lesion.
IMPRESSION:
Oral contrast from prior abdominal CT scan is now within the colon.
Nonspecific bowel gas pattern with persistent mildly dilated loops of small
bowel in the left mid abdomen.
Radiology Report
EXAMINATION: Chest x-ray
INDICATION: ___ w/ cognitive impairment, prior subtotal gastrectomy and GJ
now here with SBO// NGT to be placed in right place
TECHNIQUE: Portable chest x-ray
COMPARISON: Previous chest x-ray from ___.
FINDINGS:
The nasogastric to has been advanced and is in the stomach. Low lung volumes
are evident. Atelectatic changes are evident at the right lung base. The
heart is likely enlarged. This is difficult to assess with low lung volumes.
The trachea is midline. Degenerative changes are seen in the spine. Retained
contrast is seen in the bowel.
IMPRESSION:
NG tube is within the stomach. Atelectatic changes right lung base.
Radiology Report
INDICATION: ___ year old man with cognitive impairment,, subtotal gastrecctomy
and GJ with partial SBO// compare for interval change
TECHNIQUE: Supine and lateral decubitus abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph performed ___. CT abdomen
pelvis performed ___ 17.
FINDINGS:
Several dilated loops of small bowel measuring up to 4.0 cm are visualized
concerning for small bowel obstruction, and appears worse compared to most
recent abdominal radiograph performed ___, and unchanged
compared to prior CT abdomen pelvis performed ___. A small
amount of oral contrast is visualized in the right upper quadrant.
There is no free intraperitoneal air.
Osseous structures are notable for multilevel degenerative changes of the
lumbar spine.
Surgical clips are again visualized in the right upper quadrant. An enteric
tube is seen with its side port projecting over the expected position of the
stomach.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. Several dilated loops of small bowel concerning for small bowel obstruction
appears worse compared to most recent abdominal radiograph performed ___ and unchanged compared to prior CT abdomen pelvis performed ___.
2. Enteric tube is visualized with its side port projecting over the expected
position of the stomach.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:12 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with sudden onset AMS// eval for ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 48.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute major vascular territory
infarction,hemorrhage,edema, or mass. There is prominence of the ventricles
and sulci suggestive of involutional changes.
There is no evidence of fracture. Mild mucosal thickening is noted in the
left maxillary sinus. The frontal sinuses are not pneumatized. Otherwise,
the remaining visualized portion of the paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. Left globe is small and partially
calcified likely sequela of prior trauma or infection.
IMPRESSION:
1. No acute intracranial abnormalities.
2. Asymmetric appearance of the left orbit, which appears smaller with
posterior calcifications, likely sequela of prior trauma or infection.
Radiology Report
INDICATION: ___ with history of ams after hospitalization// eval for
aspiration or pneumonia
TECHNIQUE: Single portable view of the chest.
COMPARISON: X-ray from ___.
FINDINGS:
The lungs are grossly clear without consolidation, effusion, or edema. The
cardiomediastinal silhouette is stable. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ with just discharged with SBO now presenting with AMS,
hypotensionNO_PO contrast// eval for perforation, incarceration, recurrent sbo
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 766 mGy-cm.
COMPARISON: CT abdomen and pelvis with contrast from ___
FINDINGS:
LOWER CHEST: Atelectasis is noted in the lung bases bilaterally. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Small hypodensity near the dome is incompletely characterized, potentially
cyst or hemangioma (02:17). There is no evidence of new focal lesions. There
is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is decompressed.
PANCREAS: The pancreas appears atrophic, without evidence of focal lesions or
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows top-normal size measuring 13.8 cm. No focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A 1.1 cm cortically based hypodensity is seen in the interpolar region of the
right kidney, likely simple cysts. There is no evidence of focal renal
lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: Patient is reportedly status post partial gastrectomy.
Small bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. Colon is grossly unremarkable. The appendix is within normal
limits.
PELVIS: The urinary bladder is decompressed. There is no distal hydroureter.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged, but unchanged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
No acute intra-abdominal process. Interval resolution of recent bowel
obstruction.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Fever
Diagnosed with Unspecified abdominal pain
temperature: 98.7
heartrate: 105.0
resprate: 19.0
o2sat: 100.0
sbp: 101.0
dbp: 84.0
level of pain: 5
level of acuity: 3.0 | Mr. ___ is a ___ with cognitive impairment and past surgical
history significant with prior subtotal gastrectomy and GJ who
presented to ___ with partial small bowel obstruction. On HD 1
he had no return of bowel function and persistent abdominal
distension. He had an NGT placed with CXR confirmation. On HD
___ he still had no return of bowel function, he was continued
on bowel rest with NPO/IVFs/PPI for protection. ON HD4 he
required his NGT to be replaced after self DC. On HD 5 he was
noted to have a small bowel movement, but did not have flatus
per patient. On HD 6 he had a KUB which demonstrated the
contrast had moved completely through his bowels and out his
rectum. He underwent a clamp trial which demonstrated <50cc
residual so his NGT was removed. On HD 7 he was advanced slowly
from sips to clears to regular. He tolerated this well so was
discharged on HD 8 with return of bowel function, both flatus
and bowel movements, tolerating PO, ambulating well and with
adequate pain control. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
subacute infarct affecting L basal ganglia and internal capsule
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Ms. ___ is an ___ yo F who presented to ___ after a
fall.
She was found by her neighbors, down for unknown amount of time.
Per report, not found down in urine or feces. Per patient, she
hit her head when falling but doesn't recall the circumstances
of
why she fell. CT Head performed at ___ showed subacute infarct
in
L basal ganglia (caudate, globus pallidus), and the patient was
transferred to ___ for further care.
Of note, the patient noticed mild R sided weakness (arm and leg)
starting yesterday. Prior to that she had not noticed any
weakness. Patient does not recall prior falls, although she has
prior ED visits at ___ for falls.
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. Denies confusion. Denies
numbness, parasthesiae. No bowel or bladder incontinence or
retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Hypertension
Cataracts
Depression/Anxiety
Hx prior UTIs
Social History:
___
Family History:
Non-contributory.
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC, ecchymosis on R eyebrow
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated, R wrist/hand laceration
Skin: no rashes noted.
Neurologic:
-Mental Status: Alert, oriented to name but not month ___
or
year ___ or place. Language is fluent with intact repetition
and
comprehension. Normal prosody. There was a phonemic paraphasic
error (diagram for dial). Pt. was able to name high frequency
objects, trouble with low freq objects (diagram instead of dial
for watch face). Speech was not dysarthric. Able to follow
both
midline and appendicular commands. Mild inattention, able to
name ___ backwards but not ___ backward. Pt. was able to
register 3 objects but recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1.5mm, both directly and consentually; brisk
bilaterally. VFF to confrontation. Fundoscopic exam limited,
optic discs not visualized.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch in all distributions,
and ___ strength noted bilateral in masseter
VII: No facial droop, facial musculature symmetric
VIII: Hearing intact to finger-snap bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, paratonia 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 4+ ___ ___ ___ 5 5 4+ 5
R 4+ 4+ 4+ ___ ___ 5 5 5 4+ 5
-DTRs:
___ Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 3 0
- Plantar response was extensor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are present
on R.
Sensation: intact for fine touch, pinprick, vibratory sense,
proprioception throughout.
-Coordination: Intention tremor bilaterally on FNF, no L hand
dysrhythmic on rapid alternating movements. No dysmetria on FNF
or HKS bilaterally.
Pertinent Results:
Labs:
___ 07:20AM BLOOD WBC-6.3 RBC-3.62* Hgb-11.8* Hct-35.2*
MCV-97 MCH-32.5* MCHC-33.5 RDW-13.6 Plt ___
___ 12:25PM BLOOD Neuts-85.7* Lymphs-9.2* Monos-4.9 Eos-0.1
Baso-0.1
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD Glucose-70 UreaN-23* Creat-0.9 Na-141
K-4.1 Cl-105 HCO3-25 AnGap-15
___ 12:25PM BLOOD ALT-26 AST-41* CK(CPK)-226* AlkPhos-76
TotBili-0.4
___ 12:25PM BLOOD Lipase-48
___ 12:25PM BLOOD Lipase-48
___ 12:25PM BLOOD cTropnT-<0.01
___ 07:20AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.8 Cholest-151
___ 05:25PM BLOOD %HbA1c-5.4 eAG-108
___ 07:20AM BLOOD Triglyc-65 HDL-59 CHOL/HD-2.6 LDLcalc-79
___ 12:25PM BLOOD TSH-2.2
___ 12:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:32PM BLOOD Lactate-1.3
Studies:
SKULL AP&LAT/C-SP/CXR/ABD SLG ___:
IMPRESSION: No radiopaque foreign body. Aside from dental
amalgam. Small left-sided joint effusion. Loss of vertebral body
height at L2 and L4.
ECHO ___:
IMPRESSION: Mitral valve prolapse with mild-moderate mitral
regurgitation. Tricuspid valve prolapse with moderate tricuspid
regurgitation. Pulmonary artery hypertension. Normal
biventricular cavity sizes with preserved regional and global
biventricular systolic function. No definite cardiac source of
embolism identified.
CTA HEAD/NECK W/&W/O ___:
IMPRESSION:
1. Hyperdensity within the left basal ganglia, likely on the
basis of acute to subacute infarct, unchanged when compared to
prior exam.
2. No evidence of hemodynamically significant stenosis,
dissection, or
aneurysm within the vasculature of the head or neck.
CHEST (PA & LAT) ___:
IMPRESSION: Cardiomegaly, COPD, bilateral small pleural
effusions.
MRI Brain: Per neurology read, diffusion weighted changes in
Left Basal ganglia. Consistent with subacute infarct. Formal
radiology read pending at d/c
ECG ___:
Sinus rhythm with baseline artifact. Left axis deviation
consistent with left anterior fascicular block. Right
bundle-branch block. No previous tracing available for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
75 ___ 85 -61 51
Medications on Admission:
ASA 81 mg daily
Vit D 2000u daily
Calcium carbonate 500 mg daily
Multivitamin daily
Raloxifene 60 mg daily
Lorazepan 0.5 mg daily
Acetaminophen 650 mg BID prn
Miralax prn
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Heparin 5000 UNIT SC TID
5. Lorazepam 0.5 mg PO HS
6. Multivitamins 1 TAB PO DAILY
7. Bacitracin-Polymyxin Ointment 1 Appl TP Q6H:PRN Right
Shoulder wound
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left Basal Ganglia Ischemic Infarct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with hx unwitnessed fall, concern for rib fx, underlying
pneumonia.
TECHNIQUE: Chest AP (supine) and lateral
COMPARISON: Chest radiograph on ___ at 08:07 from an outside
facility
FINDINGS:
The heart is enlarged. The hilar contours are within normal limits. The lungs
are hyperinflated likely secondary to COPD. The lungs are clear with no focal
consolidation. There are small bilateral pleural effusions. There is no
evidence of pneumothorax. No displaced rib fractures are identified. Chronic
deformity of the left humeral neck appears unchanged.
IMPRESSION:
Cardiomegaly, COPD, bilateral small pleural effusions.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: History: ___ s/p unwitnessed fall, down for unknown amount of
time with subacute CVA of basal ganglia on CT head by outside hospital. //
signs of ischemic changes
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed from the
aortic arch through the brain during infusion of Omnipaque intravenous
contrast material. Images were processed on a separate workstation with
display of curved reformats, 3D volume rendered images, and maximum intensity
projection images.
DOSE: DLP: 1132.19 mGy-cm; CTDI: 62.9 mGy
COMPARISON: Outside CT head ___.
FINDINGS:
Focal hypodensity within the left basal ganglia, with mild edema and minimal
local mass effect on the left lateral ventricle, likely indicative of acute to
subacute infarct, unchanged when compared to prior exam. There is no evidence
of acute intracranial hemorrhage or new areas of acute ischemia. There is
moderate brain parenchymal volume loss. The orbits and paranasal sinuses are
unremarkable.
Head and neck CTA: The origins of the great vessels are patent. The left
vertebral artery is diminutive. There is no evidence of dissection, pathologic
large vessel occlusion, or hemodynamically significant stenosis within the
vasculature of the neck.
There is no evidence of aneurysm, focal vessel cut off, or hemodynamically
significant stenosis within the intracranial vasculature. There are
nonocclusive atheromatous calcifications of the bilateral supraclinoid
internal carotid arteries. The major dural venous sinuses appear patent.
There are small bilateral pleural effusions. There is multilevel degenerative
cervical spondylosis.
IMPRESSION:
1. Hyperdensity within the left basal ganglia, likely on the basis of acute
to subacute infarct, unchanged when compared to prior exam.
2. No evidence of hemodynamically significant stenosis, dissection, or
aneurysm within the vasculature of the head or neck.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old woman with subacute stroke on CT // eval for
location, extent of stroke
TECHNIQUE: Multisequence, multiplanar MRI of the brain without intravenous
gadolinium.
COMPARISON: CTA head/ neck ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage. There is slow
diffusion within the left basal ganglia and left temporal cortex/insula with
mild mass effect on the left lateral ventricle, the findings of which are
presumably on the basis of subacute infarct in the left MCA distribution,
particularly the lateral lenticulostriate arteries with probable involvement
of distal MCA branches.
There is moderate diffuse brain parenchymal volume loss. There are normal
vascular flow voids. There is increased T2/FLAIR signal hyperintensity within
the subcortical and periventricular white matter which is nonspecific although
is presumably on the basis of chronic small vessel ischemic disease.
The orbits, skull base, and paranasal sinuses are unremarkable.
IMPRESSION:
1. Slow diffusion within the left basal ganglia and left temporal
cortex/insula with mild swelling and mass effect on the left lateral ventricle
which likely represents subacute infarct in the left MCA distribution, as
described.
2. No evidence of hemorrhage.
3. Diffuse brain parenchymal volume loss and presumed sequelae of chronic
small vessel ischemic disease.
Radiology Report
INDICATION: Screening for metal
TECHNIQUE: One view skull, one view chest, and one view abdomen.
COMPARISON: ___ chest radiograph.
FINDINGS:
There is dental amalgam. There are no radiopaque metallic foreign bodies. The
heart is enlarged. There is biapical pleural thickening. There is a small
left-sided pleural effusion and atelectasis. There is mild loss of vertebral
body height at L4 and possibly L2. The degenerative changes of the femoral
acetabular joints are noted.
IMPRESSION:
No radiopaque foreign body. Aside from dental amalgam.
Small left-sided joint effusion.
Loss of vertebral body height at L2 and L4.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Transfer
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: 98.2
heartrate: 71.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | # Left Basal Ganglia Bleed
CT in the ED revealed subacute infarct of L basal ganglia and
internal capsule. She underwent evaluation of stroke risk
factors (A1C 5.4, LDL 79) and she was admitted to the neurology
stroke service, where she was continued on aspirin. Her stroke
risk factors were evaluated (as below). Echocardiogram did not
reveal a cardiac source of thrombus, but did reveal mild/mod MR,
mod TR and pulmonary hypertension. MRI reconfirmed left basal
ganglia ischemic infarct. ___ evaluated the patient and
recommended d/c to rehab.
# Delirium
- While patient's admission exam was concerning for an
underlying cognitive issue such as dementia, this was difficult
to evaluate in the hospital. During this hospitalization, she
became delirious requiring Haldol once during this hospital
stay. She otherwise tolerated the hospital stay well.
# R Shoulder abrasion
- Pt has R posterior shoulder abrasion. Small rim of erythema
around it but no fevers, chills or systemic symptoms. Started
on bacitracin. Should it fail to improve or worsen, would
recommend considering initiate of systemic antibiotics (ie PO
clinda or physician ___ for possible cellulitis)
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented (required for all patients)? (X) Yes (LDL =79)
- () No
A1C 5.4
5. Intensive statin therapy administered? () Yes - (x) No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. 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)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? () Yes - (x) No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A
==================================================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/schizophrenia, COPD, and recurrent aspiration pneumonia
presents w/AMS. Per ED documentation AMS present since 7pm.
Noted to be hypoxic to high ___ on RA by EMS. Denies dysuria, no
CP, no ___ edema. Denies falls or headstrike. Denies
dysuria/hematuria. Denies black/bloody stool. No abd pain,
n/v/d.
In ED pt given CTX, azithro, solumedrol and nebs. CT Scan with
possible sinusitis. No acute bleed.
On arrival to floor pt noted to be somnolent by RN but able to
answer questions and oriented x3. Complained of constipation,
knew he was hospitalized for PNA. On my arrival to the bedside
about 25min later pt only arrousable to painful stimuli. Glucose
112. O2 93%2Lnc. Repeat ABG w/O2 58 CO2 55. Increased to 4Lnc.
Pt improved slightly, arousable to loud voice but immediately
falls back asleep. Narcan given x1 without effect.
ROS: unable to obtain
Past Medical History:
Paranoid schizophrenia
COPD
History of psychogenic polydipsia
Anemia
Aspiration pneumonias
Rhabdomyolysis (? Chronic)
Social History:
___
Family History:
unknown
Physical Exam:
98.6 123/65 85 22 93%2L
PAIN: appears comfortable
General: nad
HEENT: edentalous, mmm, +gag reflex
Lungs: clear, poor inspiratory effort
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: lethargic, pinpoint pupils, resists eye opening,
arousable to loud voice, no neck stiffness
on discharge, exam notable for
95% on RA
lungs with fair AE, no wheeze, coarse BS throughout
alert, interactive, very pleasant
Pertinent Results:
___ 10:47PM TYPE-ART PO2-77* PCO2-58* PH-7.37 TOTAL
CO2-35* BASE XS-5 INTUBATED-NOT INTUBA
___ 10:16PM LACTATE-2.7*
___ 10:07PM GLUCOSE-122* UREA N-20 CREAT-1.0 SODIUM-138
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-30 ANION GAP-15
___ 10:07PM cTropnT-<0.01
___ 10:07PM WBC-12.3* RBC-3.61* HGB-11.7* HCT-34.4*
MCV-95# MCH-32.4* MCHC-34.0 RDW-13.7
___ 10:07PM NEUTS-77.0* LYMPHS-14.4* MONOS-7.4 EOS-0.8
BASOS-0.4
___ 10:07PM PLT COUNT-248
___ 10:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG
CT Head Preliminary ReportIMPRESSION:
No acute intracranial process.
Mucosal thickening in the ethmoid air cells, maxillary sinuses
and sphenoid sinuses can indicate sinusitis in the correct
clinical setting
___ 03:56AM TYPE-ART TEMP-37.0 PO2-58* PCO2-55* PH-7.40
TOTAL CO2-35* BASE XS-6 INTUBATED-NOT INTUBA VENT-SPONTANEOU
COMMENTS-NASAL ___
___ 03:56AM LACTATE-0.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Divalproex Sod. Sprinkles 1000 mg PO QHS
5. Ferrous Sulfate 325 mg PO DAILY
6. Mirtazapine 15 mg PO QHS
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Senna 17.2 mg PO DAILY
10. Sodium Chloride 2 gm PO QAM
11. Sodium Chloride 1 gm PO QPM
12. Tiotropium Bromide 1 CAP IH DAILY
13. Tamsulosin 0.4 mg PO QHS
14. TraZODone 50 mg PO QHS
15. Vitamin B Complex 1 CAP PO DAILY
16. Zolpidem Tartrate 5 mg PO QHS
17. Acetaminophen 500 mg PO Q4H:PRN pain
18. Bisacodyl 5 mg PO DAILY:PRN constipation
19. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze/SOB
Discharge Medications:
1. Acetaminophen 500 mg PO Q4H:PRN pain
2. Citalopram 20 mg PO DAILY
3. Divalproex (EXTended Release) 1000 mg PO QHS
4. Mirtazapine 15 mg PO QHS
5. Omeprazole 20 mg PO DAILY
6. Senna 17.2 mg PO DAILY
7. Sodium Chloride 2 gm PO QAM
8. Sodium Chloride 1 gm PO QPM
9. Tamsulosin 0.4 mg PO QHS
10. Tiotropium Bromide 1 CAP IH DAILY
11. Docusate Sodium 100 mg PO BID
12. Polyethylene Glycol 34 g PO DAILY
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze/SOB
14. Bisacodyl 5 mg PO DAILY:PRN constipation
15. Ferrous Sulfate 325 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. TraZODone 50 mg PO QHS
18. Vitamin B Complex 1 CAP PO DAILY
19. Zolpidem Tartrate 5 mg PO QHS
20. walker
rolling walker
Dx: gait instability
prognosis: fair
lenth of need 13 months
21. Mirtazapine 15 mg PO QHS:PRN insomnia
22. Amlodipine 2.5 mg PO DAILY
23. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
pneumonia
Discharge Condition:
alert, ambulatory with a walker
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with concern for silent aspiration with recurrent
pneumonias // silent aspiration?
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
COMPARISON: NONE
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There was no gross aspiration or penetration. A small amount of
vallecular pooling was in
IMPRESSION:
No evidence of aspiration or penetration.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 99.4
heartrate: 95.0
resprate: nan
o2sat: 93.0
sbp: 108.0
dbp: 57.0
level of pain: nan
level of acuity: 1.0 | Hospital Course Summary
This is a ___ year old male assisted living resident past medical
history of schizophrenia, COPD, prior episodes of aspiration
pneumonia and rhabdomyolysis presenting with altered mental
status, hypoxia, found to have a right lower lobe pneumonia,
treated with antibiotics
ACTIVE ISSUES
# Acute Hypoxic Respiratory Failure / Right Lower Lobe Pneumonia
/ Acute COPD Exacerbation - admitted with hypoxia and RLL
infiltrate on CXR, concern aspiration bacterial pneumonia given
history of similar events; patient was treated with ceftriaxone
/ azithromycin; exam also notable for wheezing, prompting
nebulizers for treatment of mild COPD exacerbation as well. pt
clinically improved and was weaned off oxygen. he completed a
course of azithro and levofloxacin in the hospital.
Pt underwent a speech eval that showed no sign of aspiration.
Video swallow eval also without aspiration.
# Acute Metabolic Encephalopathy - very lethargic on
presentation, spontaneously resolving following admission; no
focal process identified at time of episode. Pt clinically
improved, his home medications restarted.
INACTIVE ISSUES
# Schizoaffective Disorder - continued citalopram, divalproex,
mirtazapine
# Polydispia - continued home sodium chloride tabs
# Hypertension - continued home amlodipine
# CAD - continued home ASA
# BPH - continued home tamsulosin
# GERD - continued home PPI
TRANSITIONAL ISSUES
-Brother ___ (___) is Guardian
We strongly recommend to the SW at his long term assisted living
that they reach out to the pt's brother to discuss guardianship
further. They do not have official paperwork. Further, brother
is elderly and concerned that he lives too far away to continue
as guardian. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
motor vehicle collision
Major Surgical or Invasive Procedure:
___: Operative treatment left femur fracture with IM nail
History of Present Illness:
___ presents to the ED with chest pain, SOB and lower extremity
pain sp MVA. Per EMS, the patient was the unrestrained driver
traveling about 50 mph when she crashed into a pole. There was
significant major front end damage with entrapment. The patient
endorses upper abdominal pain and left femur pain. Denies CP,
SOB, dizziness, HA, vomiting, focal weakness. Otherwise without
complaints.
Social History:
___
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
BP: 139/67 Resp: 19 O(2)Sat: 97 Normal
Constitutional: Uncomfortable
HEENT: Pupils 2-3mm bilaterally and reactive, dried blood at
the top of the forehead and over the right superior eyelid
dried blood in the OP, mid face is stable, no septal
hematoma ; no spine TTP
Chest: Airway intact, bilateral breath sounds, no chest wall
tenderness, no subcutaneous emphysema
Cardiovascular: Strong carotid pulse, strong radial pulses,
strong DP pulses bilaterally
Abdominal: Soft, diffuse abdominal tenderness to palpation
Extr/Back: B/L UE without tenderness or deformity, pelvis is
stable, tenderness with palpation to bilateral hips,
significant left hip tenderness with swelling over the left
thigh, right thigh tenderness to palpation ; normal
sensation and pulses throughout
Skin: No left thigh bruising, small abrasion over the right
inner thigh and just below the right knee
Neuro: GCS 14 for confusion; CN ___ intact, moving all
extremities
Psych: Normal mood, Normal mentation
___: No petechiae
Discharge Physical Exam:
VS: 97.8, 122/76, 102, 20, 95 Ra
Gen: A&O x3. NAD
CV: HRR
Pulm: LS ctab
Abd: soft, TTP RUQ but improving
MSK: LLE: Dressing c/d/I. Firing ___, ___. SILT distally.
Foot WWP.
Pertinent Results:
___ 06:36AM BLOOD WBC-8.4 RBC-3.64* Hgb-9.9* Hct-31.0*
MCV-85 MCH-27.2 MCHC-31.9* RDW-13.2 RDWSD-40.9 Plt ___
___ 06:53AM BLOOD WBC-7.8 RBC-3.59* Hgb-9.7* Hct-30.6*
MCV-85 MCH-27.0 MCHC-31.7* RDW-13.2 RDWSD-41.2 Plt ___
___ 06:05AM BLOOD WBC-8.3 RBC-3.73* Hgb-10.2* Hct-32.1*
MCV-86 MCH-27.3 MCHC-31.8* RDW-13.2 RDWSD-41.5 Plt ___
___ 06:36AM BLOOD Glucose-83 UreaN-8 Creat-0.6 Na-138 K-4.0
Cl-100 HCO3-26 AnGap-12
___ 06:53AM BLOOD Glucose-78 UreaN-5* Creat-0.5 Na-140
K-3.9 Cl-105 HCO3-26 AnGap-9*
___ 06:05AM BLOOD Glucose-101* UreaN-4* Creat-0.6 Na-141
K-3.3* Cl-103 HCO3-28 AnGap-10
Radiology:
___ TIB/FIB (AP & LAT) RIGHT: No acute fracture or dislocation.
___ KNEE (AP, LAT & OBLIQUE) LEFT: Completed posteriorly
displaced left mid femoral diaphyseal fracture.
___ KNEE (2 VIEWS) RIGHT: No acute fracture or dislocation.
___ CT C-SPINE W/O CONTRAST: No acute fractures or traumatic
malalignment.
___ CT HEAD W/O CONTRAST: No acute intracranial process within
limitations of this noncontrast study. No evidence of acute
intracranial hemorrhage or acute fracture.
___ CT CHEST W/CONTRAST: 1. Medial liver laceration without
definite evidence of active extravasation or active bleeding.
Small perihepatic subcapsular hematoma.
2. Small right perinephric subcapsular hematoma.
3. Consecutive sixth through eighth lateral nondisplaced right
rib fractures.
4. Small volume hemoperitoneum.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezes
3. Enoxaparin Sodium 40 mg SC DAILY
4. Lidocaine 5% Patch 1 PTCH TD QAM R rib fx pain
5. Polyethylene Glycol 17 g PO DAILY
6. Ramelteon 8 mg PO QHS:PRN sleep
7. Tamsulosin 0.4 mg PO QHS
8. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
[] Left midshaft femur fracture
[] Medial liver laceration without evidence of active
extravasation
or active bleeding. Small perihepatic subcapsular hematoma.
[] Small right perinephric subcapsular hematoma.
[] Consecutive sixth through eighth lateral nondisplaced right
rib fractures.
[] Small volume hemoperitoneum.
Secondary diagnosis:
Urinary retention (resolved)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) RIGHT
INDICATION: History: ___ with trauma*** WARNING *** Multiple patients with
same last name!// ___ for traumatic injury ___ for traumatic
injury ___ for
traumatic injury
TECHNIQUE: Frontal, lateral, and cross-table view radiographs of right knee
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is seen. There are no significant
degenerative changes. There is no knee joint effusion. There is normal osseous
mineralization. No suspicious lytic or sclerotic lesions are identified.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with trauma*** WARNING *** Multiple patients with
same last name!// assess for traumatic injury
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 18.5 cm; CTDIvol = 43.5 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territorial infarction, intracranial
hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
No acute osseous abnormalities seen. The partially imaged paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The orbits demonstrate
no acute abnormalities.
IMPRESSION:
No acute intracranial process within limitations of this noncontrast study. No
evidence of acute intracranial hemorrhage or acute fracture.
Radiology Report
EXAMINATION: CT torso with contrast
INDICATION: History: ___ with trauma*** WARNING *** Multiple patients with
same last name!// assess for traumatic injury
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE:
Total DLP (Body) = 1,504 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. 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 or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are hypoinflated but clear without masses or areas of
parenchymal opacification. The airways are patent to the level of the
segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
BONES AND SOFT TISSUES: There are consecutive nondisplaced rib fractures of
the right lateral sixth, seventh and eighth ribs. No additional thoracic
osseous fractures are identified.
ABDOMEN:
HEPATOBILIARY: There is a laceration of the liver along its medial aspects
with extension into the caudate lobe (3:71, 76). No definite evidence of
active extravasation or bleeding. The liver demonstrates homogenous
attenuation throughout. There is no evidence of focal lesion or laceration.
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 lesion or laceration.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is a
small right subcapsular perinephric hematoma. No definite evidence of kidney
laceration or fracture.
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 no
evidence of mesenteric injury.
There is no free air in the abdomen.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is small
volume pelvic hemoperitoneum.
REPRODUCTIVE ORGANS: There is an bilateral adnexa 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 or retroperitoneal hematoma.
Mild atherosclerotic disease is noted.
BONES: There is L5 spondylolysis without significant spondylolisthesis. There
is no acute fracture. No focal suspicious osseous abnormality.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Medial liver laceration without definite evidence of active extravasation
or active bleeding. Small perihepatic subcapsular hematoma.
2. Small right perinephric subcapsular hematoma.
3. Consecutive sixth through eighth lateral nondisplaced right rib fractures.
4. Small volume hemoperitoneum.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with trauma*** WARNING *** Multiple patients with
same last name!// assess for traumatic injury assess for traumatic
injury
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 19.0 cm; CTDIvol = 22.5 mGy (Body) DLP = 428.0
mGy-cm.
Total DLP (Body) = 428 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No acute fractures are identified. There is no evidence
of severe spinal canal or neural foraminal stenosis. There is no prevertebral
soft tissue swelling. There is no evidence of infection or neoplasm.
IMPRESSION:
No acute fractures or traumatic malalignment.
Radiology Report
EXAMINATION: DX FEMUR AND KNEE
INDICATION: History: ___ with trauma*** WARNING *** Multiple patients with
same last name!// assess for traumatic injury
TECHNIQUE: Frontal, lateral, and prostate view radiographs of left knee and
femur.
COMPARISON: None
FINDINGS:
There is a completely posteriorly displaced fracture of the left mid femoral
diaphysis. There are no significant degenerative changes. There is no knee
joint effusion. There is normal osseous mineralization. No suspicious lytic
or sclerotic lesions are identified.
IMPRESSION:
Completed posteriorly displaced left mid femoral diaphyseal fracture.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT
INDICATION: History: ___ with trauma*** WARNING *** Multiple patients with
same last name!// trauma
TECHNIQUE: Frontal and lateral view radiographs of the right tibia and
fibula.
COMPARISON: None
FINDINGS:
No acute fracture is detected in the tibia or fibula. No suspicious lytic
lesion, sclerotic lesion, or periosteal new bone formation is detected. No
soft tissue calcification or radio-opaque foreign bodies are detected. Limited
assessment of the knee and ankle joint is unremarkable.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) LEFT
INDICATION: History: ___ with trauma*** WARNING *** Multiple patients with
same last name!// trauma trauma
TECHNIQUE: AP, lateral and oblique views of the left elbow.
AP and lateral views of the left forearm.
COMPARISON: None
FINDINGS:
No acute fractures or dislocations are seen. Joint spaces are preserved
without significant degenerative changes. No joint effusion is seen. No soft
tissue calcifications or radiopaque foreign bodies are detected.
IMPRESSION:
No acute fracture or dislocation of the left elbow or forearm.
Radiology Report
EXAMINATION: HAND (PA,LAT AND OBLIQUE) BILATERAL
INDICATION: History: ___ with trauma*** WARNING *** Multiple patients with
same last name!// trauma
TECHNIQUE: Frontal, oblique, and lateral view radiographs of bilateral hands.
COMPARISON: None
FINDINGS:
No acute fracture or dislocation is seen. There are no significant
degenerative changes. Scattered cyst-like lucencies are seen in the carpal
bones bilaterally. No bone erosion or periostitis is identified. No
suspicious lytic or sclerotic lesion is identified. No soft tissue
calcification or radio-opaque foreign bodies are detected.
IMPRESSION:
No acute fracture or dislocation of the bilateral hands.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) LEFT
IMPRESSION:
Images from the operating suite show placement of a intramedullary rod across
a fracture of the mid femur. Further information can be gathered from the
operative report.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS
INDICATION: ___ y/o unrestrained MVC with extreme facial pain on palp,
bruising, swelling// eval for any facial fx's, pls include orbits
TECHNIQUE: Helically-acquired multidetector CT axial images were obtained
through the maxillofacial bones and mandible. Intravenous contrast was not
administered. Axial images reconstructed with soft tissue and bone algorithm
to display images with 1.25 mm slice. Coronal and sagittal reformations were
also constructed. All produced images were evaluated in production of this
report.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.2 s, 55.7 cm; CTDIvol = 24.5 mGy (Body) DLP =
1,362.1 mGy-cm.
2) Spiral Acquisition 2.4 s, 19.1 cm; CTDIvol = 23.0 mGy (Head) DLP = 438.8
mGy-cm.
Total DLP (Body) = 1,362 mGy-cm.
Total DLP (Head) = 439 mGy-cm.
COMPARISON: CT head dated ___.
FINDINGS:
No fractures are identified.
There is no evidence of facial swelling.
Minimal aerosolized secretions within the left sphenoid sinus. Otherwise, the
visualized paranasal sinuses are well aerated.
There is no evidence of abnormal fluid collections.
Bilateral mastoids appear normal.
The globes, extraocular muscles, optic nerves, and retrobulbar fat appear
normal.
The visualized upper aerodigestive tract appears normal.
The mandible and temporomandibular joints appear normal.
Multiple small submandibular lymph nodes, nonspecific.
IMPRESSION:
No evidence of fracture.
Radiology Report
EXAMINATION: assess for traumatic injury
INDICATION: History: ___ with trauma*** WARNING *** Multiple patients with
same last name!// assess for traumatic injury
TECHNIQUE: Single AP view of the chest.
COMPARISON: None
FINDINGS:
Lung volumes are well expanded. The lungs are clear. The cardiomediastinal
silhouette and hilar silhouette are normal. Pleural surfaces are normal.
IMPRESSION:
No acute cardiopulmonary process. No evidence of displaced rib fractures
within limitations of this radiograph.
Although no acute or other chest wall lesion is seen, conventional chest
radiographs are not sufficient for detection or characterization of most such
abnormalities. If the demonstration of trauma or other soft tissue abnormality
involving the chest wall is clinically warranted, the location of any
referable focal findings should be described in the imaging request, clearly
marked and imaged with either bone detail radiographs or Chest CT scanning.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: MVC
Diagnosed with Displaced transverse fracture of shaft of left femur, init, Multiple fractures of ribs, right side, init for clos fx, Laceration of liver, unspecified degree, initial encounter, Minor contusion of right kidney, initial encounter, Car driver injured in collision w car in traf, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: UTA
level of acuity: 1.0 | ___ presented to the ED with left leg pain s/p MVC. A trauma
stat was activated. Primary survey was notable for a GCS 14 for
confusion. Secondary survey was notable for tenderness with
palpation to bilateral hips, significant left hip tenderness
with swelling over the left thigh, and right thigh tenderness to
palpation. EFAST negative. The patient had a XR of the chest,
hands, bilateral hips, left elbow and
forearm, the left femur. The patient had a CT of the C-spine,
head, chest, and abdomen. XR of the left femur was notable for a
displaced left mid femoral diaphyseal
fracture. CT of the chest and abdomen showed a liver laceration
without extravasation and sixth through eighth lateral
nondisplaced right rib fractures. Orthopedic Surgery was
consulted and recommended surgical repair of the femur fracture.
The patient was taken to the OR and underwent IM nailing of left
femur which went well. After a brief, uneventful stay in the
PACU, the patient arrived on the floor still on bowel rest, on
IV fluids, and IV dilaudid for pain control. The patient was
hemodynamically stable. Blood counts remained stable and there
was no sign of bleeding from liver laceration.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient initially had urinary retention and was started on
Flomax after failing a voiding trial. 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 lovenox per Ortho recommendations, and venodyne
boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assist, voiding without assistance, and
pain was well controlled. The patient was discharged to rehab.
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:
morphine
Attending: ___.
Chief Complaint:
Draining of odorous fluid from prior abdominal port site.
Major Surgical or Invasive Procedure:
___
1) Closure of 10x15 cm full-thickness abdominal wall defect with
bilateral fasciocutaneous advancement flaps.
2) Flexible Bronchoscopy, cleansing and aspiration of right
lower
lobe.
History of Present Illness:
Mrs. ___ is a ___ year old female status post robotic TAH for
endometrial carcinoma approximately 1 mo ago w/ peritoneal
metastasis c/b enterocutaneous fistula s/p ex lap/SBR. On day of
admission, she presented with drainage from one port site. The
patient states that she has been feeling well, no
nausea/vomiting, no fevers or chills. She has been breathing
w/o discomfort. She noticed purulent material draining from her
LUQ port site starting this am during her wound vac change, w/
feculent smell. The drainage hascontinued until her presentation
at the ED today.
Past Medical History:
Past Medical History:
Endometrial CA s/p hysterectomy, EC Fistula s/p SBR, HL, Asthma,
GERD.
Past Surgical History:
Robotic TAH, Ex Lap SB___ in ___.
Social History:
___
Family History:
Father had bladder cancer and passed away at ___ yo. Mother had
DM2 and colon cancer and passed away at ___ yo. 2 siblings,
sister
aged ___ and brother aged ___, healthy to patient's knowledge.
Physical Exam:
On admission:
Physical Exam:
Vitals: 98.2 103 122/58 16 98RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
On discharge:
VS 98.4, 92, 140/70, 14, 95% on room air.
Pertinent Results:
___ 06:01AM BLOOD WBC-9.6 RBC-3.05* Hgb-7.8* Hct-24.8*
MCV-81* MCH-25.7* MCHC-31.6 RDW-18.8* Plt ___
___ 06:10AM BLOOD WBC-8.7 RBC-3.02* Hgb-7.6* Hct-24.1*
MCV-80* MCH-25.3* MCHC-31.6 RDW-19.2* Plt ___
___ 02:00PM BLOOD WBC-9.9 RBC-3.55*# Hgb-8.9*# Hct-28.2*#
MCV-80*# MCH-25.1*# MCHC-31.5 RDW-18.8* Plt ___
___ 02:00PM BLOOD Neuts-81.9* Lymphs-11.1* Monos-5.0
Eos-1.2 Baso-0.7
___ 10:28AM BLOOD Glucose-106* UreaN-5* Creat-0.3* Na-136
K-3.8 Cl-103 HCO3-26 AnGap-11
___ 06:01AM BLOOD Glucose-85 UreaN-5* Creat-0.3* Na-135
K-4.0 Cl-103 HCO3-27 AnGap-9
___ 04:08PM BLOOD Glucose-84 UreaN-5* Creat-0.3* Na-136
K-3.5 Cl-102 HCO3-26 AnGap-12
___ 06:10AM BLOOD Glucose-74 UreaN-6 Creat-0.4 Na-138
K-3.0* Cl-102 HCO3-26 AnGap-13
___ 12:15AM BLOOD Glucose-81 UreaN-7 Creat-0.3* Na-136
K-3.0* Cl-100 HCO3-25 AnGap-14
___ 02:00PM BLOOD Glucose-104* UreaN-6 Creat-0.3* Na-137
K-2.8* Cl-99 HCO3-24 AnGap-17
___ 10:28AM BLOOD Calcium-7.4* Phos-2.4* Mg-1.6
___ 06:01AM BLOOD Calcium-7.3* Phos-2.3* Mg-2.1
___ 04:08PM BLOOD Calcium-7.4* Phos-3.0 Mg-1.3*
___ 06:10AM BLOOD Calcium-7.3* Phos-3.1 Mg-1.4*
___ 05:59PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:59PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-6.0 Leuks-LG
___ 05:59PM URINE RBC-0 WBC-57* Bacteri-FEW Yeast-NONE
Epi-1 TransE-1
IMAGING:
___ CT abdomen and pelvis with contrast
1. Acute partial small bowel obstruction with enteric contrast
passing to
colon and no definite transition point.
2. Complex 4.7 x 3.3 cm collection in the left hemipelvis which
may or may not have a connection to large bowel. 1.7 cm
rim-enhancing collection in pelvis may represent small abscess,
which is too small to drain.
3. Stranding and fluid around gallbladder fundus extending into
right
paracolic gutter without rim-enhancement. Correlate with
bilirubin levels.
4. Mildly rim-enhancing subcutaneous fluid collection in the
left anterior abdominal wall with sinus tract extending to the
midline skin surface.
5. Right lower abdominal wall sinus tract extending into
subcutaneous tissues without definite track to skin surface.
6. Large right Bochdalek hernia.
7. Defect in anterior abdominal wall. Scar tissue or fluid in
anterior
abdominal midline near small bowel.
Medications on Admission:
Statin (discontinued)
Provera (from OSH note ___, 10 mg)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*10 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Miconazole 2% Cream 1 Appl TP BID Duration: 5 Days *AST
Approval Required*
RX *miconazole nitrate [Antifungal Cream] 2 % Apply to affected
area twice a day Disp #*15 Gram Refills:*1
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Full thickness abdominal wall defect subsequent to above with
intra-abdominal abscess, abdominal wall abscess and extensive
exposure of unprotected bowel.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Uterine cancer status post hysterectomy with decreased
breath sounds at the right base, assess for right lung base abnormality.
FINDINGS: PA and lateral views of the chest were provided. There is
consolidation with air bronchograms in the right lower lobe compatible with
pneumonia. A small right pleural effusion is also noted. The left lung is
clear. The heart size appears normal. Mediastinal contours are unremarkable.
Bony structures are intact.
IMPRESSION: Right lower lobe pneumonia. Small right pleural effusion.
Radiology Report
INDICATION: History of uterine cancer and peritoneal carcinomatosis, status
post total abdominal hysterectomy, complicated by right lower quadrant
enterocutaneous fistula, now with a second left upper quadrant fistula, here
to evaluate for presence of enterocutaneous fistulas.
COMPARISON: No prior studies available.
TECHNIQUE: MDCT-acquired axial images were obtained from the lung bases to
the pubic symphysis following the uneventful administration of 130 cc
Omnipaque intravenous contrast and oral contrast. Coronally and sagittally
reformatted images were generated and reviewed.
FINDINGS: The visualized lung bases are clear with mild bibasilar atelectasis
on the right greater than the left. There is a large right-sided Bochdalek
hernia containing the proximal stomach. Limited imaging of the heart shows
normal size without pericardial effusion.
The liver enhances homogeneously without perfusion defects or focal liver
lesions. No intrahepatic or extrahepatic biliary ductal dilation is seen.
The gallbladder is collapsed with pericholecystic fluid and stranding
surrounding the gallbladder fundus, extending along the right paracolic gutter
lateral to the right colon. This fluid collection is not rim-enhancing to
suggest abscess. The pancreas is atrophic and fatty replaced, but otherwise
unremarkable. The spleen is not enlarged. The bilateral adrenal glands are
unremarkable. Both kidneys enhance symmetrically and excrete contrast
normally without evidence of hydronephrosis.
The duodenum and proximal jejunum are unremarkable. There are multiple
dilated contrast-filled loops of small bowel in the left upper quadrant of the
abdomen extending into the left lower quadrant with no definite transition
point. Enteric contrast makes its way past the entero-enteric anastamosis
into the distal ileum, which is normal in caliber, although there are several
abnormal angulations of the distal ileum (for example, 2:41). Enteric
contrast passes into the colon.
A small rim-enhancing fluid collection is seen superior to the bladder
measuring 1.7 x 1.5 cm (2:76, 601b:37). There is a larger, slightly more
complex collection in the left hemipelvis measuring 4.7 x 3.3 cm (2:72) with
fluid tracking superiorly into the left paracolic gutter to the descending
colon.
There is a blind-ending sinus tract in the subcutaneous right lower anterior
abdominal wall (2:49), which does not reach the skin surface. There is a 6.4
x 3.4 cm subcutaneous fluid collection in the anterior left abdominal wall,
tracking to the skin, compatible with an enterocutaneous fistula. A second
4.9 x 1.3 cm subcutaneous fluid collection lower in the left mid abdomen is
associated with a midline cutaneous defect or wound and indistinguishable from
the bowel (2:58), but with no definite tract to the skin surface.
The urinary bladder, rectum and sigmoid colon are unremarkable. There is no
free pelvic fluid. The patient is status post total abdominal hysterectomy
and bilateral salping-oopherectomy.
OSSEOUS STRUCTURES: No osseous destructive lesions concerning for malignancy
are detected.
IMPRESSION:
1. Acute partial small bowel obstruction with enteric contrast passing to
colon and no definite transition point.
2. Complex 4.7 x 3.3 cm collection in the left hemipelvis which may or may not
have a connection to large bowel. 1.7 cm rim-enhancing collection in pelvis
may represent small abscess, which is too small to drain.
3. Stranding and fluid around gallbladder fundus extending into right
paracolic gutter without rim-enhancement. Correlate with bilirubin levels.
4. Mildly rim-enhancing subcutaneous fluid collection in the left anterior
abdominal wall with sinus tract extending to the midline skin surface.
5. Right lower abdominal wall sinus tract extending into subcutaneous tissues
without definite track to skin surface.
6. Large right Bochdalek hernia.
7. Defect in anterior abdominal wall. Scar tissue or fluid in anterior
abdominal midline near small bowel.
Recommend comparison with prior studies to determine the acuity or stability
of these findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: EVAL OF SURGICAL SITE
Diagnosed with INTESTINAL FISTULA, PNEUMONIA,ORGANISM UNSPECIFIED, HYPOKALEMIA, MALIG NEO CORPUS UTERI, HYPERCHOLESTEROLEMIA
temperature: 98.2
heartrate: 103.0
resprate: 16.0
o2sat: 98.0
sbp: 122.0
dbp: 58.0
level of pain: 3
level of acuity: 3.0 | Mrs. ___ was admitted to ___ under the Acute Care Surgery
service. In brief, she presented with feculent discharge coming
from one of her prior port sites (s/p small bowel resection).
On CT imaging, she was found to have a 4.7 x 3.3 cm collection
in the left hemipelvis as well as a 1.7 cm rim-enhancing
collection in the pelvis. There was also a soft tissue defect
in the patient's anterior abdominal wall. The patient was
started on vancomycin and cefepime for empiric antibiotic
coverage. A pre-operative chest x-ray showed concerns for RLL
pneumonia and Mrs. ___ was also started on azithromycin
empirically for pneumonia. She was kept NPO in preparation for
an operative procedure.
On HD 2, Mrs. ___ was taken to the operating room where she
underwent closure of a 10cm by 15cm full-thickness abdominal
wall defect with bilateral fasciocutaneous advancement flaps.
Abdominal fluid was sent for culture and sensitivities. Please
see the operative report for further details. During the
procedure, a bronchoscopy was also conducted due to concerns of
right lower lobe pneumonia. The bronchoscopy was negative for
any acute process. Prior chest x-ray images noting a RLL
infiltrate was likely lobar atelectasis instead. Mrs. ___
was recovered in PACU and transferred to the inpatient ward for
further management and observation.
Post-operatively, Mrs. ___ antibiotics were changed to
ciprofloxacin and metronidazole. She was kept NPO and given
maintenance IV fluids until her bowel function returned. Once
she began to pass flatus and bowel movements, the patient's diet
as advanced from clears to regular, which she tolerated well.
At that time, she was transitioned to oral medications. Her
abdominal fluid sensitivities showed sparse growth of
Enterobacter cloacae which was pan-sensitive to ciprofloxacin;
therefore her metronidazole and azithromycin was discontinued.
Lastly, the patient had no issues voiding and was ambulating
independently.
As previously mentioned, Mrs. ___ was recently diagnosed with
endometrial adenocarcinoma and was being followed by physicians
in ___. Based on this new diagnosis and most recent
surgery, the ___ Oncology service was asked to see this
patient. It was their recommendation that the patient be
treated with chemotherapy (carboplatin plus paclitaxel) once she
recovers from her most recent surgery. It was communicated to
the Oncology team that she should be fine to receive
chemotherapy in approximately 4 weeks.
At the time of discharge, Mrs. ___ was afebrile,
hemodynamically stable and in no acute distress. She was given
follow-up appointments for both the ___ clinic as well as
Oncology. From a surgical perspective, the patient was informed
that she may begin chemotherapy in approximately four weeks from
the time of surgery. The patient was discharged home in the
care of her sister and was given prescriptions for pain
medications as well as antibiotics. Mrs. ___ had an
incidental, bilateral fungal groin infection which was treated
with miconazole cream. She was instructed to continue this
treatment for 5 days or when the infection resolves. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
aneurysm of right upper arm arteriovenous fistula
Major Surgical or Invasive Procedure:
___ Revision of right upper extremity arteriovenous fistula
with thrombectomy.
History of Present Illness:
___ is a ___ w/ past medical history of CAD, cardiac
arrest ___ s/p ICD placement, DM, ESRD on HD on ___, s/p
R brachiocephalic AVF, which was placed ___ years ago, s/p R AV
fistula revision and thrombectomy ___. The upper portion of
the fistula had aneurism degeration with erosion of the
overlying
skin. Mr. ___ was scheduled for AVF revision and aneurism
repair on ___. Patient has been getting HD for this portion
of the fistula, he was sent to the ED from HD because of
bleeding, unable to complete dialysis.
ROS: patient denies headache, blurry vision, shortness of
breath,
chest pain, extremity weakness or paresthesia, abdominal pain,
nausea, vomiting, diarrhea, fever or any other symptoms.
Past Medical History:
- Hospitalization for Vtach/arrest in ___
- ESRD on HD
- CHF w/ EF 30%
- ___ Bi-V ICD
- HTN
- Hyperlipidemia
- IDDM
- CAD
- Gout
- Parkinsons disease
- Revision of right upper extremity arteriovenous fistula with
thrombectomy ___.
Social History:
___
Family History:
Non-contributory
Physical Exam:
Temp: 97.7 HR: 82 BP: 98/60 Resp: 18 O(2)Sat: 94 2L NC
Patient seems comfortable in bed, alert and oriented x 3
Hydrated, no respiratory distress
Lungs: CTA bilateral
Heart: RRR"s
Abdomen: Soft, NT, BD
Right arm: no edema, no erythema, motor ___, sensation intact
Brachiocephalic AVF, upper portion with aneurism degeneration,
erosion of overlying skin. 2 points of access are covered with
compressive dressing, minimal oozing. Radial pulse palpable.
144 91 29
--------------<155 AGap=19
3.9 38 3.7
estGFR: ___ (click for details)
9.4 >11.5< 182
37.7
N:73.3 L:12.0 M:10.2 E:3.9 Bas:0.6
___: 12.9 PTT: 37.6 INR: 1.2
Pertinent Results:
___ 01:45PM BLOOD WBC-9.4 RBC-3.53* Hgb-11.5* Hct-37.7*
MCV-107* MCH-32.7* MCHC-30.7* RDW-15.5 Plt ___
___ 06:18AM BLOOD WBC-9.1 RBC-3.26* Hgb-10.8* Hct-34.8*
MCV-107* MCH-33.0* MCHC-30.9* RDW-15.5 Plt ___
___ 06:20AM BLOOD ___ PTT-39.7* ___
___ 06:18AM BLOOD Glucose-121* UreaN-27* Creat-4.1* Na-139
K-3.7 Cl-95* HCO3-34* AnGap-14
___ 06:18AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.2
___ CXR: Mild pulmonary vascular congestion. Streaky focal
opacities
projecting over the right mid lung, although suspected to
represent
atelectasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Aspirin 81 mg PO DAILY
3. Calcium Acetate 667 mg PO TID W/MEALS
4. carbidopa-levodopa-entacapone *NF* ___ mg Oral Daily
5. Clopidogrel 75 mg PO DAILY
6. Fluoxetine 10 mg PO DAILY
7. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB/Wheeze
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Rosuvastatin Calcium 20 mg PO DAILY
12. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Discharge Medications:
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Aspirin 81 mg PO DAILY
3. Calcium Acetate 667 mg PO TID W/MEALS
4. Clopidogrel 75 mg PO DAILY
5. Fluoxetine 10 mg PO DAILY
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB/Wheeze
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Nephrocaps 1 CAP PO DAILY
9. Rosuvastatin Calcium 20 mg PO DAILY
10. Acetaminophen 650 mg PO Q8H:PRN pain
11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
12. Docusate Sodium 100 mg PO BID
13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
14. Glucose Gel 15 g PO PRN hypoglycemia protocol
15. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*10 Tablet Refills:*0
16. Senna 2 TAB PO HS
17. carbidopa-levodopa-entacapone *NF* ___ mg Oral Daily
18. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
19. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ESRD
AVF bleeding/erosion
___
DM
h/o CAD/CHF/Bi-V ICD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Shortness of breath. History of congestive heart failure.
COMPARISONS: ___.
TECHNIQUE: Chest, AP and lateral.
FINDINGS: A three-lead pacemaker/ICD device with leads terminating in the
right atrium, right ventricle, and coronary sinus, respectively, appears
unchanged. The heart is moderately enlarged. The cardiac, mediastinal and
hilar contours appear stable. There is no pleural effusion or pneumothorax.
Upper zone re-distribution of pulmonary vascularity and indistinct pulmonary
vessels, as well as a mild interstitial process, suggest mild vascular
congestion, similar to mildly increased. Streaky superimposed right mid lung
opacities are suggestive of atelectasis.
IMPRESSION: Mild pulmonary vascular congestion. Streaky focal opacities
projecting over the right mid lung, although suspected to represent
atelectasis. If clinical findings are suggestive of infection in addition to
congestive heart failure, then short-term radiographs may be helpful to
re-assess.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FISTULA EVAL
Diagnosed with DUE TO RENAL DIALYSIS DEVICE,IMPLANT,GRAFT, ABN REACT-PROCEDURE NOS, END STAGE RENAL DISEASE
temperature: 97.7
heartrate: 82.0
resprate: 18.0
o2sat: 94.0
sbp: 98.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | ___ yo M w/ aneurismal degeneration of R brachiocephalic AVF,
sent from HD to ED for bleeding. Patient was seen in ED.
Bleeding had stopped. He was admitted for observation over night
as he continued on ASA/Plavix, and previously scheduled OR AVF
revision for the next day was in place. He was stable over night
and had HD the next morning with 3 liters removed. Vitals signs
were notable for SBP that decreased to the ___ during HD. He was
then take to the OR by Dr. ___ who performed a revision
of right upper extremity arteriovenous fistula with thrombectomy
(___). Please refer to operative note for details.
Postop, he continued to have SBPs in the ___. The AVF had a
bruit/thrill and dopplerable right radial pulse. RUE dressing
has a small serosanguinous stain. He received Oxycodone postop
with a breakthru IV dilaudid dose for RUE incision pain. He also
c/o pain in left arm at the peripheral iv site. This iv was
removed with relief of pain.
The next day (postop day 1), he was dialysed via the RUE AVF
with cannulation between the incisions and the are above the
incision closest to his shoulder. Flows were fine. No fluid was
removed. SBP ran in the ___ with HR in ___. RUE AVF had a strong
bruit and thrill with a faint palpable radial pulse
(dopplerable). Hand was cool with intact range of motion. He
returned to the Med-Surg unit in stable condition and felt well
enough to be discharged to rehab. His wife was driving him back
to rehab. He was given Oxycodone 2.5mg for c/o pain at right arm
incision sites.
Dispo:
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
gabapentin
Attending: ___
Chief Complaint:
RLE pain
Major Surgical or Invasive Procedure:
ORIF R periprosthetic femur fracture
History of Present Illness:
Mr. ___ is an ___ year old male with multiple medical
comorbidities who presents to ___ ED as a OSH transfer with a
right periprosthestic femur fracture. The patient and his wife
state he was pulling his pants up and fell backwards landing on
his right hip with immediate pain, and inability to ambulate.
The
patient denies head strike, LOC, other injuries. He denies any
numbness or tingling distally.
At time of examination, he denies CP/SOB/F/C/N/V/diarrhea
Past Medical History:
CAD w/hx of MI s/p stent several years ago (still on Plavix)
Moderate AS (per note in ___
? PACEMAKER (not seen on CXR)
HLD
HTN
OTHER PAST MEDICAL HISTORY:
Diabetes Type 2
Hx PsychConditions: DEPRESSION, ANXIETY
GOUT
CHRONIC BACK ISSUES
VERTIGO
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
Gen: ill appearing. in no distress Alert and oriented x 3
CV: RRR
Lungs: breathing room air comfortably.
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, swelling about thigh
- Full, painless AROM/PROM of 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: 98.3 152/68 64 16 94RA
GENERAL: Alert, oriented x2, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
RESP: Basilar crackles bilaterally, no wheezes
CV: RRR, faint systolic murmur.
ABD: +BS, soft, nondistended, nontender to palpation. No
hepatomegaly.
GU: no foley
EXT: Swollen and ecchymotic proximal thigh and abdomen, improved
from prior. Significant RLE edema
SKIN: No rashes/lesions.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:02PM BLOOD WBC-11.0* RBC-3.22* Hgb-8.5* Hct-28.3*
MCV-88 MCH-26.4 MCHC-30.0* RDW-13.2 RDWSD-42.6 Plt ___
___ 09:02PM BLOOD Neuts-85.8* Lymphs-6.2* Monos-7.2
Eos-0.1* Baso-0.1 Im ___ AbsNeut-9.45* AbsLymp-0.68*
AbsMono-0.79 AbsEos-0.01* AbsBaso-0.01
___ 09:02PM BLOOD ___ PTT-28.0 ___
___ 09:02PM BLOOD Glucose-148* UreaN-27* Creat-1.2 Na-138
K-3.8 Cl-100 HCO3-25 AnGap-17
PERTINENT LABS
==============
___ 12:17AM BLOOD cTropnT-0.09*
___ 06:08AM BLOOD cTropnT-0.11*
___ 09:23AM BLOOD CK-MB-6 proBNP-5407*
___ 01:13PM BLOOD cTropnT-0.13*
___ 05:45PM BLOOD CK-MB-4
___ 05:45AM BLOOD CK-MB-6 cTropnT-0.12*
___ 04:20AM BLOOD Calcium-8.9 Phos-1.8* Mg-2.1
___ 05:45AM BLOOD Hapto-195
DISCHARGE LABS:
===============
___ 04:20AM BLOOD WBC-8.6 RBC-2.66* Hgb-7.7* Hct-24.4*
MCV-92 MCH-28.9 MCHC-31.6* RDW-14.6 RDWSD-49.1* Plt ___
___ 04:20AM BLOOD Glucose-105* UreaN-29* Creat-1.1 Na-141
K-3.9 Cl-107 HCO3-24 AnGap-14
MICROBIOLOGY:
=============
___ 6:19 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. 10,000-100,000 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-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
REPORTS:
========
___ Hip XRay
IMPRESSION:
Status post right total hip arthroplasty with periprosthetic
fracture
involving the femoral stem. No additional fractures identified.
___ Femur XRay
IMPRESSION:
Status post right total hip arthroplasty with periprosthetic
fracture
involving the femoral stem. No additional fractures identified.
___
IMPRESSION:
No acute cardiopulmonary abnormality. Moderate cardiomegaly.
___ Echo
Conclusions
The left atrium is elongated. No atrial septal defect is seen
by 2D or color Doppler. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Doppler parameters
are most consistent with Grade II (moderate) left ventricular
diastolic dysfunction. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
regional/global systolic function. Mild aortic stenosis. Mild
aortic regurgitation. Elevated PCWP.
___ Fluoro
IMPRESSION:
Several fluoroscopic images of the right femur from the
operating room
demonstrate placement of a lateral fracture plate and screws
fixating a
periprosthetic fracture round the right total hip arthroplasty.
Total
intraservice fluoroscopic time was 30.1 seconds. Please refer
to the
operative note for additional details.
___ Femur Xray
IMPRESSION:
Several fluoroscopic images of the right femur from the
operating room
demonstrate placement of a lateral fracture plate and screws
fixating a
periprosthetic fracture round the right total hip arthroplasty.
Total
intraservice fluoroscopic time was 30.1 seconds. Please refer
to the
operative note for additional details.
___ CXR
IMPRESSION:
Decreased pulmonary vascularity.
No pulmonary edema.
___ CT A/P
IMPRESSION:
1. No evidence for retroperitoneal hematoma. Subcutaneous
stranding along the right flank, posttraumatic. No organized
hematoma.
2. Mild circumferential bladder thickening, may be reactive or
inflammatory.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pramipexole 0.25 mg PO TID
2. Simvastatin 40 mg PO QPM
3. Ezetimibe 10 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. HydrALAZINE 25 mg PO BID
8. Lisinopril 40 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Meclizine 25 mg PO BID
11. NIFEdipine CR 30 mg PO DAILY
12. Sertraline 100 mg PO DAILY
13. Tamsulosin 0.4 mg PO QHS
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
15. Fentanyl Patch 100 mcg/h TD Q48H
16. Aspirin 81 mg PO DAILY
17. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
18. Oxybutynin 10 mg PO QHS
19. Fluticasone Propionate NASAL 1 SPRY NU DAILY
20. Nitromist (nitroglycerin) 400 mcg/spray translingual q5min
prn chest pain
21. Nystatin-Triamcinolone Cream 1 Appl TP BID:PRN rash
22. TraMADol 50 mg PO TID:PRN Pain - Moderate
23. Indomethacin 25 mg PO TID:PRN gout
24. Clobetasol Propionate 0.05% Gel 1 Appl TP PRN psoriasis
25. Senna 8.6 mg PO BID constipation
26. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO Q6H:PRN
Dyspepsia
3. Ciprofloxacin HCl 250 mg PO Q12H Duration: 5 Days
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 30 mg SC Q12H
6. Milk of Magnesia 30 ml PO BID:PRN Constipation
7. Senna 8.6 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Carvedilol 12.5 mg PO BID
10. Clobetasol Propionate 0.05% Gel 1 Appl TP PRN psoriasis
11. Ezetimibe 10 mg PO DAILY
12. Fentanyl Patch 100 mcg/h TD Q48H
RX *fentanyl 100 mcg/hour Remove old patch and apply new patch
to skin Every 48 hrs Disp #*5 Patch Refills:*0
13. Finasteride 5 mg PO DAILY
14. Fluticasone Propionate NASAL 1 SPRY NU DAILY
15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
16. Furosemide 20 mg PO DAILY
17. HydrALAZINE 25 mg PO BID
18. Indomethacin 25 mg PO TID:PRN gout
19. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
20. Lisinopril 40 mg PO DAILY
21. Meclizine 25 mg PO BID
22. NIFEdipine CR 30 mg PO DAILY
23. Nitromist (nitroglycerin) 400 mcg/spray translingual q5min
prn chest pain
24. Nystatin-Triamcinolone Cream 1 Appl TP BID:PRN rash
25. Oxybutynin 10 mg PO QHS
26. Pramipexole 0.25 mg PO TID
27. Sertraline 100 mg PO DAILY
28. Simvastatin 40 mg PO QPM
29. Tamsulosin 0.4 mg PO QHS
30. TraMADol 50 mg PO TID:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R femur periprosthetic fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
INDICATION: Right femur fracture. ORIF.
COMPARISON: ___.
IMPRESSION:
Several fluoroscopic images of the right femur from the operating room
demonstrate placement of a lateral fracture plate and screws fixating a
periprosthetic fracture round the right total hip arthroplasty. Total
intraservice fluoroscopic time was 30.1 seconds. Please refer to the
operative note for additional details.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hypotension s/p surgery // ? fluid overload
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
Bilateral shoulder arthroplasties. Stable heart size. Tortuous thoracic
aorta. No pulmonary edema. Pulmonary vascularity has improved. Small focus
of calcification right chest, similar. No pneumothorax.
IMPRESSION:
Decreased pulmonary vascularity.
No pulmonary edema.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ year old man with flank ecchymosis // ? eval for RP bleed
given flank ecchymosis
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 13.6 s, 46.6 cm; CTDIvol = 17.8 mGy (Body) DLP =
803.6 mGy-cm.
Total DLP (Body) = 817 mGy-cm.
COMPARISON: None available
FINDINGS:
LOWER CHEST: Trace dependent atelectasis noted at the lung bases. Coronary
artery atherosclerotic calcifications noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. Suggestion of cholelithiasis, without gallbladder wall thickening
or fluid.
PANCREAS: Atrophic pancreas. .
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. 12 mm cyst noted in
the midpole of the right kidney. There is no hydronephrosis. Punctate
calcification in the lower pole of the left kidney may represent a small
nonobstructing stone. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. Appendix is not identified
PELVIS: Foley catheter in the bladder. Mild bladder wall thickening, may be
reactive or inflammatory, with minimal adjacent stranding. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate is not seen secondary to beam hardening artifact
from the patient's hip prostheses.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Right hip arthroplasty. Postoperative change left proximal femur
across intertrochanteric fracture. Degenerative change left hip. No
concerning osseous lesions. Bone graft donor site posterior left iliac bone.
Postoperative changes lumbar spine, advanced degenerative changes lumbar spine
most prominent at L1-L2 level. Implanted electronic device noted in the
subcutaneous tissues overlying the thoracic spine, with leads terminating in
the paraspinal musculature.
SOFT TISSUES: Extensive Subcutaneous stranding is seen along the right flank,
consistent with the given history of right flank ecchymoses. No organized
hematoma.
IMPRESSION:
1. No evidence for retroperitoneal hematoma. Subcutaneous stranding along the
right flank, posttraumatic. No organized hematoma.
2. Mild circumferential bladder thickening, may be reactive or inflammatory.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with Displaced subtrochanteric fracture of right femur, init, Fall on same level, unspecified, initial encounter, Periprosth fracture around internal prosth r hip jt, init
temperature: 97.7
heartrate: 86.0
resprate: 22.0
o2sat: 96.0
sbp: 168.0
dbp: 90.0
level of pain: 10
level of acuity: 3.0 | ___ w/pmh CAD, HTN, HLD presents to ___ ED as a OSH transfer
with a right periprosthestic femur fracture now s/p ___
transferred to medicine for management of hypotension, delirium
and CAD.
#Post-op delirium: Improved. Pt AOx2, conversant, somewhat
sluggish. Likely multifactorial including post-anesthesia
state, UTI, pain and narcotics. Approximately at baseline per
family on day of discharge. His pain was controlled with his
home fentanyl patch and tylenol and oxycodone PRN. His UTI was
treated as below.
#UTI: Foley catheter in place perioperatively. UA consistent
with infection and delirium thought to be partially driven by
infection. Started on ceftriaxone. Urine culture grew klebsiella
sensitive to cephalosporins and fluoroquinolones. He was
switched to ciprofloxacin at the time of discharge to complete a
7 day total course.
#NSTEMI/CAD: Has history of un-revascularized mild coronary
disease per his cardiologist's report from ___. Mild trop
elevations in setting of stress and anemia suggest type 2
(demand) ischemia rather than ACS. His home antihypertensives
were initially held for post-op hypertension, but gradually
resumed as his blood pressure normalized. Orthopedic surgery
cleared the patient to resume anti-platelet therapy on ___.
Per cardiology, his clopidogrel was stopped, given the increased
bleeding risk and long period of time since his last PCI. His
aspirin was continued. His home simvastatin was continued.
___: Likely pre-renal, improved with blood and crystalloid.
Lisinopril and Lasix were initially held, but resumed when
creatinine normalized.
#Anemia: Required transfusion for hyptension related to acute
blood loss anemia postoperatively. Slow decline thereafter was
thought to be dilutional with a small amount of ongoing surgical
blood loss.
Chronic Issues
#Chronic diastolic CHF: No evidence of decompensation at this
time. Comfortable on room air. Significant RLE pitting edema is
appropriate post-operatively per orthopedics. His home
furosemide was held initially for ___ and resumed when
creatinine normalized.
#Depression: continued home sertraline
#HTN: Initially held home meds as above, reintroduce as
tolerated. All appropriate to continue on discharge.
#BPH: continue home finasteride |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fever and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with EtOH cirrhosis and HTN presented to
___ with fever, weakness, ___ transferred to ___ for
treatment.
Patient was reportedly on the street today, was noted to have
to be lowered to the ground by bystanders for weakness. On
arrival by EMS patient was noted to be febrile to 104. Patient
notes weakness for a day or so, denies complete review of
systems otherwise. No N/V/D, no abdominal pain. UDS and serum
tox negative. ROS otherwise negative. Patient got 1g vancomycin,
2g ceftriaxone at ___ prior to transfer.
In the ED, initial vitals were: T98.5 HR72 BP153/71 RR18 O2Sat
99% RA.
Exam notable for no ascites, large spleen on bedside US and RLE
erythema.
Labs notable for WBC 2.7, Hgb 11.4, Plt 28, Tbili 7.2, Dbili
3.3, INR 2.5, ALT/AST ___. UA w/ moderate leuks, positive
nitrites, >1000 glucose. Lactate 2.2.
Imaging notable for negative NCHCT, normal CXR.
Hepatology was consulted and recommended: RUQUS w/ Doppler and
UA, lactulose and rifaximin. Recommended broad spectrum
antibiotics.
Patient was given Lactulose and Rifaximin.
Decision was made to admit for ongoing management of fever,
EtOH cirrhosis.
Vitals prior to transfer: HR73 BP129/75 RR30 O2Sat100% RA.
On the floor, the patient reports that he was feeling fine
prior to today. He then had rapid onset of weakness in his legs
and needed to be helped to the ground. He endorses dry cough x
couple of days. Otherwise denies fevers/chills, N/V/D/C,
dysuria. He endorses right shoulder pain. He says that his right
lower leg has looked as it does for "awhile now." He also
reports that he drinks 3 nips in 1 week and has never had
withdrawal admissions or intoxication admissions. Of note, per
Atrius records the patient has had ongoing alcohol abuse and
wife had tried to give the patient naltrexone earlier this
summer. Unclear whether patient is telling an accurate history.
Past Medical History:
EtOH cirrhosis w/o any recent EGD or ___ screening
HTN
s/p appendectomy
Alcohol abuse
Pancytopenia: leukopenia and thrombocytopenia since ___ of
unclear etiology
Social History:
___
Family History:
FAMILY HISTORY: Father with EtOH cirrhosis/NAFLD, Mom diagnosed
with colon cancer at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 101.0 147/82 76 20 97% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
heard best at RUSB, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, mildly distended, bowel sounds
present, no organomegaly, no rebound or guarding. Minimal
asterixis.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, 1+ edema b/l to mid calf.
RLE w/ purpura extending to mid-calf, non-tender, warm to touch.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred. Minimal asterixis.
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 98.8 125 / 73 62 20 99 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
heard best at RUSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, mildly distended, bowel sounds
present, no organomegaly, no rebound or guarding.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, 1+ edema b/l to mid calf.
RLE w/ purpura extending to mid-calf, non-tender, warm to touch.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred. No asterixis.
Pertinent Results:
ADMISSION LABS
==============
___ 04:58AM BLOOD WBC-1.4* RBC-2.73* Hgb-9.5* Hct-27.6*
MCV-101* MCH-34.8* MCHC-34.4 RDW-15.0 RDWSD-55.0* Plt Ct-22*
___ 04:58AM BLOOD ___ 04:58AM BLOOD ___ PTT-34.5 ___
___ 04:58AM BLOOD Glucose-161* UreaN-13 Creat-0.7 Na-139
K-3.6 Cl-107 HCO3-20* AnGap-16
___ 04:58AM BLOOD ALT-22 AST-36 LD(LDH)-194 AlkPhos-62
TotBili-5.6*
___ 04:58AM BLOOD Albumin-2.6* Calcium-8.2* Phos-1.7*
Mg-1.3*
___ 12:55PM AFP-3.3
___ 12:55PM HCV Ab-Negative
___ 12:55PM HBsAg-Negative HBs Ab-Negative HBc
Ab-Negative
MICRO
======
___ URINE CX: NEGATIVE GROWTH TO DATE
IMAGING
=======
___ ABDOMINAL US
1. Cholelithiasis in distended gallbladder. No additional
sonographic
evidence of cholecystitis.
2. Lack of visualized flow within the right portal vein may be
due to slow
flow in the setting of shunting through the left portal vein and
recannulized
umbilical vein, though occlusion cannot be excluded. If further
characterization is needed, CT may be helpful.
3. Cirrhotic liver without ascites.
4. Mild splenomegaly.
___ CT TORSO W/ CONTRAST
No suspicious pulmonary nodules or masses. No airspace
opacification to
suggest pneumonia.
Multiple subcentimeter mediastinal lymph nodes are abnormal in
number, but not
size and should be interpreted in conjunction with abdominal
findings.
Dilated pulmonary artery and pulmonary arterial hypertension
should be
excluded.
For abdominal findings please see CT abdomen report below.
1. Cirrhotic morphology of the liver with sequela of portal
hypertension
including splenomegaly, prominent collateral vessels including a
patent
paraumbilical vein, and upper abdominal lymphadenopathy which is
suspected to
be reactive. The portal vein is patent and dilated. The right
portal vein is
diminutive but opacified. There is a large patent paraumbilical
vein.
2. 3.4 cm and 2.7 cm arterially enhancing lesions without
washout or pseudo
capsule in segment V and at the junction of segment V and
segment VIII, likely
representing regenerative or dysplastic nodules. Continued
follow-up is
recommended. No lesions are seen that meet the diagnostic
criteria for
hepatocellular carcinoma.
3. A few tiny scattered foci of hyper enhancement without
correlates on
delayed imaging are indeterminate but could represent dysplastic
or
regenerative nodules or transient hepatic arterial difference
is. There are 2
sub cm hypodensities in the liver which are too small to be
characterized.
Attention to these areas on follow-up imaging is recommended.
4. No drainable fluid collections are seen.
5. Diffuse thickening of the ascending colon with mild
surrounding fat
stranding and prominent mesenteric lymph nodes is likely related
to portal
colopathy. The appendix is not definitely visualized, however
there is no
focal inflammation around the base of the cecum to suggest acute
appendicitis.
6. Cholelithiasis. There is mild gallbladder wall thickening
which may be
secondary to hepatic dysfunction.
DISCHARGE LABS
===============
___ 05:06AM BLOOD WBC-0.9* RBC-2.76* Hgb-9.3* Hct-28.6*
MCV-104* MCH-33.7* MCHC-32.5 RDW-14.6 RDWSD-54.3* Plt Ct-32*
___ 04:41AM BLOOD Neuts-69 Bands-0 ___ Monos-5 Eos-4
Baso-0 ___ Myelos-0 AbsNeut-0.48* AbsLymp-0.15*
AbsMono-0.04* AbsEos-0.03* AbsBaso-0.00*
___ 05:06AM BLOOD ___ PTT-37.4* ___
___ 05:16PM BLOOD Ret Aut-2.3* Abs Ret-0.06
___ 04:58AM BLOOD ___ 05:16PM BLOOD Fact II-36* Fact ___ FactVII-17* Fact
IX-46* Fact X-52*
___ 05:06AM BLOOD Glucose-150* UreaN-9 Creat-0.5 Na-139
K-4.0 Cl-109* HCO3-25 AnGap-9
___ 05:06AM BLOOD ALT-27 AST-42* AlkPhos-66 TotBili-2.2*
___ 05:06AM BLOOD Albumin-2.5* Calcium-8.7 Phos-4.1 Mg-1.6
___ 05:16PM BLOOD Hapto-11*
___ 05:16PM BLOOD HIV Ab-Negative
Radiology Report
EXAMINATION: CT abdomen with contrast
INDICATION: ___ year old man with ETOH cirrhosis w/ FUO and recent 50lb weight
loss // r/o malignancy, assessing portal vein vasculature
TECHNIQUE: Multiphasic Liver: Multidetector CT of the abdomen was done
without and with IV contrast. Initially, the abdomen was scanned without IV
contrast. Subsequently, a single bolus of IV contrast was injected and the
abdomen was scanned in the early arterial phase, followed by a scan of the
abdomen in the portal venous phase, followed by a scan of the abdomen in
equilibrium phase (3-min delay).
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.0 s, 31.6 cm; CTDIvol = 7.4 mGy (Body) DLP = 233.1
mGy-cm.
2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
3) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
4) Spiral Acquisition 3.3 s, 26.3 cm; CTDIvol = 22.9 mGy (Body) DLP = 602.5
mGy-cm.
5) Spiral Acquisition 9.0 s, 70.8 cm; CTDIvol = 21.6 mGy (Body) DLP =
1,530.4 mGy-cm.
6) Spiral Acquisition 3.3 s, 26.1 cm; CTDIvol = 23.2 mGy (Body) DLP = 606.0
mGy-cm.
Total DLP (Body) = 2,985 mGy-cm.
COMPARISON: Liver ultrasound ___
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
There is trace perihepatic ascites and trace ascites around the spleen.
Numerous large collateral vessels are seen within the abdomen and pelvis. The
main portal vein is patent and enlarged. The right portal vein is opacified
by diminutive. The left portal vein is also opacified. There is a large
patent paraumbilical vein.
There is diffuse stranding in the mesentery, particularly surrounding the
right colon, likely related to liver disease.
HEPATOBILIARY: The liver is nodular in contour with hypertrophy of the left
lobe compatible with cirrhosis. In segment V in at the junction of segment V
and segment VIII, there are 2 arterially enhancing lesions which do not
demonstrate washout or pseudo capsule likely representing regenerative or
dysplastic nodules, measuring up to 2.7 cm (04:53) and 3.4 cm (60b:43).
A sub cm hypodensity in the dome of the liver on 601b:66 and a linear
hypodensity in the right hepatic lobe on 601b:63 are too small to be
characterized. There are tiny scattered foci of hyper enhancement without
correlates on delayed imaging (601b:69, 33) which are indeterminate. There is
cholelithiasis. There is edema of the gallbladder wall which may be secondary
to the underlying hepatic cirrhosis.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is mild peripancreatic
stranding.
SPLEEN: The spleen is enlarged measuring 19.1 cm.
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 a sub cm hypodensity in the left kidney which is too small to
characterize. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. The visualized small bowel are
normal in caliber and thickness. Mild thickening of the right colon with
adjacent mesenteric fat stranding and prominent mesenteric lymph nodes in the
right lower quadrant is favored to represent portal collapsed C. the appendix
is not definitely visualized, however there is no focal fat stranding around
the base of the cecum to suggest acute appendicitis. There is colonic
diverticulosis without CT evidence of acute diverticulitis.
Pelvis: The urinary bladder and distal ureters are unremarkable. Prostate is
present.
LYMPH NODES: Upper abdominal lymphadenopathy is likely reactive. There is no
pelvic or inguinal adenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Prominent collateral vessels are seen in the anterior abdominal
wall. There is a left fat containing inguinal hernia.
IMPRESSION:
1. Cirrhotic morphology of the liver with sequela of portal hypertension
including splenomegaly, prominent collateral vessels including a patent
paraumbilical vein, and upper abdominal lymphadenopathy which is suspected to
be reactive. The portal vein is patent and dilated. The right portal vein is
diminutive but opacified. There is a large patent paraumbilical vein.
2. 3.4 cm and 2.7 cm arterially enhancing lesions without washout or pseudo
capsule in segment V and at the junction of segment V and segment VIII, likely
representing regenerative or dysplastic nodules. Continued follow-up is
recommended. No lesions are seen that meet the diagnostic criteria for
hepatocellular carcinoma.
3. A few tiny scattered foci of hyper enhancement without correlates on
delayed imaging are indeterminate but could represent dysplastic or
regenerative nodules or transient hepatic arterial difference is. There are 2
sub cm hypodensities in the liver which are too small to be characterized.
Attention to these areas on follow-up imaging is recommended.
4. No drainable fluid collections are seen.
5. Diffuse thickening of the ascending colon with mild surrounding fat
stranding and prominent mesenteric lymph nodes is likely related to portal
colopathy. The appendix is not definitely visualized, however there is no
focal inflammation around the base of the cecum to suggest acute appendicitis.
6. Cholelithiasis. There is mild gallbladder wall thickening which may be
secondary to hepatic dysfunction.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with ETOH cirrhosis w/ fevers of unknown origin
and a recent 50 lb weight loss // r/o malignancy
TECHNIQUE: Multi-detector helical scanning of the chest was coordinated with
intravenous infusion of nonionic, iodinated contrast agent, reconstructed as
contiguous 5 mm and 1.0 or 1.25 mm thick axial, 2.5 or 5 mm thick coronal and
parasagittal, and 8 mm MIP axial images. Sequential scanning of the abdomen
and pelvis will be reported separately. Images of the chest were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.0 s, 31.6 cm; CTDIvol = 7.4 mGy (Body) DLP = 233.1
mGy-cm.
2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
3) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
4) Spiral Acquisition 3.3 s, 26.3 cm; CTDIvol = 22.9 mGy (Body) DLP = 602.5
mGy-cm.
5) Spiral Acquisition 9.0 s, 70.8 cm; CTDIvol = 21.6 mGy (Body) DLP =
1,530.4 mGy-cm.
6) Spiral Acquisition 3.3 s, 26.1 cm; CTDIvol = 23.2 mGy (Body) DLP = 606.0
mGy-cm.
Total DLP (Body) = 2,985 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W AND W/O CONTRAST, ADDL SECTIONS)
COMPARISON: No priors
FINDINGS:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: No thyroid lesions. Multiple
subcentimeter supraclavicular lymph nodes. No axillary adenopathy.
UPPER ABDOMEN: Will be reported separately.
MEDIASTINUM: Multiple subcentimeter mediastinal lymph nodes (the number of
lymph nodes are more than would be expected). Prominent internal mammary
veins in keeping with portosystemic shunting.
HILA: Subcentimeter hilar lymph nodes.
HEART and PERICARDIUM: Normal cardiac configuration. No aortic valve
calcifications. No coronary artery calcifications. No pericardial effusion.
PLEURA: No pleural effusion.
LUNG:
-PARENCHYMA: No suspicious pulmonary nodules or masses. No confluent
airspace consolidation. No diffuse lung disease. A few millimetric pulmonary
nodules ___, 126, 156 and 76). Mild bibasal subpleural atelectasis.
-AIRWAYS: Patent to the subsegmental level.
-VESSELS: The pulmonary truncus is dilated measuring 35 mm in diameter. No
filling defects.
CHEST CAGE: Spondylotic changes of the thoracic spine. No lytic/destructive
bony lesions.
IMPRESSION:
No suspicious pulmonary nodules or masses. No airspace opacification to
suggest pneumonia.
Multiple subcentimeter mediastinal lymph nodes are abnormal in number, but not
size and should be interpreted in conjunction with abdominal findings.
Dilated pulmonary artery and pulmonary arterial hypertension should be
excluded.
For abdominal findings please see CT abdomen report.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Fever
Diagnosed with Fever, unspecified
temperature: 98.5
heartrate: 72.0
resprate: 18.0
o2sat: 99.0
sbp: 153.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | ___ male with PMH EtOH cirrhosis, HTN w/ no previous
hepatology care presented to ___ with fever to 104,
weakness, and ___ transferred to ___ for w/u and treatment.
#Fevers: Patient with an episode of fever (reportedly ___ at
___ in setting of weakness most likely due to self
limited viral illness. Patient with leukopenia on admission
(known to have neutropenia previously). Had no ascites to tap on
US, CXR and UA unremarkable, no growth on blood and urine cx to
date (___) from ___. Initially treated with
Vancomycin/Ceftriaxone IV at ___ for possible LLE
cellulitis and continued upon arrival at ___. On
re-examination, LLE appears more consistent with chronic venous
stasis +/- vascular malformation based on chronic change per
patient.
Evaluated for endocarditis due to murmur on exam but TTE was
normal with no growth on blood cultures. Evaluated for
malignancy due to recent 50lb weight loss (thought patient
states it was intentional) with CT Chest/Abdomen/Pelvis w/
contrast that was negative for malignancy. With all evaluation
negative and no signs of infection, we stopped
Vancomycin/Ceftriaxone (___). Patient remained afebrile
without other symptoms and stable leukopenia plus neutropenia.
# ETOH CIRRHOSIS: MELD 24 on admission. Unsure about history of
HE, varices, SBP given patient has never seen a hepatologist. No
ascites to tap on US on arrival. Hemodynamically stable upon
arrival and throughout admission, no melena or grossly bloody
stool. Social work c/s for alcohol abuse: patient wants to quit
but difficult to make support groups due to work schedule. AFP
normal (3.3) and Hep panel negative (HCV Ab negative, HBsAg
negative, HBsAb negative, HBcAb negative) without HBV
immunization. Will need outpatient hepatology, EGD, and q6mo HCC
screening. Started on lactulose for possible HE, Folic acid, and
thiamine for EtOH use.
#RLE Skin lesion: Most likely chronic venous stasis changes
though possibly vasculitis. Skin was marked and lesion did not
change in size during admission. Will need outpatient
evaluation.
# HEPATIC ENCEPHALOPATHY: Patient reported to have AMS at OSH,
however AOx3 and able to do days of week backwards upon arrival
to ___. Did have mild asterixis on exam. Treated w/ lactulose
and rifaximin. CT negative for portal vein thrombosis (evaluated
due to low flow on abdominal US). Continued on lactulose at
discharge but re-evaluate need as outpatient
#Pancytopenia: Hematology consulted. Attributed to
sequestration from splenomegaly and bone marrow suppression from
alcohol abuse. Plt 22, ANC 700 on admission & 480 at discharge
. Has had ANC 700s in Atrius records. Hgb 10.2->9.3, no e/o
bleed. Workup: HIV negative, Haptoglobin low (but unlikely DIC,
low ___ cirrhosis),
CHRONIC ISSUES
==============
#HTN: held amlodipine and lisinopril originally in setting of
possible infection, BP 120s. Held at discharge. Re-evaluate if
patient needs it in setting of cirrhosis.
#Chronic pain: gabapentin 100 mg PO bid
TRANSITIONAL ISSUES
===================
GENERAL
- weight at time of d/c 90.4kg
- creatinine at time of d/c 0.5
#Cirrhosis
[ ] Initiate referral to hepatology for cirrhosis
- will need q6mo HCC screening, EGD to evaluate for varices
[ ] HBV and HAV vaccination
[ ] Hepatic lesions (3.4 cm and 2.7 cm) on CT will require
further evaluation
[ ] evaluate need for ongoing lactulose since pt was not altered
when he came to ___
[ ] Reinforce EtOH cessation and sobriety
#Pancytopenia
[ ] Hematology referral for chronic pancytopenia & f/u labwork
including Factor levels
#Fever
[ ] Monitor for signs of infection/malignancy given fevers of
unclear etiology that have now resolved
#RLE Skin lesion
[ ] Evaluate RLE skin changes lesion for possible vasculitis vs
chronic changes
#HTN
[ ] Holding amlodipine and lisinopril, consider restarting if
patient becomes hypertensive
#CODE: Full Code (hadn't been confirmed, he had told me he
would think about it)
#CONTACT: Patient, wife ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
alendronate sodium / Imdur / Evista / atenolol / Prevacid /
bioxin / hydrochlorothiazide / lisinopril / Ultram / Tegretol /
calcium / amoxicillin
Attending: ___.
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is an ___ year-old right-handed ___ woman
who presents after an acute episode of nausea and dizziness
after lunch. History obtained by son, who helped translate, and
by patient.
Patient reports that she was in her usual state of health up
until
lunchtime when she suddenly felt nauseous, as if she was going
to vomit. She did not vomit or see double or develop any focal
weakness. She only reports sudden-onset nausea with some
dizziness. Her son became concerned and called EMS.
Per son, his mother is very healthy and is independent and
mobile at home. Her blood pressures usually run in the 160-180s.
She has not complained of a headache and has not had any recent
sicknesses or travel history.
Of note, she is not on anti-coagulation and does not take her
prescribed aspirin. No recent falls.
ROS: On neurologic review of systems, the patient denies
headache, or confusion. Denies difficulty with producing or
comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness, numbness, parasthesia.
Denies loss of sensation. Denies bowel or bladder incontinence
or retention. Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies diarrhea, constipation,
or abdominal pain. No recent change in bowel or bladder habits.
Denies dysuria or hematuria. Denies myalgias, arthralgias, or
rash
Past Medical History:
PAST MEDICAL HISTORY:
- R breast cancer, s/p partial mastectomy ___
- Colon cancer (___)
- SBO x3 (first was in ___, one week s/p sigmoid resection for
colon cancer management, second was ___ with two transition
points in the small bowel), last ___ likely to adhesions from
prior surgeries)
- Celiac Artery Stenosis (diagnosed in ___ as incidental
finding on CT scan, stable)
- HTN
- GERD
- Trigeminal neuralgia
- R ankle fx ___
- Osteopenia
- Blind R eye
- Constipation
PAST SURGICAL HISTORY:
- partial R breast mastectomy ___,
- glaucoma surgery,
- sigmoid colectomy (OSH, ___,
- ex-lap w/SBR (OSH, ___,
- endoscopy ___ patch of abnormal-appearing mucosa,bx
neg),
- colonoscopy ___, adenomatous polyps),
- colonoscopy ___, adenomatous polyp),
- colonoscopy ___, several polyps)
Social History:
___
Family History:
Sister had trigeminal neuralgia
Physical Exam:
PHYSICAL EXAM:
O: T:97.1 BP:193/77 --> 148/81 HR:60 R:18
General: NAD
HEENT: right side of face is asymmetric at baseline with
post-surgical changes secondary to ? trigeminal procedure
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive to conversation. Speech is
reportedly fluent (by son, limited by availability of
interpreter) with full sentences, intact repetition, and intact
verbal comprehension. Naming intact. No paraphasias. No
dysarthria. Normal prosody. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
- Cranial Nerves: Left pupil 3->2 brisk. Right eye is
post-surgical. VF on right is limited secondary to
cataract/blind/post-surgical (unclear). EOMI with a couple beats
of end-stage nystagmus that are extinguishable. V1-V3 without
deficits to light touch bilaterally. right face with NLFF,
symmetric activation (son says this is her baseline). Hearing
intact to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 4 4 4 4 ___ 4 4 4 4 4
R 4 4 4 4 ___ 4 4 4 4 4
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
- Gait: Staggering initiation with sway in both directions,
wide-based gait, veers to either side.
EXAM ON DISCHARGE:
non-focal, unchanged from above
Pertinent Results:
___ 06:07AM BLOOD WBC-3.4* RBC-3.43* Hgb-11.9 Hct-34.8
MCV-102* MCH-34.7* MCHC-34.2 RDW-13.7 RDWSD-50.7* Plt ___
___ 04:20PM BLOOD WBC-3.6* RBC-3.28* Hgb-11.3 Hct-33.5*
MCV-102* MCH-34.5* MCHC-33.7 RDW-14.0 RDWSD-51.8* Plt ___
___ 06:07AM BLOOD Neuts-58.6 ___ Monos-7.3 Eos-2.6
Baso-1.5* Im ___ AbsNeut-2.01 AbsLymp-1.02* AbsMono-0.25
AbsEos-0.09 AbsBaso-0.05
___ 06:07AM BLOOD Plt ___
___ 06:07AM BLOOD Glucose-83 UreaN-11 Creat-0.6 Na-140
K-4.0 Cl-102 HCO3-22 AnGap-16
___ 06:07AM BLOOD ALT-14 AST-20 LD(LDH)-238 CK(CPK)-50
AlkPhos-56 TotBili-0.4
___ 06:07AM BLOOD TotProt-6.3* Albumin-4.4 Globuln-1.9*
Cholest-170
___ 06:07AM BLOOD %HbA1c-5.3 eAG-105
IMAGES:
MR HEAD WITHOUT CONTRAST:
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: History: ___ with hemorrhagic stoke// ? ischemia
TECHNIQUE: MRI of the brain is performed and includes the
following
sequences: sagittal T1-weighted, axial fast spin echo
T2-weighted,axial flair,
axial diffusion weighted and axial gradient echo images .
COMPARISON: CT angiography obtained earlier on the same date ___.
FINDINGS:
Diffusion images demonstrate no evidence of an area of
restricted diffusion to
indicate acute infarct. The area of susceptibility noted on the
wet reading
in the right temporal region appears to be secondary to partial
volume
averaging of adjacent petrous bone. No definite hemorrhage or
surrounding
edema is identified. An area of hemorrhage in this region
without surrounding
edema is extremely unusual. The previously seen subtle
hyperdensity in the
right pre pontine cistern is seen on the FLAIR images as subtle
area of
hyperintensity. In presence of right posterior fossa
craniectomy this is
likely secondary to previous trigeminal neuro vascular
decompression. FLAIR
hyperintensities in the white matter indicate mild-to-moderate
changes of
small vessel disease. Moderate brain atrophy is identified.
IMPRESSION:
1. No acute infarcts identified.
2. No MRI evidence of hemorrhage.
3. Subtle signal abnormality in the right perimesencephalic
cistern (seen as hyperdensity on previous CT) is likely due to
previous trigeminal neuralgia neuro-vascular decompression.
CT HEAD/ CTA:
Final Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with sudden onset dizziness and
vomiting// ?bleed or
ischemia (CT), ?pna (CXR)
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 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy
(Head) DLP =
747.4 mGy-cm.
2) Spiral Acquisition 4.8 s, 38.0 cm; CTDIvol = 13.3 mGy
(Body) DLP = 504.0
mGy-cm.
3) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 38.6 mGy
(Body) DLP =
19.3 mGy-cm.
Total DLP (Body) = 523 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage,
edema, or mass.
The ventricles and sulci are normal in size and configuration.
Evidence of prior right occipital craniectomy. Hyperdense
material present in
the perimesencephalic cistern in the area of the right
trigeminal nerve in
keeping with trigeminal nerve surgery/decompression.
Mild mucosal thickening involving the paranasal sinuses.
Bilateral
staphylomas. Prior right lens extraction.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches
are patent without stenosis, occlusion, or aneurysm formation.
The dural
venous sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches are
patent with no
evidence of stenosis or occlusion. There is no evidence of
internal carotid
stenosis by NASCET criteria.
OTHER:
No suspicious pulmonary nodules or masses. Mild biapical
pleural-parenchymal
scarring. Small subcentimeter hypodense thyroid nodules.
Cervical
spondylosis. There is no lymphadenopathy by CT size criteria.
IMPRESSION:
No acute intracranial hemorrhage or large territorial infarct.
No intracranial aneurysm, arterial occlusion or marked stenosis.
No ICA stenosis according to NASCET criteria.
Hyperdense material present in the perimesencephalic cistern in
the area of
the right trigeminal nerve in keeping trigeminal nerve
surgery/decompression
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Carvedilol 3.125 mg PO BID
4. ibandronate 150 mg oral monthly
5. Levothyroxine Sodium 25 mcg PO DAILY
6. OXcarbazepine 450 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
9. Vitamin D 1000 UNIT PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Calcium Carbonate unknown PO Frequency is Unknown
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Carvedilol 3.125 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Ibandronate 150 mg oral MONTHLY
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. OXcarbazepine 450 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Orthostatic hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with sudden onset dizziness and vomiting// ?bleed or
ischemia (CT), ?pna (CXR)
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 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.4 mGy-cm.
2) Spiral Acquisition 4.8 s, 38.0 cm; CTDIvol = 13.3 mGy (Body) DLP = 504.0
mGy-cm.
3) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 38.6 mGy (Body) DLP =
19.3 mGy-cm.
Total DLP (Body) = 523 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
Evidence of prior right occipital craniectomy. Hyperdense material present in
the perimesencephalic cistern in the area of the right trigeminal nerve in
keeping with trigeminal nerve surgery/decompression.
Mild mucosal thickening involving the paranasal sinuses. Bilateral
staphylomas. Prior right lens extraction.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
are patent without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches are patent with no
evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
No suspicious pulmonary nodules or masses. Mild biapical pleural-parenchymal
scarring. Small subcentimeter hypodense thyroid nodules. Cervical
spondylosis. There is no lymphadenopathy by CT size criteria.
IMPRESSION:
No acute intracranial hemorrhage or large territorial infarct.
No intracranial aneurysm, arterial occlusion or marked stenosis.
No ICA stenosis according to NASCET criteria.
Hyperdense material present in the perimesencephalic cistern in the area of
the right trigeminal nerve in keeping trigeminal nerve surgery/decompression
NOTIFICATION: The findings were discussed by Dr. ___ with
Dr. ___ on the ___ ___ at 11:00 am, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (AP upright AND LAT)
INDICATION: ___ with sudden onset dizziness and vomiting// ?bleed or ischemia
(CT), ?pna (CXR)
COMPARISON: ___
FINDINGS:
AP upright and lateral views of the chest provided.
The lungs are clear. No signs of pneumonia or edema. Heart is top-normal in
size though unchanged. Mediastinal contour is unremarkable aside from aortic
knob calcifications. Imaged bony structures are intact. No free air below
the right hemidiaphragm.
IMPRESSION:
No acute findings.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: History: ___ with hemorrhagic stoke// ? ischemia
TECHNIQUE: MRI of the brain is performed and includes the following
sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial flair,
axial diffusion weighted and axial gradient echo images .
COMPARISON: CT angiography obtained earlier on the same date ___.
FINDINGS:
Diffusion images demonstrate no evidence of an area of restricted diffusion to
indicate acute infarct. The area of susceptibility noted on the wet reading
in the right temporal region appears to be secondary to partial volume
averaging of adjacent petrous bone. No definite hemorrhage or surrounding
edema is identified. An area of hemorrhage in this region without surrounding
edema is extremely unusual. The previously seen subtle hyperdensity in the
right pre pontine cistern is seen on the FLAIR images as subtle area of
hyperintensity. In presence of right posterior fossa craniectomy this is
likely secondary to previous trigeminal neuro vascular decompression. FLAIR
hyperintensities in the white matter indicate mild-to-moderate changes of
small vessel disease. Moderate brain atrophy is identified.
IMPRESSION:
1. No acute infarcts identified.
2. No MRI evidence of hemorrhage.
3. Subtle signal abnormality in the right perimesencephalic cistern (seen as
hyperdensity on previous CT) is likely due to previous trigeminal neuralgia
neuro-vascular decompression.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Dizziness
Diagnosed with Nontraumatic intracranial hemorrhage, unspecified, Essential (primary) hypertension
temperature: 97.1
heartrate: 75.0
resprate: 17.0
o2sat: 99.0
sbp: 193.0
dbp: 77.0
level of pain: 0
level of acuity: 1.0 | ___ year-old right-handed ___ woman who presented
with acute nausea after lunch, admitted for stroke work-up in
setting of dizziness and right facial droop. General exam on
admission notable for orthostatic hypotension. Neurologic exam
notable for chronic RT post surgical pupil and RT facial droop
(from previous trigeminal decompression), as well as jaw
quivering, otherwise non focal. NCHCT with hyperdense material
present in the perimesencephalic cistern in the area of the
right trigeminal nerve in keeping trigeminal nerve surgery
(decompression). CTA head and neck unremarkable. MRI with
susceptibility artifact seen in the left temporal lobe
corresponds to area initially concerning for hemorrhage seen on
earlier same day noncontrast head CT. There is no evidence of
acute ischemic infarction, mass, mass effect or midline shift.
Stroke risk factors with A1C of 5.3% and LDL of 50. Etiology of
her symptoms likely orthostatic hypotension. Medical management
with IVF volume repletion resulted in symptomatic improvement.
She was discharged home to family with instructions to continue
PO fluid intake.
Transitional Issues:
# PCP follow up one week from discharge to assess BP regimen |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo M with PMH of metastatic pancreatic colloid
carcinoma admitted from the ED with persistent fatigue,
weakness, and poor po intake and new diarrhea of two days
duration.
Patient hospitilazed ___ - ___ with weakness, fatigue
and diarrhea. He was found to have ___ and concern for bowel
obstruction and intestinal necrosis, and improved with
supportive therapy. He was discharged to rehab ___ and
received single agent nal-iri on ___.
Per oncology, pt with persistent weakness and poor po appetite
since before his last admission which continued at ___. His
weight at ___ was down to 74 lbs from 93lbs on admission and he
was initiated on mirtazapine and ranitidine. He was brought to
the ED for failure to thrive and persistent diarrhea x2 days.
In the ED, initial VS were pain 0, T 98.8, HR 97, BP 92/67, RR
18, O2 100%RA.
Initial labs: Na 142, K 5.2, HCT 25, Cr 0.7, Ca 7.7, Mg 1.6, P
3.8, WBC 5.2, HCT 24.5, PLT 340. Lactate 1.2. Patient was given
1L NS prior to transfer.
ED exam notable for:
Constitutional - No Fever/chills, +FTT, decreased appetitie,
weight loss
Head / Eyes - No Diplopia
ENT / Neck - No Epistaxis
Chest/Respiratory - No Cough, No Dyspnea
Cardiovascular - No Chest pain
GI / Abdominal - No Black stool, No Bloody stool
GU/Flank - No Dysuria
Musc/Extr/Back - No Back pain, No Joint pain
Skin - No Rash, No Diaphoresis
Neuro - No Headache
Imaging:
No new imaging
CT abd ___:
"IMPRESSION:
1. Multiple dilated small and large bowel loops are identified.
There is persistent stenosis of the sigmoid colon from the
external compression caused by large pelvic masses, which is the
likely the main site of bowel
obstruction.
2. Pneumatosis intestinalis of the small bowel loops in the
right abdomen is concerning for bowel ischemia and new from
prior study.
3. Severe right hydronephrosis is new since ___, but
similar compared to ___.
4. Multiple large peritoneal masses appear grossly similar to
___. Previously noted hepatic lesions are not
demonstrated on this noncontrast exam."
Patient received:
-CTX 1g x1
-1 L D51/2NS
-lisnopril 2.5mg
-norepi started at 0.12
Consults:
Oncology in ED
Vitals on transfer:
80s/60s, HR ___, RR 12 100% RA
Upon arrival to ___, pt reports feeling tired but "better." He
denies fever/chills, CP, cough, dyspnea, abdominal pain, N/V, or
dysuria. He reports limited appetite or fluid consumption for
several days.
PAST ONCOLOGIC HISTORY:
As per last clinic note by Dr ___ was
initially diagnosed with acute pancreatitis in ___. Imaging
raised concern for intraductal papillary mucinous neoplasm
(IPMN), and he was followed with serial MRI. MRI ___ identified interval change in the configuration of his
known pseudocyst. The study was repeated on ___ at
which time an enhancing soft tissue abnormality was seen. Upper
endoscopy then identified a large amount of mucus at the
pylorus. Biopsy by ___ did not show carcinoma. On ___
he was taken to the operating room by Dr. ___ and
underwent ___'s pancreaticoduodenectomy. Pathology showed a
4.4 cm colloid carcinoma (mucinous noncystic carcinoma) arising
from an intraductal IPMN. There was no
lymphovascular/perineural invasion; 5 of 18 lymph nodes were
involved. He was diagnosed with pT3N1Mx stage IIB mucinous
noncystic carcinoma of the pancreas. He received six cycles of
adjuvant gemcitabine under the care of Dr. ___,
which completed in ___, followed by adjuvant radiation
with concurrent capecitabine, which completed ___. He
was then followed with surveillance imaging.
CT in ___ identified a right upper lobe lung nodule for
which he underwent CT-guided FNA. Cytology was suspicious for
malignancy. He underwent repeat biopsy in ___ with
similar results and was eventually taken to the operating room
for VATS wedge resection ___. Pathology confirmed
the finding of metastasis from his pancreatic colloid carcinoma.
He initiated systemic chemotherapy with FOLFIRINOX ___. He completed 14 cycles as of ___ and then entered
a treatment break. In ___ he developed peritoneal
carcinomatosis with intra-abdominal ascites and a pulmonary
embolism. He resumed cycle ___ FOLFIRINOX and completed an
additional two cycles as of ___. Due to progression of
peritoneal carcinomatosis he then transitioned to
nab-paclitaxel/gemcitabine. He completed four cycles of this as
of ___ at which time there was further disease
progression. Mr. ___ initiated treatment with 5fu/nal-iri on
___. Snapshot analysis showed variants in ___ and p53"
He was hopitilazed ___ - ___ with weakness, fatigue and
diarrhea, found to have ___ and concern for bowel obstruction
and intestinal necrosis. Improved with supportive therapy.
Discharged to rehab ___. Received single agent nal-iri on
___ as he cannot receive ___ infusion at SNF.
Past Medical History:
1. Pancreatic colloid carcinoma, as detailed in the history of
present illness.
2. Diabetes mellitus.
3. GERD.
4. Tuberculosis, for which he had isoniazid and rifampin.
5. Hyperlipidemia.
6. Chronic pancreatitis.
7. Anemia.
8. Umbilical hernia repair in ___.
9. Appendectomy in ___.
Social History:
___
Family History:
His mother with diabetes, passed in her early ___ of jaundice.
Father with diabetes
Physical Exam:
ADMISSION PHYISCAL EXAM:
==============================
VS: 87/95, HR 93, RR 10, 100% on RA
GENERAL: cachetic appearing, NAD
EYES: Anicteric sclerea, PERLLA, EOMI, no chemosis
ENT: clear OP, no JVD, no LAD
CARDIOVASCULAR: RRR, no m/r/g, 2+ radial and DP pulses
RESPIRATORY: CTAB, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: rock hard L quadrants, soft RUQ, scaphoid,
large central palpable mass, nontender without rebound or
guarding
MUSKULOSKELATAL: Warm, well perfused extremities, 2+ pitting
edema to mid tibia
NEURO: Alert, oriented, CN II-XII intact, no focal deficits
SKIN: stage 2 pressure injury coccyx, no additional rash or
lesions
DISCAHRGE PHYISCAL EXAM:
==============================
VS: ___ 2343 Temp: 98.3 PO BP: 119/82 HR: 65 RR: 18 O2 sat:
97% O2 delivery: RA
GENERAL: Cachectic appearing man, appears older than stated age,
laying in bed in NAD
EYES: Sclera anicteric
HEENT: OP clear, MMM, no OP lesions
LUNGS: CTAB - no wheezes, rhonchi, or rales
CV: RRR, no m/r/g
ABD: +BS, S, NT, +large central palpable mass that is stable in
size
EXT: Poor muscle bulk
SKIN: warm, no rashes appreciated
NEURO: AOx3, no facial asymmetry
Pertinent Results:
ADMISSION LABS:
=============================
___:12AM BLOOD WBC-5.2 RBC-2.91* Hgb-8.2* Hct-24.5*
MCV-84 MCH-28.2 MCHC-33.5 RDW-16.1* RDWSD-48.7* Plt ___
___ 12:12AM BLOOD Neuts-77.0* Lymphs-18.3* Monos-2.9*
Eos-0.8* Baso-0.2 Im ___ AbsNeut-4.00 AbsLymp-0.95*
AbsMono-0.15* AbsEos-0.04 AbsBaso-0.01
___ 12:12AM BLOOD Glucose-94 UreaN-13 Creat-0.7 Na-142
K-5.2* Cl-107 HCO3-25 AnGap-10
___ 12:12AM BLOOD Calcium-7.7* Phos-3.8 Mg-1.6
___ 08:53PM BLOOD ___ pO2-47* pCO2-37 pH-7.37
calTCO2-22 Base XS--3
___ 12:16AM BLOOD Lactate-1.2 K-4.6
DISCHARGE LABS:
==============================
___ 03:18AM BLOOD WBC-3.4* RBC-3.03* Hgb-8.5* Hct-26.1*
MCV-86 MCH-28.1 MCHC-32.6 RDW-16.2* RDWSD-50.4* Plt ___
___ 04:50AM BLOOD Neuts-50.6 ___ Monos-10.8 Eos-1.7
Baso-0.4 Im ___ AbsNeut-1.22* AbsLymp-0.86* AbsMono-0.26
AbsEos-0.04 AbsBaso-0.01
___ 04:19AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+*
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+*
Target-1+*
___ 03:18AM BLOOD Glucose-102* UreaN-<3* Creat-0.3* Na-138
K-3.8 Cl-102 HCO3-30 AnGap-6*
___ 06:27AM BLOOD ALT-9 AST-13 LD(LDH)-189 AlkPhos-161*
TotBili-0.2
___ 03:18AM BLOOD Calcium-7.0* Phos-3.5 Mg-1.7
MICROBIOLOGY:
==============================
___ BLOOD CULTURE X2 - NEGATIVE
___ URINE CULTURE - ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ STOOL - C. DIFF - NEGATIVE
___ FECAL CULTURE - NEGATIVE FOR GNR, CAMPYLOBACTER,
SALMONELLA, SHIGELLA
IMAGING:
==============================
___ KUB IMPRESSION:
Dilated air-filled loops of large and small bowel may reflect
ileus or
early/partial obstruction. Fecal material is visualized within
the rectum and is noted to project over the descending colon as
well.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Lisinopril 2.5 mg PO DAILY
3. Mirtazapine 15 mg PO QHS
4. Enoxaparin Sodium 60 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
5. Omeprazole 20 mg PO DAILY
6. sod phos di, mono-K phos mono ___ mg oral daily
7. Vitamin D 5000 UNIT PO DAILY
8. lipase-protease-amylase 20,000-68,000 -109,000 unit oral BID
9. Glargine 23 Units Bedtime
10. insulin lispro 100 unit/mL subcutaneous SSI
11. Potassium Chloride 60 mEq PO BID
12. Prochlorperazine 10 mg IV Q8H:PRN nausea
Discharge Medications:
1. Midodrine 10 mg PO TID
RX *midodrine 10 mg 1 tablet(s) by mouth three times per day
Disp #*90 Tablet Refills:*0
2. Neutra-Phos 2 PKT PO TID
RX *potassium, sodium phosphates [Phos-NaK] 280 mg-160 mg-250 mg
2 powder(s) by mouth three times per day Disp #*180 Packet
Refills:*0
3. Potassium Chloride 40 mEq PO BID
RX *potassium chloride 20 mEq 2 tablet(s) by mouth twice per day
Disp #*120 Tablet Refills:*0
4. Enoxaparin Sodium 60 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
5. Famotidine 20 mg PO BID
6. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide 2 mg 2 mg by mouth four times a day Disp #*30
Capsule Refills:*0
7. Magnesium Oxide 400 mg PO DAILY
8. Mirtazapine 15 mg PO QHS
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. Prochlorperazine 10 mg IV Q8H:PRN nausea
11. sod phos di, mono-K phos mono ___ mg oral daily
12. Vitamin D ___ UNIT PO 1X/WEEK (___)
13. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000
unit oral TID W/MEALS
14.Hospital Bed
Name: ___
Date of Birth: ___
Diagnosis: Metastatic Pancreatic Cancer, pain due to emaciation
Length of Need: 99
15.Standard Manual Wheelchair
Including seat abd back cushion, elevating leg rests, anti-tip
and break extensions. Length = 13 months. Diagnosis: metastatic
pancreatic carcinoma
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSIS:
Sepsis from a urinary source
Urinary tract infection
SECONDARY DIAGNOSIS:
Mucinous noncystic colloid carcinoma of the pancreas
Irinotecan induced diarrhea
Urinary retention
Poor nutritional status, weakness
Sacral ulcer, stage II
History of pulmonary embolism
Type II Diabetes Mellitus
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
INDICATION: ___ year old man with pancreatic cancer, worsening distension and
now vomiting. Recent history of SBO// r/o obstruction, ileus
TECHNIQUE: Supine and left lateral decubitus views of the abdomen were
obtained
COMPARISON: CT abdomen and pelvis dated ___
FINDINGS:
There are multiple dilated air-filled loops of large and small bowel seen
predominantly within the left hemiabdomen. Fecal material is seen within the
rectum and projecting over the descending colon.
There is no free intraperitoneal air.
Osseous structures are unremarkable. There are no unexplained soft tissue
calcifications or radiopaque foreign bodies.
IMPRESSION:
Dilated air-filled loops of large and small bowel may reflect ileus or
early/partial obstruction. Fecal material is visualized within the rectum and
is noted to project over the descending colon as well.
Gender: M
Race: ASIAN - ASIAN INDIAN
Arrive by AMBULANCE
Chief complaint: Lethargy
Diagnosed with Adult failure to thrive
temperature: 98.8
heartrate: 97.0
resprate: 18.0
o2sat: 100.0
sbp: 92.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | FICU COURSE ___
=============================
ASSESSMENT AND PLAN
====================
Mr. ___ is a ___ male with a past medical history of
metastatic pancreatic colloid carcinoma admitted from the ED
with hypotension in the setting of poor PO intake and new
diarrhea of two days duration concerning for septic shock and
severe hypovolemia.
ACTIVE ISSUES
=============
#Septic shock
The patient presented with hypotension and leukocytosis with
diarrhea x2 days. On arrival, he was noted to have a positive
UA. Hence, his sepsis was thought to be from either a GI or
urinary source. It was thought that severe hypovolemia was also
contributing to his hypertension. His abdominal exam was
similar to previous examinations based on a review of records
and hence, his presentation was less likely to be from a
perforation although there was concern given that he was found
to have bowel necrosis during her recent hospitalization. He
was started on norepinephrine in the ED with the goal of
maintaining MAPs >60. Repeat abdominal imaging was not pursued
as they were multiple, very recent imaging studies in our
system. He was volume resuscitated with crystalloid and was
continued on ceftriaxone and metronidazole for antibiotic
coverage based on the concern of GI or urinary source. He was
eventually weaned off norepinephrine on ___ and remained
stable. At this time, he was thought to be stable enough to
transfer to the medical floor for further care.
#Diarrhea
His diarrhea was attributed to irinotecan during his last
admission and the offending agent had been discontinued as of
___. At that time, C. diff and stool cultures were all
negative. His current diarrhea was not temporally associated
with chemotherapy so there was concern for an infectious
etiology. C. difficile and stool culture were sent. He was
continued on metronidazole. He was given fluids and his
electrolytes were repleted as needed. His C. difficile came
back negative and he was started on loperamide for symptomatic
relief.
#UTI
Upon presentation, the patient's UA was found to be positive for
possible UTI. Urine cultures were sent for further evaluation.
However, the patient remained asymptomatic. Of note, during his
last admission, he failed a voiding trial and a foley was
re-inserted after which he developed a leukocytosis with
positive UA. UCx grew >100,000 E. coli and he was initiated on
Ceftriaxone 2gm q24h (___). The foley was removed and
his urinary retention resolved. At discharge, his leukocytosis
had resolved and he was discharged on Bactrim DS BID for
completion of a 7-day course (___). He was started on
ceftriaxone based on previous data.
# Metastatic pancreatic cancer
# Chronic partial bowel obstruction
The patient had known bulky peritoneal and mesenteric metastatic
disease. A palliative care consult was placed to further assist
the family. The patient's outpatient oncology team was notified
of his current admission. He was continued on ondansetron and
Compazine as needed.
# Anorexia
# Severe protein calorie malnutrition
This was in the setting of progressive metastatic pancreatic
cancer. A nutrition consult was placed and the patient was given
Ensure 3 times daily. PO intake was also encouraged.
CHRONIC ISSUES
==============
# Diabetes
The patient was noted to be hypoglycemic on arrival. His home
doses of insulin were held in the setting. He was placed on an
insulin sliding scale.
# GERD
His home omeprazole 20mg QHS was restarted.
# History of PE
He was continued on Lovenox 60mg daily (1.5mg/kg/day) per prior
oncology recommendations.
=========================================
OMED COURSE: ___ - ___
=========================================
Mr. ___ is a ___ male with history of
metastatic pancreatic cancer admitted from the ED with
hypotension in the setting of poor PO intake and diarrhea of two
days duration concerning for septic shock from a urinary source
and severe hypovolemia initially admitted to the ICU requiring
multiple liters of IVF and pressors. He was subsequently called
out to the oncology floor where he was observed prior to
discharge with course complicated by relative hypotension.
#s/p Septic Shock:
#E. Coli UTI
Hypotension and leukocytosis requiring temporary levophed
support which resolved with aggressive fluid resuscitation.
Likely from severe dehydration secondary to poor PO intake,
diarrhea as well as possible contribution from UTI. He completed
a 7 day course of ceftriaxone (last day ___.
#Relative ___ on ___ to 70/40,
asymptomatic in the setting of not receiving IV fluids. He was
responsive to IVF and had stable blood pressures. He will
require IV fluids at home to manage his blood pressure and he
was also written for low dose midodrine 10 mg TID.
#Diarrhea: Likely secondary to chemotherapy. Stool studies
negative. Continued loperamide and provided supportive therapy
with IVF and electrolyte repletion.
# Severe Protein-Calorie Malnutrition: Secondary to progressive
metastatic pancreatic cancer. Supplemental Ensure continued at
discharge.
# Metastatic Pancreatic Cancer:
# Chronic Partial Bowel Obstruction: Known bulky peritoneal and
mesenteric metastatic disease. He will follow-up with outpatient
Oncology on ___. Zofran and Compazine were as needed
# GERD: Held due to diarrhea, can restart home omeprazole 20mg
as an outpatient.
# Pulmonary Embolism: Continued home lovenox.
Transitional Issues:
[ ] He should receive 500 ml IVF BID
[ ] Continue vitamin D 50,000 units qweek for 8 weeks ___,
received 1 dose ___. Last dose ___
[ ] Sacral ulcer, stage II: please ensure that the patient is
turned every couple of hours and that the area is closely
monitored and cared for
[ ] Consider restarting omeprazole.
[ ] New Medications: Midodrine 10 mg PO TID, Neutra-Phos 2 PKT
PO/NG TID, Potassium Chloride 40 mEq PO BID, Simethicone 40-80
mg PO/NG QID:PRN bloating
[ ] Held Medications: None
CODE: Full Code (confirmed)
EMERGENCY CONTACT HCP: ___ (wife) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
Right hip hemiarthroplasty
History of Present Illness:
___ reasonably healthy who presents to the ED as transfer for
concern of right femur neck fracture. She normally ambulates
without any difficulties. She lives in the assisted living. She
suffered a fall when she was walking to bed. She slipped on the
carpet and hit her hip. No heads strike no LOC. She denies any
pain.
Past Medical History:
Afib
HL
HTN
Social History:
___
Family History:
NC
Physical Exam:
NAD
Breathing comfortably
Right lower extremity:
- Dressing intact
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 07:01AM BLOOD WBC-9.4 RBC-3.11*# Hgb-9.9*# Hct-29.5*#
MCV-95 MCH-31.8 MCHC-33.6 RDW-12.8 RDWSD-44.3 Plt ___
___ 06:30AM BLOOD WBC-9.5 RBC-4.17 Hgb-13.2 Hct-39.8 MCV-95
MCH-31.7 MCHC-33.2 RDW-12.9 RDWSD-45.5 Plt ___
Medications on Admission:
MVI
b12
toprox xl 50 mg po qday
calcium carbonate 1250 QDAY
vitamin d 2,000 units qday
Lipitor 20 mg qday
valsartan 160 mg qday
xarelto 20 mg po day
amiodarone 200 mg day
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 4
hours Disp #*50 Tablet Refills:*0
4. Amiodarone 200 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Calcium Carbonate 500 mg PO TID
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Rivaroxaban 15 mg PO DINNER
9. Valsartan 160 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS (AP ONLY)
INDICATION: History: ___ with R hip fx// eval for fx/ preop
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of the right hip.
COMPARISON: None.
FINDINGS:
There is a fracture through the neck of the right femur. The femoral shaft is
laterally displaced. Moderate degenerative changes of bilateral hips noted.
There is no suspicious lytic or sclerotic lesion. There is no soft tissue
calcification or radio-opaque foreign body. Limited views of the right knee
demonstrate mild degenerative changes.
IMPRESSION:
Right femoral neck fracture with lateral displacement of the femoral shaft.
Radiology Report
EXAMINATION: At
INDICATION: History: ___ with R hip fx// eval for fx/ preop
TECHNIQUE: Chest PA and lateral
COMPARISON: Outside hospital chest radiograph ___ at 00:47.
FINDINGS:
Diffuse interstitial thickening worse at the lung apices likely represent
chronic fibrosis. No focal consolidation is detected. The heart is not
enlarged. There is no pneumothorax or pleural effusion.
IMPRESSION:
Diffuse interstitial thickening worse at the lung apices likely represent
chronic fibrosis.
Radiology Report
EXAMINATION: SECOND OPINION CT Head. PSO1SECOND OPINION CT NEUROCT
INDICATION: ___ F with on xarelto, status post fall with head strike, with hip
fx. Evaluate for acute intracranial hemorrhage or fracture.
TECHNIQUE: Noncontrast head CT was performed on ___ 00:33 at ___
___, and was submitted for second opinion review on ___.
DOSE: DLP: ___ MGy-cm
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
There are periventricular and subcortical lucencies, which may represent small
vessel ischemic changes. Atherosclerotic vascular calcifications are noted of
bilateral vertebral and cavernous portions of internal carotid arteries.
There is no evidence of fracture. The visualized portion of the mastoid air
cells, and middle ear cavities are clear. And is status post bilateral lens
replacement. Minimal left sphenoid sinus mucosal thickening is present.
IMPRESSION:
1. No acute intracranial abnormality.
2. No evidence acute intracranial hemorrhage or fracture.
3. Minimal paranasal sinus disease , as described.
4. Atrophy, probable small vessel ischemic changes, and atherosclerotic
vascular disease as described.
Radiology Report
INDICATION: ___ year old woman with right hip pain, fall. Please evaluate
patient's right hip fracture.
TECHNIQUE: Multidetector CT images of the pelvis were acquired without
intravenous contrast at an outside institution (___).
Coronal and sagittal axis reformats were obtained and reviewed. A second read
request was submitted for evaluation.
Oral contrast was not administered.
DOSE: DLP: 1266 mGy-cm
COMPARISON: Radiographs from ___.
FINDINGS:
PELVIS: The imaged small and large bowel loops are within normal limits.
Sigmoid colonic diverticulosis is noted. High-density material along the
cecum may reflect surgical suture material or ingested high-density material.
There is no pelvic free fluid. The bladder is grossly unremarkable. The
uterus is within normal limits for age. There is no adnexal mass. Vascular
calcifications are noted, and there is no aneurysmal dilation of the
infrarenal abdominal aorta or its major branches. There is a small fat
containing umbilical hernia and soft tissue density extending to the skin
surface, best correlated physical exam (05:17).
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
BONES: There is an acute right femoral neck fracture, with both subcapital and
mid femoral neck components, with varus and anterior apex angulation. A small
3 mm fracture fragment is noted superior to the fracture (series 6:image 67).
No other acute fracture or dislocation is noted. There is bilateral moderate
degenerative changes in the hips including joint space narrowing and
osteophytosis.
IMPRESSION:
Right femoral neck fracture with varus and anterior apex angulation
Small fat filled umbilical hernia, with soft tissue density extending from the
subcutaneous fat to the skin, best correlated with physical exam.
Radiology Report
EXAMINATION: SECOND OPINION CT CERVICAL SPINE PSO1SECOND OPINION CT NEUROCT
INDICATION: ___ year old woman status post fall, now with hip pain. Evaluate
for cervical spine fracture.
TECHNIQUE: Noncontrast cervical spine CT was performed on ___ 00:33
at ___, and was submitted for second opinion
review on ___.
DOSE: DLP: 1266 MGy-cm
COMPARISON: None.
FINDINGS:
There is minimal anterolisthesis of C4 on C5.No definite fractures are
identified. Mild-to-moderate degenerative changes are noted, including loss
of intervertebral disc height, Schmorl's nodes, disc osteophyte complexes and
facet joint hypertrophy. There is at least mild spinal canal narrowing at
C5-6 and C6-7 secondary to posterior osteophyte and disc bulge. There is
moderate to severe neural foraminal narrowing at C3-4 on the right. There is
no prevertebral soft tissue swelling.
Limited imaging lungs demonstrate biapical nonspecific lung opacities.
IMPRESSION:
1. Minimal anterolisthesis of C4 on C5, likely degenerative. Please note MRI
of cervical spine is more sensitive for the evaluation of ligamentous injury.
2. No definite evidence of acute fracture.
3. Mild-to-moderate multilevel cervical spondylosis, as described.
4. Limited imaging of the lungs demonstrate biapical nonspecific opacities.
While findings may partially represent fibrotic changes, infectious,
inflammatory, or neoplastic etiologies are not excluded on the basis of this
examination. If clinically indicated, consider correlation with dedicated
chest imaging.
Radiology Report
INDICATION: Right hip fracture. Hemiarthroplasty placement
COMPARISON: Radiographs from ___
IMPRESSION:
Intraoperative images demonstrate placement of a right hemiarthroplasty.
There has been resection of the fractured femoral head. Mild spurring about
the acetabulum is seen. There are no hardware related complications.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old woman with hip fx. Concern for DVT.// DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
There is a fluid collection in the right popliteal fossa which measures 2.9 x
3.5 x 1.0 cm consistent with ___ cyst.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. Right ___ cyst.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFT
INDICATION: ___ year old woman with leg pain.// fracture
TECHNIQUE: Left tib-fib two views
COMPARISON: None
FINDINGS:
Degenerative changes left knee. Arterial calcifications. No fracture.
IMPRESSION:
No fracture
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT
INDICATION: ___ year old woman with point tenderness over fibula// fracture
TECHNIQUE: Right tib-fib two views
COMPARISON: None
FINDINGS:
Degenerative changes right knee, hypertrophic changes, chondrocalcinosis,
medial compartment narrowing. Arterial calcifications. The calcaneal plantar
bone spur
IMPRESSION:
No acute change.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Hip fracture, s/p Fall, Transfer
Diagnosed with Oth fracture of head and neck of right femur, init, Fall on same level, unspecified, initial encounter
temperature: 97.5
heartrate: 94.0
resprate: 18.0
o2sat: 96.0
sbp: 148.0
dbp: 88.0
level of pain: 4
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 hip fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for right 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's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated, and will not be discharged on
additional DVT prophylaxis as she is therapeutically
anticoagulated. The patient will follow up with Dr. ___
___ routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics) / Hibiclens /
nafcillin / Topamax / steroid nerve block
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ y/o female with a history of abdominal wall pain
(left-sided), prior admit ___ for right-sided abdominal
pain of unclear etiology, GERD, depression, anxiety, who
presents here today with ongoing epigastric pain x 1 week. The
patient reports that her symptoms first began one week ago with
profuse, watery diarrhea (no blood) along with uncontrollable
nausea and vomiting. She also had localized, constant, severe
epigastric pain. Due to her symptoms, she was taken to
___ (___) by EMS, where she was
reportedly given a diagnosis of "pancreatitis." She does not
know how this diagnosis was made, but notes she had a CT scan of
her abdomen while there. She was admitted to the medical
service and subsequently underwent an EGD which demonstrated a
hiatal hernia (not new). She was treated with IVF and IV pain
meds and encouraged to try po. She was not able to advance her
diet due to persistent pain and n/v. Per patient, the OSH
decided to discharge her today despite her continued symptoms
and declined to transfer her to ___. Therefore, the patient
was picked up by her mother and brought to the ___ ED.
.
In the ED, VSS. She was given Zofran and Dilaudid 1 mg x 3.
Labs were stable. She was admitted to medicine for pain
control.
.
Currently, she reports ___ epigastric pain, nausea, and
weakness. She says the diarrhea stopped a few days ago. 12-pt
ROS otherwise negative in detail except for as noted above.
Past Medical History:
- Abdominal pain secondary to anterior cutaneous nerve
compression, s/p spinal stimulator placement
- Iron deficiency
- Sleep Apnea
- Migraines
- Adenomatous colonic polyp
- Plantar fasciitis
- Seborrheic Dermatitis
- GERD
- Anxiety
- Major depression
- Obesity
- Abnormal glucose tolerance in pregnancy
- Restrictive Lung disease
- Allergic rhinitis
.
SURGICAL HISTORY:
- Emergency cholecystectomy ___
- History of C-section ___
- Abdominal Cutaneous nerve release at ___ ___
- s/p SCS placement in ___
Social History:
___
Family History:
Mother with breast cancer. Father CAD and HTN.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Tc 99.2, BP 130/84, HR 78, RR 18, SaO2 100/RA
General: uncomfortable-appearing female in NAD, AO x 3
HEENT: Anicteric sclerae, MM dry, OP clear
Neck: supple, no LAD
Chest: CTA-B, no w/r/r
CV: RRR s1 s2 normal, no m/g/r
Abdomen: soft, ND/NABS, TTP over epigastric region with
slightest touch, unable to palpate deeply due to degree of pain.
No rebound, slight voluntary guarding.
Ext: no c/c/e
Skin: warm, dry, no rashes
.
DISCHARGE PHYSICAL EXAM:
VS: AVSS
Gen: NAD, lying in bed.
HEENT: Anicteric, MMM
CV: RRR, no murmurs
Abd: soft, obese, ND, NABS, +TTP diffusely, but easily
distractable, no rebound, no guarding
Ext: no edema, WWP
Skin: dry, warm, no rashes noted
Neuro: AAOx3, fluent speech
Psych: anxious
Pertinent Results:
ADMISSION LABS:
===============
___ 02:40PM WBC-11.6*# RBC-5.31 HGB-14.9 HCT-43.9 MCV-83
MCH-28.1 MCHC-33.9 RDW-14.8
___ 02:40PM NEUTS-66.9 ___ MONOS-6.9 EOS-0.5
BASOS-1.1
___ 02:40PM PLT COUNT-247
___ 02:40PM GLUCOSE-100 UREA N-12 CREAT-0.9 SODIUM-132*
POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-22 ANION GAP-19
___ 02:40PM ALT(SGPT)-49* AST(SGOT)-56* ALK PHOS-151* TOT
BILI-0.6
___ 02:40PM LIPASE-60
___ 02:40PM ALBUMIN-4.7
___ 05:20PM URINE Color-Straw Appear-Hazy Sp ___
___ 05:20PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:20PM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE
Epi-10
.
ADDITIONAL LABS:
================
___ 06:00AM BLOOD WBC-7.2 RBC-4.35 Hgb-12.6 Hct-36.7 MCV-84
MCH-29.0 MCHC-34.4 RDW-15.4 Plt ___
___ 06:00AM BLOOD Glucose-94 UreaN-7 Creat-0.9 Na-140 K-3.3
Cl-101 HCO3-29 AnGap-13
___ 06:00AM BLOOD Lipase-56
.
MICROBIOLOGY:
=============
___ H. pylori serology: NEGATIVE
___ H. pylori serology: NEGATIVE
.
___ 5:35 pm STOOL CONSISTENCY: LOOSE ..
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
___ 1:10 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
___ Abdominal X-ray
FINDINGS:
Spinal stimulator device with wires projecting over the spine is
present. Gas is seen in nondistended loops of small and large
bowel. There are no air-fluid levels and no evidence of
obstruction or free air.
IMPRESSION:
Normal bowel gas pattern.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. ALPRAZolam 0.5 mg PO DAILY
4. ALPRAZolam 1 mg PO QHS
5. QUEtiapine Fumarate 50 mg PO QHS
6. Duloxetine 60 mg PO DAILY
Discharge Medications:
1. Duloxetine 60 mg PO DAILY
2. Gabapentin 300 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. QUEtiapine Fumarate 50 mg PO QHS
5. ALPRAZolam 1 mg PO QHS
6. ALPRAZolam 0.5 mg PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 10 mg ___ tablet(s) by mouth every 6 hours Disp
#*56 Tablet Refills:*0
8. Acetaminophen 1000 mg PO Q6H:PRN pain
9. Ibuprofen 400 mg PO Q8H:PRN pain
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*14 Capsule Refills:*0
11. Senna 8.6 mg PO BID
RX *sennosides 8.6 mg 1 tab oral twice daily Disp #*14 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Post-viral gastroparesis
Chronic abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Severe abdominal pain.
COMPARISON: ___.
FINDINGS:
Spinal stimulator device with wires projecting over the spine is present. Gas
is seen in nondistended loops of small and large bowel. There are no
air-fluid levels and no evidence of obstruction or free air.
IMPRESSION:
Normal bowel gas pattern.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN EPIGASTRIC
temperature: 98.0
heartrate: 106.0
resprate: 20.0
o2sat: 97.0
sbp: 136.0
dbp: 95.0
level of pain: 9
level of acuity: 3.0 | ___ y/o female with above medical history who presents with acute
localized, epigastric pain
.
# Epigastric pain: Recent imaging from ___
___ excluded biliary disease, mass, peptic ulcer disease.
EGD from that admission was unremarkable. The patient's
leukocytosis, mild lipase elevation and abdominal pain were all
conistent with a post-viral gastroparesis versus narcotic bowel
syndrome. She was treated conservatively with pain medications,
nausea medications and, initially, bowel rest. Her diet was able
to be slowly advanced and she was transitioned to a PO pain
regimen. We attempted to down-titrate her opioid pain
medications as empiric treatment for narcotic bowel syndrome,
but she developed worsening abdominal pain.
.
# Diarrhea: Likely viral gastroenteritis related. Stool studies
were unrevealing. Her diarrhea resolved spontaneously. She had
formed stools prior to discharge.
.
# Chronic abdominal pain reportedly due to lateral cutaneous
nerve syndrome: She is s/p spinal stimulator placement. She is
on Cymbalta and Neurontin. The Neurontin dose cannot be further
increased due to somnolence. The Chronic Pain Service followed
the patient while she was hospitalized.
.
# Transaminitis: LFTs appear to be chronically elevated, most
likely due to non-alcoholic fatty liver disease. Hep
serologies/EBV/CMV wnl during last admission ___.
Recent CT abdomen from ___ from OSH was consistent with
NAFLD.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / valproic acid
Attending: ___.
Chief Complaint:
facial droop
Major Surgical or Invasive Procedure:
TPA at outside hospital
History of Present Illness:
Ms. ___ is a ___ woman with a
complex PMHx including NIDDM, bipolar disorder, HL, HTN,
hypothyroidism, osteonecrosis of right knee who presents today
after having gone to an OSH with acute onset of aphasia and
right-sided weakness and transferred to ___ ED for post-tPA
care. She had been in her USOH until the day of presentation
when she had eaten lunch at her assisted living facility and
appeared to be at her baseline when she returned to her room.
However, when she emerged from her room at approximately 1:30pm
today, she was noted to have drooling, appeared confused, was
unable to say her RN's name and then was completely mute per RN
report from assisted living facility. Per ED notes, a right
facial droop was also noted. This part of the history is
somewhat unclear, as no one who witnessed this is available to
discuss this with. It is unclear if 1:30pm is the time she
presented with symptoms or the time she was last seen well.
Concerned, she was taken to an OSH ED (___) for urgent
evaluation.
Upon arrival, her vital signs were all within normal
limits.
Her ___ stroke scale was scored at 13
(0/1/0/0/0/1/1/1/3/3/0/0/1/1/1, especially significant for
reported b/l ___ plegia). She underwent three NCHCTs that were
read as negative. Of note, she required significant sedation
(haldol, ativan, ketamine) in order to obtain the CTs.
Telestroke was called and an NIHSS of 15 (unknown breakdown) was
scored and tPA was given at 1620. She was then transferred to
the ___ ED for further management post-tPA. Upon arrival, a
code STROKE was called and neurology was invited to urgently
consult.
Past Medical History:
Past Medical History:
1. NIDDM
2. bipolar d/o
3. GERD
4. hypothyroidism
5. HL
6. chronic renal insufficiency
7. osteonecrosis of right knee
Past Surgical History
1. ?oopherectomy
Social History:
___
Family History:
no strokes, father died at ___ of MI. older
brother s/p quadruple bypass at 57. No neurological disorders
in
family.
Physical Exam:
At admission:
VS: 96.3 112 110/63 20 100% 2L Nasal Cannula
Genl: Awake, alert, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: soft, obese, NTND, NABS, unclear if ascites present on
examination. +well healed scar in RUQ
Ext: 2+ pitting edema bilaterally to knees
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect for most part, though would get agitated at times during
examination. Oriented to person, place, and date (month =
___). Somewhat inattentive during examination, with having
to repeat simple one-step commands several times. Speech very
dysarthric, but fluent with normal comprehension and repetition,
but does have times when she is fluently aphasic, with
non-sensical speech and with abnormal content of speech (talking
about events from ___ years ago); +perseveration. naming intact.
Reading intact. No evidence of apraxia or neglect.
Cranial Nerves: Pupils equally round but minimally reactive to
light, 2mm bilaterally. Unable to assess visual fields fully,
but
generally seem to be intact. Extraocular movements intact
bilaterally, but with sustained left-beating nystagmus on left
gaze. Sensation intact V1-V3. Facial movement symmetric. Palate
elevation symmetric. Sternocleidomastoid and trapezius full
strength bilaterally. Tongue midline, movements intact.
Motor: Normal bulk and tone bilaterally. No observed myoclonus,
asterixis, or tremor. No pronator drift.
Del Tri Bi WE FE FF IP H Q DF PF TE
R ___ ___ ___ ___
L ___ ___ ___ ___
Sensation: Intact to light touch and pinprick throughout. No
extinction to DSS.
Reflexes: 2+ on right UE and 1+ on left UE. UTO on b/l patellar
or achilles. Upgoing toes b/l.
Coordination: finger-nose-finger normal without dysmetria or
termor.
Gait: deferred.
At discharge:
No deficits
Pertinent Results:
___ 06:40PM WBC-8.3 RBC-3.14* HGB-9.2* HCT-28.0* MCV-89
MCH-29.4 MCHC-33.0 RDW-15.1
___ 06:40PM PLT COUNT-317
___ 06:40PM ___ PTT-19.8* ___
___ 06:40PM CREAT-1.4*
___ 06:40PM UREA N-44*
___ 07:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 07:10PM URINE COLOR-Straw APPEAR-Clear SP ___
ECG:
Sinus tachycardia. Normal tracing. No previous tracing available
for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
110 184 90 322/409 57 -5 42
MRI Brain - limited study:
IMPRESSION: Limited study. The resolution oN DWI is somewhat
suboptimal. No
alrge area of decreased diffusion is noted. Slightly increased
increased DWI signal in the left aprietal lobe is liekly
artifactual. Consider complete study when appropriate.
Chest Xray - 1 view:
IMPRESSION:
Widened mediastinum of unknown chronicity, possibly due to
lymphadenopathy. No hilar lymphadenopathy identified. A chest
CT would be definitive in establishing the cause of this
abnormality.
Electroencephalogram:
IMPRESSION: This EEG done portably is considered borderline
normal.
There is a small amount of theta slowing which could represent
either
excessive drowsiness or medication effect or part of a mild
encephalopathy. There were no clear epileptiform features and,
while
there were some subtle asymmetries suggesting slightly greater
theta
slowing in the right hemisphere, it was not very prominently
noted.
Medications on Admission:
1. Crestor 40 mg Tab Oral 1 Tablet(s) , at bedtime
2. Lisinopril 10 mg Tab Oral 1 Tablet(s) , at bedtime
3. Risperdal 4 mg Tab Oral 1 Tablet(s) , at bedtime
4. senna 8.6 mg Cap Oral 1 Capsule(s) , at bedtime
5. trazodone 100 mg Tab Oral 2 Tablet(s) , at bedtime
6. Synthroid ___ mcg Tab Oral 1 Tablet(s) Once Daily
7. Miralax 17 gram/dose Oral Powder Oral 1 Powder(s) Once Daily
8. Claritin 10 mg Tab Oral 1 Tablet(s) Once Daily
9. Byetta 10 mcg/0.04 mL per dose Sub-Q Pen Injector
Subcutaneous
10. Lantus 100 unit/mL Sub-Q Subcutaneous 50 Solution(s) Twice
Daily
11. Humalog 100 unit/mL SubQ Cartridge Subcutaneous sliding
scale Cartridge(s) Four times daily
12. ___ Aspirin 325 mg Tab Oral 1 Tablet(s) Once Daily
13. omeprazole 20 mg Tab, Delayed Release Oral 1 Tablet, Delayed
Release (E.C.)(s) Once Daily
14. Neurontin 100 mg Cap Oral 1 Capsule(s) Once Daily
15. lithium carbonate 300 mg Tab Oral 1 Tablet(s) Twice Daily
16. Lovaza 1 gram Cap Oral 2 Capsule(s) Twice Daily
17. Lasix 40mg qDay
18. procrit (epogen) 40,000 units q2weeks last received on
___. vicodin 7.5/500 BID
20. cogentin (bentropine) 2mg PO BID
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H PRN ()
as needed for pain.
5. omega-3 fatty acids Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
6. benztropine 1 mg Tablet Sig: Two (2) Tablet PO once a day.
7. risperidone 2 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gram PO DAILY (Daily).
12. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day.
13. trazodone 100 mg Tablet Sig: Two (2) Tablet PO once a day.
14. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Byetta 10 mcg/0.04 mL Pen Injector Sig: One (1) pen
Subcutaneous once a day.
16. Lantus 100 unit/mL Solution Sig: see below units
Subcutaneous twice a day: 50 unit twice daily.
17. Humalog 100 unit/mL Solution Sig: see below unit
Subcutaneous four times a day: sliding scale insulin based on ___
qid.
18. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
19. Epogen 20,000 unit/mL Solution Sig: Two (2) ml Injection
q2weeks: last dose ___.
20. Vicodin ___ mg Tablet Sig: One (1) Tablet PO twice a day.
21. lithium carbonate 150 mg Capsule Sig: ___ Capsule PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
transient neurological event
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro: no deficits
Followup Instructions:
___
Radiology Report
INDICATION: Acute onset aphasia and right-sided weakness with facial droop.
Evaluate for stroke.
TECHNIQUE: Limited non-contrast MRI of the brain. Only diffusion-weighted
images were obtained as the pt. could not continue through the study.
FINDINGS: There are no diffusion abnormalities detected.
IMPRESSION: Limited study. The resolution oN DWI is somewhat suboptimal. No
alrge area of decreased diffusion is noted. Slightly increased increased DWI
signal in the left aprietal lobe is liekly artifactual. Consider complete
study when appropriate.
Radiology Report
INDICATION: Possible seizures of unknown etiology. Evaluate for lung
pathology.
COMPARISONS: None available.
SEMI-UPRIGHT PORTABLE RADIOGRAPH OF THE CHEST: The lungs are clear. The
upper mediastinum is widened. The cardiac and hilar margins are normal.
There is no pneumothorax or pleural effusion. The pulmonary vascularity is
normal.
IMPRESSION:
Widened mediastinum of unknown chronicity, possibly due to lymphadenopathy.
No hilar lymphadenopathy identified. A chest CT would be definitive in
establishing the cause of this abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: NEURO DEFECITS
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, DIABETES UNCOMPL ADULT
temperature: 96.3
heartrate: 112.0
resprate: 20.0
o2sat: 100.0
sbp: 110.0
dbp: 63.0
level of pain: 0
level of acuity: 1.0 | ___ woman with a complex PMHx including NIDDM, bipolar
disorder, HL, HTN, hypothyroidism, osteonecrosis of right knee
who presented after having gone to an OSH with acute onset of
apparent confusion/aphasia with right facial droop and drooling
and possible right-sided weakness and transferred to ___ ED on
___ for post-tPA care and latterly admitted to the ICU for
monitoring. The telestroke scoring does mentioned NIHSS of 15
and was given IV tPA - however, there was bilateral arm and leg
weakness noted on the telestroke examination which may be more
suggestive of weakness in the post-ictal phase after a seizure.
On examination on ___ she had no obvious deficits and instead
was felt to be manic, hallucinating with pressured speech,
flight of ideas and very tangential. Her lithium and risperidone
were continued at her home doses. Repeat CT scans requiring
significant sedation were unrevealing. Due to her agitation, the
only MRI sequence that could be obtained was the restricted
diffusion sequence. There was no area of diffusion restriction
to indicate a stroke(an area posteriorly on left is likely
artifactual) or obvious hemorrhage. She underwent a routine EEG,
which did not show any seizures or epileptiform abnormalities.
She remained clinically stable. All her home medications were
continued.
Her transient aphasia and right sided facial droop may have been
the result of a transient ischemic attack. She was diagnosed
with a TIA. It is also possible that her psychiatric disorder
may have played a role in her presentation. She remained
clinically stable and her mood returned to baseline as well. She
was transferred to the floor ___. Physical therapy saw and
evaluated her and recommended that she be sent back to her home
without need for acute rehabilitation.
.
Code Status: DNR/DNI -- confirmed by accompanying paperwork and
mother ___: ___
.
=============================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
RLQ abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
History of Present Illness:
___ w/h/o celiac disease p/t ER with RLQ pain x 2 days. He
initially started having pain on ___ morning, which he
thought was related to his celiac disease. He induced vomiting
with mild improvement in his pain. He has had chills but no
fevers. He had no appetite on day prior to admission. This AM,
his pain became slightly worse so he came to the ER for
evaluation. He currently notes ___ pain in his RLQ.
Past Medical History:
PMH: Celiac disease
PSH: denies
Social History:
___
Family History:
Non-contributory
Physical Exam:
PE on admission:
Vitals:98 92 139/72 15 99%
Gen: NAD
CV: RRR
ABD: S, TTP RLQ
EXT: No c/c/e
On discharge:
VS: 99.8, 76, 112/68, 18, 98% RA
Gen: NAD, AAOx3
CV: RRR
Pulm: CTAB
Abd: soft, appropriately TTP about incisions, non-distended, no
rebound/guarding
Ext: WWP, no c/c/e
Pertinent Results:
Labs:
___:
132 | 93 | 10 AGap=17
--------------<122
3.8 | 26 | 1.1
ALT: 17 AP: 59 Tbili: 0.8 Alb: 4.8
AST: 20 Lip: 31
9.6>15.8/46.9<115
N:87.7 L:5.3 M:6.2 E:0.2 Bas:0.5
CT:Dilated, air filled appendix with a small amount of
surrounding fluidand stranding. No drainable collection.
Hypodensity in the liver thought to be hemangioma, not liver
abscess.
Medications on Admission:
Denies
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drive nor operate other machinery while using narcotics
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with right lower quadrant abdominal pain, evaluate for
appendicitis.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after the administration of intravenous contrast. Axial images were
interpreted in conjunction with coronal and sagittal reformats. Oral contrast
was not administered.
DLP: 466 mGy-cm
COMPARISON: None available.
FINDINGS:
CHEST: The visualized lung bases are clear. The heart is normal in size and
there is no evidence of pericardial effusion.
ABDOMEN:
The liver enhances homogeneously. There is a 1.5 cm hypodense lesion
demonstrating an area of peripheral nodular enhancement in segment ___ of the
liver, which likely represents a hemangioma (2:16; 601b: 10).. The portal
venous system is patent. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is normal and without gallstones.
The spleen and adrenal glands are unremarkable. The pancreas enhances
homogenously and is without focal lesions.
The kidneys display symmetric nephrograms and excretion of contrast. There are
no focal renal lesions. There is no hydronephrosis. The ureters are normal in
caliber along their course to the bladder..
The distal esophagus is normal without a hiatal hernia. The stomach is grossly
unremarkable in appearance. The small and large bowel are normal in caliber
and without evidence of wall thickening.
The appendix is air-filled and dilated measuring up to 11 mm with extensive
surrounding fat stranding and a small amount of fluid (02:59). There is a tiny
appendicolith at the base of the appendix (2:67). Two foci of air lateral to
the cecum are likely intraluminal (2:69). There is no definite extraluminal
air or drainable fluid collection.
The abdominal aorta and its major branches are patent . The aorta and iliac
branches are normal in course and caliber. There is no retroperitoneal
lymphadenopathy. There are small mesenteric nodes adjacent to the cecum,
likely reactive.
PELVIS:
The bladder is well distended and normal. There is no pelvic side-wall or
inguinal lymphadenopathy by CT size criteria. There is a small amount of
pelvic free fluid.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy.
IMPRESSION:
1. Acute appendicitis with a small amount of surrounding fluid. No drainable
fluid collection.
2. Probable 1.5 cm hemangioma in segment ___ of the liver.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 1030AM, 10 minutes after discovery of the
findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 98.0
heartrate: 92.0
resprate: 15.0
o2sat: 99.0
sbp: 139.0
dbp: 72.0
level of pain: 4
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed results as above, no
leukocytosis. The patient underwent laparoscopic appendectomy,
which went well and without complication (please see the
Operative Note for full details). After a brief, uneventful stay
in the PACU, the patient arrived on the floor tolerating clear
liquids, on IV fluids, and with IV pain meds for pain control.
The patient was hemodynamically stable.
When tolerating a diet, the patient was transitioned to oral
pain medication with continued good effect. Diet was
progressively advanced as tolerated to a regular diet without
nausea/emesis. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
The patient is discharged to home on ___ with appropriate
information, warnings, prescriptions, and plans to follow up in
clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
1. Posterior thoracic fusion T12 to L1.
2. Posterior lumbar fusion L1, L2.
3. Posterior instrumentation T1, L1, L2.
4. Open treatment, lumbar fracture.
5. Allograft, for fusion.
6. Autograft, local, for fusion.
History of Present Illness:
___ y/o ___ chef at ___ was walking up stairs with table when
he dropped table and lost balance, fell backwards hitting wall
with hyperextension injury. Immediate pain. Went to OSH, ___,
found to have L1 and t12 vertebral body fractures. Transferred
to ___ for care. Denies LOC +HS. No other
complaints
Past Medical History:
HTN
HLD
sciatica
Social History:
Occupation: ___
Physical Exam:
General:Well appearing in NAD, sitting up in bed
Heart:RRR
Lungs:CTAB,no adventitious breath sounds
Abd:soft,nt,nd,+bs's
Extremitites:WWP,2+rad/2+dp,brisk capillary refill
___ throughout ___
+SILT and equal throughout
No clonus
Pertinent Results:
___ 05:25AM BLOOD WBC-9.3 RBC-4.90 Hgb-12.8* Hct-40.0
MCV-82 MCH-26.1* MCHC-32.0 RDW-15.1 Plt ___
___ 12:41AM BLOOD Neuts-84.9* Lymphs-8.6* Monos-5.3 Eos-0.8
Baso-0.3
___ 05:25AM BLOOD Glucose-116* UreaN-13 Creat-0.6 Na-139
K-4.4 Cl-102 HCO3-31 AnGap-10
___ 12:41AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.2
Medications on Admission:
Atenolol
Lisinopril
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
Please take while on pain medication
3. Lisinopril 40 mg PO DAILY
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Please do not operate heavy machinery, drink alcohol or drive
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
1. Ankylosing spondylitis.
2. L1 three-column fracture.
3. Spinal instability.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRA T/SP AND L/SP
INDICATION: History: ___ with T12-L1 fx // ? cord compression ? cord
compression
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed.
COMPARISON: Lumbar spine CT ___.
FINDINGS:
Again seen is anterior subluxation of L3 upon L4. Again seen are fractures of
the T12 and L1 vertebral bodies. These appear acute with high signal intensity
on the STIR images. There is a small amount of disc material retropulsed into
the spinal canal at the T12-L1 level. This slightly flattens the anterior
surface of the conus but does not appear to produce spinal cord compression.
The conus medullaris ends at L1-2.
The STIR images demonstrate hyper intensity in the T12 spinous process
consistent with the known fracture. There is hyperintensity in the
interspinous ligament suggesting injury to this structure. The ligamentum
flavum appears intact and there is no evidence of a through and through tear
of the interspinous ligament. The supraspinous ligament appears intact.
There are small disc protrusions at T4-5 and T ___ that slightly encroach on
the spinal canal but do not compress the spinal cord.
There is hyperintensity in the T6 vertebral body superior endplate on the STIR
images suggesting a nondisplaced fracture in this location.
There is no evidence of infection or neoplasm.
IMPRESSION:
T6 superior endplate fracture and fractures of T12 and L1.
Small disc protrusions encroachment on the spinal canal, most prominent at
T12-L1 where. It is slightly flattens the anterior surface of the spinal cord.
Ligamentous hyperintensity involving the interspinous ligaments at T12-L1.
Without evidence of a through and through tear.
Hyperintensity of the T12 spinous process consistent with a fracture.
Radiology Report
INDICATION: Status post motor vehicle accident. Evaluate for fracture.
COMPARISONS: CT of the thoracic and lumbar spine, obtained concurrently at
the time of this exam.
TECHNIQUE: Contiguous helical axial MDCT images were obtained through the
cervical spine from the base of the skull to the apices of the lungs without
the administration of IV contrast. Sagittal and coronal reformatted images
were obtained and reviewed. Note, the CT was obtained at ___.
The emergency room requested a second read.
TOTAL DLP: 624.04 mGy-cm.
CTDI VOLUME: 33.73 mGy-cm.
FINDINGS: There is no abnormality of the prevertebral soft tissues. No
fracture is identified. Straightening of the normal cervical lordosis is
likely due to positioning. Alignment is otherwise normal. Moderate
multilevel degenerative changes are noted throughout the cervical spine with
small posterior disc osteophyte complexes, disc space height loss, and facet
hypertrophy. Mild loss of vertebral body height in C6 and C7 is likely
chronic. No acute fracture line is identified.
The imaged portions of the brain are normal. There is no cervical
lymphadenopathy. The thyroid gland is normal. The apices of the lungs are
clear.
IMPRESSION:
1. No acute fracture or malalignment.
2. Mild loss of height in C6 and C7 is likely chronic.
3. Moderate multilevel degenerative changes.
Radiology Report
INDICATION: Status post motor vehicle crash. Evaluate for fracture.
COMPARISONS: CTs of the cervical and lumbar spine, obtained concurrently at
the time of this exam.
TECHNIQUE: Contiguous helical axial MDCT images were obtained through the
thoracic spine. Sagittal and coronal reformatted images were obtained and
reviewed. Note, this CT was obtained at ___. A second read was
requested by the emergency room physician.
TOTAL DLP: ___ mGy-cm.
CTDI VOLUME: 54.52 mGy.
FINDINGS: The vertebral bodies T1 through T10 are included in this CT. The
vertebral bodies T11 and T12 are best evaluated on the lumbar spine CT. In
the vertebral bodies that are imaged, there is no evidence for fracture. A
nondisplaced fracture in T6 is better evaluated on the MRI obtained after this
exam was reported. Alignment is normal. Moderate multilevel degenerative
changes are noted with flowing anterior osteophytes, consistent with DISH.
There is no significant central canal or neural foraminal narrowing.
The imaged portions of the lungs are clear. There is no pleural effusion.
The imaged portions of the thoracic and abdominal aorta are normal in caliber.
The imaged portions of the liver, spleen and kidneys are normal. The
paraspinal musculature is symmetric.
IMPRESSION:
1. No evidence of an acute fracture in the vertebral bodies T1 through T10 on
CT, though a nondisplaced T6 fracture is visualized on the subsequent MRI.
T11 and T12 are best imaged on the lumbar spine CT.
2. Moderate multilevel degenerative changes.
3. Evidence of DISH.
Radiology Report
INDICATION: Status post motor vehicle crash. Evaluate for fracture.
COMPARISONS: CT of the cervical and lumbar spine, obtained concurrently at
the time of this exam.
TECHNIQUE: Helical axial MDCT images were obtained through the lumbar spine
without the administration of IV contrast. Sagittal and coronal reformatted
images were obtained and reviewed. Note, this CT was obtained at ___
___. A second opinion was requested by emergency room physicians.
TOTAL DLP: 1516.7 mGy-cm.
CTDI VOLUME: 54.17 mGy.
FINDINGS: There is a minimally displaced fracture through the anterior
superior endplate of L1 with associated mild loss of vertebral body height.
The fracture extends posteriorly within the vertebral body, though does not go
through the posterior cortex. The L1 transverse and spinous processes appear
normal. This is consistent with a hyperflexion injury. There is a
non-displaced fracture through the spinous process of T11. No other fractures
are identified. Alignment is normal.
There are five lumbar-type vertebral bodies. Moderate multilevel degenerative
changes are noted including a calcified disc osteophyte complex at T12-L1 that
is causing a moderate central canal narrowing. There is severe multilevel
facet hypertrophy. Alignment is normal.
The psoas and paraspinal musculature is symmetric. There are mild
atherosclerotic calcifications in the abdominal aorta. No large soft tissue
hematoma is identified. The imaged portions of the kidneys are normal.
IMPRESSION: Minimally displaced fractures of the L1 vertebral body and
non-displaced fracture of the T12 spinous process. Note, these fractures and
the central canal are better evaluated by MRI.
Radiology Report
HISTORY: Fusion T12-L2.
LSPIONE, 3 INTRAOPERATIVE VIEWS OBTAINED PORTABLY IN THE OR.
COMPARISON: Selected review of L-spine CT from ___ showing a fracture of
the L1 vertebral body and a minimally displaced fracture of T12 spinous
process probably involving the posterior elements on both sides.
Images from the current exam are not labeled as to order. Two are lateral
and one is frontal.
On what is presumed to be the first view, a surgical marker is present and
overlies the posterior elements at the level of presumptive L2 vertebral body.
Additional surgical instrumentation and materials are present.
On the AP view, pedicle screws are seen at the presumptive T12, L1 and L2
levels.
On what is labeled as view #2, pedicle screws are seen on a lateral projection
at the T12, L1 and L2 levels, in nominal alignment.
IMPRESSION: Views related to placement of pedicle screws at T12, L1 and L2,
in nominal alignment. Correlation with real-time findings is recommended for
further assessment.
Radiology Report
INDICATION: Fracture.
COMPARISON: CT dated ___.
TWO VIEWS, LUMBAR SPINE:
There is an overlying brace. There has been posterior fixation of T12-L2 with
pedicle screws and spinal rods. The L1 fracture is again noted. There is
mild progression in the degree of vertebral body height loss. There is good
alignment. There is grade 1 anterolisthesis of L3 on L4 as before. Lower
lumbar facet arthropathy is also noted.
The bowel gas is nonspecific with a few scattered air-fluid levels. No
definitive dilated bowel loops are appreciated and air noted within the
rectum.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with FX DORSAL VERTEBRA-CLOSE, OVEREXERTION FROM SUDDEN STRENUOUS MOVEMENT
temperature: 97.2
heartrate: 148.0
resprate: 20.0
o2sat: 100.0
sbp: 157.0
dbp: 90.0
level of pain: 6
level of acuity: 1.0 | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition.TEDs/pnemoboots were used for
postoperative DVT prophylaxis.Intravenous antibiotics were
continued for 24hrs postop per standard protocol.Initial postop
pain was controlled with a PCA.Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet.Foley was removed on POD#2.Physical therapy
was consulted for mobilization OOB to ambulate.Hospital course
was otherwise unremarkable.On the day of discharge the patient
was afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ Enema / fresh fruit / fresh vegetables / Biaxin /
cefuroxime / Verapamil
Attending: ___.
Chief Complaint:
Lightheadedness w/associated shortness of breath and chest
pressure
Major Surgical or Invasive Procedure:
none this hospitalization
History of Present Illness:
Ms. ___ is a ___ with PMH of HCM (asymetric LVH,
anteroseptal wall thickness 1.7 in ___, MR, HTN, HLD
presenting with worsening chest pain x2 days. Pt has history of
substernal chest pressure and DOE in the past that had been
stable until two days ago. She has been under a lot of stress as
her husband is in the hospital and she has has been responsible
for running his business. Over the past two days, she's had
multiple episodes of substernal chest pressure, lasting ~20 min,
associated with shoulder discomfort, diaphoresis, and
lightheadedness. Relieved with rest. She reports 2 episodes
yesterday and 2 the day before yesterday. Chest pressure worsens
with exertion and pt endorses dyspnea with exertion. She has
been eating and drinking well. No fever, chills, N/V, abd pain,
or changes in BM. She reports ___ edema intermittently that is
chronic and Lt>Rt. Denies orthopnea, PND, syncope, or
palpitations.
In the ED, initial vitals were 99.0 67 ___ 18 97%.
She was given morphine for chest pain. ASA 325mg in ___. She
became hypotensive in the ED to 80's that improved with 1L NS.
EKG at baseline and trops x2 negative.
Labs notable BUN/Cr ___.
Upon arrival to the floor, vitals are 97.6 92/55 60 20 98% on
RA. She denies chest pain. Endores fatigue and thirst.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
HOCM: LV outflow tract obstruction
Hypertension
hyperlipidemia
Diabetes
Anemia-iron deficiency
Paget's disease
Vertebral artery stenosis
Social History:
___
Family History:
Her father died at the age of ___ of heart disease from
hypertension. Her mother died at ___ of alzheimers
Physical Exam:
ADMISSION PHYSICAL EXAM:
=================
Vitals - 97.6 92/55 60 20 98% on RA.
GENERAL: average build AA female with mild distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, early peaking systolic murmur best heard in
the left sternal border, louder w/ valsalva maneuver
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 1+ edema above ankle in the LLE, no edema in RLE,
warm and well perfused
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
==================
Vitals - 63.6kg, temp 98, 118-120/56-59, rr16, pulse 69, 98%RA
GENERAL: AA female, in no acute distress. Resting comfortably in
bed. AAOx3.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, early peaking systolic murmur best heard in
the left sternal border, louder w/ valsalva maneuver. 2+ radial
pulses, 2+ DP/PTs. No lower extremity edema.
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: 1+ edema above ankle in the LLE, no edema in RLE,
warm and well perfused
PULSES: See CV
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
PERTINENT LABS/STUDIES:
================
___ 03:00PM BLOOD WBC-3.9* RBC-4.78 Hgb-13.0 Hct-43.0
MCV-90 MCH-27.3 MCHC-30.3* RDW-17.7* Plt ___
___ 06:40AM BLOOD WBC-3.2* RBC-4.06* Hgb-10.9* Hct-35.8*
MCV-88 MCH-26.8* MCHC-30.4* RDW-18.0* Plt ___
(note that this second set of labs was performed after patient
received fluids)
___ 03:00PM BLOOD Glucose-82 UreaN-26* Creat-1.1 Na-139
K-4.3 Cl-106 HCO3-20* AnGap-17
___ 06:40AM BLOOD Glucose-96 UreaN-25* Creat-1.0 Na-139
K-4.2 Cl-109* HCO3-24 AnGap-10
___ 03:00PM BLOOD Calcium-9.3 Phos-3.1 Mg-2.2
___ 06:40AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.1
CARDIAC ENZYMES:
=============
___ 03:00PM BLOOD CK-MB-8 cTropnT-<0.01
___ 10:15PM BLOOD cTropnT-<0.01
IMAGING:
=======
EXERCISE STRESS TEST (___):
Good exercise tolerance. No anginal symptoms or pre-syncope
reported. ST segments are uninterpretable for ischemia in the
presence
of LBBB. Blunted systolic blood pressure response to exercise.
Blunted
heart rarte response in the presence of beta blocker therapy.
Echo
report sent separately.
ECHOCARDIOGRAM (___):
Good functional exercise capacity. Uninterpretable ECG in the
setting of a left bundle branch block. Mild resting LVOT
obstruction with minimal increase in gradient (from 16 mmHg to
20 mmHg) wih exertion. Abnormal hemodynamic response to
exercise. Mild mitral regurgitation. Mild to moderate tricuspid
regurgitation.
Compared with the prior study (images reviewed) of ___, the
LVOT inducible gradient has decreased (previously 30 mmHg) and
no mid-cavitary or apical gradients are identified. The left
ventricular systolic function is no longer borderline
hyperdynamic.
CHEST XRAY (___):
The lungs are clear without focal consolidation. No pleural
effusion or
pneumothorax is seen. The cardiac stable with mild enlargement.
Mediastinal
and hilar contours are also stable. .
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. NexIUM (esomeprazole magnesium) 20 mg oral QD:PRN acid reflux
5. Aldactazide (spironolacton-hydrochlorothiaz) ___ mg oral qd
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. NexIUM (esomeprazole magnesium) 20 mg oral QD:PRN acid reflux
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypertrophic cardiomyopathy
Secondary:
Hypovolemia
Hypertension
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with CP // eval pna
TECHNIQUE: Chest Frontal and Lateral
COMPARISON: ___
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac stable with mild enlargement. Mediastinal
and hilar contours are also stable. .
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS, ABNORM ELECTROCARDIOGRAM
temperature: 99.0
heartrate: 67.0
resprate: 18.0
o2sat: 97.0
sbp: 96.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ with PMH of HOCM (asymetric LVH,
anteroseptal wall thickness 1.7 in ___, mild/mod MR, HTN, HLD
presenting with chest discomfort on exertion x 2 days in the
context of reduced PO intake, and additional exertional
activities.
# Chest pain:
Patient has had chest discomfort, and
lightheadedness/pre-syncope in the context of poor PO intake,
additional exertion (both climbing flights of steps to see her
husband in the hospital, and managing his two stores by
accepting deliveries). Her exertion has been significantly above
her normal baseline where she is at home the majority of the
time. She was found to have no ischemic changes on EKG after
admission and had troponins x 2 that were negative. She received
fluids in the ER and also on the floor during hospitalization,
with a profound change in her CBC values, indicative of
significant hemoconcentration at admission. She remained chest
pain free throughout her hospitalization, and received an
exercise treadmill test that indicated she has good exercise
tolerance with no indication of ischemia. This test did not
achieve target heart rate given her beta blocker onboard. Before
admission she walked up 12 steps and became lightheaded with
chest pain. Before discharge, she walked with MD up and down >30
steps with no chest pain, no lightheadedness. She stated this
was a significant improvement for her. She was monitored on
telemetry throughout her hospitalization with no significant
events. At discharge, she should continue her ASA 81 and
Atorvastatin 20.
# HOCM: As evident on ETT-echo in ___ with asymetric LVH,
anteroseptal wall thickness 1.7 in ___. Pt became hypotensive
to 80's upon receiving BP meds in the ED that was concerning for
worsening LVOT gradient. However, she received fluids and an
echocardiogram that actually showed a DECREASED LVOT gradient
from previous, that as noted above, points to a hypovolemic role
due to low preload for her symptoms this hospitalization. In
addition, she has a known history of anemia that is being worked
up in the outpatient setting, including receiving both an
endoscopy and colonoscopy that offer no bleeding source. She is
now on iron supplementation for the anemia. Because she is
likely preload dependent and has not been taking in appropriate
amounts of PO fluids, we discussed the importance of drinking
non-caffeinated, non-alcoholic drinks more frequently and on
discharge we held her spironolactone/thiazide, as this may have
caused hypovolemia and her symptoms.
# HTN:
Hypotensive to 90's/50's upon arrival to floor. Became
hypotensive to 80's in the ED upon receiving home BP meds.
Likely due to hypovolemia both from poor PO intake, and from her
diuretic. With fluids her blood pressures stabilized, and on
discharge we held her diuretic.
# Dyslipidemia:
Stable. Continue atorvastatin 20mg |
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:
___ with H/O CAD, AAA, ventricular ectopy, hypertension,
hyperlipidemia, hypothyroidism and leg weakness who presents
with fall.
Patient reported that around 3 ___ on the day of admission, he
fell after walking around outside as part of recommendations by
Physical Therapy to walk using an assistive device (usually uses
a cane, waiting for a walker). He denied any loss of
consciousness and was completely aware during the entire time
but did report feeling mildly dizzy and lightheaded just before
the event. He experienced no palpitations nor other prodromal
symptoms. He did not hit his head. He has felt leg weakness
since this morning while walking.
Of note, the patient has had recurrent issues with feeling lower
extremity weakness which he states in his knees. He does not
state that there is actual muscle weakness and is able to get up
on his own most of the time. Sometimes he feels lightheaded or
dizzy beforehand but not always. He does report an issue with
orthostatic BP so was instructed by his PCP to stop his
lisinopril and HCTZ after being recently admitted to ___
___ in ___ for a fall.
Patient denies any fevers, chills, chest pain, shortness of
breath, nausea, vomiting, diarrhea, new numbness and tingling,
urinary symptoms.
In the ED, initial VS were T 98.4 70 BP 158/72 HR 18 SaO2 96% on
RA. Negative orthostatics in the ED. Troponin-T was 0.08 in the
ED with negative CK-MB.
Past Medical History:
-History of abdominal aortic aneurysm
-Coronary artery disease
-Hypercholesterolemia
-Hypertension
-Stable angina
-BPH
-Urinary retention
-Bladder calculus
Social History:
___
Family History:
non-contributory
Physical Exam:
On admission
GENERAL: Elderly white man in NAD, exceptionally hard of hearing
VS: T 97.5 PO BP 172/97 HR 71 RR 18 SaO2 96% on RA
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
mucous membranes moist
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: not distended, non-tender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis or clubbing but 1+ pitting edema in the
___ up to knee
NEURO: A&Ox3, CN II-XII intact, moving upper extremities freely
but with some mild tremor and ___ ___ strength with sensation and
rough proprioception intact.
SKIN: No rashes
At discharge
GENERAL: lying comfortably in bed in no apparent distress,
A/Ox3, with difficulty hearing questions
VITALS: Tc 98.2 BP 130-160/70-90 HR 62 RR 20 SaO2 95% on RA
HEENT: pink conjunctiva, no pain with neck flexion or extension
LUNGS: Unlabored respirations, CTAB--no wheezes, rhonchi, or
crackles
CV: RRR, no JVP appreciated, 2+ DP pulses, ___ systolic ejection
murmur at right sternal border
ABDOMEN: soft, not distended, no tenderness to palpation, +BS
EXTREMITIES: Mild bilateral upper extremity tremor, 1+
bilateral lower extremity edema to the knees
Pertinent Results:
___ 07:34PM BLOOD WBC-8.1 RBC-4.15* Hgb-13.3* Hct-40.9
MCV-99* MCH-32.0 MCHC-32.5 RDW-14.5 RDWSD-53.0* Plt ___
___ 07:34PM BLOOD Neuts-83.4* Lymphs-8.1* Monos-7.6
Eos-0.1* Baso-0.6 Im ___ AbsNeut-6.76* AbsLymp-0.66*
AbsMono-0.62 AbsEos-0.01* AbsBaso-0.05
___ 08:14PM BLOOD ___ PTT-27.5 ___
___ 07:34PM BLOOD Glucose-108* UreaN-16 Creat-1.1 Na-140
K-4.1 Cl-103 HCO3-23 AnGap-18
___ 07:34PM BLOOD CK-MB-6 cTropnT-0.08* proBNP-4299*
___ 11:30PM BLOOD CK-MB-12* MB Indx-7.5* cTropnT-0.39*
___ 07:30AM BLOOD CK-MB-13* MB Indx-7.0* cTropnT-0.37*
___ 07:34PM BLOOD TSH-0.92
___ 07:34PM BLOOD T4-7.1
___ 07:34PM BLOOD VitB12-271
ECG ___ 2:01:56 AM
Sinus rhythm with first degree A-V conduction delay. Right
bundle-branch block. Indeterminate frontal plane QRS axis.
Ventricular premature depolarizations. Diffuse non-specific
repolarization abnormalities. Compared to the previous tracing
of ___ multiple abnormalities as previously described
persist without major change.
CXR ___
Biapical pleuroparenchymal scarring is again seen. No focal
consolidation, large effusion or pneumothorax is seen. A subtle
nodular opacity is seen at the left lung base overlying the left
heart border, incompletely characterized. If needed a CT of the
chest can be performed on a nonemergent basis to further assess.
No signs of congestion or edema. Cardiomediastinal silhouette is
stable with an unfolded calcified thoracic aorta. Bony
structures are intact.
IMPRESSION: Apparent nodule at the left lung base can be further
assessed on a nonemergent CT if clinically indicated. Otherwise
unremarkable.
Head CT ___
There is no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are prominent consistent with
involutional changes. Periventricular white matter
hypodensities are nonspecific but suggestive of mild chronic
ischemic microvascular changes. Suggestion of tiny chronic left
cerebellar infarct, similar.
No osseous abnormalities seen. There is mucosal thickening of
the paranasal sinuses involving ethmoid, sphenoid sinuses, most
prominent and moderate in the left sphenoid sinus, mildly more
prominent compared to prior suggestion of microcalcification in
the nodular opacification along the floor of the sphenoid sinus,
can be seen with fungal infection,. Chronic sphenoid sinus
periostitis. The remaining paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The orbits are
unremarkable.
IMPRESSION: No intracranial hemorrhage. Paranasal sinus disease,
with suggestion of fungal infection in the sphenoid sinus.
Vasodilator nuclear stress test ___
This ___ year old man with recent NSTEMI and multiple PCIs and
LVEF of ~40% was referred to the lab for evaluation. The patient
was infused with 0.142 mg/kg/min of dipyridamole over 4 minutes.
No arm, neck, back or chest discomfort was reported by the
patient throughout the study. The baseline EKG showed deep TWI
in V2-5. At peak infusion there is an additional 1.5-2 mm STD in
these leads. They returned to baseline in recovery following the
reversal of dipyridamole with 125 mg of aminophylline IV. The
rhythm was sinus with rare isolated vpbs and one apb.
Appropriate hemodynamic response to the infusion and recovery.
IMPRESSION: No anginal type symptoms or interpretable ST segment
changes.
IMAGING: The image quality is satisfactory. Left ventricular
cavity size is enlarged at 147 ml and gets larger at exercise.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium.
Gated images reveal global hypokinesis with akinesis at the
apex. The calculated left ventricular ejection fraction is 40%.
Compared with prior study of ___, there are no longer perfusion
defects seen.
IMPRESSION:No perfusion defects, but large LV and global
hypokinesis consistent with cardiomyopathy.
Echocardiogram ___:
The left atrial volume index is mildly increased. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF = 35 %) secondary to hypokinesis of the inferior
septum, posterior wall, and apex (with focal apical dyskinesis)
and akinesis of the inferior free wall. Right ventricular
chamber size and free wall motion are normal. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is borderline pulmonary artery systolic hypertension. There is
no pericardial effusion.
DISCHARGE LABS
___ 08:15AM BLOOD WBC-8.0 RBC-4.41* Hgb-14.1 Hct-43.9
MCV-100* MCH-32.0 MCHC-32.1 RDW-14.6 RDWSD-54.6* Plt ___
___ 08:15AM BLOOD Glucose-85 UreaN-15 Creat-0.9 Na-142
K-4.5 Cl-103 HCO3-23 AnGap-16
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Isosorbide Dinitrate ER 30 mg PO DAILY
4. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Carvedilol 6.25 mg PO BID
4. Clopidogrel 75 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Non-ST segment elevation myocardial infarction
-Coronary artery disease
-Mechanical fall
-Acute left ventricular systolic heart failure
-Hypertension
-Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with generalized weakness// ?pneumonia or heart failure
COMPARISON: ___
FINDINGS:
AP portable upright view of the chest. Biapical pleuroparenchymal scarring is
again seen. No focal consolidation, large effusion or pneumothorax is seen.
A subtle nodular opacity is seen at the left lung base overlying the left
heart border, incompletely characterized. If needed a CT of the chest can be
performed on a nonemergent basis to further assess. No signs of congestion or
edema. Cardiomediastinal silhouette is stable with an unfolded calcified
thoracic aorta. Bony structures are intact.
IMPRESSION:
Apparent nodule at the left lung base can be further assessed on a nonemergent
CT if clinically indicated. Otherwise unremarkable.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with fall with NSTEMI with possible need to start
hep gtt// Eval for e/o bleed
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head from ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are prominent consistent with involutional changes. Periventricular
white matter hypodensities are nonspecific but suggestive of mild chronic
ischemic microvascular changes. Suggestion of tiny chronic left cerebellar
infarct, similar.
No osseous abnormalities seen. There is mucosal thickening of the paranasal
sinuses involving ethmoid, sphenoid sinuses, most prominent and moderate in
the left sphenoid sinus, mildly more prominent compared to prior suggestion of
microcalcification in the nodular opacification along the floor of the
sphenoid sinus, can be seen with fungal infection,. Chronic sphenoid sinus
periostitis. The remaining paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No intracranial hemorrhage.
Paranasal sinus disease, with suggestion of fungal infection in the sphenoid
sinus.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Weakness
Diagnosed with Weakness
temperature: 98.4
heartrate: 70.0
resprate: 18.0
o2sat: 96.0
sbp: 158.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with H/O CAD s/p coronary angiography ___,
AAA, ventricular ectopy, hypertension, hyperlipidemia, and
hypothyroidism who had leg weakness and suffered a fall while
ambulating with his cane. Patient was awaiting a walker because
he had experienced ___ falls in the 6 months prior while
ambulating with his cane.
ED EKG showed new ST depressions compared with prior EKG.
Troponin-T were elevated to 0.39 with peak CK-MB 13. Patient was
started on heparin gtt. Dipyridamole-MIBI showed no perfusion
defects, but enlarged left ventricle and global hypokinesis with
LVEF 40% consistent with cardiomyopathy (likely representing
underlying multivessel coronary artery disease). Echocardiogram
confirmed LVEF = 35% secondary to hypokinesis of the inferior
septum, posterior wall, and apex (with focal apical dyskinesis)
and akinesis of the inferior free wall (at least RCA disease).
He ambulated and did not develop chest pain or hemodynamic
instability. Given his need for a walker, he was not an ideal
candidate for CABG given his decreased rehabilitation potential.
Medical management was chosen with DAPT with aspirin and
clopidogrel. He was discharged to a rehabilitation facility. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Nitrate Analogues / Codeine / Percocet / Erythromycin
Base / Compazine / Lipitor / Xanax / prednisone / Seroquel /
verapamil / aspartame
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
==============
___ 08:08PM BLOOD WBC-20.2* RBC-5.32* Hgb-14.1 Hct-46.2*
MCV-87 MCH-26.5 MCHC-30.5* RDW-13.9 RDWSD-44.3 Plt ___
___ 08:08PM BLOOD Neuts-85.9* Lymphs-7.7* Monos-4.9*
Eos-0.2* Baso-0.3 Im ___ AbsNeut-17.35* AbsLymp-1.55
AbsMono-1.00* AbsEos-0.04 AbsBaso-0.07
___ 08:08PM BLOOD Glucose-432* UreaN-16 Creat-1.0 Na-133*
K-4.4 Cl-97 HCO3-23 AnGap-13
___ 08:08PM BLOOD ALT-10 AST-13 AlkPhos-113* TotBili-0.4
___ 08:08PM BLOOD Lipase-8
___ 04:08AM BLOOD CK-MB-<1 cTropnT-<0.01 proBNP-2336*
___ 08:08PM BLOOD Albumin-3.4* Calcium-9.2 Phos-3.3 Mg-1.5*
INTERVAL LABS:
===============
___ 08:07PM BLOOD Lactate-3.1*
___ 11:39PM BLOOD Lactate-2.9*
___ 02:42AM BLOOD Lactate-2.2*
___ 04:49PM BLOOD Lactate-2.0
___ 05:17AM BLOOD %HbA1c-11.6* eAG-286*
___ 04:04AM BLOOD Triglyc-290* HDL-30* CHOL/HD-7.6
LDLcalc-140*
DISCHARGE LABS:
===============
___ 06:05AM BLOOD WBC-10.5* RBC-4.38 Hgb-11.8 Hct-37.9
MCV-87 MCH-26.9 MCHC-31.1* RDW-14.1 RDWSD-44.0 Plt ___
___ 06:05AM BLOOD Glucose-92 UreaN-14 Creat-0.6 Na-145
K-4.2 Cl-105 HCO3-28 AnGap-12
___ 05:17AM BLOOD Calcium-9.2 Phos-2.8 Mg-1.7
IMAGING:
========
___ ABDOMEN
IMPRESSION: No evidence of pneumoperitoneum. Nonobstructive
bowel gas pattern.
___ Echo Report
CONCLUSION: The left atrial volume index is normal. There is
moderate symmetric left ventricular hypertrophy with a normal
cavity size. There is suboptimal image quality to assess
regional left ventricular function. Overall left ventricular
systolic function is low normal. Quantitative biplane left
ventricular ejection fraction is 55 % (normal 54-73%). Left
ventricular cardiac index is normal (>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 a normal ascending
aorta diameter for gender. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The pulmonic valve leaflets are
not well seen. The tricuspid valve leaflets appear structurally
normal. There is physiologic tricuspid regurgitation. The
pulmonary artery systolic pressure could not be estimated. There
is a trivial pericardial effusion. IMPRESSION: Suboptimal image
quality. Symmetric left ventricular hypertrophy with normal
cavity size and low normal global systolic function. No definite
valvular pathology or pathologic flow identified. No definite
structural cardiac source of embolism identified. CLINICAL
IMPLICATIONS: Based on the echocardiographic findings and ___
ACC/AHA recommendations, antibiotic prophylaxis is NOT
recommended
___ HEAD W/O CONTRAST
IMPRESSION:
1. Question artifact versus a punctate focus of slow diffusion
near the junction of the right precentral gyrus and superior
sagittal gyrus. No other foci of slow diffusion are identified.
2. No evidence of hemorrhage, mass or significant mass effect.
3. Prominence of the ventricles and sulci suggestive of
involutional changes.
4. Periventricular and subcortical FLAIR hyperintensities are
nonspecific but compatible with sequela of chronic
microangiopathy.
5. Absence of flow void within the left vertebral artery V4
segment, better evaluated on the recent CTA.
___ (PORTABLE AP)
IMPRESSION:
Compared to chest radiographs ___ and ___.
Mild cardiomegaly, pulmonary vascular congestion and small left
pleural effusion have increased. No pulmonary edema. Bibasilar
atelectasis is mild.
___ HEAD AND NECK WITH
IMPRESSION:
1. Relative hypodensity in the posterior right parietal lobe
subcortical white
matter, which may represent subacute infarct or the sequela of
chronic
microangiopathic ischemic disease. Encephalomalacia in the
right occipital
lobe compatible with a chronic infarct. No evidence of large
vessel
occlusion. CT perfusion demonstrates a large area of increased
time to
peak/mean transit time in the right MCA territory, with a
correlate area of
decreased cerebral blood volume in the right occipital lobe
consistent with a
chronic infarct core. An apparent mismatch involving both the
middle cerebral
artery and posterior cerebral artery territory could be due to
the severe
atherosclerotic disease burden with multifocal stenoses as there
is no
definite large vessel occlusion.
2. Extensive intracranial atherosclerotic disease with multiple
focal areas of
stenosis as described. No evidence of large vessel occlusion or
aneurysm.
3. Moderate atheromatous disease involving the left internal
carotid artery
with 40% stenosis. There is free-floating, ulcerated plaque
noted in the
proximal left internal carotid artery, characteristic of a high
risk plaque.
4. Complete occlusion of the distal V4 segment of the left
vertebral artery of
indeterminate chronicity. There is extensive atheromatous
plaque throughout
the posterior circulation including the bilateral vertebral
arteries, basilar
arteries and superior cerebellar arteries.
5. MRI would be more sensitive to detect areas of acute infarct.
___ OPINION CT ABD/P
IMPRESSION:
1. Emphysematous cystitis with perivesical stranding and foci of
gas in the
space of Retzius compatible with extraperitoneal perforation
however no large
volume fluid is visualized.
2. Foley catheter within a distended urinary bladder with
fullness of ureters
and renal collecting systems bilaterally concerning for Foley
malfunction.
3. Mild proctitis.
4. Apparent tiny foci of gas in segment 4A of the liver may be
within the
portal venous system, though no other signs for portal
mesenteric venous gas
identified or bowel ischemia.
5. Hepatic steatosis.
6. Distended gallbladder without specific findings to suggest
acute cholecystitis.
7. Colonic diverticulosis without evidence for diverticulitis.
___ (PA & LAT)
IMPRESSION: No acute cardiopulmonary abnormality. No
subdiaphragmatic free air.
MICROBIOLOGY:
=============
Urine cx: ___)
Proteus vulgaris(<10K)
Klebsiella pneumonia (>100k)
- Kleb sensitivities: unasyn, aztreonam, cefazolin, gentamicin,
levo, cipro, ___, tigecycline, Bactrim, Zosyn.
- Resistant to ampicillin. Indeterminate for Macrobid.
__________________________________________________________
___ 5:55 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 10:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:08 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 100 mg PO BID
2. Cephalexin 250 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Diazepam 5 mg PO DAILY:PRN anxiety
5. Fluocinonide 0.05% Ointment 1 Appl TP BID
6. FLUoxetine 30 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD Frequency is Unknown
8. Meclizine 25 mg PO TID:PRN Nausea
9. amLODIPine 5 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Ondansetron 4 mg PO BID:PRN Nausea/Vomiting - First Line
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ertapenem Sodium 1 g IV ONCE Duration: 1 Dose
3. HydrALAZINE 25 mg PO Q6H:PRN SBP >200
4. Glargine 10 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Losartan Potassium 25 mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO QPM
7. Lidocaine 5% Patch 1 PTCH TD QAM Back pain
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
9. Atenolol 100 mg PO BID
10. Clopidogrel 75 mg PO DAILY
11. Diazepam 5 mg PO DAILY:PRN anxiety
12. Fluocinonide 0.05% Ointment 1 Appl TP BID
13. FLUoxetine 30 mg PO DAILY
14. Meclizine 25 mg PO TID:PRN Nausea
15. Omeprazole 20 mg PO DAILY
16. Ondansetron 4 mg PO BID:PRN Nausea/Vomiting - First Line
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Emphysematous cystitis
Transient ischemic attack
Secondary diagnoses:
Type 2 DM
Portal vein gas
HTN
HLD
Hx of CVA with residual L hemiparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEAD and NECK
INDICATION: ___ year old woman with new onset dysarthria // Code 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 =
934.7 mGy-cm.
2) Stationary Acquisition 24.0 s, 8.0 cm; CTDIvol = 194.8 mGy (Head) DLP =
1,558.5 mGy-cm.
3) Spiral Acquisition 2.5 s, 39.0 cm; CTDIvol = 13.1 mGy (Body) DLP = 508.5
mGy-cm.
4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.7 mGy (Body) DLP = 1.4
mGy-cm.
5) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 24.4 mGy (Body) DLP =
12.2 mGy-cm.
Total DLP (Body) = 522 mGy-cm.
Total DLP (Head) = 2,493 mGy-cm.
COMPARISON: None available.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
No evidence of acute intracranial hemorrhage. There is a geographic region of
relative hypodensity centered in the posterior right parietal lobe (2:21). The
more medial aspect of this region is favored to be more chronic while the more
lateral aspect may be subacute. Gray-white matter differentiation in the basal
ganglia and insula appears preserved. No midline shift. Prominence of the
ventricles and sulci is most consistent with age-related parenchymal atrophy
in a patient of this age. Scattered periventricular and subcortical white
matter hypodensities may reflect sequelae of chronic small vessel ischemic
disease.
There is no fracture. Mild mucosal thickening of the anterior ethmoid air
cells. The visualized portion of the remaining paranasal sinuses, mastoid air
cells, and middle ear cavities are otherwise clear. The visualized portions
of the orbits are normal.
CTA HEAD:
No evidence of large vessel occlusion. However, there are multifocal moderate
to severe segments of atherosclerotic narrowing of the internal carotid
arteries bilaterally. There is an approximately 5 mm segment severe narrowing
of the right M1 segment however the vessel is patent distally (603:28). There
is focal narrowing of the left distal M1 segment just proximal to the M2
bifurcation with a normal caliber vessel distally (4:228). There is focal
narrowing of the proximal left M2 branch, just distal to the MCA bifurcation
with a normal vessel caliber distally (603:33). The anterior cerebral
arteries are patent from their origins.
The basilar artery is markedly irregular with a short segment of focal
narrowing secondary to atherosclerotic disease. There is a 1 mm focal
laterally oriented outpouching of the mid basilar artery that may reflect a
small infundibulum (603:26). The superior cerebellar arteries are irregular
multiple short segments of focal narrowing in the left superior cerebellar
artery (603:29).
The posterior cerebral arteries are patent but are notable for diffuse luminal
irregularity with multiple areas of focal narrowing (4:216). The dural venous
sinuses are patent.
CTA NECK:
There is atherosclerotic calcification of the aortic arch. Aortic origin of
the right vertebral artery is noted (4:93), a normal variant. The right
vertebral artery is patent from its origin. The left vertebral artery appears
hypoplastic from its origin. There is focal calcification in the left
vertebral artery origin. There is dense atheromatous plaque in the right V4
segment resulting in luminal irregularity and focal narrowing the distal V4
segment prior to the junction with the basilar artery. The left V3 segment
is irregular. The left vertebral artery is occluded at the V4 segment due to
dense atheromatous disease (4:190).
There is atheromatous plaque at the carotid bifurcations bilaterally. There
is approximately 40% stenosis of the left internal carotid artery due to the
presence of noncalcified atheromatous plaque at the carotid bifurcation.
There is no significant stenosis of the right internal carotid artery by
NASCET criteria.
There is free-floating ulcerated noncalcified atheromatous plaque of the
origin of the left internal carotid artery, a high-risk lesion.
CT PERFUSION: Large region of increased T-max throughout the right MCA
territory occupying a total volume of 202.44 cc, nonspecific and possibly due
to the patient's severe atherosclerotic disease burden or could reflect
penumbra although this is considered less likely as it involves anterior and
posterior vascular territories and there is no definite proximal occlusion. A
focus of abnormal cerebral blood flow is noted at the site of the presumed
chronic infarct.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is normal. Median sternotomy wires are present in keeping with
prior CABG. A fixed implant bridge is noted in the mandible. There is no
lymphadenopathy by CT size criteria.
IMPRESSION:
1. Relative hypodensity in the posterior right parietal lobe subcortical white
matter, which may represent subacute infarct or the sequela of chronic
microangiopathic ischemic disease. Encephalomalacia in the right occipital
lobe compatible with a chronic infarct. No evidence of large vessel
occlusion. CT perfusion demonstrates a large area of increased time to
peak/mean transit time in the right MCA territory, with a correlate area of
decreased cerebral blood volume in the right occipital lobe consistent with a
chronic infarct core. An apparent mismatch involving both the middle cerebral
artery and posterior cerebral artery territory could be due to the severe
atherosclerotic disease burden with multifocal stenoses as there is no
definite large vessel occlusion.
2. Extensive intracranial atherosclerotic disease with multiple focal areas of
stenosis as described. No evidence of large vessel occlusion or aneurysm.
3. Moderate atheromatous disease involving the left internal carotid artery
with 40% stenosis. There is free-floating, ulcerated plaque noted in the
proximal left internal carotid artery, characteristic of a high risk plaque.
4. Complete occlusion of the distal V4 segment of the left vertebral artery of
indeterminate chronicity. There is extensive atheromatous plaque throughout
the posterior circulation including the bilateral vertebral arteries, basilar
arteries and superior cerebellar arteries.
5. MRI would be more sensitive to detect areas of acute infarct.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 5:56 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old woman with hx of ischemic stroke x2. Most recent in
___ with residual L hemiparesis. Concern for new stroke on ___ // New
stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CTA head and neck dated ___
FINDINGS:
Questionable artifact versus punctate focus of slowed diffusion near the
junction of the right precentral gyrus and superior sagittal gyrus (5:24,
4:24). No other foci of slow diffusion are identified to suggest acute
infarction. There are foci of encephalomalacia within the right occipital
lobe and bilateral basal ganglia compatible with remote infarcts. There is no
evidence of hemorrhage, edema, masses, mass effect, midline shift or
infarction. There is diffuse prominence of the ventricles and sulci
suggestive of involutional changes. Periventricular and subcortical T2 and
FLAIR hyperintensities are noted which are nonspecific but compatible with
sequela of chronic microangiopathy.
There are mild diffuse inflammatory changes of the paranasal sinuses. The
mastoid air cells are clear. The orbits and globes appear grossly
unremarkable. Absence of flow void within the left vertebral artery V4
segment is better evaluated on the prior CTA.
IMPRESSION:
1. Question artifact versus a punctate focus of slow diffusion near the
junction of the right precentral gyrus and superior sagittal gyrus. No other
foci of slow diffusion are identified.
2. No evidence of hemorrhage, mass or significant mass effect.
3. Prominence of the ventricles and sulci suggestive of involutional changes.
4. Periventricular and subcortical FLAIR hyperintensities are nonspecific but
compatible with sequela of chronic microangiopathy.
5. Absence of flow void within the left vertebral artery V4 segment, better
evaluated on the recent CTA.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old woman with history of CAD, CVA received fluid today
with new chest pain now. // Does this patient have pulmonary edema? Does
this patient have pulmonary edema?
IMPRESSION:
Compared to chest radiographs ___ and ___.
Mild cardiomegaly, pulmonary vascular congestion and small left pleural
effusion have increased. No pulmonary edema. Bibasilar atelectasis is mild.
Radiology Report
INDICATION: ___ year old woman with emphysematous cystitis and mild worsening
of abdominal pain // Upright KUB to evaluate for subdiaphragmatic air
TECHNIQUE: Supine and upright portable abdominal radiographs were obtained.
COMPARISON: CT dated ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are notable for an S shaped curvature of the thoracolumbar
spine as well as orthopedic hardware over the proximal left femur. Evaluation
of the bladder is suboptimal on these radiographs. Sternotomy wires are
present.
IMPRESSION:
No evidence of pneumoperitoneum. Nonobstructive bowel gas pattern.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Unspecified abdominal pain
temperature: 97.6
heartrate: 74.0
resprate: 18.0
o2sat: 97.0
sbp: 155.0
dbp: 76.0
level of pain: 8
level of acuity: 2.0 | BRIEF HOSPITAL COURSE:
======================
___ F with hx of CVA in ___ with residual L hemiparesis and
recurrent UTIs who presented to OSH and was found to have
emphysematous cystitis and extraperitoneal gas on CT, concerning
for perforation. Urology and acute care surgeons evaluated the
patient and determined no acute intervention was needed. A foley
was placed to decompress the bladder and she was started on
antibiotics. Her urine culture grew klebsiella pneumoniae and <
10k CFU of proteus vulgaris, responsive to cipro. However as
patient began to show some symptoms of confusion on cipro, she
was transitioned to meropenem and then ertapenem prior to
discharge.
Her course was also complicated by TIA likely secondary to
severe cerebral atherosclerosis, for which she was started on
ASA and rosuvastatin-although they were listed as allergies- in
addition to her plavix. She tolerated the medications prior to
discharge. See below for more details.
*** Of note, the patient was started on insulin during this
hospitalization. She will likely need more education and
titration of her insulin regimen after discharge. Please ensure
that she is on a stable regimen that she is able to use with
help of her husband and ___ at discharge from rehab.*** |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
agitated saline contrast
Attending: ___.
Chief Complaint:
Weakness, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH significant for hypertension, dCHF, Afib on
Coumadin, and recent admission for hematochezia and colitis, on
ciprofloxacin and metronidazole, presents with weakness. Patient
was feeling almost back to baseline after his recent
hospitalization. The patient was seen by his PCP 2 days ago. At
that time he was told he had too much fluid in his body. His
weight was unchanged (baseline 148-151 lbs) His torsemide was
increased from 40mg daily to 60mg in the AM and 40mg in the ___,
this caused him to urinate large amounts approximately every 20
minutes. On the day prior to admission, the patient reports
feeling weak in his "mind". For example, he fell asleep at the
dinner table. At 3AM on the day of admission, the patient awoke
to use the bathroom. While standing over the toilet, he felt
more weak. This caused him to fall to the ground. He denies any
prodromal dizziness, lightheadedness, nausea, chest pain,
shortness of breath, diarrhea, or peripheral edema. He deneis
any head strike or loss of consciousness.
In the ED, initial vitals were T97.4 BP90/60 HR135 RR16 SpO2 92%
on RA. Labs were notable for WBC 17.4, lactate 2.1, and BNP
4809. CXR notable for unchanged moderate to severe cardiomegaly.
On arrival to the floor, patient appeared comfortable.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No dysuria. Denies arthralgias
or myalgias. Ten point review of systems is otherwise negative.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (+
Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
AORTIC REGURGITATION
ASBESTOSIS
ATRIAL FIBRILLATION
BIFASCICULAR BLOCK
EPILEPSY
GASTROESOPHAGEAL REFLUX
HERPES ZOSTER
HYPERTENSION
LUTS
MITRAL REGURGITATION
OSTEOPENIA
PATENT FORAMEN OVALE
PROSTATE CANCER - SEED AND LOCAL RAD
TRICUSPID REGURGITATION
COLLES' FRACTURE
Social History:
___
Family History:
Mother deceased at ___ for unknown reasons. Father with heart
problems. One sister with no medical problems. One brother
killed in World War II. One daughter and one son alive and
well.
Physical Exam:
ON ADMISSION:
VS: T97 BP120/68 (laying: 120/64 ___, sitting: ___ ___,
standing: 99/52 ___, RR20 SPO2 98 RA
Wt: 65.4kg
General: Sitting in bed, appears comfortable, no acute distress.
HEENT: Dry mucous membranes.
Neck: Supple, + JVD with prominent V wave.
CV: Tachycardic, irregular. Normal S1, S2. No S3, S4. ___
systolic murmur loudest at the LLSB.
Lungs: Clear to auscultation bilaterally. No wheezes or
crackles.
Abdomen: +BS, soft, nondistended, nontender to palpation.
Ext: Warm and well perfused. 2+ peripheral edema in right leg,
trace in left leg. Pulses 2+.
Neuro: CN II-XII grossly intact. Upper and lower motor strength
___. Sensation grossly intact. Finger to nose normal. Fine
finger movements normal.
ON DISCHARGE:
VS: Tm 100.7, Tc98.0 BP122/65 ___ RR18 95RA
Wt: 67.3kg (66.6kg ___ (65.4kg ___
I/O since midnight: 235/300
I/O over 24 hours: 2258/300++
General: Laying in bed, appears comfortable, no acute distress.
HEENT: Moist mucous membranes.
Neck: Supple, + JVD with prominent V wave.
CV: Tachycardic, irregular. Normal S1, S2. No S3, S4. ___
systolic murmur loudest at the LLSB.
Lungs: Clear to auscultation bilaterally. No wheezes or
crackles.
Abdomen: +BS, soft, nondistended, nontender to palpation.
Ext: Warm and well perfused. Trace peripheral edema. Pulses 2+.
Neuro: CN II-XII grossly intact. Moves all extremities grossly
Pertinent Results:
ON ADMISSION
___ 05:20AM BLOOD WBC-17.8* RBC-3.81* Hgb-12.0* Hct-36.5*
MCV-96 MCH-31.4 MCHC-32.8 RDW-14.0 Plt ___
___ 05:20AM BLOOD Neuts-86.9* Lymphs-7.4* Monos-4.1 Eos-1.2
Baso-0.3
___ 05:40AM BLOOD ___ PTT-40.9* ___
___ 05:20AM BLOOD Glucose-155* UreaN-20 Creat-1.0 Na-133
K-3.5 Cl-92* HCO3-31 AnGap-14
___ 05:20AM BLOOD cTropnT-<0.01
___ 05:20AM BLOOD proBNP-4809*
___ 05:24AM BLOOD Lactate-2.1*
ON DISCHARGE
___ 06:05AM BLOOD WBC-12.1* RBC-3.26* Hgb-10.6* Hct-31.3*
MCV-96 MCH-32.6* MCHC-34.0 RDW-13.8 Plt ___
___ 06:05AM BLOOD ___ PTT-42.5* ___
___ 06:05AM BLOOD Glucose-107* UreaN-12 Creat-0.6 Na-136
K-3.7 Cl-100 HCO3-28 AnGap-12
___ 06:05AM BLOOD Calcium-7.4* Phos-2.5* Mg-2.0
___ 07:05AM BLOOD ANCA-NEGATIVE B
___ 07:05AM BLOOD ___
STUDIES:
CXR (___)
No evidence of pneumonia. Unchanged moderate to severe
cardiomegaly.
CT ABDOMEN (___)
1. No acute intra-abdominal process to explain leukocytosis.
Resolution of previous transverse colitis.
2. Unchanged cystic lesion in the uncinate process of the
pancreas, MRCP is again suggested for further evaluation.
3. A 1.4 cm left adrenal nodule, unchanged from ___ but not
fully
characterized. This most likely represents an adrenal adenoma.
This lesion can be better assessed at the same time as the MRCP.
4. Persistent focal dilation of the distal left ureter could be
due to
malignant or inflammatory cause. Recommend correlation with
urine cytology and retrograde urogram or MR urography.
5. New small bilateral pleural effusions.
6. Small wedge shaped hypodensity in the right kidney upper pole
could
represent infarction or sequela of old infection.
MICROBIOLOGY:
___ 10:30 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
MICROSPORIDIA STAIN (Pending):
CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO Q12H
2. MetRONIDAZOLE (FLagyl) 500 mg PO TID
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Potassium Chloride 60 mEq PO DAILY
5. Torsemide 40 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Warfarin 3 mg PO DAILY16
8. Vitamin D 50,000 UNIT PO TWICE MONTHLY
9. Finasteride 5 mg PO DAILY
10. Omeprazole 20 mg PO BID
11. PHENObarbital 32.4 mg PO QAM
12. PHENObarbital 64.8 mg PO QPM (___)
13. Aspirin 81 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Phenytoin Sodium Extended 100 mg PO QAM
16. Phenytoin Sodium Extended 200 mg PO QPM
(___)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO BID
6. PHENObarbital 32.4 mg PO QAM
7. PHENObarbital 64.8 mg PO QPM (___)
8. Phenytoin Sodium Extended 100 mg PO QAM
9. Phenytoin Sodium Extended 200 mg PO QPM
(___)
10. Potassium Chloride 60 mEq PO DAILY
11. Tamsulosin 0.4 mg PO HS
12. Torsemide 40 mg PO DAILY
13. Vitamin D 50,000 UNIT PO TWICE MONTHLY
14. Warfarin 2 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Orthostatic hypotension
Pancreatic cyst
Left ureteral dilation
SECONDARY DIAGNOSIS
Diastolic CHF
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Weakness, evaluate for pneumonia.
COMPARISON: ___ chest radiograph.
FINDINGS: PA and lateral views of the chest. Moderate to severe cardiomegaly
is again seen and stable. There is no evidence of focal consolidation,
pleural effusion or pneumothorax. Multiple calcified pleural plaques are
again seen.
IMPRESSION: No evidence of pneumonia. Unchanged moderate to severe
cardiomegaly.
Radiology Report
CHEST RADIOGRAPH.
INDICATION: Chronic heart failure, tricuspid regurgitation. Evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is unchanged evidence
of cardiomegaly. Enlargement of both the left and the right aspects of the
heart. Tortuosity of the thoracic aorta continues to be present. Also
unchanged are pleural and parenchymal calcifications. No pleural effusions.
No overt pulmonary edema. No pneumonia.
Radiology Report
HISTORY: Patient with recent colitis, now with leukocytosis. Evaluate for
colitis flare.
TECHNIQUE: Axial helical MDCT images were obtained through the abdomen and
pelvis after administration of 130 cc of Omnipaque intravenous contrast and
oral contrast. Multiplanar reformatted images in coronal and sagittal axes
were generated.
DLP: 420 mGy/cm
COMPARISON: CT abdomen and pelvis from ___
FINDINGS:
Calcified pleural plaques are again noted consistent with prior asbestos
exposure. There are small bilateral pleural effusions with associated
bibasilar atelectasis which are new from prior. The heart is enlarged and
there is a small to moderate pericardial effusion, slightly decreased from
prior.
CT abdomen: There is a 8 mm hypodensity with peripheral nodular enhancement
in segment 5 of the liver likely representing an hemangioma (2:33). The liver
otherwise enhances homogeneously without focal lesions or intrahepatic biliary
dilatation. The gallbladder is unremarkable and the portal vein is patent.
The spleen and right adrenal gland are unremarkable. There is a 1.4 cm nodule
in the lateral limb of the left adrenal gland. Again seen is a 1.5 cm
hypodensity in the uncinate process of the pancreas, most likely representing
IPMN. The pancreatic duct is not dilated. There is a 1.7 cm simple cyst in
the mid left kidney. There is a small 10 x 7 mm wedge shaped hypodensity in
the upper pole of the right kidney, unchanged from prior (602b:26).
There is persistent focal dilatation of the distal left ureter measuring up to
12 mm (2:55) which could represent malignancy or focal inflammation.
The stomach, duodenum and small bowel are unremarkable. The colon is within
normal limits. The previously seen colonic wall thickening and
hyperenhancement has resolved. The appendix is visualized and there is no
evidence of appendicitis. The intraabdominal vasculature is unremarkable.
There is no mesenteric or retroperitoneal lymph node enlargement by CT size
criteria. No ascites or free air is noted. There is a small fat containing
umbilical hernia.
CT pelvis: The urinary bladder is unremarkable. Brachytherapy seeds are
noted in the prostate. There is no pelvic free fluid. There is no inguinal
or pelvic wall lymphadenopathy. There is a small fluid containing right
inguinal hernia and a small fat containing left inguinal hernia.
Osseous structures: No lytic or sclerotic lesions suspicious for malignancy
is present. Multilevel degenerative changes of the thoracic and lumbar spine
are noted.
IMPRESSION:
1. No acute intra-abdominal process to explain leukocytosis. Resolution of
previous transverse colitis.
2. Unchanged cystic lesion in the uncinate process of the pancreas, MRCP is
again suggested for further evaluation.
3. A 1.4 cm left adrenal nodule, unchanged from ___ but not fully
characterized. This most likely represents an adrenal adenoma. This lesion can
be better assessed at the same time as the MRCP.
4. Persistent focal dilation of the distal left ureter could be due to
malignant or inflammatory cause. Recommend correlation with urine cytology and
retrograde urogram or MR urography.
5. New small bilateral pleural effusions.
6. Small wedge shaped hypodensity in the right kidney upper pole could
represent infarction or sequela of old infection.
Telephone notification to Dr ___ by Dr ___ at 14:30 on ___, 20
minutes after review.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: WEAKNESS
Diagnosed with OTHER MALAISE AND FATIGUE, OTHER FALL, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT
temperature: 97.4
heartrate: 135.0
resprate: 16.0
o2sat: 92.0
sbp: 90.0
dbp: 60.0
level of pain: 0
level of acuity: 1.0 | ___ with PMH significant for HTN, dCHF, and AFib who presents
with weakness and hypotension.
# Hypotension:
Likely secondary to overdiuresis as patient increased his
diuretic regime (torsemide 40mg daily changed to 60mgAM/40mgPM).
He was orthostatic and tachycardic on admission. He was
rehydrated with a total of 1L IVF. He did not show any signs of
flash pulmonary edema. Patient was restarted on his home dose of
torsemide (40mg) when more euvolemic. Patient felt back to
baseline upon discharge. Discharge weight 67.3kg.
# Fever/leukocytosis:
Patient had low grade fevers during hospitalization (Tmax
100.9). He remained hemodynamically stable and felt at baseline
while febrile. WBC also elevated on admission. The patient
denied any infectious symptoms- cough, URI symptoms, abdominal
pain, and hematochezia. He did start having diarrhea during
hospitalization. C. difficile and other stool studies were
negative. GI was consulted to evaluate for inflammatory bowel
disease given his recent admission. CT abdomen showed resolution
of prior colitis. Therefore, ciprofloxacin and metronidazole
were discontinued. WBC trended down during admission, although
ESR was still elevated (86 -> 105). ANCA and ___ were ordered to
evaluate for vasculitis and autoimmune disease, which were
negative.
# Pancreatic cyst:
This was noted on previous CT abdomen from his recent admission.
Because the patient has a metal plate in his head, he is unable
to get an MRCP. GI will schedule an endoscopic ultrasound with
possible biopsy as an outpatient.
# Dilated left ureter:
This was also noted on previous CT abdomen. At that time, this
was thought to be due to peristalsis. Dilatation persisted on
repeat CT abdomen, which is concerning for malignancy vs
inflammation. Urine cytology was sent and is pending upon
discharge. Patient will be scheduled for follow up with an
urologist as an outpatient. Consider retrograde urogram as an
outpatient.
# Atrial fibrillation:
Patient tachycardic, with HR up to 120 on admission. This was
most likely due to hypovolemia as above. He was given IVF. His
metoprolol dose was also increased to 50mg for rate control. His
CHADS2 score is 3. He was anticoagulated with coumadin.
# dCHF:
Predominantly right sided secondary to severe tricuspid
regurgitation from tricuspid prolapse. Patient being followed by
the advanced heart failure service. He does not have any signs
of liver failure secondary to congestion. However, if he starts
to have signs, he will likely require valve repair. Patient
currently asymptomatic. In fact, he was under his dry weight on
admission (151 lbs) due to overdiuresis as above. His BNP is
likely elevated due to right ventricular dilation secondary to
tricuspid prolapse. He was continued on metoprolol. He was
restarted back on his home dose of torsemide when euvolemic.
# Epilepsy:
Seconary to MVA as a child. He was continued on phenytoin and
phenobarbital.
# BPH: Continued finasteride and tamsulosin.
# GERD: Continued omeprazole. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PSYCHIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"I've been depressed pretty much forever, but it's gotten a lot
worse lately."
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per Dr. ___ note from ___:
___ employed, independent, college-educated ___ transgender
individual w/ h/o self-reported history of MDD(severe,
recurrent), GAD, social anxiety, PTSD associated with sexual
abuse, OCD, eating disorder NOS, and fibromyalgia, 1
hospitalization (___ in ___ for SI), and extensive
history of self-injurious cutting, head-banging, and overdosing,
currently in outpatient psychiatric treatment and on
medications,
who was sent to ___ ED by her therapist for worsening
self-injurious behavior and suicidal ideation in the context of
severe depression and hopelessness.
For the last month, pt has been suffering from a severe
depression, characterized by hopelessness, guilt, helplessness,
and worthlessness, in addition to significant neurovegative
symptoms such as decreased sleep, interest, motivation, energy
appetite, and concentration/memory. He's found himself
"struggling to do anything" and has been having "constant
thoughts of hurting myself." Pt presented to ___ ED several
days ago with self-inflicted thigh lacerations which required
stitching and has since been thinking about re-opening these
wounds and cutting further. In addition to cutting, pt has been
banging his head against the wall until "my ears ring, and I
can't hear normally." Pt says that when he cuts, it is not in an
attempt to end his life, but rather "a way to communicate the
pain that I can't handle."
However, over the last few weeks pt has begun to have more
frequent suicidal ideation. He thinks about cutting more
seriously or "jumping in front of the last commuter train at the
end of the night." Pt says that he is struggling to come up with
a means of suicide that will have a minimal negative impact on
others. He says, for example, that it is critical that he "jump
in front of the last commuter train because I don't want people
to have trouble getting to work. Also, the train drivers are
generally prepared to hit one or two people in their career and
have the necessary psychological support." Pt says that if he
weren't in the hospital right now, he would definitely be
cutting
and might end up ending his life as a "bonus." Pt says that the
only reason he hasn't ended his life so far is because he
"hasn't
figured out exactly the right plan."
Pt attributes much of this distress to the "unbearable pain"
associated with his fibromyalgia, sciatica, and chronic back
pain. Pt says he's had pain since ___, but was not diagnosed
with fibromyalgia until this year. He's been on medications, but
has "not had relief" and finds his current condition
debilitating. The pain keeps him from leaving his house, except
for doctors' appointments and work, which he's been missing
regularly.
Pt's depression began approximately ___ years ago when he started
puberty. He describes a "difficult" childhood, including ___
years
of sexual abuse. Throughout high school, he was cutting
excessively (100x a day) and habitually overdosing on
medications, for which he was never hospitalized. He was
hospitalized in one time in ___ at ___ for suicidal
ideation and depression. Pt says that he began transitioning to
the male gender in ___ but hasn't really "settled in" until the
last couple years, although he still defines himself as "queer"
rather than male or female.
Pt also endorses anxiety, particularly related to large groups
of
people and social situations where's he has to "pretend to be
normal," and PTSD symptoms, and restrictive eating behavior.
Denies SI, AVH, and overt delusions, though he frequently
worries
that other people have "negative thoughts in their heads about
me."
Past Medical History:
Per Dr. ___ of ___:
PAST PSYCHIATRIC HISTORY:
Diagnoses: MDD- severe, recurrent; GAD, social anxiety, OCD,
PTSD, ED NOS
Hospitalizations: ___ ___ for SI/depression
Current treaters and treatment: Therapist ___ and
psychiatrist ___ @ ___
Self-injury:
Started cutting at ___ and cut ~100x daily for several years.
Stopped cutting for ___ years and then re-started in ___ and has
since been cutting thighs and forearm.
Harm to others: Denies
Access to weapons: "razors but no guns or anything"
PAST MEDICAL HISTORY:
fibromyalgia
sciatica
chronic back pain
Social History:
Per Dr. ___ from ___:
SOCIAL HISTORY:
___
Family History:
Per Dr. ___ from ___:
FAMILY PSYCHIATRIC HISTORY:
Mom/Sister- depression/anxiety
Aunt- eating disorder
___- depression
Grandfather- alcoholism
Physical ___:
Per Dr. ___ from ___:
General: NAD
HEENT: PERRL, MMM, OP clear.
Neck: Supple. No adenopathy or thyromegaly.
Back: No significant deformity, no focal tenderness
Lungs: CTAB; no crackles or wheezes.
CV: RRR; no m/r/g; 2+ pedal pulses
Abdomen: Soft, obese, NT, ND.
Extremities: No clubbing, cyanosis, or edema.
Skin: Warm and dry, no rash or significant lesions.
Neurological: CN ___ intact, no gross focal motor/sensory
deficits, gait wnl. Finger-nose-finger wnl
Pertinent Results:
___ 03:07PM URINE UCG-NEG
___ 03:07PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 03:07PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 03:07PM URINE RBC-1 WBC-13* BACTERIA-NONE YEAST-NONE
EPI-1 TRANS EPI-<1
___ 03:07PM URINE MUCOUS-RARE
___ 02:45PM GLUCOSE-92 UREA N-16 CREAT-0.8 SODIUM-138
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12
___ 02:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:45PM WBC-6.6 RBC-4.52 HGB-13.4 HCT-38.3 MCV-85
MCH-29.6 MCHC-34.9 RDW-12.9
___ 02:45PM NEUTS-66.4 ___ MONOS-3.9 EOS-1.2
BASOS-0.7
___ 02:45PM PLT COUNT-264
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluoxetine 60 mg PO DAILY depression
2. ClonazePAM 1 mg PO BID
3. TraZODone 50 mg PO HS:PRN sleep
4. Gabapentin 100 mg PO TID
5. Prazosin 1 mg PO QHS:PRN nightmares
6. Diazepam 5 mg PO BID:PRN anxiety
7. Testosterone Cypionate 100 mg IM Q14DAYS FTM transgender
Discharge Medications:
1. ClonazePAM 0.5 mg PO BID anxiety
2. Gabapentin 300 mg PO BID
RX *gabapentin 300 mg 1 capsule(s) by mouth twice a day Disp
#*28 Capsule Refills:*0
3. Fluoxetine 60 mg PO DAILY depression
RX *fluoxetine 60 mg 1 tablet(s) by mouth daily Disp #*14
Capsule Refills:*0
4. Testosterone Cypionate 100 mg IM Q14DAYS FTM transgender
5. Multivitamins W/minerals 1 TAB PO DAILY
6. QUEtiapine Fumarate 200 mg PO QHS
RX *quetiapine 200 mg 1 tablet(s) by mouth at night Disp #*14
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Major Depression
PTSD
Discharge Condition:
Brighter, improved eye contact, cooperative, calm, no suicidal
ideation, plan or intent, some chronic urges for cutting that
have improved. Help seeking. Insight/judgemnet - improved
Ambulatory status: ambulates with cane given fibromyalgia
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with history of self injurious behaviour now with
changes in hearing.
TECHNIQUE: Contiguous axial multi detector CT images were obtained of the
brain without administration of intravenous contrast. DLP 891 mGy-cm. CTDI
54 mGy.
COMPARISON: CT neck with ___
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or infarction. The
ventricles and sulci are normal in size and configuration. The basal cisterns
appear patent and there is preservation of gray-white matter differentiation.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells, middle ear cavities are clear. Bilateral ossicles are unremarkable
appear. The orbits are unremarkable
IMPRESSION:
Normal examination.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SI
Diagnosed with DEPRESSIVE DISORDER, SUICIDAL IDEATION
temperature: 98.7
heartrate: 82.0
resprate: 16.0
o2sat: 96.0
sbp: 143.0
dbp: 81.0
level of pain: 4
level of acuity: 2.0 | PSYCHIATRIC:
Note: Applied for ___ services on ___
#) Safety- Self-Injurious Behavior and Suicidality
Pt had longstanding history of self-cutting and head-banging,
which had become more intense, along with his fibromyalgia, in
the past several months. He also had suicidal ideation of
jumping in front of a commuter rail train. In the week prior to
admission, the pt had self-cut deeply enough to require suturing
of bilateral thigh lacerations. Pt was admitted to the locked
unit on q15 checks, as pt was able to contract for safety. On
___, reported that he had been surreptitiously head-banging,
and after extensive discussion with the resident physician and
his nurse, he could not contract for safety and was put on staff
constant observation, which continued overnight. When we
reassessed on ___, pt was able to contract for safety and
continued to do so throughout his admission.
Given pt's extensive history of head-banging, and reports of
tinnitis, and no prior history of CT evaluation, we ordered a
head CT w/out contrasts, the results of which were normal.
During the hospital course the pt's urges towards SIB became
less intense, and his acute suicidality resolved.
#) Major Depressive Disorder and PTSD
On admission, pt was taking fluoxetine/Prozac 50mg PO qday. Per
his own report, he was medication non-adherent at home, taking
medication when he felt down and not taking it if he felt
better. We re-established daily fluoxetine/Prozac 50mg PO qday
and then on Admission Day 2 uptitrated to 60mg PO qday. Pt
tolerated this change and experienced some benefit. For
additional help with depression, anxiety, and mood lability, we
started quetiapine/Seroquel it was increaed to 200mg po QHS He
tolerated this medication well without side effects and
significant improvement was noted in is depression, anxiety,
insomnia, mood lability, suicidality and hypervigilence. On
admission, pt was on standing clonazepam/Klonopin 1mg PO BID as
well as diazepam 5mg PO BID PRN anxiety/back pain. As use of a
single benzodiazepine seemed preferable to benzodiazepine
polytherapy, we discontinued the PRN diazepam and he was
continued on clonazepam 0.5mg po BID. Prazosin was briefly
tiralled without good benefit.
Family work with his sister, ___ was done in efforts to
increase outpatient support. Mr. ___ was an active group
member and benefited significantly from strucutre and assistence
around coping skills. He also particpated well in individual
therapy. Ideally, Mr. ___ would participate in a day
program, but given his lack of insurance at this time, this
could not be pursued. A ___ application was submitted on his
behalf given the chronic nature of his urge for self injury in
terms of cutting, head banging, and disorered eating. Aside from
the episode of head banging, there was not self injury during
this hospitalization and he ate well at meals.
At time of discharge, Mr. ___ had appeared significantly
improved with support, strucutre, and medication management. He
appeared safe and appropriate for ___ home with ongoing follow up
from his outpatient therapist and psychiatrist. He remains at
chronic risk of cutting which he views as a way to cope rather
than end his life. He was free of suicidal thoughts, and had
good knowledge of how to seek help should suicidal thoughts
reoccur in the futre.
#) Alcohol abuse (roughly 1xWk binge drinking)
Pt was sober on the unit and showed no signs/symptoms of
withdrawal. We discussed the danger of binge drinking,
especially given his depression and impulsive behavior. He
worked on coping skills both in individual psychotherapy and in
OT groups. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, fever, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yof 7 days s/p bilateral breast reduction
and liposuction presenting from OSH ED transfer with fevers,
abdominal pain, found to have + U/A now in septic shock w/ CT
c/w pyelonephritis.
Pt underwent bilateral reduction mammoplasty, liposuction of the
abdomen, flanks and bilateral axillary regions on ___ ___ on ___ and tolerated procedure well. Of note,
patient had foley in place during 4-hour procedure, per pt's
surgeon. Pt reports abdominal and flank/back pain after surgery
but improved over the course of the week. On ___, pt noted
increased abdominal pain across surgical site, increase in back
pain, subject fevers, chills, and sweating. She denies any
drainage from the 8 surgical sites. She denies any dysuria,
though endorses difficulty emptying bladder. She alternated
motrin and tylenol over the course of 48 hours wihtout
improvement. She also was taking oxycodone as prescribed by
plastic surgeon for post-op pain, and called surgeon for recent
fever and was taking tylenol w/ codeine without relief. When
pain/fever continued, she presented to ___ ED in
___ for further evaluation. There, she had a low-grade
temp of 100.1, was tachycardic to 120s, with BPs in 100s/60,
sating well on RA, she was noted to have a WBC of 15, 0.2 bands,
Hct 34.5, Platelets 265, Cr 0.96 and U/A notable for +nitrites
and >100 white cells. She was treated with 1L NS, a dose of
ceftriaxone and was transferred to ___ ED for plastic surgery
evaluation.
Pt reports previous UTIs, but no prior h/o recurrent infections.
In the ED, initial vitals: T: 99.9 BP: 100/60 HR:120 RR:16 O2:
97% on Ra
She was given an additional 1L of fluids. CT ab/pelvis with
contrast noted significant perinephritic stranding suggesting
pyelonephritis and a 2.3 cm ill-defined rounded hypodensity
within the left kidney is concerning for developing abscess.
Plastic surgery was consulted and did not have concern for
surgical-related infection. U/A here negative for nitrate but
with >182 WBCs, 11 RBCs.
Vitals prior to transfer: T: 100.2 BP: 107/53 HR:125 RR:16 O2:
97% on Ra
Currently, pt reports moderate pain her abdomen and back, and
reports some difficulty concentrating, which she attributes to
naroctics she has received over the course of the day. She
denies CP, SOB, dysuria.
ROS:
No weight changes. No changes in vision or hearing, no changes
in balance. No cough, no shortness of breath, no dyspnea on
exertion. No chest pain or palpitations. No nausea or vomiting.
No diarrhea or constipation. No dysuria or hematuria. No
hematochezia, no melena. No numbness or weakness, no focal
deficits.
Past Medical History:
___: bilateral reduction mammoplasty, liposuction of the
abdomen, flanks and bilateral axillary regions
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:98.3 HR:108 BP: 82/50 RR:20 O2: 96% on RA
General- Diaphoretic, mildly lethargic, difficulty staying alert
during interview
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Chest: Sutured incision across breast fold bilaterally,
non-tender, non erythematous, unable to express drainage, no
skin discoloration.
Abdomen- two ports on either side of abdomen, one in RLQ, other
in LLQ; overlying skin with patchy echymosis across abdomen;
soft, minimally tender in RL/LLQ, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU- foley in place
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.9 (99.5) BP: 101/53 (92-122/50-66) 100 (99-114)
94+%
Mid ___ 24 4840/4760 (200cc/hr)
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, tender in flanks superficially, bilaterally,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley in place draining yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
==============================
___ 12:40PM BLOOD WBC-15.5* RBC-3.84* Hgb-12.4 Hct-34.3*
MCV-89 MCH- 32.4* MCHC-36.2* RDW-13.6 Plt ___
___ 12:40PM BLOOD Neuts-85.6* Lymphs-7.8* Monos-5.7 Eos-0.7
Baso-0.2
___ 12:40PM BLOOD Plt ___
___ 07:55PM BLOOD ___ PTT-27.7 ___
___ 12:40PM BLOOD Glucose-119* UreaN-8 Creat-0.9 Na-135
K-4.9 Cl- 100 HCO3-23 AnGap-17
___ 07:55PM BLOOD ALT-11 AST-12 LD(LDH)-134 AlkPhos-81
TotBili-0.7
___ 12:50PM BLOOD Lactate-2.1*
___ 01:55PM URINE RBC-11* WBC->182* BACTERIA-FEW
YEAST-NONE EPI- 21 TRANS EPI-2
___ 01:55PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE- NEG KETONE-NEG BILIRUBIN-NEG
UROBILNGN-NEG PH-6.0 LEUK-LG
NOTABLE IMAGING
==============================
___ CT Ab/Pelvis w/ contrast
1. Bilateral striated nephrograms with significant perinephric
stranding
suggests pyelonephritis, right worse than left. A 2.3 cm
ill-defined rounded
hypodensity within the left kidney is concerning for developing
abscess.
2. Right side ureteritis.
NOTABLE MICROBIOLOGY
==============================
OSH URINE CULTURE: >100k colonies, e.coli, sensitive to cipro
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
NOTABLE LABS
============================
___ 06:54AM BLOOD WBC-7.7# RBC-3.09* Hgb-9.8* Hct-27.7*
MCV-90 MCH- 31.7 MCHC-35.4* RDW-13.4 Plt ___
___ 06:54AM BLOOD Glucose-119* UreaN-9 Creat-0.8 Na-141
K-3.7 Cl- 110* HCO3-22 AnGap-13
___ 08:19PM BLOOD Lactate-1.6
___ 07:55AM BLOOD Lactate-1.4
DISCHARGE LABS
=============================
___ 07:40AM BLOOD WBC-7.4 RBC-3.22* Hgb-10.4* Hct-28.9*
MCV-90 MCH- 32.2* MCHC-35.9* RDW-13.4 Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-100 UreaN-7 Creat-0.8 Na-141
K-3.9 Cl- 108 HCO3-26 AnGap-11
___ 07:40AM BLOOD LD(LDH)-228 TotBili-0.5
___ 07:40AM BLOOD Calcium-7.8* Phos-2.4* Mg-2.4 Iron-PND
Radiology Report
INDICATION: Abdominal pain and fever. Evaluate for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Same-day CT abdomen and pelvis.
FINDINGS:
The lungs are clear. There is no pleural effusion, pneumothorax or focal
airspace consolidation. Bibasilar atelectasis is better seen on the same-day
CT. Heart is normal size. The mediastinal and hilar structures are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: Right lower quadrant pain and tenderness with a white count.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
after the uneventful administration of 130 ml of Omnipaque. Coronal and
sagittal reformations were provided and reviewed. Oral contrast was not
administered at the request of the ordering physician.
DOSE: DLP: 530.08 mGy-cm
COMPARISON: None.
FINDINGS:
The included lung bases show bibasilar atelectasis. There is no pleural
effusion or pneumothorax. Imaged portion of the heart is normal size there is
no pericardial effusion. The liver enhances homogeneously without focal
lesions. The gallbladder is normal and there is no intra or extrahepatic
biliary ductal dilation. The spleen, pancreas and adrenal glands are
unremarkable. There is a small hiatal hernia. The stomach, large and small
bowel are normal. The appendix is normal (2:69). There is no free air or free
fluid.
There are bilateral striated nephrograms with perinephric stranding, right
worse than left, suggesting pyelonephritis. There is no perinephric fluid.
There is no hydronephrosis. Stranding also involves the proximal right
ureter, compatible with ureteritis (02:47). There is a 2.3 x 1.4 cm
intermediate ill-defined rounded hypodensity within the interpolar region of
the left kidney which also has surrounding inflammatory changes in the fat.
Prominent retroperitoneal lymph nodes, not meeting criteria for pathologic
enlargement, presumably reactive.
The aorta is normal caliber. Accessory right renal artery is noted. The
portal vein, splenic vein and superior mesenteric vein are patent.
The bladder, uterus, rectum and sigmoid are unremarkable. The ovaries are
normal size. There is no free pelvic fluid. There is no inguinal or pelvic
sidewall lymphadenopathy.
There are no lytic or blastic osseous lesions within the abdomen or pelvis.
IMPRESSION:
1. Bilateral striated nephrograms with significant perinephric stranding
suggests pyelonephritis, right worse than left. A 2.3 cm ill-defined rounded
hypodensity within the left kidney is concerning for developing abscess.
2. Right side ureteritis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with PYELONEPHRITIS NOS, SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS
temperature: 99.9
heartrate: 120.0
resprate: 16.0
o2sat: 97.0
sbp: 100.0
dbp: 60.0
level of pain: 4
level of acuity: 3.0 | BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ year old female
with recent bilateral breast reduction and flank/abdomen/back
liposuction 1 week prior originally presenting to ___
___ with fevers and abdominal pain. On transfer, plastic
surgery evaluated the pt. and found no concern for surgical site
infection. She had a positive UA at OSH and ___. She then
underwent CT abdomen and pelvis which showed evidence of
bilateral pyelonephritis with a possibly developing small L
renal abscess. She received aggressive fluid resuscitation with
a total of 8 L IVF and was started on vanc/zosyn with
stabilization of blood pressure and improvement of overall
clinical status. On discharge, she was off IVF for >24 hours and
had good UOP. Urine culture at ___ grew
cipro-sensitive e.coli. Pt. was discharged on a 14 day course of
cipro. Given her clinical improvement, both urology and
radiology did not recommend additional imaging of the possible
left kidney abscess. Of note, pt. was found to be persistently
tachycardic throughout her hospitalization, with a notable
anemia with Hct of 28.9 on discharge. Given that she was
otherwise improving, with blood pressures in the 110s systolic,
we attributed her tachycardia to her resolving infection and
anemia. On discharge, her anemia work-up was still pending (no
evidence of hemolysis).
ACTIVE ISSUES
==========
#Septic shock ___ pyelonephritis: Patient presented to the OSH
and ___ ED tachycardic to the 120s, with systolic blood
pressure in the ___ and mild lethargy/poor attention. Her
WBC was found to be elevated to 15 with lactate of 2.1. On
transfer, plastic surgery evaluated the pt. and found no concern
for surgical site infection. She had a positive UA at OSH and
___. She then underwent CT abdomen and pelvis which showed
evidence of bilateral pyelonephritis with a likely developing
small L renal abscess. She received aggressive fluid
resuscitation with a total of 8 L IVF and was started on
vanc/zosyn with stabilization of blood pressure and improvement
of overall clinical status. On discharge, she was off IVF for
>24 hours and had good UOP. Her urine culture at ___
___ grew cipro-sensitive e.coli. Patient was
discharged on a 14 day course of cipro. Given her clinical
improvement, both urology and radiology did not recommend
additional imaging of the possible left kidney abscess at this
time.
#Tachycardia: Patient was persistently tachycardic throughout
admission, despite aggressive fluid resuscitation, stable blood
pressures, antiobiotic treatment and improvement of clinical
status. Patient denies chest pain, leg pain and she maintained
good O2sats throughout hospitalization. She had no clinical
signs of active bleeding. Patient was discharged with HR in the
100s we attributed to resolving infection and anemia.
#Anemia: Ms. ___ had a ___ drop from 34.3 to 27.7 after 8L
IVF, and was discharged with Hct of 28.9. MCV was 90 on
discharge. No evidence of active bleeding given that Hct was
stable to improving after 8L IVF. Labs did not demonstrate
active hemolysis. Iron studies returned consistent with anemia
of chronic disease following discharge. Pt. was called and
notified of these lab findings. Her anemia should be followed
up by her outpatient provider. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
clarithromycin
Attending: ___.
Chief Complaint:
epigastric pain, fever
Major Surgical or Invasive Procedure:
ERCP on ___ with removal of sludge and sphincterotomy.
History of Present Illness:
Ms. ___ is a ___ female with history Paget's
disease of the bone and prior cholecystitis and biliary
obstruction s/p cholecystectomy and prior biliary stent
placement who presents with several days of worsening epigastric
pain, fevers and N/V found to have evidence of biliary
obstruction and biliary stent migration at OSH so transferred
here for ERCP eval.
For the last month, she reports she has had 3 or 4 episodes of
abdominal pain following eating. Prior episodes were relieved by
emesis. However, last night after dinner she developed pain and
was unable to throw up and had continued ___ pain thus
presented to ___. She also notes recent subjective fevers
at home and decreased oral intake over the past 2 days. she
underwent cholecystectomy ___ years ago, but also required stent
placement at the time. Seen again in follow up for stent pull
but they ended up replacing stent and she was told it didn't
require follow up that it would just go away on its own. She
hasn't seen surgery or ERCP since and hasn't had any episodes of
similar abdominal pain or biliary obstruction until now.
She presented to ___ this morning where a CT
demonstrated a dilated CBD with stent migration so she was
transferred to ___ ED for additional care. Here, she states
pain is better due to prior pain meds at ___. On ROS she
denies new HA, dizziness, no N/V, CP, SOB, back pain, flank
pain, change in bowel or bladder function. She notes a history
of severe hypotension after anesthesia.
Past Medical History:
PAGET'S DISEASE
OSTEOPOROSIS
FIBROCYSTIC CHANGES IN BREAST
*S/P CHOLECYSTECTOMY
H/O ANEMIA
H/O ORTHOPEDIC
H/O CHOLELITHIASIS
Surgical History
CHOLECYSTECTOMY
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
ADMISSION:
=========
VS: Temp: 98.7 PO BP: 124/69 HR: 78 RR: 20 O2 sat: 97% O2
delivery: RA
Gen - NAD, well-appearing
Eyes - PERRLA
ENT - slightly dry MM
Heart - RRR
Lungs - CTAB, breathing nonlabored
Abd - soft, minimally tender in mid-epigastrium, no rebound or
guarding
Ext - no pedal edema
Skin - no obvious skin breakdown
Vasc - WWP
Neuro - A&Ox4, no focal sensori-motor deficits
Psych - pleasant, calm, cooperative
DISCHARGE:
=========
Temp: 98.4 PO BP: 114/66 HR: 61 RR: 18 O2 sat: 96% O2 delivery:
RA
Gen: pleasant woman resting comfortably in bed, NAD
HEENT: anicteric sclera, OP clear.
Pulm: CTAB
Card: RRR, no m/r/g
Abd: nondistend, soft, nontender throughout.
Ext: well perfused, no edema
Neuro: no facial droop, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
========================
___ 04:13PM BLOOD WBC-12.1* RBC-3.78* Hgb-10.6* Hct-33.6*
MCV-89 MCH-28.0 MCHC-31.5* RDW-14.0 RDWSD-44.9 Plt ___
___ 04:13PM BLOOD Neuts-88.7* Lymphs-5.3* Monos-5.3
Eos-0.0* Baso-0.1 Im ___ AbsNeut-10.77* AbsLymp-0.64*
AbsMono-0.64 AbsEos-0.00* AbsBaso-0.01
___ 04:13PM BLOOD ___ PTT-26.3 ___
___ 04:13PM BLOOD Glucose-131* UreaN-9 Creat-0.8 Na-137
K-4.2 Cl-105 HCO3-22 AnGap-10
LFT trend:
----------
___ 04:13PM BLOOD ALT-227* AST-162* AlkPhos-345*
TotBili-4.8*
___ 06:35AM BLOOD ALT-166* AST-96* LD(LDH)-172 AlkPhos-271*
TotBili-4.9*
___ 05:05AM BLOOD ALT-118* AST-52* AlkPhos-225*
TotBili-2.6*
MICRO:
=====
___ blood Cx (no growth at time of discharge)
IMAGING/OTHER STUDIES:
====================
___ KUB
IMPRESSION:
Image findings consistent with passage of a biliary stent into
the bowel.
___ ERCP (full report available on request)
Notable for sludge in CBD, balloon sweep and sphincterotomy
performed.
LABS AT DISCHARGE:
=================
___ 12:45PM BLOOD WBC-5.2 RBC-3.08* Hgb-8.6* Hct-26.8*
MCV-87 MCH-27.9 MCHC-32.1 RDW-13.8 RDWSD-43.3 Plt ___
___ 05:05AM BLOOD Glucose-106* UreaN-18 Creat-0.8 Na-140
K-4.4 Cl-106 HCO3-26 AnGap-8*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral TID
2. Vitamin D ___ UNIT PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*7 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*10 Tablet Refills:*0
3. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral TID
4. Ferrous Sulfate 325 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# cholangitis
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 cholangitis s/p biliary stent
presents with recurrent cholestasis now s/p ERCP without evidence of stent.//
please eval for stent migration into small bowel.
TECHNIQUE: Frontal supine abdominal radiographs were obtained.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
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. Cholecystectomy clips are noted over the right upper
quadrant. There is opacification of the biliary tree as well as passes of
contrast into the large bowel. An approximately 8 cm curvilinear structure is
noted most likely within the right colon, which represents passage of a
previously seen biliary stent into the bowel.
IMPRESSION:
Image findings consistent with passage of a biliary stent into the bowel.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: RUQ abdominal pain, Transfer
Diagnosed with Displacement of bile duct prosthesis, initial encounter, Exposure to other specified factors, initial encounter, Right upper quadrant pain, Essential (primary) hypertension, Other disorders of bilirubin metabolism
temperature: 98.3
heartrate: 64.0
resprate: 16.0
o2sat: 100.0
sbp: 124.0
dbp: 70.0
level of pain: 3
level of acuity: 3.0 | Ms. ___ is a ___ female with history Paget's
disease of the bone and prior cholecystitis and biliary
obstruction s/p cholecystectomy and prior biliary stent
placement who presents with several days of worsening epigastric
pain, fevers and N/V found to have evidence of biliary
obstruction and biliary stent migration at OSH so transferred
here for ERCP eval.
#Cholangitis:
#Dislodged biliary stent:
Presented with several days of worsening epigastric pain, fevers
and N/V. Labs demonstrating cholestasic LFT derangement.
Labs demonstrating cholestastatic LFT pattern. Underwent ERCP on
___ with balloon sweep of pus and sphincterotomy. No stent
observed. KUB obtained and noted to migrate into large bowel.
Patient should pass via stool. Patient tolerated advancement of
diet and LFTs downtrending. Discharged to complete 5d of
cipro/flagyl.
# Normocytic Anemia:
Hg 10.6 on admission with decrease to 8.6 following aggressive
fluid given for cholangitis. Iron studies essentially normal. No
concern for active bleed. C-scope in ___ wnl. Further workup as
outpatient as clinically indicated. Suspect mild MDS. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / Vicodin / Iodinated Contrast Media / shellfish
derived
Attending: ___.
Chief Complaint:
Rash, Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo male with history of recent
hospitalization on ___ for unstable angina and CAD s/p 2 LAD
stents on ___, COPD, GERD, and depression who presents with
two weeks of angina and pruritic rash on shoulders, back, and
calves.
Patient was discharged on ___ after PCI with 2 LAD stents
placed for unstable angina. He was started on 6 new medications
during his hospitalization (amlodipine, atorva, clopidogril,
isosorbide nitrate, pantoprazole [switched from omeprazole],
aspirin) and reports a rash breaking out during his admission.
He
was told it would improve, but since discharge reports worsening
in the rash, which has now spread from his shoulders to his
upper
back and bilateral thighs and is increasingly more pruritic and
burning in nature. He has trialed Benadryl without benefit.
Denies any prior rash like this before, reports rashes to
Vikaden, no other known allergies. No drainage or blisters, skin
has remained intact. No fevers, chills, joint pains.
Additionally, patient has continued to endorse angina which has
been consistent since discharge and failed to improve. His
angina
is ___nd increases when he walks up stairs,
runs around with his ___ year old daughter or walks to grocery
store. Does not change, always same with this exertion, with
associated dyspnea on exertion and palpitations, no dyspnea at
rest. States that his dyspnea could also be from his COPD, gets
some relief with PRN albuterol. Takes isosorbide nitrate, but
has
not taken sublingual nitro. No diaphoresis, nausea/vomiting
during these episodes.
In the ED:
Initial VS: T 97.9, HR 78, BP 116/79, RR 18, SpO2 97% RA
Exam:
General: well appearing man
HEENT: PERRL, OP clear, no oral lesions appreciated
Pulm: CTAB, no wheezes appreciated
Cardiac: RRR, no murmurs appreciated, no pedal edema, 2+ radial
pulses
Abdomen: NTTP
Extremities: few scattered erythematous papules and macules on
anterior calves bilaterally, no warmth/edema, diffuse
erythematous macules and papules on bilateral posterior
shoulders
and upper back with associated lichenification and scratch
marks,
no erythema/edema
Neuro: CN2-12 intact, ___ strength ankle, shoulder, finger
flxn/ex, hip flx, shoulder abduction bilaterally
EKG: NSR; no ST-T segment changes or TW abnormalities
Labs notable for:
-CBC: WBC 6.8
-TropT: <0.01 x2
-MB: <1 x2
Studies notable for:
-CXR: No acute cardiopulmonary abnormality.
-TTE: discussed below.
Consults:
-Cardiology: admit to ___, consider transitioning Plavix to
alternative agent, plan to uptitrate anti-anginals and defer
repeat cor angio for now
Patient was given: aspirin 243mg, cetirizine 10mg
Vitals on transfer: HR 63, BP 113/76, RR 16, SpO2 94% RA
On the floor, pt endorses that this all started since starting
the 6 new meds. Rash has been itchy and evolving - started on
his
shoulder and migrated to back, other shoulder and to his calves.
Most bothersome symptom is the itchiness. Has not tried creams
at
home, benadryl did not help. Also notes has had cough/congestion
since last admission.
Past Medical History:
1. CARDIAC RISK FACTORS
- Dyslipidemia
- Strong family history of premature CAD
2. CARDIAC HISTORY
- Coronaries: DES to LAD and POBA to diag (___)
- Pump: EF >55%
- Rhythm: Bradycardia
3. OTHER PAST MEDICAL HISTORY
- COPD
- Depression
- GERD
Social History:
___
Family History:
Significant family history of premature MI in "14 family
members:"
- Twin Sister MI at ___
- Brother MI at ___, died suddenly in sleep
- Mother MI at ___
- Father MI at ___
- MI in uncles, maternal grandparents and paternal
grandparents,
age unknown
Physical Exam:
Admission
=============
___ 1651 Temp: 97.7 PO BP: 113/71 Lying HR: 44 RR: 18 O2
sat: 97% O2 delivery: Ra
GENERAL: Well developed, well nourished, in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. no thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Bilateral faint
crackles.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: Exanthematous faint pink macules on b/l shoulders,
resolving lesions on back and b/l ankles. No blistering or
drainage.
PULSES: Distal pulses palpable and symmetric.
Discharge
===========
VS: 98.0 PO 121 / 76 L Lying 71 18 95 Ra
Weight: Not recorded
GENERAL: Well developed, well nourished, in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. no thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: Exanthematous faint pink macules on b/l shoulders,
resolving lesions on back and b/l ankles. No blistering or
drainage.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
Admission
===========
___ 09:00AM BLOOD WBC-6.8 RBC-4.75 Hgb-14.2 Hct-43.4 MCV-91
MCH-29.9 MCHC-32.7 RDW-12.7 RDWSD-42.1 Plt ___
___ 09:00AM BLOOD Neuts-66.5 ___ Monos-9.0 Eos-4.1
Baso-0.9 Im ___ AbsNeut-4.49 AbsLymp-1.30 AbsMono-0.61
AbsEos-0.28 AbsBaso-0.06
___ 09:00AM BLOOD Plt ___
___ 09:00AM BLOOD Glucose-115* UreaN-17 Creat-1.0 Na-141
K-4.6 Cl-108 HCO3-20* AnGap-13
___ 09:00AM BLOOD CK(CPK)-95
___ 09:00AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 01:15PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 05:51AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9
Discharge
==========
___ 06:29AM BLOOD WBC-5.5 RBC-4.50* Hgb-13.5* Hct-40.6
MCV-90 MCH-30.0 MCHC-33.3 RDW-12.8 RDWSD-42.0 Plt ___
___ 06:29AM BLOOD Glucose-91 UreaN-17 Creat-1.0 Na-143
K-4.6 Cl-108 HCO3-24 AnGap-11
___ 06:29AM BLOOD Mg-2.0
OTHER TESTS
===============
___ Imaging CARDIAC PERFUSION PHARM
IMPRESSION:
1. Probably normal cardiac perfusion study, with question of
moderately fixed inferior wall defect versus attenuation. 2.
Left ventricular ejection fraction is 59% post stress and 60% at
rest.
___ Cardiovascular Transthoracic Echo Report
CONCLUSION:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler. The right atrial
pressure could not be estimated. There is mild symmetric left
ventricular hypertrophy with a
normal cavity size. There is normal regional and global left
ventricular systolic function. Quantitative 3D volumetric left
ventricular ejection fraction is 70 % (normal 54-73%). There is
no resting left ventricular outflow tract gradient. No
ventricular septal defect is seen. There is normal diastolic
function. Normal right ventricular cavity size with normal free
wall motion. The aortic sinus diameter is normal for
gender with a normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a mildly dilated descending
aorta. There is no evidence for an aortic arch coarctation. The
aortic valve leaflets (3)
appear structurally normal. There is no aortic valve stenosis.
There is trace aortic regurgitation. The mitral valve leaflets
appear structurally normal with no mitral valve prolapse. There
is trivial mitral regurgitation. The pulmonic valve leaflets are
normal. The tricuspid valve leaflets appear structurally normal.
There is mild [1+] tricuspid regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function.
Compared with the prior TTE (images reviewed) of ___,
there is no obvious change, but the suboptimal image quality of
the studies precludes definitive comparison.
___ Imaging CHEST (PA & LAT)
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.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Sarna Lotion 1 Appl TP QID:PRN itching
7. Aspirin 81 mg PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. lurasidone 60 mg oral QAM
10. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
Discharge Medications:
1. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID rash
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. lurasidone 60 mg oral QAM
10. Pantoprazole 40 mg PO Q24H
11. Sarna Lotion 1 Appl TP QID:PRN itching
Discharge Disposition:
Home
Discharge Diagnosis:
Contact Dermatitis
Coronary Artery Disease
COPD
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain // Please r/o cardiopulmonary
process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Rash
Diagnosed with Chest pain, unspecified
temperature: 97.9
heartrate: 78.0
resprate: 18.0
o2sat: 97.0
sbp: 116.0
dbp: 79.0
level of pain: 3
level of acuity: 3.0 | ___ male with recent admission where he
underwent stenting of his LAD and POBA to his diagonal for
ongoing unstable angina now presents with progressive rash on
his
torso and ongoing chest discomfort.
- Coronaries: DES to LAD and POBA to diag (___)
- Pump: EF >55%
- Rhythm: Sinus Bradycardia
#Rash: Initially suspected this was a drug rash as it began
during his last hospitalization during which he was exposed to
multiple new medications. Rash does not show concerning features
for SJS/TEN/DRESS. No bullae, skin intact, no sloughing, no
mucosal involvment. Upon careful review of the medical record
and ___ over his past admission, the time line appears to have
been:
- ___ no rash on PE
- ___ Atorva started
- ___ Aspirin loaded
- ___ initial cath without intv
- ___ omeprazole started
- ___ (night) ___ mention of rash in notes
- ___ Amlodipine started
- ___ Isosorbide started
- ___ repeat cath with intv
- ___ Plavix started/loaded
- ___ Pantoprazole started
Dermatology was consulted, and "given localization of itchy rash
to geographic areas on upper back, arms, and legs, as well as
rapid onset shortly after exposure to new drugs (drug rashes
typically take ___ weeks to begin after first exposure), and
evidence of contact derm to other irritants (EKG leads), favor
contact dermatitis to unknown contactant during previous
hospital
stay. Notably, once active, contact dermatitis may occasionally
take several weeks to clear. Recommend symptomatic care only at
this time. ___ consider substituting medications if rash fails
to
clear with tx." Recommending tx for contact dermatitis with:
-Triamcinolone ointment 0.1% BID x 2 weeks to affected area.
-If residual rash after two weeks, can continue Vaseline,
aquaphor, or eucerin bland emollient BID-TID.
-Defer medication changes until trial of topical treatment
directed to contact dermatitis (or of course if there is
worsening/changing symptoms of the rash).
# Chest pain
# CAD s/p PCI of LAD and POBA of Diagonal
The patient recently underwent PCI of the LAD and POBA of
diagonal. He reports ongoing, low-grade, atypical chest pain
since discharge. It is continuous, intermittently worsens with
exertion and is sometimes reproducible with palpation. Here, EKG
and cardiac biomarkers normal. Echocardiogram with no regional
wall motion abnormalities. Stress SPECT yesterday showed no
reversible defects, and fixed ?inferior wall defect vs.
attenuation. This morning he feels well, is chest pain free, and
electrically quiet. Overall, suspect that his symptoms are not
related to epicardial coronary disease, particularly given his
reassuring workup. Will continue his pre-hospitalization CAD
regimen.
- Aspirin 81mg daily
- Atorvastatin 80mg daily
- Imdur 60mg daily
- Plavix 75mg daily
- Home amlodipine
- Cardiology f/u scheduled with Dr. ___.
================
CHRONIC ISSUES:
================
#Depression
#Insomnia
Patient with history of depression and ?bipolar disorder. Was on
Aripiprazole, Duloxetine in past, but follows with psychiatry
and recently switched to Latuda
- resume Latuda upon discharge
#COPD
- Continue home flovent, proair
# GERD
- Continue PPI
# Dispo: discharge home today |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Plavix / heparin
Attending: ___.
Chief Complaint:
Hypotension and Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ hx sCHF (last EF 18% ___, Afib s/p
DCCV, CABG x4 (___) and prior NSTEMI s/p PCI/stent, severe
MR with ___ on ___, PVD s/p femoral endarterectomy and
fem-aort bypass, renal artery stenosis, DMII, HTN, recently
started on HD for refractory volume overload (___) who
presented on ___ with hypotension and chest pain.
The patient was recently discharged from the cardiology service
on ___ with decompensated CHF. At that time she was diuresed
aggressively without improvement, and then was initiated on HD
for refractory fluid overload. She reported that she went to HD
on ___, where she was told that her blood pressure was low.
She received IVF and her home lisinopril was stopped. On the
afternoon of admission, the patient reported feeling
intermittent, sharp, ___ left-sided chest/rib pain, without
radiation, lasting a few hours. She did not feel SOB. Because
she has had this type of chest pain before, she did nothing
about it. Her daughter gave her tramadol, which relieved the
pain. Later in the day, the patient's ___ was checking her blood
pressure while seated and noted an SBP in the ___. The patient
recalled speaking with the ___ during this time, and reported
that she was a little lightheaded and diaphoretic. Her ___
called an ambulance, and she was given a full-dose ASA.
Of note, during the patient's last admission, she was also found
to have a pan-sensitive enterobacter/klebsiella pneumoniae UTI,
and she was treated with a 7 day course of CTX. Other than the
chest pain as noted above, she denied fevers, abdominal pain,
N/V, dysuria, hematochezia, or melena. She reported that her
baseline weight is ~165 lbs (she is unsure of this; last weight
documented from ___ was 199 lbs on ___, no discharge weight
recorded).
In the ED, initial vitals were: 98.3 86 111/65 14 98% RA
- EKG showed afib @88, LBBB with TWI in lead I, biphasic T in
aVL, (consistent with prior) new TWI isolated in V6.
Labs notable for WBC 5.0 H/H 8.2/26.5 (last H/H 7.7/25.5) Plts
169
Chemistry with Na 134 K 4.9 Cl 97 HCO3 26 BUN 36 Cr 4.2
Trop-T 0.15 (consistent with troponin last admission)
pro-BNP 33750 (down from 52,000 last admission)
INR 2.3
U/A floridly positive but with 17 Epis.
No imaging was done.
Patient was given 500 ccs NS.
Decision was made to admit to medicine for further management.
Vitals prior to transfer: 97.8 84 98/45 16 99% RA
On the floor, the patient denied any chest pain, SOB,
lightheadedness, or other complaints.
Past Medical History:
PAST MEDICAL HISTORY:
-Carpal Tunnel Syndrome
-Coronary Artery Disease s/p CABG x4 ___ and prior NSTEMI
s/p PCI/stent
-Type 2 Diabetes Mellitus
-Systolic Congestive Heart Failure (EF 18% ___
-severe MR with recent ___ on ___ and MVR/ASD closure
on ___
-Gastroesophageal Reflux Disease
-Hyperlipidemia
-Hypertension
-Osteopenia
-Peripheral vascular disease s/p ___ stent on ___ lesions in
the left SFA and ___ stent ___ lesions in the left CIA
-End Stage Renal Disease on T, Th, ___ Hemodialysis (initiated
___
-HIT with positive DAT and "borderline" positive SRA ___
-Prior reported history of renal artery stenosis, although only
mildly elevated resistive indices per renal artery ultrasound in
___
PAST SURGICAL HISTORY:
-C-section
-Cholecystectomy
-Hysterectomy
-Right knee arthroplasty
-Spinal Surgery
Social History:
___
Family History:
Mother - deceased at ___, peritonitis
Father - deceased at ___, ___ Mellitus, Myocardial
Infarction
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
Vital Signs: 97.4 104/61 93 18 100%RA
Weight: 76.9 kg
General: Elderly female laying in bed in NAD, pleasant
HEENT: Anicteric sclerae (pt legally blind), MMM, JVD elevated
to edge of mandible
CV: Irregularly irregular, no murmurs/rubs/gallops. Minimally
tender at site of R tunneled dialysis catheter, dressing
clean/dry/intact
Lungs: Minimal rales in bilateral bases, no wheezes or rhonchi
Abdomen: Soft, NT/ND, no organomegaly
GU: No foley
Ext: Warm, dopplerable pulses, tender ___ to light palpation, no
edema.
Neuro: AAOx3, moving all extremities spontaneously, ___ strength
in upper extremities, CN grossly intact.
Skin: scattered ecchymoses over arms bilaterally
PHYSICAL EXAM ON DISCHARGE:
===========================
VS: Afeb, BP 93-118/46-67 HR 60-103 RR ___ SPO2 99 RA
Weight: 73.0 kg (post HD) <- 74.0 <- 75.5 kg (pre HD) < 74.9 kg
GEN: Elderly woman in NAD, alert and oriented x3.
NECK: JVP not elevated.
LUNGS: Bibasilar crackles but otherwise clear.
EXT: Trace to 1+ edema in bilateral lower extremities. Warm and
well perfused.
ACCESS: Tunneled HD catheter.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 08:08PM BLOOD Hgb-8.7* calcHCT-26
___ 08:08PM BLOOD Albumin-3.6 Calcium-8.6 Phos-4.9* Mg-1.8
___ 08:08PM BLOOD ___
___ 08:08PM BLOOD CK-MB-2 cTropnT-0.15*
___ 08:08PM BLOOD ALT-10 AST-23 AlkPhos-92 TotBili-0.4
___ 08:08PM BLOOD Glucose-121* UreaN-36* Creat-4.2*# Na-134
K-4.9 Cl-97 HCO3-26 AnGap-16
___ 09:09PM BLOOD ___ PTT-35.4 ___
___ 08:08PM BLOOD WBC-5.0 RBC-2.54* Hgb-8.2* Hct-26.5*
MCV-104* MCH-32.3* MCHC-30.9* RDW-19.3* RDWSD-73.8* Plt ___
LABS ON DISCHARGE:
==================
___ 06:00AM BLOOD WBC-4.6 RBC-2.70* Hgb-8.5* Hct-26.8*
MCV-99* MCH-31.5 MCHC-31.7* RDW-20.6* RDWSD-74.5* Plt ___
___ 06:00AM BLOOD Neuts-59.9 ___ Monos-12.6 Eos-5.0
Baso-0.7 Im ___ AbsNeut-2.75 AbsLymp-0.98* AbsMono-0.58
AbsEos-0.23 AbsBaso-0.03
___ 06:00AM BLOOD Glucose-83 UreaN-20 Creat-2.8* Na-135
K-3.8 Cl-97 HCO3-28 AnGap-14
___ 06:00AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.0
___ 06:00AM BLOOD ___ PTT-33.0 ___
MICROBIOLOGY:
=============
URINE CULTURE ___ (Preliminary):
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
BLOOD CULTURE x2 ___: No growth at time of discharge.
IMAGING/PROCEDURES:
===================
CXR (___):
Severe cardiomegaly is a stable. Right lower lobe opacities are
a combination of small effusion and adjacent atelectasis. Mild
vascular congestion is stable. Small bilateral effusions have
decreased. There is no evident pneumothorax. HD catheter is in
standard position. Sternal wires are aligned. Patient is status
post CABG.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Carvedilol 6.25 mg PO Q12H
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Pantoprazole 40 mg PO Q12H
8. Senna 17.2 mg PO DAILY:PRN constipation
9. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
10. Warfarin 7.5 mg PO DAILY16
11. Ascorbic Acid ___ mg PO BID
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Polyethylene Glycol 17 g PO DAILY
14. LORazepam 0.5 mg PO QHS:PRN anxiety
15. Lisinopril 5 mg PO DAILY
16. Furosemide 80 mg PO 4X/WEEK (___)
17. Humalog 8 Units Breakfast
Humalog 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Humalog 6 Units Breakfast
Humalog 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Warfarin 6 mg PO DAILY16
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO BID
7. Furosemide 80 mg PO 4X/WEEK (___)
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. LORazepam 0.5 mg PO QHS:PRN anxiety
11. Pantoprazole 40 mg PO Q12H
12. Polyethylene Glycol 17 g PO DAILY
13. Senna 17.2 mg PO DAILY:PRN constipation
14. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Symptomatic hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CAD, CHF on HD for refractory o/l with
hypotension, chest pain // evaluate for pulm edema vs. acute process
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___.
IMPRESSION:
Severe cardiomegaly is a stable. Right lower lobe opacities are a combination
of small effusion and adjacent atelectasis. Mild vascular congestion is
stable. Small bilateral effusions have decreased . There is no evident
pneumothorax. HD catheter is in standard position. sternal wires are
aligned. Patient is status post CABG
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Hypotension
Diagnosed with Other chest pain
temperature: 98.3
heartrate: 86.0
resprate: 14.0
o2sat: 98.0
sbp: 111.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | ___ with h/o 4-v CABG (___), systolic CHF (last EF 18% ___,
on hemodialysis as of ___ for diuretic-refractory volume
overload), s/p surgical MVR ___ (after failed ___ for
severe MR), Afib, PVD s/p femoral endarterectomy and fem-aort
bypass admitted for symptomatic hypotension (SBPs mid-60s;
associated lightheadedness) noted by ___.
# Symptomatic Hypotension: Outpatient BP noted by ___ to be in
___ on ___ (2 days after the last HD session she
received, suggesting this was less likely an HD-related volume
shift). On admission patient actually was normotensive (SBPs
___. Attempts were made to continue her afterload
reduction with lisinopril at a reduced dose of 2.5mg (compared
with 5mg), however she did not tolerate this with recurrent low
SBPs in mid ___. As a result, both metoprolol and lisinopril
were discontinued indefinitely.
# Systolic CHF (EF 18% in ___: Started on HD during last
admission for diuretic-refractory fluid overload. Weight 76.9 kg
on admission. Dry weight is not yet known (ongoing efforts to
remove volume and establish new dry weight with HD), however
with HD on ___ and ___ and ___ she weighed 73.0 kg on discharge
and appeared euvolemic at that weight. She was continued on
Lasix 80mg PO 4x/wk (non-HD days) and will resume her ___
HD schedule (next session planned for ___. Metoprolol and
lisinopril were discontinued (see above) due to patient's
inability to tolerate these medications. After she reaches a
better steady state with dialysis (she has lost a large amount
of volume weight over the last 1.5 weeks), she might be able to
tolerate gentle re-introduction of neurohormonal antagonists,
perhaps initially only on non-dialysis days.
# CAD s/p CABG, MI s/p stenting: Continued home ASA, statin.
# Afib: S/p DCCV in past. Afib on admission. Rate was
well-controlled and remained so even off metoprolol. Warfarin
dose was reduced to 6mg daily due to slightly high INR.
# ESRD on HD: On HD ___. Received HD on ___ and ___ and
___. Next HD session planned for ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
elevated creatinine
Major Surgical or Invasive Procedure:
___ diagnostic paracentesis (___)
History of Present Illness:
___ with history of autoimmune hepatitis/primary biliary
cirrhosis crossover syndrome (on prednisone and Azathioprine),
complicated by cirrhosis (splenomegaly, grade II varices without
bleeding on nadolol), h/o mycobacterium abscessus pneumonia
previously on chronic antibiotics, HTN, and DM presents from
clinic with ___.
Outpatient labs are notable for ___ with a creat of 2.1 from
a
normal baseline. Alk phos is also elevated from a normal
baseline. BMP was also noted for hyperglycemia, hyperkalemia,
and
acidosis. Patient denied any complaints.
In the ED, initial VS were: 98.1 80 130/89 19 99% RA
Exam notable for: abdomen NTND, no asterixis, AAOx3,
unremarkable
exam
Labs showed:
K:7.8, Lactate:2.5, Cr: 1.3
Imaging showed:
RUQUS
1. Cirrhotic liver with stable moderate ascites and
splenomegaly.
2. Patent main portal vein.
3. No hydronephrosis.
Patient received:
___ 16:12 IVF NS 1000 mL
___ 16:28 IV Albumin 25% (12.5g / 50mL) 50 g
Hepatology was consulted
Transfer VS were: 98.4 75 118/72 18 99% RA
On arrival to the floor, patient reports no acute symptoms.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
Chronic active hepatitis
Cirrhosis-Secondary to autoimmune hepatitis/PSC crossover
DM2-has had for years
HTN
Social History:
___
Family History:
Parents deceased. Unknown causes. Has two brothers and four
sisters. All in good health without medical problems. No
pulmonary disease, no tuberculosis.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.1 116 / 66 74 16 96 Ra
GENERAL: Adult demale 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: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
VS: 97.7 127 / 68 65 18 99 RA
GENERAL: Pleasant, elderly female, sitting up in bed, appears
comfortable and in no acute distress
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM
HEART: RRR, normal S1/S2, no murmurs, gallops, thrills, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Mildly distended, soft, non-tender, normal bowel
sounds, no rebound/guarding
EXTREMITIES: Warm and well perfused, no cyanosis, clubbing, or
lower extremity edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: No excoriations or lesions, no rashes
Pertinent Results:
ADMISSION LABS
___ 04:05PM BLOOD WBC-4.6 RBC-3.02*# Hgb-9.4*# Hct-27.4*#
MCV-91 MCH-31.1 MCHC-34.3 RDW-17.2* RDWSD-56.3* Plt ___
___ 04:05PM BLOOD ___ PTT-30.6 ___
___ 04:05PM BLOOD UreaN-26* Creat-2.1*# Na-134* K-5.2*
Cl-100 HCO3-20* AnGap-14
___ 04:05PM BLOOD Glucose-316*
___ 04:05PM BLOOD ALT-20 AST-34 AlkPhos-156* TotBili-1.3
DirBili-0.7* IndBili-0.6
___ 04:05PM BLOOD TotProt-8.1 Albumin-3.1* Globuln-5.0*
PERTINENT LABS
___ 02:10PM BLOOD WBC-4.7 RBC-2.99* Hgb-8.9* Hct-26.8*
MCV-90 MCH-29.8 MCHC-33.2 RDW-16.9* RDWSD-55.2* Plt ___
___ 04:59AM BLOOD WBC-3.0* RBC-2.52* Hgb-7.5* Hct-22.4*
MCV-89 MCH-29.8 MCHC-33.5 RDW-16.9* RDWSD-54.4* Plt Ct-98*
___ 01:05PM BLOOD Glucose-321* UreaN-25* Creat-1.3* Na-130*
K-9.1* Cl-96 HCO3-22 AnGap-12
___ 03:05PM BLOOD Glucose-334* UreaN-25* Creat-1.1 Na-136
K-5.0 Cl-101 HCO3-23 AnGap-12
___ 04:59AM BLOOD Glucose-83 UreaN-19 Creat-0.9 Na-141
K-4.1 Cl-107 HCO3-24 AnGap-10
___ 01:05PM BLOOD ALT-<5 AST-129* AlkPhos-160* TotBili-1.5
___ 04:59AM BLOOD ALT-16 AST-26 AlkPhos-98 TotBili-1.3
___ 01:18PM BLOOD Lactate-2.5* K-7.8*
DISCHARGE LABS
___ 06:25AM BLOOD WBC-4.2 RBC-3.30*# Hgb-9.8*# Hct-29.4*#
MCV-89 MCH-29.7 MCHC-33.3 RDW-16.9* RDWSD-55.0* Plt ___
___ 06:25AM BLOOD ___ PTT-32.3 ___
___ 06:25AM BLOOD Glucose-108* UreaN-22* Creat-0.9 Na-139
K-4.9 Cl-104 HCO3-24 AnGap-11
___ 06:25AM BLOOD ALT-19 AST-33 AlkPhos-128* TotBili-1.5
___ 06:25AM BLOOD Albumin-3.0* Calcium-8.2* Phos-3.4 Mg-2.3
IMAGING/STUDIES
Abdominal Ultrasound (___)- 1. Cirrhotic liver with
unchanged moderate ascites and splenomegaly.
2. Patent main portal vein.
3. No hydronephrosis.
4. Cholelithiasis.
CXR (___)- Persisting but decreased hazy and ill-defined
opacities in the right lower lobe are concerning for ongoing
albeit improved infection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Nadolol 40 mg PO DAILY
3. Spironolactone 50 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Ciprofloxacin HCl 500 mg PO Q24H
6. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
7. Humalog ___ 15 Units Bedtime
Discharge Medications:
1. AzaTHIOprine 25 mg PO DAILY
RX *azathioprine 50 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Ursodiol 300 mg PO TID
RX *ursodiol 300 mg 1 capsule(s) by mouth three times a day Disp
#*90 Capsule Refills:*0
5. Humalog ___ 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. Nadolol 20 mg PO DAILY
RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
8. Ciprofloxacin HCl 500 mg PO Q24H
9. Furosemide 20 mg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO BID
11. HELD- Spironolactone 50 mg PO DAILY This medication was
held. Do not restart Spironolactone until discussing with your
liver doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Acute kidney injury
Ascites
Secondary diagnoses:
Cirrhosis ___ primary biliary cirrhosis+autoimmune hepatitis
overlap
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with cirrhosis, worsening renal function//
Please assess for portal vein flow, hydronephrosis, ascites
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound from ___.
Abdominal MRI from ___.
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There is no focal liver mass.
The main portal vein is patent with hepatopetal flow. There is stable
moderate volume ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: Cholelithiasis. Mild gallbladder wall thickening is likely due
to third spacing and underlying liver disease.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 17.0 cm, previously 16.0 cm.
KIDNEYS: The right kidney measures 9.4 cm. The left kidney measures 9.4 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. Cirrhotic liver with unchanged moderate ascites and splenomegaly.
2. Patent main portal vein.
3. No hydronephrosis.
4. Cholelithiasis.
Radiology Report
INDICATION: ___ year old woman with cirrhosis// eval for pna
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The size and appearance of the cardiomediastinal silhouette is unchanged.
Interval decrease in extent of the ill-defined hazy opacities in the right
upper and right lower lobes. Those in the right lower lobe persist however.
There is no pleural effusion or pneumothorax identified.
IMPRESSION:
Persisting but decreased hazy and ill-defined opacities in the right lower
lobe are concerning for ongoing albeit improved infection.
Radiology Report
EXAMINATION: US INTERVENTIONAL PROCEDURE
INDICATION: ___ year old woman with cirrhosis and ___// Diagnostic
paracentesis
TECHNIQUE: Ultrasound guided diagnostic paracentesis
COMPARISON: None.
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a small
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 15 cc of clear, straw-colored fluid were removed. Fluid
samples were submitted to the laboratory for chemistry and culture.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic paracentesis.
2. 15 cc of fluid were removed.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Acute kidney failure, unspecified
temperature: 98.1
heartrate: 80.0
resprate: 19.0
o2sat: 99.0
sbp: 130.0
dbp: 89.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year-old female with history of autoimmune
hepatitis/primary biliary cirrhosis overlap syndrome (on
prednisone and azathioprine), complicated by cirrhosis
(splenomegaly, grade II varices without bleeding on nadolol),
h/o mycobacterium abscessus pneumonia previously on chronic
antibiotics, HTN, and DM who presented with acute kidney injury
on outpatient labs.
# ___: Cr bump from baseline of 0.9 to 2.1 in clinic, patient
referred to the ED. She improved back to her baseline of 0.9
with albumin and IV fluids. This could be due to a recently
increased diuretic dose. She was taking 20 mg Lasix and 50 mg
spironolactone at home. Her diuretics were held in-house and she
was restarted on 20 mg Lasix alone for diuresis on discharge. Of
note, there is questionable medication and diet compliance.
# Autoimmune hepatitis/primary biliary cirrhosis: MELD-Na 14 on
admission. Complicated by esophageal varices and SBP on Cipro
ppx, although she had recently run out of Cipro. She received a
diagnostic tap with ___, and fluid studies showed no evidence of
SBP. She was continued on her home nadolol for variceal ppx, and
restarted on pantoprazole daily, ursodiol, azathioprine, and
prednisone (home immunosuppression regimen).
# Hyperglycemia
# IDDM: Patient was admitted with hyperglycemia but no evidence
of DKA. Last A1C 7.4%. Home metformin was held and insulin was
continued.
# Med Rec: The patient was evaluated by occupational therapy who
found impairments in understanding of medications. The medical
team discussed with patient and her family that she should have
visiting nurse services to help her with medications, home
occupational therapy, and should have her family match her
medications with what is listed on the discharge paperwork, and
call her PCP's office if she runs out of meds at home. She
should also have directly observed medication consumption.
TRANSITIONAL ISSUES
[] CT at end of ___ for M. abscessus PNA
[] 20 mg Lasix on discharge, holding spironolactone, should
follow up with Dr. ___ in clinic
[] needs repeat EGD, consider whether she should continue
nadolol given history of SBP
[] Cr on discharge: 0.9
[] Questionable medication compliance; patient to be started
with ___ and should have directly observed medication
consumption
[] Follow-up scheduled with PCP and hepatology
#CODE: FULL CODE (presumed)
#CONTACT: ___, ___ or ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with history of ulcerative colitis complicated
by primary sclerosing cholangitis and cirrhosis requiring liver
transplant in ___ in ___ who presents with abdominal
pain. Patient reports that she was in her usual state of health
until 3 days ago when she developed general malaise and
abdominal pain. She reports that pain was located in RUQ and
initially felt like constipation. She took some magnesium
citrate and had a BM however did it not relieve her pain. She
describes her pain has squeezing in nature and radiating to
right flank and shoulder. She denies fevers, urinary symptoms,
or ETOH use however endorsed chills (which occurs at baseline).
She denies nausea, vomiting, and diarrhea. Given her ongoing
pain she presented to the ED for evaluation.
Of note patient has had several admissions in the past for
similar complaints of abdominal pain. In most cases, the
etiology is unknown and sometimes attributed to MSK related. The
patients reports that her prior pain was in the LUQ and her RUQ
and flank pain are new.
In the ED, initial vs were 98.3 115 106/68 20 98%. Exam was
significant for a tender abdomen. Of note because of pain,
patient was not very cooperative with exam. Received dilaudid
1mg IV x4, toradol 15mg x 1, lorazepam 2mg x 1, zofran 4mg x 1,
and cipro/flagyl. She also received a total of 2LNS. Labs were
otherwise unremarkable except an alk phos of 258 and Cr 1.2
(baseline 0.9-1.0). RUQ ultrasound was otherwise unremarkable.
While in ED, patient began to feel better and diet was advanced
to clear liquids. Transfer VS 97.9 87 99/60 16 100%.
On arrival to the floor, VS were 98.3 125/81 105 20 100%RA.
Patient was continuing to complain of significant abdominal
pain, very tearful, asking for the same pain meds as given in
the ED.
Past Medical History:
- S/p OLT ___ primary sclerosing cholangitis
- Ulcerative colitis (last ___ ___
- Gastroesophageal reflux disease
- Herpes simplex viral infection
- Chronic neck pain
- Asthma
- Migraine headaches
- Iron deficiency anemia
Social History:
___
Family History:
Mother who died of cervical cancer young in ___.
Father - healthy
brother- healthy
Uncle with ulcerative colitis
Physical Exam:
Admission Exam:
VS: 98.3 125/81 105 20 100%RA
GEN: awake, alert, tearful, crying
HEENT: OP clear, no LAD
PULM: CTAB, but pt vocalizing during exam
CV: RRR no m/r/g
ABD: +BS, soft, diffusely tender to palpation, but pt reacting
to even light touch, no rebound, voluntary guarding
EXT: WWP, no edema
Discharge Exam:
GEN: awake, alert, anxious
PULM: CTAB, but pt vocalizing during exam
CV: RRR no m/r/g
ABD: +BS, soft, diffusely tender to palpation, but pt reacting
to even light touch, no rebound, voluntary guarding
EXT: WWP, no edema
Pertinent Results:
Admission Labs:
___ 09:40AM BLOOD WBC-3.3* RBC-4.24 Hgb-12.5 Hct-35.4*
MCV-84 MCH-29.4 MCHC-35.2* RDW-13.1 Plt ___
___ 09:40AM BLOOD Neuts-59.2 ___ Monos-4.9
Eos-12.5* Baso-0.2
___ 09:40AM BLOOD ___ PTT-37.6* ___
___ 09:40AM BLOOD Glucose-105* UreaN-17 Creat-1.2* Na-141
K-4.8 Cl-104 HCO3-25 AnGap-17
___ 09:40AM BLOOD ALT-39 AST-27 AlkPhos-258* TotBili-0.9
___ 09:40AM BLOOD Albumin-4.0
___ 08:32AM BLOOD Albumin-3.4* Calcium-8.8 Phos-3.6 Mg-2.0
___ 09:52AM BLOOD Lactate-1.3
Additional labs:
___ 06:00AM BLOOD IgA-175
___ 06:00AM BLOOD tTG-IgA-10
___ 06:00AM BLOOD tacroFK-7.0
___ 08:32AM BLOOD tacroFK-7.2
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Urine:
___ 09:45AM URINE Color-Yellow Appear-Clear Sp ___
___ 09:45AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-8* pH-6.0 Leuks-NEG
___ 09:45AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-2
___ 09:45AM URINE CastHy-7*
___ 09:45AM URINE Mucous-RARE
Discharge Labs:
___ 06:00AM BLOOD WBC-2.7* RBC-3.72* Hgb-10.8* Hct-31.1*
MCV-84 MCH-29.1 MCHC-34.8 RDW-13.1 Plt ___
___ 06:00AM BLOOD Glucose-93 UreaN-12 Creat-1.0 Na-138
K-5.2* Cl-106 HCO3-25 AnGap-12
___ 08:32AM BLOOD ALT-34 AST-21 AlkPhos-229* TotBili-0.9
___ 06:00AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0
Micro:
___ Blood cultures x 2 - PENDING (no growth to date)
___ Urine cultures x 2 - FINAL no growth
Imaging:
___ Liver/Gallbladder U/S: IMPRESSION: 1. Normal-appearing
liver, with patent hepatic vasculature and appropriate
directional flow. 2. Unchanged splenomegaly with lobulated
splenic contour likely related to prior infarcts which were
better evaluated on the prior CT.
EKG ___: Sinus rhythm. Probably normal tracing for age. Since
the previous tracing
of ___ probably no significant change.
CXR ___: FINDINGS: PA and lateral views of the chest were
obtained. The lungs are
well expanded and clear. The cardiomediastinal silhouette is
unremarkable.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Apri *NF* (desogestrel-ethinyl estradiol) 0.15-30 mg-mcg Oral
daily
2. FoLIC Acid 1 mg PO DAILY
3. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain
4. HydrOXYzine 25 mg PO QID
5. imiquimod *NF* 5 % Topical 3x/week
6. Lorazepam 1 mg PO BID:PRN anxiety
7. Mesalamine ___ 2400 mg PO BID
8. Mycophenolate Mofetil 500 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. Tacrolimus 4 mg PO Q12H
11. Ondansetron 4 mg PO BID-TID:PRN nausea
12. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
13. Ursodiol 300 mg PO TID
14. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
15. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral 2 tablets BID
16. Docusate Sodium 100 mg PO BID
17. Claritin-D 12 Hour *NF* (loratadine-pseudoephedrine) ___
mg Oral daily
Discharge Medications:
1. Apri *NF* (desogestrel-ethinyl estradiol) 0.15-30 mg-mcg Oral
daily
2. Docusate Sodium 100 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain
5. Lorazepam 1 mg PO BID:PRN anxiety
6. Mesalamine ___ 2400 mg PO BID
7. Mycophenolate Mofetil 500 mg PO BID
8. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
9. Ondansetron 4 mg PO BID-TID:PRN nausea
10. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
11. Tacrolimus 4 mg PO Q12H
12. Ursodiol 300 mg PO TID
13. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
14. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral 2 tablets BID
15. Claritin-D 12 Hour *NF* (loratadine-pseudoephedrine) ___
mg Oral daily
16. HydrOXYzine 25 mg PO QID
17. imiquimod *NF* 5 % Topical 3x/week
18. DiCYCLOmine 20 mg PO TID
1 hour prior to meals
RX *dicyclomine 20 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
RX *dicyclomine 20 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Abdominal pain
SECONDARY
status-post liver transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Status post liver transplantation in ___ secondary to primary
sclerosing cholangitis, presenting with right upper quadrant pain. Evaluate
for liver abscess and assess portal venous flow.
COMPARISON: Abdominal/pelvic CT from ___. Right upper quadrant
ultrasound from ___.
FINDINGS: The liver echotexture and echogenicity are normal. No focal liver
lesions are identified. There is no intrahepatic biliary duct dilatation.
The gallbladder is surgically absent, relating to prior liver transplantation.
The visualized portion of the pancreas is unremarkable. The full extent of
the pancreatic head and tail were not well assessed secondary to overlying
bowel gas. The spleen is markedly enlarged, measuring up to 20.3 cm, not
significantly changed compared to prior CT. Marked lobulation of the splenic
contour is also not significantly changed and may be related to prior splenic
infarctions, better seen on prior CT. There is no free fluid in the abdomen.
The main portal vein, anterior and posterior branches of the right main portal
vein, and left main portal vein are patent, with appropriate waveforms and
directional flow. The main hepatic artery has a sharp systolic upstroke. The
hepatic veins are patent, with appropriate directional flow.
IMPRESSION:
1. Normal-appearing liver, with patent hepatic vasculature and appropriate
directional flow.
2. Unchanged splenomegaly with lobulated splenic contour likely related to
prior infarcts which were better evaluated on the prior CT.
Radiology Report
INDICATION: ___ female with pleuritic chest pain.
COMPARISON: Comparison is made to radiograph of the chest from ___.
FINDINGS: PA and lateral views of the chest were obtained. The lungs are
well expanded and clear. The cardiomediastinal silhouette is unremarkable.
CONCLUSION: Normal chest radiographs.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN RLQ
temperature: 98.3
heartrate: 115.0
resprate: 20.0
o2sat: 98.0
sbp: 106.0
dbp: 68.0
level of pain: 9
level of acuity: 2.0 | ___ with history of ulcerative colitis complicated by PSC and
cirrhosis requiring OTL in ___ in ___ who presents with
abdominal pain.
Active issues:
# Abdominal Pain: Patient with chronic abdominal pain of unclear
etiology. No acute process was revealed by work-up during this
admission. RUQ ultrasound was reassuring as well as mostly
normal labs. Alk phos mildly elevated which is concerning for
biliary process however it is at her baseline. Common processes
include viral gastroenteriis v. gastritis v. PUD v. dyspepsia.
Patient tolerated regular diet well. We started the patient on
bentyl and uptitrated her PPI. We maintained her home narcotic
regimen. Close follow-up appointments were scheduled with the
patient's PCP and transplant service physician.
# Acute kidney injury: Cr 1.2 at admission. Baseline Cr 0.9-1.0.
Likely in setting of poor PO intake. Received fluid in ED,
tolerated regular diet and Cr returned to baseline. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Shellfish Derived
Attending: ___.
Chief Complaint:
"Headache, N/V, abdominal pain."
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ lady SLE, sarcoid, Sjogren's disease,
HTN, and recent diagnosis of pseudotumor cerebri who presents
with worsening headache over 4 days.
She was recently admitted to ___ ___ for bitemporal
headach associated with photophobia, N/V as well as dizziness
that she characterizes as both room spinning to the right as
well as lightheadedness. Because of her extensive rheum history
as well as a ?granuloma vs hemorrhage on her left tentorium
cerebelli, a repeat MRI/V/A was performed and was non-revealing.
She then had an LP on ___, which was significant for an
opening pressure of 37cmH2O but with no pleiocytosis. She
experienced significant relief with 23cc taken off. She was then
started on diamox 500mg BID. However, conerned about not enough
fluid being taken off, she was retapped and the opening pressure
was 31cmH2O and 30cc were taken off. The LP brought her H/A from
a ___. She left the hospital with a ___ headache.
Since she left the hospital, she reports that her HA gradually
became worse, and was focused more at the top of her head than
bitemporal and radiated to the back of her head. No variance
with positional change. She also had some concomitant upper
abdominal pain with nausea and dry heaves, worse after eating.
She also had isolated episodes of diarrhea. She has been taking
ASA at home with no improvement so she presented to the ED
again.
In the ED, initial VS were: pain ___, T 97.7, HR 70, BP
175/103, RR 18, POx 100% RA. Labs were notable for elevated
amylase and lipase. her neuro exam was normal but her abdomen
exam included diffuse tenderness to palpation over
midepigastrium and LLQ. She received percocet x 1, zofran x 1,
2L NS then continuous at 100cc/hr, morphine 4mg x 1 and was
admitted to Medicine for management of headache and
pancreatitis. VS prior to transfer were: T 98.1, HR 55, BP
141/71, RR 16, POx 99%RA.
On the floor, she is sleepy. Headache is ___. She is thirsty
and hungry.
Past Medical History:
1. Sarcoidosis: Diagnosed in ___ based on hilar adenopathy with
a biopsy that showed noncaseating granulomas.
2. SLE: Positive serology for ___, double-stranded DNA,
anti-SSA,
anti-SSB anti-smooth muscle antibodies. Low titers rheumatoid
factor and negative anti-CCP antibodies, antimitochondrial
antibodies,
anticardiolipin, lupus anticoagulant, RNP, B2 glycoprotein.
History of butterfly rash responsive to plaquenil. Arthralgia
and fatigue.
3. Sjogrens: Longstanding history of Sicca symptoms with
positive SSA and positive SSB antibodies.
4. Cardiac Arrrhythmia: Prior history of PVCs. Developed atrial
fibrillation in ___ during a hospitalization for
pericardial and pleural effusions requiring decortication and
pericardiocentesis. Discharged on metoprolol 100mg tid and
aspirin for CHADS2 of 1.
5. Morbid Obesity: S/p Roux-en-Y bypass surgery in ___
6. MGUS: Diagnosed in ___. Concern for family history of
Multiple Myeloma, although adopted sister. Followed By Dr.
___ ___ previously, with protein
electropherisis biannually. Postive Rho antibody and elevated
IgG levels.
7. Asthma
8. Stage 2 Chronic Kidney Disease: Without proteinuria and
benign sediment. Baseline creatinine 1.2. Hospitalization in
___ complicated by ARF which resolved with fluids.
9. Chronic Anemia: Reported since ___.
10. Hypomenorrhea / Oligomenorrhea- ___
11. Menometrorrhagia: ___
12. CAD: Episode of chest pain in ___ worked up for ACS however
pt reports likely c/w panic attack. Several admissions in ___
for chest pain and left arm pain. EF in ___ was 69%. Work-up
reported evidence of anterior septal MI.
13. Salmonella Bacteremia: Treated with 2 weeks of ciprofloxacin
in ___. Unclear orign however multiple risk factors
including chronic prednisone.
14. Pleural Effusion: ___: Pleural effusion concerning
for rheumatologic origin. S/p large volume pleurodesis and
decortication.
15. Pericardial Effusion: ___: Requiring
pericardiocentesis.
16: HTN
17: severe headache felt to be due to idiopathic intracranial
hypertension (pseudotumor cerebri) s/p hospitalization
___ including LP x2 with post LP headache and blood
patch
Social History:
___
Family History:
7 siblings.
Adoptive Mother: ___ Heart Attack at age ___ sickle cell
trait
Biologic Sister: ___ Failure s/p transplant
Brother: ___ Sister: Multiple ___ - died in ___
Biologic Sister: sickle cell disease
Physical Exam:
Admission exam:
Vitals: T97.5 HR50 BP155/70 RR18 SpO2 98/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. Very mild
tenderness over temporal area, localizes the pain to top of her
head when I press over TA. Has some blurriness in both eyes
which she has had for a few weeks, R>L, able to read small print
up close (doesn't have glasses for diatance)
Neck: supple, JVP not elevated, no LAD
Lungs: Quiet breath sounds, clear to auscultation bilaterally,
no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, TTP in the epigastrium and mildly in all
quadrants, morbidly obese. + bowel sounds. no rebound or
guarding.
Ext: warm, well-perfused. no cyanosis, clubbing, or edema.
Neuro: CN II-XII intact. Strength ___ throughout. motor function
grossly normal
Discharge exam: Unchanged except for as below:
Abdomen: soft, obese, only slight TTP in epigastriup
Pertinent Results:
Admission labs:
___ 01:10PM BLOOD WBC-7.0 RBC-5.06 Hgb-14.5 Hct-43.5 MCV-86
MCH-28.7 MCHC-33.4 RDW-16.2* Plt ___
___ 01:10PM BLOOD Neuts-84.5* Lymphs-12.7* Monos-1.7*
Eos-0.8 Baso-0.1
___ 01:10PM BLOOD Glucose-93 UreaN-14 Creat-1.2* Na-138
K-6.4* Cl-111* HCO3-13* AnGap-20
___ 01:10PM BLOOD ALT-30 AST-61* AlkPhos-89 Amylase-191*
TotBili-0.3
___ 01:10PM BLOOD Lipase-250*
___ 06:10PM BLOOD VitB12-641 Folate-GREATER TH
Imaging:
-CT abdomen/pelvis (+/- I) - 1. No evidence of pancreatitis on
CT including no peripancreatic inflammation.
2. No evidence of pseudocyst or abscess formation. No evidence
of thrombosis
or aneurysm formation of the upper abdominal vasculature.
3. Unchanged mild intra- and extra extra-hepatic biliary
dilatation, status
post cholecystectomy.
Discharge labs:
___ 06:20AM BLOOD WBC-4.8 RBC-4.24 Hgb-11.9* Hct-36.6
MCV-86 MCH-28.1 MCHC-32.5 RDW-16.2* Plt ___
___:20AM BLOOD Glucose-85 UreaN-17 Creat-1.2* Na-141
K-3.6 Cl-114* HCO3-19* AnGap-12
___ 06:10PM BLOOD Lipase-197*
Medications on Admission:
Diamox 500mg BID
Aspirin 81 mg daily
Lisinopril 30 mg daily
Amlodipine 10 mg daily
Prednisone 7.5 mg daily
Hydroxychloroquine 200 mg BID
Azathioprine 200 mg daily
Advair Diskus 500 mcg-50 mcg: 1 puff BID
Albuterol sulfate HFA 90 mcg: 2 puffs Q4-6H PRN
Albuterol sulfate 2.5 mg/3 mL (0.083 %) Neb Q4-6H PRN
Omeprazole 20 mg daily
Sertraline 150 mg daily
Ondansetron 4 mg Q8H PRN
Calcium-Vitamin D 600 mg-400 unit daily
Multivitamin daily
Discharge Medications:
1. acetazolamide 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. azathioprine 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
8. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every ___ hours as needed for shortness
of breath or wheezing.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every ___ hours as
needed for SOB/wheezing.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
13. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
14. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: One (1) Capsule PO once a day.
15. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. tramadol 50 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
17. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
18. Outpatient Lab Work
Hemoglobin and hematocrit on ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Pseutotumor cerberi
Nausea and vomiting
Secondary diagnoses:
Lupus
Sjogren's disease
Sarcoidosis
MGUS
Chronic kidney disease - Stage 2
CAD
Morbid obesity
Adthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with elevated lipase, evaluate for pancreatitis and
complications.
TECHNIQUE:
Contiguous MDCT images of the abdomen were performed with initial non-enhanced
and subsequently enhanced MDCT images. Axial, coronal, and sagittal reformats
were acquired.
COMPARISON: CTA of the chest from ___, MRCP from ___ and
CT of the abdomen and pelvis from ___.
FINDINGS:
CT ABDOMEN:
There is elevation of the right hemidiaphragm. Left base linear
atelectasis/scarring is seen. There are no focal hepatic lesions. The patient
is status post cholecystectomy with minimal intrahepatic and mild CBD
dialation to 8 mm, unchanged from the prior.
The pancreas appears normal without evidence of peripancreatic fat stranding.
There is no pancreatic duct dilatation. No evidence of pseudocyst, abscess
formation. No evidence of splenic vein thrombosis or celiac axis aneurysm (or
splenic artery aneurysm) to suggest complications secondary to pancreatitis.
The spleen is normal.
The kidneys are homogeneously enhancing and excreting urine without evidence
of obstructing masses.
There is no retroperitoneal or mesenteric lymphadenopathy.
The patient is s/p gastric bypass which can not be well evaluated since the
oral contrast has passed distally into the distal small bowel.
BONES: There are no suspicious lytic or sclerotic bony lesions.
IMPRESSION:
1. No evidence of pancreatitis on CT including no peripancreatic
inflammation.
2. No evidence of pseudocyst or abscess formation. No evidence of thrombosis
or aneurysm formation of the upper abdominal vasculature.
3. Unchanged mild intra- and extra extra-hepatic biliary dilatation, status
post cholecystectomy.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: N/V/D
Diagnosed with ACUTE PANCREATITIS, PSEUDOTUMOR CEREBRI, SYST LUPUS ERYTHEMATOSUS, CHRONIC AIRWAY OBSTRUCTION
temperature: 97.7
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 175.0
dbp: 103.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ is a ___ lady with extensive rheumatologic
history and recent diagnosis of pseudotumor cerebri who presents
with worsening headache, nausea and epigastric pain.
#Headache - After arrival to the floor, her headache improved
and was back to her baseline on the second day of admission.
The pain was treated with tylenol and PRN morphine, which she
did not require much of. She was seen by neurology who felt
that this was an acute on chronic exacerbation of her ongoing
headaches and that no changes to her medications, including
Diamox, was necessary. She has previously been diagnosed with
pseudotumor cerebri and had an LP during her last admission, she
did not require an LP during this admission. The headache may
also have been worsened by volume depletion from diarrhea and
vomiting. Temporal arteritis was thought to be unlikely because
she did not have significant tenderness over her temporal artery
and had no acute changes in her vision. The headaches may also
have been from her high blood pressure, which was in the 160s
systolic upon arrival to the floor. We increased her lisinopril
from 30mg to 40mg daily. Her neurological exam was intact, and
per the neurology notes, this was reassuring compared to her
exam from prior admissions. She has follow-up arranged with
neurology after discharge.
#Nausea/vomiting - She did not have any vomiting upon arrival to
the floor, only some dry heaving. Her nausea waxed and waned,
but was back to baseline at the time of discharge. Lipase was
slightly elevated, but CT abd/pelvis in the ED did not show any
evidence of pancreatitis. Her diet was advanced and she was
tolerating regular diet at discharge. She was also volume
resuscitated. Nausea was controlled with Zofran and Compazine,
which helped her symptoms.
#HTN - As mentioned above, lisinopril was increased to 40mg
daily because of persistently elevated BP on the floor.
#SLE - No obvious signs of lupus flare, she was continued on her
home hydroxychloroquine, azathioprine, prednisone.
#Asthma - Continued on her home Advair and albuterol, no active
symptoms.
#Code status this admission - FULL
#Transitional issues:
-Will need ongoing evaluation of her headaches and pseudotumor
cerebri
-Has been advised to stay well hydrated, especially when
vomiting or having decreased PO intake, as this may make her
headache worse. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Tylenol
Attending: ___.
Chief Complaint:
4 days gait instability
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old man with HTN, HLD, chronic hydrocephalus,
prior episode of meningitis (___), who presents with about 1
week of gait instability and cognitive slowing. Was reportedly
well until a recent wisdom tooth extraction on ___, after
which,
was noncompliant with antibiotics due to intolerance of side
effects. He describes a wide based gait, with feet dragging
along
the floor, but has not fallen, no assistance required. Wife
reports that he seems cognitively slower over this time.
Identical symptoms in ___ when he was found with a nonspecific
viral meningitis. WBC ~160 (lymphocyte-predominant >90%) protein
was elevated ~130. ID was consulted and negative infectious
workup, cytology "reactive", no malignancy. Large volume tap
did
not improve symptoms. Presumed non-specific viral meningitis.
Currently with no HA or meningeal complaints. History of
exposure
to mold/fungus, tick bites per prior OMR notes. Incidentally
noted on prior admit with Parkinsonian
features (Right-wrist cogwheeling, intermittent pill-rolling
tremor of Right hand with stress/walking,
bradykinesia/?masked-facies) perhaps contributing to gait
decline.
Past Medical History:
- HTN
- Hyperlipidemia
- CAD s/p stents
Social History:
___
Family History:
- Neg for stroke, cancers, AVMs
Physical Exam:
PHYSICAL EXAMINATION:
VS T99.5 HR68 BP153/73 RR18 Sat97%RA
GEN - elderly M, cooperative and pleasant, NAD
HEENT - NC/AT, MMM
NECK - full ROM, supple, no meningismus
CV - RRR
RESP - normal WOB
ABD - soft, NT, ND
EXTR - atraumatic, WWP
NEUROLOGICAL EVALUATION:
MS - brightly awake, attends to examiner, but formal testing of
attention reveals he is unable to complete MOYB and struggles
(but does slowly complete) DOWB; oriented to self, place, and
month/year, but not the date; language is fluent with normal
prosody; repetition, naming, and comprehension are all intact;
he
is able to follow 2 step and grammatically complex commands;
there is no R-L confusion; his MOCA score was ___ - loosing
the
majority of points for ___ recall, go-no-go, serials 7s, trails,
and cube copying.
CN - [II] PERRL 4->2 brisk. VF full to number counting. [ III,
IV, VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light
touch bilaterally. [VII] Face is grossly symmetric though there
is questionable delayed activation of R face on volitional
smile.
[VIII] Hearing intact to voice. [IX, X] Palate elevation
symmetric. [ XI] SCM/Trapezius strength ___ bilaterally. [XII]
Tongue midline with full ROM.
MOTOR - normal bulk, unable to full assess tone given patient's
inability to fully relax tested muscle groups despite using
distracting techniques - questionable decreased tone in B/L LEs.
No pronation, no drift. When ambulating he is a
pronation-supination tremor of his RUE (?rubral).
[Del] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [___]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
SENSORY - no deficits to LT, PP, vibration, or proprioception in
B/L great toes.
REFLEXES -
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response flexor bilaterally.
+Grasp on the R, +Snout
COORD - No dysmetria with finger to nose testing. Poor cadence
with RAM bilaterally. Romberg negative.
GAIT - upon first standing, retropulses; on second try, able to
stand up but toes noted to be off the ground, appears as though
he is going to retropulse; few steps taken, stride length is
only
~2" and extremely shuffling
Pertinent Results:
PERTINENT LABS:
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ 01:20AM CEREBROSPINAL FLUID (CSF) WBC-178 RBC-4*
Polys-0 ___ Monos-7 Eos-1
___ 01:20AM CEREBROSPINAL FLUID (CSF) WBC-173 RBC-14*
Polys-0 ___ Monos-8 Eos-2
___ 01:20AM CEREBROSPINAL FLUID (CSF) TotProt-131*
Glucose-52
___ 06:22AM CEREBROSPINAL FLUID (CSF) BORRELIA BURGDORFERI
ANTIBODY INDEX FOR CNS INFECTION-PND
___ 01:20AM CEREBROSPINAL FLUID (CSF) ARBOVIRUS ANTIBODY
IGM AND IGG-PND
___ 01:20AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test
ADMISSION LABS:
___ 09:00PM BLOOD WBC-11.6* RBC-5.20 Hgb-15.5 Hct-44.1
MCV-85 MCH-29.8 MCHC-35.1 RDW-12.8 RDWSD-39.3 Plt ___
___ 09:00PM BLOOD Neuts-66.2 ___ Monos-8.6 Eos-4.5
Baso-0.8 Im ___ AbsNeut-7.69* AbsLymp-2.27 AbsMono-1.00*
AbsEos-0.52 AbsBaso-0.09*
___ 09:00PM BLOOD Plt ___
___ 09:00PM BLOOD Glucose-104* UreaN-16 Creat-1.0 Na-134
K-4.4 Cl-95* HCO3-28 AnGap-15
___ 09:00PM BLOOD ALT-22 AST-19 AlkPhos-69 TotBili-1.0
___ 09:00PM BLOOD Albumin-4.6 Calcium-9.5 Phos-3.5 Mg-2.3
___ 09:00PM BLOOD TSH-1.3
___ 09:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
___ 10:19 ___, CHEST (PA & LAT: No acute intrathoracic
process
DISCHARGE LABS:
___ 12:40PM BLOOD WBC-9.6 RBC-4.91# Hgb-14.5# Hct-41.8#
MCV-85 MCH-29.5 MCHC-34.7 RDW-12.8 RDWSD-39.6 Plt ___
___ 06:35AM BLOOD WBC-8.4 RBC-3.42*# Hgb-9.5*# Hct-29.2*#
MCV-85 MCH-27.8 MCHC-32.5 RDW-17.4* RDWSD-53.4* Plt ___
___ 12:40PM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-92 UreaN-15 Creat-1.0 Na-135
K-4.5 Cl-99 HCO3-26 AnGap-15
___ 12:40PM BLOOD LD(LDH)-209
___ 06:35AM BLOOD Calcium-7.9* Phos-2.5* Mg-1.9
___ 12:40PM BLOOD Hapto-PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. walker miscellaneous DAILY
Diagnosis: viral meningitis with gait instability
Length of need: 6 months
Prognosis: good
RX *walker use for balance daily Disp #*1 Each Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gait instability
Viral meningitis
Discharge Condition:
Alert and orientedx3
attentive
able to ambulate
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with AMS, gait difficulty // Assess for signs of infection
COMPARISON: ___
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache, Confusion
Diagnosed with ABNORMALITY OF GAIT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 99.5
heartrate: 68.0
resprate: 18.0
o2sat: 97.0
sbp: 153.0
dbp: 73.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is a ___ man with hydrocephalus ___ chronic
meningitis who was admitted for 4 days of progressive gait
instability/shuffling and memory difficulties. Exam is
significant for frontal lobe impairment, poor recall and working
memory, as well as a wide-based shuffling abnormal gait. LP
showed WBC 178, protein 131, glc 52 with 90% lymphs. Also has a
modest leukocytosis and temperature of 99.5F. His NCHCT shows
enlarged ventricles unchanged from ___. Based on CSF, likely
has viral meningitis, HSV ruled out so acylovir stopped.
Supportive care provided, pt discharged home with instructions
to follow-up in clinic in the next week. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Sulfa (Sulfonamide Antibiotics) / Cefzil /
Meclofenamate Sodium / cefazolin / vancomycin
Attending: ___.
Chief Complaint:
encephalopathy, hypercalcemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ F with multiple myeloma, CKD stage IV-V,
receives Velcade and Decadron with Revlimid twice a week
presents to the ER with encephalopathy and hypercalcemia. Of
note, she also has a history of instability of ___ s/p 10
cycles of XRT, now only requiring ___ collar with exercise
as well as pathologic compression of T11, T12 and L5 without
cord involvement related to Multiple Myeloma. History is
partially obtained via Rehab worker at 1230am via phone who
states that the patient has been confused for over a month. She
was not aware of any acute change, but when blood drawn today,
Calcium was 11.5 with Albumin of 2.5. (Calcium 9.9 at ___
yesterday). Md note states that IV fluids and Calcitonin
(presumably 200mg SC x1) were given. Pt describes feeling
anxious about the course of her treatment plan but denies any
change in bone pain, new trauma, headaches, chest pain, fevers,
chills or shakes.
.
Of note, records state Pt completed Ertapenam ___ - ___ for
UTI
.
Vitals in the ER: 97.5 108 113/69 18 95% RA. She was given
Dilaudid 1mg IV x2, Dexamethasone 40mg IV x1, and 2L NS.
.
Review of Systems:
(+) Per HPI + nausea without vomiting
(-) Denies fever, chills, night sweats, loss of vision, Denies
headache, chest pain or tightness, cough, shortness of breath,
or wheezes. Denies vomiting, diarrhea, constipation, abdominal
pain, melena, hematemesis, hematochezia. No numbness/tingling in
extremities. All other systems negative.
.
Past Medical History:
Past Medical History:
- ___: presented to OSH ED with chest pain, treated for
costochondritis with NSAIDS
- ___: presented to ___ to establish care, found to have a
creatinine of 1.4, was instructed to stop NSAIDs and was
referred for physical therapy
- ___: presented as an episodic visit with hip/back pain.
Laboratory data revealed hypercalcemia with calcium of 11.8,
anemia with a hematocrit of 29.3 and acute renal failure with a
creatinine of 3.1. She underwent plain films of the hip and
chest, which showed a lytic lesion in her right femur as well as
both clavicles. She was instructed to report to the emergency
room.
- ___: Admission to ___. CT Torso showed lytic lesions in
both clavicles. MRI L-spine showed L5 subacute compression
fracture and degenerative changes of the vertebrae without cord
compression. Skeletal survey showed multiple lytic lesions
throughout her skeleton. Immunoglobulin levels showed IgG of
456, IgA of 9, and an IgM of 5. UPEP showed monoclonal free
Bence ___ kappa protein representing 92% of urinary protein
(~8830 mg per day). Her free kappa serum level was 12.15 grams
and her free kappa to lambda ratio was greater than 1000. Bone
marrow biopsy showed 54% plasma cells in the aspirate.
Cytogenetics were normal.
- To date she has received 7 cycles of treatment. For cycles 1
and 2 she received Velcade and Decadron alone on days 1,4,8, and
11. She got a dose of Cytoxan on day 13 of her ___ cycle as she
was not having a great response. For her ___ cycle of treatment
she received Velcade/Decadron on days 1,8,11 (day 4 held d/t ?
of pneumonitis) and Cytoxan on days 1 and 8. During her ___
cycle she developed acute neck pain and had trouble holding her
head up. A cervical spine CT revealed multiple lytic lesions
with a prominent lesion in C1/C2 concerning for imminent
fracture. Neurosurgery recommended she wear a ___ J collar at
all times in addition to the TLSO brace she had already been
wearing for pathologic compression fractures of T11, T12 and L5
without cord involvement. She also received a 10 day course of
radiation to C1/C2. For her ___ cycle of treatment she received
Velcade and Decadron as before, Cytoxan was held to reduce the
risk of fracture given her new C-spine findings. Revlimid was
started with her ___ cycle of Velcade and Decadron at a low dose
of 5 mg twice a week.
- Missed C8 due to switch from ___ to another rehab that
cannot due chemo, and then has had osteomyelitis
OTHER PMHx: Depression, adjustment disorder, allergic rhinitis,
borderline hypertension, pre-hyperlipidemia, BPPV, stress
urinary incontinence, stage 4 mandibular and sacral ulcers s/p
debridement ___ with associted osteomyelitis.
Social History:
___
Family History:
Brother with kidney stones, mother with skin cancer (unknown
type) and dementia, father died of CAD/MI age ___. Maternal
grandfather may have had leukemia.
.
Physical Exam:
Admission Exam
VS: T 97.5 bp 100/69 HR 95 SaO2 94 RA
GEN: cachectic, NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, global distention and mild tenderness without rebound
or guarding, bowel sounds present
MSK: poor muscle bulk, normal tone
EXT: No c/c, normal perfusion, PICC dressing site on the left AC
fossa
SKIN: Multiple ecchymoses on extremities but not core, warm skin
NEURO: oriented x 3, no focal motor deficits. normal attention,
PSYCH: circumstantial thought process, normal thought content
.
Pertinent Results:
Admit Labs:
___ 03:35PM GLUCOSE-125*
___ 03:35PM UREA N-58* CREAT-2.1* SODIUM-133
POTASSIUM-5.3* CHLORIDE-96 TOTAL CO2-30 ANION GAP-12
___ 03:35PM ALT(SGPT)-10 AST(SGOT)-19 LD(LDH)-205 ALK
PHOS-109* TOT BILI-0.3
___ 03:35PM ALBUMIN-2.5* CALCIUM-11.1* PHOSPHATE-4.3
MAGNESIUM-3.0*
___ 03:35PM WBC-8.9 RBC-3.32* HGB-10.9* HCT-32.3* MCV-97
MCH-32.9* MCHC-33.9 RDW-17.3*
___ 03:35PM NEUTS-90.7* LYMPHS-6.2* MONOS-2.4 EOS-0.3
BASOS-0.5
___ 03:35PM PLT COUNT-256
.
Discharge Labs:
___ 04:04AM BLOOD WBC-7.3 RBC-2.48* Hgb-8.6* Hct-24.7*
MCV-100* MCH-34.4* MCHC-34.6 RDW-17.9* Plt ___
___ 03:58AM BLOOD Glucose-112* UreaN-49* Creat-1.6* Na-142
K-3.0* Cl-104 HCO3-30 AnGap-11
___ 03:58AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.5*
___ 06:20AM BLOOD VitB12-631 Folate-8.8
___ 06:18PM BLOOD ACTH - FROZEN-PND
___ 06:05AM BLOOD b2micro-10.7*
___ 06:18PM BLOOD Cortsol-13.1
___ 07:10PM BLOOD Cortsol-29.9*
___ 07:50PM BLOOD Cortsol-34.6*
___ 01:20AM URINE Color-Straw Appear-Cloudy Sp ___
___ 01:20AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 01:20AM URINE RBC-7* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
.
.
Micro Data:
.
___ Stool C. diff: POSITIVE
___ Blood cx x 2 sets: NGTD, final pending
___ Fungal Isolator blood culture: NGTD, final pending
___ Urine Cx
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
AMPICILLIN------------ =>32 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 256 R <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- 8 I 2 S
VANCOMYCIN------------ =>32 R 1 S
.
.
.
IMAGING
___
PCXR
FINDINGS: Portable AP supine view of the chest was provided.
There is a left arm PICC line with its tip extending into the
cavoatrial junction or possibly into the right atrium. The
heart is moderately enlarged. There is mild left basal
subsegmental atelectasis. Lung volumes are low. No
pneumothorax.
.
.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Rehab records.
1. Acetaminophen 650 mg PO Q6H:PRN fever
2. Acyclovir 400 mg PO Q8H
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
4. Artificial Tears ___ DROP BOTH EYES QID
5. Atovaquone Suspension 1500 mg PO DAILY
6. Bisacodyl 10 mg PR Q12H:PRN constipation
7. Calcitonin Salmon 200 UNIT SC Q 12H
8. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID
9. Dexamethasone 20 mg IV DAYS (TH)
10. Docusate Sodium 100 mg PO BID
11. ertapenem *NF* 1 gram Injection daily
Day 1 = ___ finished on ___ for UTI
12. Fluconazole 200 mg PO Q24H
13. Heparin 5000 UNIT SC BID
14. HYDROmorphone (Dilaudid) ___ mg IV Q3H:PRN pain
15. Lactulose 15 mL PO DAILY:PRN constipation
16. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
17. Metoclopramide 5 mg IV TID
18. Miconazole Powder 2% 1 Appl TP QID:PRN rash
19. Mirtazapine 15 mg PO HS
20. Morphine SR (MS ___ 15 mg PO Q12H
21. Lenalidomide 5 mg PO TUE, FRI
22. Polyethylene Glycol 17 g PO DAILY
23. Simethicone 80 mg PO TID
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
3. Artificial Tears ___ DROP BOTH EYES QID
4. Atovaquone Suspension 1500 mg PO DAILY
5. Fluconazole 200 mg PO Q24H
6. Heparin 5000 UNIT SC BID
7. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
8. Simethicone 80 mg PO TID
9. Morphine SR (MS ___ 15 mg PO Q12H
10. Mirtazapine 15 mg PO HS
11. Miconazole Powder 2% 1 Appl TP QID:PRN rash
12. Metoclopramide 5 mg IV TID
13. Lenalidomide 5 mg PO 3X/WEEK (___)
14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
take from ___ - ___ for total ___. Daptomycin 220 mg IV Q48H
7 day course for presumed complicated UTI with antibiotic
coverage from ___ to ___. Last day is ___.
16. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID
17. HYDROmorphone (Dilaudid) ___ mg IV Q3H:PRN pain
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypercalcemia
acute on chronic renal failure
hypotension
c. diff colitis
UTI - CoNS and VRE
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
CHEST RADIOGRAPH PERFORMED ON ___.
___.
CLINICAL HISTORY: ___ woman with multiple myeloma, PICC line,
question placement of right PICC line.
FINDINGS: Portable AP supine view of the chest was provided. There is a left
arm PICC line with its tip extending into the cavoatrial junction or possibly
into the right atrium. The heart is moderately enlarged. There is mild left
basal subsegmental atelectasis. Lung volumes are low. No pneumothorax.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Hypercalcemia, evaluation for pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. Low lung volumes with areas of atelectasis at both lung bases, but no
evidence of pneumonia. Markedly enlarged cardiac silhouette without pulmonary
edema. Unchanged tortuosity of the thoracic aorta and left-sided PICC line.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Worsening dyspnea, assessment for volume overload.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has developed
mild pulmonary edema, as manifested by perihilar haze, bilateral increase in
interstitial structures and mild enlargement of the diameter of the perihilar
vessels. The size of the cardiac silhouette continues to be increased.
Unchanged course of the left PICC line, no pleural effusions. Persistent well
defined transparencies of the bones (consistent with the clinical history of
multiple myeloma).
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ALTERED LEVEL OF CONSCIOUSNESS
Diagnosed with HYPERCALCEMIA
temperature: 97.5
heartrate: 108.0
resprate: 18.0
o2sat: 95.0
sbp: 113.0
dbp: 69.0
level of pain: 13
level of acuity: 2.0 | This is a ___ F with multiple myeloma, CKD stage IV-V,
receives Velcade and Decadron with Revlimid twice a week
presents to the ER with encephalopathy and hypercalcemia also
found to have ARF.
.
#Hypercalcemia secondary to Multiple Myeloma causing
encephalopathy
The patient had a subacte AMS according to rehab. She was
treated aggresively with IV fluids, lasix and pamidronate with
good result. Her MS improved while on the floor. Her calcium
levels returned to ___ and her mental status returned to
baseline, and she is alert, oriented x 3, and interactive on the
day of discharge.
.
# Sepsis with hypotension ___ C. diff colitis and possible
complicated UTI.
The patient was found to have a SBP in the 80's 1 into into her
hospital admission. Her baseline BP was though to be in the
110-120 range. Her foley was changed, BC, UC and a CXR was
taken. The presumed source of her infection was her GU tract.
She was empirically started on meropenum due to multiple
antibiotics allergies. Fugal isolator blood cultures were also
sent because the patient is on TPN. The patients picc line did
not appear to be infected. A random cortisol was checked and
found to be low at 1, but she underwent a cosyntropin stim test,
which was negative for adrenal insufficiency. She had an
appropriate adrenal reponse, with basal cortisol at 13, cortisol
level at 29 and 34, at time points 30min and 60min
post-cosyntropin. Her urine culture ended up growing CoNS and
VRE, so she was switched from Meropenem to Linezolid, and then
ultimately to Daptomycin out of concern for possible marrow
suppresion from Linezolid. These 2 pathogens may represent
colonization in the setting of Foley catheter as opposed to true
infection, but given her immunosuppression and poor nutritional
status, we opted to treat her for complicated UTI with a 7 day
course of appropriate antibiotic coverage, from ___. As
noted above, her Foley was exchanged. She was also noted to
have loose stoo, which was initially presumed to be due to her
bowel regimen, however, a stool sample returned C. diff
positive, and she was started on PO Flagyl. PO Vancomycin was
not used due to her severe Vanco allergy (per her report, a
desquamating rash). Her diarrhea improved on the Flagyl. She
will complete a 2 week course of PO Flagly from ___ to
___. At time of discharge, her blood cultures and fungal
isolator are still pending, although show no growth to date.
.
# ARF with CKD stage IV secondary to multiple myeloma
Baseline Cr variable but appears to be 1.7, and presented with
elevated Cr to 2.1, as well as elevated K. The patient was
given aggresive IVF and her Cr returned to baseline with a Cr of
1.6 on day of discharge. Likely her diarrhea also contributed
to her dehydration and with improvement of her diarrhea, her
renal function remained stable.
.
# Hyperkalemia
The was thought to be due to acute on chronic RF. She was
treated medically for this and IVF and this improved.
.
# Pulm Edema: shortly following admission, pt developed some
mild SOB and was noted to have an mild O2 requirement ___
liters). She was noted to have crackles on exam and PCXR
confirmed pulm edema. This was likely due to volume overload in
the setting of aggressive IVF repletion. She received a single
dose of IV Lasix with good UOP and resolution of her resp
symptoms and O2 requirement. She remains stable on room air at
this time and is breathing comfortably.
.
# Multiple Myeloma:
Diagnosed ___, currently dexamethasone and revlimid. Many
diffuse lytic lesions. Is on infection prophylaxis with
Acyclovir, Fluconazole, and atovaquone. She was continued on
the antibiotic prophylaxis. Her case was reviewed with Dr.
___ primary ___. She
recommended increasing her Revlimid dose to 5mg 3 x per week.
She does not recommend additional dexamethasone at this time.
She will continue to follow Ms. ___.
.
#Anorexia, cachexia, severe maluntrition:
Was on TPN at ___ for poor appetite, calorie counts on
previous admission showed intake of 300-500kcal/day, patient
requirements closer to 1800/day. She was seen by Nutrition
Consult and remained on PO intake as tolerated and supplemental
TPN.
.
#Hx of transaminitis which previously normalized following
discontinuation of TPN and Fluconazole, but curently normal on
both of these.
.
# Coccyx ulcer with history of osteomyelitis:
Pressure ulcer, had debridement ___. Was scheduled to
receive daptomycin &
moxifloxacin until ___ for osteomyelitis, which was switched
to linezolid given desire to cover HCAP on prior admission. Plan
was
for plastic surgery re-evaluation around ___ as she
will likely need a flap to close the sacral decubitus ulcer,
unless goals of care change. ___ RN, wound is improving.
Wound was re-evaluated on this admission by Wound Care and felt
that the wound was improving in all aspects and did not appear
infected, and bone could not be seen or palpated. Please see
additional paperwork for full wound care recommendations.
.
# Anemia secondary to inflammation and malignancy - transfuse as
needed. Her Hct was noted to drop during the admission, but
likely was due to hemoconcentration on presentation in the
setting of severe dehydration. Her Hct has been stable in the
mid-___, which is c/w her recent baseline. No blood was
transfused during the hospitalization.
.
# T11/12 fracture, cervical instability: She requires TLSO brace
when out of bed and if head of bed >45 degrees, or when working
with physical thearpy. Followed by Dr. ___ neurosurgery.
She should wear a soft cervical collar at night for additional
support.
.
# Anxiety / depression: Evaluated by psychiatry at ___ on
___ and felt that although depressed, Pt has full capacity
to make medical decisions. Stable moood, denied SI.
- continued mirtazipine
- seen by social work
.
F/E/N: PO as tolerated, TPN for supplement
FOLEY CATHETER in place for incontinence in the setting of
sacral decubitus ulcer.
ACCESS: Left arm PICC line
CODE STATUS: DNR/DNI
HEALTH CARE PROXY: ___ (Brother) ___
.
# Transitional Issues
[] complete course of antibiotics for C. diff colitis with PO
Flagyl and VRE/CoNS complicated UTI with daptmoycin
[] continue on-going chemotherapy treatment for MM with Revlimid
and f/u with Dr. ___
[] f/u with Neurosurgery for cervical instability and multiple
compression fracture of T- and L-spine
[] resume stool softeners and laxatives when her diarrhea
resolves
[] continue TPN
[] monitor her electrolytes
[] f/u pending lab studies and culture data, including ACTH
level and pending blood cultures and fungal isolator blood
culture
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall, left flank pain
Major Surgical or Invasive Procedure:
___:
1. Right common femoral artery access.
2. Right common femoral arteriogram.
3. Left renal arteriogram in multiple projections.
History of Present Illness:
___ PMH depression presents to ED from OSH s/p fall from
standing
with subcapsular hematoma of left kidney with evidence of active
extravasation on CT. He reports he was walking in his driveway
yesterday at 4pm when he slipped and fell, landing on his left
flank. He did not strike his head and there was no loss of
consciousness. He stood back up, went inside and went along his
day. Later that night, he noted worsening pain in his left flank
and took a Tylenol and one of his wife's hydrocodone tablets
which minimally relieved the pain. He became worried and looked
on WebMD which suggested he may have internal bleeding, which
prompted his visit to the ED. At the OSH, CT scan showed a left
renal hematoma with active extravasation. Hematocrit was 41 and
he was hemodynamically stable. He was unable to void at OSH and
Foley catheter was placed.
Past Medical History:
PMH:
-depression
PSH:
-right ankle surgery
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
Vitals-WNL
GEN: NAD
HEENT: EOMI, MMM
CV: RRR
PULM: non-labored breathing, room air
ABD: soft, non-distended, mild TTP over left flank, no
ecchymoses
noted, no rebound or guarding
EXT: no edema
NEURO: A&Ox3
PSYCH: appropriate mood, appropriate affect
Discharge Physical Exam:
VS: 97.3, 142/82, 88, 18, 96 Ra
Gen: A&O x3, lying in bed in NAD
CV: HRR
Pulm: LS ctab
Abd: soft, mildly TTP in left flank area
Ext: No edema
Pertinent Results:
___ 06:40AM BLOOD WBC-8.5 RBC-3.17* Hgb-10.0* Hct-29.6*
MCV-93 MCH-31.5 MCHC-33.8 RDW-12.0 RDWSD-41.5 Plt ___
___ 05:25PM BLOOD WBC-9.8 RBC-3.24* Hgb-10.1* Hct-30.2*
MCV-93 MCH-31.2 MCHC-33.4 RDW-11.9 RDWSD-41.0 Plt ___
___ 07:20AM BLOOD WBC-10.4* RBC-3.49* Hgb-11.2* Hct-33.1*
MCV-95 MCH-32.1* MCHC-33.8 RDW-12.5 RDWSD-43.5 Plt ___
___ 09:50PM BLOOD WBC-13.4* RBC-3.80* Hgb-11.9* Hct-35.2*
MCV-93 MCH-31.3 MCHC-33.8 RDW-12.2 RDWSD-42.2 Plt ___
___ 06:20PM BLOOD WBC-14.1* RBC-4.09* Hgb-12.8* Hct-38.4*
MCV-94 MCH-31.3 MCHC-33.3 RDW-12.2 RDWSD-42.4 Plt ___
___ 08:00AM BLOOD WBC-16.6* RBC-4.26* Hgb-13.5* Hct-39.8*
MCV-93 MCH-31.7 MCHC-33.9 RDW-12.1 RDWSD-41.7 Plt ___
___ 07:20AM BLOOD Glucose-92 UreaN-17 Creat-1.0 Na-140
K-4.3 Cl-101 HCO3-30 AnGap-9*
___ 09:50PM BLOOD Glucose-85 UreaN-18 Creat-1.2 Na-139
K-3.8 Cl-98 HCO3-27 AnGap-14
___ 08:00AM BLOOD Glucose-110* UreaN-19 Creat-1.3* Na-139
K-4.7 Cl-101 HCO3-23 AnGap-15
___ 07:20AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.2
___ 09:50PM BLOOD Calcium-8.6 Phos-2.5* Mg-2.1
Imaging:
CT A/P ___, OSH):
Large subcapsular hematoma surrounding left kidney measuring
5.5x7.6x10 cm. Area of increased density consistent with active
extravasation. Hemorrhage tracking along retroperitoneal space
into the pelvis.
___ Renal Embolization:
Left renal arteriogram demonstrates no evidence of active
extravasation. No dilatation was performed.
Medications on Admission:
BuPROPion XL (Once Daily) 300 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. BuPROPion XL (Once Daily) 300 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left renal subcapsular hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with subcapsular hematoma after trauma, flank
pain// Please embolize as indicated
COMPARISON: ___ CT from outside hospital ___
___).
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
50 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 39 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: 30 ml of Visipaque contrast.
FLUOROSCOPY TIME AND DOSE: 4.3 min, 288 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Right common femoral arteriogram.
3. Left renal arteriogram in multiple projections.
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 were prepped and draped in the usual
sterile fashion.
Using palpatory and fluoroscopic guidance, the right common femoral artery was
punctured using a micropuncture set at the level of the mid-femoral head. A
0.018 wire was passed easily into the vessel lumen. A small skin incision was
made over the needle. The needle was exchanged for a micropuncture sheath.
The inner of the micropuncture sheath and Nitinol wire were removed. A
___ wire was advanced under fluoroscopy into the aorta. A 5 ___ sheath
was placed over the ___ wire and the inner dilator was removed. A right
common femoral arteriogram was performed. The 5 ___ sheath which was
attached to a continuous heparinized saline side arm flush.
A C2 Cobra catheter was advanced over ___ wire into the aorta. The wire
was removed and the left renal artery was selectively cannulated and a small
contrast injection was made to confirm position. A left renalarteriogram was
performed in AP and ___ projections.
The catheter was then removed over the wire and the sheath was removed.
Manual pressure was held until hemostasis was achieved. Sterile dressings were
applied.
The patient tolerated the procedure well.
FINDINGS:
1. Image obtained after right common femoral arteriogram demonstrates
preferential excretion of contrast from the right kidney, with no contrast
seen within the left renal collecting system.
2. No evidence of active extravasation on left renal arteriogram, which was
performed in 2 projections.
IMPRESSION:
Left renal arteriogram demonstrates no evidence of active extravasation. No
dilatation was performed.
RECOMMENDATION(S):
1. Recommend maintaining right leg straight for 6 hours.
2. Recommend monitoring of serial hematocrit values.
3. Recommend monitoring right common femoral access site and right lower
extremity pulses.
4. Please contact our service with questions or concerns.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with Minor contusion of left kidney, initial encounter, Fall on same level due to ice and snow, initial encounter
temperature: 97.0
heartrate: 78.0
resprate: 18.0
o2sat: 98.0
sbp: 141.0
dbp: 88.0
level of pain: 6
level of acuity: 2.0 | ___ PMH depression transferred to ___ from OSH s/p fall from
standing with subcapsular hematoma of left kidney with evidence
of active extravasation on CT. Hematocrit stable on repeat at
39.8 (from 41 at OSH) and the patient was hemodynamically
stable. ___ was consulted and the patient was taken for a renal
embolization. The left renal arteriogram demonstrated no
evidence of active extravasation, no dilatation was performed.
The patient tolerated the procedure well. He returned to the
floor for serial hematocrits, pain control, and observation.
Hematocrits drifted down and then stabilized at 30. The patient
remained hemodynamically stable. Pain was well controlled. Diet
was advanced as tolerated to a regular diet with good
tolerability. The Foley was removed and 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. Venodyne boots were used during this stay,
subcutaneous heparin was held due to bleeding.
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 and his family received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / doxycycline
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo woman with a history of diabetes w/ neuropathy, CVA x2,
CAD, dementia, and epilepsy who presents with a history of
witnessed seizure at home.
At baseline the patient has SZ every few months. She was last
evaluated for SZ at BID ED ___ and Zonisamide dose was
recommended to be increased to 400mg qHS. LP and EEG at the time
were unremarkable. Apparently, she's still taking 300mg qHS.
The patient reports feeling OK this morning and last remembers
watching TV. Apparently, she was noted to have a ___ minute
starting episode today without movement, SOB, or incontinence
during which she was unresponsive to son-in-law.
She reports feeling nauseated and having R lateral neck pain
currently, but no abdominal pain, fevers, SOB, headache,
consfusion. She has bilateral foot pain from neuropathy as well.
She states she has not been feeling well, but cannot elaborate.
She was recently tx for cellulitis of R ___ metatarsal head
ulcer but only took 4 days of PO clinda given hx of intolerance
of oral abx.
- Labs were significant for: normal U/A normal TnT x1 WBC 12
ALT: 23 AP: 176 Tbili: 0.1 Alb: 4.1 AST: 42 Lip: 19
- Imaging: normal CT head, normal CXR
- The patient was given: Zofran and APAP
While in the ER she was examined by Neuro c/s for episode of
decreased responsive and this was not thought to represent
epileptic event.
REVIEW OF SYSTEMS:
(+) Per HPI : bilateral foot pain "on tops and bottoms", nausea
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
- Diabetes mellitus type II
- Dyslipidemia
- Hypertension
- CAD
- CABG in ___ LIMA to the LAD, s/p PCI in ___
- CVA x 3 with memory deficit and residual weakness in LLE
- Seizure disorder
- COPD
- Peripheral neuropathy
- Cocaine abuse
- Nephrolithiasis
- Chronic pain syndrome
- Visual loss OD (from glaucoma)
- s/p cholecystectomy
- s/p appendectomy
- s/p hysterectomy
- S/P right knee surgery
- S/P right elbow surgery
- s/p cataract surgery
- eczema
- ?celiac
- autonomic dysfunction
- R eye glaucoma
Social History:
___
Family History:
- Mother with alcohol dependence
- sister with depression
- son with ___ abuse
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.7 176/66 79 18 100% on 2L
General: Alert, oriented to place, situation, BID. NAD
HEENT: Edentulous lower, caries upper teeth. MMM. No oral or OP
lesions. R eye with clouded cornea
Neck: Supple, JVP not elevated, no TTP on lateral R neck, no
LAD. No torticollis
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 edema; multiple small
ecchymoses and abrasions on arms; several erythematous plaques
on arms and dorsal hands; R foot with 1cm round, dry, clean
ulcer with no erythema
Neuro: EOMI. R eye blind to finger ct. ___ strenght in UEs and
LEs. Resting L>R arm tremor. Increased tone in L>R. Sensation
intact to light touch.
DISCHARGE PHYSICAL EXAM:
VS - Tmax ___ HR 63 BP 124/55 RR18 94%02 sat on RA ___: ___
___ 200s-300s
General: Elderly woman in no acute distress, visibly appears
better, alert, oriented to place, situation, not time, able to
stand up on own
HEENT: MMM, no visible bites, R eye with clouded cornea
Otoscopic exam: R ear- visualized clear tympanic membrane, L
ear: limited exam due to cerumen, ___ of TM visualized, clear,
no erythema noted
Neck: Supple, JVP not elevated, full neck ROM. Lateral neck
examined, no palpable spasm, no mastoid tenderness.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, decreased tenderness to palpation in RUQ, no
suprapubic tenderness, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema; multiple small
ecchymoses and abrasions on arms; several erythematous plaques
on arms and hands;
R foot with 1cm round, dry, clean ulcer with no erythema or
drainage
Pertinent Results:
ADMISSION LABS:
___ 06:22PM WBC-11.9* RBC-4.55 HGB-12.0 HCT-39.3 MCV-86
MCH-26.4 MCHC-30.5* RDW-13.4 RDWSD-42.0
___ 06:22PM NEUTS-66 BANDS-0 ___ MONOS-6 EOS-5
BASOS-1 ___ MYELOS-0 AbsNeut-7.85* AbsLymp-2.62
AbsMono-0.71 AbsEos-0.60* AbsBaso-0.12*
___ 06:22PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 06:22PM ALT(SGPT)-23 AST(SGOT)-42* ALK PHOS-176* TOT
BILI-0.1
___ 06:22PM LIPASE-19
___ 06:22PM cTropnT-<0.01
___ 06:22PM GLUCOSE-128* UREA N-23* CREAT-1.2* SODIUM-136
POTASSIUM-5.4* CHLORIDE-100 TOTAL CO2-24 ANION GAP-17
___ 07:50PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-2
___ 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
DISCHARGE LABS:
___ 06:32AM BLOOD WBC-9.0 RBC-4.01 Hgb-10.8* Hct-34.7
MCV-87 MCH-26.9 MCHC-31.1* RDW-13.3 RDWSD-42.2 Plt ___
___ 06:32AM BLOOD Plt ___
___ 03:44PM BLOOD Glucose-160* UreaN-32* Creat-1.3* Na-139
K-4.3 Cl-108 HCO3-21* AnGap-14
___ 06:32AM BLOOD Calcium-9.6 Phos-3.2 Mg-2.0
IMAGING:
CT Head without contrast ___: There is no evidence of
acute hemorrhage, edema, or loss of gray/ white matter
differentiation. The ventricles and sulci are prominent due to
age-related parenchymal atrophy. A well-defined focus of fluid
density is again seen in
the right lentiform nucleus, image 601b:45,, and a tiny
hypodensity is again seen in the left lentiform nucleus, image
2:14. These are compatible with perivascular spaces or chronic
infarcts. Foci of ill-defined low density in the
periventricular, deep, and subcortical white matter of the
cerebral hemispheres are also again seen, nonspecific but likely
sequela of chronic small vessel ischemic disease in a patient of
this age.
Subcentimeter left parietal ossified dural-based lesion,
contiguous with the inner table, is stable, compatible with an
intraosseous meningioma, without mass effect on the adjacent
brain parenchyma. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear.
The orbits are unremarkable.
IMPRESSION: No evidence for acute intracranial abnormalities.
Chest Xray PA and LAteral ___: Multiple clips are again
demonstrated projecting over the mediastinum on the left. Heart
size is normal. A stent projecting over the heart is re-
demonstrated. Mediastinal and hilar contours are normal. Lungs
are clear. No pleural effusion, focal consolidation or
pneumothorax present. No acute osseous abnormalities detected.
Several clips are again noted within the
upper abdomen. IMPRESSION: No acute cardiopulmonary
abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Donepezil 10 mg PO HS
6. Fentanyl Patch 100 mcg/h TD Q72H
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Memantine 5 mg PO BID
10. Sarna Lotion 1 Appl TP TID:PRN pruritis
11. Sertraline 200 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Zonisamide 400 mg PO QHS
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. Travatan Z (travoprost) 0.004 % OS (Left Eye) QPM
16. Acetaminophen 325 mg PO Q6H:PRN pain
17. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q6H
18. Betamethasone Dipro 0.05% Oint 1 Appl TP DAILY
19. HydrOXYzine 25 mg PO TID:PRN itch
20. Mupirocin Ointment 2% 1 Appl TP BID
21. FiberCon (calcium polycarbophil) 1250 mg oral DAILY
22. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
23. esomeprazole magnesium 40 mg oral DAILY
24. Senna 8.6 mg PO BID:PRN Constipation
25. Polyethylene Glycol 17 g PO DAILY
26. melatonin 3 mg oral QPM:PRN For sleep
27. Docusate Sodium 100 mg PO DAILY
28. Lactobacillus acidoph-L. bifid 1 billion cell oral DAILY
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Donepezil 10 mg PO HS
6. Fentanyl Patch 100 mcg/h TD Q72H
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Memantine 5 mg PO BID
11. Sertraline 200 mg PO DAILY
12. Zonisamide 400 mg PO QHS
13. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN
arms, shins where itchy
RX *triamcinolone acetonide 0.025 % Apply to ulcers Twice a day
Refills:*0
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
15. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q6H
16. FiberCon (calcium polycarbophil) 1250 mg oral DAILY
17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
18. Sarna Lotion 1 Appl TP TID:PRN pruritis
19. Travatan Z (travoprost) 0.004 % OS (Left Eye) QPM
20. Vitamin D 1000 UNIT PO DAILY
21. Docusate Sodium 100 mg PO DAILY
22. Lactobacillus acidoph-L. bifid 1 billion cell oral DAILY
23. Polyethylene Glycol 17 g PO DAILY
24. Senna 8.6 mg PO BID:PRN Constipation
25. melatonin 3 mg oral QPM:PRN For sleep
26. Esomeprazole Magnesium 40 mg ORAL DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Post-ictal state
Secondary Diagnosis:
Diabetes Mellitus
Dementia
Epilepsy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with headache on plavix. Evaluate for hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
Coronal and sagittal as well as thin bone-algorithm reconstructed images were
obtained.
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, 16.2 cm; CTDIvol = 55.1 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: CT of the head dated ___.
FINDINGS:
There is no evidence of acute hemorrhage, edema, or loss of gray/ white matter
differentiation. The ventricles and sulci are prominent due to age-related
parenchymal atrophy. A well-defined focus of fluid density is again seen in
the right lentiform nucleus, image 60___:45,, and a tiny hypodensity is again
seen in the left lentiform nucleus, image 2:14. These are compatible with
perivascular spaces or chronic infarcts. Foci of ill-defined low density in
the periventricular, deep, and subcortical white matter of the cerebral
hemispheres are also again seen, nonspecific but likely sequela of chronic
small vessel ischemic disease in a patient of this age.
Subcentimeter left parietal ossified dural-based lesion, contiguous with the
inner table, is stable, compatible with an intraosseous meningioma, without
mass effect on the adjacent brain parenchyma.
The paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
The orbits are unremarkable.
IMPRESSION:
No evidence for acute intracranial abnormalities.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY
temperature: 97.2
heartrate: 83.0
resprate: 16.0
o2sat: 97.0
sbp: 157.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | PRIMARY PRESENTATION:
Ms. ___ is a ___ with poorly controlled DM, dementia,
epilepsy, and chronic plantar ulcer who presented with weakness,
abdominal pain, and possible seizure like event, with workup
showing no clear precipitant or indication of infection,
subjectively improved during hospitalization.
ACTIVE ISSUES
# Epilepsy/Possible ictal event: Patient has a history of
multiple seizures, usually convulsive in nature, who presented
with a ___ minute episode of unresponsiveness without any
abnormal movements or incontinence, with normal neurological
exam. Infection was thought to be the most likely precipitant
given complaints of abdominal and ear pain, but no clear source
was found with normal UA, CXR, and a recent LP for possible
seizure. Patient was continued on zonisamide 400mg qhs , with
monitoring of symptoms. Patient's mental status improved
overnight and she felt at baseline to be discharged.
# ___ metatarsal head ulcer: Patient had a long-standing
non-healing right plantar MTP ulcer s/p multiple debridements.
She was last admitted in ___ for this complaint and
recently was given few days of clindamycin for cellulits of ___
MTP, which she did not complete. On current admission, the ulcer
site was dry and intact without erythema or warmth, with recent
plain films of foot neg for changes c/f osteomyelitis.
Antibiotics were deferred and patient remained asymptomatic.
CHRONIC ISSUES
# CKD: Patient remained at baseline creatinine of 1.2. She had
one increase of creatinine to 1.6. She was scheduled for lab
followup to monitor her kidney function.
# Chronic Pain: She was continued on home Fentanyl 100mcg q72h
and Acetaminophen 650 TID.
# Dementia: Thought to be likely secondary to vascular dementia.
She was continued on home donepezil, sertraline, memantine
# Diabetes type 2, poorly controlled: She has poorly controlled
diabetes at baseline per ___ notes and uses BID ___
Sliding scale at home which was used during the hospitalization
# CAD s/p CABG ___: She was continued home aspirin,
clopidogrel, Isordil, atorvastatin.
TRANSITIONAL ISSUES
-Patient should follow up with PCP
-___ geriatric followup given chronic issues
-Please ensure podiatry followup given ulcer and excoriations
(has peripheral neuropathy and eczema), has appointment
scheduled |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, extensive lysis of
adhesions, colotomy with removal of stercoral concretion and
then primary repair, Vicryl mesh temporary repair of hernia.
History of Present Illness:
The patient is an ___ woman with a prior sigmoid
colectomy and cholecystectomy, also with multiple ventral
hernias requiring two repairs, and multiple small bowel
obstructions, who presents to the emergency room at ___
___ with a 2-day history of obstipation.
She was essentially found in her room by her aid lying in vomit
and was found to be altered. Upon transfer here to the ER she
was noted to be profoundly dehydrated. She had two incarcerated
ventral hernias on exam. Placement of an NG-tube yielded
copious feculent output. A CT scan revealed high-grade small
bowel obstruction secondary incarceration of bowel within her
midline hernia. She was taken to the operating room for
management.
Past Medical History:
PMH: HTN, CKD, colon Ca T1nO, Cholelithiasis, ventral hernia,
h/o multiple SBO, lumbar spinal stenosis, OA, depression, gout
PSH: sigmoid colectomy ___, cholecystectomy, ventral hernia
repair x2 (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam On Admission:
Vitals: 100.4, 97, 136/68, 16, 96% RA
Gen: ill-appearing, somnolent but arousable, ___
only
HEENT: NCAT, EOMI, poor dentition
CV: WWP, tachycardic to low 100s
P: tachypneic, on 3L NC
Abd: obese, distended, large ventral hernia with incarcerated
bowel to the right of midline; +pain with attempts to reduce
hernia but only mildly TTP at rest
Ext: +peripheral edema, crusted/ scabbed lesion on L lower leg
Physical Exam on Discharge:
VITALS: 98.1 66 99/51 18 95RA
GEN: AAOx3, NAD, obese
HEART: RRR S1S2
LUNGS: CTAB no respiratory distress
AB: soft, NT, ND, midline incision with staples, JPx2 serosang
output, abdominal binder in place
EXT: warm well perfused
Pertinent Results:
Imaging:
CT abdomen/ pelvis ___:
1. Small-bowel obstruction with relative transition point in the
mid to distal jejunum as it exits a large midline ventral
hernia.
Distal small bowel and large bowel are decompressed. No fat
stranding or fluid in the hernia to suggest strangulation.
2. Right lateral abdominal wall hernia now contains a segment of
large bowel with a large fecal ball.
3. Large hiatal hernia.
___ ECG: Sinus tachycardia. Left axis deviation, probably due to
prior inferior wall myocardial infarction. Left ventricular
hypertrophy with secondary repolarization changes. Poor R wave
progression is seen which may be due to prior anterior wall
myocardial infarction, although difficult to interpret in
the setting of left ventricular hypertrophy
___ ECHO: Suboptimal image quality. Left ventricular function
seems normal however due to poor image quality cannot rule out
regional wall motion abnormalities
___ CXR: Increasing basilar atelectasis and effusions, now
moderate. No overt interstitial edema. Mediastinal widening,
likely due to rotation and shift, unchanged. Unchanged large
hiatal hernia.
___ CXR: Interval removal of nasogastric tube and development
of
gastric distention within a large hiatal hernia. Otherwise, no
relevant short interval change since previous study of one day
earlier.
___ 05:25AM BLOOD WBC-16.7*# RBC-5.60*# Hgb-17.4*#
Hct-54.5*# MCV-97# MCH-31.0 MCHC-31.9 RDW-14.2 Plt ___
___ 04:30AM BLOOD WBC-6.0 RBC-3.11* Hgb-9.9* Hct-30.5*
MCV-98 MCH-31.8 MCHC-32.4 RDW-13.7 Plt ___
___ 03:50AM BLOOD ___ PTT-25.5 ___
___ 02:19AM BLOOD ___ PTT-34.4 ___
___ 03:50AM BLOOD Glucose-172* UreaN-56* Creat-2.6*# Na-137
K-5.6* Cl-100 HCO3-16* AnGap-27*
___ 04:30AM BLOOD Glucose-72 UreaN-23* Creat-1.5* Na-144
K-3.4 Cl-102 HCO3-30 AnGap-15
___ 03:50AM BLOOD Albumin-4.5 Calcium-10.1 Phos-4.5 Mg-1.6
___ 04:30AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.5*
Medications on Admission:
Allopurinol ___ qD
Amitriptyline 10mg bid
Atenolol 25mg qD
Colcrys 0.6mg qD
Compazine 10mg bid PRN Nausea
Cortisone 2.5% solution to legs qHS
Cymbalta Delayed Release 60mg bid
Docusate 100mg bid PRN constipation
Enalapril/HCTZ ___ qD
Ferrous sulfate 325mg PO qD
Flovent 110mcg inhaler 2 puffs bid
Furosemide 20mg qD
Gabapentin 100mg bid
Hydrophore topical bid
Levothyroxine 150mcg qD
Lidocaine patch q12
Loperamide 2mg PRN loose stool
Lorazepam 0.5mg PRN anxiety
Meclizine 12.5mg bid PRN anxiety
Miralax 17gm qD prn constipation
MVI 1 tab qD
Oxybutinin ER 15mg qD
Pantoprazole 40mg qD
Remeron 30mg qHS
Senna 8.6mg PO bid prn constipation
Zolpidem 5mg qHS prn insomnia
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Allopurinol ___ mg PO DAILY
3. Amitriptyline 10 mg PO BID
4. Aquaphor Ointment 1 Appl TP BID
5. Atenolol 25 mg PO DAILY
6. Colchicine 0.6 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Duloxetine 60 mg PO BID
9. Enalapril Maleate 10 mg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Furosemide 20 mg PO DAILY
12. Gabapentin 100 mg PO BID
13. Heparin 5000 UNIT SC TID
14. Hydrochlorothiazide 25 mg PO DAILY
15. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
16. Levothyroxine Sodium 150 mcg PO DAILY
17. Lidocaine 5% Patch 1 PTCH TD QPM
18. Miconazole Powder 2% 1 Appl TP TID:PRN rash
19. Mirtazapine 30 mg PO HS
20. Multivitamins 1 TAB PO DAILY
21. Pantoprazole 40 mg PO Q24H
22. Polyethylene Glycol 17 g PO DAILY:PRN constipation
23. Senna 8.6 mg PO BID:PRN constipation
24. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
25. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
26. Oxybutynin 15 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Small-bowel obstruction with incarcerated hernia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: Shortness-of-breath and hypoxia.
COMPARISON: Multiple prior chest radiographs, most recently of ___.
FINDINGS:
Frontal views of the chest. Lung volumes are low, exaggerating heart size
which remains moderately enlarged. Large hiatal hernia is air-filled and
slightly displaces the heart to the right. Prominence of the mediastinum is
attributed to patient rotation and stable widening of the vascular pedicle.
No focal consolidation, pleural effusion, or pneumothorax is appreciated.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
HISTORY: Severe sepsis and GI bleed.
COMPARISON: CT abdomen pelvis of ___.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis without administration of IV or oral contrast. Axial images were
interpreted in conjunction with coronal and sagittal reformats.
DLP: 754 mGy-cm
FINDINGS:
The visualized heart is normal. There is small bibasilar atelectasis. No
pleural or pericardial effusion.
ABDOMEN:
Evaluation of the intra-abdominal organs is limited without administration of
IV contrast. The unenhanced liver, intra and extrahepatic bile ducts,
pancreas, spleen, and adrenal glands is normal. The kidneys are atrophic
bilaterally. Cystic renal lesions are seen bilaterally, measuring up to 2.1 cm
in the left upper pole and 2.7 cm in the right lower pole. There is no stone
or hydronephrosis seen in either kidney. The ureters have a normal course and
caliber.
There is a large hiatal hernia containing fluid and gas.
There is dilatation of proximal small bowel measuring in diameter up to 4.7 cm
and containing mildly fecalized contents. Several segments of small bowel
enter and exit a large midline ventral hernia. A transition point is present
in the mid to distal jejunum as it exits the ventral hernia with distally
decompressed small and large bowel.
Postsurgical changes in the anterior abdominal wall from a prior herniorrhaphy
are similar to prior.
A right parasagittal ventral hernia contains a segment of large bowel with a
large fecal ball. The large bowel proximal and distal to this segment is also
decompressed. The appendix is normal.
No retroperitoneal or mesenteric lymphadenopathy. The aorta contains
scattered atherosclerotic calcifications and is normal diameter. No
pneumoperitoneum or free abdominal fluid.
PELVIS: The bladder contains a Foley catheter and is decompressed. The
uterus is unremarkable. No pelvic side-wall or inguinal lymphadenopathy. No
free pelvic fluid or inguinal hernia.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy. Moderately severe degenerative changes of the lumbar spine are
similar to prior with multilevel facet arthrosis and grade 1 anterolisthesis
of L3 on L4 and of L4 on L5.
IMPRESSION:
1. Small-bowel obstruction with relative transition point in the mid to
distal jejunum as it exits a large midline ventral hernia. Distal small bowel
and large bowel are decompressed. No fat stranding or fluid in the hernia to
suggest strangulation.
2. Right lateral abdominal wall hernia now contains a segment of large bowel
with a large fecal ball.
3. Large hiatal hernia.
Radiology Report
HISTORY: Central line placement.
FINDINGS: In comparison with the earlier study of this date, there has been
placement of a right IJ catheter with the tip in the mid portion of the SVC.
No evidence of pneumothorax. Endotracheal tube is now in place with its tip
approximately 4.5 cm above the carina. Nasogastric tube lies within a large
hiatal hernia within the thorax.
Radiology Report
INDICATION: ___ female with small-bowel obstruction, now intubated.
Assess for pneumonia or pulmonary edema.
COMPARISON: Chest radiographs dating back to ___, most recent
from ___.
PORTABLE FRONTAL CHEST RADIOGRAPH: An endotracheal tube and right upper
central venous line are in unchanged position. An extremely large hiatal
hernia continues to cause rightward shift of the mediastinum. Tip of the
nasoenteric catheter is above the left hemidiaphragm within the hernia sac.
Apparent widening of the mediastinum is similar to prior and likely due to a
combination of mediastinal shift and patient rotation. Opacity within the
right medial lung base has slightly progressed and is likely due to
progressive middle lobe atelectasis. Increasing right pleural effusion is
likely, now moderate. A small left pleural effusion persists. Left lower
lobe atelectasis is also likely. Upper lungs remain clear.
IMPRESSION:
1. Increasing basilar atelectasis and effusions, now moderate. No overt
interstitial edema.
2. Mediastinal widening, likely due to rotation and shift, unchanged.
3. Unchanged large hiatal hernia
Radiology Report
PORTABLE CHEST OF ___
COMPARISON: Radiograph of one day earlier.
FINDINGS: Interval removal of endotracheal tube. Central venous catheter and
nasogastric tube remain in place, with the nasogastric tube residing within a
known hiatal hernia. Heart size is enlarged but stable. Apparent interval
increase in size of small right and moderate left pleural effusions, with
adjacent persistent left lower lobe and improving right lower lobe lung
opacities which may reflect atelectasis, and less likely aspiration or
infectious pneumonia.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___.
FINDINGS: Interval removal of nasogastric tube and development of gastric
distention within a large hiatal hernia. Otherwise, no relevant short
interval change since previous study of one day earlier.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: N/V
Diagnosed with ABDOMINAL PAIN GENERALIZED, VOMITING
temperature: 97.0
heartrate: 120.0
resprate: 28.0
o2sat: 99.0
sbp: 165.0
dbp: 99.0
level of pain: 5
level of acuity: 2.0 | The patient was seen in the ED with complaints of nausea,
vomiting, and abdominal pain. CT scan showed small bowel
obstruction with transition point in the mid-jejunum and
incarceration of ventral hernia. A NGT was placed at the time of
examination with large amount of feculent-appearing output
(>1L). The patient went to the OR for an exploratory laparotomy,
extensive lysis of adhesions, colotomy with removal of stercoral
concretion and then primary repair with vicryl mesh. Please see
operative note for more details. She was transferred to the ICU
for post-operative care. On presentation to the ICU, BPs around
120s/80s, O2 sats in high ___, and HR in 110s. On POD#1 the
patient was extubated. On POD#2 the patient's HR was up to 160s,
EKG showing SVT, full labs/trops sent, no response with
metoprolol 5, given adenosine 6 followed by adenosine 12, then
broke and back in sinus with HR ___, SBP 120s. The patient was
noted to be volume overloaded and recieved IV lasix and IV
albumin. Her NGT was clamped and subsequently pulled. On POD#3
the patients labs were improving, she was hemodynamically stable
and was transferred to the floor. Her diet was advanced to
clears which she tolerated well. Her foley was removed and she
was able to void. Physical therapy began working with the
patient and deemed her suitable for rehab once medically ready.
On POD#4 the patient was back on all of her home medications.
She was passing gas and continued to slowly tolerate clear
liquids. On POD#5 her diet was advanced to regular. On POD#6
she received a fleet enema and had a liquid bowel movement. She
was accepted for transfer by ___, and verbal handoff
was given to Dr. ___. He was instructed to leave the staples
in place and to monitor the output of the two JP drains. At the
time of discharge on POD#6, she was in stable condition. She
was advised to follow up in the ___ clinic on ___. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Latex / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
left leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hypercoagulability and severe PAD having undergone
multiple ___ revascularizations for symptoms of critical limb
ischemia including wounds and claudication presents with acute
complaints of left lower extremity pain and numbness/tingling
extending from foot to proximal calf. He denies color change,
skin breakdown, ulceration or loss of motor/sensation.
Past Medical History:
PMH: DM, HTN, HLD, atypical chest pain, PVD, COPD, GERD,
diverticulosis/itis, GIB, Myalgias, BPH, Bladder CA, depression
PSH:
L CIA/EIA stent, L fem-AKP PTFE BPG (05),
R CIA/EIA stent, R fem-AKP PTFE BPG (06), L graft thrombectomy
(___), L calf fasciotomy (___), L fem-AT BP w NRGSV (06), removal
LLE infected fem-pop PTFE BPG (08), L fem-AT vein graft
stenting
(08), L fem-AT BPG (08), thrombolysis L fem-AT BPG (09),
multiple balloon angioplasties BLE (09), R pop stent (10), b/l
LSV harvest and R PFA-BKP with (11R)TMA (11), Multiple TMA
debridements (11), R TAL(12),inguinal hernia repair,
appendectomy, TURP.
L FEM COMMON/PROFUDNA EA, L ILIAC THROMB, B/L CIA KISSING
STENTS,
R EIA STENT, L ILIO-PROFUNDA BYPASS USING HYBRID GRAFT (___)
Pertinent Results:
___ 04:23AM BLOOD WBC-7.0 RBC-4.97 Hgb-13.6* Hct-42.3
MCV-85 MCH-27.4 MCHC-32.2 RDW-15.7* RDWSD-48.0* Plt ___
___ 04:23AM BLOOD ___ PTT-150* ___
___ 04:23AM BLOOD Glucose-122* UreaN-19 Creat-0.8 Na-142
K-4.1 Cl-102 HCO3-30 AnGap-10
___ 05:49PM BLOOD %HbA1c-5.8 eAG-120
___ 04:23AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.6
CTA, abd and pelvis wit run off.
1. The left anterior tibial artery is occluded distal to the
level of the
occluded femoral-anterior tibial bypass graft. There is transit
occlusion of
the left posterior tibial artery distally with reconstitution
above the ankle.
The left peroneal artery is patent to the level of the ankle.
2. Pancreatic cystic lesions measuring up to 1.0 cm branch
IPMNs. Recommend
further evaluation with MRCP if not previously worked up.
3. Multiple bilateral pulmonary nodules measuring up to 8 mm.
For incidentally detected multiple solid pulmonary nodules
measuring 6 to
8mm, a CT follow-up in 3 to 6 months is recommended in a
low-risk patient,
with an optional CT follow-up in 18 to 24 months. In a high-risk
patient, both
a CT follow-up in 3 to 6 months and in 18 to 24 months is
recommended.
4. Bilateral upper lobe paramediastinal radiation fibrosis.
5. Extensive collaterals along the right upper chest secondary
to occlusion of
the right internal jugular vein.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) ___ mg PO TID pain
2. Pregabalin 100 mg PO TID
3. Ranitidine 150 mg PO BID
4. Simvastatin 40 mg PO QPM
5. Aspirin 81 mg PO DAILY
6. LORazepam 1 mg PO QHS:PRN insomnia
7. Enoxaparin Sodium 70 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
8. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Aspirin 81 mg PO DAILY
3. Enoxaparin Sodium 70 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
4. LORazepam 1 mg PO QHS:PRN insomnia
5. OxycoDONE (Immediate Release) ___ mg PO TID pain
6. Pregabalin 100 mg PO TID
7. Ranitidine 150 mg PO BID
8. Simvastatin 40 mg PO QPM
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral Arterial Disease with left leg critical limb
ischemia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF
INDICATION: ___ year old man with pulseless limb// assess arterial flow to
bilateral lower etremities
TECHNIQUE: Non-contrast and post-contrast CTA images were acquired through
the chest, abdomen and pelvis, with lower extremity runoff. Oral contrast was
not administered. MIP and 3D reconstructions were performed on independent
workstation and reviewed on PACS.
DOSE: Total DLP (Body) = 2,195 mGy-cm.
COMPARISON: CT abdomen and pelvis with runoff ___
FINDINGS:
CTA CHEST ABDOMEN PELVIS: Reflux of contrast within veins of the right chest
wall reflect IJ occlusion around the Port-A-Cath. A tiny filling defect is
noted adjacent to the tip of the Port-A-Cath in the ___, series 301, image 39.
Thoracic aorta is normal in course and caliber with mild atherosclerotic
calcification. Coronary artery calcification is moderate. Main pulmonary
artery and central branches appear patent. The celiac artery origin is patent
with conventional anatomy. The SMA artery origin is patent. Both renal
arteries are widely patent at their origin. The ___ appears slightly narrowed
at its origin. There is been prior aortoiliac stent graft with chronically
occluded left common iliac limb. The stent extends from the aortic
bifurcation along the course of the external iliac artery. The stent excludes
the internal iliac arteries which appear chronically occluded at their origins
from the right and left common iliac artery. There is evidence of collateral
flow within the right and left internal iliac arteries, with contrast seen
just beyond their origin from the common iliacs.
LEFT LOWER EXTREMITY CTA RUNOFF: There is occlusion of the left superficial
femoral artery as well as the stents and bypass graft is in the left leg. The
profundus femora is is occluded at its origin though there is collateral flow
which appears to be supplied by branches from the ilio lumbar and left
internal iliac arteries. There is flow within the upper calf at the level of
the trifurcation supplied by collateral branches from the profundus
circulation. However, flow in the left anterior tibial artery appears
markedly attenuated at the level of the lower leg/ankle region. On the
delayed series, flow within the left anterior tibial artery remains
attenuated.
RIGHT LOWER EXTREMITY CTA RUNOFF: At the distal aspect of the right external
iliac artery which is stented, the lumen is markedly narrowed though this is
similar to prior. Just distal to this point, there is focal aneurysmal
dilation of the right common femoral artery, similar to the prior exam,
measuring up to 19 x 18 mm, series 301, image 231. The right common femoral
artery gives rise to a patent profundus femoris, however the fem-pop bypass
stent is occluded. There is minimal flow within the native right superficial
femoral artery to the level of the popliteal artery which is primarily
supplied by branches of the profundus femora is. There is a patent 3 vessel
runoff into the right calf though flow appears attenuated likely reflecting
inflow stenosis. Again noted is amputation of the right forefoot.
CHEST: Paramediastinal fibrosis likely reflect prior radiation treatment.
Prominence of anterior mediastinal lymph nodes for instance on series 301,
image 39, with these nodes measuring up to 12 mm in short axis dimension. A
pretracheal lymph node measures up to 11 mm in short axis on series 301, image
42. A superior mediastinal lymph node measures 9 mm in short axis on series
301, image 31. The heart appears within normal limits of size. No pleural or
pericardial effusion. Multiple bilateral pulmonary nodules measure up to 8 mm
(301:49) in the right lower lobe. Mild fat stranding in the left axilla is
noted, with several mildly prominent lymph nodes which are likely reactive.
Port-A-Cath over the right chest wall with right IJ access terminates in the
mid SVC. A small thrombus is seen within the SVC likely adherent to the
catheter, series 301 images 38 through 40.
ABDOMEN: The liver appears grossly unremarkable. The spleen, gallbladder, and
adrenals are unremarkable. Renal hypodensities most likely represent simple
cysts, the largest of which is seen arising from the upper pole right kidney
measuring 4.3 x 4.0 cm. No adenopathy, free air or free fluid. The stomach
and duodenum appear normal. Cystic lesions within the proximal body of the
pancreas appear similar to the prior exam and can be further evaluated by MRCP
if not already performed. The stomach is decompressed. The duodenum appears
normal.
PELVIS: Loops of small bowel demonstrate no signs of ileus or obstruction.
Diverticulosis of the colon is noted without diverticulitis. The appendix is
not visualized though there are no secondary signs of appendicitis. Urinary
bladder is well distended appearing normal. No pelvic free fluid. No
adenopathy along the pelvic sidewall or inguinal region.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Evidence of prior right forefoot amputation.
SOFT TISSUES: Multiple subcutaneous nodules overlying the anterior abdominal
wall measuring up to 2.1 cm are new since ___, may be injection
related.
IMPRESSION:
1. Abnormal CTA runoff with chronic occlusion of the stented left external
iliac artery and severe narrowing of the stented right external iliac artery
distally. Occluded stent and bypass graft in the lower extremities. Flow
preserved through the lower extremities due to collateral flow on the right
from the patent profundus femoris and on the left through left external iliac
artery collaterals supplying the profundus femoris, which in turn supplies the
popliteal artery and calf branches. Significant attenuation of the left
anterior tibial artery.
2. Pancreatic cystic lesions measuring up to 1.0 cm branch IPMNs. MRCP
advised in the absence of prior work-up.
3. Multiple bilateral pulmonary nodules measuring up to 8 mm. See ___
guidelines below. Prominent mediastinal lymph nodes can also be further
assessed at the time of follow-up chest CT.
4. Chronic occlusion of the right internal jugular vein surrounding the porta
catheter. Tiny thrombus in the SVC, likely adherent to the Port-A-Cath tip.
RECOMMENDATION(S): MRCP.
For incidentally detected multiple solid pulmonary nodules measuring 6 to 8mm,
a CT follow-up in 3 to 6 months is recommended in a low-risk patient, with an
optional CT follow-up in 18 to 24 months. In a high-risk patient, both a CT
follow-up in 3 to 6 months and in 18 to 24 months is recommended.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Leg pain, Transfer
Diagnosed with Pain in left leg
temperature: 97.7
heartrate: 90.0
resprate: 18.0
o2sat: 94.0
sbp: 103.0
dbp: 75.0
level of pain: 10
level of acuity: 2.0 | VASCULAR SURGERY DISCHARGE SUMMARY
Mr ___ is a ___ year old man with hypercoaguability and severe
bilateral ___ vascular disease sp multiple revascularizations was
transferred to the ___ on
___ for evaluation of a cool, dusky painful left leg. CTA
showed occlusion of the left common iliac and left external
iliac arteries as well as the left anterior tibial artery is
occluded distal to the level of the
occluded femoral-anterior tibial bypass graft. There is transit
occlusion of
the left posterior tibial artery distally with reconstitution
above the ankle.
The left peroneal artery is patent to the level of the ankle.
After review of the CT scan, we discussed with Mr ___ that
there are no other endovascular or surgical intervention to
restore circulation to the left leg. We also discussed that if
the ischemic pain becomes intolerable and he develops an
infection or wound in the left foot or leg, an above the knee
amputation would be an option. Lovenox as well as other usual
medications should be continued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Dilantin / gluten
Attending: ___
Chief Complaint:
Trauma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is disoriented and alone.
The patient reports that last night she got out of bed with the
intention of going to the bathroom, but does not remember what
happened after that. She regained consciousness when EMS was at
her home. She denies pain or any other symptoms. She does not
recall feeling dizzy, having palpitations or having a mechanical
fall prior to this incident.
Per OSH records, EMS reported a FSG of 50 when they evaluated
the patient at her home.
Past Medical History:
- Diabetes mellitus II
- Hypertension
- Osteoporosis
- Celiac disease
- Breast cancer status post lumpectomy and radiation therapy
- Cataracts status post surgery
Past Surgical History:
- Cataract surgery
- Lumpectomy
Social History:
___
Family History:
Mother ___ HEART FAILURE
Father ___ ABDOMINAL AORTIC ANEURYSM
Physical Exam:
Physical Exam on admission:
T 98.2 HR 74 BP 143/60 RR 18 SatO2 96% RA
Alert, oriented to person, disoriented to time and place
Left periorbital ecchymosis
Symmetrical pupils, reactive
Preserved ocular movements
No pain to palpation of the skull
Pain to palpation of the nose
Trachea midline, no respiratory distress
CTA bil, no tenderness of the chest
No tenderness of the spine
Abdomen soft, non tender, non distended.
Extremities no deformity, neurovascular intact
Physical Exam on discharge:
T 98.8 HR 92 BP 157/70 RR 18 SatO2 95% RA
Alert and oriented x3
Left periorbital ecchymosis
Symmetrical pupils, reactive
Preserved ocular movements
No pain to palpation of the skull
Trachea midline, no respiratory distress
CTA bil, no tenderness of the chest
No tenderness of the spine
Abdomen soft, non tender, non distended.
Extremities no deformity, neurovascular intact
Pertinent Results:
CT Head (second read by ___ radiology) (___):
1. Minimally displaced comminuted nasal bone fractures.
2. Mildly depressed left maxillary sinus fractures with a
concurrent left lateral orbital wall fracture, but no zygomatic
arch fracture identified. Mild asymmetric soft tissue density
along the left orbital roof of common the extraconal fat
superior to the superior rectus muscle probably reflects a small
amount of orbital hematoma.
3. Probable nondisplaced right maxillary sinus fractures.
4. Small left frontal and left temporal subarachnoid hemorrhages
with no significant mass-effect, better assessed on same day
outside hospital noncontrast head CT.
CT C spine (___): C7 compression fracture, unknown acuity
CXR (___): No evidence of traumatic injury
Pelvis X rays (___): No evidence of traumatic injury
CT HEAD W/O CONTRAST (___):
IMPRESSION:
1. Evolving subarachnoid hemorrhage of the left frontal lobe is
similar to the outside hospital earlier study, though slightly
increased and more
confluent along the sulcus (series 2, image 20 compared with
prior study
series 3, image 22).
2. Unchanged right frontal subarachnoid hemorrhage at the
vertex.
3.Unchanged 3 mm hyperdense collection along the left temporal
lobe,
possibly subdural hemorrhage versus subarachnoid hemorrhage.
4.Please refer to the CT facial bone study of ___
for full
description of the known facial bone fractures.
C-SPINE TRAUMA W/FLEX &EXT (___): IMPRESSION:
Degenerative change.
Mild retrolisthesis of C4 respect to C5 and of C5 with respect
to C6.
Superior endplate depression of indeterminate age at C7. No
significant dynamic instability is identified.
ECHO (___): The left atrial volume index is normal. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >65%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no left ventricular outflow obstruction
at rest or with Valsalva. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Mild
pulmonary artery systolic hypertension. Increased PCWP. No
valvular pathology or pathologic flow identified. No structural
cardiac cause of syncope identified.
CLINICAL IMPLICATIONS: Based on ___ AHA endocarditis
prophylaxis recommendations, the echo findings indicate
prophylaxis is NOT recommended. Clinical decisions regarding the
need for prophylaxis should be based on clinical and
echocardiographic data.
CAROTID SERIES COMPLETE (___): Wet read indicated that
carotid stenosis of less than 40% bilaterally.
Medications on Admission:
1) Amlodipine
2) Insulin
3) Lactulose
4) Lisinopril
5) Metoprolol succinate
6) Biotin
7) Ferrous sulfate
8) Aspirin 81mg
Discharge Medications:
1) Amlodipine
2) Insulin
3) Lactulose
4) Lisinopril
5) Metoprolol succinate
6) Biotin
7) Ferrous sulfate
8) LevETIRAcetam 500 mg PO Q12H Duration: 5 Days
9) Aspirin 81 mg- can be restarted seven days following her
injury (can be restarted on ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left frontal/temporal SAH
C7 compression fx ?old
Nasal bone fractures
Bilateral maxillary fracture
Orbital hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: SECOND OPINION CT NEURO
INDICATION: ___ with fall, facial swelling.
TECHNIQUE: Helical axial images were acquired through the facial bones. Bone
and soft tissue reconstructed images were generated. Coronal and sagittal
reformatted images were also obtained.
DOSE: Examination was performed at an outside institution. Provided total
DLP: 1153.93 mGy-cm
COMPARISON: Outside hospital noncontrast head CT obtained 1 day prior. Same
day outside hospital noncontrast head CT
FINDINGS:
There are minimally displaced comminuted bilateral nasal bone fractures.
There are mildly depressed fractures of the inferolateral and posterolateral
walls of the left maxillary with a blood-fluid level layering dependently.
There are probable nondisplaced fractures of the medial aspect of the anterior
wall of the right maxillary sinus and posterolateral wall of the right
maxillary sinus with a small blood-fluid level layering dependently. A
curvilinear lucency extending through the anterior aspect of the maxilla
probably reflects a nutrient foramen, rather than a maxilla fracture. There
is a probable nondisplaced fracture of the left lateral orbital wall. The
globes and extra-ocular muscles are unremarkable. There is asymmetric soft
tissue density along the left orbital roof, superior to the superior rectus
muscle, probably reflecting a small orbital hematoma in the extraconal fat.
The zygomatic arches remain intact. The pterygoid plates are intact. There
is no mandibular fracture and the temporomandibular joints are anatomically
aligned.
This examination was not tailored for evaluation of the intracranial contents.
Left frontal and left temporal subarachnoid hemorrhage appears similar to the
same-day noncontrast head CT. No significant mass-effect.
There is mild mucosal thickening of the ethmoid air cells and frontal sinuses.
There is intermediate density fluid in the sphenoid sinus. Severe carotid
siphon and left V4 segment calcifications are noted.
IMPRESSION:
1. Minimally displaced comminuted nasal bone fractures.
2. Mildly depressed left maxillary sinus fractures with a concurrent left
lateral orbital wall fracture, but no zygomatic arch fracture identified.
Mild asymmetric soft tissue density along the left orbital roof of common the
extraconal fat superior to the superior rectus muscle probably reflects a
small amount of orbital hematoma.
3. Probable nondisplaced right maxillary sinus fractures.
4. Small left frontal and left temporal subarachnoid hemorrhages with no
significant mass-effect, better assessed on same day outside hospital
noncontrast head CT.
Radiology Report
EXAMINATION: PELVIS AP ___ VIEWS
INDICATION: ___ with fall.
TECHNIQUE: Frontal view of the pelvis
COMPARISON: None
FINDINGS:
Note that the exam extends inferiorly to and only partially includes the
lesser trochanters bilaterally. No evidence of fracture or dislocation. No
suspicious osseous lesion or radiopaque foreign body. No prominent
degenerative changes.
IMPRESSION:
No evidence of fracture or dislocation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ woman with left frontotemporal subarachnoid
hemorrhage. Evaluate for 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 =
747.5 mGy-cm.
2) Sequenced Acquisition 2.0 s, 8.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
373.8 mGy-cm.
3) Sequenced Acquisition 2.0 s, 8.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
373.7 mGy-cm.
Total DLP (Head) = 1,495 mGy-cm.
COMPARISON: Outside hospital head CT and facial bone CT from ___.
FINDINGS:
The study is slightly motion degraded despite repeat acquisitions. Within
this confines, evolving subarachnoid hemorrhage involving the left frontal
lobe appears similar to the outside hospital study, slightly increased and
more confluent along the sulcus (2:20 compared with prior 3:22). Along the
left temporal lobe, there is a 3 mm thick hyperdense collection, possibly
subdural hemorrhage versus subarachnoid hemorrhage, although unchanged from
the prior study (series 2, image 15 compared with prior 3:15). Note is also
made of a small amount of subarachnoid hemorrhage involving the right frontal
lobe at the vertex, unchanged since the prior study (2:27). There is no
evidence of large territorial infarction, edema,or mass. There is prominence
of the ventricles and sulci suggestive of involutional changes.
Periventricular white matter hypodensities are nonspecific, likely sequela of
chronic small vessel ischemic disease. Note is made of calcifications of the
bilateral cavernous carotid arteries and the left vertebral artery.
Please refer to the CT facial bone study of ___ for full
description of the known facial bone fractures. Moderate mucosal thickening
is identified in the maxillary and sphenoid sinuses. Moderate ethmoidal air
cell thickening is also present. The frontal sinuses are clear. The
visualized portion of the mastoid air cells, and middle ear cavities are
clear. The globes are unremarkable, noting bilateral lens replacements.
IMPRESSION:
1. Evolving subarachnoid hemorrhage of the left frontal lobe is similar to
the outside hospital earlier study, though slightly increased and more
confluent along the sulcus (series 2, image 20 compared with prior study
series 3, image 22).
2. Unchanged right frontal subarachnoid hemorrhage at the vertex.
3. Unchanged 3 mm hyperdense collection along the left temporal lobe,
possibly subdural hemorrhage versus subarachnoid hemorrhage.
4. Please refer to the CT facial bone study of ___ for full
description of the known facial bone fractures.
Radiology Report
EXAMINATION: C-SPINE TRAUMA W/FLEX AND EXT 5 VIEWS
INDICATION: ___ year old woman with C7 spinal fracture, unknown chronicity//
?acute c-spine fracture
TECHNIQUE: Frontal, lateral, flexion extension views of the cervical spine.
FINDINGS:
C1 through C7 are visualized on lateral view. C7-T1 alignment appears
preserved. There is severe degenerative discogenic change at C4-5 and C5-6.
There is superior endplate depression of C7 with mild loss of vertebral body
height. No prevertebral soft tissue swelling in this region is identified.
There is minimal retrolisthesis of C4 with respect to C5 and of C5 with
respect to C6, measuring 3 mm on neutral lateral view. The flexion extension
view demonstrates no significant change in alignment.
IMPRESSION:
Degenerative change.
Mild retrolisthesis of C4 respect to C5 and of C5 with respect to C6.
Superior endplate depression of indeterminate age at C7.
No significant dynamic instability is identified.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old woman presented after syncope and fall// Evaluate for
occlusion
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
FINDINGS:
RIGHT:
The right carotid vasculature has mild heterogeneous atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 113 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 93, 107, and 105 cm/sec, respectively.
The peak end diastolic velocity in the right internal carotid artery is 21
cm/sec.
The ICA/CCA ratio is 0.94.
The external carotid artery has peak systolic velocity of 179 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has mild heterogeneousatherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is 139 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 95, 89, and 85 cm/sec, respectively.
The peak end diastolic velocity in the left internal carotid artery is 15
cm/sec.
The ICA/CCA ratio is 0.68.
The external carotid artery has peak systolic velocity of 156 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Right ICA <40% stenosis.
Left ICA <40% stenosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, s/p Fall, SAH, Transfer
Diagnosed with Traum subrac hem w LOC of unsp duration, init, Unspecified fall, initial encounter
temperature: 98.2
heartrate: 74.0
resprate: 18.0
o2sat: 96.0
sbp: 143.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | The patient presented to Emergency Department on ___. The
Acute Care Surgery team was asked to evaluate her. She was found
to have the following injuries:
Left frontal/temporal subarachnoid hemorrhage, C7 compression
fracture ?old, nasal bone fractures, bilateral maxillary
fracture, orbital hematoma. FAST exam was negative. She was
admitted to the trauma intensive care unit for q2 neuro checks
and appropriate monitoring. Once the patient was neurologically
stable she was transferred to the floor. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
urinary frequency, increased thirst
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ is a ___ year old man with asthma and
diagnosis of pre-diabetes presenting with one month of increased
thirst and increased urinary frequency, intermittent nausea and
emesis. No fevers, chills, chest pain, shortness of breath, or
abdominal pain. Additionally, he has noticed a painless lump on
his testicle. No associated dysuria, hematuria, or penile
discharge.
DKA protocol was initiated in ED and pt was admitted for obs
overnight. Insulin drip ran overnight in ED and pt labs
recovered
with closure AG. He was tolerating PO and was transitioned to SC
insulin per ___ recs in AM of ___. IV abx were started in ED
for scrotal cellulitis. Morning of ___ it was determined that
scrotal cellulitis was not improving enough to safely discharge
home so pt was admitted for further management.
In the ED:
- Initial vital signs were notable for: T 97.8 HR 108 BP 153/86
RR 18 99% RA
- Exam notable for: dry mucous membranes, abd soft, NT, ND, 1cm
discrete swelling to scrotum inferior to and separate from
testicle with small overlying pustule.
- Labs were notable for:
9.1>13.___/43.1<359
Na 140 K 4 BUN 9 Cr 1.1
A1c 13.9%
Ph 7.32 pCO2 41 HCO3 23
- Studies performed include:
Scrotal US: Scrotal thickening along the inferior left margin,
possibly a focal area of cellulitis. No drainable collection. No
evidence of soft tissue gas. Otherwise unremarkable.
- Patient was given:
Insulin gtt, clindamycin 600mg IV q8h, 1L LR, 1L NS w/40 mEq
KCl,
insulin glargine 30U and ISS
- Consults:
___ - presentation c/w DKA, administer insulin gtt and
transition to insulin SC with ISS
Vitals on transfer: HR 85 BP 141/84 RR 20 97% RA
Upon arrival to the floor, pt confirms above story. He as first
diagnosed with pre-DM by his PCP ___ ___ (a1c 6.1) with
lifestyle
recommendations recommended. A1c stable at 6.2 in ___. Denies
any inciting infection other than scrotal irritation which was
present for 4 days. Polyuria and polydipsia present for at least
1 month.
Past Medical History:
Morbid obesity
Glucose intolerance
Asthma
Social History:
___
Family History:
Mother - DM2
Father - DM2, CKD, HTN, asthma
Brother - asthma
___ grandmother - DM2
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 99.1 145 / 83 85 16 99 RA
GENERAL: Alert and interactive, standing in room, in no acute
distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, obese, non distended, non-tender
to deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally. Left ___ larger than right w/o pitting or erythema
(chronic per pt ___ ORIF ___ following MVA)
SKIN: Warm. Cap refill <2s. No rash.
SCROTUM: 0.5 x 1cm soft, poorly defined mass at apex of scrotum,
no TTP, break in skin, or overlying erythema
NEUROLOGIC: No focal deficits; Normal sensation. Gait is normal.
AOx3.
DISCHARGE PHYSICAL EXAM
=======================
BP 123 / 78 R Sitting HR 82 RR 18 O2 sat 97 RA
GENERAL: Pleasant, sitting up in bed comfortably
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Obese, normal bowel sounds, soft, nontender, nondistended,
no hepatomegaly, no splenomegaly.
GU: 0.5 x 0.5 cm soft edematous area of scrotum. Nontender to
palpation, no erythema.
EXT: Warm, well perfused, no lower extremity edema.
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS
==============
___ 10:16AM BLOOD WBC-9.1 RBC-5.75 Hgb-13.2* Hct-43.1
MCV-75* MCH-23.0* MCHC-30.6* RDW-17.2* RDWSD-42.6 Plt ___
___ 10:16AM BLOOD Neuts-64.6 ___ Monos-9.6 Eos-1.5
Baso-0.9 Im ___ AbsNeut-5.85 AbsLymp-2.09 AbsMono-0.87*
AbsEos-0.14 AbsBaso-0.08
___ 10:16AM BLOOD Glucose-367* UreaN-9 Creat-1.1 Na-140
K-4.0 Cl-100 HCO3-18* AnGap-22*
___ 07:47AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.8
___ 10:16AM BLOOD %HbA1c-13.9* eAG-352*
___ 10:57AM BLOOD ___ pO2-94 pCO2-41 pH-7.34*
calTCO2-23 Base XS--3
___ 04:22PM BLOOD Glucose-288* Na-139 K-3.7 Cl-103
calHCO3-22
___ 11:26AM URINE Color-Straw Appear-Clear Sp ___
___ 11:26AM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-1000* Ketone-80* Bilirub-NEG Urobiln-NEG pH-5.5
Leuks-NEG
___ 11:26AM URINE RBC-1 WBC-1 Bacteri-FEW* Yeast-NONE Epi-0
___ Urine culture: no growth
DISCHARGE LABS
==============
___ 06:17AM BLOOD Glucose-239* UreaN-8 Creat-0.9 Na-141
K-3.8 Cl-102 HCO3-26 AnGap-13
___ 06:17AM BLOOD Calcium-8.5 Phos-4.3 Mg-1.8
REPORTS
=======
SCROTAL U.S. Study Date of ___
The right testicle measures: 2.6 x 2.5 x 3.7 cm.
The left testicle measures: 2.4 x 2.0 x 3.1 cm.
The testicular echogenicity is normal, without focal
abnormalities.
The epididymides are normal bilaterally. Vascularity is normal
and symmetric in the testes and epididymides.
There is focal skin thickening along the inferior left scrotum,
with
associated hyperemia, possibly representing a focal area of
cellulitis. There is no drainable collection or evidence of gas
in the soft tissues.
IMPRESSION:
Scrotal thickening along the inferior left margin, possibly a
focal area of cellulitis. No drainable collection. No evidence
of soft tissue gas.
Otherwise unremarkable.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
Discharge Medications:
1. Glargine 45 Units Breakfast
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Diabetes mellitus type II
Scrotal cellulitis
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: SCROTAL U.S.
INDICATION: ___ with discrete swelling in scrotum inferior to left
testicle// eval mass, abscess
TECHNIQUE: Grayscale with color and spectral Doppler ultrasound of the
scrotum was performed with a linear transducer.
COMPARISON: None.
FINDINGS:
The right testicle measures: 2.6 x 2.5 x 3.7 cm.
The left testicle measures: 2.4 x 2.0 x 3.1 cm.
The testicular echogenicity is normal, without focal abnormalities.
The epididymides are normal bilaterally.
Vascularity is normal and symmetric in the testes and epididymides.
There is focal skin thickening along the inferior left scrotum, with
associated hyperemia, possibly representing a focal area of cellulitis. There
is no drainable collection or evidence of gas in the soft tissues.
IMPRESSION:
Scrotal thickening along the inferior left margin, possibly a focal area of
cellulitis. No drainable collection. No evidence of soft tissue gas.
Otherwise unremarkable.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Urinary frequency
Diagnosed with Type 2 diabetes mellitus with ketoacidosis without coma
temperature: 97.8
heartrate: 108.0
resprate: 18.0
o2sat: 99.0
sbp: 153.0
dbp: 86.0
level of pain: 0
level of acuity: 3.0 | TRANSITIONAL ISSUES
===================
[ ] Assess for resolution of scrotal cellulitis, if not
resolved, may require urology referral.
[ ] Ensure PCP follow up at ___.
BRIEF HOSPITAL COURSE
=====================
___ year old man with asthma and pre-diabetes presenting with
polyuria and polydipsia found to have mild DKA treated in the ED
with AG closure, admitted for treatment of scrotal cellulitis
and titration of insulin regimen.
# DKA
# Hypokalemia
# DMII
Presented with polyuria and polydipsia for at least one month
with A1c 6.1% on last check in ___ climbing to 13.9% on
admission. Found to be hyperglycemic with elevated anion gap and
ketones in urine consistent with DKA. No preceding illness or
other trigger identified. S/p insulin gtt in ED with closure of
anion gap and transition to subcutaneous insulin. ___ was
following during his admission and titrated his insulin to a
regimen of lantus 45mg qAM, Humalog 15U TID with meals, and
sliding scale Humalog (1 unit for every 40 increase in glucose
starting at 140 with meals and 200 at bedtime). He was started
on metformin 500mg BID.
# Scrotal cellulitis:
Patient reported mild discomfort with sitting, relieved by
repositioning scrotum, x ___ days. Received IV Clindamycin x2
days in ED. Denies pain or any other associated symptoms. No
systemic symptoms, no leukocytosis. Scrotal US with scrotal
thickening along inferior left margin, no abscess or gas,
possibly cellulitis with area of edema with overlying pustule
noted on exam. S/p treatment with IV clinda and IV cefazolin. A
5 day course of antibiotics was completed with clindamycin 300mg
q6h.
CHRONIC ISSUES:
===============
#Asthma: mild, intermittent. Does not recall last time he used
inhaler. Continue home albuterol inhaler.
>30 minutes spent on discharge planning and care coordination on
day of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
Right tibia ring fixator ___ ___
History of Present Illness:
___ w/ alcohol and opioid abuse s/p fall 3days ago w/ R proximal
tib/fib fx and 3 L rib fxs now s/p R ex-fix (ring fixator) ___,
___
Past Medical History:
chronic back pain
EtOH abuse
Opioid abuse
Social History:
___
Family History:
Non-contributory
Physical Exam:
On discharge:
General: Well-appearing, breathing comfortably
MSK: R tibial ex-fix frame in place Able to PF/DF ankle.
___ intact. Calf
soft, non tender. NVI distally, with SILT throughout. Leg edema
improving, significant bruising of R proximal shin improving.
Pertinent Results:
Admission labs:
___ 10:00PM BLOOD WBC-11.6* RBC-2.29* Hgb-8.5* Hct-25.2*
MCV-110* MCH-37.1* MCHC-33.7 RDW-12.1 RDWSD-48.6* Plt ___
___ 10:00PM BLOOD Glucose-102* UreaN-30* Creat-3.0*# Na-139
K-3.2* Cl-99 HCO3-15* AnGap-25*
___ 04:40AM BLOOD Glucose-95 UreaN-32* Creat-2.7* Na-140
K-3.1* Cl-102 HCO3-18* AnGap-20*
Please see OMR for pertinent laboratory data.
___ 07:00AM BLOOD WBC-8.9 RBC-2.24* Hgb-7.9* Hct-22.7*
MCV-101* MCH-35.3* MCHC-34.8 RDW-15.5 RDWSD-56.8* Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-90 UreaN-14 Creat-0.7 Na-138
K-3.9 Cl-103 HCO3-23 AnGap-12
___ 07:00AM BLOOD Calcium-7.6* Phos-2.0* Mg-2.1
___ 06:45AM BLOOD Glucose-71 UreaN-9 Creat-0.7 Na-139
K-3.2* Cl-97 HCO3-26 AnGap-16
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Endocet (oxyCODONE-acetaminophen) ___ mg oral Q4H:PRN
2. Viibryd (vilazodone) 40 mg oral DAILY
3. TraZODone 100 mg PO QHS:PRN insomnia
4. Omeprazole 20 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Gabapentin 800 mg PO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Use for baseline pain control.
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 4 hours Disp
#*140 Tablet Refills:*1
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Cephalexin 500 mg PO Q12H
Use as directed for 7 days following discharge.
RX *cephalexin 500 mg 1 tablet(s) by mouth twice daily (12 hours
apart) Disp #*14 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
This is a new medication to prevent post-operative constipation.
Hold for diarrhea or loose stools.
RX *docusate sodium 100 mg 2 capsule(s) by mouth daily Disp #*28
Capsule Refills:*0
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Severe
Don't take before driving, operating machinery, or with
alcohol/sedatives. Taper as tolerated.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*40 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Use daily as needed for constipation not relieved by Senna and
Colace.
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
as needed Disp #*14 Packet Refills:*0
8. Senna 8.6 mg PO BID
This is a new medication to prevent post-operative constipation.
Hold for diarrhea or loose stools.
RX *sennosides 8.6 mg 2 tablets by mouth every evening Disp #*28
Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
Take daily.
RX *thiamine HCl (vitamin B1) 50 mg 2 tablet(s) by mouth daily
Disp #*60 Tablet Refills:*1
10. wheelchair miscellaneous ongoing
RX *wheelchair Disp #*1 Each Refills:*0
11. Gabapentin 400 mg PO BID multi modal analgesia preop
Duration: 1 Dose
12. Lisinopril 20 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Viibryd (vilazodone) 40 mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right tibia fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT
INDICATION: History: ___ with right lower extremity deformity// eval fracture
eval fracture
eval fracture
TECHNIQUE: Frontal and lateral view radiographs of right tibia-fibula
COMPARISON: None ___ CT lower extremity.
FINDINGS:
Status post cast placement which obscures visualization of fine osseous
details. There is a severely comminuted fracture of the proximal tibia
metaphysis with slight varus and apex anterior angulation. There is a
comminuted fracture of the proximal fibular metaphysis with varus angulation.
Assessment for intra-articular extension is limited in this study and better
assessed in the same day CT lower extremity. There is no evidence of distal
tibia/fibular fracture. The partially visualized ankle mortise appears
congruent. There is no evidence of distal femur fracture.
IMPRESSION:
Severely comminuted fractures of the proximal tibia and fibula metaphyses with
slight angulation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with s/p fall// ? ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 48.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
Study is mildly degraded by motion. There is no evidence of acute large
territorial infarction,hemorrhage,edema, or mass. There is prominence of the
ventricles and sulci suggestive of involutional changes. There are
periventricular and subcortical lucencies, which may represent small vessel
ischemic changes. Atherosclerotic vascular calcifications are noted of
bilateral cavernous portions of internal carotid arteries.
There is no evidence of fracture. Minimal left parietal vertex scalp soft
tissue swelling is present (see 602:59). There is mild mucosal thickening of
the ethmoid air cells. The remainder of the visualized portion of the
paranasal sinuses, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable. Minimal bilateral mastoid fluid is noted.
IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality.
3. No evidence acute intracranial hemorrhage or fracture.
4. Minimal left parietal vertex scalp soft tissue swelling
5. Atrophy, probable small vessel ischemic changes, and atherosclerotic
vascular disease as described.
6. Paranasal sinus disease and nonspecific bilateral mastoid fluid, as
described.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with s/p fall// ? ICH ? ICH
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 6.1 s, 24.0 cm; CTDIvol = 22.8 mGy (Body) DLP = 547.8
mGy-cm.
Total DLP (Body) = 548 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no acute fracture or acute malalignment. There is no prevertebral
soft tissue swelling.
Mild to moderate multilevel degenerative disc disease is noted as evidence by
facet arthropathy and osteophytosis. There is severe left neural foramina
narrowing at C2-C3 secondary to uncovertebral hypertrophy and facet
arthropathy (2: 26). There is no severe neural foramina narrowing. Within
the limits of this noncontrast study, there is no evidence of infection or
neoplasm.
The partially visualized lung apices and thyroid gland are grossly preserved.
Scattered subcentimeter nonspecific lymph nodes are noted throughout the neck
bilaterally, without definite enlargement by CT size criteria.
Atherosclerotic vascular calcifications are seen in bilateral carotid
bifurcations. Left proximal T1 minimally displaced rib fracture with
corticated margins is noted (see 2:65; 602:42; 601:19). Question nondisplaced
right proximal clavicular fracture with cortication along minimally displaced
fracture fragments versus volume averaging artifact (see 602:2).
IMPRESSION:
1. No definite acute fracture or acute malalignment.
2. No prevertebral soft tissue swelling.
3. Mild to moderate multilevel degenerative disc disease with least mild
vertebral canal narrowing at C3-4. If clinically indicated, consider
dedicated cervical spine MRI for further evaluation.
4. Left T1 proximal probable chronic fracture.
5. Question chronic right proximal clavicular fracture versus volume averaging
artifact. If clinically indicated, consider dedicated clavicular imaging for
further evaluation.
6. Please see concurrently obtained noncontrast head CT for description of
cranial structures.
Radiology Report
INDICATION: ___ year old man with proximal tibia fracture. Please obtain
images from mid thigh down to the ankle// eval fracture
TECHNIQUE: CT scan from the midthigh to the ankle was performed without the
IV administration of contrast material. Axial, sagittal, and coronal
reformats of the bilateral legs and of the right leg were provided for image
interpretation.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.5 s, 74.6 cm; CTDIvol = 11.9 mGy (Body) DLP = 890.4
mGy-cm.
Total DLP (Body) = 890 mGy-cm.
COMPARISON: Same day right knee and right tibia-fibula radiographs.
FINDINGS:
Right leg: There is a comminuted fracture through the proximal right tibial
metadiaphysis with mild varus and apex anterior angulation with slight
anterior displacement of the prominent distal fracture fragment. There is
slight impaction. Fracture lines extend proximally toward the tibial plateau
(2:109 and 301:90) and likely into the tibial spines (2:99, 401: 53), However
the articular surfaces appear congruent and likely preserved. Dislodged
fracture fragments project into the anterior and medial soft tissues and come
in close proximity to the skin surface without definite disruption of the skin
(400:47, 2:124 and 103:78).
There is a severely comminuted fracture through the proximal right fibula
metadiaphysis with mild varus angulation and anteromedial displacement of the
predominant fracture fragment, dislodged fragments extend into the medial soft
tissues (2:131-133).
There is extensive surrounding soft tissue swelling. There are no distal
tibia/fibula fractures. There are no fractures visualized within the imaged
foot. There are no distal femoral fractures.
Small knee effusion. Mild hypertrophic changes proximal tibia fibular joint.
Mild hypertrophic changes of the distal fibula and fibular talar articulation.
Small focus of mineralization at the superolateral aspect of the talar dome
may represent a small OCD (image 104:84).
Small osseous excrescence measuring 7 x 6 mm from the lateral metaphysis of
the distal femur appears to have medullary continuity (image 301:70-74). This
is most consistent with a small osteochondroma.
Left-side: There are no fractures within the imaged portion of the left lower
extremity. Mild hypertrophic changes of the medial tibiotalar joint.
Small bilateral knee effusions are noted.
IMPRESSION:
Severely comminuted fracture of the proximal right tibial metaphysis with
slight varus and apex anterior angulation and slight anterior displacement and
impaction. Multiple displaced fracture fragments come close to the skin
surface though no definite skin breech is identified. There is likely
extension of fracture lines into the tibial spines, however the articular
surfaces appear congruent without definite involvement.
Severely comminuted displaced fracture through the right proximal fibula
metadiaphysis with anterior displacement and slight varus angulation.
Possible small OCD of the superolateral aspect of the right talar dome.
Likely small osteochondroma of the lateral aspect of the distal right femoral
metaphysis. This can be followed on subsequent radiographs.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT
IMPRESSION:
Images from the operating suite show placement of a fixation device about
comminuted fracture the tibia. Further information can be gathered from the
operative report.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Foot injury, s/p Fall, Transfer
Diagnosed with Oth fracture of upper end of right tibia, init for clos fx, Fall same lev from slip/trip w/o strike against object, init
temperature: 97.5
heartrate: 82.0
resprate: 12.0
o2sat: 97.0
sbp: 112.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have ___ and electrolyte abnormalities as well as a Right
tibia fracture and was admitted to the orthopedic surgery
service with Medicine consult. The patient was taken to the
operating room on ___ for external fixation of RLE in ring
fixator, 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.
CIWA protocol was ordered in the PACU and he was given IV
Magnesium as well as PO Thiamine. CIWA protocol was continued on
the floor. The patient scored low on CIWA scale during his
admission, mostly with symptoms of anxiety. Throughout admission
patient remained hemodynamically stable and patient did not
exhibit overt symptoms of either alcohol or opioid withdrawal
including tremors, hallucinations, rigors, chills, tachycardia.
Medicine was consulted given his significantly elevated
creatinine and electrolyte abnormalities. He was placed on IVF
and his electrolyes were repleted as needed.
His creatinine levels continued to downtrend, and had normalized
___.
The patient was progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
with services and wheelchair was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the Right lower extremity in ex-fix. The patient will
follow up with Dr. ___ on ___. The patient will be
discharged on a 4 week course of ASA 325mg daily, with ___
services to assist with pin site care. The patient will also
complete a 7 day course of oral Keflex upon discharge. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine / IV Dye, Iodine Containing Contrast Media
Attending: ___
Chief Complaint:
Neck and Shoulder Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx of asthma, OSA, osteoarthritis, hypertension,
hyperlipidemia, asymptomatic CAD presents with left neck pain
and fever. Patient said that his neck pain has been occurring
for the past one week when he woke up in the morning. It is to
the left of his midline, sharp and feels like his muscles are
very tight. He went to the ED on ___ and he was diagnosed
with MSK neck pain and discharged home. The pain then started to
get worse with movement and began to radiate to his left
shoulder. On the day prior to admission, the shoulder pain
worsened and he was unable to lift his shoulder because of the
pain. He denies any significant headache, photophobia, nausea,
vomiting, weakness, or numbness/tingling. He does state that
he has also been having chills, worsening shortness of
breath/wheezing, sore throat, and a worsening cough productive
of clear sputum. He further endorses some increase in his ___
edema, however, this is a chronic issue for him.
In the ED, initial VS were: 101 94 132/77 18 94% room. Exam
notable for tender to palpation over acromion and L posterior
cervical region; no erythema or edema. He was unable to turn
head to left, unable to actively abduct L shoulder due to pain,
full active ROM in elbow and beyond. Passive abduction of L
shoulder intact. Posterior pharynx erythematous, uvula midline,
no tonsillar swelling noted, significant redundant pharyngeal
tissue. No stridor, no muffled voice. Labs notable for WBC:
12.3, lactate: 1.3, H/H: 11.8/35.2. ESR125, CRP 190, U/A
negative. CT neck without signs of retropharyngeal abscess. CXR
showed atelectasis versus infiltrate. An MRI was attempted for
conern for epidural abscess, however, patient was unable to lie
flat secondary to wheezing and SOB. Neurosurg saw the patient
and was not concerned for spidural abscess anyways.
He was given methylpred 40mg IV x1, dilaudid 1mg IV x2, Moprhine
4mg IV x1, Tylenol ___ PO x1, Benadryl 50mg IV x1,
levofloxacin 750mg IV x1 and ativan 2mg IV x1.
This morning, patient feeling well and thinks that his neck pain
is improving although still unable to lift his left shoulder.
Past Medical History:
- severe lumbar canal stenosis
- episode of severe generalized weakness for which he was
hospitalized at ___ in ___ (reportedly underwent a left sural
nerve biopsy after which he was told his "nerves were dead" from
an infection; underwent a muscle biopsy that was reportedly
unrevealing; was not ever on ventilator assistance; recovered
completely)
- obstructive sleep apnea for which he uses CPAP
- REM behavioral disorder
- asthma
- hypertension
- aortic stenosis
- peripheral vascular disease
- benign prostatic hypertrophy
- anemia
- seasonal allergies
- GERD (per OMR; patient denies)
- Asymptomatic CAD - + Nuc stress test
PAST SURGICAL HISTORY:
- cholecystectomy
Social History:
___
Family History:
- Positive for: prostate cancer (father)
- negative for: seizure, stroke, migraine, neuropathy, known
neurological conditions
Physical Exam:
VS - 98.5 92/62 80 20 98% RA
GENERAL - NAD, comfortable
HEENT - EOMI, sclerae anicteric, MMM, OP clear, poor dentition
NECK - supple, no thyromegaly, no JVD
LUNGS - decreased breath sounds at the bases, poor air movement
with diffuse wheezes
HEART - RRR, II/VI crescendo/decrescendo mid pitched murmur
heard best at the RUSB that radiates to the carotids, II/VI
holosystolic murmur heard best at the apex (both previously
documented)
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 2+ edema to the knees b/l L>R
MSK- pain with abduction of the shoulder ___ degrees, pain
with both active and passive ROM no erythema or warmthover the
shoulder, but with point tenderness along the AC joint line. No
spinous process tenderness
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ except unable to abduct left shoulder, sensation intact on
upper and lower extremities, DTRs 2+ and symmetric brachial and
patellar, cerebellar exam intact, steady gait
Pertinent Results:
ADMISSION LABS:
___ 07:52PM BLOOD WBC-12.3*# RBC-3.65* Hgb-11.8* Hct-35.2*
MCV-97 MCH-32.2* MCHC-33.4 RDW-12.1 Plt ___
___ 07:52PM BLOOD ___ PTT-31.6 ___
___ 07:52PM BLOOD ESR-125*
___ 07:52PM BLOOD Glucose-113* UreaN-21* Creat-1.0 Na-138
K-4.6 Cl-100 HCO3-26 AnGap-17
___ 07:52PM BLOOD Calcium-9.0 Phos-3.6 Mg-2.2
___ 07:52PM BLOOD CRP-190.0*
CXR: Streaky bibasilar opacities, potentially due to atelectasis
given
lower lung volumes, however, developing infiltrate cannot be
entirely
excluded.
MRI C SPINE:
1. Exam is severely limited due to patient motion. No gross
marrow signal abnormality or fluid collection. If there is
continued concern for abscess, repeat exam is recommended.
2. Incompletely evaluated degenerative changes of the cervical
spine from C3-C4 through C6-C7 with spinal canal narrowing, not
adequately quantified on the current examination.
CT NECK:
IMPRESSION:
1. No abscess.
2. 4 mm ACom aneurysm could be further evaluated by MRA or CTA,
on an
elective basis.
3. Ethmoid and maxillary sinus inflammatory disease with acute
component.
XRay Shoulder:
IMPRESSION: Mild degenerative change with no acute bony or
joint space
abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Endocet *NF* (oxyCODONE-acetaminophen) ___ mg Oral QHS
3. Fish Oil (Omega 3) 1000 mg PO BID
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Gabapentin 900 mg PO TID
6. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q4H SOB/WHEEZing
7. Montelukast Sodium 10 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Acetaminophen 500 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. calcium carbonate-vit D3-min *NF* 600 mg (1,500 mg)-400 unit
Oral BID
12. Doxazosin 6 mg PO HS
13. Lisinopril 10 mg PO DAILY
Hold for SBP<100
14. Metoprolol Succinate XL 25 mg PO DAILY
Hold for SBP<100, HR<60
15. Omeprazole 20 mg PO DAILY
16. Diazepam 5 mg PO TID
Hold for sedation, RR<10
17. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
Hold for RR<10, sedation
18. Ibuprofen 600 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Diazepam 5 mg PO TID
Hold for sedation, RR<10
4. Doxazosin 6 mg PO HS
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Gabapentin 900 mg PO TID
9. Ibuprofen 600 mg PO Q6H:PRN pain
10. Lisinopril 10 mg PO DAILY
Hold for SBP<100
11. Metoprolol Succinate XL 25 mg PO DAILY
Hold for SBP<100, HR<60
12. Montelukast Sodium 10 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. calcium carbonate-vit D3-min *NF* 600 mg (1,500 mg)-400 unit
Oral BID
16. Endocet *NF* (oxyCODONE-acetaminophen) ___ mg Oral QHS
17. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q4H SOB/WHEEZing
18. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q12H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
twice a day or every 12 hours Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Shoulder Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Left-sided neck pain and sore throat. Evaluation for
retropharyngeal abscess.
TECHNIQUE: MDCT images were obtained from the skull base to the
aortopulmonary window after administration of intravenous contrast. Coronal
and sagittal reformations were acquired.
COMPARISON: MR neck, ___.
FINDINGS: There is mucosal thickening in the ethmoid air cells and maxillary
sinuses along with fluid in the nasopharynx. However, there is no
peritonsillar or retropharyngeal fluid collection. There is no cervical
lymphadenopathy. The parotid and submandibular glands are unremarkable. The
neck vessels enhance without stenosis. Incidentally noted is a 4 x 3 mm ACom
aneurysm (2:11; 300b:68). Allowing for helical acquisition, reconstruction
and algorithm, and section thickness, the included portions of the brain are
otherwise unremarkable. The orbits are normal. There is paraseptal emphysema
at the lung apices, which are otherwise clear. There is no mediastinal
lymphadenopathy.
OSSEOUS STRUCTURES: There are multilevel degenerative changes of the cervical
spine. There is no lytic or blastic lesion worrisome for malignancy.
IMPRESSION:
1. No abscess.
2. 4 mm ACom aneurysm could be further evaluated by MRA or CTA, on an
elective basis.
3. Ethmoid and maxillary sinus inflammatory disease with acute component.
Radiology Report
INDICATION: Severe left shoulder pain.
COMPARISON: Chest radiograph, ___.
STUDY: Left shoulder three views. Right shoulder, three views.
FINDINGS: There are mild degenerative changes bilaterally at the AC and
glenohumeral joints. There is a small lucency measuring approximately 6 x 6 mm
on the left, and a similar lucency measuring 4 x 5 mm on the right, both with
sclerotic margins. There is no fracture or dislocation. No soft tissue
calcification or radiopaque foreign body is seen.
IMPRESSION: Mild degenerative change with no acute bony or joint space
abnormality.
Radiology Report
HISTORY: AC joint tenderness, high ESR, CRP, fevers, question joint effusion.
TECHNIQUE: Imaging performed at 1.5 Tesla using a local coil. Multiplanar
pre- and post-contrast images were obtained.
COMPARISON: Left shoulder radiographs dated ___.
LEFT SHOULDER MRI WITH AND WITHOUT CONTRAST:
Examination was performed with large field of view, coil unknown. Some images
are degraded by patient motion. Allowing for this, there is mild-to-moderate
AC joint arthropathy with a small amount of fluid in the joint. There is
edema in the soft tissues immediately surrounding the joint, but no large
amount of fluid in the subacromial/subdeltoid bursa. Given the presence of
motion, it is difficult to completely exclude periarticular edema; a small
amount of edema may be present in the acromion adjacent to the AC joint. A
few resorptive cysts are noted in the humeral head. Otherwise, no abnormal
marrow edema is identified.
Exam was performed for infection and is not optimized for evaluation of the
rotator cuff and glenohumeral joint. Allowing for this, the glenohumeral joint
is congruent, with trace joint effusion. Focal subchondral edema along the
posterolateral glenoid is noted -- given the configuration and unremarkable
overlying soft tissues, this likely represents degenerative change. There is
a tear of the distal supraspinatus tendon involving the anterior and middle
fibers, measuring approximately 7.6 mm in the coronal plane and approximately
2.4 cm in the sagittal plane. No muscle atrophy is detected. Mild tendinosis
and possible mild fraying of the infraspinatus tendon is also present.
Subscapularis tendon and teres minor tendon are grossly intact.
IMPRESSION:
1. Mild-to-moderate AC joint arthropathy with surrounding edema. No large AC
joint effusion or large amount of fluid in the subacromial/subdeltoid bursa.
Possible mild edema in the acromion. This appearance is nonspecific. The
differential includes degenerative changes, but in the appropriate clinical
setting, infection could also account for this appearance. Infection is,
however, considered less likely based on imaging.
2. Tear of the distal rotator cuff, without significant retraction.
3. Glenohumeral joint degenerative changes, with focal edema in the posterior
glenoid inferiorly.
Radiology Report
PROCEDURE: Ultrasound aspiration of the left acromioclavicular joint.
CLINICAL INDICATION: ___ man with left acromioclavicular joint pain
and possible small effusion seen on recent MRI. The patient presents for
aspiration of this fluid for evaluation of septic arthritis.
COMPARISON: MRI from ___.
TECHNIQUE: After risk, benefits and alternatives were explained to the
patient, written informed consent was obtained. Prior to the procedure, a
timeout was performed using patient identifiers. The patient was placed in
the right lateral oblique position on the ultrasound bed.
The region of the left acromioclavicular joint was scanned with realtime and
color Doppler ultrasound.
A suitable approach to the left acromioclavicular joint was identified with
mark placed on the skin for approach. The skin above this region was prepped,
draped in the usual sterile fashion. 1% lidocaine was then applied to the
skin for anesthesia. Utilizing a 16-gauge needle, approximately 0.5 mL of
clear joint fluid aspirate was obtained.
After aspiration, needle was removed and pressure applied to the overlying
skin and subcutaneous tissues for hemostasis. There were no immediate
procedural complications, and patient tolerated the procedure well.
FINDINGS: Gray scale and color Doppler ultrasound images demonstrated minimal
amount of fluid within the acromioclavicular joint with moderate surrounding
inflammation. The underlying bones appear within normal limits.
IMPRESSION:
1. Successful aspiration of the left acromioclavicular joint, with 0.5 mL of
clear reddish aspirate obtained and sent to the lab for Gram stain and
microbiology culture analysis.
2. Moderate surrounduing inflammation with minimal amount of fluid within the
left acromioclavicular joint as described.
Dr. ___, the attending radiologist, was present and supervised the entire
procedure.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: LEFT SIDED NECK PAIN
Diagnosed with FEVER, UNSPECIFIED, CERVICALGIA, COUGH
temperature: 101.0
heartrate: 94.0
resprate: 18.0
o2sat: 94.0
sbp: 132.0
dbp: 77.0
level of pain: 10
level of acuity: 3.0 | ___ w/ hx of asthma, OSA, osteoarthritis, hypertension,
hyperlipidemia, asymptomatic CAD presents with left neck pain,
shoulder pain, and fever.
# Shoulder/Neck Pain: Neck pain seems muscular in nature, and on
further evaluation, likely referred pain form shoulder. No
symptoms or PE findings concerning for meningismus, no spinous
process tenderness to indicate abscess. Seen by neurosurg, they
are not concerned for epidural abscess; exam is reassuring. No
symptoms of a cervical radiculopathy present. In terms of his
shoulder pain, he was exquistely tender over the AC joint, and
had pain with both active and passive ROM concerning for an
inflammatory arthritis, particuarly given increased ESR/CRP. He
had an MRI of the shoulder which showed a torn supraspinatous
tendon as well as a small AC joint effusion. The effusion was
tapped under ultrasound guidance by ___, was sterile, Gram stain
negative. He was discharged with physical therapy and ortho
follow up. His pain was well controlled with percocet.
# ___ edema: Is a chronic issue for the patient, although he
states it has increased over the last several days. Had an echo
a year ago which showed AS, preserved EF, LVH, no MR ___
has a holosystolic murmur on exam today). TTE during this
admission showed no change in LV function or valve status. Will
be followed as an outpatient.
# OSA: Continued CPAP.
# Asthma: Stable, patient mildly SOB on admission, resolved by
discharge. Continued:
- Advair Diskus 500 mcg-50 mcg/dose for Inhalation 1 puff(s)
inhaled twice a day rinse after use
- Flonase 50 mcg/actuation Nasal Spray
- ProAir HFA 90 mcg/actuation Aerosol Inhaler
___ puffs inhaled every four hours as needed for for shortness
of breath or wheezing
- Singulair 10 mg Tab 1 Tablet(s) by mouth daily
- Spiriva with HandiHaler 18 mcg & inhalation Caps 1 capsule
inhaled daily use as directed
# Hypertension: Continued
- lisinopril 10 mg Tab 1 Tablet(s) by mouth once a day
- metoprolol succinate ER 25 mg 1 tablet(s) by mouth daily
# benign prostatic hypertrophy: Continued:
- doxazosin 4 mg Tab 1.5 Tablet(s) by mouth at bedtime
# GERD: omeprazole 20 mg capsule,delayed release 1 capsule(s) by
mouth daily
# Low back pain: Patient with known chronic low back pain,
lumbar stenosis at L4-L5, L5-S1 nerve roots and associated
spondylithesis. He is being followed by neurology and recently
his gabapentin has been increased with successful pain control. |
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, dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ y/o male transferred from OSH for evaluation of
dizziness and chest pain. The patient reports that he was
getting out off of public transportation when he had a sudden
onset of dizziness and a sensation that the room was spinning.
He did not syncopize and denies any head trauma. He says that
occasionally this happens with when he turns his head quickly.
He notes that he did not drink much water today. He denies any
hearing loss or ear "fullness". He is not sure if this is
related/simultaneous to the chest pain. As for the chest pain,
Mr. ___ endorses experiences it when he is "rushing around". He
has never had a heart attack and has had two hospitalizations
for this issue. He had a recent stress test in ___ which
was normal. He denies any other symptoms such as fevers, chills,
SOB. He denies paroxysmal nocturnal dyspnea and orthopnea. Of
note, he does report some leg pain with walking that resolves on
rest. His daughter in law was also in the room and noted that
the patient is a good historian and has had no difficulty with
memory or AMS recently.
In the ED:
Vitals - T97.8 HR 68 BP 144/61 R 15 O2sat 100% RA
- Labs were notable for ___ 13.9, INR 1.3, negative trops x2,
benign UA, normal CBC.
- Studies performed include...
EKG: normal rate with ectopic atrial rhythm; unknown baseline.
CXR: The lungs are mildly hypoinflated with crowding of
vasculature. Mild cardiomegaly is stable. Mediastinal contour
and hila are normal. No focal opacity. No pleural effusion or
pneumothorax.
___: Eval was completed in the ED but was limited by chest
discomfort, pt is unsafe for ___ home at this time, but
anticipate with medical workup pt.
- Patient was given losartan, tamsulosin, 1L IV fluids.
Metoprolol was held.
- Vitals on transfer: 97.8 68 144/63 15 100% RA
Upon arrival to the floor, the patient...
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
- T2DM
- Benign prostatic hypertrophy
- Gout
- Hyperlipidemia
- Varicose veins
Social History:
___
Family History:
Notable for hypertension in his father
Physical ___:
On admission:
Vitals- T 98.3 BP 130/90 HR: 80 R: 15 O2sat:99%
General: Well-appearing, in NAD.
HEENT: EOMI, PERRL. No nystagmus noted. Hall ___
maneuver was negative.
Neck: No LAD.
CV: Normal S1 and S2. ___ crescendo decrescendo murmur loudest
at the right ___ intercostal space. No radiation to the carotids
noted.
Lungs: CTAB. No wheezing, rhonchi or crackles appreciated
Abdomen: Soft, NT, ND. BS present.
GU: No foley in place
Ext: Varicose veins in b/l lower extremities. 2+ pulses
without edema or clubbing.
Neuro: AAOx3. Abstraction and cognition intact. Able to spell
world backwards. No dysdiadokinesia or dysmetria. Gait is not
wide based or unsteady.
Skin: No rashes.
Discharge:
Vitals: T 98.4 BP 120s-130s/70s P ___ R 18 O2sat 99% RA
General: Well-appearing, NAD.
HEENT: EOMI, PERRL. No nystagmus noted. Hall ___
maneuver was negative.
Neck: No LAD.
CV: Normal S1 and S2. ___ crescendo decrescendo murmur loudest
at the right ___ intercostal space. No radiation to the carotids
noted.
Lungs: CTAB. No wheezing, rhonchi or crackles appreciated
Abdomen: Soft, NT, ND. BS present.
GU: No foley in place
Ext: Varicose veins in b/l lower extremities. 2+ pulses
without edema or clubbing.
Neuro: AAOx3. Abstraction and cognition intact. Able to spell
world backwards. No dysdiadokinesia or dysmetria. Gait is not
wide based or unsteady.
Skin: No rashes.
Pertinent Results:
ADMISSION LABS
___ 01:00PM cTropnT-<0.01
___ 08:09AM cTropnT-<0.01
___ 06:50AM URINE HOURS-RANDOM
___ 06:50AM URINE HOURS-RANDOM
___ 06:50AM URINE UHOLD-HOLD
___ 06:50AM URINE GR HOLD-HOLD
___ 06:50AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 02:00AM GLUCOSE-175* UREA N-21* CREAT-1.0 SODIUM-137
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16
___ 02:00AM estGFR-Using this
___ 02:00AM cTropnT-<0.01
___ 02:00AM WBC-5.2 RBC-4.67 HGB-14.2 HCT-42.3 MCV-91
MCH-30.4 MCHC-33.6 RDW-12.5 RDWSD-40.9
___ 02:00AM NEUTS-74.1* LYMPHS-17.1* MONOS-6.8 EOS-0.4*
BASOS-0.6 IM ___ AbsNeut-3.82 AbsLymp-0.88* AbsMono-0.35
AbsEos-0.02* AbsBaso-0.03
___ 02:00AM PLT COUNT-114*
___ 02:00AM ___ PTT-31.7 ___
DISCHARGE LAB
___ 06:35AM BLOOD WBC-5.5 RBC-5.01 Hgb-15.2 Hct-46.2 MCV-92
MCH-30.3 MCHC-32.9 RDW-12.5 RDWSD-42.1 Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-109* UreaN-19 Creat-0.9 Na-141
K-4.1 Cl-104 HCO3-25 AnGap-16
___ 06:35AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.1
IMAGING
___ CXR PA/LAT
1. Stable mild cardiomegaly.
2. No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
Start: ___, First Dose: Next Routine Administration Time
2. Simvastatin 10 mg PO QPM
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. Losartan Potassium 25 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Colchicine 0.6 mg PO BID
7. Finasteride 5 mg PO DAILY
8. Tamsulosin 0.4 mg PO DAILY
9. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Simvastatin 10 mg PO QPM
4. Colchicine 0.6 mg PO BID
5. Loratadine 10 mg PO DAILY
6. Losartan Potassium 25 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO DAILY
8. Tamsulosin 0.4 mg PO DAILY
9. Walker
ICD 10 M17.1
Dx: knee arthritis Px: worsening osteoarthritis Duration 13 mo
10. Outpatient Physical Therapy
ICD 10 M17.1
Dx: knee arthritis Px: worsening osteoarthritis Duration 13 mo
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Dizziness, chest pain
Secondary: BPH, T2DM, HTN
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 chest pain. Assess for acute cardiopulmonary process?
TECHNIQUE: Chest PA and lateral
COMPARISON: Outside chest radiograph ___, chest radiograph ___.
FINDINGS:
The lungs are mildly hypoinflated with crowding of vasculature. Mild
cardiomegaly is stable. Mediastinal contour and hila are normal. No focal
opacity. No pleural effusion or pneumothorax.
IMPRESSION:
1. Stable mild cardiomegaly.
2. No acute cardiopulmonary process.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: CP RESOLVED
Diagnosed with Other chest pain, Dizziness and giddiness, Essential (primary) hypertension, Pure hypercholesterolemia
temperature: 97.8
heartrate: 68.0
resprate: 15.0
o2sat: 100.0
sbp: 144.0
dbp: 61.0
level of pain: 0
level of acuity: 2.0 | Assessment and Plan: Mr. ___ is a ___ year old man with a PMH
significant for HTN and T2DM who presents with an episode of
dizziness and chest pain.
#Dizziness: Differential includes vertigo vs. cardiogenic vs.
disequilibrium vs. drug-induced vs. vasovagal. Cardiogenic
origins of dizziness such as aortic stenosis vs. atrial
fibrillation--> TIA should be considered given the patient's
history of palpitations and a fib exhibited on telemetry.
However, most likely, his dizziness is likely ___ to BPPH given
pt's dizziness with rapid head movements, although perhaps less
likely given lack of nystagmus. Central causes of vertigo were
less likely given brainstem associated symptoms, and peripheral
causes such as Meniere's disease are also somewhat unlikely
given that he has no tinnitus or hearing loss.
- Recommend vestibular physical therapy as an outpatient.
#Chest pain: The patient has had two previous ED visits for
dizziness/chest pain (___) and has always had normal
EKGs and negative trops, and had a normal stress test in ___. Worsening valvular function/aortic stenosis is possibly
given that the patient endorses pre-syncopal symptoms and chest
pain, however, he does and has not mentioned feeling any
dyspnea. We strongly suggest patient schedule an echocardiogram
as an outpatient to further assess his aortic valvular
dysfunction. GERD is also possible given that his sx improved
with ranitidine and Maalox.
- Recommend ECHO in the outpatient setting
#Atrial Fibrillation: Pt on metoprolol but had some episodes of
atrial fibrillation (rates in the ___ on telemetry
throughout hospitalization. Via chart biopsy, appears to have an
intermittent palpitation history but not diagnosed atrial
fibrillation. He has a CHADSVASC score of 3, which would
necessitate anticoagulation. We were not able to t/b with PCP,
and so did not want to start anticoagulation given uncertainty
about how to monitor INR in the outpatient setting. This has
been added to transitional issues and should be further
discussed by PCP with patient.
- Continued home metoprolol |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Plasmapheresis: ___
History of Present Illness:
Mr. ___ is a ___ male with a PMH of necrotizing
pancreatitis attributed to EtOH and hypertriglyceridemic
pancreatitis requiring pheresis in ___ (for ___ of ~7000),
anxiety, GERD, HLD, and other issues who presented to the ED
with abdominal pain. Reports he woke up and was feeling ok and
drank Gatorade and about 30 minutes later pain started. Pain is
in RUQ to epigastrum. Pain is 10 of 10. Reports pain is also up
into his right chest that feels similar to his GERD. Reports
pain feels worse with deep breathing. Denies fever, chills,
dysuria, diarrhea, constipation. Had one episode of emesis today
without blood and had a normal bowel movement around 1 pm. He
reports having a few fatty meals over the past few days, and
tells me that his PCP stopped his gemfibrozil a few months ago
due to neck/shoulder pain, and that his TGs were normal. He has
not recently started any new medications, confirms he has not
drank EtOH in over a year, and has never smoked.
In the ED, initial VS were 96.5 79 163/84 20 99% RA. Exam
notable for RUQ tenderness. Labs were notable for WBC 7.6 with
74% PMNs, Hgb 15.6, plts 210, AST/ALT 83/<5, Lipase 161, Tbili
0.4, AP 78. BUN/Cr ___ (baseline Cr 0.9), lytes otherwise WNL
with exception of K 5.9 after multiple hemolyzed specimens. Of
note, his blood was lipemic; triglycerides were pending at the
time of admission. Troponin was <0.01 x1, Lactate was 2.0 x2,
and HCO3 was 20 -> 24. EKG with L axis deviation but no evidence
of ischemia and no peaked T waves. CXR with no acute
cardiopulmonary process, RUQ US with no evidence of acute
cholecystitis, CT a/p with edematous appearance of pancreas w/
surrounding stranding and fluid. Blood cultures were collected,
he received a total of 3L IVF, Ondansetron 4 mg IV, Dilaudid 0.5
mg x3 + 1 mg x2, and was admitted. Vitals prior to transfer were
97.2 89 172/100 17 97% RA.
On arrival to the floor, the patient reported ongoing severe
abdominal pain but had no other complaints. Shortly after
arriving on the floor, ___ returned at ~4,000. In discussion with
GI, recommended transfer to ICU for initiation of insulin gtt.
In discussion with pheresis team, will plan for pheresis in AM
(via peripheral IVs) if triglycerides still markedly elevated.
ROS: A 10-point review of systems was performed and was
negative with the exception of those systems noted in the HPI
Past Medical History:
Hypertriglyceridemic pancreatitis requiring pheresis in ___
GERD
Hyperlipidemia
Psoriasis
TMJ
Viral Meningitis
Anxiety
Social History:
___
Family History:
No family history of pancreatitis
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
VITALS: 99.0 PO ___ 22 95 RA
GENERAL: Alert and in no mild 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, tachycardic, 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, hypoactive bowel sounds, tenderness to
palpation in the epigastrium.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Scattered erythematous plaques on back and LLE
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE PHYSICAL EXAM
VS: 98.3 127 / 83 97 18 97 Ra
Gen: well appearing, NAD
ENT: MMM, grossly nl OP
CV: RRR nl S1/S2 no g/r/m
Chest: decreased at bases, no w/r/r.
Abd: softly distended, hypoactive BS, TTP in LUQ/epigastrum.
Ext: WWP, no edema
Skin: No rashes
Pertinent Results:
===============
ADMISSION LABS
===============
___ 09:17AM BLOOD WBC-7.6 RBC-4.40* Hgb-15.6 Hct-42.4
MCV-96 MCH-35.5* MCHC-36.8 RDW-12.7 RDWSD-45.2 Plt ___
___ 09:17AM BLOOD Neuts-73.5* Lymphs-17.3* Monos-6.7
Eos-1.3 Baso-0.5 Im ___ AbsNeut-5.58 AbsLymp-1.31
AbsMono-0.51 AbsEos-0.10 AbsBaso-0.04
___ 09:17AM BLOOD Glucose-144* UreaN-11 Creat-0.9 Na-137
K-5.9* Cl-103 HCO3-20* AnGap-18
___ 09:17AM BLOOD ALT-<5 AST-83* AlkPhos-78 TotBili-0.4
___ 09:17AM BLOOD Lipase-161*
___ 03:10PM BLOOD cTropnT-<0.01
___ 09:17AM BLOOD Albumin-3.6 Globuln-4.5* Calcium-8.6
Phos-3.2 Mg-1.9
___ 03:10PM BLOOD Triglyc-4109*
===============
INTERVAL LABS
===============
___ 11:32PM BLOOD Triglyc-3110*
___ 05:09AM BLOOD Triglyc-2484*
___ 07:35PM BLOOD Triglyc-436*
___ 05:09AM BLOOD WBC-8.9 RBC-4.62 Hgb-15.7 Hct-43.9 MCV-95
MCH-34.0* MCHC-35.8 RDW-12.9 RDWSD-44.9 Plt ___
___ 02:03PM BLOOD WBC-7.7 RBC-4.52* Hgb-15.0 Hct-43.7
MCV-97 MCH-33.2* MCHC-34.3 RDW-12.9 RDWSD-46.5* Plt ___
___ 07:35PM BLOOD WBC-7.4 RBC-4.40* Hgb-14.6 Hct-43.0
MCV-98 MCH-33.2* MCHC-34.0 RDW-13.2 RDWSD-47.7* Plt Ct-PND
___ 03:10PM BLOOD Glucose-103* UreaN-10 Creat-0.8 Na-142
K-5.4 Cl-105 HCO3-24 AnGap-13
___ 05:09AM BLOOD Glucose-156* UreaN-7 Creat-0.8 Na-137
K-3.9 Cl-105 HCO3-20* AnGap-12
___ 02:03PM BLOOD Glucose-144* UreaN-5* Creat-0.8 Na-132*
K-3.6 Cl-106 HCO3-17* AnGap-9*
===============
MICRO/PATH
===============
___ BCx: Pending
___ UCx: Pending
===============
IMAGING/STUDIES
===============
___ RUQUS IMPRESSION: No evidence of acute cholecystitis.
___ CXR IMPRESSION: No acute cardiopulmonary process.
___ CT A/P W/ CONTRAST IMPRESSION:
Edematous appearance of the pancreas with surrounding stranding
and fluid. Areas of relative ___ at the uncinate
process, potentially due to associated edema in the setting of
interstitial edematous pancreatitis.
Please note that sensitivity for detection of necrotizing
pancreatitis is
somewhat limited in the first 72 hours after onset of symptoms.
___ CHEST PORT XRAY IMPRESSION:
Right internal jugular line terminates in the low right atrium.
Recommend
retracting approximately 5 cm if termination at the mid SVC is
desired.
===============
DISCHARGE LABS
===============
___ 06:20AM BLOOD WBC-7.9 RBC-3.25* Hgb-10.9* Hct-32.5*
MCV-100* MCH-33.5* MCHC-33.5 RDW-13.6 RDWSD-50.0* Plt ___
___ 06:40AM BLOOD Glucose-232* UreaN-7 Creat-1.0 Na-137
K-4.1 Cl-93* HCO3-26 AnGap-18
___ 06:40AM BLOOD ALT-19 AST-21 LD(LDH)-290* AlkPhos-67
TotBili-0.7
___ 06:40AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
___ 06:25AM BLOOD Triglyc-323*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
2. Gemfibrozil 600 mg PO BID
RX *gemfibrozil 600 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate
Limit use and do not drive while taking
RX *hydromorphone 2 mg ___ tablet(s) by mouth Q6H PRN Disp
#*8 Tablet Refills:*0
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pancreatitis
Hypertriglyceridemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with abd painchest pain// choelcystitis?pna?
TECHNIQUE: AP and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or edema. The
cardiomediastinal silhouette is within normal limits.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with abd painchest pain// choelcystitis?pna?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. There is no focal liver mass. The main portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 9.7 cm.
KIDNEYS: Limited views of the kidneys demonstrate no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
No evidence of acute cholecystitis.
Radiology Report
INDICATION: ___ with necrotizing pancreatitis here with abd painNO_PO
contrast// pseudocyst? 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 not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
2) Spiral Acquisition 6.4 s, 50.1 cm; CTDIvol = 13.0 mGy (Body) DLP = 649.1
mGy-cm.
Total DLP (Body) = 662 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are notable for atelectasis. There is no
pericardial or pleural effusion.. 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: Pancreas is diffusely abnormal. There is diffuse atrophy of the
pancreatic tail, in the region of previously seen necrotizing pancreatitis.
Pancreatic head and neck are edematous with significant perihilar pancreatic
stranding. Fluid seen adjacent to the duodenum. Enhancement of the pancreas
is slightly heterogeneous with areas of ___ at the uncinate
process (02:31).. The portal vein and splenic veins 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.
Contrast within a caliceal diverticulum noted at the upper pole of the left
kidney. There is no evidence of focal renal lesions or hydronephrosis. There
is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Caps there is significant
stranding surrounding the duodenum, most likely from adjacent pancreatitis.
Distally the duodenum and remaining small bowel are within normal limits.
Colon is unremarkable. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostatic calcifications are noted. Seminal vesicles 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:
Edematous appearance of the pancreas with surrounding stranding and fluid.
Areas of relative ___ at the uncinate process, potentially due to
associated edema in the setting of interstitial edematous pancreatitis.
Please note that sensitivity for detection of necrotizing pancreatitis is
somewhat limited in the first 72 hours after onset of symptoms.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with pancreatitis s/p RIJ central line
placement// Is central line in good position? thanks! Contact name: ___
team, ___: ___
COMPARISON: Chest radiograph ___, ___
FINDINGS:
Portable AP view of the chest provided.
New right internal jugular line appears to terminate within the low right
atrium. Lung volumes are low. There is mild bibasilar atelectasis. No large
pleural effusion or pneumothorax. Cardiomediastinal silhouette is unchanged.
IMPRESSION:
Right internal jugular line terminates in the low right atrium. Recommend
retracting approximately 5 cm if termination at the mid SVC is desired.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:33 pm, 20 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pancreatitis, has gotten large amounts of
fluid resuscitation// would like to eval volume status would like to eval
volume status
IMPRESSION:
Right internal jugular line tip is relatively low potentially in the right
atrium but is difficult to assess giving the very low lung volumes. There is
interval development of vascular congestion and mild interstitial edema.
Bibasal atelectasis and bilateral pleural effusions have progressed as well.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with pancreatitis, volume repletion, pleural
effusions and pulm edema// evla change in effusions
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___
IMPRESSION:
Compared to the prior study, the lungs are better expanded and the right IJ
central venous catheter has been removed. Heart size is normal.
Cardiomediastinal silhouette and hilar contours are preserved. Lungs are
clear. Pleural surfaces are clear without large effusion or pneumothorax. No
acute findings.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Abd pain, Chest pain
Diagnosed with Unspecified abdominal pain
temperature: 96.5
heartrate: 79.0
resprate: 20.0
o2sat: 99.0
sbp: 163.0
dbp: 84.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ is a ___ yo man with history of necrotizing
pancreatitis ___, due to EtOH) and recurrent pancreatitis
___, due to ___ in 7000s requiring pheresis), HLD, GERD, and
anxiety who presented p/w pancreatitis ___ hypertriglyceridemia
- and was transferred to MICU for trial of insulin gtt and
pheresis.
# Mild pancreatitis
# Hypertriglyceridemia
Meets Dx criteria by epigastric pain and abd CT findings; lipase
elevated to 161 though <3xULN. ___ to 4000s likely due to
dietary indiscretion and stopping fibrate. nl Ca. BISAP=0,
normal lactate, and hemodynamically stable, though
tachycardic--likely due to pain and hypovolemia. Started on
Insulin gtt while in the FICU, however TGs 4000s -> 3000s only.
As such, stopped the Insulin gtt and mIVF D5NS. A pheresis line
was placed and noted to be low - however the patient deferred
adjustment multiple times while in the FICU. He ultimately
received plasmapheresis on ___, with decreased triglycerides to
436. He was monitored closely on telemetry with no noted ectopy,
and ultimately his pheresis line was removed. His pain was
controlled with IV Dilaudid while NPO.
He resumed a clear diet gradually advanced to a low-fat diet
which he tolerated. He was called up to the medical ward where
he received ongoing medical care as he had continued sinus
tachycardia and low-grade fevers consistent with ongoing
inflammation related to acute pancreatitis. GI consulted in the
ICU and recommended referral to a cardiologist specializing in
lipid disorders as well as a GI physician specializing in
pancreatitis. The patient continued to receive oral opiate on
the medical ward and his diet was gradually increased. With
time, his tachycardia improved, he was able to tolerate a
regular diet without worsened pain and he was on minimal use of
oral pain meds (which had been gradually weaned). He had a bowel
movement prior to DC. His was discharged to home with intent to
follow up with PCP (and then GI) as well as cardiology ___
clinic for his hypertriglyceridemia. Gemfibrozil was continued
through discharged. Advised to follow a low fat diet and abstain
from alcohol.
# Mild hypoxia: This relates to atelectasis and small pleural
effusions and volume resuscitation early on in his hospital
course. He had brisk urine output following arrival to the
medical ward. He autodiuresed subsequently without need of
diuretics. Repeat CXR demonstrated resolution of pulmonary edema
and pleural effusions. He was on room air with easy work of
breathing and normal respiratory effort at discharge.
# Hypokalemia
# Hyperkalemia, resolved: Initial hyperkalemia of unclear
etiology, normal renal function--possible artifact of hemolyzed,
lipemic specimens. Became hypokalemic while on Insulin gtt.
Repleted KCl as needed.
# Fever: Most likely in the setting of ongoing pancreatitis and
his inflammatory response. BCx and UCx pending. Resolved prior
to DC
# GERD: PPI
TRANSITIONAL ISSUES
[] Refer to PCP->GI for pancreatitis education and management
[] started on gemfibrozil this hospitalization
[] Refer to cardiology for lipid disorder
[] Continue counseling on remaining sober from alcohol
[] Primary care follow-up |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fatigue, Weight Loss, Fall
Major Surgical or Invasive Procedure:
Liver biopsy ___
History of Present Illness:
___ male with history of diabetes, wheelchair dependent
as a result of alcohol-induced cerebellar ataxia, presenting
with
increasing weakness and frailty. Son states that he has been
increasingly weak for the last 3 days. Today fell to the floor.
No LOC, no head strike and was just sitting. Also complaining of
chest back pain. Patient denies any dysuria, abdominal pain, or
diarrhea. He has lost 17 lbs in the past month. They were told
it
may be from a UTI. Came to emergency department for evaluation.
Past Medical History:
Hospitalized ___ ___: Dysarthria/expressive
issues/imbalance: Referred to Neurology outpatient for further
evaluation
Cerebral/cerebellar atrophy
Pulmonary nodule ___ ___: One-year followup recommended
Diabetes Mellitus
Asthma
Microalbuminuria
EtOH recovery
Social History:
___
Family History:
+ diabetes
negative for stroke, seizure, balance or walking problems,
dysarthria, or any neurologic illness
Physical Exam:
ADMISSION EXAM
===============
VS: 99.6PO 127 / 84L Lying ___ RA
GENERAL: NAD, lying in bed, chronically ill appearing
HEENT: AT/NC, anicteric sclera, mildly dry oral mucosa
NECK: supple, 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: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no edema
NEURO: A&Ox3, moving all 4 extremities with purpose, cerebellar
intention tremor
SKIN: warm and well perfused, no rashes
DISCHARGE EXAM
===============
PHYSICAL EXAM:
Vitals: 100.3PO 114 / 73 99 20 96 ra
General: Sleepy, but arousable. Answers simple questions.
Eyes: Sclera anicteric
HEENT: MMM, oropharynx clear
Neck: supple, no LAD
Resp/Chest: Inspiratory crackles at the bases bilaterally
CV: tachycardic, regular rhythm, no murmurs, gallops, or rubs
GI: soft, non-distended, tender in epigastric region and LUQ
Extremities: warm, well perfused, no peripheral edema
Neuro: motor function grossly normal
Pertinent Results:
ADMISSION LABS:
======================
___ 11:24PM BLOOD WBC-12.9* RBC-3.83* Hgb-11.2* Hct-34.5*
MCV-90 MCH-29.2 MCHC-32.5 RDW-12.9 RDWSD-42.0 Plt ___
___ 11:24PM BLOOD Neuts-80.8* Lymphs-9.4* Monos-8.3
Eos-0.4* Baso-0.5 Im ___ AbsNeut-10.44* AbsLymp-1.22
AbsMono-1.07* AbsEos-0.05 AbsBaso-0.07
___ 11:24PM BLOOD ___ PTT-27.0 ___
___ 11:24PM BLOOD Glucose-394* UreaN-36* Creat-1.2 Na-135
K-5.8* Cl-93* HCO3-21* AnGap-21*
___ 11:24PM BLOOD ALT-148* AST-155* AlkPhos-687*
TotBili-1.1
___ 11:24PM BLOOD Albumin-3.7 Calcium-11.3* Phos-3.0 Mg-2.2
___ 01:38PM BLOOD PTH-8*
___ 11:47PM BLOOD Lactate-5.7*
___ 12:50PM BLOOD freeCa-1.21
REPORTS
=======================
___ RUQUS
1. Innumerable hepatic lesions, concerning for metastatic
disease.
2. No biliary duct dilatation.
___ Chest (Pa & Lat)
1. Small left pleural effusion.
2. Left posterior rib fractures are better evaluated on CT
performed on same day.
___ CT Torso W/O Contrast
1. Mildly displaced fractures of the left posterior seventh and
eighth ribs, with a small adjacent left pleural effusion. No
pneumothorax.
2. New 7.5 cm soft tissue mass in the body and tail of the
pancreas, with innumerable hepatic lesions, concerning for
metastatic disease.
3. A 5 mm perifissural nodule in the right lung may be new
compared with prior, possibly representing an intrapulmonary
lymph node, however metastatic disease cannot be excluded.
Additional tiny pulmonary nodules bilaterally do not appear
significantly changed.
___ CT Head W/O Contrast
No fracture or acute intracranial process.
___ CT C-Spine
Degenerative disease.
No evidence of fracture
___ CXR
IMPRESSION:
Comparison to ___. The lung volumes have decreased.
Borderline
size of the cardiac silhouette. Mild elongation of the
descending aorta.
Minimal atelectasis at the right lung basis. No evidence of
pneumonia,
pulmonary edema or pleural effusions.
___ ___
IMPRESSION:
1. Mass within the pancreatic body/tail suspicious for primary
pancreatic
adenocarcinoma.
2. Innumerable hepatic metastases with obstruction of the left
lateral
segmental intrahepatic biliary tree. No specific findings of
cholangitis.
3. Occluded or severely attenuated left portal vein with
multiple left upper
quadrant collateral vessels.
4. Multiple subcentimeter pancreatic cystic lesions are likely
small side
branch IPMNs.
___ MRI Head
1. No acute intracranial abnormality. No metastases.
2. Diffuse atrophy of the cerebellum and brainstem raise
suspicion for
olivopontocerebellar cerebellar degeneration. Some of the
findings can be
seen in the setting of long-standing paraneoplastic syndrome,
clinically
correlate.
3. Minimal white matter chronic small vessel ischemic disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
4. Ranitidine 150 mg PO BID
5. Pravastatin 20 mg PO QPM
6. Naproxen 500 mg PO Q12H
7. Cetirizine 10 mg PO DAILY
8. Citalopram 20 mg PO DAILY
9. GlipiZIDE XL 10 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth Twice daily
Disp #*28 Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD DAILY Rib pain
RX *lidocaine 5 % Daily Disp #*30 Patch Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth Every 8 hours Disp
#*42 Tablet Refills:*0
5. Morphine Sulfate (Oral Solution) 2 mg/mL 5 mg PO Q6H:PRN
Pain - Severe
RX *morphine 10 mg/5 mL 2.5 mL by mouth Every six hours
Refills:*0
6. Citalopram 20 mg PO DAILY
7. Naproxen 500 mg PO Q12H
8. Ranitidine 150 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Metastatic pancreatic adenocarcinoma
Secondary: Cholangitis, intrahepatic biliary duct obstruction,
pulmonary embolism, deep vein thrombosis.
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall, AMS, Bruising over left chest and T spine
tenderness// Fracture? Bleed? PNA?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 49.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head on ___, MRI head ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. Atrophy of
the cerebellum, middle cerebellar peduncles, brainstem, and pons is not
significantly changed. There is prominence of the ventricles and sulci
suggestive of involutional changes. Subcortical and periventricular white
matter hypodensities are nonspecific, however likely represent sequela of
chronic small vessel ischemic disease.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No fracture or acute intracranial process.
Radiology Report
EXAMINATION: CT torso without contrast
INDICATION: History: ___ with fall, AMS, Bruising over left chest and T spine
tenderness// Fracture?
TECHNIQUE: Contiguous axial images were obtained through the chest, abdomen
and pelvis without intravenous contrast. Coronal and sagittal reformats were
performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.5 s, 66.6 cm; CTDIvol = 20.3 mGy (Body) DLP =
1,350.9 mGy-cm.
Total DLP (Body) = 1,351 mGy-cm.
COMPARISON: CT chest on ___, CT torso on ___, CT lumbar
spine on ___
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury based on an unenhanced scan. The heart, pericardium,
and great vessels are within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: There is a small left pleural effusion. No pneumothorax.
LUNGS/AIRWAYS: Background heterogeneity to the lung parenchyma may reflect
hypoventilation or a component of small airway disease. A 5 mm right
perifissural appears new from prior, possibly representing an intrapulmonary
lymph node (2:58, 64, 66, 55, 73). Multiple additional scattered tiny nodules
measuring up to 3 mm do not appear significantly changed. The airways are
patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: There are innumerable hypodense lesions throughout the liver.
There is no perihepatic free fluid. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The uncinate process, head and neck of the pancreas are atrophic.
In the body and tail the pancreas, there is a large soft tissue mass spanning
7.5 x 3.5 x 3.2 cm (2:112, 601:46).
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration within the limitation of an unenhanced
scan.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber. The colon and rectum are within normal limits. The appendix
is normal. There is no evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged with calcifications.
LYMPH NODES: There are multiple small borderline peripancreatic lymph nodes.
There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic
or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild atherosclerotic disease is noted.
BONES: There are acute mildly displaced fractures of the posterior seventh and
eighth left ribs (3:58,66). Compression deformities at T12 and L1 are not
significantly changed. No focal suspicious osseous abnormality.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Mildly displaced fractures of the left posterior seventh and eighth ribs,
with a small adjacent left pleural effusion. No pneumothorax.
2. New 7.5 cm soft tissue mass in the body and tail of the pancreas, with
innumerable hepatic lesions, concerning for metastatic disease.
3. A 5 mm perifissural nodule in the right lung may be new compared with
prior, possibly representing an intrapulmonary lymph node, however metastatic
disease cannot be excluded. Additional tiny pulmonary nodules bilaterally do
not appear significantly changed.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with fall, AMS, Bruising over left chest and T spine
tenderness// Fracture? Bleed? PNA?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: CT chest on ___
FINDINGS:
Lung volumes are low without focal consolidation. There is a small left
pleural effusion. No pneumothorax is seen. The cardiac and mediastinal
silhouettes are unremarkable. Left posterior rib fractures are better
evaluated on CT performed on same day.
IMPRESSION:
1. Small left pleural effusion.
2. Left posterior rib fractures are better evaluated on CT performed on same
day.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with ruq pain c/f cholangitis// cbd dilation?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: There are innumerable hypoechoic lesions throughout the liver. The
main portal vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 10.6 cm.
KIDNEYS: The right kidney measures 9.6 cm. The left kidney measures 10.1 cm.
Prominence of the bilateral renal pelvises is unchanged. 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. Innumerable hepatic lesions, concerning for metastatic disease.
2. No biliary duct dilatation.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with fall and C spine tenderness// fx?
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.7 s, 22.5 cm; CTDIvol = 22.7 mGy (Body) DLP = 511.9
mGy-cm.
Total DLP (Body) = 512 mGy-cm.
COMPARISON: CT chest on ___
FINDINGS:
There is mild anterior subluxation of C3 on C4 5 and C5 on C6, both due to
degenerative disease. No fractures are identified.
There are multilevel degenerative changes in the cervical spin.
There are no significant abnormalities at C2-3.
At C3-4, there is a small midline disc bulge that does not contact the spinal
cord. There is mild bilateral neural foraminal narrowing due to facet and
uncovertebral osteophytes.
At C4-5, there is a minimal bulge of the disc with no encroachment on the
spinal canal. The neural foramina appear normal.
At C5-6, there is a tiny midline disc protrusion that just touches the
anterior surface of the spinal cord. Uncovertebral osteophytes mildly narrow
the right neural foramen.
At C6-7, C7-T1 and the included portions of the upper thoracic spine there are
no significant abnormalities.
Uncovertebral hypertrophy and facet arthropathy results in up to mild neural
foraminal narrowing, worst on the right at C5-C6. There is no prevertebral
edema.
The included lung apices are unremarkable. Diffuse enlargement of the thyroid
gland with left-sided calcification is unchanged
IMPRESSION:
Degenerative disease.
No evidence of fracture
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ yo M with T2DM, presenting with progressive weakness and
weight loss, with likely new diagnosis of metastatic pancreatic cancer. No
cough/URI symptoms clinically but new elevated temperature.// ?any evidence of
pneumonia ?any evidence of pneumonia
IMPRESSION:
Comparison to ___. The lung volumes have decreased. Borderline
size of the cardiac silhouette. Mild elongation of the descending aorta.
Minimal atelectasis at the right lung basis. No evidence of pneumonia,
pulmonary edema or pleural effusions.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with new pancreatic mass, most likely metastatic
pancreatic cancer with worsening LFTs and T bili with fever// eval for
cholangitis, ductal obstruction/dilatation
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: CT scan of the abdomen and pelvis dated ___.
FINDINGS:
Lower Thorax: Displaced fracture of the left posterior eighth rib is again
noted. There is a small left pleural effusion. Bibasal atelectasis.
Liver: There are innumerable T2 hyperintense lesions throughout the liver
parenchyma in keeping with hepatic metastases. The left portal vein is
occluded or severely attenuated (axial series 19, image 14), with multiple
left upper quadrant collateral vessels.
Biliary: The gallbladder is unremarkable. There is moderate intrahepatic
biliary ductal dilatation of the left lateral segmental hepatic ducts, likely
related to obstruction from metastatic tumor. The common bile duct is
prominent measuring up to 5 mm in diameter. There is no enhancement or wall
thickening of the biliary tree to suggest cholangitis.
Pancreas: There is a T2 hyperintense hypoenhancing mass centered within the
pancreatic body/tail measuring approximately 3.8 x 5.8 cm. Evaluation is
limited by non breath hold technique, however the mass abuts the splenic
vessels. The SMA, celiac trunk and SMV appear uninvolved by the tumor. There
is distal pancreatic atrophy and mild distal duct dilatation. 11 mm cystic
lesion in the pancreatic head, likely a side branch IMPN.
Spleen: The spleen is normal in size.
Adrenal Glands: The adrenal glands are normal in size and morphology.
Kidneys: Bilateral peripelvic cysts. No hydronephrosis.
Gastrointestinal Tract: The stomach is unremarkable. The small and large
bowel are normal in caliber.
Lymph Nodes: No retroperitoneal or mesenteric adenopathy.
Vasculature: The left portal vein is occluded or severely attenuated with
multiple left upper quadrant collateral vessels. The right portal vein is
patent. The celiac trunk and SMA are patent. No abdominal aortic aneurysm.
Osseous and Soft Tissue Structures: No suspicious osseous or soft tissue
lesion. Fracture of the left eighth rib posteriorly is again noted.
IMPRESSION:
1. Mass within the pancreatic body/tail suspicious for primary pancreatic
adenocarcinoma.
2. Innumerable hepatic metastases with obstruction of the left lateral
segmental intrahepatic biliary tree. No specific findings of cholangitis.
3. Occluded or severely attenuated left portal vein with multiple left upper
quadrant collateral vessels.
4. Multiple subcentimeter pancreatic cystic lesions are likely small side
branch IPMNs.
Radiology Report
EXAMINATION: ULTRASOUND GUIDED CORE NEEDLE BIOPSY
INDICATION: ___ year old man with suspected new pancreatic cancer, liver mets
on imaging// Biopsy of liver metastasis to confirm dx of suspected pancreatic
CA
COMPARISON: Abdominal ultrasound ___
PROCEDURE: Ultrasound-guided targeted liver biopsy.
OPERATORS: Dr. ___, radiology trainee and Dr. ___,
attending radiologist. Dr. ___ supervised the trainee
during the key components of the procedure and reviewed and agrees with the
trainee's findings.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the liver was
performed. Multiple hypoechoic hepatic lesions suspicious for metastases were
identified. The lesion for biopsy was identified in the right hepatic lobe,
and measured up to 1.6 x 1.3 cm. A suitable approach for targeted liver
biopsy was determined.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient and his healthcare proxy. After a detailed
discussion, informed written consent was obtained by the patient's healthcare
proxy. A pre-procedure timeout using three patient identifiers was performed
per ___ protocol.
Based on the preprocedure imaging, an appropriate skin entry site for the
biopsy was chosen. The site was marked. The skin was then prepped and draped
in the usual sterile fashion. The superficial soft tissues to the liver
capsule were anesthetized with ___ mL 1% lidocaine.
Under real-time ultrasound guidance, two 18-gauge core biopsy samples were
obtained from the right lobe lesion. The sample was placed in formalin and
submitted for pathology.
The skin was then cleaned and a dry sterile dressing was applied. There were
no immediate complications.
IMPRESSION:
Uncomplicated 18-gauge targeted liver biopsy x 2, with specimen sent to
pathology in formalin. No immediate complications.
Radiology Report
EXAMINATION: CTA chest with CT abdomen and pelvis with contrast
INDICATION: ___ year old man with likely metastatic pancreatic cancer now with
persistent tachycardia.// r/o PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast in the arterial
phase. Then, imaging was obtained through the abdomen and pelvis in the
portal venous phase. Reformatted coronal and sagittal images through the
chest, abdomen, and pelvis, and oblique maximal intensity projection images of
the chest were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.2 s, 29.7 cm; CTDIvol = 11.3 mGy (Body) DLP = 335.4
mGy-cm.
2) Spiral Acquisition 4.2 s, 55.2 cm; CTDIvol = 9.0 mGy (Body) DLP = 494.6
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
4) Stationary Acquisition 3.6 s, 0.5 cm; CTDIvol = 20.1 mGy (Body) DLP =
10.0 mGy-cm.
Total DLP (Body) = 842 mGy-cm.
COMPARISON: ___ torso CT
FINDINGS:
CHEST:
The thoracic aorta is normal caliber without evidence of aneurysm or
dissection-. The main, left, and right pulmonary arteries are patent. There
is partially occlusive filling defects in the subsegmental branches of the
pulmonary arteries at the bases bilaterally (series 302, images 138 146, 133).
There may be subsegmental thrombus in the subsegmental branches of the right
upper lobe (302:81) though evaluation is somewhat degraded by respiratory
motion artifact.
Heart size is normal. There is no definite evidence of right heart strain.
No pericardial effusion.
The airways are patent to subsegmental level. Evaluation of the lung
parenchyma is limited by respiratory motion artifact. Within this limitation
there is mild dependent atelectasis and small bilateral pleural effusions.
There is no evidence of large parenchymal consolidation or suspicious
pulmonary nodules.
There is no axillary, mediastinal, or hilar lymphadenopathy.
ABDOMEN:
There is a small amount of ascites.
HEPATOBILIARY: There are numerous hypodense lesions throughout the liver,
concerning for diffuse metastatic disease. There is no intra extrahepatic
biliary dilatation. Mild gallbladder edema is likely related to adjacent
liver disease. The second order branches of the left portal vein appear
effaced by the confluent metastatic disease.
PANCREAS: There is an ill-defined 5.5 cm x 3.4 cm mass in body and tail of the
pancreas (304:30). The splenic vein courses through the mass and appears
thrombosed at the portal confluence. The portal vein and superior mesenteric
vein are patent. The splenic artery is patent, but attenuated. 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. Bilateral
parapelvic renal cysts are noted. 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 no free
intraperitoneal fluid or free air.
PELVIS:
The urinary bladder and distal ureters are unremarkable. The small amount of
ascites in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: A borderline enlarged portocaval node measures 2.3 x 1.0 cm
(304:31). 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. The left common femoral vein is moderately
expanded and demonstrates central hypodensity with wall enhancement, likely
thrombosed (304:92). Thrombus may also be present in the right common femoral
vein with definitive assessment is difficult due to inappropriate timing (304:
84).
BONES AND SOFT TISSUES: Mildly displaced left-sided rib fractures involving
the sixth and seventh ribs are unchanged compared to the recent CT scan of ___. mild endplate compressions are noted at the T12 and L1 level,
unchanged, though may simply represent large Schmorl's node formation.
IMPRESSION:
1. Subsegmental nonocclusive pulmonary embolism in bilateral lung bases and
possibly right upper lobe. No imaging evidence of right heart strain.
2. Evaluation of the veins is limited due to timing of contrast however
expanded appearance of the left common femoral vein is concerning for deep
vein thrombosis. A hypodensity in the right common femoral vein is equivocal
for thrombosis.
3. Large hypodense mass in the body/tail of the pancreas resulting in
attenuation of the splenic artery and occlusion of the splenic vein.
4. Innumerable hepatic metastases.
5. Small volume ascites.
6. Mildly displaced left-sided rib fractures, unchanged from prior.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 8:28 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: US lower extremity for DVT
INDICATION: ___ year old man with multiple bilateral subsegmental PEs.// Lower
extremity DVT extent?
TECHNIQUE: Grayscale imaging and duplex US was performed of the bilateral
lower extremity veins.
COMPARISON: None
FINDINGS:
Normal and symmetric phasic flow was identified in the bilateral common
femoral veins.
On the right, there was normal compression in the common and mid thigh femoral
veins.
The distal external iliac vein was patent.
There was evidence of acute thrombus in the popliteal, posterior tibial, and
peroneal veins.
On the left, there was evidence of partial compression in the common femoral
vein.
The distal external iliac vein was patent.
There was evidence of acute thrombus in the deep and mid thigh femoral veins.
There was also evidence of acute thrombus in the popliteal, posterior tibial
and peroneal veins. The greater saphenous vein showed normal compression. It
was patent and was the only source of filling to the common femoral vein.
IMPRESSION:
Acute DVT in the right popliteal and tibial veins.
Extensive acute left leg DVT involving the deep femoral and femoral veins as
well as the popliteal, posterior tibial, and peroneal veins. The left GSV
remains patent and fills the CFV.
Radiology Report
INDICATION: ___ year old man with diffuse abdominal masses concerning for
metastatic cancer. Now with fever.// Acute cardiopulmonary process?
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. Cardiomediastinal silhouette
is stable. There is a small right pleural effusion. No pneumothorax is seen
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with metastatic pancreatic adenocarcinoma and
altered mental status/lethargy// evaluate for brain involvement of malignancy
or new ischemic event
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, . Sagittal MPRAGE imaging was performed
and re-formatted in axial and coronal orientations.
COMPARISON: MRI brain ___
FINDINGS:
The study is partially degraded due to motion artifact.
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. A subtle punctate apparent focus of enhancement within the
right superior frontal gyrus (100:88) is favored to represent motion artifact
as there is no corresponding FLAIR signal abnormality. There is otherwise no
evidence of abnormal enhancement after contrast administration.
There is diffuse atrophy of the cerebellum, including vermis and cerebellar
hemispheres, and brainstem with questionable abnormal FLAIR signal within the
pons. Findings are progressed since ___.
There are minimal subcortical, deep and periventricular white matter T2/FLAIR
hyperintensities are nonspecific but compatible with chronic small vessel
ischemic disease.
The major intracranial vascular flow voids are maintained. There is a
partially empty sella. The paranasal sinuses, mastoid air cells and orbits
are normal.
IMPRESSION:
1. No acute intracranial abnormality. No metastases.
2. Diffuse atrophy of the cerebellum and brainstem raise suspicion for
olivopontocerebellar cerebellar degeneration. Some of the findings can be
seen in the setting of long-standing paraneoplastic syndrome, clinically
correlate.
3. Minimal white matter chronic small vessel ischemic disease.
Gender: M
Race: HISPANIC/LATINO - SALVADORAN
Arrive by WALK IN
Chief complaint: Chest pain, s/p Fall, Upper back pain
Diagnosed with Weakness
temperature: 97.7
heartrate: 133.0
resprate: 16.0
o2sat: 100.0
sbp: 113.0
dbp: 64.0
level of pain: 7
level of acuity: 1.0 | ASSESSMENT AND PLAN: ___ yo M with T2DM not on insulin,
presenting with progressive weakness and weight loss, with new
diagnosis of pancreatic adenocarcinoma now with cholangitis that
cannot be intervened upon. Patient transitioned to CMO and
discharged home on hospice.
#Goals of care
Patient with metastatic pancreatic adenocarcinoma, there are no
options for treatment. Patient transitioned to CMO and will be
discharged home on hospice.
#Metastatic pancreatic adenocarcinoma
#Elevated transaminases
#Weight loss
S/p biopsy of metastatic site (liver) with pathology consistent
with adenocarcinoma. CEA and Ca ___ markedly elevated. Heme/onc
consulted, patient not a candidate for chemotherapy in setting
of cholangitis.
#Sepsis secondary to cholangitis
#L intrahepatic duct compression
Patient with fever to 102, leukocytosis, tachycardia and rising
bilirubin. Fevers may be secondary to multiple thrombi, tumor
fever or L intrahepatic duct compression ___ to tumor burden.
Not a candidate for ERCP given location of intrahepatic duct
compression. Initially on Ceftriaxone/Flagyl (___),
antibiotics broadened given sepsis to Vanc/Flagyl/Cefepime
(___). ___ unable to offer drainage of intrahepatic duct
given concern for seeding bacteria into additional ducts and
poor functional reserve of liver. Will discharge with
Cipro/Flagyl for ___an be discontinued at any time
if they are causing patient discomfort.
#Multiple subsegmental PEs
#Tachycardia
Patient with CTA chest on ___ with multiple subsegmental PEs,
splenic vein thrombus and L femoral vein thrombus. Likely
etiology of tachycardia. Trop <.01 and BNP 365,TTE with no e/o
RH strain. Anticoagulation with heparin gtt, transitioned to
lovenox BID. Discontinued prior to discharge.
#Occluded or severely attenuated left portal vein
Patient with occlusion of L portal vein on MRCP with multiple
left upper quadrant collateral vessels. Discussed with radiology
likely secondary to tumor burden not thrombus given no e/o vein
expansion or hypoattenuation.
#Rib fractures: Pain on the left side, with extensive bruising.
Reduced inspiratory capacity. Pain well controlled with Tylenol,
Ibuprofen, Lidocaine patch, Morphine Sulfate Liquid 5mg Q6prn.
#Hypercalcemia: Could be related to malignancy, or dehydration.
PTH is low so unlikely to be primary hyperparathyroidism. PTHrP
within normal limits. 25 Vit D is 22. S/p pamidronate on ___.
#Wt loss
#Aspiration risk
Patient disinterested in eating. Evaluated by speech and
swallow, patient at risk for aspiration, recommended NPO.
Discussed with family, it is within patient's GOC to continue
eating with accepted aspiration risk.
#Elevated INR:
#Anemia and thrombocytopenia
Likely secondary to malignancy/dilution. Likely liver
dysfunction in setting of extensive mets. S/p Vit K x 3 days
with no improvement.
#DM:
Initiated on Lantus 10u QHS. Discontinued at time of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tape ___ / Augmentin / Hydrocodone / Levofloxacin /
Ciprofloxacin / fentanyl / Keflex / ceftriaxone
Attending: ___.
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
According to the Emergency Department, ___ with history of
diabetes, hypertension, gastroparesis with multiple admissions
for nausea/vomiting here with nausea and vomiting. She began to
have nausea yesterday and then at about midnight tonight started
to have dark brown emesis. Denies fever, diarrhea. She did
receive zofran by EMS."
On arrival to the ED, initial vitals were ___ 20 99%.
The patient received 20mg IV hydralazine and her blood pressure
improved while she was sleeping. She also received 10 units of
insulin, along with two doses of Ativan, followed by a dose of
droperidol.
Currently, the patient is curled in bed on her side and does not
give long responses secondary to discomfort from her nausea. She
confirms narrative above. The patient said that since her last
discharge, she has had consistent nausea, but yesterday she
began to vomit and could not keep anything down. Ms. ___ has
occasional abdominal pain with vomiting but nothing steady. She
denies any recent changes to her diet or blood sugar control.
Ms. ___ says her morning sugars have been "normal." She says
her blood sugars are typically in the low 200s and 100s. She
eats her last meal at 5pm each day and has not had any changes
in his bowel habits. She has not been exposed to any sick or
vomiting contacts. Otherwise, she only endorses non-productive
cough.
Past Medical History:
-Type 1 DM c/b retinopathy ("quiescent" proliferative on last
eye exam, ___, nephropathy (nodular glomerulosclerosis on
renal bx ___ baseline Cr ~1.0-1.1 in ___, and
gastroparesis. Diagnosed at age ___, multiple hospitalizations
for DKA. HbA1c was 7.8 on ___.
-Barrett's esophagitis, GERD, gastritis, PUD (antral ulcer ___
-HLD
-HTN
-dCHF LVEF >60% in ___
-normocytic anemia
-acquired hemophilia (FVIII inhibitor in ___ treated
w/steroids and rituximab
-anti-E and warm autoantibody (negative Coombs)
-hydronephrosis
-osteoporosis ___ T-score L spine -2.2, femoral neck -3.1)
-migraines
-depression
-h/o avascular necrosis
-h/o severe hyperemesis gravidarum requiring TPN
-h/o PEA arrest during renal biopsy ___ (on fentanyl and
versed)
Social History:
___
Family History:
No h/o bleeding disorder. Kidney cancer and colitis in maternal
grandfather.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.5F, BP 165/86, HR 126, R 18, O2-sat 98% RA
GENERAL - NAD but uncomfortable, answers appropriately but
curtly
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple,
HEART - RRR, S1-S2, no murmurs auscultated
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs III-XII grossly intact, motor function
and sensation grossly intact
DISCHARGE PHYSICAL EXAM:
VS - Temp 98, BP 141/87, HR 110 (100s - 120s), R 16, O2-sat 100%
RA
___: ___ AM - ___ L - 169
___ D - 153
___ ___ - 198
GENERAL - Pleasant, ambulating, appears comfortable in NAD
HEENT - NC/AT, PERRL, sclerae anicteric, MMM, OP clear
NECK - supple
HEART - RRR, S1-S2, no murmurs auscultated
LUNGS - CTAB, no r/rh/wh, good air movement, respirations
unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, trace edema, 2+ peripheral pulses (radials,
DPs)
NEURO - awake, A&Ox3, CNs III-XII grossly intact, motor function
and sensation grossly intact
Pertinent Results:
IMAGING:
___ EKG
Sinus tachycardia. Delayed R wave progression in the precordium.
Q-T interval prolongation. Compared to the previous tracing of
___ there is no diagnostic interim change.
.
___ CXR
IMPRESSION:
Right lung base opacities, may represent atelectasis, aspiration
or infection in the appropriate clinical setting.
ADMISSION LABS:
___ 01:05AM BLOOD WBC-7.1 RBC-3.57* Hgb-11.0* Hct-34.8*
MCV-98 MCH-30.8 MCHC-31.6 RDW-16.4* Plt ___
___ 01:05AM BLOOD Glucose-174* UreaN-26* Creat-1.9* Na-142
K-5.2* Cl-103 HCO3-26 AnGap-18
___ 01:05AM BLOOD ALT-13 AST-31 AlkPhos-53 TotBili-0.2
___ 01:05AM BLOOD Lipase-12
___ 05:50AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.1
___ 01:05AM BLOOD Albumin-2.7*
___ 12:31PM URINE Color-Straw Appear-Hazy Sp ___
___ 12:31PM URINE Blood-TR Nitrite-NEG Protein-300
Glucose-300 Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 12:31PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-8
DISCHARGE LABS:
___ 05:15AM BLOOD WBC-7.2 RBC-2.99* Hgb-9.3* Hct-29.3*
MCV-98 MCH-31.0 MCHC-31.5 RDW-15.8* Plt ___
___ 05:50AM BLOOD WBC-7.7 RBC-3.15* Hgb-9.7* Hct-31.1*
MCV-99* MCH-30.9 MCHC-31.3 RDW-16.5* Plt ___
___ 05:15AM BLOOD Glucose-159* UreaN-21* Creat-2.0* Na-137
K-4.0 Cl-107 HCO3-20* AnGap-14
___ 05:50AM BLOOD Glucose-166* UreaN-21* Creat-1.8* Na-141
K-3.9 Cl-109* HCO3-24 AnGap-12
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 20 mg PO HS
2. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Gabapentin 800 mg PO HS
5. HydrALAzine 25 mg PO Q8H:PRN SBP > 160, DBP > 100
6. Glargine 12 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
7. Lorazepam 0.5 mg PO HS
8. Losartan Potassium 12.5 mg PO DAILY
Hold for SBP < 100.
9. Metoclopramide 10 mg PO TID
With meals
10. Omeprazole 40 mg PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Sertraline 100 mg PO DAILY
13. Torsemide 20 mg PO QHS
Discharge Medications:
1. Atorvastatin 20 mg PO HS
2. Gabapentin 800 mg PO HS
3. HydrALAzine 25 mg PO Q8H:PRN SBP > 160, DBP > 100
4. Glargine 12 Units Breakfast
5. Losartan Potassium 12.5 mg PO DAILY
Hold for SBP < 100.
6. Metoclopramide 10 mg PO TID
With meals
7. Sertraline 100 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Lorazepam 0.5 mg PO HS
10. Omeprazole 40 mg PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Torsemide 20 mg PO QHS
13. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
14. DimenhyDRINATE 50 mg PO Q6H:PRN nausea
RX *dimenhydrinate 50 mg 1 tablet(s) by mouth every 6 hours Disp
#*15 Tablet Refills:*0
15. Humalog
Humalog insulin sliding scale as per your home sliding scale
regimen.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Hypoxia and vomiting. Assess for aspiration.
COMPARISONS: ___.
FINDINGS:
Upright portable view of the chest demonstrates normal lung volumes. Right
lung base opacities are more conspicuous since prior. There is no focal
consolidation, pleural effusion or pneumothorax. Hilar and mediastinal
silhouettes are unremarkable. Heart size is normal. A round opacity
projecting over right lung seen on prior right hip radiographs earlier today
is not visualized, and it was likely external to the patient. There is no
pulmonary edema. Partially imaged upper abdomen is unremarkable.
IMPRESSION:
Right lung base opacities, may represent atelectasis, aspiration or infection
in the appropriate clinical setting.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: VOMITING AND/OR NAUSEA
Diagnosed with DIAB NEURO MANIF IDDM, GASTROPARESIS, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 96.4
heartrate: 102.0
resprate: 18.0
o2sat: 100.0
sbp: 211.0
dbp: 133.0
level of pain: 0
level of acuity: 2.0 | The patient is a ___ woman with a history of diabetes
mellitus, type I, complicated by retinopathy, nephropathy,
gastroparesis, and multiple episodes of DKA who presents after
one day of emesis and inability to take food or fluid by mouth.
# Nausea/vomiting: The patient has a long history of
gastroparesis, which is poorly controlled. She has recent
admissions to ___ for flares of her gastroparesis. The patient
has not been febrile and does not have a white count. With no
changes in bowel habits, gastroenteritis appears unlikely.
Patient denying significant, consistent pain and hematocrit
stable, so flare of gastritis or PUD also less likely.
Urinalysis not suggestive of infection, and urine hCG negative.
Her home Rgelan was continued for GI motility. Her antinausea
regimen included IV Zofran, with PO dimenhydrinate or compazine.
This regimen is based on GI recommendations from previous
admission. She was initially treated with lorazepam, but that
was stopped because patient appeared to be benzodiazepine
intoxicated. Her torsemide was held and IV fluids provided while
she was unable to take PO. On ___, the patient
began to feel substantially better. She was able to take regular
breakfast and lunch without nausea or vomiting. Given her
clinical improvement, she was discharged home with dramamine
added to her medications and follow up with her PCP.
# Diabetes mellitus, type I, complicated by retinopathy,
nephropathy, and gastroparesis. The patient reports adequate
blood glucose control at home with 12U glargine and sliding
scale insulin. She was initially on a half doses, given her lack
of PO intake, and ___ helped manage her blood sugars. Her
sugars were reasonably well controlled and she was discharged on
her home dose after she resumed eating.
# Hypertension: Patient was hypertensive on presentation, likely
due to vomiting. Blood pressure drops when not nauseated, though
she has had elevated pressures at rest since ___. She
required standing hydralazine for a time due to intermittent
high blood pressures. When her nausea and vomiting had ceased,
she returned to ___ and was discharged on her home
regimen.
# Hyperlipidemia: Continued home atorvastatin.
# Depression: Continued home sertraline.
# GERD: Continued home omeprazole. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ laparoscopic cholecystectomy
History of Present Illness:
___ year old female with history of congenital deafness and
___ myotomy
for achalasia who presents with recurrent symptomatic
cholelithiasis.
Briefly, Ms. ___ had ___ myotomy back in ___ ___. Since that time she has had intermittent mild
refluxive symptoms for which she takes omeprazole. In ___,
she developed acute epigastric pain for which she presented to
the ED at which time a CT scan identified cholelithiasis without
evidence of cholecystitis. She was discharged to home. Since
that
time she has not had any similar symptoms. This morning at 0730
she again developed acute epigastric pain which persisted
throughout the day associated with emesis. She has been having
normal BMs without blood. She has not been able to tolerate any
PO food intake but has been drinking water throughout the day.
She denies fevers and chills.
Past Medical History:
Congenital deafness
Depression
Achalasia
Meralgia paresthetica
Allergic rhinitis
Nephrolithiasis
Chronic abdominal pain
Social History:
___
Family History:
Denies
Physical Exam:
PHYSICAL EXAMINATION: ___: upon admission
Temp: 98.1 HR: 54 BP: 138/86 Resp: 18 O(2)Sat: 95 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: bradycardia, RR
Abdominal: Soft, Nondistended, mild RUQ tenderness
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: deaf, no focal weakness
Psych: Normal mood, Normal mentation
___: No petechiae
Physical examination upon discharge: ___:
GENERAL: NAD
CV: ns1, s2
LUNGS: clear
ABDOMEN: hypoactive, soft, tender, port sites with DSD
EXT: no calf tenderness bil., no pedal edema bil
NEURO: via Signs interpreter: alert and oriented x 3, no
tremors
Pertinent Results:
___ 07:50AM BLOOD WBC-4.4 RBC-4.59 Hgb-12.8 Hct-40.6 MCV-89
MCH-27.9 MCHC-31.5* RDW-11.9 RDWSD-38.5 Plt ___
___ 07:10AM BLOOD WBC-5.4 RBC-4.37 Hgb-12.3 Hct-39.1 MCV-90
MCH-28.1 MCHC-31.5* RDW-12.1 RDWSD-39.9 Plt ___
___ 03:00PM BLOOD WBC-11.9* RBC-4.89 Hgb-14.0 Hct-43.9
MCV-90 MCH-28.6 MCHC-31.9* RDW-11.9 RDWSD-39.1 Plt ___
___ 03:00PM BLOOD Neuts-87.6* Lymphs-5.5* Monos-5.7
Eos-0.3* Baso-0.3 Im ___ AbsNeut-10.42* AbsLymp-0.65*
AbsMono-0.68 AbsEos-0.04 AbsBaso-0.03
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-80 UreaN-9 Creat-0.9 Na-141 K-4.3
Cl-103 HCO3-29 AnGap-9*
___ 07:50AM BLOOD ALT-53* AST-26 AlkPhos-129* TotBili-0.4
___ 03:13PM BLOOD Glucose-112* Lactate-1.5 Creat-0.8 Na-140
K-4.0 Cl-105 calHCO3-26
___ 03:13PM BLOOD Hgb-14.9 calcHCT-45
___: Liver/gallbladder US:
Cholelithiasis without sonographic evidence for cholecystitis.
___ 5:24 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
omeprazole 40'
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. ibuprofen 400 mg oral Q6H:PRN
please take with food
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
do not drive while on this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*12 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
cholelithiasis
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) PORT
INDICATION: ___ with epigastric and RUQ abd pain// cholecystitis?
choledocholithiasis?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 5 mm
GALLBLADDER: There are stones and sludge in the gallbladder without wall
thickening or pericholecystic fluid.
PANCREAS: The head, body, and tail of the pancreas are within normal limits,
without masses or pancreatic ductal dilatation.
SPLEEN: Normal echogenicity.
Spleen length: 8.9 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 8.5 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Cholelithiasis without sonographic evidence for cholecystitis.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Unspecified abdominal pain
temperature: 98.1
heartrate: 54.0
resprate: 18.0
o2sat: 95.0
sbp: 138.0
dbp: 86.0
level of pain: 10
level of acuity: 3.0 | ___ year old deaf female who was admitted to the hospital with
acute epigastric pain and emesis. Upon admission, the patient
was made NPO, given intravenous fluids, and underwent imaging.
A cat scan of the abdomen showed gallstones. The patient
underwent serial abdominal examinations and monitoring of blood
work.
She was taken to the operating room on HD #3 where she underwent
a laparoscopic cholecystectomy. The operative course was stable
with minimal blood loss. The patient was extubated after the
procedure and monitored in the recovery room.
The post-operative course was stable. The patient was started
on a clear liquid diet and advanced to a regular diet. Her
vital signs were stable and she was afebrile. She was voiding
without difficulty. Her incisional pain was controlled with
oral analgesia. The patient was discharged home on POD #1.
Discharge instructions were reviewed with the assistance of a
Sign Interpreter. A follow-up appointment was made in the Acute
Care clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ with PMH HTN, COPD, b/l THR, with mechanical fall the
morning of ___ transferred from OSH with Right ___
femur fx. Patient reports she was walking to her car this
morning, turned and tripped and fell onto R hip. Was unable to
ambulate afterwards. No head strike, LOC, neck/back pain.
Taken to ___ where X-ray showed ___ femur
fx and was transferred for orthopedic evaluation. She also has
a L ___ ___. phalax fx. She reports no numbness/weakness,
saddle anesthesia.
Of note, she was hypoxic to mid-80% on RA in ED and was given
nebulizer treatments. She denies any CP/SOB. Uses nebulizers
as directed.
Past Medical History:
- Hypertension
- COPD
- Lumbar Spinal stenosis
- Hyperlipidemia
- Arthritis
- History of lumbar laminectomy (___)
- History of cataract surgery
- History of cholecystectomy
- History of b/l total hip replacement (R THR ___, L THR ___
by Dr. ___ at ___
- History of tonsillectomy
Social History:
___
Family History:
Noncontributory
Physical Exam:
ON ADMISSION:
In general, the patient is a well appearing elderly woman in NAD
Vitals: 98.2 84 121/62 18 95%
Left upper extremity:
Skin intact
Mild pain over proximal ___ digit. Good cap refill. Full AROM
in digits.
Full, painless AROM/PROM of shoulder, elbow, wrist
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Right lower extremity:
Skin intact
Pain, minimal swelling in R mid-thigh
Full, painless AROM/PROM of knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
ON DISCHARGE:
Elderly woman in NAD.
RLE:
Skin clean and intact
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Pertinent Results:
N/A
Medications on Admission:
- Atenolol 25 mg 1 p.o. daily
- Advair inhaler
- Albuterol inhaler
- Hydrochlorothiazide 12.5 mg 1 p.o. daily.
- One Ocuvite a day.
- Aspirin 81 mg a day.
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. PredniSONE 40 mg PO DAILY Duration: 5 Days
3. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
Do not drink alcohol or drive when taking oxycodone
4. Atenolol 25 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Aspirin 81 mg PO DAILY
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Azithromycin 250 mg PO Q24H
9. Heparin 5000 UNIT SC BID
10. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
11. Outpatient Physical Therapy
Please evaluate and treat.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Right periprosthetic proximal femur fracture
Discharge Condition:
Stable
Followup Instructions:
___
Radiology Report
PELVIS AND RIGHT FEMUR FILMS: ___.
HISTORY: ___ female with pain. Question fracture.
COMPARISON: Outside films performed at ___ from earlier the same day.
FINDINGS: AP view of the pelvis and frontal and cross-table lateral views of
the proximal and distal right femur. Bilateral total hip arthroplasties are
seen which appear anatomically aligned. There is a fracture identified
through proximal left femur just below the greater trochanter involving the
femoral prosthetic component. No other fracture is identified.
Atherosclerotic calcifications are noted. Distally, the right femur is
unremarkable. Degenerative changes are seen at the knee. No suprapatellar
joint effusion.
IMPRESSION: Bilateral total hip arthroplasties. Acute fracture through the
proximal left femur below the greater trochanter involving the femoral
prosthetic component.
Radiology Report
HISTORY: ___ female with hypoxia.
COMPARISON: None.
FINDINGS:
AP and lateral views of the chest. The lungs are hyperinflated. There is
diffuse interstitial abnormality noted with relative areas of lucency
superiorly and fibrotic changes in the mid lungs bilaterally. Bilateral
calcified granulomas are also identified. Increased interstitial markings are
seen at the bases. There is no confluent consolidation nor effusion. The
cardiomediastinal silhouette is within normal limits. Atherosclerotic
calcifications are noted at the aortic arch. No acute osseous abnormalities
detected.
IMPRESSION:
Findings are suggestive of COPD and previous granulomatous disease. No
definite confluent consolidation although given increased interstitial
opacities with lack of prior for comparison to document stability, acute
process would be difficult to completely exclude.
Radiology Report
CLINICAL HISTORY: Status post right periprosthetic proximal femur fracture,
now with weightbearing.
RIGHT FEMUR WITH WEIGHTBEARING:
Comparison is made with the nonweightbearing films of ___.
Best comparable is image 1 from ___. There appears to be a bit of
a step-off at the site of the fracture on the standing film when compared to
the nonweightbearing film. I am uncertain as to whether this is of
significance. The position of the prosthesis, however, is stable.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FALL, FEMUR FX
Diagnosed with INTERTROCHANTERIC FX-CL, FX MID/PRX PHAL, HAND-CL, JOINT REPLACEMENT-HIP, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, HYPERTENSION NOS
temperature: 98.2
heartrate: 84.0
resprate: 18.0
o2sat: 95.0
sbp: 121.0
dbp: 62.0
level of pain: sore
level of acuity: 2.0 | The patient presented to the emergency department following
transfer from OSH and was evaluated by the orthopedic surgery
team. The patient was found to have Right periprosthetic
proximal femur fracture and was admitted to the orthopedic
surgery service ___. Upon reviewing the x-rays with
attending staff the morning of ___, the fracture involved only
the greater trochanter and was only minimally displaced, so the
decision was made to have the patient perform a weight-bearing
trial with ___. This weight-bearing trial went well as the
patient was able to walk 80 feet per ___ verbal report.
Weightbearing films of the Right hip were obtained following
this weightbearing trial -- these films again showed only
minimal fracture displacement, so the patient will be trated
nonoperatively. The patient was given Heparin SQ BID for DVT
prophylaxis while an inpatient. She was treated for a COPD
exacerbation with nebulized albuteral-ipratropium and a 5 day
course of prednisone 40mg and azithromycin were initiated, to be
completed as an outpatient. The patients home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home with home ___ was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, and the patient was
voiding/moving bowels spontaneously. The patient is Touchdown
weightbearing in the Right lower extremity, and will be
discharged on Heparin SQ BID for DVT prophylaxis. The patient
will follow up in two weeks per routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / epinephrine
Attending: ___
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with history of hypothyroidism, GERD, HTN,
anemia, anxiety, depression, OA who presented to the ED on ___
with hx of one fall 3 weeks ago and another fall 3 days ago
accompanied by pain on her ribs. She was found to have R
posterior ___ rib fx. She was admitted to the ___ team for
observation and from a surgical perspective she is stable. As
per her husband she had neurologic changes with increase tremors
on her neck, anxiety, and memory changes since ___. She was
evaluated by neuropsychology at ___ in the end of ___ which was
thought to be related to "affective distress". Also found
relative weaknesses in aspects of executive functioning (visual
scanning, cognitive flexibility, phonemic and semantic fluency)
which may be affecting her cognitive and daily functioning.
Parkinsonian syndrome found very unlikely; gait unsteadiness
likely ___ the shoes she is wearing. As per patient's husband
she was on lorazepam and prozac which were stopped a few weeks
ago because it was making her dizzy.
.
Patient and her husband endorse a lifelong history of anxiety
going back as far as first grade, that has become markedly worse
since ___. Her anxiety is centered around her memory loss;
when she realizes that she has forgotten something like a date,
or a recipe (formerly a ___), she becomes extremely
anxious, dizzy and disoriented. She endorses increased
depression and tearfulness recently, particularly because she is
terrified that she has Alzheimer's Disease (reportedly has a
family member with AD). Per her husband, she has been waking up
about 4 times per night for the past few months and walking to
the bathrrom. Patient reports increased fatigue and grogginess
during the day; denies trouble falling asleep or early
awakening. On the night of her fall, she awoke in the middle of
the night and appeared to be in a "trance", per her husband. She
walked to her workroom supported by her husband, and fell
backward, striking her chest but not her head. She seem confused
and agitated; she lay down with her husband and got up 30 min
later confused. She did not know where she was. Patient does not
distinctly remember the fall when asked about it today. She
endorses "dizziness and disorientation" prior to the fall but
denies palpitations, chest pain, sense of room spinning,
positional dizziness. She endorses worsening gait ever since her
first fall; states she has been feeling extremely nervous about
falling again and holding onto furniture everywhere she goes to
avoid falling. Husband endorses changes in her gait: appears to
be more short-stepping. Handwriting has also become worse, not
smaller but more messy. She has also developed voice tremor and
hand tremor which becomes worse when her anxiety worsens. Denies
weakness/numbness, headache, vision changes. Denies loss of
bowel/bladder function. Does endorse chronic h/o tinnitus.
.
On the day after patient's fall, she had increased pain and came
to the ED. Her labs were WNL, her trop was neg x 3, TSH and B12
are pending. Her cxray showed moderate emphysema and no acute
cardiothoracic process. CT head showed no acute intracranial
process and age-related atrophic changes and chronic small
vessel ischemic disease.
.
Patient is being transferred to medicine for further evaluation
for waxing and wane mental status and gait abnormality. She is
HD stable and A+Ox3, but very forgetful. ACS will follow for
management of her rib fx- however nothing to do for now. Most
recent vitals: 96.4, 119/65, 16, 100% on RA.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Hypothyroidism
GERD
HTN
Anemia
Anxiety
Depression
Osteoarthritis
Social History:
___
Family History:
(per patient and neuropsych eval notes):
-Stroke and memory problems in her mother (died at ___ yo,
cognitive decline starting ___ years prior)
-Cardiovascular disease (father)
-___
-No movement disorders, other neurologic/psychiatric disorders
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 96.0 BP 136/65 P 65 RR 16
General: AAOx2 (to person, place [hospital, did not know which
once], and partly to time [to year and month, not date or day of
week]). Anxious appearing elderly F in NAD who is tremulous and
covers her mouth when she speaks.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII grossly intact. No nystagmus. Strength ___ in
___ upper and lower extremities. Gait is grossly normal, although
patient walks slowly and hesitantly and often reaches out to
hold onto walls when she walks. Negative Romberg sign. Normal
finger to nose testing.
.
DISCHARGE PHYSICAL EXAM:
Vitals: Tc 96.6 Tm 97.5 BP 136/65 [108-139/63-77] P 67 [67-74]
RR 18 SaO2 98% RA (97-100% RA)
General: Awake, alert, oriented to self, hospital, month and
year. Slightly anxious.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB
CV: RRR, Nl S1/S2, No MRG
Abdomen: Soft, ND/NT, Normoactive bowel sounds
Ext: WWP, 2+ pulses, no edema
Neuro: CN II-XII grossly intact. Moving all extremities. Gait
deferred.
Pertinent Results:
CT HEAD WITHOUT CONTRAST (___): There is no evidence of
hemorrhage, edema, mass effect, or territorial infarction. The
ventricles and sulci are prominent, consistent with age-related
atrophy. There are mild periventricular white matter
hypodensities, consistent with chronic small vessel ischemic
disease. Apparent hypodense area in the right occipital lobe
corresponds with prominent sulcus. The visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The osseous structures are intact. There are calcifications of
the cavernous carotids.
IMPRESSION:
1. No acute intracranial process.
2. Age-related atrophic changes and chronic small vessel
ischemic disease.
.
CT CHEST WITH CONTRAST (___): A small right pleural
effusion is seen. No pneumothorax is present. The effusion
layers dependently and appears simple. The great vessels are
grossly unremarkable. No evidence of pulmonary embolism in the
central or segmental arteries is seen. There is some
atelectasis/scarring in the right middle lobe. No endobronchial
lesion is identified. There is no pericardial effusion. No
lymphadenopathy is seen. Images of the upper abdomen
demonstrate a likely calcified granuloma within the spleen.
There is some thickening of the left adrenal gland. There are
acute fractures of the right posterior ninth, tenth, and
eleventh ribs. Fracture of the right posterior seventh and
eighth ribs appear remote.
IMPRESSION: Fractures of the right ninth, tenth, and eleventh
ribs with small
right simple pleural effusion.
.
CXR (___):
IMPRESSION: PA and lateral chest compared to ___:
Lung volumes have increased substantially, now hyperinflated
indicative of
emphysema. Heterogeneous opacity in the right lung projecting
over the third
anterior rib is no longer evident and could be resolving
contusion. With deep
inspiration, there is a suggestion of a 12 mm wide nodule at the
base of the
right lung, previously obscured by elevated hemidiaphragm. I
would repeat a
chest x-ray in four weeks with shallow obliques to see if this
is a real
finding. Heart size is top normal. There is no pulmonary
vascular
engorgement or edema.
.
CXR (___):
FINDINGS:
There is moderate hyperinflation of the lungs. The
cardiomediastinal
silhouette and hila are normal. There is no pleural effusion and
no
pneumothorax. There is no focal consolidation.
IMPRESSION:
1. Moderate emphysema.
2. No acute cardiothoracic process.
Medications on Admission:
(per neuropsych eval on ___:
Gabapentin (dose unavailable)
Fluoxetine 10mg qday (initiated ___, not taking for past
few weeks)
Amiloride 5mg qday
ASA 81mg qday
Multivitamin
Calcium citrate 500mg with vitamin D 250 IU and Magnesium 80mg
Loratidine 10mg
Fluticasone propionate 50mcg
Discharge Medications:
1. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
2. amiloride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. Calcium Citrate + D with Mag Oral
8. loratidine Sig: One (1) tablet once a day.
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Anxiety
2. Mild cognitive impairment
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: ___ woman with altered mental status, please evaluate for
pneumonia.
TECHNIQUE: Frontal and lateral radiographs of the chest were obtained.
COMPARISON: There are no comparison studies available.
FINDINGS:
There is moderate hyperinflation of the lungs. The cardiomediastinal
silhouette and hila are normal. There is no pleural effusion and no
pneumothorax. There is no focal consolidation.
IMPRESSION:
1. Moderate emphysema.
2. No acute cardiothoracic process.
Radiology Report
INDICATION: ___ woman with mental status changes, status post fall
two days ago. Please evaluate for acute intracranial pathology including
hemorrhage.
COMPARISONS: None.
TECHNIQUE: Contiguous axial imaging obtained through the brain without the
administration of intravenous contrast material. Coronal and sagittal
reformats were completed.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or
territorial infarction. The ventricles and sulci are prominent, consistent
with age-related atrophy. There are mild periventricular white matter
hypodensities, consistent with chronic small vessel ischemic disease.
Apparent hypodense area in the right occipital lobe corresponds with prominent
sulcus. The visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The osseous structures are intact. There are
calcifications of the cavernous carotids.
IMPRESSION:
1. No acute intracranial process.
2. Age-related atrophic changes and chronic small vessel ischemic disease.
Radiology Report
INDICATION: Fall.
TECHNIQUE: Multidetector helical CT scan of the chest was obtained before and
after the administration of 75 cc IV Optiray contrast. Coronal and sagittal
reformations were prepared.
COMPARISON: None available.
FINDINGS: A small right pleural effusion is seen. No pneumothorax is
present. The effusion layers dependently and appears simple. The great
vessels are grossly unremarkable. No evidence of pulmonary embolism in the
central or segmental arteries is seen. There is some atelectasis/scarring in
the right middle lobe. No endobronchial lesion is identified. There is no
pericardial effusion. No lymphadenopathy is seen.
Images of the upper abdomen demonstrate a likely calcified granuloma within
the spleen. There is some thickening of the left adrenal gland.
There are acute fractures of the right posterior ninth, tenth, and eleventh
ribs. Fracture of the right posterior seventh and eighth ribs appear remote.
IMPRESSION: Fractures of the right ninth, tenth, and eleventh ribs with small
right simple pleural effusion.
Radiology Report
PA AND LATERAL CHEST, ___
HISTORY: Trauma, possible right rib fracture and pulmonary contusions.
IMPRESSION: PA and lateral chest compared to ___:
Lung volumes have increased substantially, now hyperinflated indicative of
emphysema. Heterogeneous opacity in the right lung projecting over the third
anterior rib is no longer evident and could be resolving contusion. With deep
inspiration, there is a suggestion of a 12 mm wide nodule at the base of the
right lung, previously obscured by elevated hemidiaphragm. I would repeat a
chest x-ray in four weeks with shallow obliques to see if this is a real
finding. Heart size is top normal. There is no pulmonary vascular
engorgement or edema.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: ALTERED MENTAL STATUS
Diagnosed with ALTERED MENTAL STATUS , FRACTURE THREE RIBS-CLOS, UNSPECIFIED FALL
temperature: 97.8
heartrate: 68.0
resprate: 16.0
o2sat: 99.0
sbp: 140.0
dbp: 56.0
level of pain: 13
level of acuity: 3.0 | ___ yo F with h/o anxiety, depression and relative decline in
executive function presents s/p fall complaining of 7 months of
memory loss, severe anxiety and worsening balance.
.
# MEMORY LOSS, ATAXIA, ANXIETY, DEPRESSION: patient presents
with 7 months of mild memory loss, forgetting things like
recipes, dates, and names. ___ she forgets something, she
becomes extremely anxious and sometimes dizzy and disoriented.
She is convinced that she has Alzheimer's Disease and feels that
her situation is "hopeless". On neurologic exam, her gait is
grossly normal but she walks hesitantly and clings to the walls
- a classic presentation of psychogenic gait disorder, with
anxiety about falling again causing her symptoms. On prior
neurologic and neuropsychological testing, her deficits were
found to be secondary to affective distress with ___
extremely unlikely. Her head CT showed some chronic ischemic
small vessel disease normal age-related global atrophy, but no
significant concern for NPH. B12, folate, TSH WNL, RPR negative.
It seems most likely that patient does have some progressing
mild cognitive impairment, but that her anxiety about this
impairment is the main factor that has been making her have her
current issues. Her episodes of disorientation and dizziness
actually sound like small panic attacks on top of her chronic
anxiety. She has not been taking her fluoxetine for past few
weeks as felt that combination of fluoxetine and lorazepam were
increasing her dizziness, so SSRI withdrawal may have also
contributed to her worsening anxiety and disorientation. Her
gabapentin, which she allegedly takes for back pain related to
osteopenic spine degeneration, can also cause dizziness,
disorientation and fatigue - this too could be contributing.
Patient was initially restarted on fluoxetine however after
concern for dizziness was started on citalopram. This was
communicated with patients neuropsychologist Dr. ___.
This dose can be uptitrated as needed. Patient will require
further gait training while at rehab.
.
# RIB FRACTURES: pt found to have several rib fractures on
admission, and initially admitted to ACS. Transferred to
medicine service on HD #2 and ACS signed off. Pt was started on
standing tylenol and incentive spirometry and should continue
this while at rehab.
.
# HYPOTHYROIDISM: stable off medications.
.
# HYPERTENSION: continued amoliride.
.
# OSTEOPENIA/OSTEOPOROSIS: continued Calcium/D. Outpatient
providers may consider evaluation for starting bisphosphonates
if rib fx was pathologic.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
low grade fevers, hypoglycemia, and lethargy
Major Surgical or Invasive Procedure:
Exploratory laparotomy with small-bowel resection, and repair of
internal hernia
History of Present Illness:
___ with h/o renal and pancreas transplants admitted to ___
in setting of low grade fevers, hypoglycemia, and lethargy after
being transferred from ___ ED to our ED. Until ~24 hours
prior the patient had been in his usual state of health when he
was seen in ___ ED for hypoglycemia as well as an acute
elevation in his creatinine. At the time of exam the patient was
somewhat confused/lethargic and was intermittendly able to
answer
questions. He noted abdominal pain, nausea, normal bowel
movements. Persistent chills/rigors. He had no chest pain,
shortness of breath, dysuria/hesitancy or urgency
Past Medical History:
PMH: ___ s/p pancreas transplant and removal for graft loss,
PVD, CKD, gastroparesis, skin CA of R cheek, HL, OA, peripheral
neuropathy, carotid disease, CAD
PSH:
1)CABG x ___
2)Living related kidney transplant complicated by wound
exploration ___ (___)
4)Cadaveric pancreas transplant ___ (___)
5)L CEA ___ (___),
6)Right common femoral artery to above-knee
popliteal artery bypass graft with 8 mm ringed PTFE ___
7)Right second toe amputation ___
8)Cataracts ___
9)R wrist ___
10)Left common femoral artery to above-knee popliteal artery
bypass graft with 8-mm ringed PTFE ___
11)Repair of incisional hernia ___ (___)
12)L fem-AT bypass with PTFE graft ___ explant w duodenal resection for volvulus of
___ (___)
14)Vitrectomy ___
15)Right BKA ___
16)Redo common femoral artery to anterior tibial artery, bypass
with non-reversed right arm vein, Iliofemoral and profunda
endarterectomy and angioplasty, with right arm vein patch. ___ Redo left femoral-to-anterior tibial bypass with cadaveric
vein ___
Social History:
___
Family History:
noncontributory
Physical Exam:
VS: 98.0, 68, 128/66, 18, 100% RA
CV: RRR
Pulm: CTAB
Abd: soft, nontender, nondistended, inc c/d/i
___: R BKA, Left graft palpable, Left DP dopplerable
Pertinent Results:
___ Transplant US:
IMPRESSION:
Unremarkable transplanted kidney in the right lower quadrant
without
hydronephrosis or perinephric fluid collection. Patent renal
vasculature.
___ CT head:
IMPRESSION:
1. No evidence of acute intracranial process.
2. Prominent sulci and ventricles, likely age-related
involutional changes.
3. Small vessel ischemic disease.
___ ECHO:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The 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 leaflets are
structurally normal. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. No mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No pathologic valvular abnormalities. No
echocardiographic evidence of endocarditis.
Compared with the prior study (images reviewed) of ___,
the heart rare is now faster. Otherwise, the findings are
similar.
___ CT abd/pelvis:
IMPRESSION:
1. Portal venous gas is new since ___ exam.
Approximately 15 cm small
bowel segment in the right lower abdomen at the level of
jejunoileal junction,
demonstrates bowel wall thickening and fecalization. No
definite pneumatosis
is seen. The above findings are concerning for bowel ischemia.
2. Transplanted kidney in the right pelvis demonstrates no
hydronephrosis or
perinephric fluid collection. Atrophic native kidneys.
3. Extensive calcified atherosclerotic disease of the aorta and
its branches
without associated aneurysmal changes. Their patencies cannot
be assessed due
to lack of intravenous contrast.
4. Small bibasilar consolidations, which may represent
atelectasis,
aspiration or infection in the appropriate clinical setting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
hold for sbp<100
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Collagenase Ointment 1 Appl TP DAILY
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 1200 mg PO BID
9. Glargine 20 Units Breakfast
Glargine 20 Units Bedtime
10. Lisinopril 20 mg PO DAILY
hold for sbp<100
11. Metoprolol Tartrate 100 mg PO BID
hold for sbp<100 or hr<60
12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
hold for sedation
13. PredniSONE 5 mg PO DAILY
14. Ranitidine 150 mg PO BID
15. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
16. Prograf 3 mg PO Q12H
17. Warfarin 4 mg PO DAILY16
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
hold for sbp<100
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Glargine 20 Units Breakfast
Glargine 20 Units Bedtime
6. Metoprolol Tartrate 100 mg PO BID
hold for sbp<100 or hr<60
7. PredniSONE 5 mg PO DAILY
8. Ranitidine 150 mg PO BID
9. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
10. Warfarin 4 mg PO DAILY16
11. Acetaminophen 650 mg PO Q6H:PRN PAIN
12. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
14. Glucose Gel 15 g PO PRN hypoglycemia protocol
15. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
16. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth q3h Disp #*80
Tablet Refills:*0
17. Calcitriol 0.25 mcg PO DAILY
18. Collagenase Ointment 1 Appl TP DAILY
19. Docusate Sodium 100 mg PO BID
20. Gabapentin 1200 mg PO BID
21. Prograf 2 mg PO Q12H
Please give at 6am and 6pm. NEEDS TO BE BRAND NAME PROGRAF! NO
SUBSTITUTIONS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
internal hernia
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: Patient with history of renal transplant, now with worsening
renal function.
COMPARISONS: Ultrasound exam of ___ and CTA abdomen and pelvis of
___.
FINDINGS:
The transplanted kidney in the right lower quadrant is noted measuring 11.5
cm. There is no hydronephrosis, nephrolithiasis or renal masses.
Corticomedullary differentiation appears well preserved. No perinephric fluid
collection is seen.
COLOR FLOW AND DOPPLER ANALYSIS: Renal arteries are patent and demonstrate
appropriate waveforms with brisk systolic upstroke. Resistive indices range
between 0.73 to 0.8, unchanged. The main renal vein is patent.
IMPRESSION:
Unremarkable transplanted kidney in the right lower quadrant without
hydronephrosis or perinephric fluid collection. Patent renal vasculature.
Radiology Report
INDICATION: The patient with altered mental status.
COMPARISONS: Chest, ___.
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained
without intravenous contrast at 5-mm slice thickness. Coronally and
sagittally reformatted images are provided.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass effect or shift of
normally midline structures. There is no cerebral edema or loss of gray-white
matter differentiation to suggest an acute ischemic event. The sulci and
ventricles are prominent, likely age related involutional changes. Confluent
hypodensities in periventricular white matter distribution, likely reflects
sequela of small vessel ischemic disease. Focal hypodensity in the left
parietal lobe and cerebellar hemisphere is unchanged, is compatible with
remote infarct. There is no hydrocephalus. Basal cisterns are patent.
Extensive vascular calcifications are redemonstrated. Imaged paranasal
sinuses and mastoid air cells are well aerated. No acute fracture is seen.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Prominent sulci and ventricles, likely age-related involutional changes.
3. Small vessel ischemic disease.
Radiology Report
INDICATION: Altered mental status and abdominal pain.
COMPARISONS: ___.
TECHNIQUE: MDCT-acquired contiguous images through the abdomen and pelvis was
obtained without intravenous contrast at 5 mm slice thickness. Coronally and
sagittally reformatted images are provided.
FINDINGS:
CT OF THE ABDOMEN:
Imaged lung bases demonstrate small consolidations. The heart is normal in
size without pericardial effusion.
Evaluation of visceral organs is limited due to lack of intravenous contrast.
Within this limitation, the liver demonstrates portal venous gas,
predominantly in the left hepatic lobe. There is no intrahepatic biliary
ductal dilatation. No focal hepatic lesion is noted. The gallbladder is
slightly distended. There is no gallbladder wall edema or pericholecystic
fluid collection to suggest acute inflammation. No calcified gallstones are
seen within its lumen. The spleen is unremarkable. Punctate splenic
calcifications may reflect tiny granulomas. The pancreas appears atrophic.
The right adrenal gland is normal. The left adrenal gland is slightly
prominent without discrete nodular lesions. The native kidneys are atrophic,
unchanged. There is minimal perinephric fat stranding, which is nonspecific.
There is approximately 15 cm small bowel loop segment at the level of the
ileojejunal junction (601b:24, 2:52), which demonstrates bowel wall thickening
and fecalization. No definite pneumatosis is seen within this loop. There is
no free air. There is no evidence of small-bowel obstruction. The appendix
is visualized and is normal. There are numerous mesenteric lymph nodes, which
do not meet CT criteria for pathologic enlargement. There is no
retroperitoneal lymphadenopathy. Intra-abdominal aorta and its branches are
notable for extensive calcified atherosclerotic disease. The patency of these
vessels cannot be assessed due to lack of intravenous contrast.
Intra-abdominal aorta is normal in caliber without aneurysmal changes. There
is no free fluid within the abdomen.
CT OF THE PELVIS: The bladder is collapsed around a Foley catheter. The
transplanted kidney in the right pelvis is noted, which demonstrates no
hydronephrosis. No perinephric fluid collection is seen. No free air or free
fluid within the pelvis. The rectum and sigmoid colon are unremarkable.
There is no pelvic or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is seen.
IMPRESSION:
1. Portal venous gas is new since ___ exam. Approximately 15 cm small
bowel segment in the right lower abdomen at the level of jejunoileal junction,
demonstrates bowel wall thickening and fecalization. No definite pneumatosis
is seen. The above findings are concerning for bowel ischemia.
2. Transplanted kidney in the right pelvis demonstrates no hydronephrosis or
perinephric fluid collection. Atrophic native kidneys.
3. Extensive calcified atherosclerotic disease of the aorta and its branches
without associated aneurysmal changes. Their patencies cannot be assessed due
to lack of intravenous contrast.
4. Small bibasilar consolidations, which may represent atelectasis,
aspiration or infection in the appropriate clinical setting.
Radiology Report
INDICATION: ___ y/o M with recent CT demonstrating ischemia of the bowel, who
presents for evaluation of free air. Hx of abdominal pn.
COMPARISON: Chest radiograph from ___ performed at 2:54 am; CT
abdomen and pelvis from ___ and chest radiograph from ___.
TECHNIQUE: Single AP portable exam of the chest.
FINDINGS: The heart size is normal. The hilar and mediastinal contours are
stable. The mild bilateral pulmonary edema is stable compared to the prior
exam. There are no pleural effusions, or evidence of a pneumothorax. There
appears to be an interval increase in the left lower lobe atelectasis, however
no other new focal consolidations are seen. Again seen are post-surgical
changes related to the sternotomy wires and CABG.
IMPRESSION:
1. No evidence of subdiaphragmatic free air, however, this is not an upright
film and therefore has a lower sensitivity for abdominal free-air. If there is
further clinical concern, an upright or decubitus view of the abdomen would be
more sensitive.
2. Unchanged mild bilateral pulmonary edema.
Radiology Report
HISTORY: Central catheter.
FINDINGS: Since the earlier study of this date, there has been placement of a
right IJ catheter that extends to the mid portion of the SVC. Nasogastric
tube extends well into the stomach. Little change in the appearance of the
heart and lungs.
Radiology Report
HISTORY: Post-operative pulmonary edema with desaturation.
FINDINGS: In comparison with the study of ___, there is again enlargement of
the cardiac silhouette with pulmonary edema and atelectatic changes at the
bases. Monitoring and support devices remain in place.
Radiology Report
AP CHEST, 5:35 A.M., ___
IMPRESSION: AP chest compared to ___:
Previous pulmonary edema is clearing in the mid and upper lung zones. In the
lower lungs, there is greater opacification, probably due to a combination of
residual edema and atelectasis. Small bilateral pleural effusions are
present. Heart size is top normal, and mediastinal caliber shows slight
improvement in previous distention of mediastinal veins.
There is no pneumothorax. Right jugular line ends in the upper SVC. No
pneumothorax.
Radiology Report
INDICATION: ___ after renal transplant. Please assess for pulmonary
edema.
TECHNIQUE:
Single frontal radiograph of the chest was obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
The cardiomediastinal shilhouette and hila are normal. There is no edema,
bilateral atelectasis are unchanged. A right IJ line ends at the mid SVC.
IMPRESSION: No change from yesterday. No edema.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST.
REASON FOR EXAM: Status post renal transplant and failed pancreatic
transplant with low fever status post exploratory laparotomy.
Comparison is made with prior study performed a day earlier.
Cardiac size is top normal accentuated by the projection and low lung volumes.
Bibasilar atelectases have minimally improved. Right IJ catheter tip is at
the upper SVC. There is no pneumothorax or enlarging pleural effusion.
Sternal wires are aligned. The patient is status post CABG.
Radiology Report
INDICATION: Patient with rigors. Assess for pneumonia.
COMPARISONS: ___.
FINDINGS:
Semi-upright portable view of the chest demonstrates low lung volumes. There
was minimal blunting of the costophrenic angle suggestive of trace pleural
effusions. Hilar and mediastinal silhouettes are unchanged. Heart is mildly
enlarged. There is no pneumothorax. There is mild pulmonary edema, minimally
progressed since prior. Post-surgical changes related to the sternotomy wires
and CABG are again noted. Multiple surgical clips are again seen projecting
over right axilla. Partial imaged upper abdomen is unremarkable.
IMPRESSION:
Low lung volumes. Mild cardiomegaly and pulmonary edema and possible trace
pleural effusion, slightly increased since ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GENERAL WEAKNESS
Diagnosed with ALTERED MENTAL STATUS , ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 99.5
heartrate: 85.0
resprate: 16.0
o2sat: 97.0
sbp: 120.0
dbp: 43.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ presented on ___ with lethargy, hypoglycemia,
abdominal pain, and low-grade fevers. He underwent a CT head
which was negative. Transplant renal ultrasound also showed no
abnomralities of his kidney transplant. CT abd/pelvis showed new
portal venous gas, a 15cm small bowel segment with bowel wall
thickening and fecalization concerning for bowel ischemia. He
had some ST segment changes in ECG and troponins were negative.
An echo was obtained which showed no major abnormalities, EF
>55%. Cardiology was consulted and felt it was safe to proceed
with surgery.
He was taken to the OR and underwent an exploratory laparotomy
with small-bowel
resection on ___, and repair of internal hernia. He
tolerated the procedure well and was transferred to the SICU in
stable condition. His troponins post-op trended up, with the
highest being 1.09 on POD #2. Cardiology felt this was due to
demand ischemia, and the CK-MB was WNL and ECG was improved. He
had a temperature of 101.3 immediately post-op, but was afebrile
thereafter. On POD #1, he was transfused 1U PRBCs for a low Hct
and low UOP. He was also given 60IV lasix for fluid overload and
pulmonary edema. His CXR showed fluid overload and he desatted
to high ___. His pain was well-controlled on dilaudid PCA, his
IVFs were turned off. He was started on a heparin gtt as
anticoagulation for his lower extremity bypass. He self-d/c'ed
his NGT, and gabapentin was restarted. He was again transfused
1U of blood in the evening for Hct drop from 26.3 to 24.5. On
POD #2, He was transfused another unit for Hct 22.9, given 40IV
lasix. His Cr increased from 1.8 to 2.5, and gabapentin and
diuresis was discontinued. Renal felt Cr bump was due to a
combination of overdiuresis and high tacro level. CXR showed
significantly improved pulmonary edema. He was acting
suspicious/delirious in the AM, which resolved over the course
of the day. On POD #3, his heparin gtt was held for Hct 26.4->
22.1 early AM. He was transfused another unit of blood. IVF were
started at 50. Hct was stable during the day. Half of his lantus
dose was started due to high sugars. On POD #4, he started on
sips, HSQ, and transferred to the floor. His Hct remained
stable, his foley was removed and he had a bowel movement. On
POD #5 he was advanced to clears and put on PO pain meds and
home meds. Coumadin, aspirin, and plavix were started. On POD
#6, he was advanced to a regular diet, and restarted on his home
lantus regimen. On POD #7, he continued to do well, tolerating a
regular diet, INR on discharge was 1.8 after two doses of
coumadin, 4 (___) and 2 (___). He was given coumadin 4 right
before discharge on ___. His graft was palpable throughout
his hospital admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / sulfa / Advair HFA / Lovenox
Attending: ___.
Chief Complaint:
RUE swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o dCHF, Afib s/p ablation and PPM ___, AS
s/p ___, and CKD stage III, who presented to the ED
with acute onset R arm swelling.
She was recently admitted at ___ ___nd found
to have CHF exacerbation, rib fractures, and strep gallolyticus
bacteremia in multiple bottles. TEE showed 4x5-mm echodensity on
posterior mitral valve annulus. She had a PICC line placed in
the RUE ___ by ___ to receive 2g CTX daily until ___. She was
discharged from ___ to rehab on ___.
Per the patient, she was just discharged from rehab on ___,
___. However patient did appear confused about timeline of
her illness. She reports that, while at rehab, she was weighed
daily. Her weight was 128 pounds or 50 kg. She was given all
of her home medications while at rehab, with the exception of
the oxycodone, which was stopped because of dizziness. She
states that she has been short of breath for about a month,
worse with laughing and talking. She does not notice it gets
worse with position. Has not noticed any weight gain,
orthopnea. She has noticed a nonproductive, dry cough over the
last ___ days.
She presented ___ for sudden onset RUE swelling since the
morning on ___. She denies any pain or numbess/tingling in
her arm. She triggered for hypoxia in the ED, when her SpO2 was
83%. She denies any fever, chest pain, N&V, abdominal pain, or
other complaints. She also denies productive cough
In the ED, her oxygen saturation initially responded to nasal
cannula.
ED COURSE:
VITALS: 60 143/87 18 100% 4L NC
Exam:
No acute distress
RRR
Decreased breath sounds bilaterally, no wheezing or rhonchi
Right arm distal to PICC is swollen with bruising over her
dorsal right hand, weak radial pulse, able to move RUE with no
pain, compartments soft, capillary refill <2 seconds
Abdomen soft, nontender
No peripheral edema
LABS:
___: ___
Trop 0.05
Cr 1.3 (at baseline)
INR: 1.3
___
INR: 2.88
rehab
___
INR: 1.79
rehab
IMAGING:
CXR:
AP upright and lateral views of the chest provided. A right
upper extremity access PICC line is seen terminating in the low
SVC. Lung volumes are low. Extensive chest wall calcifications
again noted. Cardiomegaly is unchanged. An aortic core valve is
in place. Hila appear engorged. Mild pulmonary edema suspected.
Retrocardiac opacity could represent pneumonia in the correct
clinical setting and appears unchanged. No pneumothorax.
CTA:
1. No evidence of pulmonary embolism to the segmental level.
2. Stable marked cardiomegaly with severe left atrial
enlargement.
3. Moderate left and trace right pleural effusions with
associated
atelectasis.
4. Multiple chronic left-sided rib deformities.
RUE Ultrasound:
Evidence of a partially occlusive deep venous thrombosis within
the right basilic, right axillary, and right subclavian vein.
___ Consult:
Ms. ___ is a ___ female with Afib s/p ablation and AS s/p TAVR
with recent admission for falls found to have endocarditis with
possible vegetations and discharged on outpatient ceftriaxone
requiring right arm PICC which was found to have an adjacent
non-occlusive DVT and cause edema on this admission. Continue to
use the PICC line.
In the ED, the patient became more tachypneic, and had increased
work of breathing. Her gas showed increasing hypercarbia. She
was started on BiPAP, with improvement in symptoms. She was
admitted to the MICU given initiation of BiPAP.
On arrival to the MICU, patient verified the above story. She
reports that her breathing felt comfortable, and she asked to
get the BiPAP removed. A VBG was obtained, and was improved
with the BiPAP mask was removed.
Past Medical History:
CAD
Atrial Fibrillation on warfarin
S/p pacemaker
Heart failure with preserved ejection fraction
AS s/p ___
COPD
CKD, stage III, baseline creatinine 1.3
Crohn's disease
Breast cancer
Hypothyroidism
Osteoporosis
Osteoarthritis
Pancreatic pseudocyst/cyst
Colonic adenoma
Adrenal nodule
___ disease
Hypercholesterolemia
Strep gallolyticus bacteremia
Social History:
___
Family History:
Reviewed with patient, non-contributory to admission
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
GENERAL: Alert, oriented, no acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Very poor air movement, very faint crackles at the bases
bilaterally
CV: Regular rate and rhythm, loud S2
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, mild tenderness
to palpation on the left flank over the rib fracture
EXT: Mild tremor
SKIN: Mild bruising, chronic venous stasis changes in bilateral
feet, tenderness to palpation in the bilateral lower
extremities. Trace pitting edema
NEURO: Grossly moving all extremities
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Pleasant, lying in bed in no acute distress
HEENT: Atraumatic, normocephalic. Sclera anicteric, MMM,
oropharynx clear.
CARDIAC: JVP non-elevated. Regular rate and rhythm. Holosystolic
murmur heard best LLSB. Loud S2. no rubs, or gallops
LUNG: Poor air movement, decreased breath sounds and decreased
bronchial breath sounds throughout lung fields. No crackles on
exam; no end expiratory wheezes on exam. Improved from previous
days.
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, 1+ lower extremity edema while in bed.
RUE significant improvement in edema from days prior.
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented 3x, motor and sensory function grossly
intact
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 02:50PM BLOOD WBC-5.5 RBC-3.60* Hgb-11.4 Hct-38.1
MCV-106* MCH-31.7 MCHC-29.9* RDW-17.3* RDWSD-66.8* Plt ___
___ 02:50PM BLOOD Neuts-81.6* Lymphs-9.6* Monos-7.6
Eos-0.2* Baso-0.5 NRBC-0.4* Im ___ AbsNeut-4.48
AbsLymp-0.53* AbsMono-0.42 AbsEos-0.01* AbsBaso-0.03
___ 02:50PM BLOOD ___ PTT-25.0 ___
___ 02:50PM BLOOD Glucose-108* UreaN-26* Creat-1.3* Na-143
K-4.0 Cl-96 HCO3-29 AnGap-18
___ 08:28PM BLOOD ALT-9 AST-21 CK(CPK)-35 AlkPhos-82
TotBili-0.3
___ 02:50PM BLOOD Calcium-9.5 Phos-4.0 Mg-1.8
___ 02:53PM BLOOD ___ pO2-31* pCO2-66* pH-7.31*
calTCO2-35* Base XS-3
DISCHARGE LAB RESULTS
=====================
___ 04:30AM BLOOD WBC-7.2 RBC-2.77* Hgb-8.7* Hct-28.4*
MCV-103* MCH-31.4 MCHC-30.6* RDW-16.9* RDWSD-61.7* Plt ___
___ 04:30AM BLOOD Plt ___
___ 04:30AM BLOOD ___ PTT-27.1 ___
___ 04:30AM BLOOD Glucose-94 UreaN-32* Creat-1.2* Na-143
K-3.9 Cl-99 HCO3-32 AnGap-12
___ 04:30AM BLOOD Calcium-8.6 Phos-4.3 Mg-1.6
___ 03:05PM BLOOD VitB12-___* Folate->20
IMAGING
=======
___ Ultrasound:
Evidence of a partially occlusive deep venous thrombosis within
the right
basilic, right axillary, and right subclavian vein.
___ CTA:
1. No evidence of pulmonary embolism to the segmental level.
2. Stable marked cardiomegaly with severe left atrial
enlargement. Reflux of contrast into the IVC and hepatic veins
may be compatible with right heart failure.
3. Moderate left and trace right pleural effusions with
associated atelectasis.
4. Multiple chronic left-sided rib deformities.
___ CXR
AP upright and lateral views of the chest provided. A right
upper extremity access PICC line is seen terminating in the low
SVC. Lung volumes are low. Extensive chest wall calcifications
again noted. Cardiomegaly is unchanged. An aortic core valve is
in place. Hila appear engorged. Mild pulmonary edema
suspected. Retrocardiac opacity could represent pneumonia in
the correct clinical setting and appears unchanged. No
pneumothorax.
___ CXR
1. Left basilar atelectasis and small left pleural effusion that
is unchanged from the prior exam.
2. Chronic severe cardiomegaly with particular left atrial and
pulmonary
artery enlargement. No evidence of acute cardiac
decompensation.
___ CXR
Compared to chest radiographs ___ through ___. Left
lower lobe is still collapsed, moderate left pleural effusion
still present. Severe cardiomegaly unchanged. Small right
pleural effusion stable.
Right lung grossly clear. Heavy calcification in the chest wall
and probably pleural surfaces as well. Transvenous right atrial
right ventricular pacer leads in standard placements.
T AVR noted.
___ CXR
No significant interval change compared to study from earlier
today.
___ CXR
COMPARED TO CHEST RADIOGRAPHS ___ THROUGH ___. MILD
PERIHILAR EDEMA IS NEW, SEVERE CARDIOMEGALY AND LEFT LOWER LOBE
ATELECTASIS ARE CHRONIC. SMALL RIGHT PLEURAL EFFUSION STABLE.
TRANSVENOUS RIGHT ATRIAL AND RIGHT VENTRICULAR PACER LEADS
UNCHANGED. T AVR NOTED.
___ Video Oropharyngeal Swallow Study
1. Silent aspiration with thin liquids via cup and straw.
2. At least moderate esophageal dysmotility associated with
prominent
accumulation of ingested materials and delayed clearance.
___ CXR
Comparison to ___. No relevant change is noted.
Moderate
cardiomegaly persists. Stable appearance of the lung parenchyma
with mild to moderate pulmonary edema. No new parenchymal
lesions.
___ CT Chest w/o contrast
New diffuse ground-glass opacities since ___, more
prominent in the right lower lobe, with some coalescent
centrilobular nodules, suggestive of new inflammatory/infectious
process. Small bilateral pleural effusions are minimally smaller
than in ___. Right apex architectural distortion and
granulomas can be attributable to
scarring from prior radiation therapy or granulomatous disease.
Round borderline enlarged left axillary lymph node, new since ___. Ultrasound evaluation, if clinically indicated.
Stable appearance of severe cardiomegaly and widespread
atherosclerosis. Bilateral adrenal nodules the were not entirely
imaged in the previous studies. A dedicated CT study can help
better evaluate these nodules.
MICROBIOLOGY
============
___ Blood culture x2: NO GROWTH.
___ MRSA Screen: No MRSA isolated.
___ Legionella Urinary Antigen: Legionella Urinary Antigen
(Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ Urine Culture: NO GROWTH
___ C. difficile
C. difficile PCR (Final ___:
Reported to and read back by ___ ON ___ @
1628.
POSITIVE. (Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of
C. difficile and detects both C. difficile infection
(CDI) and
asymptomatic carriage. Therefore, positive C. diff PCR
tests
trigger reflex C. difficile toxin testing, which is
highly
specific for CDI.
C. difficile Toxin antigen assay (Final ___:
NEGATIVE. (Reference Range-Negative).
PERFORMED BY EIA.
This result indicates a low likelihood of C. difficile
infection
(CDI).
___ C. difficile
C. difficile PCR (Final ___:
Reported to and read back by ___ AT 2323
ON ___.
POSITIVE.
The C. difficile PCR is highly sensitive for toxigenic
strains of
C. difficile and detects both C. difficile infection
(CDI) and
asymptomatic carriage. Therefore, positive C. diff PCR
tests
trigger reflex C. difficile toxin testing, which is
highly
specific for CDI.
C. difficile Toxin antigen assay (Final ___:
POSITIVE. (Reference Range-Negative).
PERFORMED BY EIA.
This result indicates a high likelihood of C. difficile
infection
(CDI).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO TID
3. Clopidogrel 75 mg PO DAILY
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Mesalamine ___ 800 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Torsemide 100 mg PO QAM
11. Torsemide 80 mg PO QPM
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
13. Docusate Sodium 200 mg PO DAILY
14. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB
15. Lactulose ___ mL PO QHS
16. Vitamin D 1000 UNIT PO DAILY
17. ___ MD to order daily dose PO DAILY16
18. Acetaminophen 1000 mg PO Q8H
19. Bisacodyl 10 mg PO/PR DAILY
20. Bisacodyl ___AILY:PRN Constipation - First Line
21. CefTRIAXone 2 gm IV Q 24H
22. Lidocaine 5% Patch 1 PTCH TD QAM
23. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
24. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
25. Senna 8.6 mg PO DAILY
26. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indigestion or upset stomach
27. Fleet Enema (Mineral Oil) ___AILY:PRN Constipation
28. ___ (guaiFENesin) 100 mg/5 mL oral Q4H:PRN
29. melatonin 5 mg oral QHS
30. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
31. TraMADol 50 mg PO Q6H:PRN BREAKTHROUGH PAIN
Discharge Medications:
1. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth Twice Daily
Disp #*60 Tablet Refills:*0
2. GuaiFENesin ER 1200 mg PO Q12H
RX *guaifenesin 1,200 mg 1 tablet(s) by mouth Every 12 Hours
Disp #*30 Tablet Refills:*0
3. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 capsule(s) by mouth Daily Disp
#*30 Capsule Refills:*0
RX *multivitamin,tx-minerals 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
5. Vancomycin Oral Liquid ___ mg PO QID Duration: 2 Days
Stop on ___
RX *vancomycin [Firvanq] 25 mg/mL 5 mL by mouth Four Times Daily
Refills:*0
6. Acetaminophen 1000 mg PO Q8H
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
8. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indigestion or upset stomach
9. Atorvastatin 10 mg PO DAILY
10. Bisacodyl ___AILY:PRN Constipation - First Line
11. Carbidopa-Levodopa (___) 1 TAB PO TID
12. Clopidogrel 75 mg PO DAILY
13. Diltiazem Extended-Release 120 mg PO DAILY
14. Fleet Enema (Mineral Oil) ___AILY:PRN Constipation
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB
17. Levothyroxine Sodium 50 mcg PO DAILY
18. Lidocaine 5% Patch 1 PTCH TD QAM
19. melatonin 5 mg oral QHS
20. Mesalamine ___ 800 mg PO BID
21. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
22. Pantoprazole 40 mg PO Q12H
23. Torsemide 100 mg PO QAM
24. Torsemide 80 mg PO QPM
25. TraMADol 50 mg PO Q6H:PRN BREAKTHROUGH PAIN
26. Vitamin D 1000 UNIT PO DAILY
27. HELD- Bisacodyl 10 mg PO/PR DAILY This medication was held.
Do not restart Bisacodyl until diarrhea has fully resolved.
28. HELD- Docusate Sodium 200 mg PO DAILY This medication was
held. Do not restart Docusate Sodium until diarrhea has fully
resolved.
29. HELD- ___ (guaiFENesin) 100 mg/5 mL oral Q4H:PRN
This medication was held. Do not restart ___ until you
see your PCP.
30. HELD- Lactulose ___ mL PO QHS This medication was held.
Do not restart Lactulose until diarrhea has fully resolved.
31. HELD- Polyethylene Glycol 17 g PO DAILY:PRN Constipation -
First Line This medication was held. Do not restart
Polyethylene Glycol until diarrhea has fully resolved.
32. HELD- Senna 8.6 mg PO DAILY This medication was held. Do
not restart Senna until diarrhea has fully resolved.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
___
#ACUTE HYPERCARBIC RESPIRATORY FAILURE
#ACUTE ON CHRONIC DIASTOLIC HEART FAILURE EXACERBATION
#COPD
#ELEVATED WBC
#DIARRHEA
#ESOPHAGEAL DYSMOTILITY
#METABOLIC ALKALOSIS
#PICC ASSOCIATED RUE DVT
#ATRIAL FIBRILLATION
SECONDARY DIAGNOSES
===================
#CKD
#AORTIC STENOSIS
#HYPERLIPIDEMIA
#HYPOTHYROIDISM
#CROHN'S DISEASE C/B PAST GIB
___ DISEASE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP upright AND LAT)
INDICATION: ___ with RUE swelling after PICC Placement
COMPARISON: ___ and ___
FINDINGS:
AP upright and lateral views of the chest provided. A right upper extremity
access PICC line is seen terminating in the low SVC. Lung volumes are low.
Extensive chest wall calcifications again noted. Cardiomegaly is unchanged.
An aortic core valve is in place. Hila appear engorged. Mild pulmonary edema
suspected. Retrocardiac opacity could represent pneumonia in the correct
clinical setting and appears unchanged. No pneumothorax.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ with PICC line placed, swollen R arm. Evaluate for RUE DVT.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is mild flow within the right subclavian vein. The right internal
jugular vein is patent and demonstrates normal color flow and compressibility.
The right axillary vein demonstrates mild flow but minimal compressibility. A
PICC line is demonstrated within the right basilic and axillary vein. There
is mild flow with minimal compressibility within the basilic vein. The
brachial and cephalic veins are compressible and show normal color flow.
IMPRESSION:
Evidence of a partially occlusive deep venous thrombosis within the right
basilic, right axillary, and right subclavian vein.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with SOB, cough, wheezing// ? acute process
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___, earlier today, at 16:24
FINDINGS:
Right-sided PICC is again seen, terminating in the low SVC, without evidence
of pneumothorax. Left-sided pacer device is stable in position. Patient is
again status post aortic valve repair. Cardiac and mediastinal silhouettes
are grossly stable. Evidence of calcified plaques project over the chest,
particularly on the right. Retrocardiac opacity persists. Central pulmonary
vascular engorgement is again seen.
Radiopaque material projects over the soft tissue lateral to the right mid to
lower chest. Re-demonstrated deformity of the mid right clavicle with
evidence of possible periosteal reaction.
Radiology Report
EXAMINATION: Chest CTA.
INDICATION: ___ with UE DVT, SOB. Evaluate for PE.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 27.3 mGy (Body) DLP =
13.7 mGy-cm.
3) Spiral Acquisition 3.7 s, 28.8 cm; CTDIvol = 13.7 mGy (Body) DLP = 393.5
mGy-cm.
Total DLP (Body) = 409 mGy-cm.
COMPARISON: Chest x-ray ___. CT torso ___.
FINDINGS:
Thoracic aorta is normal in course and caliber. Moderate to severe
atherosclerotic calcifications of the great vessels, aortic arch, and thoracic
aorta. An aortic valve replacement is again seen. The heart is markedly
enlarged, with significant left atrial enlargement again seen. Pacemaker
leads extend into the right atrium and right ventricle. Reflux of contrast
into the IVC and hepatic veins may be compatible with right heart failure.
The pulmonary arteries are well opacified to the segmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main pulmonary artery measures 3.6 cm,
similar to prior.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
Streak artifact limits evaluation of the thyroid gland.
There is no evidence of pericardial effusion. Moderate left and trace right
pleural effusions with associated atelectasis.
Probable right apical scarring. Upper lobe predominant emphysema is again
seen. The airways are patent to the subsegmental level.
A left chest wall implanted device is again seen.
Limited images of the upper abdomen are unremarkable.
A deformity of the right mid clavicle appears stable. Deformities of the left
fifth and sixth posterior ribs appear chronic. Deformities of the left
posterior seventh through tenth ribs are stable from prior. Multilevel
degenerative changes of the cervical and thoracic spine. No lytic or blastic
osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. No evidence of pulmonary embolism to the segmental level.
2. Stable marked cardiomegaly with severe left atrial enlargement. Reflux of
contrast into the IVC and hepatic veins may be compatible with right heart
failure.
3. Moderate left and trace right pleural effusions with associated
atelectasis.
4. Multiple chronic left-sided rib deformities.
Radiology Report
EXAMINATION: Portable AP chest
INDICATION: ___ year old woman with decompensated HF, AF, AS s/p TAVR, COPD,
rib fractures// Evaluate for pulmonary edema or other acute pulmonary disease,
interval change from ___
TECHNIQUE: Portable AP chest
COMPARISON: Portable AP chest ___
FINDINGS:
In comparison to the previous film, right-sided PICC line is again seen
terminating in the lower SVC. Left-sided pacer device is in stable in correct
position, with leads terminating in the right atrium and right ventricle.
There is no pulmonary edema. There is left basilar atelectasis and a small
left basilar pleural effusion that is unchanged from the prior exam. There
are no new focal opacifications. Multifocal calcifications are again noted,
which are better demonstrated on the CT scan from ___. There is
lordotic positioning of the patient resulting in a more prominent left
mediastinum. Cardiomediastinal silhouette is stable. There continues to be a
chronic enlargement of the left atrium. There is no pneumothorax. There is
abnormal mineralization of the right clavicle.
IMPRESSION:
1. Left basilar atelectasis and small left pleural effusion that is unchanged
from the prior exam.
2. Chronic severe cardiomegaly with particular left atrial and pulmonary
artery enlargement. No evidence of acute cardiac decompensation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ___ yo F w/HF, AFib, AS s/p TAVR, CKDIII
currently w/SOB, hypoxia, increased upper airway secretions// Evaluate for
interval change from ___, evidence of volume overload or pneumonia
Evaluate for interval change from ___, evidence of volume overload or
pneumonia
IMPRESSION:
Compared to chest radiographs ___ through ___.
Left lower lobe is still collapsed, moderate left pleural effusion still
present. Severe cardiomegaly unchanged. Small right pleural effusion stable.
Right lung grossly clear. Heavy calcification in the chest wall and probably
pleural surfaces as well.
Transvenous right atrial right ventricular pacer leads in standard placements.
T AVR noted.
Radiology Report
EXAMINATION: CR - CHEST ONE FILM ONLY
INDICATION: ___ year old woman with HFpEF, COPD, worsening hypoxia// Evaluate
for interval change from prior film on ___, evidence of aspiration, pneumonia,
volume overload
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph dated ___ at 12:56
FINDINGS:
Indwelling right PIC line ends at or just beyond the estimated location of the
superior cavoatrial junction. There is a left chest wall cardiac pacing
device with leads terminating in the region of the right atrium and right
ventricle. Postsurgical changes from TAVR are noted.
There has been no significant interval change compared to the study from
earlier today, including the retrocardiac opacity, moderate left pleural
effusion, small right pleural effusion, cardiomegaly, pulmonary vascular
congestion, and mild interstitial edema.
IMPRESSION:
No significant interval change compared to study from earlier today.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with h/o dCHF, Afib s/p ablation and PPM
___, AS s/p ___, and CKD stage III, who presented to the
ED with acute onset R arm swelling, admitted to the MICU for acute hypercarbic
respiratory failure requiring BiPAP, now transferred to the floor with SOB on
2L NC for further management.// consolidation, pulm edema consolidation, pulm
edema
IMPRESSION:
COMPARED TO CHEST RADIOGRAPHS ___ ONE THROUGH ___.
MILD PERIHILAR EDEMA IS NEW, SEVERE CARDIOMEGALY AND LEFT LOWER LOBE
ATELECTASIS ARE CHRONIC. SMALL RIGHT PLEURAL EFFUSION STABLE.
TRANSVENOUS RIGHT ATRIAL AND RIGHT VENTRICULAR PACER LEADS UNCHANGED. T AVR
NOTED.
Radiology Report
EXAMINATION: VIDEO SWALLOW
INDICATION: ___ year old woman with HFpEF, COPD, rib fractures, now w/ongoing
O2 requirement and c/f aspiration// Evaluate for aspiration
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: 06:54 min.
COMPARISON: None
FINDINGS:
There was silent aspiration with thin liquids via cup and straw. Penetration
was seen with nectar consistency with stroke.
There was prominent accumulation of ingested materials in the esophagus, which
was associated with delayed clearance and retrograde migration of contents and
extensive tertiary contractions.
IMPRESSION:
1. Silent aspiration with thin liquids via cup and straw.
2. At least moderate esophageal dysmotility associated with prominent
accumulation of ingested materials and delayed clearance.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: Mrs. ___ is an ___ with h/o dCHF, Afib s/p ablation and
PPM ___, AS s/p ___, and CKD stage III, who presented to
the ED with acute onset R arm swelling, admitted to the MICU for acute
hypercarbic respiratory failure requiring BiPAP, transferred to the floor with
SOB for further management, now with supplemental O2 requirement and
undergoing active diuresis.// Looking for volume status change since previous
CXR. Looking for volume status change since previous CXR.
IMPRESSION:
Comparison to ___. No relevant change is noted. Moderate
cardiomegaly persists. Stable appearance of the lung parenchyma with mild to
moderate pulmonary edema. No new parenchymal lesions.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman w/ dCHF, Afib s/p ablation and PPM
___, AS s/p ___, CKD stage III, and COPD, who was
admitted w/ R arm DVT and volume overload c/b hypercarbic respiratory failure,
undergoing active diuresis now euvolemic with supplemental O2 requirement.//
Euvolemic w/ O2 requirement. ?infection vs. aspiration vs. ILD vs. COPD
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 2.1 s, 32.7 cm; CTDIvol = 11.7 mGy (Body) DLP = 381.9
mGy-cm.
Total DLP (Body) = 382 mGy-cm.
COMPARISON: Prior chest CTs, most recently ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: There are no thyroid lesions that
warrant further imaging.
Round lymphadenopathy in the left axilla measuring 1.3 cm.
Right PICC line ends in cavoatrial junction.
Left pacemaker with leads ending in right atrium and ventricle.
Numerous coarse calcifications in right breast.
Moderate to severe atherosclerosis in head and neck vessels.
UPPER ABDOMEN: The limited sections of the upper abdomen show 1.4 cm nodule in
the right adrenal. Hypodense 1.4 cm nodule in the left adrenal.
MEDIASTINUM: Esophagus is unremarkable. Small non pathologically enlarged
mediastinal lymph nodes, unchanged.
HILA: No hilar lymphadenopathy.
HEART and PERICARDIUM: Severe cardiomegaly with predominance of left atrial
enlargement. Aortic valve stenting in severe mitral annulus calcifications
are seen. Moderate to severe atherosclerotic calcifications in thoracic aorta
and coronary arteries.
PLEURA: Small bilateral pleural effusions appear slightly smaller. Mild
bilateral apical scarring.
LUNG:
1. PARENCHYMA: Mild centrilobular emphysema. Left lower lobe new complete
collapse, with more atelectasis today than in ___. Several ground-glass
opacities are seen throughout the lungs, more prominent in the right lower
lobe with some coalescent centrilobular nodules now.
Architectural distortion of the right apex with a calcified granuloma.
2. AIRWAYS: Mild-to-moderate bronchial wall thickening, notably in the right
and left lower lobes, wchich show some secretions.
3. VESSELS: Moderate enlargement of pulmonary arteries, unchanged.
CHEST CAGE: Stable appearance of right clavicle deformity with diffuse
osteopenia. Old healed fractures in left anterior third through 6, lateral
eighth and 9, posterior seventh through tenth. Moderate dorsal spondylosis
with stable loss of height T7, T8 and T9 vertebral bodies.
IMPRESSION:
New diffuse ground-glass opacities since ___, more prominent in the
right lower lobe, with some coalescent centrilobular nodules, suggestive of
new inflammatory/infectious process.
Small bilateral pleural effusions are minimally smaller than in ___.
Right apex architectural distortion and granulomas can be attributable to
scarring from prior radiation therapy or granulomatous disease.
Round borderline enlarged left axillary lymph node, new since ___.
Ultrasound evaluation, if clinically indicated.
Stable appearance of severe cardiomegaly and widespread atherosclerosis.
Bilateral adrenal nodules the were not entirely imaged in the previous
studies. A dedicated CT study can help better evaluate these nodules.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Arm swelling
Diagnosed with Hypoxemia
temperature: 99.1
heartrate: 59.0
resprate: 16.0
o2sat: 94.0
sbp: 139.0
dbp: 47.0
level of pain: 0
level of acuity: 3.0 | ================
PATIENT SUMMARY
================
Mrs. ___ is an ___ with h/o HFpEF, Afib s/p ablation
and PPM ___, AS s/p ___, and CKD stage
III, who presented to the ED with acute onset R arm swelling,
admitted to the MICU for acute hypercarbic respiratory failure,
transferred to the floor with SOB for further management, with
supplemental O2 requirement that was weaned to ___ NC, now
euvolemic after diuresis, and resolved ___ in the setting of
fluid loss due to C. diff infection.
In brief, Mrs. ___ presented with volume overload and
respiratory failure, initially transferred to the MICU for BIPAP
but subsequently stable on nasal cannula, then was transferred
to the floor and aggressively diuresed until euvolemic. She had
poor respiratory status c/b volume overload, aspiration, and
underlying COPD. This improved with aspiration precautions and
dietary modifications, diuresis, and nebulizers. Her hospital
course was complicated by C. dif and ___ iso acute volume loss
that resolved with abx. By discharge, she was weaned to ___ NC
supplemental O2 (intermittent requirement), and was stable on
her home torsemide regimen.
================
ACUTE ISSUES
================
#Acute hypercarbic respiratory failure
#Acute on chronic diastolic heart failure
On ___, Ms. ___ presented to ___ with right arm swelling,
and shortness of breath that had been ongoing for the past
month. While in the ED, she had a CXR confirming pulmonary
edema. She also developed tachypnea and triggered for hypoxia at
83%, with signs of hypercarbia on blood gas. She was started on
Bipap, and was subsequently transferred to the MICU. While in
the MICU, Ms. ___ was given a 160mg bolus of Furosemide and
weaned off of Bipap. She was also continued on her duonebs q6H,
albuterol q2hr, daily fluticasone inhaler, and guaifenesin ER
1200BID to help with baseline COPD SOB and increased mucous
secretions. On ___, she was transferred to the general medicine
floor. Between ___, Ms. ___ was transitioned back to her
home diuretic torsemide regimen to re-assess whether regimen
would address hypervolemia. However, she continued to show signs
of hypervolemia, so she was given 160mg of Furosemide on ___ in
place of her home torsemide. On ___, she was started on losartan
25mg PO for afterload reduction. On ___, she was given 200mg of
Furosemide, and her home torsemide was re-started. On ___, she
had an increased O2 requirement to 4.5L (satting 91%) from 1.5L
O/N. There was concern for HCAP, ID was curbsided, and was
ultimately continued on ceftriaxone, which she was taking for
endocarditis. During this time, her WBC was within normal range,
and CXR showed no new focal consolidations, making pneumonia
unlikely. There was high suspicion for volume overload. She was
given IV Lasix 200 + metolazone 5 in addition to her AM
torsemide 100 mg, with some signs of improvement on volume exam.
On the evening of ___, given continued signs of hypervolemia,
her home torsemide was DC'd, and she was maintained on a Lasixs
drip 10 mg/hr. On ___, her drip was increased to 15mg/hr, and
she began to show good urine output and significant improvements
on volume exam. By ___ her O2 requirement improved to ___ NC.
On ___, her diuretics were stopped in the setting of c. diff
infection and diarrhea volume loss (see below). Between
___, she was maintained on ___ NC and found to be
euvolemic on exam. Given concern for other etiology for new O2
requirement, she was evaluated by her Atrius cardiolgist who
recommended against a right heart cath at this time to rule out
any underlying pulmonary hypertension, and recommended an
outpatient TTE. Pulmonology also evaluted, and on ___,
recommended a non-contrast chest CT showing a RLL consolidation
consistent with aspiration. Over the last week of her
hospitalization, her increased work of breathing and shortness
of breath was likely secondary to respiratory compensation for
contraction alkalosis in the setting of acute volume loss from
c.diff infection, as well as prior aspiration events, mucus
plugging, atelectasis, and decreased respiratory drive. Over the
last few days of her hospital stay, she was weaned off of
supplemental oxygen. On day of discharge (___), she was
euvolemic, with intermittent O2 requirement to 1L, and was
stable on her home torsemide diruetic regimen of 100 mg in the
morning, 80 mg in the afternoon.
___
On ___, Ms. ___ creatinine ___ in the setting of
heavy diarrhea and diuresis. Her diuretics were stopped on ___
given signs of euvolemia and developing ___. On ___, her
creatinine peaked at 1.8, and she was given two boluses 500cc
over 180 minutes that day. Labs showed that her pre-bolus FeNA
was 0.5%, the pre-renal range, and her FEUrea was 10.7%, also in
the pre-renal range. These findings suggested pre-renal azotemia
in the setting of acute volume loss from diarrhea. Diuretics
were held from ___ to ___. On ___, she experienced another
bump in creatinine, and she was given an additional 500cc bolus
over 180 minutes. Her diarrhea slowly resolved on oral
vancomycin for C. diff and her creatinine stabilized on ___,
and was consistently between 1.1-1.3. On day of discharge
(___), her creatinine was 1.2, and her home diuretic regimen
was resumed.
#C Diff Diarrhea
On ___, Ms. ___ had profuse, watery diarrhea that continued
over the next ___ hours. Her diarrhea developed in the setting of
extensive antibiotic use for her infective endocarditis. Patient
was also noted to have uptrending WBC, and she tested positive
for C. diff antigen. On ___, she was initiated on PO vancomycin
with significant improvement of symptoms and resolution of
elevated WBC. She was started on a 10 day course of oral 125 mg
vancomycin, and will complete her antibiotic regimen on ___. On
discharge she had occasional loose stools consistent with her
baseline.
#Macrocytic Anemia
Since admission, Ms. ___ has had a macrocytic anemia that is
consistent with her baseline from her previous hospitalization.
Vitamin B12 and Folate levels were normal. Given her chronic
disease, the most likely etiology of her macrocytic anemia is
COPD-induced macrocytosis. Throughout her entire admission, she
has been on multivitamin supplementation. Hg/Hct was stable over
admission.
#Esophageal Dysmotility
#Oropharyngeal dysphagia
Video oropharyngeal study showed silent aspiration with thin
liquids and moderate esophageal dysmotility associated with
prominent accumulation of ingested materials and delayed
clearance. GI recommended Barium swallow or EGD, however
deferred due to aspiration risk, plan was made for outpatient
work-up. Patient had decreased PO intake over the past two weeks
of her hospitalization and was at high risk for malnutrition.
After starting PO vancomycin on ___, her appetite and PO intake
improved with treatment of C. diff infection. She was evaluated
by speech and swallow, and nutrition, and was prescribed a solid
diet with nectar thick liquids. Speech and Swallow re-evaluated
before discharge, and recommended repeating video swallow as
appropriate in ___ weeks to transition off of nectar thick
liquids.
#Metabolic Alkalosis
On ___, Ms. ___ began to have uptrending bicarbonate in the
setting of aggresive diuresis. The most likely etiology was
contraction alkalosis secondary to aggressive diuresis. Between
___, her bicarbonate remained stable stable in the 39-43
range, and improved with resolving C. Dif infection and diuretic
holiday starting on ___. On discharge, her bicarbonate and
chloride are within normal limits.
# PICC Associated RUE DVT
Patient presented with acute onset right upper extremity
swelling in the setting of a right PICC, found to have evidence
of a partially occlusive deep venous thrombosis within the right
basilic, right axillary, and right subclavian vein on ultrasound
imaging. She was evaluated by ___, who recommended that the PICC
remain in so that she would be able to continue to receive her
antibiotics, and that she be anticoagulated with heparin in the
setting of a subtherapeutic INR. While in the ED on ___, she
was started on a heparin drip and bridged to her home dose of
warfarin. Over the course of her hospitalization, she had
resolution of her right upper extremity swelling. After
completing her antibiotic regimen for endocarditis, her PICC was
DC'd on ___. Neurosurgery was consulted to determine whether
she could be transitioned to apixaban given history of
meningioma, and with their approval, she was started on apixaban
on ___. He cardiologist, however, wanted to use reduced dose
apixaban 2.5 mg BID used in afib (for which she meets criteria)
due the to uncertainty as well as the lack of data regarding the
embolization risk of line-associated upper extremity DVT and the
use of DOACs in this situation.
# Atrial fibrillation
s/p ablation and PPM implantation. She is anticoagulated on
warfarin, although INR was 1.3 on presentation, so she was
started on a heparin drip then transitioned to apixaban (see
above). She was rate controlled on diltiazem 120 mg daily with
holding parameters for hypotension, and had no episodes of RVR
on telemetry during her hospitalization.
# Strep gallolyticus bacteremia c/b mitral valve endocarditis
Patient had recent admission for heart failure and was found to
have bacteremia c/b mitral valve endocarditis. She was followed
by OPAT, and follow-up blood cultures on ___ showed no growth.
On ___, she completed her antibiotic regimen, and showed no
signs of recurrent infection.
=============== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Augmentin
Attending: ___.
Chief Complaint:
painful R shin lesion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year female with a past medical history significant
for htn, hl here with a right painful erythematous shin skin
rash for the past 7 days. She was initially treated with 4 days
of bactrim without improvement, followed by 3 days of
clindamycin (2 IV doses, then PO since) with only minimal
improvement. She had a recent strep throat infection 3 weeks ago
and was treated with keflex for a ___nding
approximately 1.5-2 weeks ago. She has multiple small
erythematous, non-painful papular lesions that have now
resolved. The strep throat symptoms were sore throat, fevers to
101's, chills, and odynophagia that improved with a single dose
of IV steriods, IV fluids, and kefelx. She denies any fever,
chills, sore throat, dysuria, diarrhea, constipation, joint
pain, and other skins lesion(other than those describe above).
She is planning to flight out on ___ to see family and was
hoping to have a more definitive answer regardin this skin
lesion. She had a plan x-ray of the R shin at ___
that per patient was read as soft tissue swelling without
evidence of osteomyolitis.
In the ED, initial vs were unremarkable (afebrile). Labs were
unremarkable, except for a slightly elevated platelet count to
462 and ESR to 56. Blood cutures from ___ are no growth to
date. Normal UA. Patient was given a single dose of vancomycin.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
HTN
HL
recent strep throat infection
Social History:
___
Family History:
negative for significnant inflammatory or autoimmune diseases
Physical Exam:
Admission Exam:
Vitals: T: 98.4 BP:118/78 P:74 R:16 O2:97% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate, 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
Skin: painful, blanching erythematous macule on the anterior
skin that had migrated towards the distal foot from the prior
outline.
Neuro: non-focal
Discharge Exam:
Vitals: T: 98.2 BP:108/72 P:76 R:18 O2:97% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate, 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
Skin: painful(less so), blanching erythematous macule on the
anterior skin that had migrated towards the distal foot from the
prior outline.
Neuro: non-focal
Pertinent Results:
Admission Labs:
___ 12:20PM BLOOD WBC-8.4 RBC-3.96* Hgb-12.6 Hct-37.6
MCV-95 MCH-31.8 MCHC-33.6 RDW-12.4 Plt ___
___ 12:20PM BLOOD Neuts-64.8 ___ Monos-3.8 Eos-1.1
Baso-0.9
___ 12:20PM BLOOD Glucose-98 UreaN-8 Creat-0.6 Na-138 K-4.3
Cl-101 HCO3-23 AnGap-18
___ 12:31PM BLOOD Lactate-1.0
Discharge Labs:
___ 07:30AM BLOOD WBC-5.7 RBC-3.97* Hgb-12.7 Hct-37.1
MCV-94 MCH-32.0 MCHC-34.2 RDW-12.1 Plt ___
___ 07:30AM BLOOD Glucose-94 UreaN-12 Creat-0.6 Na-137
K-4.2 Cl-100 HCO3-28 AnGap-13
Imaging:
TARGETED RIGHT SHIN ULTRASOUND: Targeted ultrasound was
performed at the site of erythema at the level of the right
ankle anteriorly. No drainable fluid collection is identified.
Superficial vasculature within this region is patent.
IMPRESSION: No drainable fluid collection at site of cellulitis
along the right anterior shin at the level of the ankle.
Medications on Admission:
1. Atenolol 12.5 mg PO DAILY
2. Rosuvastatin Calcium 5 mg PO DAILY
Discharge Medications:
1. Atenolol 12.5 mg PO DAILY
2. Naproxen 500 mg PO Q8H
3. Rosuvastatin Calcium 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
erythema nodosum
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with cellulitis over the anterior right chin at
the level of the ankle. Assess for drainable abscess.
COMPARISON: None available
TARGETED RIGHT SHIN ULTRASOUND: Targeted ultrasound was performed at the site
of erythema at the level of the right ankle anteriorly. No drainable fluid
collection is identified. Superficial vasculature within this region is
patent.
IMPRESSION: No drainable fluid collection at site of cellulitis along the
right anterior shin at the level of the ankle.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LOWER EXTREMITY PAIN
Diagnosed with CELLULITIS OF LEG
temperature: 99.3
heartrate: 109.0
resprate: 14.0
o2sat: 96.0
sbp: 118.0
dbp: 68.0
level of pain: 5
level of acuity: 3.0 | ___ yo female with R Shin Lesion of Erythema Nodosum.
#. Erythema Nodosum- The patient has had a painful single
erythematous lesion over right shin, starting 2 weeks after a
strep throat infection. The patient has taken keflex, bactrim,
and clindamycin without improvement to the lesion. Given recent
strep throat, derm was consulted to evaluated for erythema
nodosum vs. cellulits. Derm agrees that R shin lesion is likely
Erythema Nodosum. Lesion improved with naproxen overnight.
Patient encourage to continue naproxen 500 q8. She was given
return precautions.
# HL- continue crestor
# HTN- continue atenolol |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Rectus sheath hematoma
Major Surgical or Invasive Procedure:
Sacral bone biopsy
History of Present Illness:
___ w/ PMH of ESRD on HD ___, HIV on ART (CD4 73 VL
undetectable), HCV, polysubstance abuse on methadone,
cryoglobulinemia, ___ ___ NICM, resistant hypertension and
GERD, s/p PEA arrest w/neurologic devastation w/seizures on
quadruple AED therapy presenting from ___ rehab with
spontaneous right rectus sheath hematoma.
In the ED initial vitals were: T100.2 P81 BP159/87 RR20 97%.
Temp later increased to 101.2. Labs were notable for Hct 26.6,
which downtrended to 24.7. CT abdomen revealed active
extravasation, likely from the right inferior epigastric artery
resulting in a Right sided rectus sheath hematoma. Both ACS and
___ were consulted. They recommended serial Hcts and abdominal
binder to compress the hematoma. ___ anticipates the hematoma
will tamponade off. 2 20G IVs were placed. His G-tube was found
to be clogged. He was given tylenol and IV valproate. He did not
require any transfusions. He was noted to have hypogycemia of
65, he was given 2 amps of D50.
On transfer, vitals were: 88 143/80 16 100% RA.
On arrival to the MICU, patient is not following commands,
speaking ___ and ___.
Past Medical History:
- HIV: He was diagnosed with HIV in ___. Most recent CD4 373,
___ VL undetectable on last admission. Risk factors included
unprotected heterosexual sex as well as intravenous drug use.
His nadir CD4 count is 91 and he has no known opportunistic
infections.
- s/p PEA arrest ___ acute pulmonary edema from hypertensive
emergency, resulting in anoxic brain injury and myoclonic
seizures.
- Hepatitis C, Genotype 1B. Viral load 187,000 in ___.
- ESRD ___ MPGN d/t hepatitis C and cryoglobulinemia and
hypertensive nephrocalcinosis. On HD ___. LUE AVF c/b
stenosis, s/p angioplasty in ___.
- Cryoglobulinemia
- Cardiomyopathy with an EF of 30%
- Hypertension
- GERD
- Stage IV sacral ulcer
- Gynecomastia; s/p bilateral gynecomastia excision with
liposuction ___
- Polysubstance abuse, including cocaine and alcohol
- s/p PEG placement
Social History:
___
Family History:
Per OMR. Mother and father have hypertension; has 3 brothers, 3
sisters: all healthy, none with hypertension. There is also
family history of type 2 diabetes. No family history of sudden
death and premature atherosclerotic disease.
Physical Exam:
Admission Physical Exam:
GENERAL: Somnolent, speaking words intermittently in ___ and
___, appears cachectic with no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Right medial abdomen TTP with visible buldging of abdominal
wall w/o overlying skin changes, otherwise soft, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN:Large sacral decubitus ulcer.
Discharge Physical Exam:
VS: 98.1 (Tmax 100.3) ___ non-labored breathing 100% RA
General: No acute distress
HEENT: Sclera anicteric, poor dentition, very dry mm
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Abdominal binder in place. Hematoma appears stable in
size, no erythema noted. Skin around PEG with no erythema,
exudate
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No tenderness noted over right or left hip
Skin: Stage IV decubitus ulcer with protruding bone over sacral
area, otherwise intact
Neuro: Responds to commands
Pertinent Results:
Admission Labs:
___ 05:25PM BLOOD WBC-5.7 RBC-2.63* Hgb-8.6* Hct-26.6*
MCV-101* MCH-32.7* MCHC-32.3 RDW-19.1* Plt ___
___ 11:30PM BLOOD Hct-24.1*
___ 05:25PM BLOOD ___ PTT-48.9* ___
___ 05:25PM BLOOD Plt ___
___ 05:25PM BLOOD Glucose-66* UreaN-59* Creat-3.4* Na-134
K-4.0 Cl-95* HCO3-29 AnGap-14
___ 05:35PM BLOOD Lactate-1.1
___ 05:32AM BLOOD WBC-8.8# RBC-2.04* Hgb-6.9* Hct-21.3*
MCV-104* MCH-33.7* MCHC-32.4 RDW-20.4* Plt ___
Other pertinent labs:
T LYMPHOCYTE SUBSET WBC Lymph Abs ___ CD3% Abs CD3 CD4% Abs CD4
CD8% Abs CD8 CD4/CD8
___ 07:15 5.5 10* 550 78 428* 58 319* 18 101* 3.1*
Relevant Microbiology:
___ 1:22 pm SWAB Source: Sacral decubitus ulcer.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT in
this culture..
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 1:42 pm SWAB Source: PEG tube.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- 16 R
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 4:40 pm TISSUE SACRAL BONE BIOPSY.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
Blood Cultures through ___: Negative
Blood Cultures drawn ___: NGTD
UCX ___: Pending
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefepime sensitivity testing confirmed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Imaging:
ABD ___: No radiographic findings suggestive of free air
or colonic volvulus. Mild colonic distention and air-fluid
levels, which are non-specific findings.
CT ABD/PELVIS (___)
1. Active extravasation likely from the right inferior
epigastric artery into a large right rectus sheath hematoma
2. Splenomegaly.
3. Cardiomegaly.
4. Ectatic common iliac arteries.
5. Small left pleural effusion and left basilar atelectasis
Echocardiogram (___)
No 2D echocardiographic evidence of endocarditis. Compared with
the prior study (images reviewed) of ___ global left
ventricular systolic function has improved somewhat. Pulmonary
pressures are lower. The possible PDA flow is not as well seen.
A very small pericardial effusion is seen. Other findings are
similar.
MRI pelvis (___)
1. Markedly limited study due to patient motion. A soft tissue
ulcer is again seen overlying the sacrococcygeal junction. Edema
within the underlying coccyx is nonspecific in nature, although
could be due to osteomyelitis.
2. Large right-sided rectus sheath hematoma that has ruptured
into the right aspect of the pelvis, overall markedly increased
in size compared to the CT from ___. Of note, active
arterial extravasation was seen on the prior CT. Correlation
with hematocrit trend is recommended.
3. Diffuse intramuscular edema is non-specific in nature,
although can be seen in the setting of myositis. Clinical
correlation is recommended.
CTA Abdomen (___)
1. Interval increase in size of right rectus sheath hematoma
extending into the pelvis compared to CT of ___, but
relatively stable compared MR of the pelvis from ___. No
evidence of active extravasation. Superinfection of the hematoma
cannot be excluded.
2. Bilateral hip joint effusions and fluid in the right
trochanteric bursa.
3. Small bilateral nonhemorrhagic pleural effusions.
4. Cholelithiasis
5. Diffuse anasarca
CXR (___)
1. Right basilar opacity, likely atelectasis, has slightly
increased; and left basilar opacity has improved since the prior
study.
2. Bilateral interstitial opacities persist, most likely edema,
however PCP pneumonia could be considered in the appropriate
clinical setting, as it can have a similar radiographic
appearance.
Discharge Labs:
___ 07:40AM BLOOD WBC-7.7 RBC-2.03* Hgb-6.5* Hct-20.9*
MCV-103* MCH-31.9 MCHC-31.0 RDW-18.9* Plt ___
___ 07:40AM BLOOD Glucose-118* UreaN-77* Creat-2.9* Na-137
K-4.6 Cl-98 HCO3-32 AnGap-12
___ 07:40AM BLOOD LD(LDH)-265* TotBili-0.2
___ 07:40AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.9*
___ 07:30AM BLOOD Hapto-<5*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Abacavir Sulfate 600 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. FoLIC Acid 1 mg PO DAILY
5. LACOSamide 200 mg PO BID
6. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
7. LeVETiracetam Oral Solution 1000 mg PO DAILY
8. LOPERamide 4 mg PO QID:PRN diarrhea
9. Thiamine 100 mg PO DAILY
10. Carvedilol 50 mg PO BID
11. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
12. Emtricitabine Oral Solution 240 mg PO 2X/WEEK (___)
13. Senna 8.6 mg PO BID:PRN constipation
14. Acetaminophen 1000 mg PO Q6H:PRN fever
15. Amlodipine 10 mg PO DAILY
16. Valproic Acid ___ mg PO Q8H
17. Raltegravir 400 mg PO BID
18. PHENObarbital 129.6 mg PO BID
19. Multivitamins W/minerals 1 TAB PO DAILY
20. Heparin 5000 UNIT SC TID
21. Isosorbide Dinitrate 40 mg PO Q8H
22. LACOSamide 200 mg IV BID:PRN high tube feed residuals
23. Lanthanum 500 mg PO TID W/MEALS
24. LeVETiracetam 500 mg PO 3X/WEEK (___)
25. HydrALAzine 100 mg PO Q8H
26. CloniDINE 0.2 mg PO TID
27. Acyclovir Ointment 5% 1 Appl TP Q6H buttocks
28. Losartan Potassium 100 mg PO DAILY
Discharge Medications:
1. Abacavir Sulfate 600 mg PO DAILY
2. Acetaminophen 1000 mg PO Q6H:PRN fever
3. Amlodipine 10 mg PO DAILY
4. Carvedilol 50 mg PO BID
5. CloniDINE 0.2 mg PO TID
6. Emtricitabine Oral Solution 240 mg PO 2X/WEEK (___)
7. LACOSamide 200 mg PO BID
8. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
9. LeVETiracetam 500 mg PO 3X/WEEK (___)
10. LeVETiracetam Oral Solution 1000 mg PO DAILY
11. LOPERamide 4 mg PO QID:PRN diarrhea
12. Losartan Potassium 100 mg PO DAILY
13. PHENObarbital 129.6 mg PO BID
14. Raltegravir 400 mg PO BID
15. Thiamine 100 mg PO DAILY
16. Valproic Acid ___ mg PO Q8H
17. Multivitamins 5 mL PO DAILY
18. Ondansetron 4 mg IV Q8H:PRN Nausea
19. Sarna Lotion 1 Appl TP BID:PRN Itch
20. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
21. Acyclovir Ointment 5% 1 Appl TP Q6H buttocks
22. FoLIC Acid 1 mg PO DAILY
23. HydrALAzine 100 mg PO Q8H
24. Isosorbide Dinitrate 40 mg PO Q8H
25. LACOSamide 200 mg IV BID:PRN high tube feed residuals
26. Multivitamins W/minerals 1 TAB PO DAILY
27. Lanthanum 500 mg PO TID W/MEALS
28. Ciprofloxacin HCl 500 mg PO Q24H Duration: 11 Days
Last day ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Rectus Sheath Hematoma
2. ESRD on HD
3. HIV
4. Chronic Hepatitis C Infection
5. Anoxic Brain Injury s/p PEA arrest
6. Multifactorial Anemia
7. Hypertension
8. Stage IV Sacral Decubitus Ulcer
9. Thrombocytopenia
10. Nutritional Deficiency
11. Systolic Heart Failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i
INDICATION: ___ year old man with HIV, multiple medical problems with fever
// Eval for pneumonia
COMPARISON: Chest radiographs ___.
IMPRESSION:
Previous rapid clearing of relatively severe consolidation in the right lung,
and interstitial edema in the left between ___ and ___ suggests that
edema was the explanation for abnormalities in both lungs. Today there is a
return of the widespread interstitial abnormality in both lungs which I think
is probably edema, particularly because the mild cardiomegaly is worse and
pulmonary vasculature is engorged.
There is also greater consolidation in the left lower lung, due to atelectasis
or pneumonia. No pneumothorax is present.
Radiology Report
INDICATION: ___ year old man with stage IV decubitus ulcers, fever // R/o
osteomyelitis. DO NOT USE contrast as ESRD.
TECHNIQUE: Imaging was performed of the pelvis on a 1.5 Tesla magnet
including the following sequences: Localizers, coronal T1, coronal STIR, axial
T1, axial T2 fat sat. Intravenous contrast material was not administered due
to end-stage renal disease.
COMPARISON: Pelvis MRI from ___. CT abdomen and pelvis from ___.
FINDINGS:
Evaluation of this study is substantially limited due to patient motion. There
is a soft tissue ulcer overlying the sacrococcygeal junction (06:27), similar
to the prior MRI from ___. There is mild marrow edema within the
coccyx, nonspecific in nature, although infection cannot be excluded. Diffuse
T1 hypointensity of the sacrum, lower lumbar spine, and bilateral iliac bones
along the sacroiliac joints is compatible with red marrow reconversion given
the loss of signal on opposed-phase imaging versus in-phase imaging on the
prior MRI from ___. The remainder the marrow signal is normal.
Moderate degenerative changes are seen along both femoroacetabular joints,
including right greater than left superior joint space narrowing as well as
right greater than left superior acetabular cystic changes. There are small
bilateral hip joint effusions. There is extensive subcutaneous and diffuse
intramuscular edema.
There is a large right-sided rectus sheath hematoma which has ruptured into
the right hemipelvis, measuring up to 12.3 x 7.5 cm in the axial plane,
previously measuring up to 6.8 x 5.8 cm on the CT from ___. There is
associated leftward deviation and compression of the bladder.
IMPRESSION:
1. Markedly limited study due to patient motion. A soft tissue ulcer is again
seen overlying the sacrococcygeal junction. Edema within the underlying coccyx
is nonspecific in nature, although could be due to osteomyelitis.
2. Large right-sided rectus sheath hematoma that has ruptured into the right
aspect of the pelvis, overall markedly increased in size compared to the CT
from ___. Of note, active arterial extravasation was seen on the
prior CT. Correlation with hematocrit trend is recommended.
3. Diffuse intramuscular edema is non-specific in nature, although can be seen
in the setting of myositis. Clinical correlation is recommended.
NOTIFICATION: Impression points #1 and #2 were discussed with Dr. ___ by
Dr. ___ at 3:30 p.m. via telephone, ___ minutes after discovery.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old man with HIV, HCV, ESRD on HD, anoxic brain injury
with idiopathic rectus sheath hematoma // Eval for enlargement, active
extravasation, occult abscess
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous administration of 130cc of Omnipaque. Coronal and
sagittal reformations were performed.
DOSE: DLP: 1191 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___ and MR pelvis dated ___
FINDINGS:
CHEST:
There are small bilateral nonhemorrhagic pleural effusions with associated
atelectasis.
ABDOMEN:
The liver enhances homogeneously without focal lesion or intrahepatic biliary
dilatation. There is cholelithiasis. The portal vein is patent. The pancreas,
spleen and adrenal glands are unremarkable. Subcentimeter hypodensities in the
bilateral kidneys are too small to characterize but statistically likely
represent cysts. The kidneys present symmetric nephrograms and excretion of
contrast with no focal lesions, stones or hydronephrosis.
The small and large bowel are normal in caliber without evidence of
obstruction. A gastrostomy tube is in place. There is no retroperitoneal or
mesenteric lymphadenopathy by CT size criteria. There is a small to moderate
amount of ascites, of low density, probably non-hemorrhagic for the most part.
The right rectus sheath hematoma has increased in size from the CT of ___ but appears stable compared to the MRI of the pelvis allowing for
differences in technique. It now extends into the pelvis measuring
approximately 6.9 x 5 x 21.2 cm (TV, AP, CC). There is no evidence of active
extravasation. Moderate-sized iliac aneurysms and mild lower aortic ectasia
appear unchanged.
PELVIS:
The urinary bladder is unremarkable. There is no evidence of pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis. Decubitus
ulceration was better delineated on the recent prior MR study.
BONES AND SOFT TISSUES:
No lytic or sclerotic lesion suspicious for malignancy is present. There is
slight increase in small to moderate effusions around the bilateral hip joints
as well as fluid adjacent to the right greater trochanter. There is diffuse
anasarca.
IMPRESSION:
1. Interval increase in size of right rectus sheath hematoma extending into
the pelvis compared to CT of ___, but relatively stable compared MR
of the pelvis from ___. No evidence of active extravasation.
Superinfection of the hematoma cannot be excluded.
2. Bilateral hip joint effusions and substantial fluid in the right
trochanteric bursa.
3. Small bilateral nonhemorrhagic pleural effusions.
4. Cholelithiasis
5. Diffuse anasarca
6. Stable small iliac aneurysms.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 7:30 ___, 10 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST RADIOGRAPH ___
INDICATION: ___ year old man with fevers // Eval for PNA
TECHNIQUE: Single AP view of the chest.
COMPARISON: Comparison is made to radiographs the chest from ___.
FINDINGS:
Left basilar opacity has improved since the prior study, with similar
appearance of bilateral interstitial opacities. Medial right lung base opacity
is likely atelectasis. The cardiomediastinal silhouette is unchanged. There
is no pneumothorax or large pleural effusion.
IMPRESSION:
1. Right basilar opacity, likely atelectasis, has slightly increased; and left
basilar opacity has improved since the prior study.
2. Bilateral interstitial opacities persist, most likely edema, however PCP
pneumonia could be considered in the appropriate clinical setting, as it can
have a similar radiographic appearance.
Radiology Report
EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW
INDICATION: ___ year old man with multiple medical comorbidities s/p anoxic
brain injury // Eval for aspiration risk.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
COMPARISON: None available.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. Gross aspiration of nectar thick fluids is visualized.
IMPRESSION:
1. Gross aspiration of nectar thick fluid.
2. Please refer to the speech and swallow division note in OMR for full
details, assessment, and recommendations.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with UTI, persistent fevers // Eval for
pyelonephritis or perinephric abscess
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CTA abdomen and pelvis from ___
FINDINGS:
The right kidney measures 11.8 cm. The left kidney measures 11.6 cm. There is
increased cortical echogenicity and poor corticomedullary differentiation in
both kidneys. No hydronephrosis, stones, or masses. Multiple small renal
cysts seen on recent CT are not well visualized on ultrasound.
Partially decompressed bladder demonstrate a mildly thickened heterogeneous
wall and a small amount of debris layering dependently. Ureteral jets could
not be demonstrated
IMPRESSION:
1. No evidence of hydronephrosis or perinephric abscess.
2. Echogenic kidneys and poor corticomedullary differentiation likely
represents medical renal disease.
3. Thickened heterogeneous appearance of the bladder wall and a small amount
of debris in the bladder lumen could reflect cystitis.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___.
FINDINGS: Persistent cardiomegaly accompanied by pulmonary vascular
congestion and mild-to-moderate edema. A more confluent opacity in the left
retrocardiac region has slightly worsened, and could reflect asymmetrical
edema and atelectasis, but a developing infectious pneumonia is also possible
given history of fevers. Followup radiographs after diuresis may be helpful
in this regard.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: RLQ MASS
Diagnosed with NONTRAUMATIC HEMATOMA OF SOFT TISSUE, END STAGE RENAL DISEASE, RENAL DIALYSIS STATUS, ASYMPTOMATIC HIV INFECTION
temperature: 100.2
heartrate: 81.0
resprate: 20.0
o2sat: 97.0
sbp: 159.0
dbp: 87.0
level of pain: 10
level of acuity: 3.0 | ___ w/ PMH of ESRD on HD, HIV on ART, HCV, polysubstance abuse
on methadone, cryoglobulinemia, sCHF ___ NICM, resistant
hypertension and GERD, s/p PEA arrest w/neurologic devastation
w/seizures on quadruple AED therapy presenting from rehab with
spontaneous right rectus sheath hematoma. |
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
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with history of
prior migraines in remission who initially presented 6wks ago
with new daily headaches (dull/achy periorbital pain b/l),
thought to be analgesic overuse headaches. He was subsequently
admitted to the neurology service ___ for further
evaluation given discovery of leukocytosis. Subsequent head
imaging and LP were unremarkable. Patient then unfortunately
developed a positional post-LP headache, unable to get epidural
patch ___ leukocytosis. There was some concern for Lyme Disease
by CPS team, patient was started on Doxycycline four days PTA
(though Lyme IgM/IgG NEG ___. Patient says that headaches
have
persisted, increasing in frequency and severity (also now with
nausea), and so he represented to the ED.
In the ED, initial VS were: 97.0 91 136/70 18 100% RA
Exam notable for: VSS and wnl; mild distress, lying with arm
covering eye; CN II-XII intact bilaterally; strength ___
throughout, no pronator drift; sensation intact to soft touch
throughout; gait normal; negative Romberg.
Labs showed:
CBC 20.7>14.___/42.5<484 (85% neutrophils)
Received:
___ 22:31 IV Ketorolac 15 mg
___ 22:31 IV Ondansetron 4 mg
___ 23:17 PO Prochlorperazine 10 mg
___ 23:18 IV DiphenhydrAMINE 25 mg
___ 00:30 PO Doxycycline Hyclate 100 mg
___ 00:34 IVF NS
___ 04:10 PO Acetaminophen 1000 mg ___
Neurology was consulted and suspected new multifactorial chronic
daily headaches (muscle tension, sinus disease, hypovolemia, s/p
LP, frequent analgesic use, poor sleep). Exam notable only for
cervical muscular tenderness. No indication for repeat LP.
Patient cannot undergo MRI given prior placement of RFIDs.
Given
rising white count and possibility of occult systemic infection,
neurology recommended admission and ID consult.
Transfer VS were: 98.2 60 128/72 16 100% RA
On arrival to the floor, patient recounts the history as above.
He endorses some improvement in his pain s/p Toradol,
Ondansetron, Prochlorperazine, and IVF, though still with ___
periorbital discomfort. No vision changes or weakness/sensory
loss. No confusion. Of note, patient describes drenching night
sweats the week of ___ also lower back pain and knees at the
time. No recent travel other than to ___ this past ___.
No fevers/chills. 10-point ROS is otherwise NEGATIVE.
Past Medical History:
Migraines
RFID placement
Knee surgery ___ ago
ADHD
OCD
Anxiety
Social History:
___
Family History:
Father with migraines, mother with celiac disease, grandmother
with rheumatoid and psoriatic arthritis.
Physical Exam:
ADMISSION PHYSICAL:
==================
VS: 98.1 115/74 73 18 97RA
GENERAL: AOx3, NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, OP
clear
with MMM. Mild main to palpation of frontal and maxillary
sinuses
NECK: No JVP elevation.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: No cyanosis, clubbing, or edema.
PULSES: 2+ Radial/DP pulses bilaterally.
MSK: no tenderness at spinous processes, paraspinal muscles, or
sacroiliac joints
NEURO: AOx3. CN II-XII intact bilaterally. strength and
sensation intact in all four extremities.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes.
DISCHARGE PHYSICAL:
===================
GENERAL: AOx3, NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, OP
clear
with MMM. Mild main to palpation of frontal sinuses, but overall
improved
NECK: No JVP elevation.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: No cyanosis, clubbing, or edema.
PULSES: 2+ Radial/DP pulses bilaterally.
MSK: no tenderness at spinous processes, paraspinal muscles, or
sacroiliac joints
NEURO: AOx3. CN II-XII intact bilaterally. strength and
sensation intact in all four extremities.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes.
Pertinent Results:
ADMISSION LABS:
==============
___ 10:38PM BLOOD WBC-20.7* RBC-4.93 Hgb-14.7 Hct-42.5
MCV-86 MCH-29.8 MCHC-34.6 RDW-12.2 RDWSD-38.5 Plt ___
___ 10:38PM BLOOD Neuts-84.9* Lymphs-7.6* Monos-6.0
Eos-0.3* Baso-0.4 Im ___ AbsNeut-17.59* AbsLymp-1.58
AbsMono-1.24* AbsEos-0.06 AbsBaso-0.08
___ 07:02AM BLOOD WBC-14.6* RBC-4.99 Hgb-14.3 Hct-44.4
MCV-89 MCH-28.7 MCHC-32.2 RDW-12.5 RDWSD-40.1 Plt ___
___ 07:20AM BLOOD Glucose-77 UreaN-8 Creat-0.8 Na-143 K-4.7
Cl-101 HCO3-27 AnGap-15
___ 06:59AM BLOOD ALT-17 AST-15 LD(LDH)-177 AlkPhos-129
TotBili-0.3
___ 07:33AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.0
___ 06:59AM BLOOD CRP-14.0*
___ 07:33AM BLOOD QUANTIFERON-TB GOLD-PND
___ 06:59AM BLOOD SED RATE-Test
DISCHARGE LABS:
===============
___ 07:02AM BLOOD WBC-14.6* RBC-4.99 Hgb-14.3 Hct-44.4
MCV-89 MCH-28.7 MCHC-32.2 RDW-12.5 RDWSD-40.1 Plt ___
___ 07:02AM BLOOD Plt ___
MICROBIOLOGY:
==============
___ Urine Cx Negative
IMAGING:
==========
___ CXR
In comparison with the study of ___, there is little overall
change.
Cardiac silhouette is within normal limits and there is no
vascular
congestion, pleural effusion, or acute focal pneumonia.
Bilateral apical pleural thickening is consistent with old
tuberculous
disease.
___ CT SINUS
No fractures are identified.
There is no evidence of facial swelling.
There is mild mucosal thickening within the ethmoid air cells
bilaterally,
left maxillary sinus, and bilateral sphenoid sinuses, left
greater than right.
The frontal sinuses are clear. The extent of mucosal thickening
has improved
compared to the head CT dated ___.
There is no evidence of abnormal fluid collections.
Bilateral mastoids appear normal.
The globes, extraocular muscles, optic nerves, and retrobulbar
fat appear
normal.
The visualized upper aerodigestive tract appears normal.
The mandible and temporomandibular joints appear normal.
IMPRESSION:
Improved paranasal sinus disease compared to ___ with
mild persistent
mucosal thickening involving the bilateral ethmoid air cells,
bilateral
sphenoid sinuses, and left maxillary sinus.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CloNIDine 0.1 mg PO QHS
2. MethylPHENIDATE (Ritalin) 10 mg PO QAM
3. Sertraline 100 mg PO DAILY
4. MethylPHENIDATE (Ritalin) 10 mg PO DAILY
Discharge Medications:
1. Fluticasone Propionate NASAL ___ SPRY NU DAILY
RX *fluticasone 50 mcg/actuation ___ sprays Nasal daily Disp #*1
Spray Refills:*0
2. GuaiFENesin ER 1200 mg PO Q12H
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
4. NeilMed NasaFlo (sod bicarb-sod chlor-neti pot) 1 wash
nasal BID
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Pseudoephedrine 30 mg PO Q4H:PRN congestion
Do not take for longer than 7 days
7. CloNIDine 0.1 mg PO QHS
8. MethylPHENIDATE (Ritalin) 10 mg PO QAM
9. MethylPHENIDATE (Ritalin) 10 mg PO DAILY
10. Sertraline 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Headache w/ chronic sinusitis
Positive Lyme IgM
Secondary Diagnoses:
Anxiety, ADHD
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with leukocytosis, HA, negative spinal tap//
Infectious process?
IMPRESSION:
In comparison with the study of ___, there is little overall change.
Cardiac silhouette is within normal limits and there is no vascular
congestion, pleural effusion, or acute focal pneumonia.
Bilateral apical pleural thickening is consistent with old tuberculous
disease.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS
INDICATION: ___ year old man with persistent headache and recent nausea and
vomiting. Extensive neurologic, rheumatologic, and infectious workup negative.
Last CT Head showed sinus disease.// Extent of sinus disease (for ORL consult
management)
TECHNIQUE: Helically-acquired multidetector CT axial images were obtained
through the maxillofacial bones and mandible. Intravenous contrast was not
administered. Axial images reconstructed with soft tissue and bone algorithm
to display images with 1.25 mm slice. Coronal and sagittal reformations were
also constructed. All produced images were evaluated in production of this
report.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.0 s, 15.7 cm; CTDIvol = 26.8 mGy (Head) DLP = 421.3
mGy-cm.
Total DLP (Head) = 421 mGy-cm.
COMPARISON: CT head dated ___.
FINDINGS:
No fractures are identified.
There is no evidence of facial swelling.
There is mild mucosal thickening within the ethmoid air cells bilaterally,
left maxillary sinus, and bilateral sphenoid sinuses, left greater than right.
The frontal sinuses are clear. The extent of mucosal thickening has improved
compared to the head CT dated ___.
There is no evidence of abnormal fluid collections.
Bilateral mastoids appear normal.
The globes, extraocular muscles, optic nerves, and retrobulbar fat appear
normal.
The visualized upper aerodigestive tract appears normal.
The mandible and temporomandibular joints appear normal.
IMPRESSION:
Improved paranasal sinus disease compared to ___ with mild persistent
mucosal thickening involving the bilateral ethmoid air cells, bilateral
sphenoid sinuses, and left maxillary sinus.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Headache
Diagnosed with Headache
temperature: 97.0
heartrate: 91.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 70.0
level of pain: 7
level of acuity: 3.0 | Mr. ___ is a ___ year old male with history of prior migraines
in remission who initially presented six weeks ago with new
daily headaches thought to be multifactorial and now re-presents
with persistent headache and nausea/emesis, likely in the
context of chronic sinusitis.
ACTIVE ISSUES
==================
# Headaches - Patient has been evaluated by neurology multiple
times, with recent admission on their service in ___. Lumbar
puncture and CT head imaging at the time was unremarkable
(except for extensive sinusitis), making meningitis/encephalitis
very unlikely. Extensive rheumatologic testing was also
unrevealing. There are multiple contributing factors to
patient's headaches including sinus disease, hypovolemia
secondary to vomiting, cervical muscle tension, and poor sleep.
Patient was started on empiric Doxycycline ___ by CPS given
concern for Lyme Disease despite negative antibody test on
___, but was discontinued on ___ due to low suspicion for
Lyme. Given persistent headaches with leukocytosis, basic
infectious work up with chest radiograph and urinalysis were
ordered. Chest radiograph revealed apical pleural thickening
suggestive of old tuberculosis infection, and urinalysis was
negative. Follow up quantiferon-TB Gold test was ordered, which
was pending at discharge. Given complaint of sinus pressure,
localization of pain to sinuses, and previous CT showing
extensive sinus disease, ENT was consulted. They recommended a
CT Sinus and starting Flonase and Neilmeid sinus rinses BID,
which helped with symptom control. The ENT team did not feel
that the patient had acute bacterial sinusitis, or that any
surgical intervention was warranted. Symptomology was otherwise
managed with ketorolac/ibuprofen, Zofran/Compazine, guaifenesin,
and pseudophedrine. Outpatient follow-up with neurology Dr.
___ is already scheduled for ___, and patient will
follow up with ENT if symptoms continue to persist.
Of note, repeat lyme serology from ___ was positive for IgM.
Inpatient team felt that this was likely a false positive given
the fact that it was drawn several weeks after the onset of his
symptoms, which would not be consistent with when IgM would be
expected to be positive. Thus further treatment with antibiotics
was deferred. Recommend repeat serology in two weeks.
CHRONIC ISSUES
===================
# Psych (ADHD, anxiety, OCD): Patient's home methylphenidate,
sertraline, and clonidine were continued.
TRANSITIONAL ISSUES
==========================
[ ] Follow up on Quantiferon gold testing, pending at discharge
[ ] Repeat Lyme serologies in two weeks with followup per PCP
[ ] Pt should stop pseudoephedrine after 7 days
#CODE: Full
#CONTACT: ___ (MOTHER) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / codeine /
Voltaren
Attending: ___
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with a history of paroxysmal atrial
fibrillation on anticoagulation, CKD III, HTN/HLD, osteoporosis,
chronic back pain/lumbar radiculopathy s/p spinal stimulation,
and bilateral greater trochanteric bursitis (GTB) for which she
receives steroid injections (last performed ___, who
presented from pain clinic with ___ days of acute worsening of
her right hip pain.
Briefly, pt presented to her pain clinic urgently today
requesting a GTB injection for acute worsening of her right hip
pain. Per documentation from pain clinic, the severity of the
pain and her physical exam were not consistent with GTB and thus
a steroid injection was not offered. Instead, she was advised to
go to the ED to rule out a fracture of her hips/femurs.
Pt states that she is unable to ambulate and the pain is
excruciating with any hip movement, rated a 15 out of 10. Ice
packs mildly helped the pain in the ED but none of the
medications helped. The pain does not radiate and does not have
any associated symptoms, including fever, chills, chest pain,
shortness of breath, lightheadedness with standing, and
abdominal
or urinary symptoms. She denies prolonged steroid use and trauma
to the area.
In the ED, she was afebrile with heart rates ranging from 63-72,
blood pressures 100s-130s/50-60s, respiratory rate ___ and
oxygen saturation 98-100% RA. Her exam was notable for palpable
bony protrusions on the femoral neck and head and both passive
and active range of motion were limited by pain. Labs were
remarkable for an elevated BUN/Cr of 40/1.3, with baseline
creatinine of 1.0; she also has a macrocytosis which appears
chronic. A bilateral hip XR was negative for a fracture or
dislocation, though did show mild degenerative changes and a
nerve stimulator device projecting over the right hemipelvis.
She
subsequently underwent a non-contrast CT scan of the right hip
which similarly did not show a fracture or dislocation. She was
given a Lidocaine patch, 1 gm of acetaminophen, and 800 mg
ibuprofen; she was offered 2 mg IV morphine but declined as she
doesn't like how this makes her feel. Due to persistent
inability
to ambulate (and thus inability to carry out daily activities at
home), she was admitted to medicine for pain control at the
request of the geriatrics fellow.
VS prior to transfer:
AF HR 63 BP 105/56 RR 18 O2 98% RA pain ___
On arrival to the floor, pt endorses the above story. She is
accompanied by her daughter/HCP ___, who also confirms the
above. Pt reports feeling much better now s/p receiving
ibuprofen
in the ED, though notes a bit of acid reflux/epigastric
irritation. Her left hip is not bothering her any more than
usual, but her right hip continues to bother her. The character
of the pain is similar to her chronic pain (ie burning, sharp),
but the severity is significantly worse. She states that it
feels
similar to the first episode of her "pain flair" that occurred ___
years ago. She and her daughter both voice frustration that
while
physicians are trying to manage her chronic (now acute on
chronic) pain, no one seems to understand the etiology of this
pain. She feels that it has to do with her scoliosis (as her
right rib is nearly touching her hip) and has been unsuccessful
in scheduling an orthopedic appointment. She has no back pain
and
the remaining ROS are entirely negative.
Past Medical History:
CARDIOLOGY:
- Paroxysmal Atrial Fibrillation on anticoagulation
- Hypertension
- Hypertension
- Dyslipidemia
- Palpitations
- Ascending Aortic Aneurysm
- Atypical Chest Pressure
MSK:
- Greater trochanteric bursitis (GTB) for which she receives
frequent injections
- Osteoporosis
- Lumbar Radiculopathy (s/p spinal stimulation), chronic low
back
pain
- Scoliosis
- Gait instability, right leg height discrepancy
- Decreased propioception (age related)
OTHER:
- CKD III
- History of diabetes, diet controlled (HbA1c in ___ = 5.5)
- History of Breast, Uterine Cancer
- GERD
- Right eye blindness
- Vocal cord atrophy and muscle tension dysphonia (new dx)
Social History:
___
Family History:
Mother and father died of heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 111)
Temp: 97.8 (Tm 97.8), BP: 99/58, HR: 72, RR: 18, O2 sat:
97%,
O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. MMM.
CARDIAC: Regular rate, slightly irregular rhythm, no murmurs
LUNGS: Clear bilaterally
BACK: No spinous process tenderness
ABDOMEN: soft, non tender, non distended
EXTREMITIES: Protruding right iliac crest, tenderness to
palpation along anterior/lateral right hip, able to ilicit
severe
pain with flexion, adduction and internal rotation of the right
hip. Left hip without tenderness and less protrusion of the
iliac
crest.
NEUROLOGIC: AOx3. Facial symmetry. Ability to lift right leg
against gravity is limited by pain.
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: NAD, well-groomed
HEENT: sclera anicteric, MMM, oropharynx clear, EOMI grossly
intact
CARDIAC: RRR, no murmurs/rubs/gallops
LUNG: CTAB, no rhonchi, wheezes, rales
ABD: normoactive BS, soft, nontender, nondistended
EXT: wwp, no ___ edema
PULSES: 2+ symmetric radial, DP pulses
NEURO: Alert, oriented, moving all extremities spontaneously
SKIN: warm, dry, no rashes
MSK:
R hip -no obvious swelling or deformity. Tenderness to
palpation at greater trochanter. Logroll with severe pain
elicited across lateral and anterior hip C-shaped distribution.
Difficult to tolerate ___. Strength ___ flexion. Left
hip similar although with much less pain in comparison.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:30PM BLOOD WBC-5.7 RBC-3.85* Hgb-12.4 Hct-38.5
MCV-100* MCH-32.2* MCHC-32.2 RDW-13.2 RDWSD-49.0* Plt ___
___ 03:30PM BLOOD Neuts-62.8 ___ Monos-7.2 Eos-1.4
Baso-0.5 Im ___ AbsNeut-3.55 AbsLymp-1.57 AbsMono-0.41
AbsEos-0.08 AbsBaso-0.03
___ 03:30PM BLOOD Plt ___
___ 03:30PM BLOOD Glucose-137* UreaN-40* Creat-1.3* Na-141
K-3.9 Cl-102 HCO3-29 AnGap-10
___ 03:30PM BLOOD ALT-12 AST-26 AlkPhos-55 TotBili-0.3
___ 03:30PM BLOOD Albumin-4.0 Calcium-10.2 Phos-3.1 Mg-2.0
___ 03:30PM BLOOD Glucose-137* UreaN-40* Creat-1.3* Na-141
K-3.9 Cl-102 HCO3-29 AnGap-10
DISCHARGE LABS:
===============
___ 07:27AM BLOOD Glucose-97 UreaN-37* Creat-1.3* Na-142
K-4.0 Cl-101 HCO3-26 AnGap-15
___ 07:27AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0
IMAGING:
1. Bilateral hip XR (___): There is no fracture or
dislocation. There are mild degenerative changes of both hip
joints. There is no suspicious lytic or sclerotic lesion. A
nerve stimulator device projects over the right hemipelvis.
There is no soft tissue calcification or unexpected radio-opaque
foreign body.
2. CT of the right hip (___):
- Pelvis: No free fluid. The partial eyes visualized bladder
and distal right ureter appear unremarkable. No abnormality
appreciated in the visualized loops of small and large bowel. A
right buttock device is partially visualized.
- Bones: No evidence of fracture or dislocation in the right
hip. Degenerative changes are again noted with mild subchondral
sclerosis and osteophytosis. No suspicious lytic or sclerotic
lesion is identified. There is no soft tissue calcification or
unexpected foreign body. No hematoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. lisinopril-hydrochlorothiazide ___ mg oral DAILY
2. amLODIPine 5 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Pravastatin 80 mg PO QPM
5. Apixaban 2.5 mg PO BID
6. Metoprolol Succinate XL 12.5 mg PO DAILY
7. Acerola C (ascorbic acid (vitamin C)) 500 mg oral DAILY
8. Calci-Chew (calcium carbonate) 500 mg calcium (1,250 mg) oral
DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. coenzyme Q10 10 mg oral DAILY
11. Cyanocobalamin 1000 mcg PO DAILY
12. Cidatrine (glucosamine sulfate) 500 mg oral BID
13. lutein 40 mg oral DAILY
14. Multivitamins 1 TAB PO DAILY
15. Fish Oil (Omega 3) 1000 mg PO DAILY
16. Vitamin E 1000 UNIT PO DAILY
Discharge Medications:
1. Gabapentin 100 mg PO QHS
RX *gabapentin 100 mg 1 capsule(s) by mouth at bedtime Disp #*10
Capsule Refills:*0
2. Acerola C (ascorbic acid (vitamin C)) 500 mg oral DAILY
3. amLODIPine 5 mg PO DAILY
4. Apixaban 2.5 mg PO BID
5. Calci-Chew (calcium carbonate) 500 mg calcium (1,250 mg)
oral DAILY
6. Cidatrine (glucosamine sulfate) 500 mg oral BID
7. coenzyme Q10 10 mg oral DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Levothyroxine Sodium 50 mcg PO DAILY
11. lisinopril-hydrochlorothiazide ___ mg oral DAILY
12. lutein 40 mg oral DAILY
13. Metoprolol Succinate XL 12.5 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Pravastatin 80 mg PO QPM
16. Vitamin D 1000 UNIT PO DAILY
17. Vitamin E 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right hip pain
Acute kidney injury
Chronic kidney disease, stage III
Paroxysmal atrial fibrillation
Hypertension
Hypothyroidism
Hyperlipidemia
Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT HIPS (AP, LAT, AND PELVIS) 5 OR MORE VIEWS
INDICATION: ___ with bilateral hip pain, R > L, palpable bony growths on
femur neck an head// ?eval for fracture
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of both hips.
COMPARISON: None.
FINDINGS:
There is no fracture or dislocation. There are mild degenerative changes of
both hip joints. There is no suspicious lytic or sclerotic lesion. A nerve
stimulator device projects over the right hemipelvis. There is no soft tissue
calcification or unexpected radio-opaque foreign body.
IMPRESSION:
No fracture or dislocation.
Radiology Report
EXAMINATION: CT right hip
INDICATION: ___ with right hip pain, unable to ambulate, active/passive
range of motion limited by pain, ?eval for fracture
TECHNIQUE: Helical axial MDCT images of the right hip were obtained without
the use of IV contrast. Bone and soft tissue algorithm reconstructions and
coronal and sagittal reformations were provided.
DOSE: Total DLP (Body) = 864 mGy-cm.
COMPARISON: Hip radiographs dated ___
FINDINGS:
Pelvis: No free fluid. The partial eyes visualized bladder and distal right
ureter appear unremarkable. No abnormality appreciated in the visualized
loops of small and large bowel. A right buttock device is partially
visualized.
Bones: No evidence of fracture or dislocation in the right hip. Degenerative
changes are again noted with mild subchondral sclerosis and osteophytosis. No
suspicious lytic or sclerotic lesion is identified. There is no soft tissue
calcification or unexpected foreign body. No hematoma.
IMPRESSION:
No acute fracture or dislocation.
Gender: F
Race: HISPANIC/LATINO - CUBAN
Arrive by AMBULANCE
Chief complaint: R Hip pain
Diagnosed with Pain in right hip
temperature: 97.3
heartrate: 72.0
resprate: 16.0
o2sat: 99.0
sbp: 130.0
dbp: 63.0
level of pain: 10
level of acuity: 3.0 | BRIEF HOSPITAL COURSE:
======================
___ year old woman with a history of paroxysmal atrial
fibrillation on anticoagulation, CKD III, HTN/HLD, osteoporosis,
chronic back pain/lumbar radiculopathy s/p spinal stimulation,
and bilateral greater trochanteric bursitis (GTB) for which she
receives steroid injections (last performed ___, who
presented from pain clinic with ___ days of acute worsening of
her right hip pain. Pain resolved after taking the 100 mg
ibuprofen in ED, and she was able to walk morning after
admission. CT and CXR of her hip showed no fractures. Physical
exam revealed pain more pelvic than hip and likely related to
lumbar spine disease. She was started on gabapentin 100 mg QHS
for improved pain control. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ceclor / Percocet / Fish Containing Products / adhesive
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
chest tube placement
History of Present Illness:
___ h/o stage IIIC uterine carcinosarcoma who has been treated
with carboplatin and taxol and external beam radiation therapy
and brachytherapy who was recently found to have disease
recurrence with lung nodule and new large pleural effusion. She
is transferred from ___ today where she was seen
for increasing dyspnea and hypoxemia. Results of her recent CT
torso were communicated to patient by Dr. ___
was scheduled to have thoracentesis in the next 7 days. The ED
contacted the interventional pulmonary fellow and thoracentesis
was not performed in the ED.
Patient noted increasing dyspnea for the past 5 days. She has
not had productive cough, fevers, abdominal pain, or leg
swelling. She did not have relief of dyspnea with use of
bronchodilators. She has had mild unintentional weight loss
recently (<10lbs). She has had rash on back for past several
weeks, improved per family, her Radiation Oncologist is aware of
rash and advised emolients. 13pt ROS otherwise negative.
Past Medical History:
OB Hx:
G6P5
5 SVD's, no complications
1 early miscarriage
GYN Hx:
Menopausal > ___ years, denies any bleeding until ___
Denies any abnormal Pap smears, Last Pap per patient was ___
and was WNL
Denies any STI or pelvic infections
Denies any gynecological procedures
Med Hx:
- Asthma, no recent hospitalization, never been intubated
- COPD, never required oxygen, not a smaoker but works around a
lot of smokers and her husband smoked.
- Hypertension
- Breast cancer (diagnosed in ___ s/p lumpectomy on the left
side. She required radiation for the breast in ___ and has been
in remission. She follows up oncologist at ___.
- Denies any heart disease, mitral valpe prolapse etc.
Surgical Hx:
- LSC cholecystectomy ___
- Lumpectomy ___
- Ankle surgery
Social History:
___
Family History:
One brother who passed away from throat cancer. His cancer
metastasized to the bone and the lungs before he passed. He was
a nonsmoker. One of her other brothers has COPD, but he was a
very heavy smoker. She has a third brother who is healthy. She
has five children. All of her children are healthy. She has 13
grandchildren ranging in age from ___ to ___. She has three
great-grandchildren. All of the grandchildren and
great-grandchildren are healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
97.5 130/73 104 100% 4lNC
thin adult female
JVP not elevated
dullness to percussion and minimal breath sounds in majority of
R lung field. L lung field clear,
regular tachycardic pulse
soft abd
borderline hepatomegaly
no ascites
no peripheral edema
wing shaped red dermatitis, symmetrical appearance, no raised
lesions, in mid back
aox3, speech fluent, i did not test gait or motor strength
calm
DISCHARGE PHYSICAL EXAM:
VS 98, 111/49, 89, 20, 95% on RA
O/n: 50cc's from chest tube, 420 cc's yesterday (24h)
Gen: thin adult female
Neck: JVP not elevated
Lungs: L lung CTA, R lung with crackles diffusely
CV: regular tachycardic pulse
Abd: soft abd, borderline hepatomegaly, no ascites
Ext: no peripheral edema
Back: wing shaped red dermatitis, symmetrical appearance, no
raised lesions, in mid back
Neuro: aox3, speech fluent
Pertinent Results:
ADMISSION LABS
___ 05:50PM GLUCOSE-100 UREA N-20 CREAT-0.8 SODIUM-140
POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-28 ANION GAP-15
___ 05:50PM CALCIUM-9.5 PHOSPHATE-4.4 MAGNESIUM-2.2
___ 05:50PM WBC-5.9# RBC-3.65* HGB-11.9* HCT-38.6
MCV-106* MCH-32.6* MCHC-30.8* RDW-13.4
___ 05:50PM NEUTS-69.7 LYMPHS-15.4* MONOS-12.0* EOS-2.4
BASOS-0.6
___ 11:00AM PLEURAL WBC-250* RBC-3050* Polys-59* Lymphs-26*
Monos-9* Eos-1* Macro-1* Other-4*
___ 11:00AM PLEURAL TotProt-5.0 Glucose-111 Creat-0.7
LD(LDH)-148 Albumin-3.1 ___ Misc-PROBNP = 2
DISCHARGE LABS
___ 06:30AM BLOOD Glucose-91 UreaN-17 Creat-0.6 Na-138
K-4.5 Cl-101 HCO3-30 AnGap-12
___ 06:30AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.8
___ 10:30AM BLOOD WBC-5.1 RBC-3.12* Hgb-10.6* Hct-32.0*
MCV-103* MCH-33.9* MCHC-33.0 RDW-13.3 Plt ___
MICROBIOLOGY
___ 10:58 am PLEURAL FLUID PLEURAL 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..
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Preliminary):
Reported to and read back by ___ ___ ___
5:50AM.
GRAM POSITIVE COCCUS(COCCI). 1 COLONY ON 1 PLATE.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ 10:35 pm PLEURAL FLUID
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
IMAGING
___ CXR
FINDINGS: Complete opacification of right hemithorax with
ipsilateral shift of mediastinum suggests complete right lung
collapse in addition to known large right pleural effusion
demonstrated on ___. Interval placement of right
pleural catheter in the lower right hemithorax. Probable very
small right apical pneumothorax. Left lung is hyperexpanded,
but grossly clear except for minimal scar or atelectasis
adjacent to left heart border. Findings discussed by phone with
Dr. ___ at 11:50 a.m. on ___ at time of discovery.
___ CXR
IMPRESSION:
As compared to the previous radiograph, the patient has received
a right
pigtail catheter. The pleural effusion on the right is almost
completely
drained. Only a small amount of effusion remains visible at the
level of the right costophrenic sinus. However, there is on
going volume loss of the right lung, with mild shift of the
mediastinal and cardiac structures to the right. No evidence of
pneumothorax. Normal appearance of the left lung.
___ CXR
IMPRESSION:
Although the right pleural effusion was largely drained on ___ there has been some re-accumulation of moderate right pleural
effusion. The condition of the right lower lobe is uncertain,
still largely atelectatic. Left lung is clear. Heart size
top-normal. No pneumothorax.
___ CT CHEST
1. Significant decrease in size of right pleural effusion now
mild to
moderate. There is residual, possible re-expanding atelectasis
particularly in the right lower lobe, however underlying
malignant involvement of lung parenchyma cannot be excluded.
Prior right middle lobe bronchus obstruction is resolved.
2. Areas of pleural thickening and nodularity have progressed.
Additionally, irregularity and nodularity of the right major
fissure is revealed following drainage of pleural effusion.
Findings are highly suspicious for pleural malignant
involvement.
3. Small apical and anterior pneumothorax in the setting of a
pleural drain.
___ PLEURAL FLUID CYTOLOGY
DIAGNOSIS:
PLEURAL FLUID, RIGHT:
POSITIVE FOR MALIGNANT CELLS.
Consistent with metastatic serous carcinoma (see note).
Note: The malignant cells are morphologically similar to the
serous carcinoma component of the
patient's previously resected uterine carcinosarcoma ___,
slides G, I, & J reviewed). By
immunohistochemistry, the malignant cells in the pleural fluid
are positive for PAX8 and negative for
TTF1, supporting the above diagnosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Lisinopril 10 mg PO DAILY
3. Psyllium 1 PKT PO TID:PRN consti
4. Calcium Carbonate 1500 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
Discharge Medications:
1. Calcium Carbonate 1500 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Psyllium 1 PKT PO TID:PRN consti
4. Vitamin D 1000 UNIT PO DAILY
5. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*0
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Do not take when sleepy, with alcohol, or when operating
machinery.
RX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours
Disp #*56 Capsule Refills:*0
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
8. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Stage 3 uterine carcinoma
Malignant pleural effusion
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
PORTABLE CHEST ___
Compared to ___ radiograph and CT chest of ___.
FINDINGS: Complete opacification of right hemithorax with ipsilateral shift
of mediastinum suggests complete right lung collapse in addition to known
large right pleural effusion demonstrated on ___. Interval placement
of right pleural catheter in the lower right hemithorax. Probable very small
right apical pneumothorax. Left lung is hyperexpanded, but grossly clear
except for minimal scar or atelectasis adjacent to left heart border.
Findings discussed by phone with Dr. ___ at 11:50 a.m. on ___ at
time of discovery.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with stage 3 uterine carcinoma, admitted for
DOE, found to have new large-r-sided pleural effusion concerning for malignant
effusion, now s/p chest tube placement. // ?Reassess R lung collapse
COMPARISON: ___, 11:40
IMPRESSION:
As compared to the previous radiograph, the patient has received a right
pigtail catheter. The pleural effusion on the right is almost completely
drained. Only a small amount of effusion remains visible at the level of the
right costophrenic sinus. However, there is on going volume loss of the right
lung, with mild shift of the mediastinal and cardiac structures to the right.
No evidence of pneumothorax. Normal appearance of the left lung.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i
INDICATION: ___ year old woman with uterine cancer now with new R-sided
pleural effusion concerning with recurrent disease, now s/p chest tube
placement. // ?pneumothorax
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
Although the right pleural effusion was largely drained on ___ there has
been some re-accumulation of moderate right pleural effusion. The condition of
the right lower lobe is uncertain, still largely atelectatic. Left lung is
clear. Heart size top-normal. No pneumothorax.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with stage 3 uterine cancer with new R-sided
pleural effusion, now s/p chest tube placement; would like to assess for any
loculated fluid collection. // ?pleural effusion/loculations
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent and 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: 195 mGy cm
COMPARISON: CT chest ___ and ___.
FINDINGS:
CT CHEST WITHOUT CONTRAST: A new right pigtail pleural drain has been placed.
There is a new small anterior and apical pneumothorax (4:96 and 178). Prior
large right pleural effusion is significantly decreased, now small to
moderate. Atelectasis is improved however there is significant residual
atelectasis particularly of the right lower lobe. Right lung bronchi appear
patent to the subsegmental level however there are air bronchograms passing
through the right lower lung in the regions of atelectasis. The left lung
appears relatively clear.
Pleural-based or subpleural nodules forming obtuse angles with the chest wall
are re- demonstrated in the right hemi thorax. 1.4 x 0.9 cm right anterior
upper lobe nodule is unchanged (02:24). There are less well-defined areas of
pleural thickening anteriorly along the right hemi thorax adjacent to the
aforementioned nodule. Laterally in the right upper lobe a 0.9 x 0.7 cm nodule
is larger, previously 0.7 x 0.4 cm (02:23). Following drainage of pleural
effusion the right major fissure irregularity and nodularity of the right
major fissure is revealed (4:144).
Previously described mediastinal lymphadenopathy is much less well-visualized
without IV contrast. However, a 9 mm right lower paratracheal lymph node is
unchanged. Other smaller anterior mediastinal lymph nodes are not well
appreciated.
The heart is not enlarged. Trace pericardial effusion is unchanged. The aorta
and main pulmonary arteries are normal in caliber but otherwise incompletely
evaluated without contrast. There are scattered atherosclerotic calcifications
predominantly in the aortic arch and at the origin of the left subclavian
artery.
Although this study is not designed for evaluation of the subdiaphragmatic
structures included portions of the solid organs and stomach are grossly
unremarkable. There are surgical clips in the gallbladder fossa status post
cholecystectomy.
OSSEOUS STRUCTURES: There is no sclerotic or lytic lesion suspicious for
metastasis.
IMPRESSION:
1. Significant decrease in size of right pleural effusion now mild to
moderate. There is residual, possible re-expanding atelectasis particularly in
the right lower lobe, however underlying malignant involvement of lung
parenchyma cannot be excluded. Prior right middle lobe bronchus obstruction is
resolved.
2. Areas of pleural thickening and nodularity have progressed. Additionally,
irregularity and nodularity of the right major fissure is revealed following
drainage of pleural effusion. Findings are highly suspicious for pleural
malignant involvement.
3. Small apical and anterior pneumothorax in the setting of a pleural drain.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Dyspnea, Dyspnea on exertion
Diagnosed with PLEURAL EFFUSION NOS, SECONDARY MALIG NEO LUNG, HX-UTERUS MALIGNANCY NEC, HYPERTENSION NOS
temperature: 97.3
heartrate: 100.0
resprate: 18.0
o2sat: 100.0
sbp: 116.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | ___ with uterine cancer s/p ___ with past radiation
therapy who presents with increasing dyspnea and hypoxemia,
found to have new right-sided pleural effusion. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, malaise.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ history of hypertension, hypothyroidism, COPD, and stage 3
lung cancer ___ years in remission who presents with 1.5 weeks of
cough and malaise and 3 days of nausea.
Patient was last in her usual state of health until 1.5 weeks
prior to presentation when she developed nasal congestion, and
cough productive of mucous. The sputum was mostly clear but was
transiently more green. She took mucinex at home but no other
OTC cold medications. She had persistent symptoms but 3 days
prior to presentation had worsening of the above symptoms and
also developed facial sinus pain.
She called her PCP 2 days PTA and was prescribed amoxicillin
from home without office visit. She took the medication and on
that day also developed nausea. She has had dry heaves but no
emesis. She was tolerating POs until the day prior to
presentation when she ate a tuna fish sandwich which produced
worsened nausea.
On the day of presentation, patient's malaise was persistant and
she was only able to take crackers and water PO. Her son and
daughter-in-law saw her and recommended that she present to the
ED for evaluation as she had previously not felt well enough to
visit her PCP ___.
In the ED, initial vital signs were 14:47 0 98.2 68 219/88 20
99% RA.
Patient was thought to have likely viral syndrome exacerbated by
nausea/vomiting induced with PO antibiotics.
She was also noted to be hypertensive - thought to be
situational with initial SBP 219 --> repeat 170.
CXR was performed to rule out pneumonia, which showed no acute
cardiopulmonary abnormality.
The patient was initially observed, but repeat lytes in the AM
showed Na decreased from 132 --> 126 in addition to acidosis
after receiving IVF. Urine lytes were added on this AM but not
available for review.
UA was also suggestive of UTI for which macrobid was given.
VS on transfer 98.4, 125/68, 64, 18, 98RA, patient was in no
distress and had no specific comlpaints denied any fevers,
chills, nausea vomitting, diahrrha, chest pain, SOB, cough or
loss of appetitie.
Past Medical History:
1. COPD last PFT's ___. stage III Non-small cell ling ca s/p L upper lobectomy when
stage I with concurrant chemo, then lefo pneumonectomy ___,
completed further course of chemo. CT ___ shows no evidence of
new dz
3. HTN
4. Echo ___: LVEF 65%, mild LVF, mild MR, LAE, mild TR
Social History:
___
Family History:
Father - died in ___ from gastric cancer
Mother - died of natural causes in ___
9 siblings:
- 3 brothers who died of lung cancer, all smokers
- other 6 are healthy
Children are healthy
Physical Exam:
Admission:
VITALS: 98.4, 125/68, 64, 18, 98RA
GEN: NAD, resting comfortably in bed.
HEENT: NC & AT. Sclera anicteric, conjunctiva pink, PEERLA, EOMs
intact. No sinus tenderness. MMM, oropharynx clear.
Lungs: CT on the right, unable to appreciate air conduction on
the left.
HEART: RRR, nl S1 S2, no MRG.
Abdomen: + BS. Soft, nontender, nondistended. fullness in the
LLQ adjacent to surgical scars.
Extremities: Warm and well perfused. 2+ pulses DP and ___. No
clubbing, cyanosis.
Neuro: PERRL, left pupil 1mm larger than right
Discharge:
PE: 98.6, 130/80, 68, 18, 96%RA
GEN: NAD
Lungs: CT on the right, unable to appreciate air conduction on
the left.
HEART: RRR, ___ SEM at the LUSB
Abdomen: soft, nontender, fullness in the LLQ adjacent to
surgical scars, NABS
extremities: warm and well perfused
Neuro: PERRLA, EOMI
Pertinent Results:
Admission:
___ 02:25PM BLOOD WBC-9.5# RBC-4.39 Hgb-14.7 Hct-42.7
MCV-97 MCH-33.6* MCHC-34.5 RDW-13.1 Plt ___
___ 02:25PM BLOOD Neuts-92.7* Lymphs-5.3* Monos-1.8*
Eos-0.1 Baso-0.1
___ 02:25PM BLOOD Glucose-78 UreaN-14 Creat-0.7 Na-128*
K-5.2* Cl-88* HCO3-21* AnGap-24*
___ 02:25PM BLOOD ALT-18 AST-27 AlkPhos-83 TotBili-0.5
___ 02:25PM BLOOD Albumin-5.0 Calcium-9.0 Phos-3.4 Mg-1.9
___ 02:25PM BLOOD Acetone-LARGE
___ 02:25PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 06:39PM BLOOD Lactate-1.1
INTERIM:
___ 05:30AM BLOOD Osmolal-274*
___ 06:16AM BLOOD Osmolal-265*
___ 05:30AM BLOOD Osmolal-274*
___ 09:05PM BLOOD Glucose-80 UreaN-11 Creat-0.6 Na-132*
K-4.1 Cl-94* HCO3-19* AnGap-23*
___ 06:16AM BLOOD Glucose-113* UreaN-8 Creat-0.6 Na-126*
K-4.1 Cl-93* HCO3-21* AnGap-16
___ 04:55PM BLOOD Glucose-126* UreaN-7 Creat-0.7 Na-126*
K-3.7 Cl-92* HCO3-27 AnGap-11
___ 06:10PM URINE Hours-RANDOM Na-83 K-41 Cl-47
___ 05:01PM URINE Hours-RANDOM
___ 05:01PM URINE Hours-RANDOM Creat-40 Na-17 K-16 Cl-26
___ 05:01PM URINE Osmolal-175
___ 06:10PM URINE Osmolal-403
Discharge:
___ 05:30AM BLOOD WBC-4.5# RBC-3.84* Hgb-12.5 Hct-37.1
MCV-97 MCH-32.5* MCHC-33.6 RDW-13.2 Plt ___
___ 05:30AM BLOOD Glucose-109* UreaN-6 Creat-0.6 Na-134
K-4.0 Cl-98 HCO3-29 AnGap-11
EKG: Sinus rhythm. Left ventricular hypertrophy with secondary
repolarization
abnormalities. Borderline prolonged Q-T interval. Compared to
the previous
tracing, Q-T interval is longer. The other findings are similar.
CXR: FINDINGS: AP and lateral views of the chest are compared
to previous exam
from ___ and chest CT from ___.
Expected post-operative changes of left pneumonectomy are seen.
The right
lung remains clear. There is no effusion. Osseous and soft
tissue structures
are unchanged.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. CloniDINE 0.2 mg PO BID
hold for HR<60, SBP<100
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Lisinopril 20 mg PO BID
hold for SBP<100
5. Lovastatin *NF* 10 mg Oral daily
6. Metoprolol Succinate XL 50 mg PO QAM
hold for HR<60, SBP<100
7. Metoprolol Succinate XL 25 mg PO QPM
hold for HR<60, SBP<100
8. Ipratropium Bromide MDI 2 PUFF IH QID
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. CloniDINE 0.2 mg PO BID
hold for HR<60, SBP<100
4. Ipratropium Bromide MDI 2 PUFF IH QID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Lisinopril 20 mg PO BID
hold for SBP<100
7. Lovastatin *NF* 10 mg Oral daily
8. Metoprolol Succinate XL 50 mg PO QAM
hold for HR<60, SBP<100
9. Metoprolol Succinate XL 25 mg PO QPM
hold for HR<60, SBP<100
10. Outpatient Lab Work
please have a complete electrolyte panel including sodium drawn
on ___ with results faxed to Dr. ___ at
___. ICD-9 276.1
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia
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: ___ female with cough productive of sputum and malaise for
1.5 weeks, now with nausea and vomiting. Question pneumonia. Additional
history from medical record is history of lung cancer and left pneumonectomy.
FINDINGS: AP and lateral views of the chest are compared to previous exam
from ___ and chest CT from ___.
Expected post-operative changes of left pneumonectomy are seen. The right
lung remains clear. There is no effusion. Osseous and soft tissue structures
are unchanged.
IMPRESSION: No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: NAUSEA, MALAISE
Diagnosed with DEHYDRATION, NAUSEA, HYPERTENSION NOS, CHRONIC AIRWAY OBSTRUCTION, HYPERCHOLESTEROLEMIA
temperature: 98.2
heartrate: 68.0
resprate: 20.0
o2sat: 99.0
sbp: 219.0
dbp: 88.0
level of pain: 0
level of acuity: 3.0 | This is a ___ year old female with a history of lung cancer s/p
penumonectomy several years ago and hypothyroidism presenting
with lethargy and hyponatremia.
# Hyponatremia: Hyponatremia likely a mixed picture hyponatremia
in the setting of drinking water but not eating well secondary
to nausea and SIADH. Her BP was high on admission but has come
back down near her baseline. No signs of fluid overload on exam.
Hyponatremic to 128 on admission corrected to 132 with 2L of NS
suggesting a hypovolemic hyponateremia at least initially and
then with further volume resusitation Na fell to 126 suggesting
persistent elevation in ADH. TSH and AM cortisol was normal.
This hyponatremia picture may also represent low solute diet
given recent URI and nausea at least temporarily related to
amoxicllin induced nausea and intake of free water without other
oral intake. Pt also looks hemoconcentrated admission. Her
sodium had corrected without intervention to 134 at the time of
discharge. Patient discharged with interim labs to be faxed to
her primary care doctor prior to a scheduled office visit on
___.
# Nausea: Pt was not feeling well during the week leading up to
admission when she developed nausea on top of that which was
induced by the amoxicillin likely. No active pain, nausea or
vomitting during hospital stay. Gastroenteritis unlikely. Gave
ondansetron for nausea as needed and held amoxicillin. Nausea
resolved quickly and patient began tolerating POs quickly and
well.
# URI: Her symptoms likely related to viral URI. No evidence of
pneumonia on CXR. No antibiotics given. Symptoms resolved over
hospital stay.
# Ketonuria: 150 ketones found on admission UA. Likely secondary
to poor PO intake in the setting of nausea. Non-diabetic and
anion gap based on ED labs was 12. Resolved on repeat labs after
PO intake resumed.
# Hypertension: Noted to be hypertensive - thought to be
situational with initial SBP 219 --> repeat 170. Likely was in
the setting of failure to take all home meds and rebound
withdrawal from clonidine. She was continued on her home BP
regimen and was stable during her hospital stay.
# Possible UTI: Treated w/ macrobid in ED based on UA. No urine
cultures taken in ED but ordered on the floor and no growth to
date. UA was not impressive with negative nitrite, trace leuks,
7 WBC, no bacteria. Did not continue macrobid given lack of
symptoms.
# Hypothyroidism: Stable and TSH level was normal. Continued her
on her home levothyroxine 50 mcg.
# COPD: Long smoking history with prior lung cancer. No left
lung. No SOB during hospitalization and was stable. Continued
her on home atrovent and proair. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tegretol / Ibuprofen / Bactrim / titanium
Attending: ___.
Chief Complaint:
s/p fall down stairs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with T1DM on insulin, adrenal
insufficiency on chronic steroids, CMML, and chronic venous
stasis c/b cellulitis x2 (admissions ___ and ___ who
presented s/p unwitnessed fall, subsequently found to have TBI
and T8 compression fracture.
Per ED Dashboard: "Was walking down stairs at midnight when wife
heard pt fall to ground. Wife reports that patient was conscious
however briefly did not respond to verbal command, consistent
with prior episodes vasovagal episodes. No apparent head strike,
unable to recall if preceding chest pain, palpitations, light
headedness. Pt currently reports pain along L ribs cage, L arm,
L
hip, and worsening chronic back pain. Was unable to ambulate
following the incident. EMS was called and pt brought to ED."
In the ED, initial vitals: 97.7F, 79, 97/48, 16, 92% RA
- Exam notable for: +Chest wall TTP, +anterior L hip TTP,
limited
flexion of L hip, +diffuse ecchymosis along L thigh and L
abdomen
- Labs notable for:
---CBC: WBC 85.9, Hgb 8.9, Plts 105
---BMP: BUN 23, Cr 0.8
---Coags: INR 1.3
---Influenza: Negative
- Imaging notable for:
---CXR: Low lung volumes. Patchy left base opacity could be due
to atelectasis, pneumonia, aspiration, and/or pulmonary
contusion
in the setting of trauma. No large pleural effusion, though
trace
left pleural effusion be difficult to exclude. Subtle
irregularity of the posterior left seventh rib could represent a
fracture, although not definitely substantiated on CT.
---NCHCT:
1. Acute intraparenchymal hemorrhage in right paramedian frontal
lobe with right parafalcine subdural hematoma.
2. Hyperdensities along the bilateral paramedian sulci
consistent
with subarachnoid hemorrhage.
3. No mass effect.
4. No acute fracture.
---CT A/P w/ Contrast:
1. Likely acute on chronic compression fracture of T8 with
moderate retropulsion resulting in mild spinal canal narrowing.
2. Partially imaged hematoma measuring up to 7.7 cm within the
soft tissues along the left proximal femur.
3. Incompletely characterized 1.5 cm cystic lesion in body of
the
pancreas, for which MRCP in a non-emergent setting is
recommended.
---XR Pelvis/L Femur/: Knee: The oblique view of the knee is
suboptimal due to underpenetration and technique. Otherwise, no
evidence of acute fracture.
- Consults: Neurosurgery
"Patient examined and imaging reviewed by attending. Agree with
admission to medicine for complex medical issues. We recommend
the following:
# TBI: GCS 13 on evaluation. Not on any anticoagulation. Would
typically treat as a mild TBI with ED obs however the CT head
was
16 hours after his reported fall. There is no indication for
urgent or emergent neurosurgical intervention.
- q4h neuro checks
- Keppra 500mg BID x7 days
- Recommend MRI/MRA to ensure no underlying lesion
- No anticoagulation unless cleared by neurosurgery
- PTT has not resulted, recommend re-checking
- Please enroll patient in TBI pathway
- Please provide patient with TBI Education Packet
# T8 compression fracture (worsened since prior):
- Please place formal spine consult
- urgent MRI ___ to evaluate for cord compression given LLE
weakness
- NPO until MRI results
- log roll, bedrest
- TLSO brace"
- Pt given: 500cc NS, Gabapentin 300mg x1, Oxycodone 20mg x1, IV
Morphine Sulfate 4 mg IV, hydrocortisone 10mg PO, D10W @ 100/hr
x 1L
- Vitals prior to transfer:
75 |104/52| 15 | 92% (unsepcified amount) of Nasal Cannula
Patient sent to floor prior to inpatient team accepting patient
straight from MRI and was found to be on a non-rebreather. He
was
down-titrated to 4L nasal cannula with saturation of 92%. Upon
arrival to the floor, the patient was drowsy but arousable to
voice and answering some questions appropriately. He reports
that
he had unknown cause of fall. He replies not being in any acute
pain at this time. Reports limited mobility in left shoulder s/p
fall.
Past Medical History:
Chronic Myelomonocytic Leukemia
DM1
ADRENAL INSUFFICIENCY
ANEMIA
DIABETES MELLITUS
GRAVE'S DISEASE
HYPOTHYROIDISM
OSTEOARTHRITIS
PAIN
VENOUS INSUFFICIENCY
MONILIAISIS
HYPERTENSION
SPINAL STENOSIS
NECK PAIN
DERMATOHELIOSIS
SEBORRHEIC DERMATITIS
IRRITABLE BOWEL SYNDROME
Social History:
___
Family History:
A son has DM1
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: ___ 0148 Temp: 97.4 PO BP: 115/57 HR: 81 RR: 18 O2
sat: 94% O2 delivery: 4L Dyspnea: 0 RASS: -1 Pain Score:
___
General: Drowsy, rousable to voice, answers questions
appropriately, unwell appearing. Multiple ecchymoses.
HEENT: Multiple ecchymoses. Exopthalmos. R eyelid shut. Sclerae
anicteric, MMM, oropharynx clear, EOMI unable to be assessed
secondary to drowsiness, PERRL constricting from 2.5 to 2.0 mm
b/l, neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
Abdomen: Normoactive bowel sounds. Soft, non-tender,
non-distended, no organomegaly, no rebound or guarding
GU: No foley
Ext: Diffuse ecchymoses over L shu___, forearm, flank. Warm,
well perfused, 2+ pulses, no clubbing, cyanosis. 1+ edema in b/l
___. LLE is wrapped.
Skin: Skin type III. Diffuse ecchymoses over L shulder, forearm,
flank. Scattered petechiae. Erythematous papules and plaques
over
chest and trunk.
Neuro: Mental Status: Alert to self, place. Drowsy.
Cranial Nerves:
Visual Fields: unable to assess, vision grossly intact.
Visual Acuity: Vision grossly intact
Eye Movements: Unable to assess, appear grossly intact.
V: Unable to assess.
VII: Facial expression is unable to be assessed.
VIII: Hearing intact to voice
IX, X: Uvula position unable to be assessed.
XI: Shoulder shrug and strength in sternocleidomastoid
diminished
on LUE, intact on RUE
XII: Slurred speech, unable to assess tongue protrusion.
Motor:
Bulk, tone: Appropriate for age, sex and body habitus. Without
rigidity.
RUE: 5+
LUE: 4+, ROM limited at shoulder
RLE: 5+
LLE: ___
Abnormal movements: Absent
Pronator drift: unable to assess
Sensory:
Light touch: Intact
Reflexes:
Patellar: 1+ b/l
DISCHARGE PHYSICAL EXAM:
======================
Vitals: 24 HR Data (last updated ___ @ 824)
Temp: 99.6 (Tm 99.6), BP: 97/59 (93-107/54-64), HR: 83
(81-92), RR: 18 (___), O2 sat: 91% (91-95), O2 delivery: 1 L
General: Sitting up in bed, no apparent distress
HEENT: Pale, no icterus, MMM. Multiple ecchymoses. Exopthalmos.
No cervical or supraclavicular LAD
CV: RRR normal S1 and S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation anterolaterally, no wheezes, rales,
rhonchi
Abdomen: Normoactive bowel sounds. Soft, non-tender,
non-distended, no organomegaly, no rebound or guarding
Ext: Large, firm hematoma involving L lateral thigh. 2+ edema in
b/l ___ to thighs.
Skin: Diffuse ecchymoses over L shoulder, forearm, hip, flank.
Scattered
petechiae.
Neuro: Alert, oriented to person, place, ___, responding
appropriately. CN ___ grossly in tact, moving all 4 extremities
with purpose
Pertinent Results:
ADMISSION LABS:
=============
___ 01:42PM NEUTS-52 BANDS-4 LYMPHS-14* MONOS-26* EOS-0*
___ METAS-3* MYELOS-1* AbsNeut-48.10* AbsLymp-12.03*
AbsMono-22.33* AbsEos-0.00* AbsBaso-0.00*
___ 01:42PM WBC-85.9* RBC-3.57* HGB-8.9* HCT-31.2* MCV-87
MCH-24.9* MCHC-28.5* RDW-16.4* RDWSD-52.8*
___ 01:42PM POIKILOCY-1+* OVALOCYT-1+* ECHINO-1+*
RBCM-SLIDE REVI
___ 01:42PM CK(CPK)-104
___ 01:42PM GLUCOSE-143* UREA N-23* CREAT-0.8 SODIUM-136
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-25 ANION GAP-13
___ 01:50PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
MICROBIO:
========
-All blood and urine cultures negative throughout admission. C.
diff PCR negative
IMAGING:
=======
CT HEAD ___ CONTRASTStudy Date of ___ 4:09 ___
1. Focal 2.3 x 1.3 x 0.9 cm right frontal intraparenchymal
hematoma with
surrounding mild edema. Adjacent right parafalcine subdural
hematoma measures
up to 0.6 cm in width, 3.5 cm in length.
2. Bilateral parafalcine acute subarachnoid hemorrhage.
3. No acute fracture.
CHEST (SINGLE VIEW)Study Date of ___ 4:09 ___
Low lung volumes. Patchy left base opacity could be due to
atelectasis,
pneumonia, aspiration, and/or pulmonary contusion in the setting
of trauma.
No large pleural effusion, though trace left pleural effusion be
difficult to
exclude.
Subtle irregularity of the posterior left seventh rib could
represent a
fracture, although not definitely substantiated on CT.
CT ABD & PELVIS WITH CONTRASTStudy Date of ___ 4:10 ___
1. Concern for acute on chronic compression fracture of the T8
vertebral body
with 3 mm of retropulsion resulting in mild spinal canal
narrowing.
2. Partially imaged hematoma measuring up to 7.7 cm within the
soft tissues
lateral to the proximal left femur.
3. Incompletely characterized 1.5 cm cystic lesion in body of
the pancreas,
for which nonemergent MRCP is recommended.
RECOMMENDATION(S): Nonemergent MRCP for further
characterization cystic
lesion in the body of the pancreas.
FEMUR (AP & LAT) LEFTStudy Date of ___ 4:13 ___
No definite acute fracture is seen. The oblique view of the
knee is limited
in and underpenetrated. There are mild to moderate bilateral
hip degenerative
changes. The pubic symphysis and sacroiliac joints are not
widened.
Multilevel degenerative changes of the partially imaged lower
lumbar spine are
partially imaged. Minimal to no suprapatellar joint effusion is
seen. There
is mild patellar enthesopathy and tiny posterior patellar spurs.
Vascular
calcifications are seen.
KNEE (AP, LAT & OBLIQUE) LEFTStudy Date of ___ 4:14 ___
The oblique view of the knee is suboptimal due to
underpenetration and
technique. Otherwise, no evidence of acute fracture.
MR THORACIC SPINE ___ CONTRASTStudy Date of ___ 12:38 AM
1. Recent T8 compression fracture with approximately 75%
vertebral body height
loss and evidence of 7 mm retropulsion resulting in severe
spinal canal
stenosis with compression of the spinal cord but no evidence of
definitive
cord signal abnormality. Severe bilateral T8-T9 neural
foraminal narrowing.
2. Diffuse low signal within the vertebral bodies could be due
to anemia or an infiltrative process. Prominence of paraspinal
soft tissues could be due to fat deposition or due to
extramedullary hematopoiesis at the site of compression fracture
(08:11).
3. Despite the abnormal appearance of the bony structures with
diffuse low
signal, the presence of a high intensity cleft within the
fractured vertebra suggest posttraumatic component. MRI with
gadolinium can help for further assessment if clinically
indicated.
4. Thin epidural hematoma along the right posterior aspect of
the T6 through T9 vertebral bodies.
5. Chronic T3, T6, L1 and L2 superior endplate compression
deformities.
6. Prevertebral soft tissue edema extending from T7 through T9.
RECOMMENDATION(S): MRI with gadolinium to further assess the
nature of T8
compression fracture.
SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFTStudy Date of
___ 4:40 ___
No evidence of fracture or dislocation.
T-SPINEStudy Date of ___ 4:41 ___
No definite change in moderate T8 compression fracture.
___ CT HEAD ___ CONTRAST:
1. Study is degraded by motion.
2. Grossly stable right frontal intraparenchymal and right
parafalcine
subdural hematomas with question interval increased edema, as
described.
3. Question interval increase in bilateral parietal subarachnoid
hemorrhage.
___ CTA ABD & PELVIS:
1. Interval increase in size of a large soft tissue hematoma in
the anterior compartment of the left thigh, now measuring 21.4 x
14.1 x 8.3 cm. No evidence of active bleed.
2. Interval increase in size of a layering nonhemorrhagic left
pleural
effusion with bibasilar atelectasis.
3. 12 mm hypodense lesion in the pancreatic head, statistically
likely
representing a side-branch IPMN. Further evaluation with
noncontrast MRCP in 6 months is recommended to ensure stability.
___ CT HEAD ___ CONTRAST:
1. New right hemispheric subdural hematoma measuring up to 3 mm
from the inner table without significant mass effect.
2. Otherwise unchanged right parafalcine subdural hematoma,
right frontal
intraparenchymal hematoma, left parietoccipital subarachnoid
hemorrhage.
___ MR HEAD W/ & ___ CONTRAST:
1. Grossly unchanged right parafalcine and frontal lobe subdural
hematoma and right frontal intraparenchymal hematoma. No
evidence of new intracranial hemorrahge.
2. No evidence of suspicious intracranial lesions, mass effect,
or
hydrocephalus.
3. Punctate hyperintense cortical focus in the right posterior
frontal lobe, likely related to blood products or tiny
infarction
4. No evidence of stenosis, occlusion, or aneurysm in the major
intracranial arteries.
5. No definite MRI signs of diffuse axonal injury within the
limitation of
motion limited GRE images.
___ MR ___/ & ___ CONTRAST:
1. Unchanged T8 vertebral body compression fracture and
retropulsion of the intervertebral disc without evidence of
abnormal cord signal or worsening cord compression.
2. Stable epidural hematoma extending from the T6-T8 vertebral
bodies.
3. Multilevel degenerative changes in the thoracic and lumbar
spine are
unchanged.
4. Chronic compression deformity of the L1 vertebral body,
unchanged
___ CTA ABD & PELVIS:
1. Increase in size of a left anterior thigh hematoma without
evidence of
active extravasation.
2. Enlarging subcarinal lymph node now measuring up to 16 mm in
short axis. Further evaluation with CT chest could be performed
for further evaluation if clinically indicated.
3. Cystic lesions within the pancreas are stable from prior, the
largest of which measures 12 mm possibly representing a
side-branch IPMN.
4. Colonic diverticulosis without evidence of diverticulitis.
5. Reactive pelvic and inguinal lymphadenopathy is stable from
prior.
6. Subacute T8 compression fracture and chronic L1 compression
fracture are stable.
___ CXR
IMPRESSION:
Compared to chest radiographs ___ through ___.
Lung volumes are persistently low, but nevertheless greater
mediastinal venous engorgement and mild pulmonary edema are
recognizable and moderate cardiomegaly has increased. Pleural
effusion small if any. Healed fracture deformities left mid rib
should not be mistaken for lung lesions.
___ Ultrasound Face
IMPRESSION:
Scans show it appears to be just it diffuse enlargement of the
left parotid gland, without hypervascularity and without any
focal solid or cystic lesions. This may represent parotitis.
___ CXR
IMPRESSION:
In comparison with the study of ___, there again are low
lung volumes. The chin of the patient substantially obscures the
superior mediastinum. Cardiomediastinal silhouette is stable.
The degree of pulmonary edema has decreased. Given the low lung
volumes and size of the cardiac silhouette, it would be very
difficult to exclude a retrocardiac aspiration/pneumonia in the
appropriate clinical setting, especially in the absence of a
lateral view.
DISCHARGE LABS:
=============
___ 05:50AM BLOOD WBC: 67.9* RBC: 3.35* Hgb: 8.6* Hct:
30.1* MCV: 90 MCH: 25.7* MCHC: 28.6* RDW: 17.6* RDWSD: 56.9* Plt
Ct: 149*
___ 05:50AM BLOOD Glucose: 114* UreaN: 17 Creat: 0.5 Na:
143 K: 3.8 Cl: 104 HCO3: 25 AnGap: 14
___ 05:50AM BLOOD Calcium: 7.2* Phos: 2.6* Mg: 1.8
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Calcium Carbonate 1000 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. OxyCODONE (Immediate Release) ___ mg PO BID:PRN Pain -
Moderate
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
5. Rosuvastatin Calcium 10 mg PO DAILY
6. Selenium Sulfide ___ mL TP WEEKLY AND AS DIRECTED
7. TraZODone 50 mg PO QHS:PRN sleep
8. Vitamin D ___ UNIT PO DAILY
9. Alendronate Sodium 70 mg PO QSAT
10. Furosemide 20 mg PO PRN edema
11. Hydrocortisone ___ mg PO QID:PRN titrated per patient
12. Opium Tincture (morphine 10 mg/mL) 10 mg PO DAILY:PRN
diarrhea
13. salicylic acid 6 % topical QOD
14. NPH 12 Units Breakfast
NPH 12 Units Bedtime
Regular 8 Units Breakfast
Regular 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl ___AILY:PRN Constipation - Second Line
3. Hydrocortisone Na Succ. 20 mg IV Q8H Duration: 1 Dose
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Multivitamins ___ Chewable 1 TAB PO DAILY
6. Senna 8.6 mg PO BID
7. NPH 12 Units Breakfast
NPH 12 Units Bedtime
Regular 8 Units Breakfast
Regular 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*24 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
10. Rosuvastatin Calcium 10 mg PO QPM
11. Calcium Carbonate 1000 mg PO DAILY
12. Furosemide 20 mg PO PRN edema
13. Levothyroxine Sodium 150 mcg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
15. HELD- Alendronate Sodium 70 mg PO QSAT This medication was
held. Do not restart Alendronate Sodium until you are told to do
so by a physician
16. HELD- Hydrocortisone ___ mg PO QID:PRN titrated per patient
This medication was held. Do not restart Hydrocortisone until
you are told to do so by a physician
17. HELD- Opium Tincture (morphine 10 mg/mL) 10 mg PO DAILY:PRN
diarrhea This medication was held. Do not restart Opium
Tincture (morphine 10 mg/mL) until you are told to do so by a
physician
18. HELD- salicylic acid 6 % topical QOD This medication was
held. Do not restart salicylic acid until you are told to do so
by a physician
19. HELD- Selenium Sulfide ___ mL TP WEEKLY AND AS DIRECTED
This medication was held. Do not restart Selenium Sulfide until
you are told to do so by a physician
20. HELD- TraZODone 50 mg PO QHS:PRN sleep This medication was
held. Do not restart TraZODone until you are told to do so by a
physician
___:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Intraparanchymal Hemorrhage
Subarachnoid Hemorrhage
T8 Compression Fracture
T6-T9 Epidural Hematoma
Left Thigh Hematoma
Secondary Adrenal Insufficiency
Hemorrhagic Shock
Sialoadenitis
Paroxysmal Atrial Fibrilation
Type 1 Diabetes
Encephalopathy
SECONDARY DIAGNOSIS:
====================
CMML
Chronic Venous Stasis Ulcers
Grave's Disease/Hypothyroidism
Osteoarthritis
HLD
Osteoporosis
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - sometimes.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with fall, bruising over left flank, pain over left
ribs// fracture, hemorrhage
TECHNIQUE: Single AP portable view of the chest
COMPARISON: ___
FINDINGS:
There are low lung volumes. Patchy left base opacity is seen which could be
due to atelectasis, pneumonia, aspiration, or pulmonary contusion in the
setting of trauma. No large pleural effusion though a trace left pleural
effusion be difficult to exclude. Cardiac silhouette is enlarged. Subtle
irregularity of the posterior left seventh rib could represent a fracture,
although not definitely substantiated on subsequent CT.
IMPRESSION:
Low lung volumes. Patchy left base opacity could be due to atelectasis,
pneumonia, aspiration, and/or pulmonary contusion in the setting of trauma.
No large pleural effusion, though trace left pleural effusion be difficult to
exclude.
Subtle irregularity of the posterior left seventh rib could represent a
fracture, although not definitely substantiated on CT.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall, bruising over left flank, pain over left
ribs. Evaluate for fracture, hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.8 cm; CTDIvol = 48.1 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 6.0 s, 6.3 cm; CTDIvol = 48.1 mGy (Head) DLP =
301.0 mGy-cm.
Total DLP (Head) = 1,204 mGy-cm.
COMPARISON: Head CT from ___.
FINDINGS:
A focal 2.3 x 1.3 x 0.9 cm cm (series 601, image 46) intraparenchymal hematoma
is present in the right paramedian frontal lobe, with surrounding mild edema.
Adjacent right parafalcine subdural hematoma is seen measuring up to 0.6 cm in
width. Additional linear bilateral parafalcine densities in the sulci are
consistent with subarachnoid hemorrhage.
Nonspecific periventricular white-matter hypodensities are again demonstrated,
probably reflecting sequela of chronic microangiopathy. There is prominence
of the ventricles and sulci suggestive of involutional changes.
There is no evidence of acute fracture. Mild mucosal thickening and mucous
retention cyst are present in the right maxillary sinus. Small amount
fluid/opacity is seen in inferior left mastoid air cells.
IMPRESSION:
1. Focal 2.3 x 1.3 x 0.9 cm right frontal intraparenchymal hematoma with
surrounding mild edema. Adjacent right parafalcine subdural hematoma measures
up to 0.6 cm in width, 3.5 cm in length.
2. Bilateral parafalcine acute subarachnoid hemorrhage.
3. No acute fracture.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with fall, bruising over left flank, pain over left ribs.
Evaluate for fracture, hemorrhage.
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 8.5 s, 0.5 cm; CTDIvol = 40.9 mGy (Body) DLP =
20.5 mGy-cm.
2) Spiral Acquisition 7.3 s, 57.1 cm; CTDIvol = 26.9 mGy (Body) DLP =
1,536.4 mGy-cm.
Total DLP (Body) = 1,557 mGy-cm.
COMPARISON: CT of the abdomen and pelvis from ___. Chest CT from
___.
FINDINGS:
LOWER CHEST: There is a basilar right middle lobe and lingular atelectasis.
Underlying aspiration is not excluded. The heart is mildly enlarged.
Coronary calcifications are again demonstrated. There also aortic valve
calcifications. There is no pericardial effusion.
ABDOMEN:
HEPATOBILIARY: A well-circumscribed hypodensity/cyst in right hepatic lobe is
largely unchanged. Additional small subcentimeter hypodensities, primarily in
the right hepatic lobe are too small to characterize. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas is atrophic. A 1.5 cm cystic lesion is seen in the
body of the pancreas (series 4, image 31). 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: Stomach is collapsed. No bowel obstruction is seen.
Duodenal diverticulum is seen along the proximal third portion of the
duodenum. Scattered diverticulosis of the colon is noted, without evidence of
wall thickening and fat stranding. The appendix is normal.
PELVIS: The urinary bladder is moderately distended. The 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.
BONES: A compression fracture of the T8 vertebral body with 3 mm of
retropulsion resulting in mild spinal canal narrowing is increased as compared
to the prior study. This deformity is associated with focal prevertebral soft
tissue thickening, suggestive of an acute on chronic fracture.
A chronic compression fracture of L1 is largely unchanged. Chronic fractures
are seen on the 10th rib on the left, and on the ___ and 10th ribs on the
right. Post-operate changes of L4 laminectomies are seen. Multilevel
degenerative changes of the thoracolumbar lumbar spine, with grade 1
anterolisthesis of L3 over L4 are largely unchanged.
SOFT TISSUES: A partially imaged soft tissue density measuring approximately
7.5 x 7.7 x 4.0 cm and compatible with a hematoma is seen lateral to the left
proximal femur. There is surrounding soft tissue stranding associated with
the hematoma extending superiorly to the level of the left iliac crest. Small
amount of fluid/edema is seen in the midline along the lower anterior abdomen,
in the region of the umbilicus.
IMPRESSION:
1. Concern for acute on chronic compression fracture of the T8 vertebral body
with 3 mm of retropulsion resulting in mild spinal canal narrowing.
2. Partially imaged hematoma measuring up to 7.7 cm within the soft tissues
lateral to the proximal left femur.
3. Incompletely characterized 1.5 cm cystic lesion in body of the pancreas,
for which nonemergent MRCP is recommended.
RECOMMENDATION(S): Nonemergent MRCP for further characterization cystic
lesion in the body of the pancreas.
Radiology Report
INDICATION: History: ___ with polyneuropathy, CMML, T1DM on insulin woh
presents for evaluation following traumatic fall on L, significant
ecchymosisoverlying L femur// eval for fx in setting of fall
TECHNIQUE: AP view of the pelvis in AP and lateral views of the left femur
and AP and lateral and oblique views of the left knee, 8 total images
COMPARISON: None.
FINDINGS:
No definite acute fracture is seen. The oblique view of the knee is limited
in and underpenetrated. There are mild to moderate bilateral hip degenerative
changes. The pubic symphysis and sacroiliac joints are not widened.
Multilevel degenerative changes of the partially imaged lower lumbar spine are
partially imaged. Minimal to no suprapatellar joint effusion is seen. There
is mild patellar enthesopathy and tiny posterior patellar spurs. Vascular
calcifications are seen.
IMPRESSION:
The oblique view of the knee is suboptimal due to underpenetration and
technique. Otherwise, no evidence of acute fracture.
Radiology Report
INDICATION: History: ___ with polyneuropathy, CMML, T1DM on insulin woh
presents for evaluation following traumatic fall on L, significant
ecchymosisoverlying L femur// eval for fx in setting of fall
TECHNIQUE: AP view of the pelvis in AP and lateral views of the left femur
and AP and lateral and oblique views of the left knee, 8 total images
COMPARISON: None.
FINDINGS:
No definite acute fracture is seen. The oblique view of the knee is limited
in and underpenetrated. There are mild to moderate bilateral hip degenerative
changes. The pubic symphysis and sacroiliac joints are not widened.
Multilevel degenerative changes of the partially imaged lower lumbar spine are
partially imaged. Minimal to no suprapatellar joint effusion is seen. There
is mild patellar enthesopathy and tiny posterior patellar spurs. Vascular
calcifications are seen.
IMPRESSION:
The oblique view of the knee is suboptimal due to underpenetration and
technique. Otherwise, no evidence of acute fracture.
Radiology Report
EXAMINATION: MR THORACIC SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: History: ___ with T8 compression fracture and LLE weakness IV
contrast to be given at radiologist discretion as clinically needed// cord
compression cord compression
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: CT of the thoracic spine from ___
FINDINGS:
Recent T8 compression fracture with approximately 75% vertebral body height
loss and evidence of approximately 7 mm retropulsion which results in severe
spinal canal stenosis with compression of the spinal cord but no definitive
evidence of cord signal abnormality.
There is severe bilateral neural foraminal narrowing at T8-T9.
Note is made of a thin right, intrinsic T1 epidural collection spanning along
the posterior aspect of the T6-T7 to T8-T9 vertebral bodies, most consistent
with a small epidural hematoma.
There is also anterior bulging of the T8 vertebral body with associated
prevertebral soft tissue edema spanning from T7 through T9.
Note is made of an old T3 vertebral body compression fracture which appears
significantly sclerotic on the prior CT. A mild T6 superior endplate
compression deformity appears unchanged. Additionally, there is mild superior
endplate compression deformities of the L1 and L2 vertebral bodies. The L1
vertebral body appears similar to the CT from ___. However, the L2
vertebral body is not identified. Given that there is no STIR signal
hyperintensity in the L2 vertebral body, this deformity is also considered
most likely chronic.
Vertebral body alignment is otherwise preserved. There is mild diffuse
intervertebral disc disease throughout the thoracic spine. Aside from the
fracture site, there is no spinal canal stenosis or significant neural
foraminal narrowing.
Subcentimeter hyperdense lesion in the right liver lobe (series 8, image 15)
most likely represents a hepatic cyst.
IMPRESSION:
1. Recent T8 compression fracture with approximately 75% vertebral body height
loss and evidence of 7 mm retropulsion resulting in severe spinal canal
stenosis with compression of the spinal cord but no evidence of definitive
cord signal abnormality. Severe bilateral T8-T9 neural foraminal narrowing.
2. Diffuse low signal within the vertebral bodies could be due to anemia or an
infiltrative process. Prominence of paraspinal soft tissues could be due to
fat deposition or due to extramedullary hematopoiesis at the site of
compression fracture (08:11).
3. Despite the abnormal appearance of the bony structures with diffuse low
signal, the presence of a high intensity cleft within the fractured vertebra
suggest posttraumatic component. MRI with gadolinium can help for further
assessment if clinically indicated.
4. Thin epidural hematoma along the right posterior aspect of the T6 through
T9 vertebral bodies.
5. Chronic T3, T6, L1 and L2 superior endplate compression deformities.
6. Prevertebral soft tissue edema extending from T7 through T9.
RECOMMENDATION(S): MRI with gadolinium to further assess the nature of T8
compression fracture.
Radiology Report
EXAMINATION: Thoracic spine radiographs, four views.
INDICATION: Recent T8 compression fracture with cord impingement now in talus
so brace.
COMPARISON: MR from ___.
FINDINGS:
Fracture site is partly obscured on the cross table lateral views, but the
degree of loss in height and alignment appear very similar. Again noted is a
moderate compression fracture of the T8 vertebral body, better characterized
on the recent MR without any definite interval change allowing for differences
in modality.
IMPRESSION:
No definite change in moderate T8 compression fracture.
Radiology Report
EXAMINATION: Left shoulder radiographs, three views.
INDICATION: Left shoulder bruising and reduced motion. T8 compression
fracture with cord impingement.
COMPARISON: ___ and ___.
FINDINGS:
Small inferior acromioclavicular osteophytes, unchanged. Along the anterior
margins of the left first and second ribs, there is some bony hypertrophy,
similar to the prior studies. No evidence for fracture, dislocation or lysis.
IMPRESSION:
No evidence of fracture or dislocation.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Hypotension and labored breathing.
COMPARISON: ___.
FINDINGS:
Lung volumes are very low. Chin flexion obscures the medial right lung apex.
There are also a number of densities obscuring parts of the chest overlying
the patient. Cardiac, mediastinal and hilar contours appear stable. Aside
from some shifting morphology, opacities at each lung base seem similar in
overall extent, to the extent that this can be assessed with portable
radiography, suggesting atelectasis. No definite pleural effusion or
pneumothorax.
IMPRESSION:
Limited study with the fairly similar opacities at each lung base which
suggest atelectasis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with T1DM, adrenal insufficiency on chronic steroids,
CMML, and chronic venous stasis c/b cellulitis x2 (admissions ___ and ___ who presented s/p unwitnessed fall, subsequently found to have
intraparenchymal hemorrhage and T8 compression fracture, managing
non-surgically, transferred to the MICU for concern for hemorrhagic shock from
thigh hematoma.// new hemorrhage or interval change in prior
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
2) Sequenced Acquisition 3.0 s, 12.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
560.5 mGy-cm.
Total DLP (Head) = 1,495 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
Study is degraded by motion. Within these confines:
Grossly stable focal intraparenchymal hematoma in the right paramedian frontal
lobe measuring 2.0 x 1.2 cm, previously measuring 2.3 x 1.3 cm (02:28) is
seen. There is mild interval increase in adjacent vasogenic edema. There is
adjacent right parafalcine subdural hematoma, unchanged in size. Additional
bilateral parietal probable subarachnoid hemorrhage and are slightly again
noted.
Chronic microvascular ischemic and involutional changes are again seen. There
is no evidence of acute territorial infarction or mass. The ventricles and
sulci are grossly stable in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are preserved.
IMPRESSION:
1. Study is degraded by motion.
2. Grossly stable right frontal intraparenchymal and right parafalcine
subdural hematomas with question interval increased edema, as described.
3. Question interval increase in bilateral parietal subarachnoid hemorrhage.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ male neuropsychiatrist with T1DM, adrenal insufficiency on
chronic steroids, CMML, and chronic venousstasis c/b cellulitis x2 (admissions
Feb and ___ whopresented s/p unwitnessed fall, subsequently found to
have intraparenchymal hemorrhage and T8 compression fracture, managing
non-surgically, transferred to the MICU for concern for hemorrhagic shock from
thigh hematoma.// ? tachypnea ? tachypnea
IMPRESSION:
Comparison to ___. The pre-existing pleural effusions have resolved.
Lung volumes have increased, likely reflecting improved ventilation. Left
retrocardiac and right basilar atelectasis persist. No pulmonary edema. No
pneumonia. No pneumothorax.
Radiology Report
EXAMINATION: CTA ABD/PEL WANDW/O C W/REONS
INDICATION: ___ year old man with L thigh hematoma, c/f extension for hematoma
per ___// Please perform GI bleed protocol, extend arterial and venous phase up
to the knee. Eval for interval change in hematoma, ongoing bleeding
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen, pelvis, and proximal bilateral lower
extremities (to the level of the knees).
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 94.7 cm; CTDIvol = 5.3 mGy (Body) DLP = 497.8
mGy-cm.
2) Spiral Acquisition 7.1 s, 93.9 cm; CTDIvol = 11.6 mGy (Body) DLP =
1,089.2 mGy-cm.
3) Spiral Acquisition 7.1 s, 93.9 cm; CTDIvol = 11.6 mGy (Body) DLP =
1,089.5 mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
5) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 13.2 mGy (Body) DLP =
6.6 mGy-cm.
Total DLP (Body) = 2,685 mGy-cm.
COMPARISON: CT abdomen pelvis ___, ___ ___.
FINDINGS:
LOWER CHEST: Interval increase in size of a small nonhemorrhagic layering left
pleural effusion with associated compressive atelectasis. There is right
basilar atelectasis. No pericardial effusion. Coronary artery calcifications
are partially visualized.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There are no suspicious focal lesions. A 4.4 cm simple cyst in the right
hepatic lobe is stable (303:25). There is no intra or extrahepatic biliary
ductal dilatation. The gallbladder is unremarkable. There is no perihepatic
ascites.
PANCREAS: The pancreas is atrophic. A 12 mm hypodense lesion in the pancreatic
head statistically likely represents a side-branch IPMN (303:52). Multiple
side-branch IPMNs were seen on MRCP from ___, though there is no definite
correlate for this lesion, therefore follow-up MRCP in 6 months is recommended
to ensure stability. 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 stones, focal renal lesions, or hydronephrosis. There
is no perinephric abnormality.
GASTROINTESTINAL: Small bowel loops are normal in caliber. There is sigmoid
diverticulosis, without evidence of acute diverticulitis. The rectum is
unremarkable. The appendix is normal. There is no mesenteric
lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder is decompressed by Foley catheter. The distal
ureters are within normal limits. There is no evidence of pelvic or inguinal
lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate does not appear enlarged. Seminal vesicles
are symmetric. There are moderate bilateral hydroceles.
BONES: Patient's known T8 compression fracture is not well seen on the current
exam. There is a chronic compression deformity at L1. Patient is status post
L4 laminectomy. There are multilevel degenerative changes of the
thoracolumbar spine including grade 1 anterolisthesis of L3 on L4. Chronic
rib fractures of the posterior right ninth and tenth ribs and left tenth rib
are unchanged.
VASCULAR:
SOFT TISSUES: There is a large soft tissue hematoma in the anterior
compartment of the left thigh. This hematoma has increased in size compared
to CT from ___, now measuring 8.3 x 14.1 x 21.4 cm (TV x AP x CC).
This hematoma previously measured 4.3 x 8.3 cm in axial diameter but the
craniocaudal dimension was incompletely imaged. There is no evidence of
active bleed. Limited images of the bilateral lower extremities are notable
for bilateral suprapatellar knee joint effusions and extensive subcutaneous
edema in the left thigh.
IMPRESSION:
1. Interval increase in size of a large soft tissue hematoma in the anterior
compartment of the left thigh, now measuring 21.4 x 14.1 x 8.3 cm. No
evidence of active bleed.
2. Interval increase in size of a layering nonhemorrhagic left pleural
effusion with bibasilar atelectasis.
3. 12 mm hypodense lesion in the pancreatic head, statistically likely
representing a side-branch IPMN. Further evaluation with noncontrast MRCP in
6 months is recommended to ensure stability.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with worsening mental status, hx of CML and known
ICH after unwitnessed fall.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
2) Sequenced Acquisition 3.0 s, 12.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
560.5 mGy-cm.
Total DLP (Head) = 1,495 mGy-cm.
COMPARISON: Noncontrast head CTs between ___ and ___
FINDINGS:
New right hemispheric subdural hematoma measuring up to 3 mm from the inner
table without significant mass effect. Unchanged right parafalcine subdural
hematoma measures mm in thickness (series 2, image 29). Unchanged size,
decreased attenuation of a right frontal intraparenchymal hematoma measuring
1.2 cm with similar adjacent hypoattenuation reflecting vasogenic edema. Left
parieto-occipital subarachnoid hemorrhage is not significantly changed (series
2, image 25). No evidence of new hemorrhage or large territorial infarction.
Periventricular, subcortical, and pontine white matter hypodensities are
nonspecific but likely sequelae of chronic small vessel ischemic disease.
There is no evidence of fracture. The imaged paranasal sinuses are clear.
There is nonspecific partial opacification of the left mastoid air cells. The
middle ear cavities are clear.
IMPRESSION:
1. New right hemispheric subdural hematoma measuring up to 3 mm from the inner
table without significant mass effect.
2. Otherwise unchanged right parafalcine subdural hematoma, right frontal
intraparenchymal hematoma, left parietoccipital subarachnoid hemorrhage.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:51 pm, approximately 10
minutes after discovery of the findings.
Radiology Report
EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE
INDICATION: ___ year old man with complex PMH w/ acute on chronic T8
compression fracture who presented s/p fall w/ mild TBI. Patient has new
absent rectal tone and worsening LLE weakness concerning for cord
compression// Evaluate for cord compression Evaluate for cord compression
Evaluate for cord compression
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of Gadavist
contrast agent.
COMPARISON: MRI thoracic spine dated ___. spine MRI of ___.
FINDINGS:
Thoracic spine: There is redemonstration of a compression fracture at the T8
vertebral body with approximately 75% vertebral body height loss with 7 mm of
retropulsion of the intervertebral disc causing severe spinal canal stenosis.
There is no evidence of abnormal cord signal or worsening cord compression at
this level. There is severe bilateral T8-T9 and neural foraminal narrowing,
unchanged from prior study. There is redemonstration of a thin epidural
hematoma spanning along the posterior aspect of the right T6 to T8 vertebral
bodies, unchanged. There is additional anterior bulging of the T8-T9
intervertebral disc with stable prevertebral soft tissue edema.
Lumbar spine: At L1-2 disc bulging is seen. From L2-3 to L4-5 level, there
has been laminectomy. Mild anterolisthesis of L3 over L4 is again seen.
There is no high-grade spinal stenosis. Foraminal narrowing seen previously
are unchanged.
At L5-S1 level, degenerative disc disease and bulging seen with mild bilateral
foraminal narrowing. No change is noted. Multilevel endplate degenerative
changes and chronic compression of L1 vertebra are again seen. No acute
compression fracture is identified.
IMPRESSION:
1. Unchanged T8 vertebral body compression fracture and retropulsion of the
intervertebral disc without evidence of abnormal cord signal or worsening cord
compression.
2. Stable epidural hematoma extending from the T6-T8 vertebral bodies.
3. Multilevel degenerative changes in the thoracic and lumbar spine are
unchanged.
4. Chronic compression deformity of the L1 vertebral body, unchanged
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: ___ year old man with complex PMH w/ acute on chronic T8
compression fracture who presented s/p fall w/ mild TBI.// Evaluate for
underlying lesion I/s/o TBI
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Sagittal and axial T1 weighted imaging were performed along with diffusion
imaging.
Axial imaging was performed with gradient echo, FLAIR, T2, and T1 technique.
Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: CT head dated ___.
FINDINGS:
MR BRAIN:
There is redemonstration of a right interhemispheric and frontal lobe subdural
hematoma, grossly unchanged from prior study. There are additional areas of
blood products in the posterior aspect of the frontal lobe, likely
representing either subarachnoid or intraparenchymal hematoma. There is no
evidence of masses, mass effect, ormidline shift. No evidence of
hydrocephalus. On diffusion images, there is a punctate hyperintense focus in
the posterior frontal lobe. GRE images are limited, but this could represent
a tiny infarct or blood products. Additional diffusion abnormalities are
likely related to blood products. The ventricles are dilated, likely
representing global parenchymal atrophy. There is redemonstration of fluid
within the mastoid air cells and left maxillary sinus.
MRA brain: The intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm formation.
IMPRESSION:
1. Grossly unchanged right parafalcine and frontal lobe subdural hematoma and
right frontal intraparenchymal hematoma. No evidence of new intracranial
hemorrahge.
2. No evidence of suspicious intracranial lesions, mass effect, or
hydrocephalus.
3. Punctate hyperintense cortical focus in the right posterior frontal lobe,
likely related to blood products or tiny infarction
4. No evidence of stenosis, occlusion, or aneurysm in the major intracranial
arteries.
5. No definite MRI signs of diffuse axonal injury within the limitation of
motion limited GRE images.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p endotracheal intubation// Assess ETT position
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT dated ___
IMPRESSION:
There are low bilateral lung volumes. There is a layering left pleural
effusion with subjacent atelectasis. No pneumothorax is visualized. No focal
consolidation is seen on the right. The tip of the endotracheal tube projects
at the level of the thoracic inlet and should be repositioned. An enteric tube
extends to the stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with fall, known SDH, SAH, IPH c/b hemorrhagic
shock ___ hematoma in left leg, new O2 requirement and now with tachypnea.//
?PNA, pulmonary effusion
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. Interstitial edema is
slightly improved. The NG tube has been removed in the interim. There are
healed left-sided rib fractures. Small bilateral effusions left greater than
right are unchanged. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ man with T1DM on insulin, adrenal insufficiency on chronic
steroids, CMML, and chronic venous stasis c/b cellulitis x2 (admissions Feb
and ___ who presented s/p unwitnessed fall, subsequently found to have
TBI and T8 compression fracture with impingement upon the cord managed
medically, course complicated by hemorrhagic shock ___ L Leg hematoma. Now
with tachypnea and dyspnea.// ?aspiration PNA ?aspiration PNA
IMPRESSION:
Compared to chest radiographs ___ through ___.
Lung volumes are persistently low, but nevertheless greater mediastinal venous
engorgement and mild pulmonary edema are recognizable and moderate
cardiomegaly has increased. Pleural effusion small if any. Healed fracture
deformities left mid rib should not be mistaken for lung lesions.
Radiology Report
EXAMINATION: CTA ABD/PEL WANDW/O C W/REONS
INDICATION: ___ year old man with thigh hematoma with concern for active
bleeding// eval for active extrav
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis with extension to the
level of the bilateral knees.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Total DLP (Body) = 2,768 mGy-cm.
COMPARISON: CTA abdomen pelvis ___.
FINDINGS:
LOWER CHEST: Simple appearing left pleural effusion is stable to slightly
smaller from prior with associated compressive atelectasis in the left lower
lobe. Right lower lobe atelectasis is worsened from prior. A 9 mm soft
tissue density in the lateral segment of the right middle lobe may reflect a
focus of rounded atelectasis, attention on follow-up is recommended (02:13).
A 16 mm right-sided subcarinal node has enlarged in comparison to the CT of
the thoracic spine dated ___ (301:5).
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. The 4.3 cm simple cyst in the right hepatic
lobe is stable (303:27). There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is within normal limits, without stones
or gallbladder wall thickening. The main portal vein is patent.
PANCREAS: Pancreas demonstrates normal attenuation throughout. There is no
main ductal dilatation. Numerous cystic lesions are again noted within the
pancreas. For example, a 12 mm hypodensity in the pancreatic head is stable
and most likely represents a side branch IPMN (303:58). 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 stones, focal renal lesions, or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. There is pancolonic diverticulosis, predominantly
involving the sigmoid colon without evidence of diverticulitis. There is no
evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: Urinary bladder is decompressed but does demonstrate abnormal mucosal
enhancement, likely the sequelae of prior Foley catheter placement. The
distal ureters are normal.
REPRODUCTIVE ORGANS: The prostate and vesicles are normal. Simple appearing
fluid is again seen within the scrotum, similar from prior.
VASCULAR: No retroperitoneal or mesenteric lymphadenopathy. Prominent pelvic
sidewall nodes are stable and likely reactive. Enlarged inguinal nodes
measuring up to 16 mm in short axis are stable from prior and also felt to be
likely reactive (303:55)
BONES: The patient's known subacute T8 compression fracture is again seen. A
chronic L1 compression deformity stable. Patient is status force laminectomy
at the level of L4. Multilevel degenerative changes of the thoracolumbar
spine are again noted including grade 1 anterolisthesis of L3 on L4. Chronic
rib fractures are unchanged.
SOFT TISSUES: Large soft tissue hematoma in the anterior compartment of the
left thigh demonstrates slightly different morphology from prior. The
hematoma is slightly smaller in the transverse dimension but significantly
larger in the craniocaudal dimension. There is no evidence of active
extravasation. The hematoma now measures approximately 38 cm in the
craniocaudal dimension, previously 25 cm (602:70). There are bilateral
suprapatellar knee joint effusions. There is diffuse body wall edema.
IMPRESSION:
1. Increase in size of a left anterior thigh hematoma without evidence of
active extravasation.
2. Enlarging subcarinal lymph node now measuring up to 16 mm in short axis.
Further evaluation with CT chest could be performed for further evaluation if
clinically indicated.
3. Cystic lesions within the pancreas are stable from prior, the largest of
which measures 12 mm possibly representing a side-branch IPMN.
4. Colonic diverticulosis without evidence of diverticulitis.
5. Reactive pelvic and inguinal lymphadenopathy is stable from prior.
6. Subacute T8 compression fracture and chronic L1 compression fracture are
stable.
Radiology Report
EXAMINATION: US SOFT TISSUE HEAD AND NECK (THYROID, PARATHYROID, PAROTID)
INDICATION: ___ year old man with new facial swelling on right side of unclear
etiology.// Evaluate soft tissue swelling right face near angle of
mandible/ear
TECHNIQUE: Grayscale ultrasound and color flow Doppler images were obtained
of the superficial tissues of the -right face with comparison views of the
left side..
COMPARISON: None
FINDINGS:
Imaging was performed over the area of swelling in the right face in the
region of the parotid gland. This was quite tender to palpation, but imaging
with multiple probes at multiple frequencies fail to show any discrete mass,
cystic or solid lesion or fluid collection. The parotid gland itself appeared
to be diffusely enlarged but not hypervascular. Comparison views of the left
side showed a similar appearance all lobes smaller ___ to the left
parotid.
IMPRESSION:
Scans show it appears to be just it diffuse enlargement of the left parotid
gland, without hypervascularity and without any focal solid or cystic lesions.
This may represent parotitis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with slowly rising leukocytosis, mildly worsening
hypoxia, increased work of breathing// Evidence of pneumonia or pulmonary
edema?
IMPRESSION:
In comparison with the study of ___, there again are low lung volumes.
The chin of the patient substantially obscures the superior mediastinum.
Cardiomediastinal silhouette is stable. The degree of pulmonary edema has
decreased.
Given the low lung volumes and size of the cardiac silhouette, it would be
very difficult to exclude a retrocardiac aspiration/pneumonia in the
appropriate clinical setting, especially in the absence of a lateral view.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: s/p Fall
Diagnosed with Adult failure to thrive
temperature: 97.7
heartrate: 79.0
resprate: 16.0
o2sat: 92.0
sbp: 97.0
dbp: 48.0
level of pain: 7
level of acuity: 2.0 | SUMMARY:
========
Dr. ___ is a ___ year old man with T1DM on insulin, adrenal
insufficiency on chronic steroids, CMML, and chronic venous
stasis c/b cellulitis x2 (admissions ___ and ___ who
presented s/p unwitnessed fall, subsequently found to have TBI
and T8 compression fracture with impingement upon the cord. He
was evaluated by Neurosurgery on admission who felt that there
was no role for acute intervention. He was stable until ___
when he was noted to be progressively tachycardic with dropping
BPs, as well as rapidly expanding L thigh hematoma. CBC checked
with Hb 3.3 from 7.3 earlier in day. BPs as low as ___,
improved with fluids and blood. Massive transfusion protocol
initiated and patient transferred to ICU. His Hgb has stabilized
and his last transfusion was ___. No intervention was
necessary to stop the bleeding. He went into Afib during his ICU
stay and was started on amiodarone due to worsening hypotension
with trial of beta blockers. Patient transferred to medicine
service ___ again once stable and remained he remained
stable until ___ when he was again noted to be hypotensive
with SBP in ___, and tachypneic to ___, with concern for
re-expanding L thigh hematoma. SBP improved to ___ with ~1L IVF.
CTA in ICU revealed no active extravasation into left thigh and
a negligibly larger hematoma. Ultimately it was felt that his
hypotension this time was due to too rapid of tapering his
stress dose steroids. His steroid dose was increased and his
blood pressures stabilized. He was again transferred to a
medicine service where he remained stable until discharge. He
was worked up for a coagulopathy with elevated INR by our
hematology service. They felt that his coagulopathy was most
likely nutritional and patient was given 10mg po vitamin K for 4
days. ___ followed patient while hospitalized to assist with
titration of his insulin dosing while blood sugars labile in the
setting of stress dose steroids. Endocrinology followed after
second transfer back to medicine service to assist with taper of
stress dose steroids. Prior to discharge amiodarone was
discontinued due to long QTc. Patient remained in sinus rhythm
despite holding amiodarone and he was not started on an
alternative rate or rhythm control agent. ___ and OT evaluated
patient while admitted and felt that safest discharge plan would
be for him to go to rehab for further recovery before going
home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right SDH vs. ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ (AKA ___ is a ___ yo male with history
of developmental delay, stroke, DM, HTN, who is transferred to
___ from ___ on ___ with a TBI.
He was found down at his group home and was more confused than
baseline. He was unable to ambulate or get into wheelchair
without assistance.
Neuro exam at ___ was significant for Ox0 (unclear baseline),
___
BUE, ___ BLE and pinpoint pupils. His RR was ___, so was
intubated due to concern for potential deterioration. Head CT
was
done which showed a right occipital EDH vs SDH. He was
subsequently transferred to ___ ED for neurosurgery
evaluation.
Past Medical History:
-Developmental delay (per ___ notes)
-HTN
-HLD
-Depression
-DM II with diabetic retinopathy, nephrophathy, and diabetic
neuropathy
-Osteoporosis
-Hip fracture x2
-Toe osteomyelitis ___
-CVA ___
-PVD
Social History:
___
Family History:
Non-contributory
Physical Exam:
On Admission:
-------------
Physical Exam:
O: T: 97.0 BP: 136/74 HR: 60 RR: 9 O2 Sat: 100% ETT
GCS at the scene: 10 @ OSH
GCS upon Neurosurgery Evaluation: 10T (E3V1M6)
Time of evaluation: 19:40
Airway: [x]Intubated [ ]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[x]3 Opens eyes to voice
[ ]4 Opens eyes spontaneously
Verbal:
[x]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[ ]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam:
Gen: elderly male intubated and sedated. sedation held for exam
Extrem: warm and well perfused
Neuro:
Mental Status: intubated; EO to voice
Orientation: intubated
If Intubated:
[ ]Cough [ ]Gag [x]Over breathing the vent
Cranial Nerves:
I: Not tested
II: Pupils pinpoint. Visual fields unable to assess.
III, IV, VI: midline gaze
V, VII: Facial appears symmetric
VIII: Hearing intact to voice.
IX, X: + gag and cough
XI: unable to assess
XII: attempts to sick out tongue around tube
Motor:
follows commands to squeeze bilateral hands and show thumbs up
bilaterally. wiggles bilateral toes to command. Does not lift
legs antigravity but moves in plane on bed. Briefly holds arms
antigravity if lifted.
Sensation: difficult to assess
On Discharge:
-------------
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [ ]Place - "rehab in ___ [ ]Time
Baseline is oriented to self only and intermittent place
Follows commands: [x]Simple [ ]Complex [ ]None
Pupils: PERRL 2mm reactive
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
Pt has difficulty with fine motor exam - following complex
commands
Moving BUE spontaneously and independently - ___ in strength
Moving BLE spontaneously and independently and equally : ___
Increased tone noted in all four extremities
[x]Sensation intact to light touch
Pertinent Results:
Please see OMR for relevant laboratory and imaging results.
Medications on Admission:
-Acetaminophen 975 mg PO Q8H:PRN Pain - Mild
-Atorvastatin 80 mg PO QPM*
-FLUoxetine 20 mg PO DAILY
-irbesartan 150 mg oral DAILY*
-MetFORMIN (Glucophage) 1000 mg PO BID*
-Metoprolol Succinate XL 50 mg PO DAILY*
-Repaglinide 0.5 mg PO TIDAC*
-Tradjenta (linagliptin) 5 mg oral DAILY*
-amLODIPine 5 mg PO DAILY
-Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Third Line
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
4. Docusate Sodium 100 mg PO BID
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. Glucose Gel 15 g PO PRN hypoglycemia protocol
7. Heparin 5000 UNIT SC BID
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
10. Senna 8.6 mg PO BID:PRN Constipation - Second Line
11. Tradjenta (linaGLIPtin) 5 mg oral DAILY
12. amLODIPine 5 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Atorvastatin 80 mg PO QPM
15. Ferrous Sulfate 325 mg PO DAILY
16. FLUoxetine 20 mg PO DAILY
17. irbesartan 150 mg oral DAILY
18. MetFORMIN (Glucophage) 1000 mg PO BID
19. Metoprolol Tartrate 25 mg PO BID
20. Multivitamins 1 TAB PO DAILY
21. Repaglinide 0.5 mg PO TIDAC
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right subdural hematoma
urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Trauma.
COMPARISON: None available.
FINDINGS:
Patient is been intubated. Endotracheal tube terminates about 4 cm above the
carina. An orogastric tube terminates in the stomach. Heart is normal in
size. Mediastinal and hilar contours appear within normal limits. There is
no pleural effusion or definite pneumothorax although it is noted that the
Left costophrenic sulcus is deeper than the right and not fully imaged.. No
displaced fracture is found.
IMPRESSION:
No definite injury, however somewhat deep left costophrenic sulcus.
Correlation with planned CT is recommended regarding the possibility of
pneumothorax. Findings discussed with Dr. ___ at 7:48 pm by
telephone 1 minute after discovery.
Radiology Report
EXAMINATION: CT torso
INDICATION: History: ___ with fall from standing, AMS, no rectal tone***
WARNING *** Multiple patients with same last name!// Please evaluate for
spinal fractures, abdominal injuries
TECHNIQUE: Contiguous axial images were obtained through the chest, abdomen
and pelvis without intravenous contrast. Coronal and sagittal reformats were
performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.4 s, 74.1 cm; CTDIvol = 15.9 mGy (Body) DLP =
1,173.9 mGy-cm.
Total DLP (Body) = 1,174 mGy-cm.
COMPARISON: None
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury based on an unenhanced scan. The heart, pericardium,
and great vessels are within normal limits. Extensive coronary artery
calcifications are noted. Trace pericardial fluid is likely physiologic.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There are ___ opacities in the right upper lobe and
mild dependent atelectasis. Lungs are otherwise clear. Endotracheal tube
terminates approximately 2 cm above the level the carina. Airways are patent
subsegmental levels bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration within the limitation of an
unenhanced scan.There is no perihepatic free fluid. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout. The pancreatic duct
is moderately dilated immediately upstream of the ampulla within the head
measuring 5-6 mm, although it is not dilated along the distal part of the
pancreas. Biliary ducts are not dilated.. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration within the limitation of an unenhanced
scan.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. Contrast in the
collecting systems from prior contrast enhanced exam is noted. Duplicated
collecting system on the left side is noted. No hydronephrosis. No focal
renal lesions within limitations of an unenhanced scan. There is no
perinephric abnormality.
GASTROINTESTINAL: Stomach is unremarkable. An enteric tube terminates in the
region of the pylorus. Small bowel loops demonstrate normal caliber. There
is diffuse wall thickening of the rectum and distal sigmoid colon. Colon is
otherwise unremarkable. Appendix is not definitively visualized. There is no
evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS:
Bladder contains a Foley catheter and is opacified with contrast. There is no
free fluid in the pelvis. The Left renal collecting system is duplicated.
Separate ureters seem to join very shortly before entering the bladder.
REPRODUCTIVE ORGANS: Prostate and seminal vesicles are unremarkable. Artifact
from left hip prosthesis limits evaluation.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Moderate atherosclerotic disease is noted.
BONES: There is no acute fracture. No focal suspicious osseous abnormality.
Left total hip arthroplasty is noted. Chronic right inferior pubic ramus
fracture is noted.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of acute intrathoracic or intraabdominal injury within the
limitation of an unenhanced scan.
2. ___ opacities in the right upper lobe of the lung, possibly
infectious, inflammatory, or related to prior aspiration.
3. Diffuse wall thickening of the rectum and distal sigmoid colon suggesting
colitis of inflammatory, ischemic, or infectious etiology.
4. Mildly dilated proximal pancreatic duct. This is probably not significant
clinically but sequela of chronic inflammation or very early evidence for a
main duct intra ductal papillary mucinous neoplasm cannot be excluded. It may
be appropriate to consider MRCP follow-up, depending on clinical
circumstances, in ___ months to reassess in addition to correlation with
laboratory data.
Radiology Report
INDICATION: ___ year old man with TBI, now febrile// infectious workup
TECHNIQUE: AP portable chest radiograph
COMPARISON: None
FINDINGS:
There is mild bibasilar atelectasis. No focal consolidation, pleural effusion
or pneumothorax is identified. The size of the cardiac silhouette is within
normal limits.
IMPRESSION:
No focal consolidation. Mild bibasilar atelectasis.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: s/p Fall, Transfer
Diagnosed with Unsp focal TBI w/o loss of consciousness, init, Unspecified fall, initial encounter
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: ett
level of acuity: 1.0 | ___ year old male with right SDH vs. EDH.
#Right SDH vs. EDH
Patient was admitted for close neurologic monitoring. He was
extubated and was determined to be at his neurologic baseline.
He remained neurologically stable throughout his hospitalization
and at his baseline on day of discharge.
#Lip swelling
The patient was noted to have swelling of his upper lip, likely
due to trauma from intubation. He did not have any respiratory
compromise and swelling improved over his hospital stay.
#Fever
Patient was febrile on ___, urinalysis was concerning for UTI
so he was started on 3 day course of IV ceftriaxone. He
completed 2 days of his ceftriaxone course and was transitioned
to Ciprofloxacin 500mg BID x 5 days to complete his treatment.
#Discharge planning
The patient was evaluated by physical therapy who recommended
discharge to rehab. Anticipate rehab length of stay less than
30 days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Nickel
Attending: ___.
Chief Complaint:
Nausea, Jaundice
Major Surgical or Invasive Procedure:
___: Upper EGD with EUS with biopsy
.
___: Flex bronch/EBUS-TBNA
.
___:
1. Bilateral PTBD, resulting in placement of right and left
internal-external biliary drains.
2. Brushings and radial forceps biopsies from central hilar
stricture.
3. Pushing of ERCP placed plastic stent into the duodenum.
.
___:
1. Right-sided pullback cholangiography.
2. Balloon dilatation of a stenosis in the right anterior
system duct.
3. Percutaneous removal of the ___ endoscopically placed
plastic biliary stent.
4. Placement of a new 10 ___ internal-external biliary drain
via the right-sided access.
5. Pullback cholangiography via the left-sided access.
6. Placement of a new 10 ___ internal-external biliary drain
via the left-sided access.
History of Present Illness:
Mr ___ is a pleasant ___ with HTN, s/p ERCP ___ for
obstructive jaundice now s/p stenting, that re-presents to the
ED with complaint of nausea, itching, decreased appetite. Today
the patient was called by pcp to come ___ a lab draw
revealing his Alk Phos and T. Bili remain elevated. Of note the
patient was recently hospitalized on ___ on the ___ for
one day for obstructive jaundice where he underwent ERCP with
stent placement. Brushings were taken (non-diagnostic). The
patient was then discharged with outpatient follow-up. He was
discharged on PO Ciprofloxacin. The patient returned back in ED
with symptoms of nausea and increased jaundice.
Past Medical History:
# DMII
# HTN
# Chronic nasal congestion
# hx AAA repair
# hx hernia repair
# CKD baseline creatinine 1.4
Social History:
___
Family History:
brother with colon ca, another brother with cancer of unknown
etiology.
Physical Exam:
On admission:
VS: 97.6 119/74 84 18 97% RA
GENERAL: NAD, comfortable, appropriate, jaundiced
HEENT: NC/AT, PERRLA, EOMI, sclerae icteric, MMM, OP clear
NECK: supple, no thyromegaly, no JVD
HEART: PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS: CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, two old surgical scars.
EXTREMITIES: WWP, no c/c/e
SKIN: no rashes or lesions
NEURO: awake, A&Ox3, CNs II-XII intact, muscle strength and
sensation grossly intact
Prior Discharge;
VS: 97.8, 79, 108/72, 18, 98% RA
GEN: AAO x 3, jaundiced, NAD
HEENT: NC/AC, PERRL, EOMI, sclerae interic
CV: RRR, no m/r/g
PULM: CTAB
ABD: Righ flank and midline with PTBD drains to gravity drainage
and draining bile. Sites with drain spounge and c/c/d.
EXTR: Warm, no c/c/e
Pertinent Results:
___ 07:10AM BLOOD WBC-10.2 RBC-3.33* Hgb-10.5* Hct-32.2*
MCV-97 MCH-31.5 MCHC-32.6 RDW-17.0* Plt ___
___ 07:10AM BLOOD Glucose-106* UreaN-11 Creat-1.2 Na-137
K-4.1 Cl-102 HCO3-25 AnGap-14
___ 07:10AM BLOOD ALT-69* AST-117* AlkPhos-261*
TotBili-14.8*
___ 07:10AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.1
___ 11:48AM BLOOD %HbA1c-5.9 eAG-123
___ 06:00AM BLOOD TSH-3.1
___ 06:20AM BLOOD CEA-1.9
IGG SUBCLASSES 1,2,3,4
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
IMMUNOGLOBULIN G SUBCLASS 1 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 2 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 3 84
___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 4 525.2 H
4.0-86.0 mg/dL
IMMUNOGLOBULIN G, SERUM ___ H
___ mg/dL
___ CA ___ - 164
___ CTA ABD:
IMPRESSION:
1. Malignant strictures along the CBD, one near the liver hilum
and one along the mid extent of CBD as demonstrated on prior
reference MRI from one week prior. Patient is status post ERCP
and CBD stenting, and these areas are poorly assessed.
2. Allowing for lack of delayed phase imaging, no discernable
hepatic hilar mass or intraparenchymal hepatic mass. Persistent
but mildly improved intrahepatic biliary dilatation. Recommend
further assessment by MRI to definitively exclude
cholangiocarcinoma, and correlate with CBD brushing results.
(Particuarly given reference MRCP on file had no post contrast
imaging).
3. Large progressively enhancing pancreatic tail mass could
represent either primary neuroendocrine tumor of the pancreas,
less likely adenocarcinoma, or metastatic lesion to the
pancreas. This could also be further delineated at the time of
MRI.
4. Multiple bilateral renal cysts, some of which calcified.
5. Large anterior left thigh lipomatous mass with minimal
internal complexity could represent either a lipoma or, much
less likely, low-grade liposarcoma. Correlation to more remote
prior exam would be helpful if available. Consider further
characterization by MRI to guide tissue sampling.
___ MRCP:
IMPRESSION:
1. 3.5 cm mass-like lesion at the hepatic hilum which is
obstructing the right and left hepatic ducts, appearance most
concerning for Klatskin type
cholangiocarcinoma. However, it is notable that with the
presence of a focal pancreatic lesion (described below) which
has the appearance of autoimmune pancreatitis, that IgG4-related
cholangiopathy can present with
circumferential biliary wall thickening and stricturing with
obstructive
jaundice, and can be difficult to differentiate on imaging from
cholangiocarcinoma.
The common bile duct is thickening and enhancing, it is not
possible to
delineate if this is secondary to the indwelling stent or a ___
lesion.
There is a biliary stent within the common bile duct; however
the stent does not extend through this lesion to decompress
either the right or left
intrahepatic ductal systems. There is a 1.8 cm node adjacent to
the inferior vena cava.
2. 7 cm mass within the pancreatic tail which is unusual
appearance. While
primary pancreatic tumors such as primary pancreatic
adenocarcinoma or
neuroendocrine tumor might have this appearance, appearances are
more
suggestive of focal autoimmune pancreatitis. Cytology from EUS
aspiration is pending.
3. Bilateral simple renal cysts, the largest measuring 15.6 cm
at the left
upper pole.
4. Marked atherosclerotic disease of the abdominal aorta.
Pathology Examination:
SPECIMEN SUBMITTED: PROXIMAL CBD (1 JAR)
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___
DIAGNOSIS:
Proximal common bile duct, biopsy (A): Strips of atypical
glandular epithelium, favor reactive.
___ CYTOLOGY: NON-DIAGNOSTIC
___ LYMPH NODE CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS.
Lymphocytes, consistent with lymph node sampling.
___ BILE DUCT BRUSHING CYTOLOGY: ATYPICAL CELLS
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Oxymetazoline 1 SPRY NU BID:PRN nasal congestion
5. Sodium Chloride Nasal ___ SPRY NU BID:PRN nasal congestion
6. HydrOXYzine 50 mg PO BID itching
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. HydrOXYzine 50 mg PO BID itching
3. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*4 Tablet Refills:*0
4. Sodium Chloride Nasal ___ SPRY NU BID:PRN nasal congestion
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*6 Tablet Refills:*0
6. Ondansetron ___ mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth every twelve (12)
hours Disp #*6 Tablet Refills:*0
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
8. Omeprazole 20 mg PO DAILY
9. Oxymetazoline 1 SPRY NU BID:PRN nasal congestion
10. pioglitazone-metformin *NF* ___ mg Oral qd
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Common bile duct stricture
2. Hepatic hilum mass
3. Pancreatic tail mass
4. Mediastinal lymphadenopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with biliary obstruction, prior studies
suggesting obstruction in the liver hilum, also has a pancreatic tail mass,
raising question of IgG4 autoimmune pancreatitis versus cholangiocarcinoma,
pathology specimens are pending.
PHYSICIAN: ___, M.D., fellow, performed the procedure. ___
___, M.D., attending, was supervising the procedure.
FLUOROSCOPY TIME: 9 minutes 36 seconds.
MEDICATIONS: Moderate sedation was provided by administering divided doses of
fentanyl totaling 150 mcg and Versed totaling 2 mg throughout the total
intraservice time of 45 minutes, during which the patient's hemodynamic
parameters were continuously monitored.
PROCEDURES: Left and right lobe over the wire cholangiography with bilateral
biliary drain exchange.
PROCEDURE DETAILS: Informed consent was obtained from the patient. He was
positioned supine. The area was prepped and draped in sterile fashion. A
timeout was performed. Fluoroscopy was used intermittently.
Both tubes were cut at the hub and the skin retention sutures were also cut.
___ wires were advanced through both tubes through the end hole and into
the duodenum distally. Both tubes were removed and exchanged with 6 ___
___ sheaths. The sheaths were injected with contrast in various
positions to opacify the biliary tree and multiple images were obtained,
detailed in findings as below. A rotational acquisition was also obtained,
but unfortunately due to a technical malfunction could not be broken down into
axial images. 8 ___ internal-external biliary drains were then placed, the
left lobe drain was unmodified, the right lobe drain had 4 cm of additional
sideholes cut proximal to the radiopaque marker. There were no immediate
complications.
FINDINGS: There are two separate areas of disease seen. There is diffuse
irregularity and narrowing of the mid to lower portion of the common bile
duct. It is unclear whether this represents a pathologic stricture or could be
a reactive or inflamatory response related to the multiple procedures, both
ERCP and percutaneous. There is a significant stricture affecting the most
cephalad portion of the common bile duct, common hepatic duct and extending
into the left and right hepatic ducts. On the right side, it extends to
involve the bifurcation of the anterior and posterior ducts. There is no
clearcut duodenal involvement during this examination. A small duodenal
diverticulum is incidentally noted.
CONCLUSION:
1. Uncomplicated over-the-wire cholangiography with findings as detailed
above suggestive for liver hilar mass extending into both lobes and a possible
second area of involvement of the mid-to-lower CBD.
2. Should this prove to be an inoperable malignancy, the patient will require
a separate access into the right anterior ducts and for this reason will need
to return with general anesthesia at the time of that procedure. Of note, the
differential could still include IgG4 related autoimmune pancreatitis (though
biliary distribution in that process is similar to PSC). Pathology results are
still pending at this time.
Radiology Report
INDICATION: ___ man with biliary obstruction status ___ PTBD x 2
placement with persistent high bilirubin, please upsize drains to 10 ___.
PHYSICIANS: Dr. ___ (radiology fellow) and Dr. ___
___ (radiology attending) who was present throughout and supervised the
procedure.
MEDICATION: The procedure was performed under moderate conscious sedation.
The patient received 350 mcg of fentanyl and 6.5 mg of Versed in divided doses
for the total intraservice time of 2 hours and 43 minutes during which time
the patient's hemodynamic parameters were continuously monitored. In
addition, the patient received 4 mg of Zofran IV and 400 mg of Ciproxin IV.
PROCEDURES:
1. Right-sided pullback cholangiography.
2. Balloon dilatation of a stenosis in the right anterior system duct.
3. Percutaneous removal of the ___ endoscopically placed plastic biliary
stent.
4. Placement of a new 10 ___ internal-external biliary drain via the
right-sided access.
5. Pullback cholangiography via the left-sided access.
6. Placement of a new 10 ___ internal-external biliary drain via the
left-sided access.
PROCEDURE DETAILS:
Following discussion of the risks, benefits and alternatives to the procedure,
informed written patient consent was obtained. The patient was brought to the
angiographic suite and placed supine on the table. A preprocedure timeout was
performed using three patient identifiers. The skin of the anterior abdominal
wall was prepped and draped in the usual sterile fashion including both
indwelling 8 ___ biliary drains.
Approximately 10 cc of 1% lidocaine was infiltrated into the skin and
subcutaneous tissues surrounding both drains. An initial scout image
demonstrated unchanged positioning of both drains. Initially, we assessed the
right-sided drain. The catheter was cut and ___ wire was advanced
through the catheter into the duodenum. The catheter was removed and a 7
___ ___ Tip sheath was advanced over the wire and a pullback
cholangiogram was performed. This demonstrated a persistent hilar stricture
in the distal portion of the right anterior duct extending into the right
posterior duct. An Amplatz wire was passed through the sheath and this was
left as a safety wire, the sheath was repositioned over the ___ wire only
and at the level of the confluence of the right anterior and posterior ducts.
Using a Glidewire and a Kumpe catheter, we successfully accessed right
anterior duct. The Glidewire was exchanged for ___ wire and the Kumpe
catheter was removed. Balloon dilatation was performed initially with a 6-mm
x 4-cm long balloon; however, this was not fully inflated as it was felt to be
too large, this was removed and a 4 mm x 2 cm balloon was deployed instead.
This was inflated over the area of stricturing with a clear waist seen which
opened up after balloon dilatation.
We then assessed the left side. Again, the catheter was cut and a Glidewire
was used to pass through the catheter tubing, the catheter was removed and a
Kumpe catheter was passed over the wire which was then exchanged for an
Amplatz wire for better security. The Kumpe catheter was removed and
exchanged for an 8 ___ ___ Tip sheath. Of note, the plastic biliary
stent which had previously been displaced into the duodenum was wedged against
the duodenal wall and had not moved since the initial displacement.
Therefore, we elected to try to retrieve this. Using the 8 ___ left-sided
sheath, we initially attempted to snare the distal tip of the stent using an
Ensnare device, this was not successful, therefore, we redirected our efforts
using the right-sided access. The sheath was upsized to an 8 ___ sheath
and with considerable difficulty, we successfully snared the tip of the stent,
dislodging it from the duodenal wall. It was not possible to withdraw the
biliary stent into the sheath completely, it was partially within the sheath,
however. So, this was withdrawn en bloc leaving the safety wire through the
ampulla. Having completed this maneuver, a new 10 ___ biliary drain was
advanced over the wire and positioned in the duodenum. The wire and
introducer were removed, the pigtail was formed and the catheter was secured
to the skin with 0 silk suture and a StatLock device. Given the extensive
manipulation for the removal of the biliary stent, the drains have been left
attached to bags overnight. The sheath was also removed from the left side
and a new 10 ___ drain was advanced over that wire and positioned in the
duodenum. Injection of contrast via both drains at the termination of the
procedure demonstrated minimally dilated intrahepatic ducts and free flow of
contrast into the duodenum. There were no immediate post-procedure
complications.
IMPRESSION:
1. Technically successful upsizing of right and left biliary drains, 10
___ drains are now in situ.
2. Successful but technically challenging percutaneous removal of a retained
plastic biliary stent impacted in the duodenal lumen .
Radiology Report
HISTORY: Proximal and mid common bile duct strictures concerning for
malignancy, mediastinal lymphadenopathy and pancreatic tail mass. Please
assess mass in liver as well as mucinous mass in pancreas.
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 (10 ml). 2.5 mL
of Gadavist with 75 mL of water was administered orally prior to the
procedure.
COMPARISON: CT ___.
FINDINGS:
The liver parenchyma is of normal signal and morphology on T1 and T2 weighted
imaging, no signal drop-off on out of phase imaging when compared to in phase
T1 weighted imaging to indicate fatty deposition. There is marked
intrahepatic biliary dilatation slightly more prominent within the left lobe
but not significantly changed from the recent CT. There is an ill-defined
mass-like region at the hepatic hilum which involves and obstructs the central
aspects of the left and right hepatic ducts and the superior portion of the
common hepatic duct. It is difficult to tell based on our imaging whether
this is from a focal mass, eccentric mass, or circumferential thickening of
the biliary wall in this region. It is best visualized on the non contrast
and delayed phase imaging T1 weighted imaging (10,51 and 1204, 56) and
measures approximately 3.5 x 3.2 cm. There is a biliary stent within the
common bile duct however the stent does not extend through the lesion to
decompress either the right or left intrahepatic ducts. The superior aspect
of the stent is approximately 1.5 cm from the closest intrahepatic duct. The
common bile duct is thickened and enhancing, it is not possible to identify if
this relates to a further lesion or the indwelling stent. The lesion abuts
the left and right portal veins however both remain patent. There is
conventional hepatic arterial anatomy, the main, right and left hepatic
arteries are patent and appear uninvolved. No further liver lesions.
There is a 1.9 x 1.5 cm node anterior to the IVC (1204, 79). No further
adenopathy.
There is a 7.0 x 3.0 cm mass involving the pancreatic tail which is isointense
to the pancreatic parenchyma on T2 weighted imaging and slightly hypointense
on T1 weighted imaging (5, 41 and 4, 19). It demonstrates restricted
diffusion on diffusion-weighted imaging (900, 11). Post administration of
contrast it is hypoenhancing on arterial phase imaging demonstrating
progressive enhancement on more delayed phase imaging. The main pancreatic
duct is not visualized within this lesion. The remainder of the pancreas is
unremarkable. No pancreatic duct dilatation. No further pancreatic lesions.
The spleen is unremarkable. There is a 2.0 cm circumscribed lesion adjacent
to the lower pole of the spleen and the pancreatic tail which follows the
signal characteristics of the spleen on post-contrast and diffusion weighted
imaging and most likely represents a small splenunculus.
There are bilateral simple renal cysts, the largest is a 15 cm renal cyst
arising from the lower pole of the left kidney. No suspicious renal lesion or
hydronephrosis. No adrenal lesion.
There is marked atherosclerosis of the abdominal aorta without significant
stenosis of the superior mesenteric, celiac or bilateral renal arteries. The
aorta measures 3.4 cm in maximal anteroposterior dimension.
The visualized small and large bowel are unremarkable. Normal signal within
the visualized skeletal system. No abnormality identified at the visualized
lung bases.
3D reformations including MinIP reconstructions of the biliary tree were
created on an independent workstation.
IMPRESSION:
1. 3.5 cm mass-like lesion at the hepatic hilum which is obstructing the right
and left hepatic ducts, appearance most concerning for Klatskin type
cholangiocarcinoma. However, it is notable that with the presence of a focal
pancreatic lesion (described below) which has the appearance of autoimmune
pancreatitis, that IgG4-related cholangiopathy can present with
circumferential biliary wall thickening and stricturing with obstructive
jaundice, and can be difficult to differentiate on imaging from
cholangiocarcinoma.
The common bile duct is thickening and enhancing, it is not possible to
delineate if this is secondary to the indwelling stent or a ___ lesion.
There is a biliary stent within the common bile duct; however the stent does
not extend through this lesion to decompress either the right or left
intrahepatic ductal systems. There is a 1.8 cm node adjacent to the inferior
vena cava.
2. 7 cm mass within the pancreatic tail which is unusual appearance. While
primary pancreatic tumors such as primary pancreatic adenocarcinoma or
neuroendocrine tumor might have this appearance, appearances are more
suggestive of focal autoimmune pancreatitis. Cytology from EUS aspiration is
pending.
3. Bilateral simple renal cysts, the largest measuring 15.6 cm at the left
upper pole.
4. Marked atherosclerotic disease of the abdominal aorta.
This result was discussed with Dr ___ # ___ by telephone at 2pm on
___.
5. Recommend correlation with IgG4 levels given the possibility of autoimmune
pancreatitis and IgG4 related biliary strictures. This was emailed to Dr.
___ on ___, at 12:16 AM.
Radiology Report
BODY 3D
INDICATION: ___ man with question of liver/CBD/pancreatic cancer,
already had CT, please evaluate liver volumes of lobes and segments.
3D LIVER IMAGING: Using 3D reformations, liver volumes were calculated. The
total liver volume is ___ cc, right hepatic lobe 1025 cc, left hepatic lobe
947 cc, left lateral segment 470 cc, and caudate lobe 39 cc.
Radiology Report
INDICATION: ___ year-old patient with proximal and mid CBD strictures
concerning for malignancy. The patient is status post ERCP placed stent which
is however not crossing the hilar stricture. PTBD requested.
OPERATORS: Dr. ___ (fellow) and Dr. ___ (attending)
performed the procedure.
PROCEDURES PERFORMED:
1. Bilateral PTBD with placement of 8 ___ internal-external biliary
drains.
2. Pushing of existing plastic biliary stent into duodenum.
3. Brushings and forceps biopsies obtained from hilar stricture.
MEDICATIONS: Full anesthesia was induced.
PROCEDURE DETAILS:
After discussion of the risks, benefits, and alternatives to the procedure
with the patient, written informed consent was obtained. The patient was
brought to the angiography suite and placed supine on the imaging table. A
preprocedure timeout and huddle were performed as per ___ protocol. General
anesthesia was induced. The right upper quadrant was prepped and draped in
the usual sterile fashion.
Ultrasound was used to obtain sequential, first right posterior, then left
peripheral duct access using a 21-gauge Cook needle, which was passed
centrally. After successful access to the bilateral biliary tree was
obtained, 0.018 inch Headliner wires were advanced centrally. Over those, the
needle was replaced for the outer or inner portions of an AccuStick system.
While the outer portion of the AccuStick system on the right side was
exchanged for a 6 ___ sheath over ___ wire, the inner portion on the
left was used to advance a stiff Glidewire through and then exchange for a 6
___ sheath.
At this stage, injection of contrast demonstrated tight stenosis of the right
and left hepatic ducts at the level of the confluence with only minimal
passage of contrast down the CBD. Using the combination of Kumpe catheters
and stiff Glidewires, the crossing of the stricture was eventually achieved
bilaterally, and the wires were passed down the CBD and into the duodenum.
Exchange for stiff Amplatz wires was performed over the Kumpe catheters. In
an attempt to push out the previously (by ERCP) placed CBD plastic stent into
the duodenum, the bilateral 6 ___ sheath were sequentially advanced into
the proximal CBD. However, this did not result in dislodging of the stent.
Accordingly, the bilateral sheaths were withdrawn partially, and a Kumpe
catheter and stiff Glidewire from the right side used to cannulate the distal
end of the stent. Finally, we managed to access the stent with the Glidewire
and cannulate and advance it through the entire stent and into the duodenum.
The 6 ___ sheath was carefully pulled back and a ___ F then reinserted over
the Glidewire only, thus leaving the Amplatz wire as a safety access. The
sheath dilator was reinserted and the sheath then slowly advanced, pushing the
stent into the duodenum. The Glidewire was removed, and the sheath then
pulled back distal to the level of the stricture. Brushings and radial
forceps biopsies were obtained from the stricture.
Finally, the sheaths were removed, and two 8 ___ biliary drains advanced
over the indwelling Amplatz wires. The pigtails were coiled in the duodenum
and fixation to the skin performed by 0 silk sutures and StatLock devices.
FINDINGS:
1. Indwelling ERCP placed plastic stent which does, however, not cross the
central hilar biliary duct stricture.
2. Almost complete occlusion of right and left-sided ducts at the level of
the confluence.
3. Moderate dilatation of intrahepatic right and left-sided ducts.
IMPRESSION:
1. Bilateral PTBD, resulting in placement of right and left internal-external
biliary drains.
2. Brushings and radial forceps biopsies from central hilar stricture.
3. Pushing of ERCP placed plastic stent into the duodenum.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABNORMAL LAB VALUE
Diagnosed with JAUNDICE NOS, OBSTRUCTION OF BILE DUCT
temperature: 99.0
heartrate: 81.0
resprate: 16.0
o2sat: 97.0
sbp: 114.0
dbp: 66.0
level of pain: 3
level of acuity: 3.0 | ___ DMII (diet), HTN, recently undergoing ERCP for obstructive
jaundice s/p stenting now presenting with increased Alk Phos and
T. Bili.
Obstructive Jaundice: The pt was admitted following a recent
ERCP bx that revealed atypical cells. A CT Scan on admission
showed a malignant appearing strictures along the CBD. The pt
was without fever, leukocytosis or other SIRS criteria to
suggest ascending cholangitis, however was empirically started
on Cipro. CA-19 slightly elevated. Patient's abdomina CTA and
MRCP demonstrated hepatic hilum lesion, common bile duct
stricture, and pancreatic tail mass.
The patient was transferred from Medicine Service to HPB Surgery
Service on ___.
His Cytology report from pancreatic mass and common bile duct
brushing was non-diagnostic. On ___ patient completed
cardiac evaluation by Medicine Service and was found to have low
risk level for cardiac complications. On ___ patient
underwent flexible bronchoscopy with mediastinal lymph node
biopsy, and bilateral PTBD placement with brushing. Patient was
empirically started on Cipro and Flagyl to prevent cholangitis.
Patient's T.Bili started to downward on ___. The patient's
diet was advanced to clears and patient tolerated diet well.
Cytology from mediastinal lymph biopsy and CBD brushing was non
diagnostic. Patient's diet was advanced to regular on ___. On
___ patient underwent cholangiography, which demonstrated liver
hilar mass extending into both lobes and a possible second area
of involvement of the mid-to-lower CBD. The patient continue to
have large daily output from his bilateral PTBDs, and his T.
Bilirubin decreased to 15. Dr. ___ PTBD catheter
upsize. On ___, patient underwent CT-guided biliary catheter
exchange to ___. Post procedure patient's diet was advanced to
regular. Patient's IGG 4 result returned back high (525). The
patient was discharged home on ___ in stable condition. He was
discharged home with open drains to gravity drainage as T. Bili
and output still high. The patient was discharged home with ___
service to check his labs on ___ and help to monitor PTBDs
output. Prior discharge the patient was educated about signs and
symptoms of dehydration and importance to drink adequate amount
of fluid while drains still open. He verbalized understanding.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. Labwork was routinely followed;
electrolytes were repleted when indicated.
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:
Jaundice, Epigastric pain
Major Surgical or Invasive Procedure:
Liver Biopsy ___
EGD ___
History of Present Illness:
Ms. ___ is a ___ female with no significant
past medical history who presents to the hospital for evaluation
of new onset painless jaundice. She reports that she was in her
usual state of health until the prior week. She reports that
she
got her flu shot approximately 1 week ago. She reports that
over
the course of the last week she has had significant epigastric
pain with radiation to the back. She reports that she has had
several episodes of feeling chills with uncontrolled shaking.
She is uncertain if this pain is associated with food. She does
report that has some association with nausea. She reports that
she has had normal bowel movements. She has been taking
Pepto-Bismol so is uncertain if her stool has changed color.
Prior to taking the Pepto-Bismol over the course of the last
several weeks that her stool has stayed the same normal brown
color. She reports that her urine has significantly darkened
over the course of the last ___ days. She specifically denies
any
Tylenol use. She reports no other family history of liver
disease. She reports that she woke up on the day of admission
and noticed that she is yellow and that she was urinating very
dark urine. Given that she presented initially to an outpatient
clinic which then referred her to the ___
emergency
department who then referred her to the ___ emergency department for further evaluation and
management.
In the emergency department she was seen and evaluated. Her
initial vital signs were notable for a BP of 178/149 which on
recheck was 178/98. Remainder of her vital signs were
unremarkable. She was afebrile. She had labs that were drawn
that were notable for an ALT of 170 and AST of 171, alkaline
phosphatase of 148, total bilirubin of 13.6, and an albumin of
3.4. Her CBC was notable for thrombus cytopenia with a platelet
count of 115. Her lactate was noted to be 1.7. She underwent a
right upper quadrant ultrasound which showed spinal megaly
measuring up to 18.3 cm. She had a diffusely echogenic liver.
She had no evidence of cholelithiasis or acute cholecystitis.
She was seen by the liver consult team who given her lack of
medical history and factors for chronic liver disease concerning
for painless jaundice in the setting of a pancreatic malignancy.
They also noted however that she had spinal megaly and therefore
may have portal vein hypertension. They recommended an MRCP to
further evaluate her liver parenchyma. They also recommended
sending a series of studies. Recommended admission to medicine
for further evaluation and management.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
PAST MEDICAL/SURGICAL HISTORY:
The patient denies any significant medical history. She reports
seasonal allergies.
SOCIAL HISTORY:
___
FAMILY HISTORY: Reviewed and found to be not relevant to this
illness/reason for hospitalization. She specifically denies any
family history of liver disease. She reports that her mother
and
brother have both had their gallbladders out.
Past Medical History:
VITALS: 97.9 PO 167 / 96 67 18 94 RA
GENERAL: Alert and in no apparent distress
EYES: Scleral icterus, 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, tender to palpation in the
right
upper quadrant and epigastric region. Obese. 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: Jaundice present. No other 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
Social History:
___
Family History:
See HPI
Physical Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Scleral icterus, 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, tender to palpation in the
right
upper quadrant and epigastric region. Obese. 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: Jaundice present. No other rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 05:50PM BLOOD WBC-4.4 RBC-4.39 Hgb-14.2 Hct-41.2 MCV-94
MCH-32.3* MCHC-34.5 RDW-13.4 RDWSD-45.9 Plt ___
___ 05:50PM BLOOD ___ PTT-27.7 ___
___ 05:50PM BLOOD Glucose-101* UreaN-10 Creat-0.8 Na-140
K-3.6 Cl-100 HCO3-23 AnGap-17
___ 05:50PM BLOOD ALT-170* AST-171* AlkPhos-148*
TotBili-13.6*
___ 05:50PM BLOOD Albumin-3.4*
___ 05:54AM BLOOD calTIBC-286 Ferritn-279* TRF-220
___ 05:54AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 05:54AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
ANCA-NEGATIVE B
___ 05:54AM BLOOD IgG-714 IgA-208 IgM-118
___ 05:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge labs
___ 06:55AM BLOOD WBC-5.2 RBC-3.98 Hgb-13.1 Hct-38.3 MCV-96
MCH-32.9* MCHC-34.2 RDW-14.3 RDWSD-50.6* Plt ___
___ 06:55AM BLOOD Glucose-114* UreaN-7 Creat-0.6 Na-140
K-3.9 Cl-101 HCO3-26 AnGap-13
___ 06:55AM BLOOD ALT-77* AST-76* AlkPhos-111* TotBili-4.8*
___ 06:55AM BLOOD Albumin-3.4* Calcium-8.4 Phos-2.7 Mg-2.0\
EGD
Grade A esophagitis was seen in the gastroesophageal junction.
Protruding Lesions 1 cords of grade I varices were seen in the
gastroesophageal junction.
Stomach:
Mucosa: Patchy friability, erythema, congestion and erosion of
the mucosa with contact bleeding were noted in the antrum. These
findings are compatible with gastritis. Cold forceps biopsies
were performed for histology at the stomach antrum and stomach
body.
Duodenum: Normal duodenum.
Impression: Grade A esophagitis in the gastroesophageal junction
Varices at the gastroesophageal junction
Friability, erythema, congestion and erosion in the antrum
compatible with gastritis (biopsy)
Otherwise normal EGD to third part of the duodenum
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. levocetirizine 5 mg oral DAILY
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Lisinopril 20 mg PO DAILY
3. Omeprazole 20 mg PO BID Duration: 8 Weeks
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every four
hours Disp #*15 Tablet Refills:*0
5. levocetirizine 5 mg oral DAILY
6. HELD- Ibuprofen 400 mg PO Q8H:PRN Pain - Mild This
medication was held. Do not restart Ibuprofen until for the next
5 days as you had a biopsy and we don't want you to bleed
Discharge Disposition:
Home
Discharge Diagnosis:
Cirrhosis
Splenomegaly, Hyperbilirubinemia, Abnormal LFTS and concern for
PSC or Autoimmune hepatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with RUQ pain, jaundice// Cholecystitis, CBD
dilation
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears diffusely echogenic, with heterogeneous
appearance and contours involving predominantly the left hepatic lobe. The
main portal vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 18.3 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Diffusely echogenic hepatic echotexture with heterogeneous appearance and
lobular liver contour involving predominantly the left hepatic lobe, not fully
characterized on this exam. A dedicated CT or MR exam can be obtained for
further evaluation/characterization.
2. No evidence of cholelithiasis or acute cholecystitis.
3. Splenomegaly, measuring up to 18.3 cm
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with painless jaundice with RUQUS// Please eval
for obstruction, Pancreatic head mass
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 3.0 T magnet.
Intravenous contrast: 9 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Ultrasound dated ___.
FINDINGS:
Lower Thorax: Visualized lungs are clear. There is no pleural effusion.
Liver: There is atrophy of the left lobe of the liver, mild hypertrophy of the
caudate lobe and nodular appearance of the liver contour consistent with
morphologic changes of cirrhosis. Reticular delayed enhancement within the
left lobe and anterior segments of the right lobe are suggestive of hepatic
fibrosis. There is no evidence of hepatic steatosis. There is no suspicious
arterially enhancing liver lesion or centrally obstructing mass.
Biliary: The gallbladder is left-sided located between segments II/III and IV.
Small focal cystic changes are noted at the gallbladder fundus which may
represent adenomyomatosis. There are no gallstones. There is mild dilatation
of the central intrahepatic bile ducts.
Pancreas: The pancreas is normal in morphology and signal intensity. There is
no evidence of a solid pancreatic. 4 mm cystic in the pancreatic body (series
5, image 23) may represent a side branch IPMN. Main pancreatic duct is normal
in caliber.
Spleen: The spleen is enlarged measuring 15.2 cm in craniocaudal length. No
focal splenic lesion identified.
Adrenal Glands: Adrenal glands are unremarkable.
Kidneys: The right kidney is slightly inferiorly displaced and rotated
compared to the left. The kidneys are otherwise normal in size and
demonstrate normal cortical medullary differentiation. 11 mm simple
peripelvic cyst noted. There is no hydronephrosis.
Gastrointestinal Tract: Visualized small and large bowel loops are in
caliber. Note is made a 10 mm diverticulum arising from the third portion of
the duodenum.
Lymph Nodes: There are no enlarged retroperitoneal or mesenteric lymph nodes.
Vasculature: Abdominal aorta is normal in caliber. Main mesenteric branch
vessels are normal in caliber and patent. Hepatic arterial anatomy is
conventional. The portal vein, SMV and splenic vein are patent. Note is made
dilated portosystemic collaterals, including splenorenal shunts, suggestive
portal hypertension.
Osseous and Soft Tissue Structures: No suspicious osseous or soft tissue
lesion.
IMPRESSION:
1. Cirrhotic liver morphology with hepatic fibrosis predominantly in the left
lobe and anterior segments of the right lobe and evidence of portal
hypertension.
2. Mild dilatation of the central intrahepatic bile ducts without evidence of
a central obstructive mass.
3. Left-sided gallbladder are noted as an anatomic variant.
4. 4 mm cystic lesion in the body of the pancreas is likely a side branch
IPMN. Follow-up MRCP in ___ year is recommended for reassessment.
RECOMMENDATION(S): Follow-up MRCP in ___ year for reassessment of a 4 mm cystic
lesion in the pancreas.
Radiology Report
INDICATION: ___ year old woman with hyperbilirubinemia, splenomegaly and
negative MRCP with concern for PSC or autoimmune hepatitis.// Liver biopsy to
rule out autoimmune hepatitis. Right and left lobe biopsies requested by liver
team. concern for PSC
COMPARISON: Abdominal ultrasound from ___.
MRCP from ___
PROCEDURE: Ultrasound-guided non-targeted liver biopsy.
OPERATORS: Dr. ___ trainee and Dr. ___ radiologist.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the right and
left hepatic lobes was performed and a suitable approach for non targeted
liver biopsy was determined.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
Based on the preprocedure imaging, 2 appropriate skin entry sites for the
biopsy was chosen. The sites were marked. The skin was then prepped and
draped in the usual sterile fashion. The superficial soft tissues to the
liver capsule were anesthetized with 10 mL 1% lidocaine. Under real-time
ultrasound guidance, an 18 gauge core biopsy needle was then advanced into the
liver and a single core biopsy sample was obtained and placed in formalin.
The skin was then cleaned and a dry sterile dressing was applied. There was no
immediate complications.
SEDATION: Moderate sedation was provided by administering divided doses of
2.5 mg Versed and 100 mcg fentanyl throughout the total intra-service time of
18 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse. During the procedure the
patient's blood pressure was noted to be elevated with systolic pressure
measuring 208. 5 mg of IV hydralazine was administered with subsequent
systolic blood pressures in the 160s.
IMPRESSION:
Uncomplicated non-targeted liver biopsy of the left and right hepatic lobes.
Gender: F
Race: NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
Arrive by AMBULANCE
Chief complaint: Jaundice
Diagnosed with Unspecified jaundice
temperature: 98.1
heartrate: 72.0
resprate: 18.0
o2sat: 95.0
sbp: 178.0
dbp: 149.0
level of pain: 0
level of acuity: 3.0 | ___ female without significant medical history who
presents with one week of worsening jaundice and prandial
epigastric pain found to have elevated transaminitis with
bilirubin to 13, now improving.
1. Jaundice, Hyperbilirubinemia, abnormal LFTs, Epigastric pain,
Splenomegaly - MRCP with evidence of cirrhosis primarily in the
left lobe, and anterior right lobe, with mild dilatation of
central intrahepatic portal ducts. Also with evidence of portal
hypertension including splenomegaly. Serologic work-up has been
negative for viral etiologies or autoimmune hepatitis. ___ have
a biliary stricture or obstruction leading to more focal atrophy
of her liver. S/p liver biopsy on ___.
[ ] will need f/u with Dr. ___ in 2 weeks (see below)
2. EGD on ___ notable for esophagitis for which she has been
started on omeprazole 20mg bid for 8 weeks.
3. Epigastric pain - had significant pain during liver biopsy
yesterday complicated by severe HTN. ___ will see her in f/u but
they are not concerned about procedural complications at this
time. the pain is in same location as the pain she presented
with. Her epigastric pain worsened significantly after liver
biopsy; discussed with ___ no concern for post procedural
complication given. She was discharged on a limited amount of
oxycodone to help manage her pain at home.
3. Hypertension: No prior h/o HTN but hypertensive to 170's on
admission and was started on captopril which has been titrated
up to 37.5 tid. She was converted to lisinopril on discharge.
Discussed with her at length the need to find a PCP and for her
to have ongoing medication titration. She had an episode of
dizziness when she received her blood pressure medication and
oxycodone at the same time.
Transitional Issues: EGD with grade 1 varices, no need for
treatment at this time. Should have repeat EGD in ___ years. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
atorvastatin
Attending: ___.
Chief Complaint:
recurrent lateral cellulitis and sinus tract
Major Surgical or Invasive Procedure:
left tibia/fibula irrigation and excisional debridement of bone
for infection, removal of hardware, application of negative
pressure dressing ___, ___
left ankle I&D, removal of hardware ___, ___
History of Present Illness:
___ yo female with history of ORIF L ankle fracture by Dr.
___. She has had multiple clinic visits for slow
recovery including one course of Keflex given in ___. Over
the last week she has had worsening pain, erythema and drainage
from her left lateral malleolus, the pain has become so severe
with walking that she is now using a walker. She denies any
fevers or other systemic symptoms. She was seen at urgent care
and referred in for evaluation by orthopedics.
Past Medical History:
BENIGN NEOPLASM OF THE PANCREAS
OSTEOPENIA
SEBORRHEIC KERATOSIS
OSTEOARTHRITIS OF HANDS
RIGHT BUNION AND HAMMER TOE
SUI
HYPERTENSION
HYPERLIPIDEMIA
L ANKLE FX
Social History:
___
Family History:
NC
Physical Exam:
Exam on discharge:
Exam:
Vitals: AVSS
General: Well-appearing, breathing comfortably on RA.
MSK:
Left lower extremity:
-Incision clean, dry intact
-Fires ___
-SILT s/s/sp/dp/t nerve distributions distally
-Foot WWP
Pertinent Results:
please see OMR
Medications on Admission:
Vitamin D ___ UNIT PO DAILY
Fish Oil (Omega 3) 1000 mg PO DAILY
Fluticasone Propionate NASAL 1 SPRY NU DAILY
Lisinopril 5 mg PO DAILY
Multivitamins 1 TAB PO DAILY
Omeprazole 20 mg PO DAILY
Pravastatin 40 mg PO QPM
raloxifene 60 mg oral QAM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY Duration: 4 Weeks
3. Calcium Carbonate 500 mg PO TID
4. CeFAZolin 2 g IV Q8H Duration: 6 Weeks
___ to ___
5. Docusate Sodium 100 mg PO BID
hold for loose stools
6. Heparin Flush (10 units/ml) 2 mL IV ONCE MR1 For PICC
insertion Duration: 1 Dose
7. TraMADol ___ mg PO Q4H:PRN pain
RX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
8. Vitamin D ___ UNIT PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Lisinopril 5 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Pravastatin 40 mg PO QPM
15. raloxifene 60 mg oral QAM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
recurrent left ankle lateral cellulitis and sinus tract
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with pain// eval hardware
TECHNIQUE: Left ankle, three views
COMPARISON: Left ankle radiographs ___
FINDINGS:
Patient is status post ORIF of medial and lateral malleolar fractures
transfixed by lateral plate with multiple screws as well as pins and cerclage
wires extending through the medial malleolus. There is no change in
alignment, and minimal perihardware lucency about the syndesmotic screws
appears similar. There is no new fracture or dislocation. The osseous
structures are demineralized, likely from disuse. The ankle mortise remains
symmetric. There are no concerning lytic or sclerotic osseous abnormalities.
Diffuse soft tissue swelling is noted in the distal leg.
IMPRESSION:
No acute fracture or dislocation. Status post ORIF of medial and lateral
malleolar fractures without new hardware complications or change in alignment.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with left ankle pain// pre op
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Streaky right base opacity could be due to atelectasis, underlying infection
is not entirely excluded. There is a hiatal hernia with retrocardiac
air-fluid level seen. No pleural effusion or pneumothorax is seen. Cardiac
and mediastinal silhouettes are unremarkable.
IMPRESSION:
Streaky right base opacity most likely due to atelectasis, underlying
infection is not excluded. Hiatal hernia.
Radiology Report
INDICATION: ___ year old woman s/p removal of hardware// f/u s/p hardware
removal- AP and lateral only
COMPARISON: Radiographs from ___.
IMPRESSION:
There has been removal of most of the hardware within the distal tibia and
fibula. There remains an interfragmentary screw within the fibula. There is
soft tissue swelling. Mild degenerative changes of the tibiotalar joint.
Mineralization is relatively preserved.
Radiology Report
INDICATION: ___ year old woman s/p removal of hardware on IV abx.// Failed
PICC placement at bedside. Rehab today pending PICC placement.
TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the
procedure.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: None
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.5 min, 7 mGy
PROCEDURE:
1. Single lumen PICC placement through the right brachial vein.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the right
brachial vein was punctured under direct ultrasound guidance using a
micropuncture set. Permanent ultrasound images were obtained before and after
intravenous access, which confirmed vein patency. A peel-away sheath was then
placed over a guidewire. The guidewire was then advanced into the superior
vena cava using fluoroscopic guidance. A single lumen PIC line measuring 38 cm
in length was then placed through the peel-away sheath with its tip positioned
in the distal SVC under fluoroscopic guidance. Position of the catheter was
confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and
guidewire were then removed. The catheter was secured to the skin, flushed,
and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Brachialvein approach single lumen right PICC with tip in the distal SVC.
IMPRESSION:
Successful placement of a right 38 cm brachial approach single lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Ankle pain
Diagnosed with Pain in left ankle and joints of left foot
temperature: 97.0
heartrate: 98.0
resprate: 16.0
o2sat: 100.0
sbp: 140.0
dbp: 69.0
level of pain: 4
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 recurrent left ankle lateral cellulitis and sinus tract
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for left tibia/fibula
irrigation and excisional debridement of bone of infection,
removal of hardware, application of negative pressure dressing,
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. ID was consulted. Please see their
note for full details. Per their recommendations, the patient
was started on Vancomycin pending sensitivities. The patient was
taken back to the OR on ___ for left ankle I&D, removal of
hardware. 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. The patient was given ___ antibiotics
and anticoagulation per routine. The patient's home medications
were continued throughout this hospitalization. The patient was
switched to IV Cefazolin on ___ per ID's recommendations. The
patient received a PICC line. The patient is weight-bearing as
tolerated in an air cast boot in the left lower extremity, and
will be discharged on Aspirin for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. The patient
worked with ___ and in combination with case management,
discharge to rehab was deemed appropriate. Patient stay at rehab
expected to be less than 30 days. The ___ hospital course
was otherwise unremarkable. The patient expressed readiness for
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Rocephin / IV Dye, Iodine Containing Contrast Media / Phenergan
/ bee sting / Versed / fentanyl
Attending: ___.
Chief Complaint:
Mid abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ well known to the ___ service, who had
a sigmoid colectomy for diverticulitis followed by ___
procedure for anastomotic leak, later reversed with placement of
diverting loop ileostomy. His ileostomy was taken down in
___.
In the middle of last night he awoke with acute onset of focal
supraumbilical abdominal pain, worse than any previous episode.
He reports some mild nausea, but no vomiting. He has been having
bowel movements (as recently as the AM of presentation) and has
been passing flatus. The patient has a known ventral hernia and
has had discussions about repair at a later date during recent
clinic visits. He denies fever. The patient recently had his
second of 3 colonoscopic dilations of his rectal anastomosis
with
a third planned for 2 weeks from now.
Past Medical History:
-Diverticulitis (sigmoid) with involvement of descending colon
-chronic lumbar back pain
-Depression at the time of his hepatitis B diagnosis
-Left hip bursitis
-chronic insomnia
-Erectile dysfunction, non-organic
-Restless leg syndrome, mild
-Sleep apnea, obstructive (Lost weight, no longer on sleep app)
-Hypertension, controlled
-Gout, chronic
-GERD
-Fibromyalgia (old diagnosis, no recent pain meds)
-Asthma
-Allergic rhinitis, seasonal
-HEPATITIS B, ACUTE -___, spontaneously resolved after being on
liver transplant list at ___
-GLAUCOMA, PRIMARY OPEN-ANGLE
Osteopenia-found after having bone pain and being on chronic
steroids for asthma
-Schatzki's ring-diagnosed about ___ years ago
-Right herpes zoster opthalmicus/keratitis-c/b loss of vision in
R eye (now with tunneled vision, and blurry vision)
-left rotator cuff tears with surgical repair X3 ___,
___, also reports R rotator cuff repairs
-R Carpometacarpal joint athritis s/p surgical repair
-EPS study and radiofrequency ablation for SVT in
s/p TRABECULECTOMY
s/p CATARACT REMOVAL, INSERTION OF LENS: RIGHT EYE
s/p UPPER EGD ___, AND ___
-R knee meniscal removal surgery 2X ___ years ago and ___
___
-reports negative HIV test in ___
-reports negative colonoscopy ___ years ago
Past Surgical History:
-LAR for chronic diverticulitis on ___
-HArtmanns on ___
-Hartmanns takedown with diverting ileostomy on ___
Social History:
___
Family History:
Father: GI ulcer history
Physical Exam:
On admission:
VS: 97.7 50 114/55 16 98%
Gen: NAD
CV: RRR S1 S2
Lungs: CTA B/L
Abd: soft, ND, palpable midline supraumbilical defect approx 4x6
cm with reducible contents, but acutely tender to palpation.
Abdomen otherwise non-tender. Midline scar and R sided ileostomy
take-down site well-healed.
Pertinent Results:
___ 05:24AM BLOOD WBC-10.9 RBC-4.74 Hgb-13.4* Hct-41.9
MCV-88 MCH-28.3 MCHC-32.0 RDW-14.8 Plt ___
___ 06:49AM BLOOD WBC-10.4# RBC-4.91 Hgb-14.0 Hct-42.9
MCV-88 MCH-28.6 MCHC-32.7 RDW-15.2 Plt ___
___ 05:55AM BLOOD Glucose-95 UreaN-11 Creat-1.2 Na-141
K-4.0 Cl-104 HCO3-30 AnGap-11
___ 05:24AM BLOOD Glucose-118* UreaN-14 Creat-1.2 Na-138
K-4.1 Cl-101 HCO3-28 AnGap-13
___ 06:49AM BLOOD Glucose-102* UreaN-22* Creat-1.3* Na-137
K-4.4 Cl-105 HCO3-24 AnGap-12
___ 06:49AM BLOOD ALT-19 AST-27 AlkPhos-102 TotBili-0.6
___ 06:59AM BLOOD Lactate-1.4
___ CT A/P:
IMPRESSION:
1. Mild dilatation of the ileum with fecalized contents and
transition point
noted at the small bowel anastomosis in the right hemiabdomen
with collapse of
ileal bowel loops distal to the anastamosis. Findings suggest
early or partial
small-bowel obstruction.
2. Ventral hernia containing a loop of small bowel but without
any evidence
of complications.
___ CT A/P:
IMPRESSION:
1. Progression of contrast through the anastomotic site with
resolution of
the previously noted small bowel partial/early obstruction.
2. Ventral hernia containing a single loop of small bowel
without evidence of
incarceration or obstruction.
Medications on Admission:
___:
-Centrum 0.4 mg-162 mg-18 mg Tab daily
-EpiPen 0.3 mg/0.3 mL (1:1,000) IM Injector as directed
-Levitra 20 mg PRN
-Restasis 0.05 % Eye gtt, Dropperette in the right eye twice a
day
-Singulair 10 mg daily
-acetaminophen 650 mg Tab q6h PRN pain
-acyclovir 800 mg daily
-allopurinol ___ mg daily
-fluoxetine 20 mg daily
-lorazepam 1 mg qhs:prn
-omeprazole 40 mg
-oxycodone-acetaminophen 5 mg-325 mg Tab ___ times daily PRN
-prednisolone 1 % Eye Drops, 1 Drop Right eye BID, L eye daily
-trazodone 100 mg HS
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
2. cycloSPORINE *NF* 0.05 % ___ twice a day
* Patient Taking Own Meds *
3. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
1 gtt in R eye BID, 1 drop in L eye ___ only
4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
Duration: 2 Weeks
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every four (4) hours Disp #*50 Tablet Refills:*0
5. Mineral Oil ___ mL PO DAILY
You should take this medication to keep your stools soft and
help you go to the bathroom. You can take it daily as you need.
RX *mineral oil 1 by mouth once a day Disp #*14 Bottle
Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
RX *Miralax 17 gram 1 by mouth once a day Disp #*14 Packet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental status: awake, alert, and oriented appropriately
Ambulatory: independent
Condition: good
Followup Instructions:
___
Radiology Report
HISTORY: ___ gentleman with complicated surgical history now with
abdominal pain.
COMPARISON: Multiple prior CTs, most recently from ___.
TECHNIQUE: CT of the abdomen and pelvis was performed with oral contrast. IV
contrast was withheld due to patient's allergy.
FINDINGS: The lung bases and cardiac apex are clear and unremarkable.
Non-contrast appearance of the spleen, bilateral kidneys, bilateral adrenals
and gallbladder are unremarkable. The pancreas is fatty replaced. In the
liver, there are several small hypodensities, including one in segment V
(2:32) which is too small to characterize but stable since prior exams.
Otherwise, non-contrast appearance of the liver is unremarkable. Abdominal
aorta appears normal in its course and caliber. No abdominal or pelvic
lymphadenopathy by CT criteria.
The stomach is filled with oral contrast and not dilated. Oral contrast is
seen within the proximal small bowel only. A ventral hernia is noted
containing a loop of small bowel without evidence of complications. A more
caudally located area of rectus diastasis is noted (2:38).
The patient is status post distal transverse and left colectomy and takedown
of a loop ileostomy with small bowel anastamosis noted in the right
hemiabdomen. Distal to the loop of small bowel within the ventral hernia,
there is fecalization of contents within the ileum leading up to the small
bowel anastomosis (2:39). Additionally, at the small bowel anastamosis, there
is a transition in the caliber of the small bowel with the bowel proximal to
this point dilated to 3.4 cm, and the bowel distal to this point collapsed
(2:42). These findings are suggestive of a partial or early small-bowel
obstruction. No free air or abdominal free fluid is noted.
Post-surgical changes are seen in the right abdominal wall at the site of
prior ileostomy.
CT OF THE PELVIS: The ascending and proximal transverse colon extending to
the colorectal anastomosis (2:67) is essentially unremarkable except for a few
diverticula. The rectum and colorectal anastamosis are unremarkable. Seminal
vesicles, prostate and bladder are unremarkable. No pelvic or inguinal
lymphadenopathy.
BONES: No suspicious lytic or sclerotic lesions are seen.
IMPRESSION:
1. Mild dilatation of the ileum with fecalized contents and transition point
noted at the small bowel anastomosis in the right hemiabdomen with collapse of
ileal bowel loops distal to the anastamosis. Findings suggest early or partial
small-bowel obstruction.
2. Ventral hernia containing a loop of small bowel but without any evidence
of complications.
Radiology Report
INDICATION: ___ male status post sigmoid resection with recent
ileostomy takedown, now with supraumbilical tenderness, evaluate for
progression of contrast through the bowel.
COMPARISONS: CT abdomen and pelvis without contrast, ___.
TECHNIQUE: MDCT axially acquired images were obtained from the dome the liver
to the pubic symphysis without IV or oral contrast. Coronal and sagittal
reformations are provided and reviewed.
DLP: 857.92 mGy-cm.
ABDOMEN: The visualized lung bases are clear. There is no pleural effusion
or pneumothorax. The imaged portion of the heart is normal in size, and there
is no pericardial effusion.
Evaluation of the intra-abdominal contents is limited by the lack of IV and
oral contrast. A hypodensity seen within the inferior portion of the right
lobe and another hypodensity adjacent to the caudate lobe are not fully
characterized but are likely cysts as seen on the CT with contrast from ___. The gallbladder is normal, and there is no intrapancreatic biliary
ductal dilatation. The spleen and adrenal glands are unremarkable. There has
been fatty infiltration of the pancreas. The kidneys are grossly unremarkable
without nephrolithiasis or hydronephrosis. There is no retroperitoneal or
mesenteric lymphadenopathy. There is no free air or free fluid.
A ventral hernia is again noted to contain a loop of bowel without evidence of
incarceration or obstruction. In addition, the previously noted partial small
bowel obstruction with a transition point at the anastomosis has since
resolved. A gastric tube has been placed with its distal tip in the stomach
for decompression, and there has been resolution of small bowel fecalization.
Contrast has progressed from the small bowel into the remaining colon and
rectum.
PELVIS: The bladder and prostate are normal. There is no inguinal or pelvic
sidewall lymphadenopathy. There is no free pelvic fluid.
BONES: There are no suspicious osseous lesions.
IMPRESSION:
1. Progression of contrast through the anastomotic site with resolution of
the previously noted small bowel partial/early obstruction.
2. Ventral hernia containing a single loop of small bowel without evidence of
incarceration or obstruction.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: MID ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, VENTRAL HERNIA NOS
temperature: 97.7
heartrate: 83.0
resprate: 16.0
o2sat: 99.0
sbp: 131.0
dbp: 87.0
level of pain: 5
level of acuity: 3.0 | The patient was admitted to the ACS service for evaluation and
treatment of his abdominal pain on ___. He had acute
supraumbilical pain and tenderness in the setting of a known
ventral hernia without evidence of incarceration or obstruction.
He was admitted for serial abdominal exams and pain control. He
was made NPO and started on IVF. His exam continued to improved
over HD#2 with continued pain medication. He had another CT scan
of his abdomen to evaluate for intra-abdominal changes and it
was negative for acute pathology. He was able to tolerate POs
and his pain resolved by HD#3. The patient was discharged home
with pain medications and recommendations for a bowel regimen at
home. He had appointments previously scheduled with his usual
surgeon, Dr. ___ his GI doctor, ___ follow-up
in ___ weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
latex gloves / Percocet / lisinopril
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with history notable for CAD s/p CABG (LIMA-LAD,
SVG-OM1, SVG-RPDA) in ___, HTN, HLD, CKD, and seizures
presenting for chest pain.
Per his cardiologist's notes, he has a history of atypical chest
pain first documented in ___, with a sharp pinching quality
that
lasts 3 or 4 seconds at a time and is unrelated to physical
exertion. There are no aggravating or alleviating factors and
previous workup has been negative. Exercise stress
echocardiography when these symptoms were first documented found
no evidence of active ischemia.
The patient reports these symptoms have continued to occur
intermittently. However, the sensation worsened in the evening
of
___, and he initially presented to the ED early on ___ for
chest pain and reported left arm numbness. The pain had a hot
quality that worsened with palpation and possibly with rapid
shallow breathing. There was perhaps some positional element to
his pain as it worsened with leaning forward as well as laying
down. He had troponin <0.01 x2 as well as stress echo showing no
inducible ischemia. His chest pain ultimately resolved and he
was
discharged around 5 ___ without symptoms.
At home, he ate a heart-healthy meal and then went to lay down.
While laying down, his symptoms of a pinching sensation "over
the
heart" recurred. This was unlike his GERD pain, which is
typically abdominal. The pain was so severe at home that he had
difficulty walking and his wife had to assist him to a chair. He
took two aspirin and re-presented to the ED, approximately 24
hours after his initial presentation. He endorsed a pressure and
tingling on the left side of his chest above the nipple and a
feeling of decreased sensation where his chest had been shaved
for leads. He had no weakness in his arms or pain. The severe
pain did not persist upon his presentation. He noted no change
in
symptoms during exercise stress echo, and noticed some pain
after
laying in bed afterwards.
- In the ED, initial vitals were: 98.8 57 159/59 14 97% RA
- Exam notable for no acute abnormalities. Clear lungs and
normal
heart sounds. Moving all extremities with normal strength.
- Labs notable for Hgb 11.8, Cr 1.4, troponin <0.01 x2.
- Imaging was notable for:
CT HEAD
1. No acute intracranial process.
2. Right frontal sinus disease, similar to prior.
CTA CHEST (prelim)
No evidence of pulmonary embolism or aortic abnormality.
- Patient was given: 1L NS.
Upon arrival to the floor, patient reports continued
intermittent
pain and a hot sensation that he is increasingly aware of with
massage and deep palpation of the skin above the left nipple. He
has no pain in the arm or shoulder beyond his chronic left
shoulder pain. He continues to endorse altered sensation on the
left chest in the pattern where he was shaved. He has not
noticed
any skin changes in the area. He denies nausea.
Past Medical History:
1. CARDIAC RISK FACTORS
- hypertension
- type II diabetes
- hyperlipidemia
- chronic kidney disease
2. CARDIAC HISTORY
- coronary artery disease s/p CABG (LIMA-LAD, SVG-OM1, SVG-RPDA)
in ___
3. OTHER PAST MEDICAL HISTORY
- seizures
- GERD
- left shoulder arthritis / rotator cuff injury
- h/o detached retina
Social History:
___
Family History:
Reviewed in ___. Parents with CAD in their ___. No family
history
of early MI, arrhythmia, cardiomyopathies, or sudden cardiac
death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
VITALS: ___ 0704 Temp: 98.3 PO BP: 185/70 HR: 67 RR: 18 O2
sat: 96% O2 delivery: RA
GENERAL: Well appearing adult male in no acute distress.
Comfortable. AAOx3.
NEURO: AAOx3. CNII-XII intact. Motor strength ___ in upper and
lower extremities bilaterally. Sensation grossly intact.
HEENT: Normocephalic, atraumatic. EOMI. MMM. No lymphadenopathy.
CARDIAC: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs,
or gallops.
PULMONARY: Clear to auscultation bilaterally. Breathing
comfortably on room air.
ABDOMEN: Soft, non-tender, non-distended. No hepatosplenomegaly.
MSK/EXTREMITIES: Tenderness to palpation of left chest, no
tenderness on right. ___ warm, well perfused, non-edematous.
SKIN: Rings of erythema over the left thorax consistent with
irritation from EKG lead stickers. No obvious rashes over the
chest, abdomen, or back.
DISCHARGE PHYSICAL EXAM
=========================
VITALS: ___ 0532 Temp: 98.9 PO BP: 182/63 L Lying HR: 67
RR:
20 O2 sat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0
GENERAL: Well appearing adult male in no acute distress.
Comfortable.
NEURO: AAOx3.
CARDIAC: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs,
or gallops.
PULMONARY: Clear to auscultation bilaterally. Breathing
comfortably on room air.
Pertinent Results:
ADMISSION LABS
===============
___ 01:00AM BLOOD WBC-6.7 RBC-3.97* Hgb-11.8* Hct-35.6*
MCV-90 MCH-29.7 MCHC-33.1 RDW-13.9 RDWSD-45.3 Plt ___
___ 01:00AM BLOOD Neuts-51.3 ___ Monos-13.5*
Eos-11.6* Baso-0.9 Im ___ AbsNeut-3.46 AbsLymp-1.50
AbsMono-0.91* AbsEos-0.78* AbsBaso-0.06
___ 06:43PM BLOOD ___ PTT-30.1 ___
___ 01:00AM BLOOD Glucose-110* UreaN-15 Creat-1.4* Na-142
K-4.0 Cl-103 HCO3-26 AnGap-13
___ 01:00AM BLOOD cTropnT-<0.01
___ 05:10AM BLOOD cTropnT-<0.01
___ 01:00AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.0
___ 06:49PM BLOOD Lactate-1.1
DISCHARGE LABS
=================
___ 06:34AM BLOOD WBC-6.3 RBC-3.97* Hgb-11.7* Hct-35.7*
MCV-90 MCH-29.5 MCHC-32.8 RDW-14.0 RDWSD-45.6 Plt ___
___ 06:34AM BLOOD Glucose-116* UreaN-12 Creat-1.4* Na-143
K-3.8 Cl-104 HCO3-26 AnGap-13
STUDIES/IMAGES
================
___ CT Head
1. No acute intracranial process.
2. Isolated complete opacification right frontal sinus, stable.
___ CTA Chest
No evidence of pulmonary embolism or aortic abnormality.
MICROBIOLOGY
===============
Urine cultures negative.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LamoTRIgine 200 mg PO BID
2. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram
oral DAILY
3. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
4. Multivitamins 1 TAB PO DAILY
5. MetFORMIN (Glucophage) 250 mg PO BID
6. Losartan Potassium 100 mg PO DAILY
7. Atorvastatin 60 mg PO QPM
8. Aspirin 81 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 650 mg 1 tablet(s) by mouth Q6H PRN Disp #*30
Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % 1 QAM PRN Disp #*30 Patch Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 60 mg PO QPM
6. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram
oral DAILY
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. LamoTRIgine 200 mg PO BID
9. Losartan Potassium 100 mg PO DAILY
10. MetFORMIN (Glucophage) 250 mg PO BID
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses
==================
# Chest pain
# Altered mental status
# Acute Behavioral Changes
# Possible seizure like activity
Secondary diagnoses
====================
# TYPE II DIABETES
# HYPERTENSION
# HYPERLIPIDEMIA
# SEIZURE DISORDER
# GERD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with unsteadiness// eval 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) Sequenced Acquisition 16.0 s, 16.7 cm; CTDIvol = 48.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: MR from ___, CT from ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration for age.
There is no evidence of fracture. There is complete opacification of the
right frontal sinus, with chronic periostitis, no evidence of sinus expansion
or bone destruction, similar to prior. The visualized portion of the
remaining paranasal sinuses, mastoid air cells, and middle ear cavities are
clear. The visualized portion of the orbits show a right scleral band.
IMPRESSION:
1. No acute intracranial process.
2. Isolated complete opacification right frontal sinus, stable.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with chest pain// evaluate for aortic pathology
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 3.3 s, 26.1 cm; CTDIvol = 11.4 mGy (Body) DLP = 296.4
mGy-cm.
Total DLP (Body) = 299 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
HEART AND VASCULATURE: Motion artifact mildly limits evaluation of the
subsegmental branches. Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
The thoracic aorta is normal in caliber with mild atherosclerotic
calcifications without evidence of dissection or intramural hematoma. The
pericardium and great vessels are within normal limits. There is mild
cardiomegaly. There are dense coronary artery calcifications. Surgical clips
are seen in the mediastinum. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. A calcified granuloma seen in the right lower lobe (3; 113).
The airways are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen show a subcentimeter
hypodensity in the right hepatic lobe, too small to characterize, but stable
since at least ___ and likely a hepatic cyst or biliary hamartoma.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Patient is status post median sternotomy. Mild degenerative changes are seen
in the thoracic spine.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with CAD acutely non responsive// Eval for
hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.7 mGy-cm.
Total DLP (Head) = 748 mGy-cm.
COMPARISON: CT ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. Complete opacification of the right frontal
sinus with associated chronic periostitis is unchanged. The visualized
portion of the remaining paranasal sinuses, mastoid air cells and middle ear
cavities are clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
No evidence of acute intracranial process.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 98.8
heartrate: 57.0
resprate: 14.0
o2sat: 97.0
sbp: 159.0
dbp: 59.0
level of pain: 10
level of acuity: 2.0 | SUMMARY: ___ man with history notable for CAD s/p CABG
(LIMA-LAD, SVG-OM1, SVG-RPDA) in ___, HTN, HLD, CKD, and
seizure disorder
who presented for chest pain, found to have negative troponin x4
and negative stress echo. Hospital course complicated by altered
mental status and acute behavioral changes.
====================
Acute Medical Issues
====================
# Chest pain
Patient's description of non-exertional left chest pain was
concerning for unstable angina vs. non cardiac chest pain. He
had a troponin <0.01 four times during 24 hours, no new EKG
changes, as well as a negative stress echo. CTA chest confirmed
no aortic pathology or pulmonary embolism. Additionally, on
further review of his history, he has had similar symptoms since
___. Taken together, this was strongly suggestive of a
non-cardiac etiology, that was further supported by years of
symptom duration, positional changes, non exertional character,
and sensitivity to palpation. Additionally, interval resolution
after initial presentation to the ED was also reassuring against
cardiac cause. The cause for the patient's non anginal chest
pain is not clear, possibly consistent with costochondritis. He
received acetaminophen and lidocaine patch for pain control. He
was continued on home aspirin, atorvastatin, metoprolol, imdur,
and losartan for treatment of his known coronary artery disease.
# Altered mental status
# Acute Behavioral Changes
# Possible seizure like activity
Patient had 20 min episode of unresponsiveness on the evening of
___ with prodrome of hunger, dizziness, and anxiety that
resolved spontaneously without change in vital signs. He has
history of generalized tonic-clonic seizure disorder on
lamotrigine with last known seizure in ___, although per family
report, he does have unresponsive episodes at home. The patient
then had an episode of confusion and agitation at ___, and
attempted to leave the hospital wearing hospital a gown, unable
to state where he was. The episode on ___ improved when family
members arrived.
Neurology was consulted on ___ and did not feel this was
consistent with seizure. With regards to behavioral changes, it
was very reassuring that he returned to baseline with family and
recalls events surrounding episode on ___. Psychiatry
consulted attributed to underlying mood or anxiety disorder on
background of dementia (MOCA score ___, but also felt that
possible breakthrough seizure could not be ruled out. The
patient was continued on home lamotrigine. He was discharged
with follow up plans with Dr. ___ in neurology. Formal
neurocognitive evaluation could also be considered as an
outpatient.
# HTN
BPs still elevated while on home regimen. He was continued on
home imdur, losartan, and metoprolol. Amlodpine 5mg daily was
also started for better BP control given known CAD.
=====================
Chronic Medical Issues
======================
# TYPE II DIABETES
He was on sliding scale insulin during admission.
# HYPERLIPIDEMIA
He was continued on home atorvastatin
# SEIZURE DISORDER
He was continued on home lamotrigine
# GERD
He was continued on home home pantoprazole
===================
Transitional Issues
===================
[] Follow-up chest pain, consider alternative remedies if
persistent.
[] The patient was persistently hypertensive on his home regimen
of antihypertensives. The patient was started on amlodipine 5mg
daily. Please check BP and titrate medications accordingly.
[] Unclear per reports whether patient had discontinued
simvastatin. Patient himself was not sure, would confirm that
patient is on high dose statin such as atorvastatin 40-60mg.
[] The patient had an episode of unresponsiveness concerning for
seizure as described above. Please monitor for seizure like
activity and titrate antiepileptic as indicated.
[] Lamotrigine level pending at time of discharge, concern for
possible breakthrough seizure and unclear medication adherence.
Would confirm if at therapeutic level.
[] Patient reported anxiety and intrusive thoughts, concern
regarding mood and anxiety disorder. Per psychiatry on consult,
there is also concern for cognitive disorder given reports of
forgetfulness at home and a MOCA score of ___ while here.
Would recommend formal neurocognitive testing and consider
psychiatry follow up.
Advanced Care Planning
Code status: Full code, presumed
Contact: ___ (daughter) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Plaquenil / Amoxicillin / Food
Extracts / shrimp / Oxycodone
Attending: ___.
Chief Complaint:
hematuria and flank pain
Major Surgical or Invasive Procedure:
Ureteral stent ___
History of Present Illness:
The patient is a ___ with history of nephrolithiasis s/p
lithotripsy x2 (___), hypertension, hyperlipidemia, and
hypothyroidism who presented to the ED with abdominal pain and
hematuria. The patient began experiencing left flank pain on
___ for which she presented to her PCP's office. Given her
acutely worsening pain, she was referred to the ED. An
ultrasound at the time demonstrated nonobstructing left
nephrolithiasis without hydronephrosis, and a UA was negative.
She was discharged with hydromorphone, tamsulosin, and
instructions to follow-up in Urology.
The patient re-presented to the ED today with persistent pain
since that time and gross hematuria. She had one fever to 100.4
and chills. The patient reports that she has been unable to have
bowel movements for the last three days.
A CT scan was performed yesterday which reportedly demonstrates
an obstructing 4.5 mm left ureteral stone approximately one
third the way from the UPJ, with resultant hydroureter and
hydronephrosis, though no read is available in OMR.
In the ED, initial vital signs were 97.3 77 123/58 16 97%RA with
pain ___. Initial labs demonstrated WBC 10k (baseline generally
around ___ with N80 L12. Her chem-7 was remarkable for
creatinine of 2.0 (baseline 0.9-1.0). A UA demonstrated moderate
leukesterase, large blood, >182 RBC and 32 WBC with moderate
bacteria. A KUB was suggestive of passage of the stone from the
left mid ureter into the lower pelvis, possibly immediately
upstream or at the left ureterovesical junction. She was given
hydromorphone and ondansetron for symptomatic relief.
Past Medical History:
PAST MEDICAL HISTORY:
1. Ductal breast hyperplasia.
2. Hemorrhoids.
3. Herniated cervical disc, C5/6.
4. Hyperlipidemia.
5. Hypertension.
6. Hypothyroidism.
7. Insomnia.
8. Irritable bowel syndrome.
9. Lichen sclerosus.
10. Obesity, following Weight Watchers.
11. Osteopenia.
12. Nephrolithiasis, status post lithotripsy x2, ___ and ___.
PAST SURGICAL HISTORY:
1. Removal of basal cell carcinoma on back and chest, ___.
2. Status post right wrist Colles fracture, ORIF ___.
Social History:
___
Family History:
Father died of CVA, also status post MI. Mother died in ___.
___ died with melanoma
Physical Exam:
ADMISSION:
98.8 Tmax 100.9 110/70 68 18 99%RA
GENERAL: well-developed, well-appearing, overweight adult female
lying comfortably in bed in NAD
HEENT: NC/AT, sclerae anicteric, MM moist and pink
NECK: supple, no LAD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: normal rate, regular rhythm, no MRG, nl S1-S2
ABDOMEN: normoactive bowel sounds, soft, mild distention. +
tenderness to palpation over Left flank. no rebound or guarding,
no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
DISCHARGE:
VITAL SIGNS: 98.3 123/67 60 18 97%RA
GENERAL: well-developed, well-appearing, overweight adult female
lying comfortably in bed in NAD
HEENT: NC/AT, sclerae anicteric, MM moist and pink
NECK: supple, no LAD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: normal rate, regular rhythm, no MRG, nl S1-S2
ABDOMEN: soft but distended. bowel sounds present and not
hyperactive. tympanitic to percussion. mostly non-tender with
only minimal gas discomfort on deep palpation. no rebound or
guarding. minimal CVA tenderness, much improved.
EXTREMITIES: no edema, 2+ pulses radial and dp
Pertinent Results:
ADMISSION:
___ 03:20PM BLOOD WBC-10.4 RBC-4.84 Hgb-14.9 Hct-45.0
MCV-93 MCH-30.7 MCHC-33.0 RDW-12.3 Plt ___
___ 03:20PM BLOOD Neuts-80.0* Lymphs-11.6* Monos-6.5
Eos-1.3 Baso-0.6
___ 03:20PM BLOOD Glucose-95 UreaN-16 Creat-2.0* Na-135
K-4.3 Cl-99 HCO3-21* AnGap-19
___ 07:10AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.2
DISCHARGE:
___ 07:30AM BLOOD WBC-8.1 RBC-4.64 Hgb-14.9 Hct-42.3 MCV-91
MCH-32.2* MCHC-35.3* RDW-12.7 Plt ___
___ 07:30AM BLOOD Glucose-105* UreaN-11 Creat-1.2* Na-143
K-4.2 Cl-106 HCO3-23 AnGap-18
___ 07:30AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.1
OTHER RELEVANT:
___ 07:15AM BLOOD ___ PTT-29.9 ___
___ 07:10AM BLOOD Glucose-101* UreaN-18 Creat-2.0* Na-138
K-4.3 Cl-101 HCO3-25 AnGap-16
___ 07:15AM BLOOD Glucose-109* UreaN-18 Creat-1.9* Na-138
K-4.3 Cl-104 HCO3-26 AnGap-12
___ 11:15AM BLOOD Glucose-130* UreaN-14 Creat-1.5* Na-140
K-4.3 Cl-105 HCO3-27 AnGap-12
___ 07:10AM BLOOD Glucose-108* UreaN-14 Creat-1.3* Na-142
K-4.1 Cl-107 HCO3-26 AnGap-13
___ 02:55PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 02:55PM URINE RBC->182* WBC-32* Bacteri-MOD Yeast-NONE
Epi-1 RenalEp-<1
___ 7:24 pm URINE Site: CYSTOSCOPY
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 2:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ CT ABD/PELVIS:
CONCLUSION:
1. 5 mm stone is sitting in left mid ureter at the level of L4
causing mild obstruction.
2. Significant liver steatosis.
___ KUB:
IMPRESSION: Findings suggesting passage of stone from the left
mid ureter
into the lower pelvis, possibly immediately upstream of or at
the left
ureterovesical junction.
___ KUB:
IMPRESSION:
Nonspecific bowel gas pattern.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO HS
Hold for SBP<100
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Moexipril 22.5 mg PO DAILY
4. Simvastatin 10 mg PO HS
5. Tamsulosin 0.4 mg PO HS
Hold for SBP<100
6. HYDROmorphone (Dilaudid) 4 mg PO Q4-6H:PRN pain
7. Aspirin 81 mg PO DAILY
8. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit Oral daily
9. Vitamin D 1000 UNIT PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO HS
2. Aspirin 81 mg PO DAILY
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Simvastatin 10 mg PO HS
5. Tamsulosin 0.4 mg PO HS
6. Docusate Sodium 100 mg PO TID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth three
times a day Disp #*90 Capsule Refills:*1
7. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*16 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth once
a day Disp #*1 Box Refills:*2
9. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*1
10. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg calcium- 200 unit Oral daily
11. Moexipril 7.5 mg PO TID
12. Multivitamins 1 TAB PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*1
15. Probiotic *NF* (lactobacillus rhamnosus GG) 10 billion cell
Oral once per day
Any over-the-counter probiotic for the next few weeks, which may
help to prevent certain infections related to antibiotic use.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Ureterolithiasis
Secondary Diagnosis:
Acute Kidney Injury
Pyelonephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
RADIOGRAPHS OF THE ABDOMEN
HISTORY: Question change in ureteral stone.
COMPARISONS: Remote prior abdominal radiographs from ___, more
recent renal ultrasound from ___ and CT from ___.
TECHNIQUE: Abdomen, three views.
FINDINGS: On the recent prior CT, a stone in the mid left ureter resided at
level of the lower L4 vertebral body. The calcification is now seen more
distally in the pelvis. There is no free air. The quantity of stool is
mildly prominent along the ascending colon.
IMPRESSION: Findings suggesting passage of stone from the left mid ureter
into the lower pelvis, possibly immediately upstream of or at the left
ureterovesical junction.
Radiology Report
INDICATION: ___ woman with one week of constipation, likely secondary
to pain medications, refractory to very aggressive bowel regimen, rule out
obstruction.
COMPARISON: ___.
FINDINGS: Upright and supine frontal abdominal radiographs demonstrate gas
within the stomach and multiple loops of nondilated small and large bowel.
Gas is also seen in the rectum. Left ureteral stent is in proper position.
IMPRESSION:
Nonspecific bowel gas pattern.
Radiology Report
INDICATION: Left stent placement.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS: Seven fluoroscopic spot images submitted for review. No
radiologist was present during the image acquisition. A left retrograde
ureterogram demonstrates a filling defect, reflecting the known renal stone in
the distal left ureter and minimal dilatation of the ureter. Distal to the
stone there is a 1.6 cm long ureteral stricture. Final images show a JJ stent
with the proximal pigtail in the left renal pelvis and the distal pigtail
within the bladder. For the nephrology operative report please see OMR.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN/HEMATURIA
Diagnosed with CALCULUS OF KIDNEY
temperature: 97.3
heartrate: 77.0
resprate: 16.0
o2sat: 97.0
sbp: 123.0
dbp: 58.0
level of pain: 8
level of acuity: 3.0 | The patient is a ___ with history of recurrent nephrolithiasis
s/p lithotripsy x2 in past years who presents with worsening
abdominal pain, gross hematuria, elevated temperatures, found to
have left partially-obstructing ureterolithiasis, improved s/p
ureteral stent placement ___. |