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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Morphine / Codeine / Demerol / Iodine-Iodine
Containing
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ PMH significant for CHF (LVEF 30% in ___, ESRD s/p renal
transplant in ___, type 1 diabetes, CAD, hld, and recent
admission at OSH for CHF and possible RLL pneumonia, d/c on
___, now presenting to ___ with worsening SOB. Pt reports
that she had been feeling dyspneic since ___. She initially
went to OSH ED and was diagnosed with acute bronchitis,
prescribed steroids and nebulizer, which helped her symptoms. Pt
feels that ever since then, she started to gain weight and
become more edematous. She finally went to another OSH ___
___ in ___) on ___, where she was treated for
CHF exacerbation based on her BNP of 8265. Per discharge
summary, her diuresis was limited by acute renal insufficiency
w/ increase in Cr from baseline 1.4 to 2.0 after several days of
diuretics. OSH report Pt was 100.7 kg on admission on ___ kg on discharge on ___. Pt was also noted to have
significant stool in abdomen w/out evidence of obstruction,
moderate R pleural effusion, and anasarca. Pt was given bowel
regimen and also treated with azithromycin for 3 days and
cefpodoxime 5 days on discharge (assuming they were started 2
days prior to discharge, but no mention in DC summary). She was
also discharged on torsemide 40mg po bid (was on furosemide
120mg po qam and 80mg po qpm) and spironolactone 25mg po bid
(new).
Pt states that since she has been at home, her dyspnea has
worsened. States that she has been taking her medications as
prescribed by feels more edematous and dyspneic, with worsening
orthopnea. Pt denies fevers, chest pain, cough, any myalgias.
In the ED, initial vitals were
97.9 78 134/71 32 100%
EKG showed v-paced rhythm at 73, difficult to compare to prior
since that was sinus rhythm, but diffuse T wave inversions were
also present at that time. BNP 10902, Troponin mildly elevated
to 0.09 but no chest pain symptoms and CK-MB flat. Other labs
benign and UA was bland. CXR suggestive of volume overload w/ R
pleural effusion. Pt was given nitroglycerin 0.4mg w/ some
improvement in dyspnea. Pt was also given aspirin 325 and renal
consult was called. Pt was previously admitted for CHF
exacerbations in the past, and per renal consult, Pt had a foley
placed and was given furosemide 40mg iv x 1 w/ admission to ET
service for further management.
On arrival to the floor:
97.3, 145/79, 76, 20, 96% 2L nc. Wt 100kg bed.
Pt states that she feels that her breathing is improved. Denies
fever, cough, myalgias, rhinorrhea. States that she was taking
all her medications as previously prescribed. Denies sick
contacts, though she was recently hospitalized.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-CAD s/p CABG ___, s/p coronary angiography in ___ showing
native 3VD but patent vv grafts (2) and patent LIMA-LAD. T
-systolic CHF w/ EF 35-45% in ___
-pacemaker implanted, unclear type
-chronic kidney disease s/p transplant ___
-HTN
-hyperlipidemia
-PVD s/p b/l BKAs
-type 1 diabetes
-osteoporosis
-Peripheral neuropathy
Social History:
___
Family History:
-DM on mother's side.
Physical Exam:
Admission:
97.3, 145/79, 76, 20, 96% 2L nc. Wt 100kg bed.
GENERAL: obese woman sleeping in mild respiratory distress
HEENT: Sclera icteric. PERRL, EOMI. Clear oropharynx
NECK: Supple, JVP difficult to discern
CARDIAC: RRR, normal S1, S2, no m/r/g
LUNGS: reduced breath sounds in R > L bases, bibasilar
inspiratory crackles, no wheezes
ABDOMEN: normal bowel sounds, obese, distended, Soft, non-tender
to palpation, no masses. 1+ pitting edema
EXTREMITIES: 2+ pitting edema in bilateral upper extremities to
elbows. Lower extremities s/p bilateral BKA. 2+ pitting edema to
abdomen.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Discharge
VS 98.3 131/70 75 20 96%RA
GENERAL: A&Ox3, NAD, bilateral BKAs with prostheses
HEENT: Sclera icteric. PERRL, EOMI. Clear oropharynx
NECK: Supple, JVP difficult to discern
CARDIAC: RRR, normal S1, S2, no m/r/g
LUNGS: reduced breath sounds in R > L bases, no wheezes
ABDOMEN: normal bowel sounds, obese, distended, Soft, non-tender
to palpation, no masses. 1+ pitting edema
EXTREMITIES: 2+ pitting edema in bilateral upper extremities to
elbows. Lower extremities s/p bilateral BKA. 2+ pitting edema to
abdomen.
NEURO - awake, A&Ox3, moving all extremities
Pertinent Results:
___ 07:30PM BLOOD WBC-8.3 RBC-4.78 Hgb-12.6 Hct-40.2 MCV-84
MCH-26.4* MCHC-31.4 RDW-15.7* Plt ___
___ 06:55AM BLOOD WBC-7.0 RBC-4.71 Hgb-12.3 Hct-41.1 MCV-87
MCH-26.0* MCHC-29.8* RDW-15.8* Plt ___
___ 07:30PM BLOOD Glucose-221* UreaN-61* Creat-1.5* Na-138
K-4.9 Cl-98 HCO3-23 AnGap-22*
___ 06:55AM BLOOD Glucose-46* UreaN-59* Creat-1.5* Na-142
K-4.3 Cl-100 HCO3-28 AnGap-18
___ 07:30PM BLOOD ALT-17 AST-20 CK(CPK)-43 AlkPhos-65
TotBili-0.4
___ 07:30PM BLOOD CK-MB-3 ___
___ 07:30PM BLOOD cTropnT-0.09*
___ 07:20AM BLOOD CK-MB-3 cTropnT-0.08*
___ 06:45AM BLOOD tacroFK-3.3*
___ 06:40AM BLOOD tacroFK-5.7
___ 07:30PM BLOOD Lactate-1.4
___ ECG: Atrial sensing and ventricular pacing which has
replaced regularly conducted beats. Clinical correlation is
suggested.
___ CXR: IMPRESSION: Enlarged cardiac silhouette and engorged
pulmonary hila with pulmonary vascular congestion may be due to
CHF. Right lower hemithorax opacity could be due to pleural
effusions with overlying atelectasis and/or consolidation,
elevation of the right hemidiaphragm. If patient able,
dedicated PA and lateral views would be helpful for further
evaluation.
___ TTE: There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is mildly dilated. Overall left
ventricular systolic function is severely depressed (LVEF = 25
%). The right ventricular free wall thickness is normal. The
right ventricular cavity is dilated with depressed free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. Significant pulmonic regurgitation is
seen. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, left ventricular contractile function is
further impaired.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 12.5 mg PO BID
hold for sbp < 90 or HR < 60
2. Vitamin D 50,000 UNIT PO MONTHLY
3. Torsemide 40 mg PO BID
hold for sbp < 90
4. Gabapentin 2400 mg PO HS
5. Levemir 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Start: In am
hold for sbp < 90
7. Mycophenolate Mofetil 500 mg PO QAM Start: In am
8. Mycophenolate Mofetil 1000 mg PO QPM
9. Pantoprazole 40 mg PO Q12H
10. Spironolactone 25 mg PO BID
hold for sbp < 90
11. Pravastatin 80 mg PO DAILY Start: In am
12. Tacrolimus 0.5 mg PO Q12H
13. Aspirin 81 mg PO DAILY Start: In am
14. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -400 unit
Oral daily
15. TraMADOL (Ultram) 50 mg PO QHS: PRN back pain
16. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob/wheeze
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
hold for sbp < 90 or HR < 60
3. Levemir 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for sbp < 90
5. Mycophenolate Mofetil 500 mg PO QAM
6. Mycophenolate Mofetil 1000 mg PO QPM
7. Pantoprazole 40 mg PO Q12H
8. Pravastatin 80 mg PO DAILY
9. Spironolactone 25 mg PO BID
hold for sbp < 90
10. Tacrolimus 0.5 mg PO Q12H
11. Torsemide 60 mg PO QAM
RX *torsemide 20 mg 3 tablet(s) by mouth qAM Disp #*90 Tablet
Refills:*0
12. Torsemide 40 mg PO QPM
RX *torsemide 20 mg 2 tablet(s) by mouth qpm Disp #*60 Tablet
Refills:*0
13. TraMADOL (Ultram) 50 mg PO QHS: PRN back pain
14. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -400 unit
Oral daily
15. Vitamin D 50,000 UNIT PO MONTHLY
16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
disk INH twice a day Disp #*1 Inhaler Refills:*0
17. Gabapentin 1200 mg PO HS
18. Outpatient Lab Work
On ___
Check basic metabolic panel, tacrolimus
.
Please fax results to ___ Attn Dr ___
19. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob/wheeze
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
CHF exacerbation
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
EXAM: Chest, single AP upright portable view.
CLINICAL INFORMATION: Dyspnea on exertion, history of CHF.
___.
FINDINGS: Single AP upright portable view of the chest was obtained. There
has been interval placement of a left-sided pacer device with a lead seen
extending to the expected location of the right ventricle and the coronary
sinus. There may also be a lead extending to the right ventricle, although
this is not well seen on the current study. Right lower hemithorax opacity is
seen which may be due to underlying subpulmonic effusion with overlying
atelectasis, although underlying consolidation is not excluded. Findings may
also be due to elevation of the right hemidiaphragm. If patient able, suggest
dedicated PA and lateral views for better evaluation. There is prominence and
indistinctness of the hila. The cardiac silhouette remains enlarged. Patient
is status post median sternotomy.
IMPRESSION: Enlarged cardiac silhouette and engorged pulmonary hila with
pulmonary vascular congestion may be due to CHF. Right lower hemithorax
opacity could be due to pleural effusions with overlying atelectasis and/or
consolidation, elevation of the right hemidiaphragm. If patient able,
dedicated PA and lateral views would be helpful for further evaluation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SHORTNESS OF BREATH
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 97.9
heartrate: 78.0
resprate: 32.0
o2sat: 100.0
sbp: 134.0
dbp: 71.0
level of pain: 13
level of acuity: 1.0 | ___ w/ PMH significant for CHF (LVEF 30% in ___, ESRD s/p
renal transplant in ___, type 1 diabetes, CAD, hld, and recent
admission at OSH for CHF and possible RLL pneumonia, d/c on
___, now presenting to ___ with worsening SOB and
hypervolemia.
___ Exacerbation: The pt presented with worsening dyspnea,
hypoxia, and weight gain. Most likely due to CHF exacerbation
given elevated BNP, known CHF w/ history of exacerbations,
clinical appearence of hypervolemia, and improvement with
diuresis. The pt seems to have had difficulty with volume status
since a prednisone taper in ___ for bronchitis. Pt was
recently discharged from OSH on torsemide 40mg po bid plus
spironolactone 25mg po bid, though previously taking furosemide
120mg po qam and 80mg po qpm. This is unlikely to be sufficient
diuresis and may explain her repeat CHF exacerbation. The pt was
treated initially with a few doses of lasix 80mg IV with
significant output, and then transitioned to torsemide 60mg qam
and 40mg qpm. The pt was successfully weaned from O2 and edema
decreased, though still present at discharge. Repeat TTE showed
worsening LVEF from 30% previously to 25%, without current ACS.
Pt scheduled for f/u with outpt cardiology and home ___ to help
with daily weights.
# Dyspnea: mainly due to sCHF exacerbation as above. Pt also
with some episodes of wheezing and mild hypoxia improved with
albuterol nebs. Started on advair (which pt has taken in the
past) and continued on home albuterol nebs.
# s/p renal transplant: Cr is close to baseline (1.3-1.5).
Prot/cr ratio 0.1. UA bland. No evidence of infection,
obstruction, or rejection. Hypervolemia most likely cardiac in
origin. Continued MMF 500mg po qam and 1000mg po qpm and
tacrolimius 0.5mg po q12h. Tacro level 3.3 and 5.7 (goal ___.
# Dysuria: Pt with pain at meatus, in the setting of foley in
place, possibly worse with urination. U/a with blood but without
e/o infection. Pain likely ___ trauma from foley.
# Hypertension: normotensive. Lisinopril has been held due to
___. Continued home carvedilol, isosorbide mononitrate
# Diabetes: highly variable insulin regimen. States ___ U
levemir qhs plus tid sliding scale based on carb counting.
During admission, treated with 30U glargine qhs (levemir is
non-formulary) and humalog sliding scale adjusted per pt carb
counting.
.
# h/o CAD s/p CABG: continued home pravastatin, aspirin 81 daily
# Back pain, chronic: continued home tramadol
# GERD: continued home pantoprazole
# neuropathy: continued home gabapentin, of note, pt taking
2400mg qhs at home, agreed to decrease to 1200mg qhs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute confusion, left facial droop, right arm weakness
Major Surgical or Invasive Procedure:
Lumbar Puncture (___)
History of Present Illness:
EU CRITICAL,WARD ___ (aka ___ is a
___
man with a history of Hodgkin's lymphoma currently undergoing
chemotherapy and hypertension who presented as a transfer from
___ for acute onset confusion, left facial
droop,
right arm weakness, and agitation who is now status post TPA.
Per notes from the emergency room and discussion with patient's
wife he was in his usual state of health this morning when he
woke up and last known well was at 7:00 this morning. Shortly
after patient was noted to be confused. Per his wife he was
getting upset very easily and was getting mad at her for
"touching everything and changing everything". She called her
daughter who came over and noted a slight left facial droop so
they called ___. Patient was brought into ___.
On initial assessment in the emergency room by the ___
staff, he had an ___ stroke
scale of 6 for which he was scored for orientation questions,
dysarthria, right upper extremity drift, ataxia of right upper
extremity, left facial droop, and aphasia. He was also noted to
be very agitated and yelling out. Vitals on presentation to
___ were notable for glucose of 87, temp 98.4, respiratory
rate
14, heart rate 88, blood pressure 120/79, 99% on room air. EKG
was reportedly normal sinus rhythm.
When Dr. ___ a ___ consultation, he found
that Mr. ___ had an ___ stroke scale of 12. He was agitated,
moaning, did answer
questions or follow commands, had a left lower facial droop. He
could hold either arm in the air for at least five seconds and
held each leg in the air for at least two seconds, but then
showed motor impersistence - this was not a drift downwards. He
withdrew to noxious with all four extremities.
He had a CT and CTA. A CT was notable for chronic white matter
changes but no evidence of large infarct or hemorrhage. CTA was
negative for any large vessel occlusion or dissection. Was
significant for 2.1 cm round mass in the left lower neck.
He was given TPA at 0915. In addition he was also given 5 mg of
Haldol, 50 mics of fentanyl, 1 mg of lorazepam. During
transport
in ambulance to be I he was given an additional 2 mg of Versed
and 1 mg divided doses for agitation.
Upon my initial assessment in the emergency room, Vitals HR 108,
BP 135/88, RR 12, 98% 2 L NC
Patient is agitated but not opening his eyes, moving all of his
extremities around swinging and pushing away at staff. There is
no speech production but he is moaning.
Initially in the emergency room he was given an additional 1 mg
of Versed as the ___ was going to intubate him for agitation in
order to get a repeat CT head. After discussion with the ___ and
stroke fellow felt that agitation was prior to TPA and exam was
similar to prior other than decreased speech production and not
following directions which can be attributed to the large amount
of benzodiazepines the patient had received. Decided to not
intubate patient and to get CT head if patient was calmer but
did
not require intubation to get this done.
Due to confusion and agitation unable to ask review of systems
questions to patient. Per his wife who I spoke to on the phone
he was having some side effects from chemotherapy. He was very
fatigued and had been dealing with some joint pain for which he
has been receiving prednisone on and off. She said it was from
his cancer from high uric ___. In addition he also been
dealing
with some issues with constipation and diarrhea on and off. She
denies him being sick otherwise with fever, chills, cough.
Per patient's wife he is currently undergoing chemotherapy for
non-Hodgkin's lymphoma at ___. She does not know the
name of his oncologist but says that he is supposed to be
admitted on ___ for scheduled chemotherapy.
Past Medical History:
Hypertension
Non-Hodgkin's lymphoma (R-CHOP cycle 4 on ___ systemic
methotrexate cycle 1 ___
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
==============
ADMISSION EXAM
==============
Physical Exam:
Vitals: T98.9, HR94, BP 138/69, RR12, 100% RA
General: Agitated, moaning, keeps eyes closed but moving all of
his extremities.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity appreciated
Pulmonary: Normal work of breathing
Cardiac: Tachycardic, warm, well-perfused
Abdomen: non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic: Exam limited by agitation
-Mental Status: Patient keeps his eyes closed, no speech
production but moans, not following directions, not opening his
eyes to sternal rub or voice, resists eye opening bilaterally
-Cranial Nerves: PERRL 3 to 2mm and brisk. Not looking to voice
or attending examiner, eyes are midline, positive VOR, does not
blink to threat bilaterally but difficult to assess as I have to
hold his eyelids open, resisting eyelid opening bilaterally both
are strong, no clear facial asymmetry but difficult to tell,
unable to assess tongue and palate or shoulder shrug
-Motor: Normal bulk, tone throughout. Moving all extremities
spontaneously and antigravity. Pushes examiner away with 5 out
of 5 strength in bilateral upper extremities and lower
extremities, withdraws briskly to noxious stimulation in all 4,
though unable to do formal confrontational testing
-Sensory: React to noxious stimuli in all 4 extremities
-DTRs: 2+ biceps bilaterally, 1 patella bilaterally, plantar
response was flexor bilaterally
-Coordination: Unable to assess formally but when pushing away
examiner or reaching out no clear dysmetria
-Gait: Unable to assess due to agitation
==============
DISCHARGE EXAM
==============
MS: eyes are open intermittently, he says a limited number of
words, he says his name, he says "yes" and "no". Mr. ___ is
not oriented to place or time. He follows a limited number of
simple commands.
CN: he is able to track, pupils reactive bilaterally, no facial
droop, intact sensation bilaterally.
Motor: moves arms and legs with at least ___ strength but formal
testing was not possible
Sensory: localizes to noxious in all four extremities.
Pertinent Results:
====
LABS
====
___ 05:00PM BLOOD WBC-12.3* RBC-3.21* Hgb-9.5* Hct-30.9*
MCV-96 MCH-29.6 MCHC-30.7* RDW-21.1* RDWSD-70.5* Plt ___
___ 05:00PM BLOOD Neuts-90* Bands-6* Lymphs-1* Monos-2*
Eos-0 Baso-0 ___ Myelos-1* AbsNeut-11.81*
AbsLymp-0.12* AbsMono-0.25 AbsEos-0.00* AbsBaso-0.00*
___ 05:00PM BLOOD Hypochr-NORMAL Anisocy-2+* Poiklo-2+*
Macrocy-1+* Microcy-1+* Polychr-1+* Ovalocy-1+* Schisto-1+* Tear
Dr-1+*
___ 06:16AM BLOOD WBC-12.6* RBC-3.07* Hgb-9.1* Hct-28.7*
MCV-94 MCH-29.6 MCHC-31.7* RDW-21.3* RDWSD-69.3* Plt ___
___ 06:16AM BLOOD Neuts-84* Bands-4 Lymphs-2* Monos-10
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-11.09*
AbsLymp-0.25* AbsMono-1.26* AbsEos-0.00* AbsBaso-0.00*
___ 06:16AM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+*
Macrocy-1+* Microcy-OCCASIONAL Polychr-1+* Ovalocy-1+* Tear
Dr-1+*
___ 07:25AM BLOOD WBC-8.7 RBC-3.14* Hgb-9.2* Hct-29.6*
MCV-94 MCH-29.3 MCHC-31.1* RDW-21.2* RDWSD-70.7* Plt ___
___ 06:16AM BLOOD ___ PTT-27.0 ___
___ 07:25AM BLOOD ___ PTT-26.0 ___
___ 05:00PM BLOOD Glucose-90 UreaN-9 Creat-0.8 Na-140 K-4.0
Cl-101 HCO3-24 AnGap-15
___ 06:16AM BLOOD Glucose-80 UreaN-10 Creat-0.8 Na-140
K-3.5 Cl-102 HCO3-24 AnGap-14
___ 07:25AM BLOOD Glucose-76 UreaN-8 Creat-0.6 Na-144
K-3.0* Cl-106 HCO3-26 AnGap-12
___ 05:00PM BLOOD ALT-17 AST-31 LD(LDH)-581* AlkPhos-75
TotBili-0.3
___ 06:16AM BLOOD ALT-14 AST-26 LD(___)-357* AlkPhos-63
TotBili-0.4
___ 05:00PM BLOOD CK-MB-5 cTropnT-0.04*
___ 06:16AM BLOOD cTropnT-0.04*
___ 05:00PM BLOOD Albumin-3.8 Calcium-8.9 Phos-3.1 Mg-1.9
UricAcd-4.6
___ 06:16AM BLOOD %HbA1c-5.3 eAG-105
___ 06:16AM BLOOD Triglyc-134 HDL-32* CHOL/HD-4.3
LDLcalc-80
___ 05:00PM BLOOD TSH-1.5
___ 12:38PM CEREBROSPINAL ___ (CSF) TNC-334* RBC-229*
Polys-4 ___ Monos-0 Other-96
___ 12:38PM CEREBROSPINAL ___ (CSF) TNC-465* RBC-199*
Polys-5 ___ Monos-1 Other-94
___ 12:38PM CEREBROSPINAL ___ (CSF) IPT-PND
___ 12:38PM CEREBROSPINAL ___ (CSF) TotProt-97*
Glucose-18
___ 12:38PM CEREBROSPINAL ___ (CSF) HERPES SIMPLEX VIRUS
PCR-negative
___ 04:42PM CEREBROSPINAL ___ (CSF) VARICELLA DNA
(PCR)-negative
___ 12:38 pm CSF;SPINAL ___ SOURCE: LP // CSF TUBE
#3.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
___ FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take ___ weeks to grow..
___ CSF;SPINAL ___ VIRAL CULTURE-negative
___ CULTURE-negative
___ CULTURE-negative;
___ FAST CULTURE-PRELIMINARY
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
Results should be evaluated in light of culture results
and clinical
presentation.
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ URINE URINE CULTURE-FINAL
CSF cytology from ___:
Positive for malignant cells. Findings consistent with high
grade lymphoma. Cells are positive for CD 45 and negative for
the cytokeratin cocktail.
CSF flow cytometry from ___:
INTERPRETATION:
Immunophenotypic analysis detected an abnormal CD10 positive
B-cells that lack surface immunoglobin expression and show
lambda restriction by cytoplasmic staining and dim/equivocal
nTdT expression. The corresponding W-G stained cytospin slides
were reviewed and show numerous variably sized cells with
vacuolated basophilic cytoplasm and immature fine nuclear
chromatin (Burkitt's-like cells). The overall findings raise the
differential diagnosis of involvement by an acute lymphoblastic
lymphoma/leukemia versus a high-grade B-cell. The patient's
prior history of DLBCL in conjunction with the lack of CD34,
lack of myeloid and T cell markers and the expression of
cytoplasmic lambda light chain immunoglobulin favor a high grade
B cell lymphoma. Sending fresh sample for cytogenetic studies
for further characterization is highly recommended. Correlation
with clinical,and other ancillary findings is recommended. Flow
cytometry immunophenotyping may not detect all abnormal
population due to topography, sampling, or artifacts of sample
preparation.
=======
IMAGING
=======
- ___ MRI Head W/WO Contrast
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old man with acute confusion, s/p tpa. CNS
involvement of lymphoma, acute ischemic stroke.
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 ___
from outside
facility.
CTA head and neck with contrast dated ___ from
outside facility.
FINDINGS:
Examination is moderately degraded by motion. Specifically,
MPRAGE images are markedly degraded by motion artifact.
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift or infarction. Mild prominence of the ventricles
and sulci is suggestive of involutional changes. Multiple
scattered T2 and FLAIR hyperintense foci in the periventricular
and subcortical white matter are nonspecific, but may reflect
chronic small vessel ischemic changes.
Postcontrast images are markedly degraded by motion artifact.
There is no
definite area of abnormal enhancement. There is mild mucosal
thickening of the ethmoid sinuses. The mastoid air cells are
clear. The intraorbital contents are unremarkable.
IMPRESSION:
1. No evidence of infarction or hemorrhage.
2. Markedly degraded postcontrast images. Within these
limitations, no
definite focal area of abnormal enhancement.
3. Multiple scattered nonspecific white matter signal
abnormalities, which
could represent findings of chronic small vessel ischemic
disease.
- ___ CT Head (24 hours post-tPA)
1. No acute intracranial abnormality.
2. Periventricular and subcortical white-matter hypodensities
are nonspecific, but likely represent sequela of chronic small
vessel ischemic disease.
- ___ Abdomen XR Supine
Nonspecific bowel gas pattern, without dilated small bowel loops
to suggest obstruction.
===============
NEUROPHYSIOLOGY
===============
- ___ EEG (prelim wet read)
Intermittent focal slowing over the left hemisphere and
sometimes over the right, some triphasics, no epileptiform
discharges or seizures.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Moderate
4. Pantoprazole 40 mg PO Q24H
5. Pravastatin 20 mg PO QPM
6. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - First
Line
7. Sertraline 50 mg PO DAILY
8. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Moderate
4. Pantoprazole 40 mg PO Q24H
5. Pravastatin 20 mg PO QPM
6. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - First
Line
7. Sertraline 50 mg PO DAILY
8. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
Discharge Disposition:
Home
Facility:
___
Discharge Diagnosis:
Secondary CNS Lymphoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with aphasia, facial droop, s/p TPA// hemorrhagic
conversion after TPA Needs to be done at 0915 on ___
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 =
934.6 mGy-cm.
Total DLP (Head) = 935 mGy-cm.
COMPARISON: MR head from ___. Outside reference CTA head neck
from ___.
FINDINGS:
There is no evidence of infarction,hemorrhage,edema,or mass-effect. There is
prominence of the ventricles and sulci suggestive of age-related atrophy.
Periventricular and subcortical white-matter hypodensities are nonspecific,
but 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:
1. No acute intracranial abnormality.
2. Periventricular and subcortical white-matter hypodensities are nonspecific,
but likely represent sequela of chronic small vessel ischemic disease.
Radiology Report
INDICATION: ___ year old man with abdominal pain, constipation// evaluate for
obstruction, stool burden
TECHNIQUE: Supine abdominal radiograph
COMPARISON: None relevant
FINDINGS:
There are no abnormally dilated loops of large or small bowel. There is mild
stool burden predominantly in the rectosigmoid colon.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Degenerative changes are noted throughout the lumbar spine, which is most
pronounced at the lumbosacral junction. There are no unexplained soft tissue
calcifications or radiopaque foreign bodies.
IMPRESSION:
Nonspecific bowel gas pattern, without dilated small bowel loops to suggest
obstruction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with CVA// eval aspiration/pna eval
aspiration/pna
IMPRESSION:
No prior chest imaging available.
Lungs well expanded and clear. Normal cardiomediastinal and hilar silhouettes
and pleural surfaces. The skin fold projecting over the right lateral chest,
simulates a pneumothorax.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with acute confusion, s/p tpa. CNS involvement
of lymphoma, acute ischemic stroke.
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 ___ from outside
facility.
CTA head and neck with contrast dated ___ from outside facility.
FINDINGS:
Examination is moderately degraded by motion. Specifically, MPRAGE images are
markedly degraded by motion artifact.
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. Mild prominence of the ventricles and sulci is suggestive of
involutional changes. Multiple scattered T2 and FLAIR hyperintense foci in
the periventricular and subcortical white matter are nonspecific, but may
reflect chronic small vessel ischemic changes.
Postcontrast images are markedly degraded by motion artifact. There is no
definite area of abnormal enhancement.
There is mild mucosal thickening of the ethmoid sinuses. The mastoid air
cells are clear. The intraorbital contents are unremarkable.
IMPRESSION:
1. No evidence of infarction or hemorrhage.
2. Markedly degraded postcontrast images. Within these limitations, no
definite focal area of abnormal enhancement.
3. Multiple scattered nonspecific white matter signal abnormalities, which
could represent findings of chronic small vessel ischemic disease.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: CVA, Transfer
Diagnosed with Altered mental status, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: UTA
level of acuity: 1.0 | Mr. ___ is a ___ man with a history of hypertension
and non-Hodgkin's lymphoma currently undergoing R-CHOP (cycle 4
on ___ with systemic methotrexate (cycle 1 ___ for CNS
prophylaxis. He presented to ___ on the
morning of ___ due to symptoms of irritability which quickly
progressed to confusion and agitation. He was last known well at
7AM on ___. On initial exam at ___, he had NIHSS 6
for disorientation, aphasia, ataxia, left facial and right arm
weakness. During the ___ consultation by Dr. ___,
___ had
an ___ stroke scale of 12. He was agitated, moaning, did answer
questions or follow commands, had a left lower facial droop. He
could hold either arm in the air for at least five seconds and
held each leg in the air for at least two seconds, but then
showed motor impersistence - this was not a drift downwards. He
withdrew to noxious with all four extremities.
He was given iv tPA at 9:15AM and subsequently transferred to
___ for post-tPA monitoring. CTA did not show any large vessel
occlusions.
He remained severely confused and agitated, and received several
doses of sedatives including Haldol, Versed, and fentanyl during
transfer. On arrival, NIHSS was 14 -- though this was confounded
by severe agitation. On arrival, he had a fever to 102.5 and WBC
12.6, so empiric CNS-dosed antibiotics were started (vancomycin,
cefepime, ampicillin, and acyclovir). MRI brain with contrast
showed no evidence of stroke or abnormal enhancement.
Lumbar puncture was performed on ___ and showed 465 nucleated
cells (5% PMN, 0% lymph, and 94% other), 199 RBC, protein 97,
glucose 18 (serum 80). Infectious disease had initially been
consulted, however given the abnormal differential, CSF cytology
was urgently reviewed by the on-call pathologist, Dr. ___
neuro-oncologist, Dr. ___. This was consistent with high
grade lymphoma. His primary oncologist at ___, Dr.
___, had been informed of his admission and these results
were relayed to him that evening. Arrangements were made to
transfer to ___ on the morning of ___
for further treatment. Antibiotics were stopped. EEG showed
intermittent focal slowing of the left>right hemispheres, but no
epileptiform discharges or seizures.
CSF gram stain showed no microorganisms. CSF flow cytometry
showed:"The overall findings raise the differential diagnosis of
involvement by an acute lymphoblastic lymphoma/leukemia versus a
high-grade B-cell. The patient's prior history of DLBCL in
conjunction with the lack of CD34, lack of myeloid and T cell
markers and the expression of cytoplasmic lambda light chain
immunoglobulin favor a high grade B cell lymphoma."
CSF bacterial and ___ culture Cryptococcus, HSV, and VZV were
negative. CSF ___ fast culture results are pending. Blood
cultures have thus far been negative. CXR did not show any
evidence of pneumonia.
While he did continue to have lower grade fevers immediately
following presentation, he defervesced over the course of the
day (last elevated temp of 100.1 at 8AM on ___. Late that
evening, his mental status also improved and he was able to pass
a swallowing screen, state his name and that he was confused,
and was able to speak to his family on the telephone. WBC
resolved on ___ ___.6->8.7. His home acyclovir po and
Bactrim DS were continued. Empiric CNS-dosed antibiotics
(vancomycin, cefepime, ampicillin, and iv acyclovir) were
stopped.
___, MD | ___ Neurology PGY-4 | ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Chief Complaint:
Dyspnea, cough, right posterior back pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with hx of lung cancer, with 2 weeks of progressively
worsening dyspnea. Notes dry cough started 1 week ago. Also with
new right-sided scapular pain that has been treated only with
hot and cold packs with some relief. Over this time course
patient notes anorexia, and dry heaving with food resulting in
poor PO intake. 10 lb weight loss over the last month. Denies
f/c/cp/diarrhea/dysuria. No sick contacts.
In the ED, initial vital signs were: 98.4 102 122/70 16 100% 2L
(previously high ___ on room air)
Exam notable for baseline proptotic left eye, baseline right lid
lag, rhonchi heard in right upper lobe.
Labs were notable for normal wbc count with 80% PMNs, h/h
11.9/34.8, sodium 129 with repeat 132 and slight NAGMA with
bicarb 21.
CXR showed multi focal airspace opacities, most confluent in the
right upper lung, concerning for pneumonia.
Patient was given 5 mg oxycodone for pain, duoneb x 1, 1 L NS,
levofloxacin 750 mg IV.
On Transfer Vitals were: 98.3 109 110/59 22 96% Nasal Cannula
REVIEW OF SYSTEMS:
(+) per hpi, also with new right sided headache no visual
changes
(-) fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, chest pain, abdominal pain, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Lung Adenoca- recent treatment over the past year with
cisplatin/pemetrexed, last tx in ___ per patient
COPD
HTN
DM
graves disease s/p RAI, now hypothyroid
deafness
glaucoma
CKD? follows with nephrologist but patient unsure why.
Parapneumonic effusion s/p drainage ___
Social History:
___
Family History:
Mother with diverticulosis
Father with diverticulosis, died of cardiac causes at ___
Brother died in early ___ from brain cancer, other brother
healthy
Physical ___:
Admission Physical Exam:
Vitals: 97.8 142/65 113 20 95 2L NC
General: Mild distress ___ pain
HEENT: NCAT, PERRL, EOMI, MMM, OP clear
Lymph: Cervical and supraclavicular lymphadenopathy
CV: tachy RR, nl S1, S2
Lungs: Decreased BS throughout, poor air movement, incr crackles
right side. no wheezes. reproducible posterior chest wall
tenderness
Abdomen: Some ruq tenderness on deep palpation, no g/r/r
GU: deferred
Ext: thin, no edema, pulses 2+
Neuro: cn ___ intact, moving all extremities, right eyelid
droop, left eyelid ptosis
Skin: wwp
Discharge Physical Exam:
Vitals: 98.0 125/83 76 20 98% on 2L
GEN: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular LAD
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: Good air entry b/l but has scattered wheezes
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no ___
sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro:Grossly wnl
Pertinent Results:
Admission Labs:
___ 04:00PM BLOOD WBC-8.5# RBC-3.97* Hgb-11.9* Hct-34.8*
MCV-88 MCH-30.0 MCHC-34.2 RDW-13.8 Plt ___
___ 04:00PM BLOOD Neuts-80.0* Lymphs-13.5* Monos-5.5
Eos-0.6 Baso-0.4
___ 04:00PM BLOOD ___ PTT-28.8 ___
___ 04:00PM BLOOD Glucose-224* UreaN-19 Creat-0.9 Na-129*
K->10 Cl-100 HCO3-21*
___ 04:00PM BLOOD ALT-18 AST-84* AlkPhos-237* TotBili-0.2
___ 04:00PM BLOOD Calcium-9.2 Phos-4.1# Mg-1.7
Discharge Labs:
- ___ Blood cx: pending
___ 06:58AM BLOOD WBC-20.6* RBC-3.87* Hgb-10.9* Hct-34.4*
MCV-89 MCH-28.2 MCHC-31.8 RDW-13.5 Plt ___
___ 06:58AM BLOOD Plt ___
___ 06:58AM BLOOD Glucose-111* UreaN-13 Creat-0.6 Na-134
K-4.6 Cl-93* HCO3-27 AnGap-19
___ 06:58AM BLOOD Calcium-9.7 Phos-3.0 Mg-2.0
Imaging:
- Portable CXR ___: Multi focal airspace opacities, most
confluent in the right upper lung, concerning for pneumonia.
- CTA ___ PRELIM:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Interval progression of large, irregular, heterogeneous
pleural-based soft tissue mass in the right apex, abutting the
suture material, consistent with recurrent disease. A portion of
the mass erodes into the right posterior fifth rib and
transverse process of the T5 vertebral body, and into the
posterior chest wall. Additionally, numerous bilateral pleural
and parenchymal nodules and masses are present, consistent with
metastatic spread.
3. Large, heterogeneous, soft tissue density mass in the region
of the right anterior chest wall and innumerable heterogeneous,
peripherally enhancing mass lesions within the liverare
consistent with metastatic disease.
4. Extensive bulky axillary, supraclavicular, mediastinal, and
hilar
lymphadenopathy.
Microbiology:
BCx negative x2
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
2. Alendronate Sodium 70 mg PO 1X/WEEK (MO)
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atenolol 50 mg PO DAILY
6. brimonidine 0.2 % ophthalmic BID
7. Ferrous Sulfate 325 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. GlipiZIDE 1.25 mg PO DAILY
10. Levothyroxine Sodium 150 mcg PO DAILY
11. Losartan Potassium 50 mg PO DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. Pravastatin 10 mg PO QPM
15. Spironolactone 12.5 mg PO DAILY
16. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. GlipiZIDE 1.25 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
8. Levothyroxine Sodium 150 mcg PO DAILY
9. Losartan Potassium 50 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Pravastatin 10 mg PO QPM
12. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine [MS ___ 30 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
13. Morphine Sulfate ___ ___ mg PO Q3H:PRN pain
RX *morphine 15 mg 1 tablet(s) by mouth every 3 hours Disp #*60
Tablet Refills:*0
14. brimonidine 0.2 % ophthalmic BID
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. Benzonatate 100-200 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*60 Capsule Refills:*0
17. Dexamethasone ___ mg PO Q8H
4mg q8h on ___. 2mg q8h on ___. On ___ ask
radiation oncologist how much to take.
RX *dexamethasone 2 mg ___ tablet(s) by mouth every 8 hours Disp
#*24 Tablet Refills:*0
18. Guaifenesin-CODEINE Phosphate ___ mL PO Q4H:PRN cough
Do not drive or consume alcohol while taking this medication
RX *codeine-guaifenesin [Guaifenesin AC] 100 mg-10 mg/5 mL 5 mL
by mouth every 4 hours Refills:*0
19. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
20. Senna 8.6 mg PO BID constipation
hold this medication if you have more than 1 bowel movement per
day
RX *sennosides [senna] 8.6 mg 1 mg by mouth twice a day Disp
#*60 Capsule Refills:*0
21. Polyethylene Glycol 17 g PO DAILY
hold this medication if you have more than 1 bowel movement a
day
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*60 Packet Refills:*0
22. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, short of
breath
RX *albuterol sulfate 90 mcg 2 puffs IH every 4 hours Disp #*1
Inhaler Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Metastatic Lung Cancer
Dyspnea
Secondary Diagnoses:
Chronic Obstructive Pulmonary Disease
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 hx mesothelioma and adenocarcinoma, new upper back pain,
SOB, cough
TECHNIQUE: Portable chest x-ray.
COMPARISON: Chest radiographs dated ___ through ___.
FINDINGS:
Evaluation limited due to multiple overlying wires and overlying device.
Portable semi-upright radiograph of the chest was provided. There is apparent
increased opacity in the right upper lung which could reflect pneumonia.
Suture material projecting over the right upper lung again noted. Blunting of
the left costophrenic angle is chronic. Chain suture material projects over
the right upper lung. The heart is not enlarged. Mediastinal contour appears
grossly stable though right margin is difficult to accurately assess. No
pneumothorax.
IMPRESSION:
Increased opacity in the right upper lung could represent pneumonia. Consider
repeat with more optimized technique to better assess.
Radiology Report
INDICATION: History: ___ with active Ca, new tachycardia and hypoxia, likely
PNA, to r/o PE // Evidence of PE
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: 132 mGy-cm
COMPARISON: PET-CT dated ___, and prior chest radiographs dated ___ and ___. Additionally, images from CT of the chest dated ___ were viewed via the Atrius Epic PACS viewer.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence
of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
Thyroid gland is not well seen. Extensive axillary, supraclavicular,
mediastinal, and hilar lymphadenopathy is seen.
Emphysematous changes are noted in the bilateral lungs.
There has been interval development of a large, irregular heterogeneous
soft-tissue density pleural-based mass at the right apex, abutting the suture
material, consistent with recurrent disease. A portion of the mass erodes into
the right posterior fifth rib and transverse process of the T5 vertebral body,
and into the posterior chest wall. Additionally, numerous bilateral pleural
and parenchymal nodules and masses are present, consistent with metastatic
spread. Bulky axillary, supraclavicuar, mediastinal and hilar lymphadenopathy
is noted including a heterogeneous 3.1 x 2.6 cm right hilar nodal mass. A
large, heterogeneous right subpectoral nodal mass is also noted, measuring 3.2
x 2 cm.
There is no evidence of pericardial effusion. There is no pleural effusion.
Innumerable heterogeneous, peripherally enhancing mass lesions are seen within
the liver, consistent with metastatic disease.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Interval progression of large, irregular, heterogeneous pleural-based soft
tissue mass in the right apex, abutting the suture material, consistent with
recurrent disease. A portion of the mass erodes into the right posterior fifth
rib and transverse process of the T5 vertebral body, and into the posterior
chest wall. Additionally, numerous bilateral pleural and parenchymal nodules
and masses are present, consistent with metastatic spread.
3. Large heterogeneous right subpectoral nodal mass and innumerable
heterogeneous, peripherally enhancing mass lesions within the liver are
consistent with metastatic disease.
4. Extensive bulky axillary, supraclavicular, mediastinal, and hilar
lymphadenopathy.
5. Emphysematous changes are seen in the bilateral lungs
Radiology Report
EXAMINATION: MR THORACIC SPINE W/O CONTRAST
INDICATION: ___ year old woman with metastatic lung adenoca and mesothelioma
with new thoracic rib mets. // evaluate for thoracic spine mets evaluate
for thoracic spine mets
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed.
COMPARISON: No prior MRI of the thoracic spine available. Prior CT scan dated
___.
FINDINGS:
As seen on recent prior CT scan, there is a dominant heterogeneous soft tissue
mass in the right lung apex with numerous additional bilateral smaller pleural
based masses. There is abnormal signal intensity noted in the T2 through T5
vertebral bodies adjacent to the dominant mass. There is extension of this
mass into the right aspects of the T4 and T5 vertebral bodies including the T5
transverse process. Soft tissue extending into the ventral epidural space is
noted posterior to the T3 and T4 vertebral bodies. There is resultant severe
narrowing of the right T4-T5 neural foramen and right aspect of the thecal
canal with mass effect on the right ventral cord at this level.
Signal abnormality is also seen involving the left aspects of the T2 vertebral
body secondary to a smaller left-sided medial pleural based soft tissue mass
with extension of this soft tissue abnormality into the left neural foramen
which is narrowed.
There is an additional expansile lesion seen involving the posterior elements
of the left T9 vertebral body with extension into the posterior paraspinal
musculature at this level. This mass measures approximately 3.7 cm SI by 2.8
cm AP x 1.7 cm TV. There is no resultant spinal canal stenosis or neural
foraminal narrowing.
Signal abnormality is also noted within the anterior aspect of the T11
vertebral body and more diffusely within the T12 and L1 vertebral bodies
without obvious soft tissue mass.
Alignment is normal. There is loss of height of the T4 vertebral body with
retropulsion into the spinal canal with resultant mild spinal canal narrowing.
This likely represents a pathological burst fracture and is unchanged from
recent prior CT.
There is a disc protrusion seen only on sagittal images at C6-C7 which is
indenting the ventral thecal sac and possibly remodeling the ventral aspect of
the cord. There is no other significant disc herniation.
There are perineural cysts noted bilaterally at several levels.
IMPRESSION:
Multiple heterogeneous metastatic lesions are noted. A dominant pleural-based
mass in the right lung apex extends into the T4 and T5 vertebral bodies,
results in epidural extension at T3 and T4, and right T4-T5 neural foraminal
narrowing. Additional heterogeneous lesions are seen involving the left
aspects of the T2 and T9 vertebra as described above. Signal abnormality
without obvious soft tissues mass is also noted within the T11 through L1
vertebra.
Unchanged fracture deformity of the T4 vertebral body likely representing a
pathological fracture.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with recurrent small cell lung cancer with bone
metastasis // please evaluate for brain metastasis
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations. The
post gadolinium images are somewhat limited by motion.
COMPARISON: No prior similar examinations. Correlation was made with thoracic
spine MRI of ___.
FINDINGS:
There is a soft tissue mass identified at the right orbital apex extending
intracranially in the subfrontal region. The optic nerve appears to be
displaced in the right orbital apex. Following contrast administration there
is enhancement seen both in the intraorbital and intracranial components. Mild
surrounding edema is seen in the inferior frontal lobe and at the anterior
right temporal lobe. The pattern of enhancement and the appearance more
suggestive of bony metastasis involving the greater wing of sphenoid and the
right orbital plate of the frontal bone with intracranial and intraorbital
extension . The appearance is not typical for hemangioma. There is a smaller
area on FLAIR images without corresponding area of enhancement ON somewhat
motion limited post gadolinium images. No definite parenchymal areas of
enhancement seen.
Soft tissue changes are seen in the left maxillary sinus bilateral mastoid air
cells . The small hyperdensity in the right frontal lobe on the diffusion
images appears to be due to T2 shine through. Mild to moderate changes of
small vessel disease are seen.
IMPRESSION:
Right orbital apex mass involving the bony structures and extending
intracranially in the right subfrontal region with associated surrounding
edema. Although the mass is predominantly extra-axial, and post gadolinium
images are somewhat limited by motion, the abnormality most likely due to
metastasis.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ F with hx of lung cancer, COPD, presenting with 2 weeks of
cough and dyspnea with imaging revealing metasatic disease throughout the
lung, bones and liver transferred to OMED for further managment. // Cancer
survelliance for mets; (please perform after MR head, as that is higher
priority).
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: DLP: 876 mGy-cm (abdomen and pelvis).
IV Contrast: 100 mL Omnipaque
COMPARISON: PET scan from ___
FINDINGS:
LOWER CHEST:
Please refer to separate report of CT chest performed on the same day for
description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: There are numerous new, hypoenhancing metastatic liver lesions
diffusely throughout all hepatic lobes. The largest lesion is in segment VIII
and measures 3.0 x 3.2 cm (07:44). There is a large simple appearing hepatic
cyst in segment VI that measures 4.2 cm ( 10:27). The gallbladder is within
normal limits, without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: There is a subtle 8 mm left adrenal nodule that is not well
characterized but is suspicious ( 07:56). The right adrenal gland is normal.
URINARY: There are numerous bilateral hypoenhancing cortical subcentimetric
kidney lesions that are indeterminate but may represent metastatic lesions..
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall
thickness and enhancement throughout. There is mild colonic diverticulosis.
The appendix is not well seen.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is mild calcium
burden in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal limits
BONES AND SOFT TISSUES:
There is a tiny lytic lesion within the left anterior acetabulum (7:101 ), new
from previous that may represent a metastatic deposit but is indeterminate.
There is no other definitely suspicious bone lesion identified. There is
enhancing soft tissue mass in the left paraspinal muscles measuring 1.7 x 2.0
cm suspicious for metastases (7:66), with another enhancing nodule superior to
this, enhancement and enlargement of the left quadratus lumborum muscles and
another tiny subcutaneous 8 mm nodule in the right lower lumbar region also
suspicious.
IMPRESSION:
Interval significant progression of disease with multiple hepatic, left
adrenal and soft tissue metastases, and indeterminate left acetabular bone
lesion.
Radiology Report
EXAMINATION: Chest CT
INDICATION: Assessment for metastatic disease
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen. Axial images were reviewed in conjunction with coronal and sagittal
reformats
COMPARISON: ___ and ___ and ___
FINDINGS:
Since ___ there is interval increase/development of right
supraclavicular lymph node, series 7, image 2, 17 mm in diameter. Additional
cluster of lymph nodes is noted in the same area, series 7, image 6.
Subpectoral lymph nodes are present, series 7, image 7, at least 3 cm in
diameter as well as mass if axillary lymphadenopathy on the right and soft
tissue disease extensively involving right lung with erosion of the adjacent
ribs, series 7, image 18 and pathologic fracture as well as involvement of the
spinal canal, please review MRI of the thoracic spine obtained on ___
for pre size description). Mediastinal and hilar bulky lymphadenopathy is
present with attenuation of the right upper lobe pulmonary artery. Pleural
metastatic disease on the left is less extensive but noticeable. Image
portion of the upper abdomen will be reviewed separately as part of the CT
abdomen but metastatic disease involving the liver is noticeable.
Airways are patent to the subsegmental level bilaterally. Within the lungs
multiple ill-defined nodular opacities are present as well as discrete nodules
for example series 7, image 18, series 7, image 22 as well as large lesion in
the lingula, series 7, image 27.
Heart size is normal. There is no pericardial effusion.
IMPRESSION:
Extensive metastatic disease involving supraclavicular, subpectoral, axillary
lymph nodes on the right as well as substantial involvement of the pleural
disease with bulky metastatic involvement with subsequent erosion of the right
ribs as well as spinal canal of the thoracic spine. Less pronounced but still
present involvement of the left pleura. Pulmonary nodules with the largest 1
being in the lingula.
For assessment of the upper abdomen please review CT abdomen and the
corresponding report.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Lower back pain
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPOSMOLALITY/HYPONATREMIA, HYPOXEMIA
temperature: 98.4
heartrate: 102.0
resprate: 16.0
o2sat: 100.0
sbp: 122.0
dbp: 70.0
level of pain: 8
level of acuity: 2.0 | ___ y/o F ___ F with hx of lung cancer, COPD, presenting with 2
weeks of cough found to have widespread metastatic disease with
possible COPD exacerbation component. CTA negative for PE.
Treated with pain control, nebulizers, 1 dose of antibiotics and
steroid burst with 5 day course which was completed on ___.
She was transferred to the oncology service where she was
evaluated by radiation oncology who initated radiation therapy.
She also underwent MR of her head, CT torso for further
evaluation and cancer survellience. She was discharged with a
plan for continued radiation treatments ___ for spine, then
starting ___ she will undergoe CK for R orbital mass).
# Dyspnea: CTA concerning for spread of known malignancy. Also
on ddx is PE vs PNA vs COPD exacerbation. PE ruled out by prelim
CTA. Less likely pneumothorax based on imaging. No fever or
leukocytosis to suggest pneumonia however it remains possible.
Later with wheezing prompting initiation of steroids and duonebs
for possible COPD component, completed 5 day course of oral
steroids. Further details per "metastatic lung ca" below.
# Metastatic lung ca: Lft's trended for known liver mets. MRI
t-spine ordered for metastatic disease seen on CT. Pain treated
initially with dialudid, later transitioned to long and short
acting morphine. Transferred to oncological medicine service.
# COPD:
- duonebs per above
# CHF: last ECHO with EF 55-60%, some MR, no diastolic
dysfunction
- continued home ___, aldactone, monitor fluid status
# HTN:
- continued home atenolol, amlodipine, losartan, spironolactone
# DM:
- continued home glipizide
- SSI prn
# Graves disease s/p RAI, currently hypothyroid:
- continued replacement
# Glaucoma:
- continued eye drops
# Osteoporosis:
- home alendronate, day of week unknown |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ambien / shellfish derived / nafcillin
Attending: ___.
Chief Complaint:
Weakness, fall, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of advanced dementia, systolic CHF (EF35%) ___ ischemic
CM, s/p bioprothestic MVR, atrial fibrillation on xarelto, h/o
VT/VF and AF s/p AVJ ablation s/p BiV ICD, PVD s/p L external
iliac to femoral bypass presenting for evaluation of slowly
progressive decline in his mental status particularly over the
last week.
Patient limited historian. Denies pain. Says he's had trouble
swallowing. Unsure if any falls. Unable to confirm history
personally from family, so mostly derived from ED ___. "Has had
decreased p.o. intake over the last 2 days, episode of vomiting
today. Per his son was at bedside the patient has had occasional
falls, difficulty with ambulation and episodes of emesis over
the
last 2 days. Of note the patient has had progressive dysphasia
and recently had an EGD that confirmed that he did have
esophageal hiatal hernia without reflux but with severe ___
esophagitis with ulceration, no evidence of malignancy.
GI note from ___: "Patient underwent endoscopy to evaluate
dysphagia shows severe ___ esophagitis and some retained
food
in stomach. will treat with fluconazole for 14 days 200 mg bid"
PCP ___ ___: "We will continue to treat his xerosis with a
emollient and I discussed skin care including choice of soap.
We
discussed possible risk factors for his ___ esophagitis. I
advised him that the likelihood of chronic viral infection is
remote, but he has had multiple blood transfusions in the past.
He agrees to
HIV, HBV and HCV serology along with a lymphocyte profile."
In the ED, initial VS were: 97.8 116/59 66 18 96/RA
Orthostatics: 147/72@80 lying -> 136/72@80 sitting -> 127/72@81
standing.
Exam notable for: Orientation x1, trace edema bilaterally
ECG: Paced, Sgarbossa negative
Labs showed:
- WBC 4.8 Hb 9.4 Plt 139
- Cr 1.8 Bicarb 19 AG 21 lytes otherwise WNL
- INR 2.3
Imaging showed:
- CXR: No PNA
- CT A/P:
1. No acute findings in the abdomen or pelvis.
2. Large stool ball in the rectum.
- CT C-spine:
No cervical spine fracture or malalignment
- CT head:
1. No acute intracranial abnormality.
2. Large area of encephalomalacia involving the right posterior
temporoparietal lobes is unchanged from ___.
- XR R elbow: No evidence of fracture or dislocation. No
erosions.
Patient received:
___ 14:29 IVF NS ___ Started
___ 17:07 IVF NS 500 mL ___ Stopped (2h
___
___ 17:24 IVF LR ___ Started 100 mL/hr
___ 17:47 IVF LR ___ Confirmed Rate
Changed
to 50 mL/hr
___ 18:15 PO/NG QUEtiapine Fumarate 25 mg
___
___ 19:01 PO/NG Rivaroxaban 15 mg ___
___ 20:23 PO Pravastatin 40 mg ___
___ 20:23 PO Tamsulosin .4 mg ___
___ 20:23 PO/NG QUEtiapine Fumarate 75 mg
___
___ 20:23 PO/NG Senna 8.6 mg ___
___ 20:23 PO/NG Labetalol 200 mg ___
___ 20:24 PO/NG Lactulose 30 mL ___
On arrival to the floor, patient is somnolent but responsive. Is
limited historian. Reports some abdominal discomfort, unsure
when
his last bowel movement was. Denies black or bloody stool.
REVIEW OF SYSTEMS: As above, limited by patient cooperation.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Systolic Heart failure- (LVEF = 35 %) ___
- CAD s/p CABG in ___
- Mitral Valve replacement due to severe MR in ___
(Bioprosthetic)
- Syncopal episode leading to MVA. Suspected to be due to VT/VF
s/p dual chamber ICD at ___ in ___.
- Atrial fibrillation s/p AV junctional ablation and placement
of a biventricular ICD device in ___
3. OTHER PAST MEDICAL HISTORY
- Hypothyroid
- Cholelithiasis
- Anemia
- PVD / Femoral aneurysm
- OSA on home CPAP
- Depression
- Cervical spondylosis
- Gout
- Sigmoid diverticulitis
PAST SURGICAL HISTORY:
- EVAR ___ coil embolization ___
- Left external iliac to femoral bifurcation bypass ___.
- CABG ___
- MVR ___ Bioprosthetic
- B/l cataracts
- Dual chamber ICD ___ (___)
- Trach/PEG s/p MVC ___, now removed
Social History:
___
Family History:
father with cardiac disease, specifics unknown
Physical Exam:
ADMISSION:
VS: 97.4 132/74 81 20 99/RA
GENERAL: Somnolent, NAD, arousable, dry MMM, limited historian
but following commands
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, no nystagmus. No
oropharyngeal ___ appreciable (exam limited by patient
cooperation)
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 alghough some
discomfort in lower regions, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing; trace edema bl ___
___: 2+ DP pulses bilaterally
NEURO: A&Ox1, moving all 4 extremities with purpose
SKIN: scaling ecchymosis over arm, warm and well perfused
GU: some BR blood at meatus of penis
DISCHARGE:
97.7 146/82 82 16 100 Ra
GENERAL: Alert, pleasant, NAD
HEENT: anicteric sclera, no thrush
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Few crackles at left base, no wheezes or rhonchi,
breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, no ttp
EXTREMITIES: warm, trace edema in ___ bilaterally
NEURO: Alert and oriented to self only, moving all 4 extremities
with purpose
SKIN: scaling ecchymosis and bruising over arm, warm and well
perfused
Pertinent Results:
ADMISSION:
___ 12:50PM BLOOD WBC-4.8 RBC-3.16* Hgb-9.4* Hct-29.0*
MCV-92 MCH-29.7 MCHC-32.4 RDW-15.2 RDWSD-51.1* Plt ___
___ 12:50PM BLOOD Neuts-79.4* Lymphs-8.3* Monos-7.3 Eos-3.3
Baso-1.3* Im ___ AbsNeut-3.81 AbsLymp-0.40* AbsMono-0.35
AbsEos-0.16 AbsBaso-0.06
___ 12:50PM BLOOD ___ PTT-41.1* ___
___ 12:50PM BLOOD Glucose-115* UreaN-36* Creat-1.8* Na-142
K-4.1 Cl-102 HCO3-19* AnGap-21*
___ 07:05AM BLOOD TotProt-5.4* Calcium-8.7 Phos-3.7 Mg-1.6
UricAcd-6.7
___ 12:50PM BLOOD ALT-8 AST-30 LD(LDH)-278* AlkPhos-88
Amylase-31 TotBili-0.9
___ 12:50PM BLOOD calTIBC-233* Ferritn-316 TRF-179*
___ 07:05AM BLOOD VitB12-421
___ 01:01PM BLOOD Lactate-1.5
___ 05:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:20PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:20PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
NOTABLE:
___ 07:05AM BLOOD TSH-5.9*
___ 07:05AM BLOOD Free T4-0.9*
___ 12:50PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 07:05AM BLOOD PEP-NO SPECIFI IgG-699* IgA-206 IgM-59
DISCHARGE:
___ 05:30AM BLOOD WBC-3.3* RBC-3.26* Hgb-9.6* Hct-29.7*
MCV-91 MCH-29.4 MCHC-32.3 RDW-15.0 RDWSD-50.1* Plt ___
___ 05:30AM BLOOD Glucose-101* UreaN-14 Creat-1.1 Na-143
K-3.7 Cl-103 HCO3-21* AnGap-19*
___ 05:30AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.7
MICRO:
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
IMAGING:
___ Elbow X ray:
No comparison. Three views of the right elbow are provided.
Parts of a
venous access device are visualized in the cubital fossa and
projecting over the joint. No other soft tissue abnormalities.
No evidence of fracture or dislocation. No erosions.
___ CT head without contrast:
1. No acute intracranial abnormality.
2. Large area of encephalomalacia involving the right posterior
temporoparietal lobes is unchanged from ___.
___ CT A/P without contrast:
1. No acute findings in the abdomen or pelvis.No acute fracture.
2. Large stool ball in the rectum.
___ CT C spine without contrast:
No cervical spine fracture or malalignment.
___ Chest X ray:
The cardiomediastinal silhouette remains enlarged, but is not
significantly changed. No focal consolidations are seen. There
is mild pulmonary vascular congestion without interstitial
edema. No pleural effusion or pneumothorax.
Again seen is a left chest wall AICD with lead wires terminating
in their
expected locations
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Labetalol 200 mg PO BID
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Rivaroxaban 15 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Ferrous Sulfate 325 mg PO BID
7. urea 10 % topical TID:PRN
8. Tamsulosin 0.4 mg PO QHS
9. Levothyroxine Sodium 25 mcg PO DAILY
10. QUEtiapine Fumarate 75 mg PO QHS
11. Senna 17.2 mg PO BID
12. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
13. Aqua Care (urea) 10 % topical TID:PRN
14. Bisacodyl ___ID:PRN Constipation - First Line
15. Calcium Carbonate 500 mg PO Q6H:PRN indigestion
16. Docusate Sodium 100 mg PO BID
17. Doxycycline Hyclate 100 mg PO Q12H
18. QUEtiapine Fumarate 25 mg PO QPM
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Polyethylene Glycol 17 g PO DAILY
3. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
4. Allopurinol ___ mg PO DAILY
5. Aqua Care (urea) 10 % topical TID:PRN
6. Bisacodyl ___ID:PRN Constipation - First Line
7. Calcium Carbonate 500 mg PO Q6H:PRN indigestion
8. Docusate Sodium 100 mg PO BID
9. Doxycycline Hyclate 100 mg PO Q12H
10. Ferrous Sulfate 325 mg PO BID
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY
12. Labetalol 200 mg PO BID
13. Levothyroxine Sodium 25 mcg PO DAILY
14. Pravastatin 40 mg PO QPM
15. Rivaroxaban 15 mg PO DAILY
16. Senna 17.2 mg PO BID
17. Tamsulosin 0.4 mg PO QHS
18. urea 10 % topical TID:PRN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute metabolic Encephalopathy
Constipation
Acute kidney injury secondary to Dehydration
Chronic Systolic CHF
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) RIGHT
INDICATION: History: ___ with right elbow pain status post fall// Evaluate
for fracture Evaluate for fracture
IMPRESSION:
No comparison. Three views of the right elbow are provided. Parts of a
venous access device are visualized in the cubital fossa and projecting over
the joint. No other soft tissue abnormalities. No evidence of fracture or
dislocation. No erosions.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with slowly declining altered mental status in the
context of frequent falls and patient on Xarelto// Evaluate 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 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 842 mGy-cm.
COMPARISON: Outside reference CT head from ___.
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema,or mass-effect.
Large area of encephalomalacia involving the right posterior temporoparietal
lobes is unchanged. There is prominence of the ventricles and sulci
suggestive of involutional changes. Extensive subcortical and periventricular
white-matter hypodensities are nonspecific, but likely represent sequela of
chronic ischemic small vessel disease.
There is no evidence of fracture. There is mild mucosal thickening of the
ethmoid air cells. The visualized portion of the other paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. Large area of encephalomalacia involving the right posterior
temporoparietal lobes is unchanged from ___.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ s/p unwitnessed fall// evaluate for 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 5.3 s, 20.8 cm; CTDIvol = 22.6 mGy (Body) DLP = 470.0
mGy-cm.
Total DLP (Body) = 470 mGy-cm.
COMPARISON: CT cervical spine from ___.
FINDINGS:
Alignment is maintained. No fractures are identified.There is fusion of the
posterior aspect of the C4 and C5 vertebral bodies and fusion of the bilateral
facet joint. There is no significant canal or foraminal narrowing.There is no
prevertebral edema.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
No cervical spine fracture or malalignment.
Radiology Report
EXAMINATION: CT ABDOMEN PELVIS WITHOUT CONTRAST
INDICATION: ___ s/p unwitnessed fall NO_PO contrast// evaluate for fracture
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 6.5 s, 51.1 cm; CTDIvol = 9.1 mGy (Body) DLP = 465.9
mGy-cm.
Total DLP (Body) = 466 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion. Heart is moderately enlarged.
Partially imaged cardiac lead wires are again 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. The gallbladder contains gallstones without wall thickening or
evidence of inflammation.
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. Bilateral low-density
lesions, likely simple renal cysts measure up to 3 cm in the right lower pole.
There is no hydronephrosis. There is no nephrolithiasis. There is no
perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops
demonstrate normal caliber and wall thickness throughout. Diverticulosis of
the sigmoid colon is noted, without evidence of wall thickening and fat
stranding. The appendix is normal. A large stool ball is noted within the
rectum.
PELVIS: The urinary bladder is 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: Patient is post aorta bi-iliac stent graft with extension of graft
into the right common iliac artery. Aneurysmal dilatation of the infrarenal
abdominal aorta to 3.7 x 3.2 cm is stable (3:279). Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Rod and screw fixation of the left proximal femur is again noted.
SOFT TISSUES: There is a small fat containing left inguinal hernia. The
abdominal and pelvic walls are otherwise within normal limits.
IMPRESSION:
1. No acute findings in the abdomen or pelvis.No acute fracture.
2. Large stool ball in the rectum.
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: ___ with weakness and vomiting// eval for pneumonia
TECHNIQUE: Chest AP and lateral
COMPARISON: Multiple chest radiographs, most recent from ___.
FINDINGS:
The cardiomediastinal silhouette remains enlarged, but is not significantly
changed. No focal consolidations are seen. There is mild pulmonary vascular
congestion without interstitial edema. No pleural effusion or pneumothorax.
Again seen is a left chest wall AICD with lead wires terminating in their
expected locations
IMPRESSION:
No pneumonia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V
Diagnosed with Acute kidney failure, unspecified
temperature: 97.8
heartrate: 66.0
resprate: 18.0
o2sat: 96.0
sbp: 116.0
dbp: 59.0
level of pain: 0
level of acuity: 3.0 | This is a ___ year old male with past medical history of
dementia, systolic CHF, bioprothestic MVR, atrial fibrillation
on xarelto, history of VT/VF, atrial fibrillation, peripheral
vascular disease, admitted with metabolic encephalopathy,
dehydration and constipation, now renal function and mental
status back to baseline, able to be discharged to rehab
# Nausea/vomiting
# Contipation:
Patient's son described decreased PO intake within the 2 days
prior to presentation as well as a few episodes of non-bloody,
non-bilious emesis. A CT A/P was done in the ED which showed a
large stool ball and no other acute findings. He was treated
with an aggressive bowel regimen and had bowel movements with
improvement in his nausea. He had no episodes of emesis and was
able to tolerate a diet and maintain his nutritional and
hydration status. Started and continued miralax at discharge.
# Acute kidney injury: Baseline Cr around 1 but was 1.8 on
admission. Likely prerenal in the setting of poor PO intake
secondary to nausea and constipation. Resolved to baseline with
IV fluids. .
# Acute metabolic Encephalopathy
# Dementia with behavioral disturbance
Patient with baseline severe dementia admitted with lethargy in
the setting of dehydration and ___ as above. After IV fluids
and moving bowels his mental status improved to his baseline per
his son. At baseline, he was non-lethargic, alert and oriented
to self only but calm and answered questions appropriately. An
infectious work up for other causes of encephalopathy was done
and was unremarkable. TSH and B12 were unremarkable.
# Gait instability:
# Fall: Patient's son described more instability with walking
and falls. A trauma work up including CT head was negative. ___
assessed the patient and recommended discharge to rehab. B12,
TSH, and SPEP were sent and were normal.
# Dysphagia
Evaluated by speech and swallow with recommendation for pureed
solids and thin liquids.
# Chronic Systolic CHF
Initially dehydrated as above. Continued Labetalol. Of note,
has not been maintained on metoprolol or lisinopril for unclear
reasons. If consistent with goals of care, would consider
starting. Per report from his facility, he is no longer on a
diuretic. Once taking PO, he remained euvolemic without the
need for diuresis this admission.
# Afib
# History of VT/VF
Patient continued on rivaroxaban
# Dementia
Discontinued Seroquel given initial encephalopathy. Course
notable for absence of agitated, behavioral disturbance or other
indication for this medication. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Taxol / simvastatin
Attending: ___.
Chief Complaint:
constipation, nausea/vomiting
Major Surgical or Invasive Procedure:
Paracentesis ___
History of Present Illness:
Ms. ___ is a ___ year old woman with stage IV ovarian ca,
recent recurrence, C2D4 Carboplatin/Doxil presents with nausea,
vomiting and constipation. She had not had BM for ___ days prior
to receiving chemo on ___. Prior to that, her stools were
hard
and painful. She received enema from ___ on ___ with successful
bowel movement. She felt better 3 days prior to admission.
Though
for the past 2 days, she began having worsening nausea. Taking 2
senna QPM and 1 Colace daily. Passing flatus. One episode of
vomiting in ED after taking PO KCL repletion. She had been
avoiding Zofran at home for nausea -taking Compazine BID for
past
few days. Takes occasional Ativan. Took Dexamethasone as
prescribed. She received Neulasta yesterday. Denies any
abdominal
pain. denies fevers. Occasionally feels chilled. Appetite poor
currently. Not drinking much liquid. Denies SOB or chest pain.
Denies dysuria.
Per patient report while in the hospital previously she was
constipated and a liquid medicine in brown cup worked the best
?lactulose.
ED: Patient received Zofran 4 mg after taking 40 meq KCL PO;
also
given 1L NS
98.6 84 127/81 18 100%
98.6 88 135/79 18
Past Medical History:
PAST ONCOLOGIC HISTORY:
Stage IV Ovarian CA
S/p ___ and debulking surgery now with recurrent disease
Currently C1D6 ___ AUC 5 and Doxil 30 mg/m2 IV q28 days
PAST MEDICAL HISTORY:
- HLD
- CKD
- Anemia
Social History:
___
Family History:
Aunt- ___ CA
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 99.1 HR 90 BP 122/70 RR 18 100 RA Wt 156.4 lbs
General: NAD
HEENT: PERRL, EOMI, MMM
CV: S1, S2, RRR, no m/r/g
Respiratory: CTAB, normal WOB
Abdomen: S, NT, distended, BS+, no HSM
Extremities: WWP, no c/c/e
Skin: No rash
DISCHARGE PHYSICAL EXAM:
Vitals: 99 110-115/70s ___ RR ___ 98-100% RA
General: sitting up in bed, in NAD, pleasant and conversant
HEENT: PERRL, EOMI, MMM
CV: S1, S2, RRR, no m/r/g
Respiratory: CTAB, normal WOB
Abdomen: S, TTP RLQ with rebound and guarding, distended, BS+,
no HSM
Extremities: WWP, no c/c/e
Skin: No rash or excoriations
Pertinent Results:
ADMISSION LABS
------------------
___ 02:25PM BLOOD WBC-21.6*# RBC-2.91* Hgb-8.5* Hct-26.8*
MCV-92 MCH-29.2 MCHC-31.7* RDW-14.4 RDWSD-48.0* Plt ___
___ 02:25PM BLOOD Neuts-82* Bands-5 Lymphs-10* Monos-3*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-18.79*
AbsLymp-2.16 AbsMono-0.65 AbsEos-0.00* AbsBaso-0.00*
___ 02:25PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
___ 02:25PM BLOOD Plt Smr-NORMAL Plt ___
___ 02:25PM BLOOD Glucose-80 UreaN-14 Creat-0.9 Na-139
K-3.1* Cl-102 HCO3-22 AnGap-18
___ 02:25PM BLOOD estGFR-Using this
___ 02:25PM BLOOD AST-16 AlkPhos-78 TotBili-0.4
___ 02:25PM BLOOD Lipase-28
___ 02:25PM BLOOD Albumin-3.3*
___ 02:25PM BLOOD GreenHd-HOLD
URINE STUDIES:
---------------
___ 02:25PM URINE Color-Straw Appear-Clear Sp ___
___ 02:25PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 02:25PM URINE RBC-1 WBC-5 Bacteri-NONE Yeast-NONE
Epi-<1
___ 02:25PM URINE Mucous-RARE
___ 02:25PM URINE
___ 02:25PM URINE Hours-RANDOM
___ 02:25PM URINE Hours-RANDOM
___ 02:25PM URINE Uhold-HOLD
___ 02:25PM URINE Gr Hold-HOLD
MICRO:
----------------
___ 1:58 pm PERITONEAL FLUID
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
IMAGING:
----------------
CXR ___
IMPRESSION: No acute cardiopulmonary abnormality.
KUB ___
IMPRESSION:
Large amount of stool throughout the colon. No evidence of
small bowel obstruction or free intraperitoneal gas.
___ U/S guided paracentesis
IMPRESSION:
Ultrasound guided paracentesis with removal of 2.25 L
serosanguineous fluid.
DISCHARGE LABS:
___ 06:38AM BLOOD WBC-21.4* RBC-3.01* Hgb-8.8* Hct-27.0*
MCV-90 MCH-29.2 MCHC-32.6 RDW-14.3 RDWSD-45.9 Plt ___
___ 06:11AM BLOOD Neuts-90* Bands-1 Lymphs-6* Monos-2*
Eos-1 Baso-0 ___ Myelos-0 AbsNeut-25.94*
AbsLymp-1.71 AbsMono-0.57 AbsEos-0.29 AbsBaso-0.00*
___ 06:38AM BLOOD Plt ___
___ 06:38AM BLOOD Glucose-90 UreaN-6 Creat-1.0 Na-138 K-3.5
Cl-103 HCO3-25 AnGap-14
___ 06:38AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Dexamethasone 4 mg PO Q12H 2 days following chemo
3. pegfilgrastim 6 mg/0.6 mL subcutaneous ASDIR
4. Lorazepam 0.5 mg PO Q4H:PRN anxiety, nausea
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Docusate Sodium 100 mg PO DAILY
7. Senna 17.2 mg PO QHS
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Lorazepam 0.5 mg PO Q4H:PRN anxiety, nausea
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Please take once daily as needed
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 unit by
mouth Once daily mixed in water as needed Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. Dexamethasone 4 mg PO Q12H 2 days following chemo
6. pegfilgrastim 6 mg/0.6 mL subcutaneous ASDIR
7. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth by mouth prior to
meals daily Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
1. Constipation
2. Malignant Ascites
3. Abdominal Pain
Secondary Diagnosis:
1. Stage IV Ovarian Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Ultrasound-guided paracentesis.
INDICATION: ovarian cancer,malignant ascites, therapeutic para // malignant
ascites,___ ovarian cancer,unspecified laterality,183.0
TECHNIQUE: Ultrasound guided right lower quadrant paracentesis
COMPARISON: Paracentesis ___, CT abdomen and pelvis ___.
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites with septations and a minimally complex component in the
pelvis. 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 2.25 L of serosanguineous fluid was removed.
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:
Ultrasound guided paracentesis with removal of 2.25 L serosanguineous fluid.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with weakness and constipation status post
chemotherapy
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Right-sided Port-A-Cath tip terminates in the low SVC. Heart size is
borderline enlarged. Mediastinal and hilar contours are unchanged. Pulmonary
vasculature is normal. Elevation of the right hemidiaphragm is chronic. No
pleural effusion, focal consolidation or pneumothorax is identified. No acute
osseous abnormalities seen. Previously noted lytic lesion in the mid thoracic
spine is not clearly visualized on the current exam There is no
subdiaphragmatic free air.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: History: ___ with weakness and constipation status post
chemotherapy
TECHNIQUE: Supine and upright AP views of the abdomen
COMPARISON: ___ chest abdominal radiographs and CT abdomen pelvis
___
FINDINGS:
A nonobstructive bowel gas pattern is demonstrated without dilated loops of
small bowel, free intraperitoneal air, or definite pneumatosis. Large amount
of stool is seen throughout the colon. No acute osseous abnormality is
visualized. No concerning soft tissue calcifications are present.
IMPRESSION:
Large amount of stool throughout the colon. No evidence of small bowel
obstruction or free intraperitoneal gas.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Constipation
Diagnosed with NAUSEA, OTHER MALAISE AND FATIGUE, UNSPECIFIED CONSTIPATION, MALIGN NEOPL OVARY
temperature: 98.6
heartrate: 84.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 81.0
level of pain: 1
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with stage IV ovarian ca,
recent recurrence, on cycle 2 of Carboplatin/Doxil who presented
with nausea, vomiting, abdominal pain and constipation. KUB
showed large stool burden, no evidence of obstruction. Patient
was started on aggressive bowel regimen as well as Reglan given
patient reported some abdominal fullness after eating. Patient's
home Compazine was discontinued given interaction with Reglan.
Patient underwent therapeutic/diagnostic paracentesis removing
2.25L of ascitic fluid which was negative for SBP. Additionally
patient was noted to have leukocytosis, thought secondary to
neulasta. She was without fevers during admission. CXR was
negative, and peritoneal fluid was not consistent with SBP. Her
abdominal symptoms resolved after passing stool. Patient was
tolerating diet, passing flatus / stool on day of discharge. For
a more detailed discussion of each problem please see below.
# Constipation: Most likely chronic constipation that is
worsened by chemo and zofran. Imaging did not show an
obstruction. Abdominal exam was benign - soft, no
guarding/rebound, +flatus. Patient given lactulose, discontinued
senna/colace as patient reported these make her nauseous,
started bisacodyl, miralax, and gave mag citrate X 1. She was
also given a fleet enema. Reglan was started for her feelings of
increased satiety / nausea after eating. Patient stooled, and
nausea resolved after above interventions.
# Nausea: most likely from constipation + chemo. She was treated
with ativan PRN and use of zofran was minimized as she states
this makes her more constipated. Reglan was started during this
admission with resolution of nausea.
# Leukocytosis: most likely from Neulasta; she did not have
signs or symptoms of infection. White count downtrended during
admission to 21.4 on day of discharge
# h/o malignant ascites: patient receives intermittent paras.
- s/p paracentesis ___ of serosanguinous fluid removed,
negative for SBP (<250 PMNs), SAAG <1.1 not c/w portal
hypertension
- ascites fluid gram stain negative, culture negative
# Ovarian ca: C2D4 ___, received Neulasta ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Latex / Iodinated Contrast- Oral and IV Dye / thimerosal
Attending: ___.
Chief Complaint:
Right hip erythema and pain
Major Surgical or Invasive Procedure:
None
(Prior R Hip I/D ___
History of Present Illness:
Mr. ___ is a ___ year old male who presented on ___
originally with right hip native septic arthritis. He
subsequently underwent right hip I/D on ___ and was discharged
without issue. He returned with continued right hip erythema and
pain, diagnosed as cellulitis.
Past Medical History:
Psoriatic arthritis
GERD
LBBB
HLD
Social History:
___
Family History:
NC
Physical Exam:
General: Well-appearing, non-toxic
CV: RRR
Resp: Normal breathing
Abd: Soft, NT/ND
RLE:
Lateral erythema overlying the surgical wound
Incision is C/D/I with staples in place
No pain with logroll
Fires TA/GSC/FHL - limited ___ function per baseline
SILT s/s/t/dp/pt
Warm and well-perfused
Pertinent Results:
___ 10:57PM CRP-91.2*
___ 10:57PM WBC-12.5* RBC-3.18* HGB-10.6* HCT-32.7*
MCV-103* MCH-33.3* MCHC-32.4 RDW-13.2 RDWSD-49.1*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nafcillin 2 g IV Q4H
2. Lisinopril 10 mg PO DAILY
3. meloxicam 15 mg oral Q24H
4. Omeprazole 20 mg PO DAILY
5. Simvastatin 40 mg PO QPM
6. SulfaSALAzine_ 1000 mg PO BID
7. Acetaminophen 650 mg PO Q6H
8. Carvedilol 6.25 mg PO BID
9. Enoxaparin Sodium 40 mg SC QHS
10. Aspirin 81 mg PO DAILY
11. Cosentyx (secukinumab) 150 mg/mL subcutaneous EVERY 4 WEEKS
12. Methotrexate 20 mg PO QSAT
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right hip septic arthritis, cellulitis of the right thigh
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT
INDICATION: History: ___ with septic hip within the last 2 weeks now
presenting with worsening hip pain// ? fracture ? osteo
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of the right hip.
COMPARISON: Radiograph dated ___.
FINDINGS:
No fracture or dislocation detected about the right hip. No aggressive bone
erosion identified. The joint space is grossly preserved, with small marginal
spur. Small rounded lucency (6.6 mm) overlies the femoral head on the
frog-leg lateral view. This has a thin corticated rim and is unlikely to
represent a bone erosion. Possible overlying soft tissue swelling. No
subcutaneous emphysema detected. Overlying skin staples noted.
Limited assessment of the left hip on single AP view the pelvis is
unremarkable except for tiny marginal spur along the acetabulum.
The pelvic girdle is congruent, with trace degenerative changes of the pubic
symphysis.
IMPRESSION:
No acute fracture or dislocation. No aggressive osteolysis detected about the
right hip. Skin staples noted.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with picc// picc placement picc placement
IMPRESSION:
Comparison to ___. The patient has received the new right-sided
PICC line. The course of the line is unremarkable, the tip of the line
projects over the cavoatrial junction. No complications, notably no
pneumothorax.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Hip pain, Wound eval
Diagnosed with Pain in right hip
temperature: 99.3
heartrate: 88.0
resprate: 22.0
o2sat: 96.0
sbp: 121.0
dbp: 63.0
level of pain: 4
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. Had undergone R hip
I/D on ___. For full details of the procedure please see the
separately dictated operative report. The patient was found to
have right hip cellulitis and was admitted to the orthopedic
surgery service. The patient was started on IV Vancomycin per ID
recommendations. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home with ___ services 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 with some
surrounding erythema, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the RLE extremity, and
will be discharged on Lovenox as previously prescribed 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: F
Service: SURGERY
Allergies:
Dapsone / Strawberry / lanilon / Oysters / Provocholine /
Tegaderm Transparent Dressing
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: 8 mm TIPS placed; Lysis catheter removed
removed
___: Transjugular transheptic SMV lysis catheter placement
History of Present Illness:
___ PMHx bullous pemphigoid, HTN, and HLD presents as
transfer from ___ w/ c/o three days of diffuse abdominal
pain and bloody diarrhea w/ CT findings at ___ concerning
for
mesenteric ischemia due to venous thrombosis extending into the
portal vein with small bowel edema and free fluid concerning for
bowel ischemia. Patient reports she had mild abdominal pain
starting ___ and assumed it was constipation and so took
laxatives. She then began having large volume bloody diarrhea on
___ and ___. As of now, she continues to have loose
bowel movements but they are no longer bloody. She has had poor
solid PO due to abdominal pain, but is tolerating fluids. She
presented to ___ this morning because her abdominal
pain continued to worsen, and she was noted to having rebound
and
guarding on abdominal exam.
Patient is a former smoker and denies any previous vascular
disease, blood clots, or hormone replacement therapy. Patient
otherwise denies fevers/chills, nausea/vomiting, chest pain/SOB,
lightheadedness/dizziness. Her lactate at the OSH was 1.3, WBC
10.2, and Hct 42.
Past Medical History:
___: HLD, HTN, pemphigoid, colonic adenoma last colonoscopy
___, osteoporosis
PSHx: BUNIONECTOMY, no prior abdominal operations
Social History:
___
Family History:
amily History Hx:
-no family history of hypercoagulable disorders
-no family history of GI malignancy or IBD
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
Vitals - T 99.3 / HR 92 / BP 123/85 / RR 20 / O2sat 96% RA
General - comfortable, NAD
HEENT - PERRLA, EOMI, moist mucous membranes
Cardiac - RRR, no M/R/G
Chest - CTAB
Abdomen - soft, diffusely tender, positive rebound and guarding,
nondistended
Extremities - warm and well-perfused
Neuro - A&OX3
DISCHARGE PHYSICAL EXAM:
=======================
General - NAD
HEENT - PERRLA, EOMI, moist mucous membranes
Cardiac - RRR, no M/R/G
Chest - CTAB
Abdomen - soft, mildly tender, no rebound, no guarding
Extremities - warm and well-perfused
Neuro - A&OX3
Pertinent Results:
ADMISSION LABS:
===============
___ 03:15PM BLOOD WBC-9.6 RBC-4.97 Hgb-13.9 Hct-40.8 MCV-82
MCH-28.0 MCHC-34.1 RDW-13.1 RDWSD-39.1 Plt ___
___ 03:15PM BLOOD Neuts-78.9* Lymphs-12.2* Monos-7.7
Eos-0.2* Baso-0.6 Im ___ AbsNeut-7.55* AbsLymp-1.17*
AbsMono-0.74 AbsEos-0.02* AbsBaso-0.06
___ 03:15PM BLOOD ___ PTT-150* ___
___ 03:15PM BLOOD Glucose-104* UreaN-13 Creat-0.7 Na-142
K-3.9 Cl-109* HCO3-19* AnGap-14
___ 03:15PM BLOOD ALT-85* AST-36 AlkPhos-64 TotBili-0.6
___ 03:15PM BLOOD Albumin-3.5
___ 10:32PM BLOOD ___ pO2-68* pCO2-44 pH-7.34*
calTCO2-25 Base XS--2 Comment-GREEN TOP
DISCHARGE LABS:
==================
___ 04:15AM BLOOD WBC-7.6 RBC-3.65* Hgb-10.1* Hct-31.0*
MCV-85 MCH-27.7 MCHC-32.6 RDW-13.2 RDWSD-41.1 Plt ___
___ 11:21AM BLOOD ___ PTT-40.5* ___
___ 04:15AM BLOOD Glucose-116* UreaN-10 Creat-0.6 Na-141
K-4.3 Cl-104 HCO3-25 AnGap-12
___ 04:15AM BLOOD ALT-70* AST-23 AlkPhos-73 TotBili-0.4
___ 04:15AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.9
IMAGING:
========
CAT SCAN - CT ABD & PEL ___
IMPRESSION:
1. Findings consistent with mesenteric vein thrombosis in the
right lower quadrant with extension of thrombus to the main
Portal
vein. Marked bowel wall edema with associated free fluid and
mesenteric stranding is noted concerning for bowel ischemia
secondary to
the thrombosis. No definite evidence for feeding mesenteric
artery
cutoff however study is suboptimal on this non arteriographic
phase and would be better assessed on dedicated angiogram.
2. Portal vein thrombosis with extension to the right and left
main portal branches as above.
3. Small amount of perihepatic, pelvic, and mesenteric free
fluid. No frank free air.
4. Bibasilar opacities, left greater than right with trace
bilateral pleural effusions.
FINDINGS:
1. Right basilic vein double-lumen PICC tip in the superior vena
cava.
2. Pre-TIPS right atrial pressure of 20 .
3. CO2 portal venogram failed to show portal veins.
4. Contrast portal venogram showing nonocclusive thrombus
within the portal veins.
5. Venogram of 2 superior mesenteric vein branches, ultimately
demonstrated
thrombus within 1 branch extending into the portal veins.
6. Post procedure ultrasound.
PORTAL VENOGRAPHY
Study Date of ___ 5:48 ___
IMPRESSION:
Technically successful right internal jugular access with
transjugular
transhepatic placement of a superior mesenteric vein lysis
catheter using a 65 cm, 5 cm infusion length ___
infusion catheter.
Successful placement right basilic vein double lumen PICC with
tip in the
superior vena cava. OK to use immediately.
___ Portable CXR
IMPRESSION:
In comparison with the study of ___, there are
lower lung
volumes, which may account for some of the increased prominence
of the cardiac
silhouette. Indistinctness of pulmonary vessels is consistent
with some
elevation of pulmonary venous pressure. Retrocardiac
opacification with
obscuration of the hemidiaphragm is consistent with substantial
volume loss in
the left lower lobe and small pleural effusion.
Right subclavian PICC line extends to the lower SVC.
___ PORTAL VENOGRAPHY
FINDINGS:
1. Superior mesenteric venogram demonstrates patent superior
mesenteric vein
with hepatopetal flow. Patent right portal vein with residual
thrombus in the
left portal vein.
2. Pre-TIPS portal pressure measurement of 13 mm Hg.
3. Post-TIPS portal venogram showing brisk antegrade flow
through the TIPS
with residual thrombus in the left portal vein.
4. Post-TIPS right atrial pressure of 8 mm Hg and portal
pressure of 13 mm Hg
resulting in portosystemic gradient of 5 mmHg.
IMPRESSION:
Successful right internal jugular approach lysis catheter check
and
transjugular intrahepatic portosystemic shunt placement with
porto-systemic
pressure gradient of 5 mm Hg following TIPS placement.
RECOMMENDATION(S): 1. Continue heparin drip with goal PTT of
60-90.
MICROBIOLOGY:
=============
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
Alendronate 70mg weekly, amlodipine 10mg, cyclobenzaprine 10mg,
mycophenolate mofetil 250mg every other day, pravastatin 40mg,
aspirin 81mg daily,
Discharge Medications:
1. Rivaroxaban 15 mg PO BID Duration: 3 Weeks
RX *rivaroxaban [Xarelto] 15 mg 1 tablet by mouth twice a day
Disp #*40 Tablet Refills:*0
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Mycophenolate Mofetil 500 mg PO EVERY OTHER DAY
Discharge Disposition:
Home
Discharge Diagnosis:
Mesenteric and portal vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with portal and SMV thrombus// TIPS approach
thrombolysis
COMPARISON: CT abdomen pelvis
TECHNIQUE: OPERATORS: Dr. ___, attending Interventional
Radiologists and Dr. ___, Interventional Radiology fellow performed the
procedure. Dr. ___ personally supervised the trainee during any
key components of the procedure where applicable and reviewed and agrees with
the findings as reported below.
ANESTHESIA: Anesthesia was administered by the anesthesia staff.
MEDICATIONS: 1 milligram/hour tPA infusion was started.
CONTRAST: 75 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 58.4 min, 590 mGy
PROCEDURE: 1. Right basilic vein double-lumen PICC placement.
2. Right internal jugular venous access using ultrasound.
3. Pre-procedure right atrial pressure measurements.
4. CO2 portal venogram.
5. Portal venogram.
6. Superior mesenteric venogram.
7. Placement of ___ infusion catheter in the superior mesenteric
vein.
8. Limited post procedure ultrasound.
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 arm/neck/abdomen/chest was prepped and draped in the usual
sterile fashion
The right basilic 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 double lumen PIC line measuring 39 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.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Images of
ultrasound access were stored on PACS. Subsequently a Nitinol wire was passed
into the right atrium using fluoroscopic guidance. A small incision was made
at the needle entry site. The needle was exchanged for a micropuncture sheath.
The Nitinol wire was removed and ___ wire was advanced distally into the
IVC.
The micropuncture sheath was then removed, the tract was dilated with an 8
___ dilator, and a 10 ___ sheath was advanced over the wire into the
right atrium where pressure measurement was obtained. The sheath was then
advanced into the inferior vena cava. An MPA, followed by a modified C2 Cobra
and 035 glidewire wire were advanced in the sheath next to the ___ wire and
used to select the right hepatic vein. Lateral view was performed to confirm
position. Images were stored on PACS. Then a occlusion balloon was advanced
over the wire into the distal right hepatic vein. A CO2 portal venogram was
performed in the AP projection.
The ___ wire and occlusion balloon were removed and the sheath was advanced
into the right hepatic vein over an Amplatz wire. Once the sheath was placed
in an appropriate position, the cannula device was inserted over the Amplatz
wire and the wire was exchanged for ___ needle. The angled sheath
was turned anteriorly. The needle was then advanced through liver parenchyma
and the needle was withdrawn over its sheath. Multiple passes were attempted.
Under real-time ultrasound guidance, a 21 gauge needle was used to access a
peripheral right portal vein branch. A 018 Nitinol wire was advanced through
the needle into the superior mesenteric vein to mark the course of the portal
vein.
The 018 wire was targeted using the ___ tips set and was confirmed
using ___ and ___ projections. An 035 Glidewire was passed into the portal
vein and subsequently into the superior mesenteric vein. The 10 ___ sheath
was advanced into the portal vein and contrast was injected to confirm
position. The 10 ___ sheath was then advanced into the superior mesenteric
vein. Contrast was injected to confirm position, and demonstrated
nonocclusive thrombus within the portal vein.
A straight flush catheter was advanced over the Glidewire, the Glidewire was
removed and venogram was performed of 2 superior mesenteric vein branches,
ultimately demonstrating thrombus within 1 branch extending into the portal
veins, which corresponded with the prior CT.
An Amplatz wire was advanced through the flush catheter, the flush catheter
was exchanged for a 65 cm, 5 cm infusion length ___ infusion
catheter which was set up with a 1 milligram/hour infusion rate of tPA.
The portal venography was clinically necessary to guide placement of the lysis
catheter and determine the burden of clot.
Postprocedure ultrasound demonstrated a small amount of simple ascites
inferior to the liver with no significant perihepatic hematoma.
The sheath and infusion catheter was left in place with a side arm heparin
flush running. The side arm and tPA Catheter were labeled. Sheath and
infusion catheter were sutured in place.
Sterile dressings were applied.
The patient tolerated the procedure well. There were no immediate
post-procedure complications. The patient was transferred to the ___ in
stable condition with tPA running and plan for repeat venogram +/-tips
+/-thrombolysis +/-intervention tomorrow.
FINDINGS:
1. Right basilic vein double-lumen PICC tip in the superior vena cava.
2. Pre-TIPS right atrial pressure of 20 .
3. CO2 portal venogram failed to show portal veins.
4. Contrast portal venogram showing nonocclusive thrombus within the portal
veins.
5. Venogram of 2 superior mesenteric vein branches, ultimately demonstrated
thrombus within 1 branch extending into the portal veins.
6. Post procedure ultrasound.
IMPRESSION:
Technically successful right internal jugular access with transjugular
transhepatic placement of a superior mesenteric vein lysis catheter using a 65
cm, 5 cm infusion length ___ infusion catheter.
Successful placement right basilic vein double lumen PICC with tip in the
superior vena cava. OK to use immediately.
RECOMMENDATION(S): Plan for repeat venogram +/-tips +/-thrombolysis
+/-intervention tomorrow.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with s/p EKOS catheter to portal vein// eval
change, in icu
IMPRESSION:
In comparison with the study of ___, there are lower lung
volumes, which may account for some of the increased prominence of the cardiac
silhouette. Indistinctness of pulmonary vessels is consistent with some
elevation of pulmonary venous pressure. Retrocardiac opacification with
obscuration of the hemidiaphragm is consistent with substantial volume loss in
the left lower lobe and small pleural effusion.
Right subclavian PICC line extends to the lower SVC.
Radiology Report
INDICATION: ___ year old woman with portal vein thrombosis status post TIPS
access into the portal vein and thrombolysis catheter placement. At the time
of this exam, tPA had been running for over 12 hours.
COMPARISON: None.
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___, Interventional Radiology fellow performed the procedure.
ANESTHESIA: None.
MEDICATIONS:
CONTRAST: 10 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 2 min, 5 mGy
PROCEDURE: 1. SMV and portal venogram
2. Portal venous thrombolysis catheter repositioning.
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.
A SMV venogram was performed through the pre-existing thrombolysis catheter
situated in the distal SMV demonstrating resolution of the distal SMV
thrombosis. The thrombolysis catheter was then retracted into the proximal
SMV. Contrast was injected again to opacify the portal system. The portal
venogram demonstrated persistent but improved thrombosis of the main portal
vein with clot extending into the right and left portal veins. At this point,
tPA was restarted and the patient was transferred back to the ICU.
FINDINGS:
SMV venogram through the pre-existing lysis catheter demonstrated resolution
of the distal SMV thrombosis.
Portal venogram through the pre-existing lysis catheter demonstrated
persistent but improved main portal vein thrombosis extending into the right
and left portal veins.
IMPRESSION:
Resolution of thrombosis in the distal SMV and improved but persistent
thrombosis in the main portal vein.
Successful reposition of the thrombolysis catheter in the proximal SMV.
The tPA infusion was restarted and the patient was transferred back to the
ICU.
Radiology Report
INDICATION: ___ year old woman with smv thrombus s/p lysis// ___ year old woman
with smv thrombus s/p lysis
COMPARISON: Lysis catheter check ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ performed
the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 70 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: 60 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 7.7 minutes, 36 mGy
PROCEDURE: 1. Right internal jugular approach lysis catheter check
2. Superior mesenteric venogram
3. Pre tips portal pressure measurement.
4. Placement of a 10 mm x 6 cm x 2 cm Viatorr covered stent.
5. Post-stenting balloon angioplasty of the TIPS shunt with a 8 mm balloon.
6. Post-stenting portal venogram.
7. Post stenting right atrial and portal pressure measurement.
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 indwelling right internal jugular approach lysis catheter sheath
was prepped and draped in the usual sterile fashion.
An Amplatz wire was advanced through the indwelling lysis catheter within the
main portal vein and exchange was made for a 5 ___ Omni Flush marking
catheter. Superior mesenteric venogram was performed. Main portal pressure
measurement was obtained. The Amplatz wire was readvanced into the superior
mesenteric vein and pull-back venogram was performed to delineate the portal
vein entry site and hepatocaval junction. The catheter was removed and a 10
mm x 6 cm x 2 cm Viatorr covered covered stent was advanced into appropriate
position and deployed. Following stent deployment, the stent was dilated using
a 8 mm balloon.
A straight flush catheter was advanced over the wire and the wire was removed.
Repeat portal pressure measurements were performed. Post stenting portal
venogram was performed.
The sheath was then removed from the right internal jugular vein site and
pressure held for 10 minutes to achieve hemostasis. Steri-strips and sterile
dressings were applied.
The patient tolerated the procedure well. There were no immediate
post-procedure complications. The patient was transferred to the PACU in
stable condition.
FINDINGS:
1. Superior mesenteric venogram demonstrates patent superior mesenteric vein
with hepatopetal flow. Patent right portal vein with residual thrombus in the
left portal vein.
2. Pre-TIPS portal pressure measurement of 13 mm Hg.
3. Post-TIPS portal venogram showing brisk antegrade flow through the TIPS
with residual thrombus in the left portal vein.
4. Post-TIPS right atrial pressure of 8 mm Hg and portal pressure of 13 mm Hg
resulting in portosystemic gradient of 5 mmHg.
IMPRESSION:
Successful right internal jugular approach lysis catheter check and
transjugular intrahepatic portosystemic shunt placement with porto-systemic
pressure gradient of 5 mm Hg following TIPS placement.
RECOMMENDATION(S): 1. Continue heparin drip with goal PTT of 60-90.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Acute ischemia of intestine, part and extent unspecified, Right lower quadrant pain, Portal vein thrombosis
temperature: 99.3
heartrate: 92.0
resprate: 20.0
o2sat: 96.0
sbp: 123.0
dbp: 85.0
level of pain: 10
level of acuity: 2.0 | Ms ___ was transferred to this ___ with complaints
of abdominal pain, and extensive thrombosis of the portal vein
and SMV, and ischemic bowel changes on CT scan but no frank sign
of perforation or necrosis.
She was taken to the ___ suite, and underwent a lysis catheter
placement via a transhepatic approach. She was taken to the
trauma ICU where she was started on cipro and flagyl and,
received TPA and heparinized saline through the lysis catheter
as well as systemic heparin through PICC line.
On ___, she was taken back to the ___ suite for a venogram
rate was found to have deep calcified cysts has been partially
successful and clot burden has decreased. The patient felt that
the pain has improved considerably and she was started on a
regular diet before going back to the ___ suite for final time on
___, where it was found that the clot burden has decreased
significantly, therefore the catheter was removed and a tips
stent was placed in case further intervention was indicated in
the future.
On ___, she was continuing systemic heparin tolerating a
regular diet. She will need a US for TIPS evaluation in one
week.
Hepatology service was consulted and recommended coagulopathy
workup which is pending at the time of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
clopidogrel / metronidazole
Attending: ___.
Chief Complaint:
Shortness of breath, weakness, weight gain.
Major Surgical or Invasive Procedure:
Cardiac Catheterization: ___
Impression: 99% occlusion of mid L circumflex, with 70% OM1. The
mid left circumflex was stented.
Cardiac Catheterization: ___
Impression: Severe stenosis of left circumflex. Occlusion of
probably small D1 without other significant LAD disease.
Consider PCI of left circumflex.
History of Present Illness:
___ yo M with a h/o LFLG severe AS ___ 1.0), ischemic
cardiomyopathy(EF 40%), CAD s/p NSTEMI, CKD, recent admission
for HF, who presented ___ with weakness, bradycardia, and 4 lb
weight gain. On ___, felt fatigue, pt went to PCP, found to be
bradycardic to ___, referred to ED, found to be in ventricular
bigeminy, fel to to be asymptomatic. Then presented to HCA on
___, sent home, found to be dyspneic with Cr increasing, so
admitted to ED. Took 80 mg torsemide daily (from normal dose 60
mg) but persistent NYHA III sx (ambulating 40 ft), with
increasing lower extremity edema.
ROS:
On review of systems, denies any prior history of stroke, TIA,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. Denies recent fevers, chills or rigors. Denies
exertional buttock or calf pain. All of the other review of
systems were negative. Cardiac review of systems is notable for
absence of dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, palpitations, syncope or presyncope.
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:
OSA, RLS, CKD stage IV, Gout, Colon cancer s/p right colectomy
___.
Social History:
___
Family History:
Mother died from complications related to CHF. Father passed
away from colon cancer.
Physical Exam:
Physical Exam on Admission:
VS: T= 97.9 F BP= 98.0 HR= 72 RR=20 O2 sat=SaO2: 92% RA 99% 2L
I/O: ___
Wt: 87.0 kg. Last reported dry weight 87.6.
GENERAL: In NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 12 cm.
CARDIAC: Late peaking crescendo-decrescendo murmur best heard at
RUSB. HSM at Apex. No pulsus brevis tardus.
LUNGS: Bibasilar crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: ___ +2 Pitting edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Hematoma on left forearm.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
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Physical Exam on Discharge:
VS: T 98.2 HR ___ BP 100s-130s/40s-60s RR ___ SaO2 98% RA
Weight: 83.6kg
24HR Is/Os: ___
8H Is/Os: 120/400
GENERAL: ___, in NAD.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with flat JVP.
CARDIAC: Late peaking crescendo-decrescendo murmur best heard at
right upper sternal border
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No peripheral edema, wwp. mildly palpable petechial
over bilateral shins. R groin site banadaged. No thrill or
murmur. Old hematoma improving in size.
Pertinent Results:
Labs on Admission:
___ 12:30PM BLOOD WBC-5.7 RBC-2.80* Hgb-9.0* Hct-27.2*
MCV-97 MCH-32.1* MCHC-33.1 RDW-13.6 RDWSD-48.6* Plt ___
___ 12:30PM BLOOD ___ PTT-27.9 ___
___ 12:40PM BLOOD UreaN-80* Creat-3.7* Na-132* K-4.6 Cl-93*
HCO3-25 AnGap-19
___ 08:33PM BLOOD CK(CPK)-151
___ 07:25AM BLOOD ALT-23 AST-21 AlkPhos-84 TotBili-0.6
___ 12:30PM BLOOD Calcium-9.1 Phos-4.1 Mg-2.1
___ 08:33PM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1
___ 12:40PM BLOOD Free T4-1.4
___ 12:40PM BLOOD TSH-5.0*
___ 12:30PM BLOOD GreenHd-HOLD
___ 08:33PM BLOOD RedHold-HOLD
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Labs on Discharge:
___ 04:47AM BLOOD WBC-6.3 RBC-2.61* Hgb-8.3* Hct-26.2*
MCV-100* MCH-31.8 MCHC-31.7* RDW-14.7 RDWSD-53.6* Plt ___
___ 04:47AM BLOOD Plt ___
___ 04:47AM BLOOD Glucose-98 UreaN-95* Creat-3.3* Na-145
K-4.1 Cl-106 HCO3-24 AnGap-19
___ 04:47AM BLOOD Calcium-9.1 Phos-5.3* Mg-2.1
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Clinical Studies/Imaging:
___: MRI Torso
FINDINGS:
Chest: The heart is normal in size. There is no pericardial
effusion. The main pulmonary artery trunks are normal in
diameter.
The thoracic aorta is normal in caliber without evidence of an
aneurysm. The ascending aorta measures 3.4 cm. The aortic arch
measures 2.7 cm. The descending aorta measures 2.4 cm. There
is difficult to evaluate the amount of atherosclerotic plaque on
this noncontrast CT, though no large plaques are identified
within the aorta.
There are trace bilateral pleural effusions and dependent
atelectasis. Within the limitations of MRI, the lungs are
otherwise clear.
The imaged portions of the thyroid gland are normal. There is
no axillary, mediastinal, or hilar lymphadenopathy.
Abdomen: The abdominal aorta is normal in caliber without
evidence of an
aneurysm. There is mild-to-moderate atherosclerotic plaque.
There is mild
narrowing at the take-off of the celiac artery, though it is not
likely
clinically significant. The SMA origin bilateral renal artery
origins are
widely patent.
The liver is normal in shape and contour. No focal liver
lesions are
identified on this limited noncontrast exam. There is no intra
or
extrahepatic biliary duct dilation. The gallbladder is not
distended.
Incidentally noted is a gallstone. The spleen is normal in
size. Within the spleen is lobulated T2 hyperintense lesion,
similar to the prior noncontrast CT in ___. This is compatible
with a cyst. There is mild atrophy of the pancreatic
parenchyma. In the tail, there are several cysts measuring up
to 9 mm (8, 16). The duct slightly irregular, though not
dilated. The right adrenal gland is normal. The left adrenal
gland is thickened without a focal nodule. The kidneys are
slightly atrophic. There are multiple T2 hyperintense lesions,
which are most compatible with cysts. These are not fully
characterized on this noncontrast exam.
The stomach and small bowel are normal in course and caliber.
There is no
evidence of obstruction. There is diverticulosis without
evidence of
diverticulitis. The large bowel is otherwise normal. There is
no abdominal lymphadenopathy.
Pelvis: The bilateral common iliac arteries are normal in
caliber without
evidence of an aneurysm or significant stenosis. The right
common iliac is mildly tortuous. The bilateral external iliac
arteries and imaged upper femoral arteries are also normal in
caliber.
A Foley catheter is present within the bladder. The seminal
vesicles and
prostate are grossly unremarkable. There is no pelvic or
inguinal
lymphadenopathy. Trace free fluid is noted in the pelvis.
Osseous structures and soft tissues: There are no concerning
osseous lesions. Moderate degenerative changes are noted
throughout the spine. The soft tissues are unremarkable.
IMPRESSION:
1. Patent arterial vasculature without significant stenosis or
aneurysm. The right common iliac artery is mildly tortuous,
though the course of the
remainder of the arteries is within normal limits.
2. Cholelithiasis.
3. Bilateral cystic renal lesions without overtly concerning
features.
4. Unchanged splenic cyst.
5. Subcentimeter pancreatic cystic lesions, which are likely
side-branch
IPMNs. In lesions of this size, in a patient of this age, no
specific
follow-up is recommended.
___: TTE
Conclusions
There is mild regional left ventricular systolic dysfunction.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch and complex (>4mm)
atheroma in the descending thoracic aorta to 33 cm from the
incisors. The aortic valve leaflets are severely
thickened/deformed. No masses or vegetations are seen on the
aortic valve. Significant aortic stenosis is present (not
quantified). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Moderate (2+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Calcific aortic stenosis (not quantified). Aortic
___ include an aortic annulus of 2.4 cm; sinuses of
Valsalva of 3.3 cm; sinus of Valsalva height of 2.1 cm; and
proximal ascending aortic dimension of 3.4 cm. Thickened mitral
valve leaflets with moderate mitral regurgitation. Depressed
regional left ventricular systolic function. Complex, non-mobile
atheroma in the descending thoracic aorta and simple atheroma in
the aortic arch. Tortuous descending thoracic aorta.
___: EKG
Sinus rhythm. Right bundle-branch block. Left axis deviation.
Left anterior
fascicular block. Compared to tracing #1 the findings are
similar.
TRACING #2
___: EKG
Possible ectopic atrial rhythm. Right bundle-branch block. Left
axis
deviation. Inferior myocardial infarction, age indeterminate.
Compared to the previous tracing of ___ ventricular ectopy
is no longer present.
TRACING #1
___: Cardiac Catheterization:
Impression: Baseline angio from previous cath showed 99% LCX
from 70% OM1 (bifurcation). Crossed OM1 and distal LCX and
stented mid LCX with 0% residual and no change in OM1.
___: Cardiac Catheterization:
Impression: Severe stenosis in large dominant LCX
Probably nondominant RCA occlusion
Occlusion of probably small D1 without other significant LAD
disease
Aortic stenosis with peak gradient 20mm hg.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcitriol 0.25 mcg PO DAILY
4. Felodipine 2.5 mg PO DAILY
5. Felodipine 5 mg PO QPM
6. Finasteride 5 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 600 mg PO QPM restless leg syndrome
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CP
13. Omeprazole 20 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. Tamsulosin 0.4 mg PO DAILY
16. Torsemide 60 mg PO DAILY
17. TraZODone 50 mg PO QHS:PRN insomnia
18. Acetaminophen 325-650 mg PO DAILY:PRN pain
19. Allopurinol ___ mg PO DAILY
20. Fish Oil (Omega 3) 1000 mg PO BID
21. Lidocaine 5% Patch 1 PTCH TD QAM
22. solifenacin 5 mg oral DAILY
Discharge Medications:
1. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [BRILINTA] 90 mg 1 tablet(s) by mouth Twice a day
Disp #*60 Tablet Refills:*0
2. Acetaminophen 325-650 mg PO DAILY:PRN pain
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
5. Atorvastatin 80 mg PO QPM
6. Calcitriol 0.25 mcg PO DAILY
7. Felodipine 2.5 mg PO DAILY
8. Felodipine 5 mg PO QPM
9. Finasteride 5 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Gabapentin 600 mg PO QPM restless leg syndrome
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Levothyroxine Sodium 50 mcg PO DAILY
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Multivitamins 1 TAB PO DAILY
16. Omeprazole 20 mg PO DAILY
17. Tamsulosin 0.4 mg PO DAILY
18. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*0
19. TraZODone 50 mg PO QHS:PRN insomnia
20. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN itch
RX *triamcinolone acetonide 0.1 % Apply a quarter size of cream
over the itchy area. Use up to three times a day as needed for
itch Disp #*45 Gram Gram Refills:*0
21. solifenacin 5 mg oral DAILY
22. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Severe Aortic Stenosis
Coronary Artery Disease
Non-ST elevation Myocardial Infarction
Leukocytoclastic Vasculitis
Chronic Kidney Disease
Benign Prostate Hyperplasia
Urinary Retention
Anemia
Secondary Diagnoses:
Obstructive Sleep Apnea
Restless Leg Syndrome
Hypothyroidism
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 bradycardia, shortness of breath, weakness
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Mild to moderate cardiomegaly is unchanged. The aorta remains tortuous and
diffusely calcified. Mild pulmonary edema appears slightly worse in the
interval with perihilar haziness and vascular indistinctness. Patchy
bibasilar opacities may reflect areas of atelectasis. There are likely trace
bilateral pleural effusions. Elevation of the left hemidiaphragm is
unchanged. No pneumothorax is present. Multilevel degenerative changes are
noted in the thoracic spine.
IMPRESSION:
Mild pulmonary edema, slightly worse in the interval with probable trace
bilateral pleural effusions and bibasilar atelectasis.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man ___ severe aortic stenosis and systolic CHF
presents with fatigue and volume overload, evaluate for hydronephrosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen and pelvis without contrast from ___
FINDINGS:
The right kidney measures 10.6 cm. The left kidney measures 10.4 cm. There is
no hydronephrosis, stones, or suspicious masses bilaterally. Bilateral renal
cysts are identified measuring up to 3.5 cm in the left upper pole and a 1.7
cm in the interpolar region of the right kidney. Normal cortical echogenicity
and corticomedullary differentiation are seen bilaterally.
The bladder is only minimally distended due to the presence of a Foley
catheter and can not be fully assessed on the current study.
A hypoechoic lesion with peripheral calcification is noted in right lobe of
the liver measuring 2 cm, corresponding to a prior larger hepatic cyst, now
smaller due to interval hemorrhage/involutional changes.
IMPRESSION:
No hydronephrosis. Bilateral renal cysts.
Radiology Report
INDICATION: Severe aortic stenosis. Evaluate prior to TAVR.
TECHNIQUE: Multiplanar and multisequence T1 and T2 weighted images were
acquired through the chest abdomen and pelvis without the administration of IV
contrast per the noncontrast MRA protocol.
COMPARISON: Renal ultrasound from ___. MRI of the pelvis from
___. CT of the abdomen and pelvis from ___.
FINDINGS:
Chest: The heart is normal in size. There is no pericardial effusion. The
main pulmonary artery trunks are normal in diameter.
The thoracic aorta is normal in caliber without evidence of an aneurysm. The
ascending aorta measures 3.4 cm. The aortic arch measures 2.7 cm. The
descending aorta measures 2.4 cm. There is difficult to evaluate the amount
of atherosclerotic plaque on this noncontrast CT, though no large plaques are
identified within the aorta.
There are trace bilateral pleural effusions and dependent atelectasis. Within
the limitations of MRI, the lungs are otherwise clear.
The imaged portions of the thyroid gland are normal. There is no axillary,
mediastinal, or hilar lymphadenopathy.
Abdomen: The abdominal aorta is normal in caliber without evidence of an
aneurysm. There is mild-to-moderate atherosclerotic plaque. There is mild
narrowing at the take-off of the celiac artery, though it is not likely
clinically significant. The SMA origin bilateral renal artery origins are
widely patent.
The liver is normal in shape and contour. No focal liver lesions are
identified on this limited noncontrast exam. There is no intra or
extrahepatic biliary duct dilation. The gallbladder is not distended.
Incidentally noted is a gallstone. The spleen is normal in size. Within the
spleen is lobulated T2 hyperintense lesion, similar to the prior noncontrast
CT in ___. This is compatible with a cyst. There is mild atrophy of the
pancreatic parenchyma. In the tail, there are several cysts measuring up to 9
mm (8, 16). The duct slightly irregular, though not dilated. The right
adrenal gland is normal. The left adrenal gland is thickened without a focal
nodule. The kidneys are slightly atrophic. There are multiple T2
hyperintense lesions, which are most compatible with cysts. These are not
fully characterized on this noncontrast exam.
The stomach and small bowel are normal in course and caliber. There is no
evidence of obstruction. There is diverticulosis without evidence of
diverticulitis. The large bowel is otherwise normal. There is no abdominal
lymphadenopathy.
Pelvis: The bilateral common iliac arteries are normal in caliber without
evidence of an aneurysm or significant stenosis. The right common iliac is
mildly tortuous. The bilateral external iliac arteries and imaged upper
femoral arteries are also normal in caliber.
A Foley catheter is present within the bladder. The seminal vesicles and
prostate are grossly unremarkable. There is no pelvic or inguinal
lymphadenopathy. Trace free fluid is noted in the pelvis.
Osseous structures and soft tissues: There are no concerning osseous lesions.
Moderate degenerative changes are noted throughout the spine. The soft
tissues are unremarkable.
IMPRESSION:
1. Patent arterial vasculature without significant stenosis or aneurysm. The
right common iliac artery is mildly tortuous, though the course of the
remainder of the arteries is within normal limits.
2. Cholelithiasis.
3. Bilateral cystic renal lesions without overtly concerning features.
4. Unchanged splenic cyst.
5. Subcentimeter pancreatic cystic lesions, which are likely side-branch
IPMNs. In lesions of this size, in a patient of this age, no specific
follow-up is recommended.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Bradycardia
Diagnosed with Bradycardia, unspecified, Heart failure, unspecified
temperature: nan
heartrate: 34.0
resprate: nan
o2sat: nan
sbp: 114.0
dbp: 69.0
level of pain: 0
level of acuity: 1.0 | ___ with systolic CHF, CKD, BPH c/b urinary retention who was
admitted to the hospital on ___ after presenting with DOE and
weight gain c/w CHF exacerbation ___ worsening ischemic
disease. ___ underwent two cardiac catheterizations with one DES
placed in the LCx, as well as an evaluation for TAVR for severe
AS, now pending procedural date TBD on an outpatient basis.
#Severe Aortic Stenosis: Mr. ___ has severe aortic stenosis and
on cardiac cath demonstrate severe aortic stenosis with peak
gradient 20mm hg. For his severe aortic stenosis, we performed a
TEE and MRI of the chest to evaluate for annular sizing (2.4cm
aortic). ___ was evaluated by the Transcatheter Aortic Valve
Replacement (TAVR) team and is scheduled for close follow-up. ___
will see Dr. ___ on ___ and at that time they will
determine the date of his procedure.
#CAD, NSTEMI s/p PCI: During this admission, Mr. ___ developed
NSTEMI with elevated troponin that peaked at 1.37 without EKG
changes. ___ underwent cardiac catheterization on ___ that
showed severe stenosis in large dominant LCX, probably
nondominant RCA occlusion, as well as occlusion of probably
small D1 without other significant LAD disease. ___ was medically
managed and on ___ returned to the cath lab and had one DES to
the L Cx. ___ was continued on aspirin, ticagrelor and
atorvastatin post-procedurally, and discharged on these
medications.
#Acute on chronic systolic heart failure exacerbation, likely
secondary to coronary artery disease and severe aortic stenosis
combined with poor dietary compliance. We diuresed him
progressively and ___ became euvolemic. ___ was discharged on
felodipine 2.5/5mg alternating dose, imdur, torsemide 40mg
daily. His discharge weight was 84.7kg.
#Acute on chronic CKD: While was here, his chronic kidney
disease was stable and his creatinine fluctuated with diuresis
but was at baseline prior to discharge (Cr 3.3).
#BPH c/b urinary retention: Mr. ___ has a history of BPH c/b
urinary retention. During this admission, due to difficulty
voiding, a foley was placed. ___ was evaluated by urology who
recommended that we pull the foley and perform a void trial.
Urology suggested that if ___ fails, ___ should be discharged with
a foley and be followed-up in ___ clinic for a repeat void
trial. Due to his inability to urinate without a foley on the
day of discharge, ___ was sent home with a foley to be
followed-up in ___ clinic in 7 days. We discharged him on
his home finasteride and tamsulosin.
#Leukocytoclastic Vasculitis: During this admission, Mr. ___
developed pinpoint petechiae. ___ was clinically evaluated by
dermatology who felt that this was likely leukocytoclastic
vasculitis (clinical diagnosis, no biopsy obtained). They
recommended triamcinolone 0.1% cream PRN itch. The etiology was
unclear and they believe it will resolve on it's own. We
discussed this with renal and they decided ___ was unlikely to
have nephritis and did not recommend any further evaluatory
workup.
#Gout: For his gout, we continued him on his home allopurinol.
#Physical Therapy: Physical Therapy recommended home following
___ ___ visits for home ___. Treatment Plan: Progress functional
mobility, progress aerobic
capacity, progress pt education to include further use of RPE.
Frequency/Duration: ___.
TRANSITIONAL ISSUES:
====================
1. Please follow-up with patient s/p NSTEMI, with one
drug-eluting stent placement. ___ was started on ticagrelor.
2. Please follow-up with patient regarding TAVR and the
scheduled date when it is known. Please evaluate the TEE and MRI
results.
3. Please follow-up regarding his chronic kidney disease and
ensure the creatinine is at baseline. Discharge creatinine 3.3.
4. Please follow-up on his chemistry panel (to be drawn on ___
when ___ sees Dr. ___. Please evaluate and replete
electrolytes as needed.
5. Please follow-up on his leukocytoclastic vasculitis and
ensure complete resolution, consider dermatology follow-up if
persistent.
6. Please follow-up regarding his anemia, his H/H has been
stable during this hospitalization.
7. Please follow-up his MRI torso results, there were many
incidental findings, which are included below:
a. Cholelithiasis.
b. Bilateral cystic renal lesions without overtly concerning
features.
c. Unchanged splenic cyst.
d. Subcentimeter pancreatic cystic lesions, which are likely
side-branch IPMNs. In lesions of this size, in a patient of this
age, no specific follow-up is recommended.
8. Please follow-up regarding his BPH and urinary retention.
Remove foley on ___ at the urology follow-up appointment and
perform another void trial.
9. Please follow-up regarding his acute on chronic systolic
heart failure. ___ was discharged on torsemide 40mg daily and the
discharge weight was 84.7kg. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with history of hypertension, COPD who came
to the ED on ___ after a fall now with hypoxia.
Patient reported falling onto her buttocks prior to evaluation
and was omplaining of right hip pain. Pelvis and hip films
revealed communited fracture of the R superior pubic ramus and
possible fracture of the R inferior pubic ramus. CT of the head
was w/o acute intracranial abnormality. Pt was initially triaged
to have case manager and ___ evaluate for rehab placement. On
___, pt was noted to have new oxygen requirement with desats
(mid ___ on room air). This was thought to be d/t COPD
exacerbation. CTA was ordered and did not show evidence of PE
but did show a mildly displaced R ___ posterior rib fx of
unclear acuity, multiple old fx's in ribs and spinous processes,
mild pulmonary emphysema, and "2.1 cm subpleural lesion with
internal aeration/cavitation in posterior left lower lobe" that
was favored by radiology to represent rounded atelectasis.
ED:
Labs were significant for WBC 11.5, H/H 11.4/34.9, Plt 166, SCr
0.9 (unknown baseline), INR 1.3, PTT 27.9, UA negative.
NCHCT notable for chronic microvascular ischemic changes, Pelvic
x-ray revealed "Acute, comminuted fracture of the right superior
pubic ramus and possible fracture of the right inferior pubic
ramus." CXR showed no acute process, no definite rib fx's.
During her ED stay, she received pain control, home lisinopril
and HCTZ, tiotropium, SCH. Once she was noted to be hypoxic,
she was started on 500mg azithromycin and 40mg prednisone.
Vitals prior to transfer: 98.4 84 126/55 19 95% Nasal Cannula
On arrival to the floor, pt reports that she came in after a
fall. She had just had gotten to the ___s ___ on ___
(___). Was out of the car and pivoted to the R w/o shifting
weight. Landed in "fetal position" on R side. Has had similar
falls in the past. No prodromal sx-CP, palpitations, n/v. No
LOC. No head strike. Continues to have pain in R pelvic area.
Per the patient she has not noted worsening SOB over the last
few days. Daughter notes that she has been on oxygen
intermittently in the ED. She was not getting her Spiriva.
Currently denies fevers, chills, CP, SOB, cough, congestion,
rhinorrhea, nausea/vomiting, dysuria. Notes issues with
urination as "urinating feels different." Says that when she
coughs, urine comes out and she has been having issues
urinating. Denies chest pain with exertion at home. No
orthopnea. Reports that pain is mostly in the R buttock area. No
recent travel, night sweats, change in weight. Travelled to
___ many years ago but to never ___ world places such as
___. Also reports that last ___ was on ___ and she is
feeling distended. Has been passing gas. Daughter notes that
memory has worsened and patient has good insight, but has not
been formally worked up by PCP. Had fall in ___, which was
similar to this most recent fall.
Past Medical History:
HTN
COPD
hyperlipidemia
Hysterectomy
CCY
Social History:
___
Family History:
Father- MI
Mother- ___
Physical Exam:
Exam upon admission:
VS: 98.1 136 / 77 81 20 95 2LNC
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI
NECK: Supple without LAD, no JVD
PULM: Diffuse wheezing heard throughout
COR: RRR, s1/s2 heard, no m/r/g
ABD: NABS, soft, LLQ and RLQ area appears distended, non tender
to palpation in all four quadrants, and no rebound or guarding
EXTREM: Warm, well-perfused, no ___ edema , RLE ___ thigh
strength, ___ dorsiflexion and plantar flexion, ___ right leg
strength, limited by pain
NEURO: L pupil with upward gaze (chronic), EOMI, axo x3
Exam upon discharge:
VS: 97.9 155 / 77 78 20 93 2L
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI
NECK: Supple without LAD, no JVD
PULM: Diffuse wheezing heard throughout (improved from
yesterday)
COR: RRR, s1/s2 heard, no m/r/g
ABD: NABS, soft, LLQ and RLQ area appears distended, non tender
to palpation in all four quadrants, and no rebound or guarding
EXTREM: Warm, well-perfused, no ___ edema , RLE ___ thigh
strength, ___ dorsiflexion and plantar flexion, ___ right leg
strength, limited by pain
NEURO: L pupil with upward gaze (chronic), EOMI, axo x3
Pertinent Results:
ADMISSION LABS:
___ 09:10PM BLOOD WBC-11.5* RBC-3.58* Hgb-11.4 Hct-34.9
MCV-98 MCH-31.8 MCHC-32.7 RDW-12.2 RDWSD-44.4 Plt ___
___ 09:10PM BLOOD ___ PTT-27.9 ___
___ 09:10PM BLOOD Glucose-119* UreaN-17 Creat-0.9 Na-135
K-3.9 Cl-96 HCO3-28 AnGap-15
___ 09:10PM BLOOD Glucose-119* UreaN-17 Creat-0.9 Na-135
K-3.9 Cl-96 HCO3-28 AnGap-15
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-11.5* RBC-3.24* Hgb-10.2* Hct-31.1*
MCV-96 MCH-31.5 MCHC-32.8 RDW-12.1 RDWSD-42.3 Plt ___
___ 07:20AM BLOOD Glucose-98 UreaN-18 Creat-0.7 Na-146*
K-3.8 Cl-103 HCO3-25 AnGap-22*
IMAGING:
CT HEAD ___
FINDINGS:
There is no evidence of acute large territorial infarction,
hemorrhage, edema, or mass. There encephalomalacia related to
prior infarcts as well as periventricular and subcortical white
matter hypodensity,, likely representing chronic microvascular
ischemic changes. The ventricles and sulci are prominent,
consistent with involutional changes. There is calcification
the bilateral carotid siphons and V4 segments of the bilateral
carotid arteries.
Incidentally noted tiny osteoma near the vertex ___ ___). No
fractures. There is mucosal thickening in the right maxillary
sinus. There is a rightward nasal spur. The paranasal sinuses,
mastoid air cells, and middle ear cavities are otherwise clear.
Status post bilateral lens replacements.
IMPRESSION:
1. No acute intracranial abnormality.
2. Sequelae of prior infarcts as well as periventricular and
subcortical white matter hypodensity, likely representing
chronic microvascular ischemic changes.
3. No fractures.
PELVIC/HIP PLAIN FILMS ___
FINDINGS:
There is acute, comminuted fracture of the right superior pubic
ramus.
No additional fractures are identified.
There are degenerative changes of the bilateral hips.
Extensive phleboliths and vascular calcifications.
IMPRESSION:
Acute, comminuted fracture of the right superior pubic ramus and
possible
fracture of the right inferior pubic ramus. No other fractures
are
identified.
CXR ___
IMPRESSION:
No acute cardiopulmonary process. No obvious acute fracture
identified,
however, if there is clinical concern for such, dedicated rib
series or CT is more sensitive.
CTA ___
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mildly displaced posterior right 11 rib fracture is of
unclear acuity.
Multiple old fractures are identified in multiple right ribs and
right
thoracic spine transverse process.
3. Moderate hiatal hernia.
4. Mild pulmonary emphysema.
5. 2.1 cm subpleural lesion with internal aeration/cavitation in
posterior
left lower lobe is likely rounded atelectasis.
PORTABLE ABDOMEN ___:
Report pending at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Simvastatin 10 mg PO QPM
3. Lisinopril 40 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB/wheez
3. Azithromycin 250 mg PO Q24H Duration: 4 Days
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth q 6 hours Disp #*10
Tablet Refills:*0
6. PredniSONE 40 mg PO DAILY Duration: 4 Days
7. TraMADol 50 mg PO Q6H:PRN Pain - Mild
RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth q 6 hours Disp
#*10 Tablet Refills:*0
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Lisinopril 40 mg PO DAILY
10. Simvastatin 10 mg PO QPM
11. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Comminuted fracture of the right superior pubic ramus
Acute on chronic COPD exacerbation
Rib fractures
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: DX PELVIS AND HIP UNILATERAL
INDICATION: History: ___ with s/p fall onto buttocks. R hip pain //
?fracture
TECHNIQUE: AP pelvis, and right hip, two views
COMPARISON: None.
FINDINGS:
There is acute, comminuted fracture of the right superior pubic ramus.
No additional fractures are identified.
There are degenerative changes of the bilateral hips.
Extensive phleboliths and vascular calcifications.
IMPRESSION:
Acute, comminuted fracture of the right superior pubic ramus and possible
fracture of the right inferior pubic ramus. No other fractures are
identified.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with s/p fall // ?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, 16.4 cm; CTDIvol = 49.1 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, hemorrhage, edema,
or mass. There encephalomalacia related to prior infarcts as well as
periventricular and subcortical white matter hypodensity,, likely representing
chronic microvascular ischemic changes. The ventricles and sulci are
prominent, consistent with involutional changes. There is calcification the
bilateral carotid siphons and V4 segments of the bilateral carotid arteries.
Incidentally noted tiny osteoma near the vertex ___ B/ ___). No fractures.
There is mucosal thickening in the right maxillary sinus. There is a
rightward nasal spur. The paranasal sinuses, mastoid air cells, and middle
ear cavities are otherwise clear. Status post bilateral lens replacements.
IMPRESSION:
1. No acute intracranial abnormality.
2. Sequelae of prior infarcts as well as periventricular and subcortical white
matter hypodensity, likely representing chronic microvascular ischemic
changes.
3. No fractures.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with SOB // rib fractures, contusion?
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Cardiac and mediastinal silhouettes are stable. Left base atelectasis/
scarring is seen. No definite focal consolidation is seen. No large pleural
effusion or pneumothorax. No obvious acute rib fracture is seen, however, if
there is clinical concern for such, dedicated rib series or CT is more
sensitive.
IMPRESSION:
No acute cardiopulmonary process. No obvious acute fracture identified,
however, if there is clinical concern for such, dedicated rib series or CT is
more sensitive.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with sob after fall // PE? pulmonary contusion? rib
fractures?
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 4.9 mGy (Body) DLP = 2.4
mGy-cm.
2) Spiral Acquisition 3.6 s, 28.4 cm; CTDIvol = 6.4 mGy (Body) DLP = 181.0
mGy-cm.
Total DLP (Body) = 183 mGy-cm.
COMPARISON: None
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. Coronary artery calcification is heavy. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: Trace left pleural effusion is noted.
LUNGS/AIRWAYS: Minimal atelectasis is noted in bilateral lungs posteriorly.
Multiple millimetric calcified pulmonary granulomas are noted. A 2.1 x 1.0 cm
subpleural lesion with internal aeration/cavitation is identified in posterior
left lower lobe (3:125). The lesion is associated with several small foci of
calcifications. A 3 mm nodule is identified in the right middle lobe (3:140).
Centrilobular emphysema is mild. 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.
7 mm nodule is identified in the left thyroid lobe, which do not require
follow-up per ACR guideline.
ABDOMEN: Included portion of the upper abdomen is notable for moderate hiatal
hernia.
BONES: No suspicious osseous abnormality is seen. ?Mildly displaced posterior
right 11 rib fracture is of unclear acuity. Multiple old fractures are
identified in multiple right ribs and right thoracic spine transverse process.
There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mildly displaced posterior right 11 rib fracture is of unclear acuity.
Multiple old fractures are identified in multiple right ribs and right
thoracic spine transverse process.
3. Moderate hiatal hernia.
4. Mild pulmonary emphysema.
5. 2.1 cm subpleural lesion with internal aeration/cavitation in posterior
left lower lobe is likely rounded atelectasis.
Radiology Report
INDICATION: ___ year old F with constipation and abdominal distention //
Stool burden? Free air?
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Chest x-ray from ___.
FINDINGS:
There are no abnormally dilated loops of small or large bowel. There is a
large stool burden primarily in the cecum and ascending colon. Multiple stool
balls and air are noted in the rectum.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Of the lumbar spine and bilateral hip joints are noted.
Surgical clips are present in the right upper quadrant. Vascular
calcifications are present in the femoral arteries.
IMPRESSION:
1. No abnormally dilated loops of small or large bowel to suggest obstruction.
2. Large stool burden, mostly in the cecum and ascending colon, with stool
balls and air noted in the rectum.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Hip pain, s/p Fall
Diagnosed with Fracture of superior rim of right pubis, init for clos fx, Other fall on same level, initial encounter
temperature: 99.0
heartrate: 74.0
resprate: 20.0
o2sat: 95.0
sbp: 177.0
dbp: 85.0
level of pain: 1
level of acuity: 3.0 | ___ with PMHx of HTN, COPD who presented s/p fall with pelvic
rami fractures, now admitted for ongoing pain control and
hypoxia.
#Pelvic fracture and fall
Fall thought to be mechanical in nature. No prodromal sx. No
LOC. CT head performed that was WNL. CTA revealed rib fractures,
both acute and old. Plain films revealed "Acute, comminuted
fracture of the right superior pubic ramus and possible fracture
of the right inferior pubic ramus. No other fractures are
identified." Orthopedic evaluated and recommended physical
therapy and pain control. No surgical intervention needed. ___
evaluated and recommended acute rehab.
#Hypoxia:
Pt developed hypoxia to 84% on RA during ED visit. CTA without
PE but does show mild emphysema. No e/o PNA. No hx c/w ACS or
CHF & EKG w/o ischemia. Etiology thought to be due to COPD
exacerbation. Pt treated with prednisone and azithromycin (end
date ___. Pt also treated with standing nebulizer
treatments. Pt initially required 2 L of supplemental O2 and was
weaned to .5L (with saturations in the low ___ upon discharge.
#Abd distention:
Pt noted to have abdominal distention on exam. KUB was not read
prior to discharge but prelim read by resident was w/o
significant bowel dilation. Likely related to stool burden and
pt should be treated with bowel regimen at rehab.
#HTN:
Continued BP control with HCTZ and lisinopril
#HLD
Continued statin
**TRANSITIONAL ISSUES**
**TRANSITIONAL ISSUES** |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a ___ gentleman with a pmhx. significant for
splenic marginal zone lymphoma and asthma who is admitted from
the ED with PE.
Patient was in his usual state of health until about last week
when he developed shortness of breath. Saw his PCP who
prescribed neb treatments and prednisone. Felt somewhat better
but then worsened over the weekend. Went to see ___ PCP again
on day of admission; patient's O2 sats did not come up despite
nebs and he was sent to the ED.
In the ED, initial vitals were: 98.6 82 126/86 22 98% 15L
Non-Rebreather. A CTA showed: left upper lobe pulmonary
embolism in the segmental arteries and stable LAD. Patient was
given 100mg of Lovenox, 5mg of coumadin, 125mg of methylpred,
and admitted to the floor. On admission, vitals were: 97.4 80
117/80 19 95% on O2 with NC.
ROS: Significant for shortness of breath and the feeling that
someone is poking him in the middle of his chest. No unilateral
leg swelling. Some dry heaves. No fevers, chills, nausea,
vomiting, dysuria, rash, or other concerning signs or symptoms.
Past Medical History:
Splenic marginal zone lymphoma, anxiety, hiatal hernia, asthma,
Hypothyroidism, splenectomy, umbilical hernia repair.
Social History:
___
Family History:
Mother with COPD and RA. Father died of cancer, not sure what
kind.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.3, 125/77, 73, 18, 96% on RA
GENERAL: Sitting in bed, no acute distress, slightly sallow
complexion
CHEST: Wheezing on right, good air movement
CARDIAC: RRR, no MRG
ABDOMEN: +BS, soft, non-tender, non-distended
EXTREMITIES: Trace edema bilaterally
NEURO: Alert and oriented, CN II-XII grossly intact
SKIN: Warm and dry
PSYCH: Calm and appropriate
Pertinent Results:
___ 07:47PM LACTATE-2.0
___ 07:44PM GLUCOSE-146* UREA N-20 CREAT-1.2 SODIUM-140
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-26 ANION GAP-16
___ 07:44PM estGFR-Using this
___ 07:44PM cTropnT-<0.01 proBNP-119
___ 07:44PM WBC-14.5* RBC-4.58* HGB-14.6 HCT-44.9 MCV-98
MCH-31.8 MCHC-32.5 RDW-14.0
___ 07:44PM NEUTS-92.3* LYMPHS-6.3* MONOS-0.4* EOS-0.7
BASOS-0.2
___ 07:44PM PLT COUNT-236
___ 07:44PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
CTA ___:
1. Segmental pulmonary embolism affecting the branches of the
left upper lobe. Probable segmental right upper lobe pulmonary
artery filling defects as well, although contrast timing is not
optimal. No evidence of right heart strain. 2. Lymphadenopathy,
unchanged since ___.
ECHOCARDIOGRAM ___
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Doppler parameters are indeterminate for
left ventricular diastolic function. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Normal regional and global biventricular systolic
function. Indeterminate indices to assess diastolic function. No
pathologic valvular abnormalities. Unable to estimate pulmonary
artery systolic pressure.
Lower extremity dopplers ___
IMPRESSION:
No evidence of DVT in either lower extremity.
Discharge labs:
___ 11:00AM BLOOD ___ PTT-40.6* ___
___ 07:10AM BLOOD ___ PTT-43.2* ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 50 mg PO QAM
2. Sertraline 25 mg PO QPM
3. ALPRAZolam 0.5 mg PO QHS:PRN Insomnia, anxiety
Please hold for oversedation or RR <10.
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Shortness of
breath
5. Ipratropium Bromide Neb 1 NEB IH Q6H
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Omeprazole 40 mg PO BID
9. Ferrous Sulfate 325 mg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 110 mg SC Q12H
RX *enoxaparin 120 mg/0.8 mL 110 mg sub-q every twelve (12)
hours Disp #*10 Syringe Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Shortness of
breath
3. ALPRAZolam 0.5 mg PO QHS:PRN Insomnia, anxiety
4. Cyanocobalamin 1000 mcg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Ipratropium Bromide Neb 1 NEB IH Q6H
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Omeprazole 40 mg PO BID
10. Sertraline 50 mg PO QAM
11. Sertraline 25 mg PO QPM
12. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
13. PredniSONE 60 mg PO DAILY Duration: 2 Days
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
14. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*10 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Acute pulmonary embolus
Asthma, with exacerbation
History of lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: New pulmonary embolism. Assess for deep venous thrombosis.
COMPARISON: None.
FINDINGS:
Grayscale and color sonograms were acquired of the bilateral common femoral,
superficial femoral, popliteal, posterior tibial, and peroneal veins. There
is normal compressibility, flow, and augmentation throughout.
IMPRESSION:
No evidence of DVT in either lower extremity.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with PULM EMBOLISM/INFARCT
temperature: 98.6
heartrate: 82.0
resprate: 22.0
o2sat: 98.0
sbp: 126.0
dbp: 86.0
level of pain: 0
level of acuity: 2.0 | ___ yo M with history of splenic marginal zone lymphoma and
asthma who presents with dyspnea and wheezing, found to have a
new pulmonary embolism as well as an asthma exacerbation.
# Acute pulmonary embolism: Likely related to known malignancy
(indolent lymphoma). Patient was started on Lovenox as bridge to
anticoagulation with coumadin. Patient will likely need
life-long anticoagulant therapy. His PCP ___ was
contacted and follow up with Dr. ___ the ___
clinic there was arranged.
Of note, lower extremity dopplers were negative and
echocardiogram was normal.
# ASTHMA EXACERBATION: Likely triggered in part by PE, heat and
patient's job at a sewage treatment plant. Continued controller
inhalers, albuterol, ipratropium and started a Prednisone burst.
Also started levofloxacin since pt is asplenic and there was a
question of bronchitis.
# SPLENIC MARGINAL ZONE LYMPHOMA: Patient is being followed
with serial exams and imaging. Treatment as per outpatient
providers. He was seen by hematology/oncology while
hospitalized, and they recommended sooner follow up be arranged
with Dr. ___ hematologist. This was set up prior to
discharge.
# HYPOTHYROIDISM: Continued levothyroxine
# DEPRESSION/ANXIETY: Continued zoloft and alprazolam.
# COMMUNICATION: Patient and mother ___
___
# CODE STATUS: Full (confirmed) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Enbrel / Methotrexate / Ampicillin
Attending: ___
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
___ CABGx6
History of Present Illness:
___ s/p CABGx6 on ___ presented to ___ on ___
with thrombocytosis and cellulitis at ___ saphenectomy site.
She was treated with vancomycin and discharged back to rehab on
clindamycin on ___. On ___, she returned to ___ with
dizziness, decreased PO intake x1 week, and no BMs x 1 wk. Labs
were significant for Na 123, K 6.6, Cr 1.9. She was given 1L NS
and transferred to ___.
Past Medical History:
Hypertension
Dyslipidemia
Peripheral artery disease
Hypothyroidism
Anxiety
Depression
Osteoporosis
Rheumatoid arthritis
Psoriasis
Lupus (remote)
C-diff (___)
Past Surgical History:
Cholecystectomy
Bilateral cataracts
Social History:
___
Family History:
No premature CAD.
Physical Exam:
Pulse: 65 Resp: 19 O2 sat: 100% 3 liters NC
B/P Right: 100/47 Left:
Height: 65 inches Weight: 59 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]decreased
bowel sounds +
Chest: sternal incision healing well, sternum stable.
Extremities: Warm [x], well-perfused [x] Edema [] __no___
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
___ Right: 1+ Left: 1+
Radial Right: 1+ Left: 1+
L saphenectomy site healing well, no errythema
Carotid Bruit Right: no Left: no
Pertinent Results:
___ 08:05PM ___ PTT-35.2 ___
___ 08:05PM WBC-13.1* RBC-3.51* HGB-10.0* HCT-31.4*
MCV-89 MCH-28.4 MCHC-31.8 RDW-13.5
___ 08:05PM PLT SMR-VERY HIGH PLT COUNT-1008*
___ 08:05PM NEUTS-83* BANDS-3 LYMPHS-7* MONOS-7 EOS-0
BASOS-0 ___ MYELOS-0
___ 08:05PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
___ 08:05PM ALT(SGPT)-16 AST(SGOT)-21 ALK PHOS-145*
AMYLASE-67 TOT BILI-0.1
___ 08:05PM ALBUMIN-3.5
___ 08:05PM LIPASE-72*
___ 08:05PM GLUCOSE-94 UREA N-32* CREAT-1.6* SODIUM-125*
POTASSIUM-5.8* CHLORIDE-95* TOTAL CO2-17* ANION GAP-19
___ 08:18PM LACTATE-2.3*
___ 09:46PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 09:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 09:46PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 09:46PM URINE HYALINE-1*
___ 09:46PM URINE MUCOUS-RARE
Medications on Admission:
1. Albuterol-Ipratropium ___ PUFF IH Q6H
2. Aspirin 81 mg PO DAILY
3. Carbamazepine 400 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Nortriptyline 200 mg PO HS
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY poor grafts
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Metoprolol Tartrate 6.25 mg PO BID
10.Ranitidine 150 mg PO BID
11.TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
12.Calcium Carbonate 500 mg PO QID:PRN reflux
___ 0.05% Cream 1 Appl TP BID:PRN prn
14. Insulin SC
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Carbamazepine 400 mg PO DAILY
3. Diazepam 5 mg PO Q12H:PRN anxiety
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Nortriptyline 200 mg PO HS
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H pain
8. Clopidogrel 75 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN itchiness
11. Multivitamins 1 TAB PO DAILY
12. Atenolol 25 mg PO DAILY
hold for SBP<95 or HR<55 and notify ___ if held
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Lidocaine 5% Patch 1 PTCH TD DAILY
to lower mid back
15. Simponi *NF* (golimumab) 50 mg/0.5 mL Subcutaneous once
* Patient Taking Own Meds *
16. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
17. Polyethylene Glycol 17 g PO DAILY
18. Lactulose 30 mL PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
dehydration
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol and Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
No Edema of lower extremities
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: ___ female with history of shortness of breath.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. The lungs
are hyperinflated with flattening of the diaphragms, suggesting chronic
obstructive pulmonary disease. Likely persistent left pleural effusion status
post median sternotomy and CABG. The cardiac and mediastinal silhouettes are
overall stable. Frontal view shows a small anterior loculation of pleural air
and fluid, slightly decreased in size as compared to ___.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Status post CABG, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is unchanged evidence
of bilateral pleural effusions, left slightly more than right. On the left,
there is blunting of the costophrenic sinus as well as minimal areas of medial
atelectasis.
The sternal wires are intact. Suture fragment projecting over the sternum.
No pulmonary edema. No pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DEHYDRATION/VOMITING
Diagnosed with RESPIRATORY ABNORM NEC, VOMITING, ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPOSMOLALITY/HYPONATREMIA, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, HYPOTHYROIDISM NOS, AORTOCORONARY BYPASS
temperature: 98.3
heartrate: 100.0
resprate: 18.0
o2sat: 98.0
sbp: 103.0
dbp: 46.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ was re-admitted from ___ s/p CABG x6 on
___ with hypotension, dehydration and, abdominal discomfort.
She was noted to have hyperkalemia and hyponatremia. She was
hydrated with normal saline and underwent an aggressive bowel
cleanout with resolution of her abdominal pain. Her hyperkalemia
was treated with hydration as well as IV insulin and D50. She
was on Clindamycin from a previous visit to ___ last
week for reported cellultitis of her left SVGH site. The site
was benign on admission and the clindamycin was d/c'd.
By the time of this discharge, her sternal incisional pain is
well controlled, her bowel function has returned and she is
eating a heart healthy/carbohydrate consistent diet with a fair
appetite. Her sodium is normalizing and her hyperkalemia has
resolved. She was started back on her atenolol which had been
held while she was hypotensive. She was seen by physical therpay
for strength and conditioning and she was discharged to ___
___ and rehab on HD#5. anticpate less than 30 day length of
stay. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Insulin,Pork / Haldol / Thorazine / Trilafon / IV Dye, Iodine
Containing Contrast Media / polyethylene glycol 3350
Attending: ___.
Chief Complaint:
Feels unsafe at home
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ h/o Bipolar disorder and PTSD presents with "feeling
unsafety." Patient with a prior history of multiple suicide
attempts. In the ED, patient was quoted as saying she was having
suicidal ideation. However, on the floor, she reports that she
has felt unsafe, giving her flashbacks to when she previously
had suicide attempts. She reports she feels unsafe because
people are "following her to the grocery store, the bank." These
are not people she knows "but random people on the street." She
reports that she wants to find an all women group due to her hx
of being raped. She has occasional nightmares about being raped.
She also reports that she has had a manic episode recently
(unclear time course as she mentioned recently as well as this
past ___. During this, she sleeps much less and feels
unsafe. She also has a poor appetite (both now and when she has
other manic episodes).
Patient also states "I can't be safe when I feel other people
are reading my mind." She feels that everyone can do this. She
has not had any homicidal ideations and feels she was close to
having suicidal ideations again. The worsening of this feeling
came after having an argument with an acquaintance. She reports
that she has 3 VNAs that help her medication administration. She
is able to recall her medications but not sure of doses. She
does not believe she has had any monitoring levels since she
left the hospital.
She notes DOE, nausea, palpitations. Felt like she was having a
heart attack in the ED. She reports she has felt this way
previously when she gets upset.
Of note, patient recently admitted in ___ with confusion
of unknown etiology. Workup was extensive and there was thought
to be a psychiatric component as well as med-effect as multiple
psychiatric medications had a high level.
In the ED, initial vitals were: 96.9 120 140/80 16 96% RA
In the ED, labs were significant lactate 3, AG intially 19 which
on ABG 9hrs later was 21. Patient received fluids. UA negative
for infection with 10 ketones and trace glucose. EKG showed
sinus tachycardia with QtC 423.
On the floor, patient appears comfortable, talking on her phone
Past Medical History:
PMH:
- NIDDM, well controlled with PO meds, diet, and exercise,
+microalbuminuria
- HL
- obesity
- h/o SAH
- hx tobacco abuse
- tubal ligation
- ?COPD
.
PSYCHIATRIC HISTORY:
- Psychiatrist: Dr. ___, ___, @ ___. Prior to
that she was treated by Dr. ___ at ___ x ___ yrs and then by
his replacement for approx ___ yr.
- Therapist: ___ @___ ___. Prior to that her
therapist x ___ yrs was ___.
- Hospitalizations: Multiple, last from ___ to ___ at ___.
- Suicide attempts: Multiple, patient reports greater than 30
SA, that began with wrist cutting at age ___ (per OMR). She
reports last SA was ___ years ago.
- Previous diagnoses: Bipolar disorder, PTSD, borderline
personality disorder. Pt reports a h/o AH "years ago", h/o
"dissociating," and self-injurious behavior (last time more than
___ yrs ago).
- Psych med hx: Reports h/o topamax, seroquel, zyprexa,
depakote, neurontin, abilify. Reports good response to lithium
in the past and greatest period of stability on clozaril.
Social History:
Ms. ___ was born and raised in ___. She recalls a
stressful childhood due to violence in her home and in her
neighborhood. She has one younger sister, and both she and her
sister were sexually abused by their father. When she was ___
years old, her parents separated. Her mother has passed away and
she has a difficult relationship with her sister, but she
maintains contact with her father. Her symptoms of PTSD come
from a witnessing someone getting shot in her neighborhood when
she was ___ years old.
- Attended ___ where she was an honor roll
student, had perfect attendance, many friends and says that high
school was "the best ___ years of my life." She went on to get a
job at ___ as a ___ and ___, where she worked for
one year before stopping due to depression. She has taken some
college courses at ___ over the years.
- She has been incarcerated for 7 months in ___ for
shoplifting, and arrested one other time for stealing.
- Ms. ___ was married for ___ years, has been separated since
___, and finalized her divorce papers in ___. She has
had two children, and gave them both her children up for
adoption shortly after they were born and has no contact with
them.
- She currently lives alone in an apartment on ___,
but feels well supported by her ___ community, friends and
father. She works part-time as a ___.
- Pt smoked in past and quit ___ years ago, pt does not recall
exact quantity
- Drank EtOH socially in past, denies current use
- Denies illicits
- ___ nurse comes only to fill pill box, otherwise she is
independent
Family History:
Father with possible ___, mother and sister with depression.
DM, HTN and heart disease in mother, sickle cell in family and
psychiatric issues.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:98.5 BP:102/76 P:98 R:18 O2:100RA
General: NAD, comfortable
HEENT: NCAT. EOMI. Sclera anicteric.
Neck: Supple, no LAD appreciated
CV: RRR no m/r/g
Lungs: CTA b/l, no w/r/r
Abdomen: +BS, NTND
Ext: No peripheral edema, frail toe nails
PSYCH: Flat affect, tangential thought process
DISCHARGE PHYSICAL EXAM:
Vitals: T:98.3 BP:103-160/51-106 P:98-119 R:18 O2:99RA
General: NAD, comfortable
HEENT: NCAT. EOMI. Sclera anicteric.
Neck: Supple, no LAD appreciated
CV: RRR no m/r/g
Lungs: CTA b/l, no w/r/r
Abdomen: +BS, NTND
Ext: No peripheral edema
PSYCH: Flat affect, tangential thought process. Delusional
thought process. Hyperactive thought process.
Pertinent Results:
ADMISSION:
___ 02:30AM BLOOD WBC-6.7 RBC-3.94* Hgb-12.0 Hct-37.8
MCV-96 MCH-30.6 MCHC-31.9 RDW-13.8 Plt ___
___ 02:30AM BLOOD Neuts-58.3 ___ Monos-9.9 Eos-0.9
Baso-0.7
___ 02:30AM BLOOD Glucose-230* UreaN-14 Creat-0.6 Na-141
K-4.2 Cl-106 HCO3-17* AnGap-22*
___ 02:30AM BLOOD ALT-10 AST-13 AlkPhos-56 TotBili-0.1
___ 02:30AM BLOOD Albumin-4.1
___ 02:30AM BLOOD TSH-2.0
___ 02:30AM BLOOD Lithium-0.8 Valproa-120*
___ 02:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE:
___ 09:00AM BLOOD WBC-6.7 RBC-4.28 Hgb-13.0 Hct-40.9 MCV-96
MCH-30.3 MCHC-31.7 RDW-13.7 Plt ___
___ 09:00AM BLOOD Glucose-223* UreaN-10 Creat-0.6 Na-139
K-4.8 Cl-105 HCO3-19* AnGap-20
___ 09:00AM BLOOD Calcium-9.9 Phos-3.9 Mg-1.9
URINE
___ 10:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 02:30AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
STUDIES:
CXR ___: IMPRESSION: No evidence of pneumonia as can be
excluded on single portable chest examination.
EKG ___:
Sinus tachycardia. Non-diagnostic Q waves in high lateral leads.
Non-specific
ST segment flattening. Compared to the previous tracing of
___ the
ventricular rate is faster.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Atorvastatin 10 mg PO HS
3. Lactulose 45 mL PO DAILY:PRN constipation
4. Psyllium 1 PKT PO DAILY:PRN constipation
5. Senna 1 TAB PO HS:PRN constipation
6. Clozapine 700 mg PO HS
7. Divalproex (EXTended Release) 1500 mg PO HS
8. Lithium Carbonate 900 mg PO QHS
9. Topiramate (Topamax) 25 mg PO QHS
10. Ketoconazole 2% 1 Appl TP BID
to feet
Discharge Medications:
1. Atorvastatin 10 mg PO HS
2. Clozapine 650 mg PO HS
3. Divalproex (EXTended Release) ___ mg PO QHS
4. Lithium Carbonate 900 mg PO QHS
5. Senna 1 TAB PO HS:PRN constipation
6. Fluphenazine 5 mg PO Q3H:PRN Agitation
7. Ketoconazole 2% 1 Appl TP BID
8. Lactulose 45 mL PO DAILY:PRN constipation
9. Psyllium 1 PKT PO DAILY:PRN constipation
10. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Bipolar with psychotic features
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: ___ female patient with rising lactate, evaluate for
pneumonia.
FINDINGS: AP single view of the chest has been obtained with patient in
semi-upright position. Comparison can be made with the next preceding chest
examination of ___. The heart size now fulfills criteria for
normality considering bedside examination. Again remarkable is a relative
prominence of the left ventricle. Thoracic aorta appears unremarkable. The
pulmonary vasculature is not congested and there are no signs of acute or
chronic parenchymal infiltrates. Lateral pleural sinuses are free, and no
pneumothorax is present in the apical area.
When comparison is made with the next preceding examination ___,
the at that time existing right-sided PICC line has been removed. The at that
time existing more marked cardiac enlargement was probably the result of
patient's more recumbent position resulting in geometric distortion.
IMPRESSION: No evidence of pneumonia as can be excluded on single portable
chest examination.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: SI
Diagnosed with DEPRESSIVE DISORDER, SUICIDAL IDEATION
temperature: 96.9
heartrate: 120.0
resprate: 16.0
o2sat: 96.0
sbp: 140.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | ___ yo female with hx of bipolar disorder with psychotic
features, multiple SAs, DM2, and HL presenting for requested
psychiatric admission for feeling unsafe who was admitted to
medicine for acidosis who is now MEDICALLY STABLE FOR
PSYCHIATRIC TRANSFER |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Iodinated Contrast Media - IV Dye / Augmentin / glucosamine /
Sulfa (Sulfonamide Antibiotics) / ibuprofen
Attending: ___.
Chief Complaint:
Headache and worsening vision x3wks
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o craniopharyngioma c/b chiasmopathy, blindness OS now
p/w 3 weeks near constant & progressive R sided headache of
unclear etiology with subjective R hemifield vision loss since
that time as well.
Pt was never a headache sufferer until about 3 weeks ago when
she
developed a high right frontal headache (no clear radiation,
explicitly denies any retro-orbital component) unlikely any
priors. Cannot recall what she was doing at onset or whether she
woke with is. Quality is difficult for her to characterize; at
least not always pulsatile. HA has been almost continuous with
occasional periods of remission lasting only a few (? 15)
minutes
and occurring a few times a day (perhaps up to 4/day). Unclear
what triggered these brief remissions but did not seem to be
position, analgesics (tried 2 tabs APAP). There are no clear
provoking factors (light, sound, bending, straining, coughing).
Says that it wakes her from sleep, but not consistently early
morning - only felt nauseated once last week but did not throw
up. She has not been evaluated for this and the only change over
time has been general worsening.
Over about the same amount of time (3 weeks), she started to
notice the vision in her right eye worsening. Though it is
difficult to describe, it seems like the right hemifield of the
eye is blurry or dark. Seems to be most noticeable when reading,
doesn't notice it so much if watching television. She denies
photopsias, TVOs, dyschromatopsia, or marked decrease in acuity.
Two weeks ago (___) she developed what she describes as
room-spinning vertigo which was constant and R ear/jaw pain;
there was no hearing loss, aural fullness, nausea but walking
was
difficult. Again cannot say if she woke with this or not. She
has
chronic tinnitus (for years). She was seen on ___ by her
PCP
for this and was treated for what was thought to be R otitis
externa (Augmentin tx x10d c/b diarrhea). Also noted tenderness
of the R jaw area at that visit. The vertigo is now less severe
but has been constant since onset. Walking is almost baseline.
She came here today because she spoke to one of the nurses at
her
PCP's office who referred her in here. However she is clear that
there was no acute precipitant or worsening of HA or vision.
ROS: Ocular hx per HPI. Jaw hurts when she opens wide but not
classic jaw claudication; she can eat normally. There is no
scalp
tenderness though deeper palpation near the right jaw hurts.
Denies fevers, chills, sweats, no girdle stiffness. No neck pain
at rest or with motion. No back pain. Denies rash, chest pain,
cough, abdominal pain, nausea, vomiting, constipation, diarrhea.
Receptive and productive speech normal. No difficulties with
dysphonia, dysphagia, dysarthria, facial sensation. Hearing nl
as
above. Strength, sensation, continence, walking at baseline
(walked with a cane sine age ___ after she broke bilateral feet).
Past Medical History:
- Craniopharyngioma diagnosed at ___; presented with headaches
and
vision loss OS, s/p surgery age ___ c/b:
* Chiasmopathy -> NLP OS, cannot recall last time she was able
to see light) w atrophy L>R. OD requires glasses but Rx has not
changed recently. Followd by Dr. ___.
* Strabismic post-operatively
* Hypopituitarism
* Radiation retinopathy
* Radiation-induced meningiomas x2 (s/p resection of L mening,
still has R meningioma). Was previously followed by Dr. ___ at
the ___ but since he left has followed with a neurologist or
neurosurgeon whose name she does not know - she thinks at the
___. Most recent MRI brain was done ___ ___
redemonstrating the craniopharyngioma (displacing chiasm,
resulting in L optic nerve atrophy) and a right frontal
extra-axial T1/2 isointense & enhancing lesion c/w meningioma
(specific sizes are not mentioned in the report). Compared to
prior ___ studies available to them the cranipharyngioma size
was
not changed (no mention made of meningioma).
- Dacrocystitis OS
- Drusen
- Cataracts, unclear etiology but she thinks steroid replacement
has only been physiologic
- HTN & HLD c/b CAD s/p stent x2 vessels
- Anemia
- Dermatosis papulosa nigra
- Renal angiomyolipoma
- Lumbar radiculopathy; initially L leg, now R leg, has been a
problem for months but no current radiation
- Osteopenia
- Gastritis
- Syncope x3 this year or last, positional
- Peripheral edema
- Squamous cell ca (in situ) R foot removed a few years ago
- Verruca vulgaris
- Total hysterectomy ___ pt does not know why
- Irritable bowel
Social History:
___
Family History:
Father deceased, cause unknown. Mother alive, healthy.
3 sisters, all alive and 2 with cancer (2 w breast cancer, 1 w
"something wrong with her glands"). No children.
Physical Exam:
ADMISSION PHYSICAL EXAM:
9 97.1 66 172/76 18 96% RA on arrival; not in pain now
General: NAD NT ND
Head: ED tono pen 11 OD / 10 OS (by ED resident), no ptosis or
injection of the sclera. No orbital bruits. Temporal artery
pulsations felt bilaterally. No obvious TMJ pathology.
Neck: R paraspinals are mildly tender to touch but do not
reproduce headache. Mild restriction in range bilaterally.
Negative Spurling/cervical loading.
Card: RRR could not hear murmur in ED
Pulm: CTAB
Abd: Soft NT ND NABS
Extrem: Previously broken feet (incl R hallux), mildly swollen
but no pitting. Negative straight leg raise.
Neurologic
- Mental status: ___ (initially says ___, corrects to ___ quickly). Names knuckles and watch normally. Speech fluent.
Normal repetition and comprehension. Follows 3 step commands but
got the order wrong. Days in the week in reverse done normally.
Registers ___, recalls ___.
- Cranial nerves: OS NLP. OD ___ with glasses, no improvement
with PH. Fields to finger counting are normal OD but with red
pin
there is a RUQ/RLQ deficit vs the nasal fields where perception
is normal. Red color looks normal OD but obviously cannot
compare
it to OS and no ___ plates available to test color. RAPD OS
with no pupillary response to direct stimulation but with
retained response (3->2) when light is shined in the right eye.
OD 3.5 -> 2. Fundoscopy OS showed a pale disc with venous
pulsations and sharp margins. Fundoscopy OD showed mildly pale
to
normal disc with normal pulsations and sharp margins. Comitant
exo deviation no response to alternate cover (OS blind, cannot
take up fixation) but EOMI. V1-3 intact to pin. Corneal
equivalents normal. Facial activation is full. Audition equal
and
the Weber does not lateralize. Tongue, palate, and shrug
symmetric.
- Motor: No drift, ___, Babinski with nl tone arms, ?
slightly increased legs. Arms are full except for 4+ IOs
bilaterally. Legs full (including abductors) save 4+ hams b/l
and
4+ R ___ / 4 L ___. Left toe flexors also 4.
- Sensory: Can differentiate warm from cool in all extremities;
no gradient to temperature.
- Reflexes: Very brisk in the legs, slightly less so in the
arms. Spread and crossed adductors in the legs, mild pectoralis
reflexes b/l.
- Cerebellar: Mild end point tremor in RUE without dysmetria
but
no DDK or obvious mirroring deficit. Heel/shin symmetric.
============================================
DISCHARGE PHYSICAL EXAM:
T 98.7 BP 132-150/53-82 HR 64-67 RR 18 ___ 96 RA
MS: AAO x3. Able to say the months of the year backwards.
CN: Left eye exo deviated, not reactive to light. Right eye
briskly reactive. Mild temporal field cut on the right,
unchanged from prior.
Pertinent Results:
ADMISSION LABS:
___ 02:55PM BLOOD WBC-5.8 RBC-3.68* Hgb-10.3* Hct-32.2*
MCV-88 MCH-28.0 MCHC-32.0 RDW-14.0 RDWSD-45.1 Plt ___
___ 02:55PM BLOOD Neuts-46.7 ___ Monos-7.5 Eos-3.0
Baso-0.2 Im ___ AbsNeut-2.69 AbsLymp-2.43 AbsMono-0.43
AbsEos-0.17 AbsBaso-0.01
___ 05:05AM BLOOD ___ PTT-39.7* ___
___ 02:55PM BLOOD Glucose-103* UreaN-8 Creat-0.5 Na-137
K-3.7 Cl-99 HCO3-28 AnGap-14
___ 05:05AM BLOOD ALT-19 AST-13 LD(LDH)-140 AlkPhos-70
TotBili-0.4
___ 02:55PM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1
___ 05:05AM BLOOD VitB12-481 Folate-GREATER TH
___ 05:05AM BLOOD TSH-<0.02*
___ 05:05AM BLOOD T4-8.1 T3-125
___ 05:05AM BLOOD CRP-11.9*
___ 05:05AM BLOOD ___ * Titer-1:160
___ 05:15AM BLOOD CRP-19.9*
IMAGING:
CT HEAD ___:
1. Large sellar/ suprasellar calcified mass consistent with
provided history of known craniopharyngioma. No hydrocephalus,
midline shift, or edema.
2. Otherwise, no acute intracranial hemorrhage.
MRI BRAIN ___:
1. Re- demonstration of the patient's known densely calcified
the sellar and supra sellar mass. No evidence of pituitary
apoplexy.
2. Asymmetrically abnormal left optic nerve. Nonvisualized
optic chiasm.
These findings are likely due to chronic compression.
3. A 1.9 cm right frontal convexity meningioma with no
significant underlying mass effect.
4. A 2 mm anterolateral outpouching from the right A2 segment,
most consistent with a small aneurysm.
DISCHARGE LABS:
___ 05:15AM BLOOD WBC-5.4 RBC-3.89* Hgb-10.7* Hct-33.7*
MCV-87 MCH-27.5 MCHC-31.8* RDW-14.2 RDWSD-44.8 Plt ___
___ 05:15AM BLOOD Glucose-84 UreaN-8 Creat-0.6 Na-141 K-4.2
Cl-103 HCO3-28 AnGap-14
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
5. Rosuvastatin Calcium 10 mg PO QPM
6. Gabapentin 300 mg PO QHS
7. Hydrocortisone 7.5 mg PO QAM
8. Hydrocortisone 2.5 mg PO QPM
9. Levothyroxine Sodium 175 mcg PO DAILY
10. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
11. DiCYCLOmine 20 mg PO PRN abd pain
12. Citalopram 20 mg PO DAILY
13. Simethicone 80-120 mg PO QID:PRN gas pain
14. Aspirin 162 mg PO DAILY
15. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
16. Polyethylene Glycol 17 g PO DAILY
17. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral
DAILY
Discharge Medications:
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 3
Days
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1
capsule(s) by mouth twice a day Disp #*6 Capsule Refills:*0
2. Aspirin 162 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Gabapentin 300 mg PO QHS
5. Hydrocortisone 7.5 mg PO QAM
6. Hydrocortisone 2.5 mg PO QPM
7. Levothyroxine Sodium 175 mcg PO DAILY
8. Omeprazole 20 mg PO BID
9. Rosuvastatin Calcium 10 mg PO QPM
10. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
11. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
13. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
14. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral
DAILY
15. DiCYCLOmine 20 mg PO PRN abd pain
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
17. Polyethylene Glycol 17 g PO DAILY
18. Simethicone 80-120 mg PO QID:PRN gas pain
Discharge Disposition:
Home
Discharge Diagnosis:
Dry macular degeneration, headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with known craniopharyngioma with 3 weeks worsening headache
and right sided visual changes
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 available.
FINDINGS:
There is no evidence of large territorial infarction or hemorrhage. A large,
lobulated, calcified sellar/suprasellar mass is noted, slightly eccentric to
the right, consistent with the provided history of a known craniopharyngioma.
It measures approximately 1.9 x 2.6 x 3 cm. Mild-to-moderate periventricular
white matter hypodensities are noted, consistent with chronic small vessel
ischemic disease. Minimal age related cortical volume loss is noted. No
hydrocephalus, shift of midline structures, or edema is noted.
No acute osseous abnormalities seen. Patient is status post left frontal
craniotomy. The paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The orbits are unremarkable.
IMPRESSION:
1. Large sellar/ suprasellar calcified mass consistent with provided history
of known craniopharyngioma. No hydrocephalus, midline shift, or edema.
2. Otherwise, no acute intracranial hemorrhage.
RECOMMENDATION(S): MRI can be obtained for further assessment if needed.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: ___ year old female with history of craniopharyngioma, Right
frontal meningioma (Left frontal meningioma status post resection) and 3 wks
progressive right sided headache. Evaluate for hemorrhage within
craniopharyngioma obscured by calcification on CT.
TECHNIQUE: Sagittal and coronal T1 weighted imaging were performed along with
axial and coronal T2 imaging. Sagittal, coronal, and axial T1 and axial FLAIR
weighted imaging were repeated after the uneventful intravenous administration
of 9 mL of Gadavist contrast.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: CT from ___.
FINDINGS:
MRI PITUITARY: There is expansion of the sella turcica with an ill-defined
2.5 cm x 2.1 cm T1/ T2 hypo intense, noncontrast enhancing mass in the sella
and suprasellar region. Multiple foci of intrinsic T1 hyperintense signal may
represent hemorrhage or calcium deposite. No discrete fluid levels to
indicate pituitary apoplexy or intra tumoral hemorrhage. No residual normal
pituitary gland is visualized. The left optic nerve is asymmetrically
edematous in its distal intra orbital, canalicular, and pre chiasmatic
segments. The optic chiasm is not clearly visualized.
Faint T1 hyperintense signal within the basal ganglia and dentate nuclei may
be the sequela of mineralization, prior radiation, or multiple gadolinium
injections. Periventricular and subcortical T2 and FLAIR hyperintensities are
noted. Left frontal craniotomy changes are seen. There is a 1.9 cm x 0.9 cm
extra-axial, dural based mass with homogeneous contrast enhancement and FLAIR
hyperintense signal along the right frontal convexity, series 10, image 26.
Ethmoid sinus mucosal thickening is noted. Generalized calvarial thickening
MRA brain: There is a 2 mm anterior lateral outpouching from the right A2
segment, series 9, image 107. There is mild irregularity of the bilateral
cavernous internal carotid arteries, secondary to atherosclerosis. Otherwise,
the intracranial vertebral and internal carotid arteries and their major
branches appear normal without evidence of stenosis or occlusion.
IMPRESSION:
1. Re- demonstration of the patient's known densely calcified the sellar and
supra sellar mass. No evidence of pituitary apoplexy.
2. Asymmetrically abnormal left optic nerve. Nonvisualized optic chiasm.
These findings are likely due to chronic compression.
3. A 1.9 cm right frontal convexity meningioma with no significant underlying
mass effect.
4. A 2 mm anterolateral outpouching from the right A2 segment, most consistent
with a small aneurysm.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Headache, Visual changes
Diagnosed with HEADACHE, VISUAL DISTURBANCES NEC
temperature: 97.1
heartrate: 66.0
resprate: 18.0
o2sat: 96.0
sbp: 172.0
dbp: 76.0
level of pain: 9
level of acuity: 2.0 | Ms. ___ is a ___ year-old woman with a past medical history
of craniopharyngioma complicated by chiasmopathy, blindness in
the left eye now p/w 3 weeks of headache and visual complaints
found to have dry macular degeneration.
Patient was admitted with concern for progression of her
craniopharyngioma causing a right sided visual field cut,
however on formal visual field testing with neuro-ophtho, there
was no change in her visual fields compared to prior. MRI showed
an unchanged size of the craniopharyngioma without new
compression or elevated intracranial pressure. The eye exam did
show evidence of dry macular degeneration which was likely to
account for her right sided visual complaints.
Her headache and visual symptoms were concerning for temporal
arteritis with elevated ESR to 63 and CRP to 11.9, however there
was no scalp tenderness, loss of pulsations or jaw claudication
so this was considered less likely. She also was found to have
an incidental UTI which could have accounted for her elevated
inflammatory markers. ESR was rechecked on discharge after
initiating antibioitics and the result will be communicated with
the patient. If it continues to be elevated, temporal artery
biopsy should be considered. Her headache resolved on discharge.
She will follow-up in neurology and ophtho clinc as an
outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Latex / Ace Inhibitors
Attending: ___.
Chief Complaint:
Right pathologic femur fracture
Major Surgical or Invasive Procedure:
___: Right cephalo-medullary nail, open biopsy
History of Present Illness:
___ female with a history of non-Hodgkin's lymphoma with
known metastasis to the right thigh status post chemotherapy and
radiation with presumed right femur stress fracture status post
nonoperative management presents with right thigh pain and
inability to ambulate over the last 1 day.
Briefly her oncologic history is as follows:
-___, diagnosis of low-grade B-cell lymphoma considered to be
low-grade marginal zone lymphoma which was treated with
chlorambucil and prednisone
-___ relapse of disease as noted with an enlarging PET avid
sites in the neck, thorax, abdomen. Relapse was treated with
rituximab and bendamustine for 6 cycles.
-___ patient was found to have a transformation of her
disease into diffuse large B-cell lymphoma with disease in and
around her right femur (biopsy dated ___ this
transformation was treated with 6 cycles of R-CHOP
-___ PET/CT demonstrates residual uptake in her right
femur and she subsequently underwent 4500 Gy of radiation
therapy.
-___ completion of radiation therapy to her right
thigh
-___ to present no evidence of disease.
In terms of her orthopedic history she presented to Dr.
___ office in ___ with right thigh pain and a
lesion in the right femur cortex concerning for a stress
fracture. The lesion appeared to be a stress fracture along the
medial cortex at the mid diaphysis. It was decided at that time
to treat this stress fracture nonoperatively and her
bisphosphonates were held. She was followed clinically until
___ when it was felt that her pain is improved and
there
was radiographic signs of healing. She was then progressed to
weightbearing as tolerated and her bisphosphonate was restarted.
Since ___ she has not had any more pain in the mid
thigh. She has had some right knee pain secondary to known
arthritis and she received a corticosteroid injection for that
pain on ___. She was then relatively pain-free until
approximately 2 weeks prior to presentation when she noted
atraumatic progressive right thigh pain. Her family noted that
this pain was similar to that which she experienced with the
stress fracture. One day prior to presentation she noted that
the pain acutely worsened despite there being no trauma. She
was
then unable to rise from her bed or ambulate comfortably. She
denies numbness and tingling in the extremity. She denies
trauma
to the extremity. She denies any fevers, sweats, chills, weight
loss, skin changes, enlarging lymph nodes,=. She is currently
not taking any chemotherapy or receiving any radiation.
She last had local staging to her right thigh in ___ with
right thigh CT and MRI. Since that time she had a CT chest
abdomen and pelvis with and without contrast in ___ and an
MRI had without contrast in ___ for workup of other
medical
issues. Her oncologist believes her to be disease free at this
time per the chart review. She does have a remote history of
deep vein thrombosis in ___ when she was diagnosed with diffuse
large B-cell lymphoma. She has been on warfarin ever since.
Her
goal is ___. With previous recurrences of her oncologic process
she has not had an elevated LDH which has been trended by her
oncologist. Her last known value was 187 on ___.
Past Medical History:
PMH/PSH:
*S/P TOTAL VAGINAL HYSTERECTOMY.
CYSTOCELE
MARGINAL ZONE NHL
NHL LOW GRADE
UTERINE PROLAPSE
DEEP VENOUS THROMBOPHLEBITIS
NON-HODGKIN'S LYMPHOMA
STRESS FRACTURE RIGHT FEMUR
ALZHEIMER'S DISEASE
H/O NON-HODGKIN'S LYMPHOMA
Social History:
___
Family History:
NC
Physical Exam:
General: Well appearing woman in NAD
Right lower extremity:
Fires ___
SILT sural, saphenous, superficial peroneal, deep peroneal and
tibial distributions
Dorsalis pedis pulse 2+ with distal digits warm and well
perfused
Pertinent Results:
___ 04:43AM BLOOD WBC-8.6 RBC-2.79* Hgb-9.3* Hct-27.6*
MCV-99* MCH-33.3* MCHC-33.7 RDW-14.2 RDWSD-51.8* Plt ___
___ 05:10AM BLOOD Glucose-122* UreaN-9 Creat-0.5 Na-142
K-3.3* Cl-101 HCO3-31 AnGap-10
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QMON
2. Donepezil 10 mg PO QHS
3. Escitalopram Oxalate 5 mg PO DAILY
4. estradiol 0.01 % (0.1 mg/gram) vaginal 2X/WEEK
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN rhinitis
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Atorvastatin 20 mg PO QPM
9. Losartan Potassium 100 mg PO DAILY
10. Warfarin 5 mg PO 5X/WEEK (___)
11. Warfarin 2.5 mg PO 2X/WEEK (___)
12. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral
DAILY
13. Multivitamins 1 TAB PO DAILY
14. Fish Oil (Omega 3) 1000 mg PO DAILY
15. Phenazopyridine 100 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous Nightly Disp
#*30 Syringe Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 6 hours as needed
Disp #*25 Tablet Refills:*0
5. Senna 8.6 mg PO BID
6. Alendronate Sodium 70 mg PO QMON
7. Atorvastatin 20 mg PO QPM
8. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral
DAILY
9. Donepezil 10 mg PO QHS
10. Escitalopram Oxalate 5 mg PO DAILY
11. estradiol 0.01 % (0.1 mg/gram) vaginal 2X/WEEK
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN rhinitis
14. Hydrochlorothiazide 12.5 mg PO DAILY
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
16. Losartan Potassium 100 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Phenazopyridine 100 mg PO TID
19. Warfarin 2.5 mg PO 2X/WEEK (___)
20. Warfarin 5 mg PO 5X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right pathologic femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) RIGHT
INDICATION: History: ___ with sudden onset of r lateral pain/swelling when
getting out of car, did not fall// r/o fx r/o fx
IMPRESSION:
6 views of the right femur are compared to ___ 18 and one ___. Angulated transverse fracture through the midshaft of the right femur
is new since ___. There is no destructive bone lesion to explain a
pathologic fracture but there is cortical thickening that may be an indication
of Paget's disease. Hip and knee are intact.
Radiology Report
EXAMINATION: US LOWER EXTREMITY, SOFT TISSUE RIGHT
INDICATION: ___ year old woman with worsening R lower extremity pain.//
evaluate for R thigh hematoma
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right thigh, superficial to the known mid femur fracture..
COMPARISON: Right femur radiographs ___.
FINDINGS:
There is no fluid collection, solid or cystic lesion overlying the right
femur. The fractured femur is much better assessed on concurrent radiographs.
IMPRESSION:
No evidence of hematoma.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: History: ___ with R femur fracture.// evaluation prior to
traction pin
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the right knee.
COMPARISON: Knee radiographs ___.
FINDINGS:
No fracture or dislocation is seen. There is moderate medial femorotibial
joint space narrowing, and patellar spurring. There is no knee joint
effusion. There is normal osseous mineralization. No suspicious lytic or
sclerotic lesions are identified. Sclerotic focus in the distal right femoral
diaphysis is again seen, either enchondroma versus bone infarct.
IMPRESSION:
No fracture or dislocation. Moderate tricompartmental degenerative changes.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) RIGHT
INDICATION: Open reduction internal fixation
TECHNIQUE: 7 intraoperative images were obtained
COMPARISON: ___
FINDINGS:
7 intraoperative images were acquired without a radiologist present.
Images show open reduction internal fixation of a mid femoral diaphyseal
fracture with a long intramedullary rod and trochanteric fixation nail. A
single distal interlocking screws also present.
IMPRESSION:
Intraoperative images were obtained during open reduction internal fixation of
a right femoral diaphyseal fracture. Please refer to the operative note for
details of the procedure.
Gender: F
Race: PORTUGUESE
Arrive by WALK IN
Chief complaint: R Leg pain, R Leg swelling
Diagnosed with Path fracture in neoplastic disease, right femur, init
temperature: 96.3
heartrate: 63.0
resprate: 18.0
o2sat: 97.0
sbp: 147.0
dbp: 76.0
level of pain: 5
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right pathologic femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right cephalo-medullary nail and
open biopsy, 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.
Patient was also evaluated by the orthopedic oncology service
while admitted who agreed with decision to proceed with
cephalo-medullary nail. During the procedure intraoperative
specimens were sent for pathology as well as lymphoma protocol
which were pending at the time of discharge. Patient already
has scheduled appointments with hematology oncology and
orthopedic oncology.
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
weightbearing as tolerated right lower extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vitamin K1
Attending: ___
Chief Complaint:
subacute critical limb ischemia of L leg
Major Surgical or Invasive Procedure:
___
1. Left femoral to anterior tibial artery bypass using
ipsilateral nonreversed great saphenous vein.
2. Angioscopy with lysis of the valves
___ 1. Coronary artery bypass graft x 4.
2. Skeletonized left internal mammary artery graft to left
anterior descending artery.
3. Skeletonized right internal mammary artery graft to
posterior descending artery.
4. Long saphenous vein sequential grafting to obtuse marginal
1 and obtuse marginal 2.
5. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
___ is a ___ w/ hx of PVD s/p R fem-ALpop bypass and L
SFA/pop stent x2 who is presenting here to the ED w/ a ~2 wk hx
of intermittent L lower leg/calf pain w/ walking and a ~1 wk hx
of worsening discoloration of L foot, for which we were
consulted. He says he has never had these sx and was o/w in his
usual state of health before ~2 wks ago. He endorses some back
pain (chronic), and denies any f/c/s, chest pain, SOB,
lightheadedness and/or dizziness, blurry vision, h/a's, change
in appetite, change in BMs, n/v, difficulty urinating, other
myalgias/arthralgias, or other skin changes; ROS is o/w -ve
except as noted before. He initially presented to ___,
and at that time no signal were noted in his L foot, and was
txfr'ed here for further management. Of note on evaluation here
he did have dopplerable L DP. He was started on a hep gtt in the
ED.
Past Medical History:
PMHx: PVD, DM2, HTN, HLD, asthma, chronic back pain,
pancreatitis
(likely gallstone)
PSHx: R fem-AKpop bypass w/ in situ GSV ___, L SFA/pop
stent
x2, appy, colonic resection for diverticulitis (?sigmoidectomy,
?ostomy w/ reversal), lap CCY ___, back surgery
Social History:
___
Family History:
uncle w/ DM
Physical Exam:
Physical Exam at Admission:
VS - 98.7 103 154/86 18 95% RA
Gen - NAD
CV - tachycardic, reg rhythm
Pulm - non-labored breathing, no resp distress, satting
adequately on RA
Abd - soft, nondistended, nontender, healed incisional scars
MSK & extremities/skin - R: p/p(graft)/p/p, L: p//d/-, L foot
slightly cool, mottled/purple color, mild swelling, no ttp, mild
decreased sensation compared to R, intact strength
Physical Exam at Discharge:
Gen - NAD
CV - reg rhythm
Pulm - non-labored breathing, no resp distress, satting
adequately on RA
Abd - soft, nondistended, nontender
Sternal incision healing well, clean, dry, intact. No sternal
click. Prevena dressing intact
Left lower extremity with extensive staples, clean, dry, intact
___ edema
Pertinent Results:
___ 10:30PM BLOOD WBC-13.4* RBC-3.38* Hgb-9.7* Hct-31.2*
MCV-92 MCH-28.7 MCHC-31.1* RDW-13.0 RDWSD-43.3 Plt ___
___ 09:15AM BLOOD WBC-9.8 RBC-3.08* Hgb-9.2* Hct-28.6*
MCV-93 MCH-29.9 MCHC-32.2 RDW-13.0 RDWSD-43.9 Plt ___
___ 10:30PM BLOOD Glucose-183* UreaN-16 Creat-1.2 Na-142
K-5.4 Cl-107 HCO3-17* AnGap-18
___ 04:34AM BLOOD %HbA1c-7.6* eAG-171*
CTA Abd/Pelvis ___:
IMPRESSION:
1. Patent right femoropopliteal bypass and dorsalis pedis.
Severe
calcifications involving the right lower extremity including
portions of the trifurcation as above.
2. Occluded left femoral artery, left popliteal and dorsalis
pedis.
Calcifications involving the left lower extremity and likely
occlusion of the whole of the left trifurcation.
3. Incidental findings as above including an indeterminate
hyperdense right renal lesion measuring 1.8 cm. Thus could be
followed during routine imaging of the abdomen if the these will
be performed in the future. Alternatively, this could be
further characterized with dedicated CT/MR renal in a
nonemergent basis.
CT PE ___:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Consolidations in bilateral posterior lungs with surrounding
ground-glass opacity are suspicious for pneumonia.
3. Pulmonary emphysema.
4. 2 mm right upper lobe pulmonary nodule. Please see
recommendation below.
RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule smaller than 6 mm, no CT follow-up is
recommended in a low-risk patient, and an optional CT in 12
months is recommended in a high-risk patient.
TTE ___:
IMPRESSION: The image quality was extremely poor with these
limitations in mind the following observation can be made: 1)
Mild regional LV systolic dysfunction predominantly effecting
the left ventricular apex. The apical inferior myocardial
segment is contracting well on some views suggestive of
___'s cardiomyopathy however mid LAD myocardial
ischemia/prior
myocardial infarction cannot be full excluded. 2) The patient
has a sulfa allergy which precludes IV ultrasound contrast
administration.
Carotid duplex ___:
IMPRESSION:
Less than 40% stenosis on the right carotid system.
40-59% stenosis on the left carotid system.
Cardiac Cath ___
Findings
Three vessel coronary artery disease.
Videoswallow ___
RECOMMENDATION(S): 1. Intermittent trace penetration with thin
liquids. No evidence of aspiration.
2. Barium tablet was held at the mid esophagus and subsequently
passed with liquid wash. Consider esophagram for further
evaluation.
Echocardiographic Measurements TEE: ___
Left Ventricle - Ejection Fraction: 35% to 40% >= 55%
Aortic Valve - Peak Gradient: 16 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 8 mm Hg
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Moderately depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma
in the aortic arch. Simple atheroma in descending aorta.
AORTIC VALVE: Moderately thickened aortic valve leaflets.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
Physiologic MR ___ normal limits).
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with ___
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
The left ventricle is moderately dysfunctional, with akinesis
of the septum and apex. There is general hypokinesis in all
other walls.
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
The aortic valve leaflets are moderately thickened. The left
cusp is calcified and immobile, creating the appearance of a
functionally bicuspid valve.
The mitral valve leaflets are mildly thickened. Physiologic
mitral regurgitation is seen (within normal limits).
There is no pericardial effusion.
Post-CPB:
The patient is paced, on an infusion of epinephrine.
No change in RV systolic fxn.
Mild improvement in overall LV systolic fxn,.
Trivial MR and TR.
No AI. Aorta intact.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 100 mg PO DAILY
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SBO/wheeze
3. Gabapentin 300 mg PO QID
4. glimepiride 4 mg oral BID
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Atorvastatin 40 mg PO QPM
3. Cetirizine 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Furosemide 40 mg PO DAILY Duration: 14 Days
7. Glargine 24 Units Breakfast
Humalog 7 Units Breakfast
Humalog 7 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Isosorbide Dinitrate 5 mg PO TID Duration: 6 Months
9. Metoprolol Succinate XL 200 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
RX *tramadol [Ultram] 50 mg one tablet(s) by mouth every four
hours Disp #*40 Tablet Refills:*0
12. Lisinopril 2.5 mg PO DAILY
13. Albuterol Inhaler ___ PUFF IH Q6H:PRN SBO/wheeze
14. Aspirin 81 mg PO DAILY
15. Atenolol 100 mg PO DAILY
16. Gabapentin 300 mg PO QID
17. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Acute on chronic left lower extremity ischemia
Multivessel coronary artery disease
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema 1+ ___
Followup Instructions:
___
Radiology Report
EXAMINATION: NON-INVASIVE PERIPHERAL ARTERIAL STUDY
INDICATION: ___ year old man with L SFA stent x2// eval ABIs/PVRs
TECHNIQUE: Non invasive of the arterial system of the lower extremities was
performed using doppler signal recording, pulse volume recording and segmental
limb blood pressure measurements.
COMPARISON: None
FINDINGS:
On the right side, triphasic Doppler waveforms are seen in the femoral,
superficial femoral, popliteal, posterior tibial and dorsalis pedis arteries.
Absentwaveforms are seenthe posterior tibial artery.
On the left side, monophasic doppler waveforms are seen in the femoral artery.
Absentwaveforms are seenpopliteal, posterior tibial and dorsalis pedis.
ABIs could not be calculated due to noncompressibility. TBI on the right is
0.58, left is 0.
IMPRESSION:
1. Severe left femoral disease with absence of flow beyond the common femoral
artery. This is highly suggestive of left SFA stent occlusion in this patient
with known prior stenting.
2. Mild to moderate right infrapopliteal disease and arterial insufficiency.
NOTIFICATION: Dr. ___ M.D was paged with this result at 11:25 AM
___. Dr. ___ was emailed.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old man with Hx/ right fem pop and Left SFA stent x 2
with LLE ischemia/ on heparin gtt// ********** CTA ABD/PELVIS/ PLEASE DO LOWER
EXTREMITY RUN OFF ****THANK YOU
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.6 s, 152.2 cm; CTDIvol = 2.7 mGy (Body) DLP = 404.7
mGy-cm.
2) Spiral Acquisition 11.5 s, 152.7 cm; CTDIvol = 7.1 mGy (Body) DLP =
1,081.1 mGy-cm.
3) Spiral Acquisition 5.6 s, 74.2 cm; CTDIvol = 10.1 mGy (Body) DLP = 750.6
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
5) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.7 mGy (Body) DLP =
8.3 mGy-cm.
Total DLP (Body) = 2,246 mGy-cm.
COMPARISON: No prior similar.
FINDINGS:
VASCULAR:
Moderate atherosclerotic calcifications are seen throughout the abdominal
aorta. There are mild calcifications at the origins of the celiac axis. A
replaced left hepatic artery seen from the left gastric. There are moderate
calcifications and stenosis of the SMA with reconstitution of the branches.
The ___ is patent. The renal arteries are patent with moderate diffuse
calcifications.
The common, internal and external iliacs demonstrate moderate calcifications
and are patent.
The runoff is as follows:
Right lower extremity: The common femoral artery is patent with moderate
calcifications. The deep femoral artery is patent.
Right femoral artery: Occluded. There is a patent right femoral popliteal
bypass.
Right popliteal artery: There is mild stenosis of the right popliteal artery.
The right trifurcation is patent, however there are regions of severe stenosis
of the mid distal peroneal and posterior tibial arteries. The anterior tibial
artery appears diffusely calcified but overall patent and the dorsalis pedis
is seen patent up to the level of the distal foot.
Left lower extremity:
Common femoral artery: Patent with moderate calcifications.
Deep left femoral artery: Patent.
Left femoral artery: Occluded beyond its origin.
Left popliteal artery: Occluded.
Left trifurcation: Severe calcifications limiting patency. There is likely
severe stenosis or occlusion of the whole of trifurcation and the dorsalis
pedis is most likely severely calcified and occluded rather than severely
stenotic.
LOWER CHEST: Scattered linear atelectasis.
ABDOMEN: The liver demonstrates diffuse steatosis evidenced by regions of
sparing. Cholecystectomy changes are noted. No biliary ductal dilatation.
The spleen, pancreas and adrenal glands are unremarkable. There is a 3.2 cm
left renal cyst with thin linear calcification. There is an indeterminate
hyperdense right renal lesion measuring 1.8 cm.
GASTROINTESTINAL: No intestinal obstruction or ascites demonstrated. Sigmoid
sutures are seen. Likely appendectomy changes are present.
LYMPH NODES: No abdominopelvic lymphadenopathy.
PELVIS: There is no free fluid in the pelvis.
BONES: There is no evidence of worrisome osseous lesions.
SOFT TISSUES: Small fat containing paraumbilical hernia. Postoperative
changes they are seen in the right inguinal region.
IMPRESSION:
1. Patent right femoropopliteal bypass and dorsalis pedis. Severe
calcifications involving the right lower extremity including portions of the
trifurcation as above.
2. Occluded left femoral artery, left popliteal and dorsalis pedis.
Calcifications involving the left lower extremity and likely occlusion of the
whole of the left trifurcation.
3. Incidental findings as above including an indeterminate hyperdense right
renal lesion measuring 1.8 cm. Thus could be followed during routine imaging
of the abdomen if the these will be performed in the future. Alternatively,
this could be further characterized with dedicated CT/MR renal in a
nonemergent basis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ hx of PVD s/p R fem-pop and L SFA stent x2 here w/
likely subacute LLE ischemia, angio today with SFA ollusion will need bypass
tomorrow ___, pre op x ray// pre op x ray Surg: ___ (bypass)
TECHNIQUE: AP portable chest radiograph
FINDINGS:
There are low bilateral lung volumes. No focal consolidation, pleural
effusion or pneumothorax is identified. The size of the cardiomediastinal
silhouette is within normal limits. Calcification of the aortic arch is
present. A single screw projects over the right axillary region adjacent to
the humeral head and scapula.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: VENOUS MAPPING FOR DIALYSIS ACCESS
INDICATION: ___ w/ hx of PVD s/p R fem-pop and L SFA stent x2 here w/
likely subacute LLE ischemia, s/p L angio ___, will get fem distal bypass
___. unclear what time surgery will go, but this vein mapping will need
this done either today or early tomorrow morning. PLEASE MARK SKIN FOR
SURGEON// ___ w/ hx of PVD s/p R fem-pop and L SFA stent x2 here w/ likely
subacute LLE ischemia, s/p L angio ___, will get fem distal bypass ___.
unclear what time surgery will go, but this vein mapping will need this done
either today or early tomorrow morning. PLEASE MARK SKIN FOR SURGEON
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of both
cephalic veins, radial artery, brachial artery, basilic vein and subclavian
veins was performed.
COMPARISON: None
FINDINGS:
RIGHT:
The cephalic vein measures 0.13 cm at the proximal arm, 0.42 cm at the mid arm
and 0.37 cm at the distal arm. The basilic vein measures 0.08 cm at the
antecubital fossa, 0.18 cm at its mid portion, and 0.28 cm at the proximal
portion.
LEFT:
The cephalic vein measures 0.51 cm at the proximal arm, 0.38 cm at the mid arm
and 0.26 cm at the distal arm. The basilic vein measures 0.16 at the proximal
arm, 0.60 cm at its mid portion, and 0.51 cm at the proximal portion.
IMPRESSION:
1. Bilateral patent cephalic and basilic veins with measurements as reported
above.
Radiology Report
EXAMINATION: VENOUS MAPPING FOR DIALYSIS ACCESS
INDICATION: ___ year old man with LLE ischemia/ s/p angiogram needs bypass//
please vein map and mark bilateral lower extremities in preparation for OR
tomorrow. Thank you
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of both
cephalic veins, radial artery, brachial artery, basilic vein and subclavian
veins was performed.
COMPARISON: None
FINDINGS:
RIGHT:
The cephalic vein 0.13 cm at the proximal arm, 0.42 cm at the mid arm and
0.37 cm at the distal arm. The basilic vein measures 0.08 cm at the proximal
arm, 0.18 cm at its mid portion, and 0.28 cm at the proximal portion.
LEFT:
The cephalic vein measures 0.51 cm at the proximal arm, 0.38 cm at the mid arm
and 0.26 cm at the distal arm. The basilic vein measures 0.16 cm at the
proximal arm, 0.16 cm at its mid portion, and 0.51 cm at the proximal
portion.
IMPRESSION:
1. Patent bilateral cephalic and basilic veins with measurements as reported
above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with increased O2 requirement after bypass
surgery.// atelactatic? PNA? edema?
TECHNIQUE: Frontal view of the chest
COMPARISON: None.
FINDINGS:
Patient is rotated limiting evaluation. Vascular congestion with minimal
edema.
Moderate cardiomegaly again noted.
Trace right effusion. No pneumothorax. There is a screw projecting in the
right axillary region.
IMPRESSION:
Minimal edema. No focal infiltrate.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Oxygen desaturation.
COMPARISON: ___ earlier on the same day.
FINDINGS:
Cardiac, mediastinal and hilar contours appear stable. Vague opacity in the
right upper lobe has become apparent, possible pneumonia. Elsewhere, lungs
appear clear. Trace pleural effusions are possible. There is no
pneumothorax.
IMPRESSION:
Concern for developing pneumonia in the right upper lobe. Short-term
follow-up radiographs may be helpful to reassess.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old man with hypoxia// r/o PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 459 mGy-cm.
COMPARISON: None
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain. Heavy
coronary artery and aortic valve calcification is noted.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is small bilateral
pleural effusion.
Bilateral lower lobes are consolidated posteriorly with adjacent ground-glass
opacities. Posterior aspect of the right upper lobe also demonstrates
consolidation. Findings are suspicious for pneumonia.
There is mild to moderate pulmonary emphysema.
2 mm pulmonary nodule is identified in the right upper lobe (301:59)
Bilateral lower lobe subsegmental airways are intermittently occluded. The
bronchial walls are diffusely thickened.
Limited images of the upper abdomen are unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
Chronic compression deformities of multiple thoracic vertebra is noted.
A loose screw is partially imaged in the soft tissues anterior to the right
humeral head. 1 cm ossific loose bodies noted at the anterior aspect of the
right glenohumeral joint.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Consolidations in bilateral posterior lungs with surrounding ground-glass
opacity are suspicious for pneumonia.
3. Pulmonary emphysema.
4. 2 mm right upper lobe pulmonary nodule. Please see recommendation below.
RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with aspiration PNA// eval for interval change
TECHNIQUE: Chest AP
COMPARISON: Comparison to multiple prior radiograph studies dating from ___ to ___
FINDINGS:
Cardiomediastinal silhouette is moderately enlarged unchanged from prior.
Interval increase in right upper lung opacity and new right lower lung
opacity, concerning for worsening multifocal pneumonia. Unchanged small
bilateral pleural effusions. No pneumothorax. Again demonstrated is a
surgical screw projecting over the right scapula.
IMPRESSION:
Interval worsening of right upper and lower lung multifocal pneumonia.
Radiology Report
EXAMINATION: Lower extremity arterial duplex US.
INDICATION: ___ year old man with left fem AT bypass// eval for flow
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the left lower extremity graft was obtained.
FINDINGS:
On the left, the common femoral artery is patent with a peak velocity of 137
cm/sec. The proximal anastomosis is patent with a velocity of 108 cm/sec.
Velocities within the vein graft measure 65-108 cm/sec. Velocities at the
distal anastomosis measure 181 cm/sec and in the distal anterior tibial artery
63 cm/sec. There is a 2.2 fold step up at the distal anastomosis.
IMPRPRESSION: Patent left fem AT bypass with mild stenosis at the distal
anastomosis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ hx of PVD s/p R fem-pop and L SFA stent x2 here w/
likely subacute LLE ischemia, s/p L angio ___, SFA/pop complete occl, bypass
___// Etiology of desaturation
TECHNIQUE: Chest AP
COMPARISON: Multiple chest radiographs dating back to ___ and
most recent dated ___
FINDINGS:
Low lung volumes. Cardiomediastinal silhouette is unchanged. There are
multifocal opacifications in bilateral lungs consistent with evolving
multifocal pneumonia. Additionally, there is superimposed, short interval
increase of airspace opacifications in the left upper lobe and right upper
lobe which in the setting of cardiomegaly may represent worsening pulmonary
edema. Stable bilateral small pleural effusions. A surgical screw projecting
over the right scapula is again demonstrated
IMPRESSION:
1. Evolving multifocal pneumonia is again demonstrated.
2. Minimal superimposed short interval increase of airspace opacification in
the lateral upper lobes likely represents pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with aspiration pna// eval changes to pna
eval changes to pna
IMPRESSION:
Compared to chest radiograph ___ through ___.
Mild edema in the left lung and right lower lung is improving. Worsening
consolidation in the right upper lobe suggest progressive aspiration
pneumonia. A another region of slightly improved consolidation at the left
lung base is probably pneumonia as well.
Small pleural effusions are likely. Heart is mildly enlarged.
Radiology Report
EXAMINATION: Video oropharyngeal swallow study
INDICATION: ___ w/ hx of PVD s/p R fem-pop and L SFA stent x2 here w/
likely subacute LLE ischemia, s/p L angio ___, SFA/pop complete occl, bypass
___ c/b hypoxemia likely ___ asp PNA// rule out silent aspiration per SLP
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: 2 minutes and 50 seconds
COMPARISON: No prior video oropharyngeal swallow study
FINDINGS:
There was no gross aspiration or penetration.
IMPRESSION:
Intermittent trace penetration was seen with thin liquids. No evidence of
aspiration. Additionally, there was mild pharyngeal weakness.
The 13 mm barium tablet was held at the mid esophagus and subsequently passed
with liquid wash.
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).
RECOMMENDATION(S): 1. Intermittent trace penetration with thin liquids. No
evidence of aspiration.
2. Barium tablet was held at the mid esophagus and subsequently passed with
liquid wash. Consider esophagram for further evaluation.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ w/ hx of PVD s/p R fem-pop and L SFA stent x2 here w/
likely subacute LLE ischemia, s/p L angio ___, SFA/pop complete occl, bypass
___ c/b hypoxemia likely ___ asp PNA// carotid stenosis
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None
FINDINGS:
RIGHT:
The right carotid vasculature has mild heterogeneous atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 83 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 70, 77, and 87 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 36 cm/sec.
The ICA/CCA ratio is 0.84.
The external carotid artery has peak systolic velocity of 180 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has moderate heterogeneous atherosclerotic
plaque.
The peak systolic velocity in the left common carotid artery is 133 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 78, 148, and 83 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 32 cm/sec.
The ICA/CCA ratio is 1.1.
The external carotid artery has peak systolic velocity of 125 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Less than 40% stenosis on the right carotid system.
40-59% stenosis on the left carotid system.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old man pre-op CABG// pre-op baseline study Surg:
___ (CABG)
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Interval decrease in extent of a right upper lobe consolidation. Similar
opacities are also seen in the left upper lung, not significantly changed
since prior. There are few scattered opacities in the right midlung which may
also be infectious in etiology. There is no pleural effusion or pneumothorax.
Bibasilar opacities are decreased when compared to the CT chest dated ___. The size of the cardiomediastinal silhouette is unchanged.
IMPRESSION:
Interval decrease in extent of a right upper lobe consolidation. Multiple
additional opacities are seen throughout both lungs concerning for ongoing
aspiration/pneumonia.
Radiology Report
EXAMINATION: ART DUP EXT LO UNI;F/U LEFT
INDICATION: ___ year old man with L fem-AT bypass// eval graft
TECHNIQUE: Grayscale and color Doppler with pulse wave ultrasound images were
obtained of the left lower extremity arteries and bypass graft.
COMPARISON: ___
FINDINGS:
Right lower extremity peak systolic velocities:
Common femoral artery: 110 centimeters/second
Proximal anastomosis of femoral to AT bypass graft: 80 centimeters/second
Bypass graft proximal thigh: 91 centimeters/second
Bypass graft midthigh: 95 centimeters/second
Bypass graft distal thigh: 88 centimeters/second
Bypass graft above knee: 98 centimeters/second
Bypass graft mid knee: 163 centimeters/second
Distal anastomosis: 227 centimeters/second
Anterior tibial artery: 90, 111 centimeters/second
Dorsalis pedis artery: 118, 140 centimeters/second
IMPRESSION:
Increased velocity at the distal anastomosis (without > 2:1 step up).
Compared to ___: Velocities increased slightly at the distal
anastomosis (181 to 227 cm/sec).
Radiology Report
EXAMINATION: VENOUS MAPPING of lower extremity superficial veins
INDICATION: ___ year old man with CAD- pre-op for CABG// eval bilat greater
and lesser SVG diameter for conduit
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of both greater
saphenous veins.
COMPARISON: None
FINDINGS:
RIGHT:
The right greater saphenous vein was previously harvested in the thigh.
Proximal calf: 0.53 cm
Mid calf: 0.28 cm
Distal calf: 0.32 cm
Ankle: 0.28 cm
The right small saphenous vein measures:
Proximal calf: 0.20 cm
Mid calf 0.19 cm
Distal calf: 0.20 cm
Ankle: 0.22 cm
LEFT:
The left greater saphenous vein was previously harvested.
The left small saphenous vein measures:
Proximal calf: 0.23 cm
Mid calf 0.29 cm
Distal calf: 0.29 cm
Ankle: 0.27 cm
IMPRESSION:
Previously harvested proximal right greater saphenous vein and left greater
saphenous vein.
Patent small saphenous veins bilaterally with measurements as above.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with S/P CABG// fast track extubation, effusion,
pneumothx Contact name: ___, Phone: 1
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Patient is status post cardiac surgery in the interim. Support lines and
tubes are in acceptable position. There is asymmetric edema right greater
than left. Cardiomediastinal silhouette is stable. Small bilateral effusions
are stable. No pneumothorax is seen
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p CABG// eval for pneumothorax s/p chest tube
removal
TECHNIQUE: AP and lateral chest radiographs
COMPARISON: ___
FINDINGS:
The endotracheal tube, gastric tube, Swan-Ganz catheter, chest tubes and
mediastinal drains have been removed. There is no pneumothorax identified.
Patchy opacities are again seen in the right upper lobe, decreased in extent
since ___ however relatively similar to what was seen on ___. The left lung is grossly clear. There are small bilateral pleural
effusions. The size of the cardiomediastinal silhouette is unchanged.
IMPRESSION:
No pneumothorax. Interval decrease in extent of right upper lobe patchy
opacities.
Small bilateral pleural effusions.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Leg pain, L Pulseless foot
Diagnosed with Other disorder of circulatory system
temperature: 98.5
heartrate: 104.0
resprate: 20.0
o2sat: 97.0
sbp: 181.0
dbp: 96.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ yo Male who presented to Emergency Department
on ___ with Subacute chronic limb ischemia of the left
leg. Given findings, the patient was taken to the operating room
on ___ for a LLE angio, external iliac stent, with
complete occlusion of SFA/pop. Given the findings he underwent
vein mapping and on ___ he underwent a L fem-AT bypass w/
ipsilateral nrGSV. There were no adverse events in the
operating room; please see the operative note for details.
Pt was extubated, taken to the PACU until stable, then
transferred to the ward for observation.
Floor ___:
He developed worsening respiratory status on the floor requiring
increased O2 supplementation and Lasix. He had a chest X-ray
consistent with fluid overload. Lasix was given without great
response. He had a CTA which was negative for PE but concerning
for aspiration pneumonia. He was transferred to the ICU for
further management.
ICU ___:
Initially upon transfer to the ICU he required high-flow nasal
cannula for his hypoxic respiratory failure. He was started on
cefepime/vancomycin empirically. He underwent frequent chest ___.
On ___, he was started on 20mg IV Lasix BID without much
effect. Chronic pain was consulted and patient was restarted on
his home medication regimen. On ___, he received 1 unit
PRBC for HCT 20 which improved to 25. He was weaned to an
oxymizer and briefly transferred to the floor. However,
overnight into ___, he desaturated to 87% on 12L oxymizer
which failed to improve with Lasix, and CPAP was not effective.
Patient began to report chest pain, troponin elevated to 0.26
which was stable on recheck. EKG demonstrated new ST depressions
in anterolateral leads from admission. He was transferred back
to the ICU on a nonrebreather and was transitioned back to HFNC.
Cardiology was consulted and they felt he had experienced a Type
II NSTEMI, coreg was started and atenolol was discontinued. His
vancomycin was discontinued and he remained on cefepeme. On
___ he underwent an echocardiogram which demonstrated mild
left ventricular systolic dysfunction suggestive of ___'s
cardiomyopathy although mid LAD myocardial ischemia/MI could not
be excluded. Pulmonology was consulted for his persistent oxygen
requirement which they felt was due to V/Q mismatch secondary to
the dense multifocal consolidations. Per their recommendations,
urine legionella and strep antigen were sent (both negative),
antibiotics were broadened to Zosyn, SLP was consulted for
evaluation of aspiration, and a sputum sample was sent
(contaminated). On ___, a bedside swallow was performed
which found patient was safe for soft solids/thin liquids with
supervision and a video swallow was recommended. He remained on
the HFNC. On ___, cardiology decided that due to patient's
echocardiogram findings, he would require an inpatient
catheterization to evaluate for CAD. Physical therapy evaluated
the patient and felt he would benefit from rehabilitation.
___ was consulted and his insulin was adjusted per their
recommendations. On ___, patient received 1u PRBC for HCT
22.3 in setting of hypoxic respiratory failure, improving to
30.9 on recheck. On ___, he required straight
catheterization x1 for urinary retention and he was started on
Flomax. On ___, he was able to have his oxygen weaned to 5L
on nasal cannula and he was transferred to the VICU.
Floor ___ - ___:
Patient was transferred out of the ICU to the floor on ___.
He received a cardiac catheterization on ___ which
demonstrated three vessel disease, thus Cardiac Surgery was
consulted. His Plavix was stopped to allow for washout prior to
an anticipated CABG. On ___, he underwent a video swallow
evaluation for concern of aspiration contributing to his
pneumonia, however it showed only trace aspiration and he was
evaluated to be safe for a regular diet per SLP. He was noted to
have mild blanching erythema around his calf incision so he was
started on a 7 day course of augmentin. His Zosyn was
discontinued. On ___, Cardiac Surgery decided that patient
was a good candidate for a CABG and a preoperative workup was
obtained. On ___, patient was felt to have weaker Doppler
signals of his left ___ and DP, so he was started on a heparin
drip. A duplex was obtained on ___, which showed somewhat
increased velocity at the distal anastomosis, however patent
vessels with good flow. His AM insulin was held due to his NPO
status, and his blood glucose increased to >500. He received his
appropriately scheduled insulin and sliding scale, with his
blood glucose appropriately responding (with a nadir of 84). On
___, his AM labs demonstrated hyperkalemia to 6.0, and EKG
showed no changes and he was asymptomatic. It was felt to
represent relative insulin deficiency and on afternoon recheck
his potassium improved to 5.6. On ___, he was NPO after
midnight and started on maintainance IVF. He went to the
operating room with Cardiac Surgery for CABG on ___ and was
transferred onto their service following the procedure. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Diflucan
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ year old woman
with
history of dysfunctional uterine bleeding, iron deficiency
anemia, and polysubstance abuse including crack cocaine
presenting with chest pain.
Notably, she was seen the ED on ___ for chest and abdominal
pain
worsened with inspiration. She underwent CT abd/pelvis and was
diagnosed with a right lower lobe pneumonia based on that CT,
and
was discharged on azithromycin.
She initially felt better, but then the day prior to this
admission developed left-sided chest pressure, constant, worse
with deep breathing. She also reported dyspnea on exertion. She
denied any nausea, vomiting, diaphoresis, or exertional
component
to the pain.
She denied any unilateral leg pain, history of blood clots, or
recent surgeries. She did report a flight to ___ 2 weeks
prior
(12 hours). She is a daily smoker. Not on OCPs.
In the ED:
Initial vital signs were notable for: 99.0 92 155/70 16 99%
RA
Labs were notable for:
- D-Dimer ___
- Trop < 0.01
- BNP 113
- Lactate 0.7
- Hb 6.8 (has been ___ since ___
Studies performed include:
___ CTA CHEST
1. Segmental and subsegmental pulmonary emboli in the lingula,
right middle lobe and bilateral lower lobes. Upper lobes are not
particularly well assessed due to motion. No evidence of right
heart strain.
2. Findings compatible with a pulmonary infarct in the lingula.
Areas of atelectasis at the lung bases with suspected right
basilar infarct as well.
3. Small right and trace left pleural effusions.
4. The rounded 1.5 cm lesion in the upper and slightly outer
right breast which likely correlates with lesion worked up by
prior ultrasound in ___.
Patient was given:
___ 09:06 PO Acetaminophen 1000 mg
___ 12:14 PO Ibuprofen 600 mg
___ 13:42 IVF NS 1000 mL
___ 14:11 IV Heparin 6900 UNIT
___ 14:11 IV Heparin Started 1550 units/hr
___ 16:15 PO Ibuprofen 600 mg
Upon arrival to the floor, patient reports story as above. She
reports continued left chest pain with inspiration and dyspnea
with activity, but this has improved since initiation of the
heparin gtt.
She notes dysfunctional uterine bleeding and a history of
anemia.
We discussed blood transfusion given Hb < 7, although I relayed
that this is chronic and she does not need urgent transfusion at
this time. She preferred to think about it overnight.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
PMH
1. hypertension
2. genital herpes
3. fatty liver by ultrasound study
PSH
1. S/P C-section x ___ and ___
2. S/P multiple myomectomy for fibroids in ___
Social History:
___
Family History:
Her family history is noted for hyperlipidemia and
father living age ___ and diabetes in her mother living age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98.2PO 152/77 86 18 98Ra
GENERAL: Alert and interactive.
HEENT: NCAT.
CARDIAC: Regular rhythm, normal rate.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Normal bowels sounds, non distended, non-tender.
EXTREMITIES: No clubbing, cyanosis, or edema. No palpable cords.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. AOx3.
=============================
DISCHARGE PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 946)
Temp: pt refused v/s (Tm 98.2), BP: 136/82 (136-152/77-82),
HR: 78 (78-86), RR: 18, O2 sat: 98%, O2 delivery: Ra, Wt: 190.7
lb/86.5 kg
GENERAL: Alert and interactive.
HEENT: NCAT.
CARDIAC: Regular rhythm, normal rate.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Normal bowels sounds, non distended, non-tender.
EXTREMITIES: No clubbing, cyanosis, or edema. No palpable cords.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. AOx3.
Pertinent Results:
ADMISSION LABS:
___ 09:08AM BLOOD WBC-10.4* RBC-4.36 Hgb-6.8* Hct-25.2*
MCV-58* MCH-15.6* MCHC-27.0* RDW-22.3* RDWSD-42.5 Plt ___
___ 09:08AM BLOOD Glucose-86 UreaN-10 Creat-1.0 Na-142
K-4.2 Cl-104 HCO3-23 AnGap-15
___ 09:08AM BLOOD ___ 09:08AM BLOOD cTropnT-<0.01
___ 09:08AM BLOOD proBNP-113
___ 09:08AM BLOOD Iron-15*
___ 09:08AM BLOOD calTIBC-529* Ferritn-29 TRF-407*
___ 09:12AM BLOOD Lactate-0.7
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-10.3* RBC-4.00 Hgb-6.3* Hct-23.3*
MCV-58* MCH-15.8* MCHC-27.0* RDW-22.3* RDWSD-42.8 Plt ___
___ 06:35AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-140 K-4.2
Cl-104 HCO3-23 ___ CXR:
IMPRESSION:
Perhaps minimal residual opacity at the right costophrenic angle
as seen on prior CT. No new consolidation.
___ CHEST CTA: IMPRESSION:
1. Segmental and subsegmental pulmonary emboli in the lingula,
right middle lobe and bilateral lower lobes. Upper lobes are
not particularly well assessed due to motion. No evidence of
right heart strain.
2. Findings compatible with a pulmonary infarct in the lingula.
Areas of
atelectasis at the lung bases with suspected right basilar
infarct as well.
3. Small right and trace left pleural effusions.
4. The rounded 1.5 cm lesion in the upper and slightly outer
right breast
which likely correlates with lesion worked up by prior
ultrasound in ___.
___ TTE: IMPRESSION: LVEF 69%. Mild symmetric left ventricular
hypertrophy with normal cavity size and regional/
global biventricular systolic function. Mild mitral
regurgitation. Mild pulmonary hypertension.
Radiology Report
INDICATION: ___ with cough and left sided chest pain// PNA
TECHNIQUE: Frontal and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Focal opacity at the right lung base seen on prior CT abdomen pelvis is
faintly visualized. The lungs are otherwise clear, no new consolidation.
There is no effusion, edema or pneumothorax.. Cardiomediastinal silhouette is
stable. No acute osseous abnormalities.
IMPRESSION:
Perhaps minimal residual opacity at the right costophrenic angle as seen on
prior CT. No new consolidation.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with pleuritic chest pain// PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 21.3 mGy (Body) DLP =
10.6 mGy-cm.
2) Spiral Acquisition 3.8 s, 29.8 cm; CTDIvol = 11.8 mGy (Body) DLP = 350.9
mGy-cm.
Total DLP (Body) = 362 mGy-cm.
COMPARISON: Correlation made to CT abdomen pelvis from ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental. There are numerous filling defects within subsegmental branches
of the bilateral lower lobes. Segmental filling defect noted in the right
middle lobe as well as within the lingula. Evaluation of the upper lobes is
limited by respiratory motion and the vessels beyond the lobar level are not
well assessed. There is no evidence of right heart strain. The thoracic
aorta is normal in caliber without evidence of dissection or intramural
hematoma. The heart, pericardium, and great vessels are within normal limits.
No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: There is a small right and trace left pleural effusion.
LUNGS/AIRWAYS: Ground-glass opacity noted in the lingula most suggestive of an
infarct. There is bibasilar atelectasis in the lower lobes noting that
component of infarct is suspected on the right 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 notable for hyperenhancing
1.2 cm focus in the right lobe, incompletely characterized, potentially flash
filling hemangioma or altered perfusion. Partially imaged changes of
Roux-en-Y gastric bypass are noted.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
There is a 1.5 x 1.2 cm oblong density in the upper and slightly outer aspect
of the right breast (3:86).
IMPRESSION:
1. Segmental and subsegmental pulmonary emboli in the lingula, right middle
lobe and bilateral lower lobes. Upper lobes are not particularly well
assessed due to motion. No evidence of right heart strain.
2. Findings compatible with a pulmonary infarct in the lingula. Areas of
atelectasis at the lung bases with suspected right basilar infarct as well.
3. Small right and trace left pleural effusions.
4. The rounded 1.5 cm lesion in the upper and slightly outer right breast
which likely correlates with lesion worked up by prior ultrasound in ___.
NOTIFICATION: Findings were discussed with Dr. ___ at 14:00 on ___ by Dr. ___.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified
temperature: 99.0
heartrate: 92.0
resprate: 16.0
o2sat: 99.0
sbp: 155.0
dbp: 70.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with history of dysfunctional
uterine bleeding, iron deficiency anemia, and polysubstance
abuse including crack cocaine presenting with chest pain, found
to have a pulmonary embolism.
# Non-submassive PE:
Pt presented with a week of worsening dyspnea and left sided
chest pain. ___ chest CTA notable for segmental PE in lingual,
RML, b/l lower lobes with pulmonary infarct in lingual and
suspected R. basilar infarct. She was hemodynamically stable.
___ TTE was obtained: LVEF 69%, there was no e/o R heart
strain, but TTE notable for mild symmetric LVH with regional
biventricular function, mild mitral regurg and mild pulm HTN.
Risk factors include smoking (7 cig/day), recent ~12 hr flight
from ___. She was started on a hep gtt and transitioned to PO
Eliquis 10mg bid x7 days followed by 5mg bid. For her pain, she
was given standing Tylenol ___ q8h + PRN ibuprofen.
# Dysfunctional uterine bleeding
# Iron deficiency anemia:
Reports Hgb ___ since ___ im the setting of fibroids and
dysfunctional uterine bleeding. She has undergone intermittent
iron infusions. This admission Hb 6.8 (baseline), with most
recent ferritin 6.8 in ___. Her Hgb was 6.3 on ___, but she
was asymptomatic. Previously, she repeatedly refused blood
transfusions, but was amenable to receiving 1U pRBC prior to
being discharged. She was adamant about being discharged on
___, as she had to go home to take care of her two younger
boys. She indicated she would present to the ED if she noticed
any active bleeding or become symptomatic. She has an outpatient
OBGYN appointment on ___ and said she would contact her PCP
for an appointment.
# Polysubstance use:
Pt with active EtOH use ___ drinker daily) and daily crack
cocaine inhalation. She was seen by addiction psychiatry in
___, started on acamprosate, and referred to social work. She
stopped taking this medication and missed her most recent social
work appointment. SW was initially consulted; however, pt did
not seem amenable to meeting with them. She denied any illicit
drug use after admission. Will suggest she f/u with outpatient
PCP ___ Psychiatry regarding substance use.
====================
MEDICATION CHANGES
====================
[]Started Eliquis 10mg bid x7 days (last day ___ followed by
5mg bid.
====================
TRANSITIONAL ISSUES
====================
[] Re-check H/H at next clinic visit, within 1 week of
discharge. Continue to monitor for active bleeding.
[] She has a f/u scheduled with OBGYN on ___. Please assess
for vaginal bleeding at that time, as she was recently started
on Eliquis for PE.
[] She denied a history of polysubstance abuse during this
admission. Please re-address possible illicit drug use either
with PCP or ___.
[]Consider EGD to evaluate for anastamosis, colonoscopy for
Fe-deficiency anemia.
[]s/p Roux-en-Y bypass. Consider multivitamin, Fe supplements,
B12, vitamin D and calcium supplementation.
# CONTACT: Husband, ___, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right wrist swelling and temporal mass
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
Patient is a ___ male with a history of HTN, HL, recent
L hand cellulitis, and a recent diagnosis of a R temporal lobe
lesion of unknown etiology who presented to the ED yesterday
from the MRI suite with severe right handed pain. He is from
___ and was getting all of his care at ___
___, but presented to Dr. ___ in ___ clinic yesterday
for a second opinion regarding his brain mass. The patient
states that yesterday morning, he first began to note a pins and
needles sensation in his fingertips when he woke up with a dull
ache in his right forearm. Did not note this to Dr. ___
had a normal neuro exam. In the MRI waiting area, the pain was
becoming increasingly severe, and during the MRI, he was unable
to sit still because of the pain. The study was stopped and he
was taken to the ED.
In the ED, initial VS were: 98.1 79 124/97 18 97% RA. Neurology
was consulted and felt that there was no clear neurologic
explanation for his current symptoms and that the R temporal
lobe flair changes could not explain his current complaints. The
patient had CT w/o contrast of head that was normal, and CXRay
without acute process. Notably, lactate elevated and White count
33. The patient received 4 mg morphine x2 for the pain.
Of note, he was recently diagnosed with cellulitis of the left
hand ___ days ago after experiencing pain near his wrist. He
says his current pain on the right side is very different from
this however, as he had no tingling previously. He was started
on Bactrim and Keflex for the cellulitis about a week ago, and
the pain and swelling in his left hand have greatly improved.
His wife reports that he had a transthoracic echocardiogram 2
days ago as well to rule out infection; this was reportedly
negative, although he was told he may need a TEE to better
evaluate the valves.
Per his wife's report, he has also been having short term memory
problems for about a month, which prompted the initial neuro
evaluation at ___. Per the neuro note, this began shortly
after his daughter's wedding in ___. It was initially
attributed to stress, but then it got worse to the point that he
had to quit his job as a ___ as he was getting
lost and having difficulty recognizing his surroundings. His
wife also reports some confusion regarding the season, at one
point thinking ___ had already passed (when it was 2
weeks away) and then thinking it was almost ___.
On the floor this morning, patient describes severe pins and
needles and tingling beginning in all five of his fingertips.
The pain then shoots from the fingertips to the elbow, described
as a lightning-like pain and a sharp pain, lasting several
seconds. He is afebrile, but drenched in sweat, stating that he
is having severe nightsweats.
In terms of his MRI findings, per Dr. ___ description
(images not currently available for review) showed the "entire
mesial temporal lobe on the right side involved with FLAIR
changes. This extends at least 4 or 5 cm and involves the
hippocampus. He has a small area of enhancement also near the
uncus." He also had an EEG at ___ to rule out complex
partial seizures and this was reportedly normal. Dr. ___
that this abnormality could potentially represent lymphoma vs.
AVM vs. dural AV fistula, and recommended the MRI with and
without contrast. He was also referred to Dr. ___ in
neuro-oncology for consideration of an LP and further work-up
for possible lymphoma.
Pt denies diarrhea, sick contacts, weight loss, excessive
fatigue, fevers/chills, cough, shortness of breath above
baseline. No change in bowel or bladder habits.
Past Medical History:
HTN
HL
L hand cellulitis
S/p L rotator cuff surgery in ___
Social History:
___
Family History:
Mother with dementia
Father died of throat cancer at age ___
No known history of any other neurologic problems including
stroke, seizure, brain tumors.
Physical Exam:
ADMISSION PE:
98.6 158/90 76 24 98% RA
GENERAL - well-appearing man obese male in NAD, drenched in
sweat
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no m/r/g nl S1-S2
ABDOMEN - Obese, No tenderness, abdomen mildly firm, normoactive
bowel sounds, no guarding or rebound.
EXTREMITIES - Right hand erythematous, more swollen than the
left. 2+ equal pulses.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary
NEURO - awake, A&Ox3, CNs II-XII grossly intact. Upper
extremity strength ___ in arm and forearm. Difficult to assess
grip strength and hand muscle on the right due to pain. Full
sensation to light touch intact on the right.
discharge exam:
Tc 97.4, 122-139/62-81, 66-72, 20, 98% RA.
GENERAL - well-appearing man obese male in NAD, diaphoretic
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - Soft expiratory wheeze biltaerally
HEART - RRR, no m/r/g nl S1-S2
ABDOMEN - Obese, No tenderness, abdomen mildly firm, normoactive
bowel sounds, no guarding or rebound.
EXTREMITIES - mild-moderate with movement of right > left wrist
but no edema. No pain on direct palpation of joints bilaterally.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
___ 07:00PM BLOOD WBC-33.0* RBC-4.95 Hgb-13.7* Hct-41.9
MCV-85 MCH-27.7 MCHC-32.7 RDW-13.0 Plt ___
___:00PM BLOOD Neuts-85.6* Lymphs-7.7* Monos-6.0 Eos-0.6
Baso-0.1
___ 07:00PM BLOOD ___ PTT-26.9 ___
___ 07:00PM BLOOD Glucose-140* UreaN-27* Creat-1.1 Na-134
K-5.3* Cl-96 HCO3-21* AnGap-22*
___ 07:00AM BLOOD ALT-31 AST-25 LD(LDH)-219 CK(CPK)-114
AlkPhos-89 TotBili-0.5
___ 07:00AM BLOOD Albumin-3.8 Calcium-8.9 Phos-4.3 Mg-2.2
UricAcd-4.1
___ 07:00AM BLOOD RheuFac-66* CRP-122.4*
___ 07:05PM BLOOD Lactate-2.6* K-4.9
___ 07:53AM BLOOD Lactate-1.7
ANTI-CCP: > 250
___ 07:00AM TSH-1.4
___ 07:00AM ___
___ 07:00AM RHEU FACT-66* CRP-122.4*
___ 07:00AM SED RATE-70*
___ 07:05PM LACTATE-2.6* K+-4.9
___ 07:00PM LIPASE-37
___ Radiology CT HEAD W/O CONTRAST
IMPRESSION: No acute intracranial process
___hest ABD & PELVIS W & W/O
1. Left lung nodule for which follow up in 6 months is
recommended to
document stability.
2. Left adrenal adenoma.
___ Radiology MR HEAD W & W/O CONTRAS
1. No acute intracranial abnormality. 2. The focal signal and
enhancing abnormality involving the medial aspect of the right
temporal lobe, including that hippocampal formation has
resolved, without residuum. This evolution should be correlated
with a detailed history; for example, had the patient
experienced seizure activity shortly before the previous study
was obtained?
___ Radiology HAND (AP, LAT & OBLIQUE
Severe left and moderate right degenerative joint disease of the
first
carpometacarpal joints.
___ EEG w/ Sphenoidal leads:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of the presence of diffuse background slowing compatible
with a mild encephalopathy. However, this is also admixed with
intermittent multifocal bitemporally predominant slowing
suggesting perhaps a multifocal pathology. There are also
paroxysmal runs of sharp theta activity in the left temporal
region during drowsiness compatible with a psychomotor variant.
Admixed with this normal variant are more pathological appearing
small spike and wave discharges in the same distribution. This
raises the possibility of multifocal pathology and potential
interictal epileptiform activity particularly in the left
temporal region.
___ Radiology MR HEAD W & W/O CONTRAS and Spectroscopy -
read pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Cephalexin 500 mg PO Q6H
Start date: To be clarified
3. Ezetimibe 10 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Naproxen 500 mg PO Q12H:PRN pain
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Sulfameth/Trimethoprim DS 1 TAB PO BID
Start date: Unclear
8. Aspirin 81 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Aspirin 81 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Rosuvastatin Calcium 20 mg PO DAILY
6. Ezetimibe 10 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*50 Tablet Refills:*0
8. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*6
9. Docusate Sodium 100 mg PO DAILY
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*6
10. Naproxen 500 mg PO Q12H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
arthritis (osteoarthritis vs rheumatoid)
Seizure
lung nodule
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
STUDY: THREE VIEWS OF THE RIGHT HAND ___.
COMPARISON: None.
INDICATION: Severe hand pain.
FINDINGS: Very minimal diffuse soft tissue swelling. Otherwise, no definite
soft tissue abnormality. Mild bone demineralization. Mild DIP and PIP joint
space narrowing. Mild sclerosis and joint space narrowing at the thumb CMC
joint. No erosive changes. No fractures. No dislocation.
IMPRESSION: Scattered mild degenerative changes.
Radiology Report
CLINICAL HISTORY: Left wrist swelling for one week. High rheumatoid factor.
LEFT WRIST, THREE VIEWS: Marked degenerative changes are present at the first
carpometacarpal joint with loss of the joint space, sclerosis of the
articulating surface and osteophyte formation. Elsewhere, the joints are
essentially normal. No radiologic evidence of rheumatoid is identified.
Radiology Report
MR EXAMINATION OF THE BRAIN WITHOUT AND WITH CONTRAST, ___
HISTORY: ___ male with worsening confusion x 1 month and ? mass
versus congenital abnormality on OSH MR study.
TECHNIQUE: Routine ___ enhanced MR examination, with T1-weighted axial SE
and sagittal MP-RAGE sequences, post-contrast administration, the latter with
axial and coronal reformations.
FINDINGS: The study is compared with the recent NECT and highly-incomplete
non-enhanced MR examination, both dated ___, and the ___
___ enhanced MR examination, dated ___.
On the present examination, the previous relatively ill-defined focus of
asymmetric T2- and FLAIR-hyperintensity involving the medial aspect of the
right temporal lobe, with central 9 mm focus of enhancement appears to have
resolved completely. There is no abnormal signal intensity or enhancement,
either at this site or elsewhere in the brain. Currently, the FLAIR sequence
is entirely unremarkable, and there is no pathologic parenchymal,
leptomeningeal or dural focus of enhancement. There is no intra- or
extra-axial hemorrhage and the midline structures are in the midline.
There is relatively mild prominence of the extra-axial CSF spaces, the
cortical sulci and fissures and the ventricles and cisterns, representing
global atrophy, likely age-related. Incidentally noted is a cavum septum
pellucidum et vergae variant. The sella, parasellar region and remainder of
the skull base and orbits are unremarkable. There are relatively mild
inflammatory changes involving the anterior ethmoidal and frontal air cells,
bilaterally, unchanged. The included mastoid air cells are grossly clear.
IMPRESSION:
1. No acute intracranial abnormality.
2. The focal signal and enhancing abnormality involving the medial aspect of
the right temporal lobe, including that hippocampal formation has resolved,
without residuum. This evolution should be correlated with a detailed
history; for example, had the patient experienced seizure activity shortly
before the previous study was obtained?
Radiology Report
HISTORY: Likely CNS malignancy with a temporal lobe lesion, evaluate for
primary malignancy.
COMPARISON: None.
TECHNIQUE: Continuous axial sections were obtained through the chest, abdomen
and pelvis after the uneventful administration of 150 mL of Omnipaque and oral
contrast. Coronal and sagittal reformations were provided and reviewed. A 3
minutes delayed series through the abdomen was also performed.
DLP: 1749.20 mGy/cm.
FINDINGS:
The thyroid is normal. There is no axillary, hilar or mediastinal
lymphadenopathy. The aorta and heart size are normal. There is no
pericardial effusion. Mild calcifications are seen within the aortic arch.
The airways are patent to the subsegmental level. There is no pleural
effusion or pneumothorax. Mild centrilobular emphysema is noted. A 5 mm
ground-glass nodule abuts the left major fissure (series 3:36).
CT abdomen: The liver enhances homogeneously. An area of focal hypodensity
seen along the falciform ligament likely represents focal fat (3:56). The
gallbladder is normal and there is no intrahepatic biliary ductal dilation.
The spleen and pancreas are unremarkable. A 1.5 cm nodule within the left
adrenal gland demonstrates enhancement patterns consistent with an adenoma
with early washout seen on the three minute delayed series. The right adrenal
gland is normal. The kidneys enhance symmetrically history contrast without
hydronephrosis. A 7 mm hypodensity lesion seen in the interpolar region of
the left kidney is too small to characterize and the ___ are unreliable. The
stomach, large and small bowel are normal. There is no retroperitoneal or
mesenteric lymphadenopathy. There is no free air free fluid. A mild amount
of atherosclerosis is noted within a non aneurysmal aorta. The portal vein,
splenic vein and superior mesenteric vein are patent.
CT pelvis: The bladder, prostate and rectum are normal. There is mild
sigmoid diverticulosis without diverticulitis. There is no inguinal or pelvic
sidewall lymphadenopathy.
Bones: There are no suspicious osseous lesions. Mild degenerative changes of
the lower lumbar spine are seen.
IMPRESSION:
1. Left lung nodule for which follow up in 6 months is recommended to
document stability.
2. Left adrenal adenoma.
These findings were posted to the critical results dashboard at 1552 on
___ by Dr. ___.
Radiology Report
HISTORY: Pain. Evaluation for possible rheumatoid versus osteoarthritis.
TECHNIQUE: Six views of the hands.
COMPARISON: Radiographs of the left wrist performed ___.
FINDINGS:
LEFT WRIST:
There is severe joint space narrowing, subchondral sclerosis, and osseous
spurring again present at the left first carpometacarpal joint. There is also
mild joint space narrowing with subchondral sclerosis at the distal
interphalangeal joints of the left index and middle fingers. There are no
osseous erosions.
RIGHT HAND:
There is moderate joint space narrowing, subchondral sclerosis, and osseous
spurring at the first carpometacarpal joint. There are no osseous erosions.
There is no acute fracture or dislocation.
IMPRESSION:
Severe left and moderate right degenerative joint disease of the first
carpometacarpal joints.
Radiology Report
HISTORY: ___ man had indeterminant left temporal lobe abnormality in
the outside MRI, but improved in the most recent inhouse MRI study.
COMPARISON: Multiple prior studies with the outside MRI on ___
and inhouse MRI on ___.
TECHNIQUE: Multiplanar, multisequence T1- and T2-weighted images were
acquired through the brain before and after administration of IV gadolinium
contrast. Arterial spinal labeling (ASL) perfusion study was also performed.
Both multivoxel and single voxel MR spectroscopy was performed, centered at
the right temporal lobe.
FINDINGS:
MRI HEAD: The ill-defined 9-mm focus of enhancement in the medial aspect of
the right temporal lobe, which was first noted in the original outside study
on ___ but completely resolved in the study dated ___,
remains resolved. There is no abnormal intracranial enhancement at all.
However, there is persistent mild asymmetric prominence of the medial right
temporal lobe compared to the contralateral side, but less conspicuous
compared to the previous studies. Again noted is cavum septum pellucidum et
vergae, an anatomical variant. There is no shift of normally midline
structures. There is no acute infarct or hemorrhage.
ASL PERFUSION: There is no evidence of increased ASL perfusion in the medial
right temporal lobe.
MR SPECTROSCOPY: The single voxel study, centered at the medial aspect of the
right temporal lobe, demonstrated no spectral abnormality. In the multivoxel
study, at pixels 20 and 21, which correspond to the medial aspect of the right
temporal lobe, there is mild elevation of choline peak with abnormal
choline-to-NAA ratio. These findings are non-specific, but could sometime be
seen as a normal variation in the medial temporal lobe.
IMPRESSION:
1. No acute intracranial process.
2. No abnormal intracranial enhancement. The ill-defined subcentimeter focal
enhancement in the right medial temporal lobe, noted in the original outside
study, remains completely resolved. The course of changes could be seen in
post-ictal or inter-ictal evolution.
3. Mild asymmetric prominence at the medial right temporal lobe, less
conspicuous than the prior studies.
4. No increased ASL perfusion. Mild elevation of choline peak with abnormal
choline-to-NAA ratio in the right medial temporal lobe is non-specific, but
could sometime be seen as a normal variation in the medial temporal lobe.
Long-term followup is recommended to document stability.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R/O STROKE
Diagnosed with OTHER CONDITIONS OF BRAIN, LEUKOCYTOSIS, UNSPECIFIED
temperature: 98.1
heartrate: 79.0
resprate: 18.0
o2sat: 97.0
sbp: 124.0
dbp: 97.0
level of pain: 10
level of acuity: 1.0 | ___ male with a history of HTN, HL, recent L hand
cellulitis, recent cognitive difficulties, and a recent
diagnosis of a R temporal lobe lesion of unknown etiology who
presented with severe right wrist pain, elevated white count,
ESR/CRP and rheumatoid factor.
# Inflammatory arthritis of right wrist: Per outside hospital
records, patient acutally had a swollen left wrist 1.5 weeks
ago, which may indicate a migratory arthritis such RA. RF
returned high at 66, anti CCP was very elevated at >250, Patient
was evaluated by rheumatology, who performed an arthrocentesis,
but with only enough fluid to send a gram stain which was
negative. Patient was started on standing high dose NSAIDs.
Plain radiograph showed severe left and moderate right
degenerative joint disease of the first carpometacarpal joints.
Pt was re-evaluated by rheum, who felt that he most likely had
osteoarthritis and possibly carpal tunnel syndrome but would
re-evaluate him in clinic for rheumatoid arthritis. Pt was
discharged with oxycodone and naproxen for pain control.
# Leukocytosis: Was 33k on admission, down to 17.5k on
discharge. Per hematology, smear showing likely reactive leuko
and thrombocytosis. ___ be reactive from inflammatory arthritis.
Afebrile, no evidence of infection.
# L Temporal lesion: Per Dr. ___ note, mass suspicious for
lymphoma vs. AVM, seen in left temporal brain. LP with cytology
was done and was negative for malignant cells. Pt was evaluated
by but neurology and neurosurgery after repeat MRI showed no
evidence of the previously visualized lesion. Both teams
recommended against brain biopsy. Pt also had an EEG, which
showed some evidence of possible epileptiform activity. Seizure
activity would explain the visualized lesion. Pt had a repeat
MRI seizure protocol with spectroscopy per neurology; the read
was pending on discharge. Pt has a follow-up appointment with
neurology in 4 weeks. Pt was advised by neurology that since his
supposed seizure activity never caused loss of consciousness, he
is fine to drive per his comfort.
# Hyponatremia: Urine lytes indicated SIADH. Na worsened with
IVFs, was stable once IVFs were stopped and improved to 133-135
on discharge.
# left lung nodule, adrenal adenoma: Pt has a 5 mm ground-glass
lung nodule abutting the left major fissure seen on CT torso
incidentally and needs 6 month follow up CT. Pt also has an
adenoma of 1.5 cm in the left adrenal gland.
# HTN: Held lisinopril while K elevated, restarted once
normalized.
# HL: Continued Crestor |
Name: ___ ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R sided weakness and difficulty speaking
Major Surgical or Invasive Procedure:
___: left carotid endarterectomy
History of Present Illness:
___ year old man with right hand clumsiness, right facial droop,
mild dysarthria, mild hesitation with speech and known critical
left internal carotid stenosis on anticoagulation presents to ER
at the recommendation of his neurologist, Dr. ___. Symptoms
eventually resolved but he was admitted for monitoring.
Past Medical History:
- Amblyopia R eye, sees light, motion, can see some shapes but
can't read or watch TV out of R eye
- R frontal hemorrhage in ___
- Seizure disorder, thought to be due to hemorrhage, last
seizure ___ pt is unclear on his sz type, but was told that it
was "grand mal" previously
- Fall after a seizure in ___, resulting in L subdural
hematoma, did not require evacuation
- squamous cell carcinoma s/p R ___ toe amputation
- R sided hemicolectomy
- HTN
- HLD
Social History:
___
Family History:
Mother passed away from CHF, father passed away from MI in their
___. Sister with CAD s/p bypass in her ___.
Physical Exam:
Awake and alert,normal affect.
Oriented to person, place, date and context. N0 hesitation and
trace dysarthria. Fluent, normal comprehension, repetition,
naming. Fund of knowledge for recent events within normal
limits.
Cranial nerves, strength, grossly intact. Ambulatory ad lib.
BP 107/50, HR 64
Lung Clear
Left carotid endarterectomy incision open to air, steristripped.
Dorsum of left foot swollen and ecchymotic as are ___ and ___
toes. Foot warm, dop DP.
Pertinent Results:
___ 04:53AM BLOOD WBC-4.6 RBC-2.85* Hgb-9.4* Hct-27.5*
MCV-96 MCH-32.9* MCHC-34.2 RDW-12.6 Plt ___
___ 04:53AM BLOOD Glucose-140* UreaN-8 Creat-0.7 Na-135
K-3.2* Cl-104 HCO3-25 AnGap-9
___ 04:53AM BLOOD Calcium-7.5* Phos-2.5* Mg-1.6
___ head and neck
IMPRESSION:
1. Significant calcified and noncalcified atherosclerotic
disease at the left carotid bifurcation with high-grade stenosis
of the left ICA. Possible small filling defect just distal to
the bifurcation in the left internal carotid artery, however
overall improved appearance of the prior noted filling defects
in left proximal ICA. Significant narrowing of the left internal
carotid artery up to the petrous segment as seen previously.
2. Approximately 20% stenosis of the right internal carotid
artery by CT
criteria.
3. Similar right frontal encephalomalacia. ___ major vascular
territorial
infarction or intracranial hemorrhage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY
2. Carbamazepine 300 mg PO BID
3. Enoxaparin Sodium 90 mg SC BID
4. Warfarin 4 mg PO DAILY16
5. Aspirin 325 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Carbamazepine 300 mg PO BID
4. Acetaminophen 650 mg PO Q6H:PRN pain or fever
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
for the next 7 days
Discharge Disposition:
Home
Discharge Diagnosis:
Symptomatic carotid stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with history.
COMPARISON: Comparison is made to outside radiographs of the chest from ___.
FINDINGS:
PA and lateral views of the chest demonstrate hyperinflation of the lungs,
consistent with emphysematous changes. The cardiomediastinal silhouette is
unremarkable. There is no evidence of pleural effusion, pneumothorax or focal
consolidation. There is evidence of DISH along the thoracic spine.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
HISTORY: ___ man with slurred speech and right facial droop.
Question dissection or stroke.
TECHNIQUE: MDCT axial imaging was obtained through the brain without the
administration of intravenous contrast material. Subsequently MDCT axial
imaging was obtained from the aortic arch through the brain following the
administration of intravenous contrast material according to CTA protocol.
Coronal, sagittal and axial maximum intensity projection images were
completed. 3D reformations were completed on a separate work station.
DLP: to 2496.05 mGy-cm.
COMPARISON: CTA of the head and neck from ___.
FINDINGS:
CT head without contrast: There is no acute hemorrhage, edema, mass effect or
acute large territorial infarction. Encephalomalacia of the right frontal
lobe is unchanged from the prior study. There is slight asymmetry in the
frontal horns of the lateral ventricles likely due to ex vacuo dilatation of
the frontal horn of the right lateral ventricle. The ventricles and sulci are
enlarged consistent with atrophy. There is periventricular white matter
hypodensity likely due to chronic small vessel ischemic disease. The
visualized paranasal sinuses, mastoid air cells and middle ear cavities are
clear. The bones are intact.
CTA head and neck: There is a 3 vessel aortic arch with mild calcification of
the aortic arch. There is calcified and noncalcified plaque at the right
carotid bifurcation. The dmin of the right proximal and distal ICA measure
3.8 and 4.7 mm respectively. There is severe calcified and noncalcified
plaque at the left carotid bifurcation with severe stenosis at this level.
The previously seen intraluminal filling defects in the proximal left internal
carotid artery are no longer present except for a small filling defect just
distal to the bifurcation (3: 143). The left internal carotid artery is
significantly narrowed into the petrous segment after which there is a slight
increase in caliber.
There is small amount of calcification at the origin of the left vertebral
artery. The vertebral arteries are patent without stenosis or occlusion.
The intracranial vessels are patent without evidence of occlusion. There is
decreased vascularity of the left MCA which is slightly decreased in caliber
compared to the right, similar in apperance to the prior exam. Again seen is
significant atherosclerotic calcification of the bilateral cavernous internal
carotid arteries. There is no aneurysm or vascular malformation noted.
There is abnormal lymphadenopathy or masses within the neck. Again seen are
emphysematous changes in the apices. Multilevel degenerative changes are
present within the cervical spine.
IMPRESSION:
1. Significant calcified and noncalcified atherosclerotic disease at the left
carotid bifurcation with high-grade stenosis of the left ICA. Possible small
filling defect just distal to the bifurcation in the left internal carotid
artery, however overall improved appearance of the prior noted filling defects
in left proximal ICA. Significant narrowing of the left internal carotid
artery up to the petrous segment as seen previously.
2. Approximately 20% stenosis of the right internal carotid artery by CT
criteria.
3. Similar right frontal encephalomalacia. No major vascular territorial
infarction or intracranial hemorrhage.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: SLURRED SPEECH
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: nan
heartrate: 81.0
resprate: 18.0
o2sat: 98.0
sbp: 148.0
dbp: 61.0
level of pain: 13
level of acuity: 1.0 | ___ yo right-handed man with PMH significant for HLD, HTN with
recent admission for recurrent episodes of R sided weakness and
speech difficulty x3, found to have significant L ICA (intra and
extracranial) stenosis. He was discharged on ___ on
lovenox/coumadin but re-presented to the hospital with another
episode of right sided weakness/facial droop and speech
difficulty at home.
He had a repeat CTA in the ED which still showed significant
left internal carotid stenosis, though on read from neurology,
it was thought to have possible improvement in clot. Discussion
was had with vascular, neurosurgery and the patient/family again
regarding intervention and patient wished to proceed with
carotid endarterectomy which was performed on ___. The
procedure was without complications. He was continued on full
dose aspirin and atorvastatin 80 mg daily.
His home antihypertensives were held secondary to relative
hypotension. He was instructed to monitor his BP twice daily at
home and restart his lisinopril/atenolol with goal BP of 120.
During his he evidently has some type trauma to the dorsum of
his left room. It is slightly swollen and ecchymotic including
the ___ and ___ toes. He is ambulatory with out pain although
the area is tender to palpation. THe foot is warm with
dopplerable DP pulse.
He will follow up with Dr. ___ in one month. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Droperidol / Gadolinium-Containing Agents / Demerol
/ Morphine / Haldol / Cardizem / Protonix / epinephrine / IV
Dye, Iodine Containing Contrast Media / Narcan / Keflex
Attending: ___.
Chief Complaint:
Dyspnea.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with mast cell deactivation syndrome, recurrent chest pain,
CAD s/p CABG x2 in ___, hypothyroidism,
ADHD/depression/anxiety, and achalasia s/p ___ myotomy/Dor
fundoplication by Dr. ___ on ___ presented with chest
pain, diffuse pruritis, dyspnea similar to prior mast cell
flares. She was admitted for mast cell degranulation flare
protocol.
Patient reports symptoms started 1 hour prior to ED arrival with
dyspnea, chest pain, pruritis of face and neck. Denied fevers or
chills. She took Benadryl at home but vomited it. Intermittent
chest pain and epigastric pain over past few weeks. Evaluated by
thoracic surgery by ___ for post-op visit. Her dysphagia
improved. Acid reflux felt to not be GERD related as she is s/p
partial fundoplication, reflux unchanged since myotomy, and it
is not responsive to PPIs. Dr. ___ has suggested that
pH/impedance testing might be the next step.
In the ED, initial vitals were T98.3 HR85 BP142/101 RR27 100%
RA. On arrival, she was extremely tachypneic, anxious, and
clutching chest. She improved with ED protocol for mast cell
degranulation - IV benadryl 50mg, solumedrol 80mg IV, albuterol,
zofran 4mg IV, and dilaudid 2mg. Repeated benadryl 50mg,
dilaudid 1mg IV, Zofran 2mg IV. Got 40mg pantoprazole IV.
Received 2L NS, 75cc/hr. She was alert and oriented throughout.
Per ___ discharge summary:
Of note, the patient has had frequent hospital admissions over
past several years for recurrent chest pain that has been
attributed to multiple possible etiologies including mast cell
degranulation, esophageal spasm/GERD, and CAD, but largely found
to be non-cardiac in origin with stable disease, negative stress
tests, and negative troponins across multiple admissions. There
has been some concern that there is a component of drug-seeking
behaviour in her repeated admissions which have included her
leaving AMA when denied IV nartcotics. Per previous d/c
summaries: "Patient has been seen by allergy at ___ in the
past that have recommended against the use of IV narcotics as it
can actually exacerbate her symptoms. Additionally per the
medical record the physician who has made the diagnosis has
stated the IV protocol should be used in cases of true
anaphylaxis."
On the floor, initial vitals were T97.6, BP 140/60, HR69, RR22,
100% on RA. Patient was calm prior to my entering the room. She
then became tachypneic with positive ___ sign when I
approached. She complained of nausea, headache, cough, acid
reflux, chest pain, dyspnea, and joint pains. When I left the
room and returned later, she was found resting quietly in her
bed.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria or frequency.
Past Medical History:
- ___ EGD, ___ myotomy, Dor fundoplication
- Sees multiple providers: recently Dr. ___
at ___ re:diffuse esophageal spasm & CP
- Recently seen at ___ ___
- Seen in ___ - ___ - ED d/c summary
- Seen at ___ ___ after being seen in allergy
clinic & then reported experiencing sx c/w mast cell activation
syndrome.
- 2 CABG ___, PCI w/ stent placed ___
- Mast Cell Degranulation Syndrome: Primary allergist: Dr
___ (___; ___ ___ &
Dr. ___ Asthma and Immunology;
___
- Portacath ___ - removed for MRSA infection within 3 days,
re-placed ___
- Syncope attributed to orthostatic hypotension w/ positive
tilt table testing ___. No episodes recently
- Hypothyroidism
- ADHD/depression/anxiety: especially ___ years post difficult
divorce
- Erosive rheumatoid arthritis
- GERD, gastritis and esophagitis on EGD ___
- Paradoxical Vocal Cord Dysfunction on fiberoptic laryngoscopy.
Rechecked by ENT within last year: no sign of dysfx
- s/p hysterectomy and oophorectomy
- left wrist cellulitis concerning for necrotizing fasciitis s/p
fasciotomy (found to be MRSA)
- s/p cholecystectomy
- s/p tonsillectomy
- bilateral avascular necrosis of hip
Social History:
___
Family History:
Mother had OA, died of MI at ___. Mother's family: early ___ and
___. Sister with breast cancer and bilateral mastectomy and
thyroid cancer. Brother with ___ and hyperlipidemia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T97.6, BP 140/60, HR69, RR22, 100% on RA
General: Mild respiratory distress with audible airway sounds.
Calm when alone in room. When I enter room, she becomes dyspneic
and tachypenic with positive ___ sign.
CV: Regular rate and rhythm, normal S1 S2, no murmurs
Lungs: Scattered wheezing in upper lobes, no crackles, decreased
respiratory effort
Abdomen: soft, nontender, nondistended, normal bowel sounds, no
rebound or guarding
GU: no Foley
Ext: Warm, well perfused, 2+ pulses, no peripheral edema
Neuro: Alert and oriented to person, hospital, and date. ___
strength upper/lower extremities, grossly normal sensation.
DISCHARGE PHYSICAL EXAM:
Vitals: T97.9 112/57 HR55 RR18 100RA
General: No distress. Resting in bed.
CV: Regular rate and rhythm, normal S1 S2, no murmurs
Lungs: Decreased breath sounds, no wheezing or crackles
Abdomen: soft, nontender, nondistended, normal bowel sounds, no
rebound or guarding
GU: no Foley
Ext: Warm, well perfused, 2+ pulses, no peripheral edema
Neuro: Alert and oriented to person, hospital, and date. ___
strength upper/lower extremities, grossly normal sensation.
Pertinent Results:
LABS:
___ 06:02AM BLOOD WBC-3.8* RBC-3.86* Hgb-11.9* Hct-37.2
MCV-97 MCH-30.9 MCHC-32.0 RDW-13.8 Plt ___
___ 05:59AM BLOOD WBC-3.8* RBC-3.95* Hgb-12.2 Hct-38.2
MCV-97 MCH-30.9 MCHC-32.0 RDW-13.5 Plt ___
___ 10:20AM BLOOD WBC-3.2* RBC-4.02* Hgb-12.2 Hct-38.5
MCV-96 MCH-30.4 MCHC-31.7 RDW-13.6 Plt ___
___ 05:59AM BLOOD Neuts-61 Bands-0 ___ Monos-4 Eos-8*
Baso-0 Atyps-2* ___ Myelos-0
___ 10:20AM BLOOD Neuts-50 Bands-0 ___ Monos-8
Eos-18* Baso-1 Atyps-1* ___ Myelos-0
___ 06:02AM BLOOD Glucose-106* UreaN-10 Creat-0.6 Na-144
K-3.8 Cl-107 HCO3-29 AnGap-12
___ 05:59AM BLOOD Glucose-95 UreaN-12 Creat-0.6 Na-142
K-4.1 Cl-107 HCO3-28 AnGap-11
___ 10:20AM BLOOD Glucose-112* UreaN-14 Creat-0.7 Na-141
K-3.8 Cl-103 HCO3-31 AnGap-11
___ 05:59AM BLOOD ALT-66* AST-39 AlkPhos-107* TotBili-0.2
___ 05:59AM BLOOD Lipase-41
___ 10:20AM BLOOD cTropnT-<0.01
___ 06:02AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.1
___ 05:59AM BLOOD Albumin-3.8 Calcium-6.9* Phos-3.5 Mg-2.4
___ 05:59AM BLOOD PTH-62
___ 05:59AM BLOOD 25VitD-PND
___ ECG
Sinus rhythm with sinus arrhythmia. Baseline artifact. RSR'
pattern, probable
normal variant. Leftward axis. Poor R wave progression.
Non-specific
ST-T wave abnormalities. Compared to the previous tracing of
___, no
significant change.
___ Barium swallow study
HISTORY: Status post ___ myotomy and dor fundoplication with
dysphagia and dyspepsia
COMPARISON: Barium swallow ___.
FINDINGS:
While in the upright position, barium passed freely through the
esophagus and into the stomach without evidence of holdup. In
this position, there were tertiary contractions seen in the
distal esophagus. With the patient drinking in prone position,
there was a primary peristaltic wave. However, there was
unsuccessful stripping of barium through the esophagus and into
the stomach in this position. Barium remained pooled in the mid
esophagus and cleared only when the patient was repositioned
upright.
There was no evidence of esophageal stricture or narrowing.
There was no
hiatal hernia or reflux seen during this examination. A 13 mm
barium tablet passed freely into the stomach.
IMPRESSION:
1. Esophageal dysmotility with an incomplete primary stripping
wave while
drinking in the prone ___ position. Gravity was needed to
completely clear the barium from the esophagus. Multiple
uncoordinated tertiary contractions were seen in the distal
portion of the esophagus.
2. Passage of a 13 mm barium tablet without evidence of
esophageal narrowing or stricture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 3.125 mg PO DAILY
2. Duloxetine 60 mg PO QAM
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 600 mg PO BID
5. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Nuvigil (armodafinil) 250 mg Oral qday
8. Aripiprazole 2 mg PO DAILY
9. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
10. Omeprazole 80 mg PO TID
11. Ranitidine 300 mg PO BID
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Rosuvastatin Calcium 40 mg PO DAILY
14. Methadone 5 mg PO TID
15. Lorazepam 1 mg PO HS:PRN insomnia
16. Aspirin 81 mg PO DAILY
17. Docusate Sodium 100 mg PO BID:PRN constipation
18. Senna 1 TAB PO BID:PRN constipation
19. Acetaminophen 650 mg PO Q6H:PRN pain
20. ZyrTEC (cetirizine) 10 mg Oral qday
21. Zolpidem Tartrate 10 mg PO HS
22. Vitamin D 1000 UNIT PO DAILY
23. Ondansetron 8 mg PO Q8H:PRN nausea
24. Gabapentin 900 mg PO HS
25. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID:PRN
wheezing
26. Ferrous Sulfate 325 mg PO DAILY
27. NIFEdipine 20 mg PO Q8H
28. etanercept 50 mg/mL (0.98 mL) subcutaneous ___
29. Methotrexate 22.5 mg PO QFRI
30. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
3. Aripiprazole 2 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Carvedilol 3.125 mg PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Duloxetine 60 mg PO QAM
8. Ferrous Sulfate 325 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID:PRN
wheezing
10. FoLIC Acid 1 mg PO DAILY
11. Gabapentin 600 mg PO BID
12. Gabapentin 900 mg PO HS
13. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
14. Levothyroxine Sodium 25 mcg PO DAILY
15. Lorazepam 1 mg PO HS:PRN insomnia
16. Methadone 5 mg PO TID
17. Multivitamins 1 TAB PO DAILY
18. NIFEdipine 20 mg PO Q8H
19. Ondansetron 8 mg PO Q8H:PRN nausea
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
21. Ranitidine 300 mg PO BID
22. Rosuvastatin Calcium 40 mg PO DAILY
23. Senna 1 TAB PO BID:PRN constipation
24. Vitamin D 1000 UNIT PO DAILY
25. Zolpidem Tartrate 10 mg PO HS
26. etanercept 50 mg/mL (0.98 mL) subcutaneous ___
27. Methotrexate 22.5 mg PO QFRI
28. Nuvigil (armodafinil) 250 mg Oral qday
29. ZyrTEC (cetirizine) 10 mg Oral qday
30. Omeprazole 80 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1) Atypical chest pain, shortness of breath, possible mast cell
degranulation syndrome flare
SECONDARY DIAGNOSES:
- ___ EGD, ___ myotomy, Dor fundoplication
- CABG, PCI
- Mast Cell Degranulation Syndrome: Primary allergist: Dr
___ (___; ___ ___ &
Dr. ___ Asthma and Immunology;
___
- ADHD/depression/anxiety
- Hypothyroidism
- GERD, gastritis and esophagitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Status post ___ myotomy and dor fundoplication with dysphagia and
dyspepsia
COMPARISON: Barium swallow ___.
FINDINGS:
While in the upright position, barium passed freely through the esophagus and
into the stomach without evidence of holdup. In this position, there were
tertiary contractions seen in the distal esophagus. With the patient drinking
in prone position, there was a primary peristaltic wave. However, there was
unsuccesful stripping of barium through the esophagus and into the stomach in
this position. Barium remained pooled in the mid esophagus and cleared only
when the patient was repositioned upright.
There was no evidence of esophageal stricture or narrowing. There was no
hiatal hernia or reflux seen during this examination. A 13 mm barium tablet
passed freely into the stomach.
IMPRESSION:
1. Esophageal dysmotility with an incomplete primary stripping wave while
drinking in the prone ___ position. Gravity was needed to completely clear the
barium from the esophagus. Multiple uncoordinated tertiary contractions were
seen in the distal portion of the esophagus.
2. Passage of a 13 mm barium tablet with evidence of esophageal narrowing or
stricture.
10 min after completing this study, the patient complained of worsening chest
pain radiating to the back and was visibly short of breath. A emergency
medical response was called and the primary team was notified. The patient
was placed on 4 L of oxygen via face mask and oxygen saturation was initially
98%. The patient was given 2 puffs of an albuterol inhaler at 14:50, 50 mg of
IV Benadryl at 14:55, and and an Epipen at 15:00. After medication
administration vitals: HR: 80 and BP: 170/105. The patient experienced
improvement of symptoms with the above interventions. Vitals at the time of
transfer to the floor HR: 80s O2:100% on 2L, and BP 155/84.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Difficulty breathing
Diagnosed with CHEST PAIN NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT, AORTOCORONARY BYPASS
temperature: 98.3
heartrate: 85.0
resprate: 27.0
o2sat: 100.0
sbp: 142.0
dbp: 101.0
level of pain: 9
level of acuity: 1.0 | ___ with past diagnosis of mast cell degranulation syndrome, CAD
s/p CABG x2 in ___, hypothyroidism, ADHD/Depression/Anxiety,
and GERD, s/p Dor fundoplication and ___ myotomy ___
presents with dyspnea, pruritis, and chest pain consistent with
her prior mast cell degranulation flare. Patient requested to be
discharged multiple times on her last day of admission.
# Mast cell degranulation flare. Patient received mast cell
protocol in ED, with IV diphenhydramine, IV Zofran, IV dilaudid,
IV Solumedrol, IV pantoprazole, and 2L NS. Unclear diagnosis in
the past. From Dr. ___ note: "Inconsistent with this
diagnosis in the past is that blood histamine and/or Tryptase
levels have never been abnormal with any ___ admissions
including for what appears to be significant symptoms of
?anaphylaxis. In these instances, we would expect to see florid
increases in blood histamine and tryptase." Patient's home
medications were continued. On the floor, she had several
episodes of severe subjective chest pain and audible wheezing
with positive ___ sign and requested IV Benadryl by name.
Patient had normal lipase, troponin, and unchanged ECG. She was
noted to be calm in her room alone, but became subjectively
aggravated and distressed when providers entered her room. She
received Benadryl 12.5mg IV Q6H PRN which treated her symptoms
appropriately. She was discharged on all of her home meds with
no changes or additions.
# GERD, reflux symptoms. Status post myotomy and partial
fundoplication on ___ which was uncomplicated and stable on
outpatient followup on ___. Her outpatient GI Dr. ___ has
suggested an outpatient pH/impedance testing given her
persistent symptoms. Her thoracic surgeron Dr. ___ not
think her reflux is GERD related as she had a
myotomy/fundoplication with no change in symptoms and she is not
responsive to PPIs. Per request of Dr. ___ had a
barium swallow study which showed esophageal dysmotility while
drinking. No problems with swallowing barium tablet.
# Elevated ALT and alkaline phosphatase. Unclear etiology.
Patient was not complaining of RUQ abdominal pain. No risk
factors for hepatitis. No ___ medications started per patient.
Recommend outpatient followup as patient was clinically stable
and this was not relevant to her presenting complaints.
# Hypocalcemia. Calcium 6.9 with albumin 3.8. This resolved with
calcium gluconate 2g IV and discharge calcium level was 8.4. PTH
was normal. Vitamin D level was pending. Patient was continued
on her home calcium supplement. Saponification in pancreatitis
would not be possible given normal lipase. ___ have element of
malnutrition. Suspect hyperventilation in acute anxiety flares
leading to respiratory alkalosis, in which hydrogen ions
decrease, albumin is freed to bind to calcium, and calcium level
is lowered as a result.
# ACCESS: Port-A-Cath Right chest wall
# CODE: Full (confirmed ___ with patient)
# CONTACT: HCP/son ___ ___
### ___ ISSUES ###
1) Follow up with PCP and Dr. ___ dysmotility and
next steps.
2) Outpatient pH/impedance testing if clinically needed.
3) No changes in medication list during this admission.
4) Follow up abnormal LFTs. |
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 hip pain
Major Surgical or Invasive Procedure:
Open reduction and internal fixation right intertrochanteric hip
fracture with sliding hip plate
History of Present Illness:
___ who was walking his dog, when he tripped
and fell down from standing. No head strike, no LOC, remembers
entire event. Was unable to ambulate afterwards, and was taken
to OSH where x rays were performed, he requested transfer to
___.
Of note patient broke his right hip in ___, fixed at ___ by Dr.
___ of hardware ___, denies much antecedent hip pain,
but some discomfort
He denies any pain other than right hip, left wrist pain.
Past Medical History:
Multiple Sclerosis, Trigeminal Neuralgia
Social History:
___
Family History:
NC
Physical Exam:
NAD
Alert and oriented
No respiratory distress
Right Lower Extremity
Wound clean, dry and intact, no erythema or evidence or
infection
Appropriate postoperative tenderness at surgical site.
Saphenous, Sural, Deep Peroneal, Superficial Peroneal, Tibial
sensation intact to light touch but decreased (also at baseline
from MS)
Extensor Hallucis Longus, Flexor Hallucis Longus, Tibialis
Anterior fire
1+ posterior tibial and dorsalis pedis pulse
Left Lower Extremity
skin clean and intact
No tenderness, deformity, erythema, ecchymosis
No pain with passive motion of hip, knee, ankle, toes
Saphenous, Sural, Deep Peroneal, Superficial Peroneal, Tibial
sensation intact to light touch but decreased
Extensor Hallucis Longus, Flexor Hallucis Longus, Tibialis
Anterior fire
1+ posterior tibial and dorsalis pedis pulse
Pertinent Results:
___ 07:05PM GLUCOSE-88 UREA N-11 CREAT-0.6 SODIUM-138
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16
___ 07:05PM estGFR-Using this
___ 07:05PM WBC-10.3 RBC-4.32* HGB-13.7* HCT-42.3 MCV-98
MCH-31.7 MCHC-32.4 RDW-13.0
___ 07:05PM NEUTS-76.5* LYMPHS-17.8* MONOS-4.7 EOS-0.5
BASOS-0.5
___ 07:05PM PLT COUNT-196
___ 07:05PM ___ PTT-30.0 ___
Medications on Admission:
Copaxone, Carbamazpine, Baclofen
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous QPM (once a day (in the evening)) for 4 weeks.
Disp:*28 syringe* Refills:*0*
3. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. glatiramer 20 mg Kit Sig: One (1) Kit Subcutaneous Daily ().
12. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
13. carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
14. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right intertrochanteric hip 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
CHEST SINGLE VIEW: ___.
HISTORY: ___ male with right hip fracture. Question acute
cardiopulmonary process. Pre-op.
FINDINGS: AP supine view of the chest. No prior. The lungs are
hyperinflated, but clear of focal consolidation. Cardiomediastinal silhouette
is within normal limits. Osseous and soft tissue structures are grossly
unremarkable.
IMPRESSION: Hyperinflation without visualized acute cardiopulmonary process.
Radiology Report
PELVIS, RIGHT HIP AND RIGHT FEMUR FILMS, ___.
CLINICAL HISTORY: ___ man with hip fracture. Traction views.
FINDINGS: AP view of the pelvis and AP views of the right hip and right
femur. Correlation is made to outside films from earlier the same day. Again
seen is an acute intertrochanteric fracture of the right femur. There is no
significant displacement or angulation based on AP views. Evaluation of the
left hemipelvis is limited secondary to significant overlying bowel gas.
There is no other visualized fracture. Pubic symphysis and SI joints are
grossly preserved. Distally, the femur is intact.
IMPRESSION: Acute right intertrochanteric femur fracture without significant
angulation or displacement based on AP views alone.
Radiology Report
LEFT WRIST, FOUR VIEWS, ___.
HISTORY: ___ man with wrist pain.
FINDINGS: AP, lateral, and oblique views and scaphoid views of the left
wrist. No prior. There is no visualized fracture or acute osseous
abnormality. Joint spaces are maintained. Soft tissues are unremarkable.
IMPRESSION: No visualized fracture.
Radiology Report
STUDY: Right hip intraoperative study ___.
CLINICAL HISTORY: Patient with right hip ORIF.
FINDINGS: Multiple fluoroscopic images of the right hip from the operating
room demonstrate interval placement of a dynamic compression screw. There are
no signs for hardware-related complications. There are baseline degenerative
changes of the hip joint. The total intraservice fluoroscopic time was 92.7
seconds.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RT HIP FX
Diagnosed with INTERTROCHANTERIC FX-CL, UNSPECIFIED FALL, MULTIPLE SCLEROSIS
temperature: 100.2
heartrate: 67.0
resprate: 18.0
o2sat: 100.0
sbp: 146.0
dbp: 59.0
level of pain: 3
level of acuity: 3.0 | The patient was admitted to the Orthopaedic Trauma Service for
repair of a right intertrochanteric fracture. The patient was
taken to the OR and underwent an uncomplicated open reduction
internal fixation with sliding hip plate. The patient tolerated
the procedure without complications and was transferred to the
PACU in stable condition. Please see operative report for
details. Post operatively pain was controlled with a PCA with a
transition to PO pain meds once tolerating POs. The patient
tolerated diet advancement without difficulty and made steady
progress with ___.
Weight bearing status: Right lower extremity weight bearing as
tolerated .
The patient received ___ antibiotics as well as
Lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 4 weeks post-operatively. All questions were
answered prior to discharge to rehab and the patient expressed
readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Mr. ___ is a ___ male with past medical history
notable for chronic pancreatitis with h/o
roux-en-y-pancreaticojejunostomy, chronic low back pain (due to
osteoarthritis), who presents with abdominal pain.
Patient presented to the ___ with complaints of diffused pain
"all
over." He states he was moving lumbar 2 days ago and afterwards
developed worsening of his chronic back pain. Reports shooting
pain down bilateral legs and a sense of global weakness. He also
reports diffuse abdominal pain and distention that started a
couple of days prior to admission.
In the ___ he reported subjective fever/chills, headache, chest
pain, and diarrhea but on the floor reported only chills. He
states chest pain is intermittent (~once monthly with sharp pain
that resolves immediately).
He also reported worsening depression over the past month. Per
___
triage RN, he reported he had suicidal thoughts and a plan.
Denied HI or auditory/visual hallucinations. He stated he is
depressed by his chronic pain and fatigue. Despite no changes in
night-time sleeping habits he "falls asleep everywhere"
including
work. The only recent change in his life is he started Chantix 3
months ago.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
In the ___:
- Initial vitals: 97.7 73 124/86 20 100% RA
- Exam was notable for: no acute distress, abdomen distended,
diffuse tenderness worse in epigastric area, voluntary guarding,
bowel sounds active, no appreciable mass or organomegaly, no
appreciable abdominal bruit
- Labs:
+ CBC: WBC 8.2, Hgb 13.3, Plt 277
+ Chem 10: Na 138, K 5.0 Creat 0.8
+ LFTS: ALT 15, AST 20, Alkphos 98, T bili 0.5, Lipase 8
+ Tox screem: Serum positive for benzos, urine positive for
benzos and opiates
- Imaging notable for: no acute intra-abdominal process. Chronic
splenic vein thrombosis compatible with chronic pancreatitis
- Patient was given: Dilaudid 0.5mg x2. Dilaudid PO 4mg and
lovenox 80mg
- Consults: psych was consulted who after speaking the patient
felt there no need for ___: No S12 or need for suicide
precautions; discussed with PCP referral to therapy and
consideration of SSRI in future
- Transfer vitals: 98.6 66 141/100 18 97% RA
On arrival patient reports feeling ok. Reports abdominal pain is
___. Baseline is ___. He reports one watery bowel movement
this morning. He states he tolerated PO with a ___ sandwich
for lunch in the ___.
He denies SI and HI (discussed the boat he bought and looking
forward to picking it up next week). He however reports
increased
drinking in the past 1 month, drinking ___ ounces of alcohol
daily.
Past Medical History:
Chronic Pancreatitis s/p roux-en-y-pancreaticojejunostomy ___
Tobacco Abuse
History of alcohol abuse
Anxiety
Chronic Back pain/spasm, on narcotics and benzodiazepines
OA
Social History:
___
Family History:
Family Hx: No history of pancreaticobiliary disease.
Physical Exam:
ADMISSION EXAM:
===============
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, tender to palpation in
epigastric region. Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
===============
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, nontender to palpation. Bowel
sounds present. Well-healed transverse incision
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. Straight leg raise
negative, gait intact
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
LABS:
=====
___ 08:45AM BLOOD WBC-4.8 RBC-3.82* Hgb-12.5* Hct-37.0*
MCV-97 MCH-32.7* MCHC-33.8 RDW-12.9 RDWSD-45.9 Plt ___
___ 10:20AM BLOOD Neuts-55.8 ___ Monos-8.2 Eos-1.2
Baso-0.2 Im ___ AbsNeut-4.54# AbsLymp-2.79 AbsMono-0.67
AbsEos-0.10 AbsBaso-0.02
___ 08:45AM BLOOD ___ PTT-29.2 ___
___ 08:45AM BLOOD Glucose-143* UreaN-11 Creat-0.7 Na-139
K-4.3 Cl-99 HCO3-24 AnGap-16
___ 10:20AM BLOOD ALT-15 AST-20 AlkPhos-98 TotBili-0.5
___ 10:20AM BLOOD Lipase-8
___ 08:45AM BLOOD Calcium-9.2 Phos-4.5 Mg-1.8
___ 10:20AM BLOOD Albumin-4.1
___ 10:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS* Barbitr-NEG Tricycl-NEG
___ 10:15AM URINE Color-Yellow Appear-Clear Sp ___
___ 10:15AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-SM* Urobiln-2* pH-5.5 Leuks-NEG
___ 10:15AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
TransE-<1
___ 10:15AM URINE CastGr-1* CastHy-45*
___ 10:15AM URINE bnzodzp-POS* barbitr-NEG opiates-POS*
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
IMAGING:
========
CT abd/pel ___:
IMPRESSION:
1. No acute intra-abdominal process to explain the patient's
symptoms.
2. Pancreatic atrophy with parenchymal calcifications and
chronic splenic vein
thrombosis compatible with chronic pancreatitis. Status post
Puestow
procedure. No evidence for acute pancreatitis or peripancreatic
collections.
3. Hepatic steatosis.
4. Previously noted intrahepatic biliary dilatation has
improved. No
extrahepatic biliary dilatation identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Cetirizine 10 mg PO DAILY
3. Chantix (varenicline) 0.5 mg oral DAILY
4. Diazepam 5 mg PO Q8H:PRN back spasm
5. Gabapentin 600 mg PO BID
6. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
7. Omeprazole 20 mg PO DAILY
8. Propranolol 20 mg PO BID
9. Zenpep (lipase-protease-amylase) 25,000-85,000- 136,000 unit
oral DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cetirizine 10 mg PO DAILY
3. Diazepam 5 mg PO Q8H:PRN back spasm
4. Gabapentin 600 mg PO BID
5. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
6. Omeprazole 20 mg PO DAILY
7. Propranolol 20 mg PO BID
8. Zenpep (lipase-protease-amylase) 25,000-85,000- 136,000 unit
oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Musculoskeletal back pain
SECONDARY: Chronic pancreatitis complicated by splenic vein
thrombus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ with abdominal and low back pain// ? pancreatitis vs.
obstruction
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 7.5 s, 0.5 cm; CTDIvol = 36.1 mGy (Body) DLP =
18.1 mGy-cm.
2) Spiral Acquisition 4.8 s, 52.9 cm; CTDIvol = 13.3 mGy (Body) DLP = 702.8
mGy-cm.
Total DLP (Body) = 721 mGy-cm.
COMPARISON: CT dated ___.
FINDINGS:
LOWER CHEST: There is minimal bilateral dependent atelectasis. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous hypoattenuation throughout.
There is no evidence of focal lesions. Previously noted intrahepatic biliary
dilatation has substantially improved. There is no extrahepatic biliary
dilatation. The gallbladder is surgically absent.
PANCREAS: Changes from chronic pancreatitis are again evident with atrophy of
the pancreatic parenchyma and multiple calcifications throughout the
parenchyma. The patient is status post Puestow procedure without
complications. No evidence of focal lesions or pancreatic ductal dilatation.
There is no peripancreatic stranding or fluid collections.
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. Small bowel
anastomosis is intact. Diverticulosis of the 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.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. Chronic thrombosis of the splenic vein is re-demonstrated with
perigastric varices re-demonstrated.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Mild degenerative changes, most significant at L4-5 and L5-S1 with
intervertebral disc space narrowing and vacuum disc phenomenon resulting in
mild central canal narrowing.
SOFT TISSUES: There is a small umbilical hernia containing fat and a tiny
ventral hernia just superior in the midline containing fat.
IMPRESSION:
1. No acute intra-abdominal process to explain the patient's symptoms.
2. Pancreatic atrophy with parenchymal calcifications and chronic splenic vein
thrombosis compatible with chronic pancreatitis. Status post Puestow
procedure. No evidence for acute pancreatitis or peripancreatic collections.
3. Hepatic steatosis.
4. Previously noted intrahepatic biliary dilatation has improved. No
extrahepatic biliary dilatation identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Acute embolism and thrombosis of other specified veins, Suicidal ideations
temperature: 97.7
heartrate: 73.0
resprate: 20.0
o2sat: 100.0
sbp: 124.0
dbp: 86.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ is a ___ male with past
medical history notable for chronic pancreatitis with h/o
roux-en-y-pancreaticojejunostomy, chronic low back pain (due to
osteoarthritis), risky alcohol use, current smoking and other
issues admitted with back pain after lifting heavy lumber. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
___ ADMISSION NOTE
PCP: Dr. ___, ___
CC: ___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an ___ F with history of hypertension, hyperlipidemia
and osteoporosis presents with left groin pain following a fall
last night.
Pt was see ny her PCP on ___ for diarrhea. The diarrhea began
on ___. It was watery, non bloody diarrhea. She was having
multiple episodes per day. She had associated nausea but no
vomiting. Denies fever or chills. She also had some crampy lower
abdominal pain associated with the diarrhea. The diarrhea
persisted so she took ___ immodium on Thyrsday and again on
___. She was evaluated by per PCP on ___ and started on a
short course of Cipro after her WBC count was elevated. Of note,
the patient reports a course of antibiotics for a urinary tract
infection- she thinks in ___. She denies sick contacts.
Denies recent travel or changes in food/medictions. Has been
taking ibuprofen/vicodin intermittently for back spasm.
Then, yesterday evening, she woke from sleep to go to the
bathroom. Her husband found her in the bathroom, she was
incontinent of stool. She then fell to the floor. There was no
LOC but her reports she was acting like she was drunk during
this episode. She then complained of pain in her left elbow and
left groin. After calling her PCP she was advised to go to the
ER for evaluation.
In the ED, initial VS: T97.8 P:100 BP: 115/67 R: 20 97% ra. Labs
notable for WBC 25, lactate 1.4, UA with 20WBC, mod leuks, no
bacteria.
EKG: lateral ST depressions, inferior TWIs. CXR without acute
process.
She underwent a CT which showed pan colitis and Left ovarian
varices. The patient Patient received IV cipro/flagyl and 2L IVF
and was admitted to medicine for futher care.
On arrival to the floor, the patient is feeling well. She denies
abdominal pain. Reports left groin pain only on moving her left
leg against gravity.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies cough, shortness of breath, or wheezing. Very
active at baseline- does aerobics twice weekly without SOB.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia
GERD
Osteoporosis
DJD
Social History:
___
Family History:
Her mother died at ___ from complications of heart disease.
Father deceased at ___ CVA. Son died at age ___ from angiosarcoma.
Two living sons are healthy
Physical Exam:
VS: T: 98.3 Bp: 135/69 HR: 105 R: 18 O2: 95% RA
GENERAL: well appearing, in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2 present
ABDOMEN: high pitched bowel sounds, soft, slightly tender. No
rebound no guarding. No masses. Groin non tender to palpation.
EXTREMITIES: No tenderness on palpation of greater trochanter.
no edema, 2+ pulses radial and dp. Full ROM of right and left
hip. Pain in groin on passive leg raise in left groin.
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout
Pertinent Results:
___ 09:20PM cTropnT-<0.01
___ 03:30PM cTropnT-<0.01
___ 06:15PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
___ 06:15PM URINE RBC-1 WBC-20* BACTERIA-NONE YEAST-NONE
EPI-1
___ 06:15PM URINE HYALINE-10*
___ 06:15PM URINE MUCOUS-RARE
___ 03:39PM LACTATE-1.4
___ 03:30PM GLUCOSE-102* UREA N-19 CREAT-1.0 SODIUM-134
POTASSIUM-3.5 CHLORIDE-91* TOTAL CO2-27 ANION GAP-20
___ 12:21PM UREA N-11 CREAT-0.7 SODIUM-136 POTASSIUM-3.2*
CHLORIDE-91* TOTAL CO2-33* ANION GAP-15
___ 12:21PM ALT(SGPT)-17 AST(SGOT)-19 ALK PHOS-99 TOT
BILI-0.9 DIR BILI-0.3 INDIR BIL-0.6
___ 12:21PM LIPASE-21
___ 12:21PM WBC-25.5*# RBC-4.49 HGB-13.9 HCT-42.4 MCV-94
MCH-30.9 MCHC-32.7 RDW-13.2
___ 12:21PM NEUTS-82.5* LYMPHS-10.5* MONOS-6.5 EOS-0.2
BASOS-0.3
___ 12:21PM PLT COUNT-429
CT abdomen-pelvis: prelim
Diffuse pan-colitis, with inflammatory changes slightly more
apparent in the cecum. Etiologies could include infection or
ischemia. No areas of bowel thinning or decreased enhancement.
No abscess or free air. Mild left ovarian varices and prominence
of the left ovarian vein.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 50 mg PO DAILY
2. Ramipril 2.5 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Aspirin 81 mg PO 3X/WEEK (___)
Takes on M, W, F
6. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q8H:PRN pain
Discharge Medications:
1. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*27 Tablet Refills:*0
2. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 8 hours as needed
for pain Disp #*15 Tablet Refills:*0
3. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q8H:PRN pain
4. Aspirin 81 mg PO 3X/WEEK (___)
5. Atorvastatin 20 mg PO DAILY
6. Hydrochlorothiazide 50 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Ramipril 2.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
___.difficle colitis (infection in the colon of a bacteria)
pulled muscle in the left leg
Discharge Condition:
improved
Followup Instructions:
___
Radiology Report
EXAM: AP semi-erect portable view of the chest.
CLINICAL INFORMATION: Hypoxia.
___.
FINDINGS: Single AP upright portable view of the chest was obtained. The
lungs are hyperinflated, suggesting chronic obstructive pulmonary disease.
Evidence of very prominent costochondral calcifications are seen bilaterally.
Mild bibasilar atelectasis is seen. There is no definite focal consolidation.
There is no large pleural effusion or pneumothorax. The cardiac and
mediastinal silhouettes are stable and unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ woman with abdominal pain and diarrhea. Evaluate for
colitis or diverticulitis.
COMPARISONS: Abdominal ultrasound from ___.
TECHNIQUE: MDCT-acquired axial images from the lung bases through the pubic
symphysis were obtained after administration of 130 cc Omnipaque intravenous
contrast material as well as enteric contrast. Coronal and sagittal reformats
prepared and reviewed.
DLP: 404.19 mGy-cm.
FINDINGS:
LOWER CHEST: There are atherosclerotic calcifications in the visible coronary
vessels. The heart size is normal and there is no pericardial or pleural
effusion. There is bilateral dependent atelectasis. Pulmonary mphysema is
noted.
ABDOMEN: There is a 4.4 x 4.0 cm cyst in the dome of the liver. These were
present but slightly smaller on the prior ultrasound from ___. No other
focal liver lesions identified. There are several small gravity dependent
radiopaque gallstones. The gallbladder otherwise looks normal. There is no
bile duct dilation. The pancreas, spleen, and adrenal glands appear normal.
The kidneys enhance normally and excrete contrast symmetrically. There are
several bilateral renal hypodensities which are too small to characterize by
CT. The stomach and small bowel appear normal.
There is diffuse colonic wall thickening is seen predominantly affecting the
cecum, ascending colon, and descending colon, with small segments of relative
sparing in the transverse colon. There is mild mesenteric fat stranding
around the thickened segments. The appendix is not well seen. There is no
intra-abdominal fluid collection, ascites, or pneumoperitoneum. There is no
lymphadenopathy. Extensive atherosclerotic disease can be seen throughout the
abdominal aorta and its branch vessels. There is no aneurysm or dissection.
Although there are no signs of occlusion, there is tight stenosis at the
origin of the celiac artery and the superior mesenteric artery. The inferior
mesenteric artery may be filled in a retrograde fashion given the extent of
calcification at its ostium.
PELVIS: The urinary bladder appears normal. The uterus is atrophic and
contains a coarsely calcified probable involuted uterine fibroid. There are
left ovarian varices and mild dilation of the left ovarian vein through its
entire course up to the left renal vein. There is no pelvic lymphadenopathy
or free fluid.
MUSCULOSKELETAL: There are no destructive osseous lesions concerning for
malignancy. Multilevel degenerative changes of the spine are noted.
IMPRESSION:
1. Diffuse colonic wall thickening consistent with pancolitis, with small
segments of relative sparing in the transverse colon. Etiologies could
include infection, inflammation, or ischemia. No free air or drainable
collection.
2. Extensive atherosclerotic disease with stenoses at the origins of multiple
abdominal arteries, without evidence of complete occlusion.
3. Left ovarian varices and dilated left ovarian vein may be clinically
irrelevant; however, these findings can be seen in chronic pelvic congestion
syndrome.
Radiology Report
LEFT HIP STUDY DATED ___
No prior hip radiographs for comparison.
FINDINGS: The bones are diffusely demineralized consistent with the patient's
advanced age. With this limitation in mind, no acute fracture is evident, and
there is no evidence of dislocation. Within the imaged portion of the pelvis,
incidental note is made of a calcified fibroid uterus. Degenerative changes
are evident in the lower spine.
IMPRESSION: Diffuse osseous demineralization. No fracture identified.
However, if there is strong clinical suspicion for fracture, MRI may be
considered if warranted clinically in order to exclude a radiographically
occult fracture.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FALL YESTERDAY
Diagnosed with UNIVERSAL ULCERATIVE COLITIS, SYNCOPE AND COLLAPSE
temperature: 97.8
heartrate: 100.0
resprate: 20.0
o2sat: 97.0
sbp: 115.0
dbp: 67.0
level of pain: 10
level of acuity: 2.0 | ___ female with hx of of hypertension/hyperlipidemia who
presents with pre-syncope and hip pain in the setting of severe
diarrhea illness.
Pt initially has profuse watery diarrhea. She was placed on IVF
and metronidazole. Over time, she had improvement in the
diarrhea, was taken off IVF, and was able to eaet and drink
normally. She bowels decreased in frequency and began to become
normal in consistently. Pt initially had severe left medical
thigh/groin pain. there was no point tenderness. This improved
over time. Pt did not fall on the hip per her and also acc to
her partner there was no fall. Xray showed no fx. She had no
furhter pre-symcope. Her profuse diarrhea with volume depletion
was the cause of this prior to admission. Pt was discharged to
home in good condition with close outpt follow up. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
NEPHROLITHIASIS,6mm obstructing right proximal ureteral stone
Urinary tract infection (Klebsiella)
Major Surgical or Invasive Procedure:
Cystoscopy, with right retrograde pyelogram, right ureteral
stent placement 6 x 24 cm.
History of Present Illness:
___ w/ obesity s/p Roux en Y and Afib now with 6mm obstructing
right proximal ureteral stone and UTI.
Past Medical History:
Atrial Fib (paroxysmal
hypothyroidism
hyperlipidemia with elevated triglycerides
osteoarthritis of lower extremity joints
vitamin D deficiency
history of type 2 diabetes essentially resolved with WLS and her
most recent hemoglobin A1c of 6.1%
history of positive H. pylori
Morbid obesity
Her surgical history is significant for:
s/p Roux en Y Gastric Bypass
s/p Tubal Ligation
s/p laparoscopic adjustable gastric band ___
s/p removal of lap band ___
s/p laparoscopic cholecystectomy ___
s/p right knee repair ACL ligament ___
s/p C-section x 2 in ___ and ___
s/p carpal tunnel release ___
Social History:
___
Family History:
Family history is significant for father living with obesity.
Her mother is living with heart disease, hyperlipidemia, a
thyroid disorder and breast cancer; her brother is living with
heart disease; her sister is living with obesity; another sister
is deceased with AML.
Physical Exam:
WdWn, NAD, AVSS
Interactive, cooperative
Abdomen soft, non-tender
Extremities w/out edema or pitting and there is no reported calf
pain to deep palpation
Pertinent Results:
___ 06:14AM BLOOD WBC-9.1 RBC-3.89* Hgb-11.2 Hct-33.6*
MCV-86 MCH-28.8 MCHC-33.3 RDW-12.8 RDWSD-39.9 Plt ___
___ 11:45AM BLOOD WBC-10.6* RBC-4.45 Hgb-12.6 Hct-38.2
MCV-86 MCH-28.3 MCHC-33.0 RDW-12.8 RDWSD-39.6 Plt ___
___ 11:45AM BLOOD Neuts-71.6* Lymphs-18.6* Monos-7.1
Eos-1.9 Baso-0.4 Im ___ AbsNeut-7.57* AbsLymp-1.96
AbsMono-0.75 AbsEos-0.20 AbsBaso-0.04
___ 06:14AM BLOOD Glucose-72 UreaN-8 Creat-0.8 Na-137 K-4.0
Cl-104 HCO3-26 AnGap-11
___ 11:45AM BLOOD Glucose-92 UreaN-11 Creat-0.8 Na-138
K-4.5 Cl-101 HCO3-22 AnGap-20
___ 01:59PM BLOOD Lactate-1.3
___ 01:00PM BLOOD Lactate-1.8
___ 07:00PM URINE Color-Straw Appear-Clear Sp ___
___ 03:50PM URINE Color-Yellow Appear-Hazy Sp ___
___ 11:45AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 07:00PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
___ 03:50PM URINE Blood-MOD Nitrite-POS Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 11:45AM URINE Blood-MOD Nitrite-POS Protein-600
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 07:00PM URINE RBC-5* WBC-58* Bacteri-FEW Yeast-NONE
Epi-2
___ 03:50PM URINE RBC-78* WBC->182* Bacteri-FEW Yeast-NONE
Epi-11
___ 11:45AM URINE RBC-111* WBC->182* Bacteri-MANY
Yeast-NONE Epi-19
___ 11:53 am URINE 63075P.
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
Allergies: Sulfa
Meds: Metoprolol Tartrate, Levothyroxine, Sertraline
Discharge Medications:
1. Metoprolol Tartrate 12.5 mg PO BID
2. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin [Flomax] 0.4 mg ONE capsule(s) by mouth Daily
Disp #*30 Capsule Refills:*0
3. Sertraline 50 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*1
5. Levothyroxine Sodium 137 mcg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q6hrs Disp #*40 Tablet
Refills:*0
7. Phenazopyridine 100 mg PO TID:PRN bladder spasms Duration: 3
Days
RX *phenazopyridine 100 mg one tablet(s) by mouth Q8hrs Disp #*9
Tablet Refills:*0
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Oxybutynin 5 mg PO Q6H:PRN urgency/spasms
RX *oxybutynin chloride 5 mg one tablet(s) by mouth Q6hrs Disp
#*40 Tablet Refills:*0
10. Cipro (ciprofloxacin;<br>ciprofloxacin HCl) 500 mg/5 mL oral
BID Duration: 5 Days
RX *ciprofloxacin 500 mg/5 mL 5 mL by mouth twice a day Disp
___ Milliliter Refills:*0
11. WORK NOTE
Please excuse Ms. ___ from work ___ through
___.
Discharge Disposition:
Home
Discharge Diagnosis:
nephrolithiasis (right ureteral stone)
urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ with R flank pain // r/o nephrolithiasis, hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 13.2 cm. There is right-sided pelviectasis,
asymmetric from the left, without definite shadowing stone identified. The
left kidney measures 13.1 cm. No hydronephrosis is seen on the left. No
shadowing calculi are definitely identified. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Right-sided pelviectasis without definite shadowing stone identified.
Radiology Report
INDICATION: ___ with severe R flank pain setting of roux-en-Y ___ evaluate
for leak, obstruction, pyelonephritis.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: Total DLP (Body) = 940 mGy-cm.
COMPARISON: Reason renal ultrasound dated ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: A 6 mm obstructing stone in the proximal ureter has a measured
density of 418 Hounsfield units (02:40). There is associated mild
hydronephrosis similar to the recent ultrasound with extensive perinephric
stranding and a delayed nephrogram on the right. There is no evidence of
focal renal lesions or left hydronephrosis.
GASTROINTESTINAL: Patient is status post Roux-en-Y gastric bypass without
evidence of anastomotic complication. Small bowel loops demonstrate normal
caliber, wall thickness, and enhancement throughout. The colon and rectum are
within normal limits. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The right-sided corpus luteal cyst is noted. The
reproductive organs are otherwise 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. Circumaortic left renal vein is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
A 6 mm obstructing proximal right ureteral stone with upstream mild
hydronephrosis and perinephric stranding. .
Radiology Report
EXAMINATION: Retrograde ureterogram.
INDICATION: Ureterolithiasis and hydronephrosis.
TECHNIQUE: Retrograde ureterogram.
COMPARISON: CT abdomen/pelvis dated ___.
FINDINGS:
8 intraoperative images were acquired without a radiologist present.
Images show a wire projecting over the pelvis and traveling superiorly over
the expected location of the right ureter. Contrast is seen filling the lumen
of the right ureter. Final images show the proximal end of the double-J stent
coiled within the expected location of the right renal pelvis. There are no
images of the distal end of the double-J stent..
IMPRESSION:
Intraoperative images were obtained during cystoscopy, retrograde ureterogram,
and right ureteral stent placement. Please refer to the operative note for
details of the procedure.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Right sided abdominal pain, R Flank pain
Diagnosed with CALCULUS OF KIDNEY
temperature: 98.1
heartrate: 55.0
resprate: 18.0
o2sat: 100.0
sbp: 147.0
dbp: 95.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ was admitted to Dr. ___ service from
the ED on ___ for right ureteral calculus. She was
optimized with intravenous hydration, pain control and given
antibiotics and subsequently taken to the OR on ___ where
she underwent cystoscopy, right retrograde pyelogram with
intraoperative interpretation, right ureteroscopy, laser
lithotripsy, right ureteral stent change. She tolerated the
procedure well and recovered in the PACU before transfer to the
general surgical floor. See the dictated operative note for full
details. Overnight, the patient was hydrated with intravenous
fluids and received appropriate perioperative prophylactic
antibiotics. At discharge on POD1, Ms. ___ pain was
controlled with oral pain medications, she was tolerating a
regular diet, ambulating without assistance, and voiding without
difficulty. Ms. ___ was explicitly advised to follow up as
directed as the indwelling ureteral stent must be removed and or
exchanged and she was given a course of antibiotics to complete. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zofran (as hydrochloride)
Attending: ___.
Chief Complaint:
Epigastric Pain
Major Surgical or Invasive Procedure:
CVL Placement
History of Present Illness:
Ms. ___ is a ___ with discoid lupus, sickle cell, HTN, GERD,
and heavy alcohol abuse (pint per day) who presented to the
___ ED with progressively worsening ___ abdominal pain that
began the night PTA and nausea with non-bloody bilious vomiting.
Pain is worst in epigastrium and radiates to her chest. She last
vomited while in the ED. She has been drinking heavily over the
past few days (at least 1 pint/day). She has had 3 admissions
for epigastric pain in the past, most recently earlier this
___.
Endorses chills and intermittent CP/SOB associated with her
pain. Denies fevers, night sweats, hematemesis, diarrhea,
palpitations. She has had difficulty tolerating PO intake, last
attempt was the night PTA.
In the ED, initial vitals: 98.7 78 156/110 18 99% RA
She was given 3L NS, Dilaudid 1 mg IV x 2, Zofran 4 mg IV x 2,
Pantoprazole 40 mg IV, Thiamine 100 mg IV, and a Nicotine patch
21 mg.
RUQUS showed evidence of pancreatitis without peripancreatic
fluid or dilation of the peripancreatic duct. Fatty liver and no
gallstones.
Labs notable for WBC 8.9 with left shift, Hct 45.3, K 3.2, Gap
28, lipase 1174, ALT/AST 103/118, Alk phos 151, lactate 1.6, plt
113, STox neg, UTox neg, HCG neg, UA with urobilinogen 2 and
mild protein/ketones
She was admitted to the medicine floor w/tele on ___ for acute
pancreatitis and hypokalemia. She had intermittent episodes of
polymorphic V-tach concerning for Torsades in the setting of
chronic alcoholism and known hypomagnesia of 1.0 this afternoon.
She would have ___ second intervals of LOC but would flip back
into sinus rhythm w/o intervention. She was given 3g IV
Magnesium and was transferred to the MICU in stable condition.
On arrival to the MICU, vitals 80, 140/105, 16, 100% RA. AOx3 in
NAD.
Past Medical History:
Discoid lupus
Alcohol abuse
HTN
GERD
Social History:
___
Family History:
Father alive and well. Mother died in late ___, with history of
obesity, diabetes mellitus, and hypertension. Multiple siblings
with hypertension.
Physical Exam:
>> Admission Physical Exam:
Vitals- T: 97.4 BP: 140/105 P: 84 R: 16 O2: 100% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, ttp epigastrium, no guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CN grossly intact, moving all extremities
.
>> Discharge Physical Exam:
Vitals: T97.4, BP 130s/73-91, HR ___, RR 16, ___
General: Patient alert, interactive, no acute distress.
HEENT: MMM. Posteripr pharynx is clear.
Neck: Supple, no cervical lympha. R CVL in palce, no surrounding
erythema.
CV: RRR. S1, S2. No extra sounds haerd.
Lungs: CTAB/L. No adventitial sounds heard. Poor inspratory
effort.
Chest: Tender to palpation directly pinpiont at sternum.
Abdomen: soft, nT/ND. BS+ in all quadrants.
Extremities: No ___ edema bilaterally, pulses 2+
Pertinent Results:
>> Admission Labs:
___ 06:50AM WBC-8.9 RBC-4.67 HGB-15.0 HCT-45.3 MCV-97
MCH-32.1* MCHC-33.1 RDW-14.7
___ 06:50AM NEUTS-82.7* LYMPHS-10.5* MONOS-6.3 EOS-0.2
BASOS-0.2
___ 06:50AM ALBUMIN-5.2 CALCIUM-9.8 PHOSPHATE-2.6*
MAGNESIUM-1.2*
___ 06:50AM ASA-4.9 ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:50AM GLUCOSE-100 UREA N-6 CREAT-0.6 SODIUM-136
POTASSIUM-3.2* CHLORIDE-88* TOTAL CO2-23 ANION GAP-28*
.
>> Pertinent Imaging:
___ CXR: IMPRESSION: Right internal jugular line tip is at
the level of cavoatrial junction/proximal right atrium and might
be pulled back 2 cm to secure it position above the cavoatrial
junction. Heart size and mediastinum are stable. Lungs are
essentially clear. The only abnormality within the lung is
linear opacity in the right upper lobe most likely representing
atelectasis. No appreciable pleural effusion or pneumothorax
demonstrated
___ RUQ US:
LIVER: The liver is diffusely echogenic. 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 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: The imaged portion of the pancreas appears hypoechoic
and
heterogeneous with indistinct borders, compatible with known
pancreatitis. The body and tail are obscured by overlying bowel
gas. There is no peripancreatic fluid collection. The main
pancreatic duct is not dilated.
SPLEEN: Normal echogenicity, measuring 9.6 cm.
KIDNEYS: The right kidney measures 12 cm. The left kidney
measures 11.1 cm. Normal cortical echogenicity and
corticomedullary differentiation is seen bilaterally. There is
no evidence of masses, stones or hydronephrosis in the kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within
normal
limits.
.
IMPRESSION: 1. Heterogeneous pancreas compatible with the
provided diagnosis of pancreatitis. No peripancreatic fluid
collection or dilation of the main pancreatic duct. 2. Fatty
liver. More advanced forms of liver disease, including
cirrhosis, cannot be excluded by this study. 3. No gallstones or
biliary dilatation.
.
>> Discharge Labs:
___ 06:04AM BLOOD WBC-6.9 RBC-3.34* Hgb-10.5* Hct-32.3*
MCV-97 MCH-31.4 MCHC-32.4 RDW-14.0 Plt ___
___ 06:04AM BLOOD Glucose-115* UreaN-6 Creat-0.4 Na-133
K-4.2 Cl-95* HCO3-26 AnGap-16
___ 06:04AM BLOOD Calcium-9.8 Phos-5.4* Mg-1.4*
___ 12:16PM URINE Hours-RANDOM Creat-123 Na-94 K-59 Cl-90
Mg-76.6
Medications on Admission:
The Preadmission Medication list is accurate and complete. Med
list is as of ___ per Dr. ___. Per patient, not
taking any of these.
1. Amlodipine 5 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Famotidine 20 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Multivitamins 1 TAB PO DAILY
3. Thiamine 100 mg PO DAILY
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice daily Disp #*3 Tablet Refills:*0
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Amlodipine 5 mg PO DAILY
7. Famotidine 20 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Magnesium Oxide 800 mg PO DAILY
RX *magnesium oxide 420 mg 2 tablet(s) by mouth daily Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Acute Pancreatitis ___ to Alcohol
2. SIADH
3. Polymorphic Ventricular Tachycardia
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: Pancreatitis. Evaluate for gallstone pancreatitis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis ___ P
FINDINGS:
LIVER: The liver is diffusely echogenic. 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 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears hypoechoic and
heterogeneous with indistinct borders, compatible with known pancreatitis.
The body and tail are obscured by overlying bowel gas. There is no
peripancreatic fluid collection. The main pancreatic duct is not dilated.
SPLEEN: Normal echogenicity, measuring 9.6 cm.
KIDNEYS: The right kidney measures 12 cm. The left kidney measures 11.1 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones or hydronephrosis in the
kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Heterogeneous pancreas compatible with the provided diagnosis of
pancreatitis. No peripancreatic fluid collection or dilation of the main
pancreatic duct.
2. Fatty liver. More advanced forms of liver disease, including cirrhosis,
cannot be excluded by this study.
3. No gallstones or biliary dilatation.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with hypomag w/ torsades, s/p CVL // eval for
line placement Contact name: ___: ___
TECHNIQUE: CHEST PORT. LINE PLACEMENT
COMPARISON: None
IMPRESSION:
Right internal jugular line tip is at the level of cavoatrial
junction/proximal right atrium and might be pulled back 2 cm to secure it
position above the cavoatrial junction. Heart size and mediastinum are stable.
Lungs are essentially clear. The only abnormality within the lung is linear
opacity in the right upper lobe most likely representing atelectasis. No
appreciable pleural effusion or pneumothorax demonstrated
Radiology Report
INDICATION: ___ year old woman with new central line. xray for placement
TECHNIQUE: Frontal chest radiographs were obtained with the patient in the
upright position.
COMPARISON: Radiograph from ___.
FINDINGS:
There is a right internal jugular central venous line which terminates within
the mid SVC. No pneumothorax is seen. Lungs are clear without focal
consolidation, pleural effusion or frank pulmonary edema. Right upper lobe
linear atelectasis is noted, and the heart size is normal.
IMPRESSION:
Placement of right central venous line without pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with cough, sputum production, and
leukocytosis. // Eval for pneumonia.
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Increasing opacities in the right base could represent atelectasis but
superimposed infection cannot be excluded. There are low lung volumes. Cardiac
size is normal. There is no pneumothorax or effusion. Right IJ catheter tip is
in the cavoatrial junction
Gender: F
Race: BLACK/AFRICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, n/v/d
Diagnosed with ACUTE PANCREATITIS
temperature: 98.7
heartrate: 78.0
resprate: 18.0
o2sat: 99.0
sbp: 156.0
dbp: 110.0
level of pain: "200"
level of acuity: 3.0 | Ms. ___ is a ___ with discoid lupus, HTN, and heavy alcohol
abuse (1 pint per day) who presented to the ___ ED with
progressively worsening ___ abdominal pain that began the
night PTA and non-bloody N/V. Elevated lipase and RUQUS findings
consistent with pancreatitis. She was admitted to medicine floor
on ___ for acute pancreatitis and hypokalemia. On medicine
floor, she had intermittent episodes of polymorphic V-tach
concerning for Torsades in the setting of chronic alcoholism and
known hypomagnesia of 1.0, and was subsequently transferred to
the MICU where she was stabilized and transferred back to the
medical floor.
.
>> ACTIVE ISSUES:
# Pancreatitis: Patient had history, exam, and lab/imaging
findings consistent with pancreatitis: alcohol abuse with
epigastric abdominal pain, bilious non-bloody vomiting, elevated
lipase, US imaging e/o pancreatitis with no peripancreatic
fluid. Other potential causes include cholecystitis, but US did
not show e/o inflamed gallbladder and no stones were seen. Not
peritonitic given non-rigid abdomen and stable vitals. Her BISAP
score was 0, ___ score 0, so <5% risk for mortality. She
has had 2 prior admissions for pancreatitis before ___ heavy
alcohol abuse. No role for ERCP given stable, without sepsis,
with normal Tbili. No role for prophylactic abx at this time.
Given Torsades below; used lorazepam for nausea instead of
ondansetron. Due to electrolyte abnormalities, IVF were held.
She did not complain of epigastric pain during her MICU stay.
Upon rest of hospital stay, patient was tolerating PO intake
well without nausea/vomiting. She was counseled on alcohol
cessation.
.
#Torsades/Polymorphic VT: Patient had recurrent episodes of
torsades which resolved with aggresive electrolyte repletion;
over course of first night in ICU patient had 2X episodes of
intermittent loss of pulse for seconds in context of torsades
episodes which resolved spontaneously with ~ 10 sec of chest
compressions. Hypomagnesia was noted likely ___ chronic
alcoholism and malnutrition. Hyponatremia likely ___ to volume
depletion in setting of pancreatitis. Patient had R IJ central
line placed in MICU for access without complications. On night
of ___, patient had recurrent episodes of NSVT with increasing
frequency, with episodes resmbling torsades; patient was
interactive during these episodes and reported palpitations.
Patient was given 1 mg atropine which pushed her HR to 120's but
stopped episodes of torsades. She was evaluated by EP who were
concerned that she has a congenital prolonged QT syndrome -
genetic testing was performed and results are pending.
#Hyponatremia
#Hypomagnesemia
Hypomagnesemia thought to be due to alcohol use as above. The
patient was also found to have hyponatremia. She was evaluated
by nephrology and on ___ the patient was fluid restricted and
started on hypertonic saline for hyponatremia likely ___ SIADH
in the setting of urine lytes significant for high urine osm and
high sodium ___ pancreatitis vs pain per nephrology
recommendation. Her sodium responded appropriately to strict
fluid restriction of 1L total intake/day. Upon transfer to
medical floor, patient continued to have fluid restriction, with
mild improvement in her sodium level.Patient also continued to
require IV magnesium replacement, which was persistently low
despite repletion. Potassium levels were normal during end of
hospital stay. Although it was discussed with patient that she
would beneift from further inpatient stay, as daily intravenous
correction of electrolyte abnormalities were needed, patient
insisted upon leaving. To facilitate discharge, patient was
placed on a magnesium supplement as outpatient, and was
instructed to continue a 1L fluid restriction. Post-hospital
discharge plans for laboratory monitoring as outpatient after
discharge, at which point full set of electrolytes can be
checked. Risks of electolyte abnroamliteis and cardiac
complications, including fatal arrhtyhmias was discussed with
the patient, and she agreed for discharge with close follow-up.
.
#Pneumonia: A CXR on ___ was concerning for increasing
opacities in the right base in the setting of increasing
productive cough. Pan cultures were sent; sputum culture (+)
gram (+) cocci. She was empirically started on vanc/cefepime on
___. On ___ the sputum was specific for strep pneumo. On
___ the cefepime was discontinued and she was transitioned to
Augmentin, for course to end on ___. Patient noted
improvement in cough like symptoms and sputum production during
hospital stay.
.
# Alcohol abuse: Patient has an extensive history of alcohol
abuse, reporting that she drinks approx 1 pint of liquor/day.
There was concern that she was withdrawing in the setting of
worsening tachycardia after resolution of her Torsades. She was
started on the phenobarbital protocol on ___ and continued
through ___. Given heavy alcohol use, patient was seen by
social work consult, however deferred to additional help or
services at this time. Completed protocol and no further signs
of withdrawal ___ hospital stay.
.
>> CHRONIC ISSUES:
# Hypertension: Held home amlodipine in house; BP's stable.
# GERD: Patient was restarted on PPI and H2 blocker
# Anemia: Patient was continued on home ferrous sulfate upon
discharge.
# Discoid lupus : Not on any medications/steroids at home.
Stable in hospital.
.
>> TRANSITIONAL ISSUES:
# Electroltyes: Patient required continous IV replacement during
hospital stay. Discharged on supplement, will need recheck of
all electrolytes at ___ clinic, including Mg, Phosph,
Na, K.
# SIADH: Close monitoring of her sodium as outpatient. Will have
renal follow-up, and is to maintain fluid restriction of 1L at
home as well. Continue high protein diet, with Ensure as part of
fluid restriction.
# Prolonged QTc/Torsades: Patient is to have followup with
cardiology as outpatient in ___ months for genetics evaluation
with Dr. ___.
# Aspiration Pneumonia: Patient to finish course of Augmentin on
___.
# Substance Abuse: Social work offerred services for alcohol
abuse, however patient deferred at this time. Continue to
encouarge as outpatient.
# Anemia: Most likely in the setting of alcohol abuse, further
work up as outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Benadryl Decongestant / Fish Product Derivatives / Penicillins /
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ w/ Hx of EtOH abuse (prior withdrawal,
DTs), Hx of pancreatitis, GERD, depression, polysubstance abuse,
and other issues who presents w/ epigastric pain similar to
prior episodes of pancreatitis. The pain started yesterday. She
reports drinking about her usual 1 pint alcohol/day. Also of
note, she used crack 2 days ago and reports not having eaten in
2 days. She has had NBNB emesis several times over past day,
also with loose stools, no hematochezia/melena. No
fevers/chills. Pt also complained of a dry cough.
On arrival to the ED, initial vitals were 97.6 103 127/89 18 96%
___. Notable labs included Lipase 199, ALT/AST 52/92, Tbili 0.1,
Albumin 4.8, BUN/Cr ___, AP 83, WBC wnl, Chem panel WNL. CXR
without effusions or pneumonia. The patient was made NPO and
received 2L NS, Zofran, and Morphine. She was also placed on
CIWA and scoring in the low ___, so she receievd 1 mg IV
Lorazepam x2.
On transfer to the floor, VS were 98.1 95 170/92 18 99% ___. The
patient complained of abdominal pain but overall felt better
than on arrival and was tolerating PO.
Past Medical History:
1. EtOH abuse w/ multiple admissions for pancreatitis,
intoxication, and detox; has had withdrawal c/b delerium tremens
in the past
2. Moderate persistent asthma, previously used albuterol inhaler
___ per week but has not refilled her Rx in over a year.
3. GERD
4. Depression - has not filled meds in over a year
5. Tobacco abuse
6. Crack cocaine dependence
7. s/p c-section x2
Social History:
___
Family History:
Denies FHx of liver/gallbladder/pancreatic Dz, No FHx of asthma,
CAD, depression
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS - 98.1 95 170/92 18 99% ___: NAD, comfortable appearing, lying in bed, not
tremulous, diaphoretic, or agitated
HEENT: MMM, OP clear, poor dentition
Neck: Supple, no LAD
CV: RRR, S1 S2 auscultated, no m/g/r
Lungs: CTA, moderate air movement, no crackles or wheeze
Abdomen: Soft, mildly distended, +BS, mild TTP in epigastrium,
no suprapubic tenderness
GU: Deferred
Ext: No ___ edema
Neuro: CN II-XI intact, sensation to light touch intact in bilat
LEs, gait not assessed
DISCHARGE PHYSICAL EXAM:
========================
VS - 98.4 80 159/98 16 100% ___: NAD, comfortable appearing, lying in bed, not
tremulous, diaphoretic, or agitated
HEENT: MMM, OP clear, poor dentition
Neck: Supple, no LAD
CV: RRR, S1 S2 auscultated, no m/g/r
Lungs: CTA, moderate air movement, no crackles or wheeze
Abdomen: Soft, mildly distended, +BS, mild TTP in epigastrium,
no suprapubic tenderness
GU: Deferred
Ext: No ___ edema
Neuro: CN II-XI intact, sensation to light touch intact in bilat
LEs, gait not assessed
Skin: No rash
Pertinent Results:
ADMISSION LABS:
===============
___ 10:00PM BLOOD WBC-5.1 RBC-3.36* Hgb-8.7* Hct-28.5*
MCV-85 MCH-26.0* MCHC-30.6* RDW-19.6* Plt ___
___ 10:00PM BLOOD Neuts-62 Bands-0 ___ Monos-11 Eos-4
Baso-0 ___ Metas-1* Myelos-0
___ 10:00PM BLOOD Glucose-98 UreaN-13 Creat-0.9 Na-146*
K-3.8 Cl-105 HCO3-28 AnGap-17
___ 10:00PM BLOOD ALT-52* AST-92* AlkPhos-83 TotBili-0.1
___ 10:00PM BLOOD Lipase-199*
___ 10:00PM BLOOD Albumin-4.8
PERTINENT LABS:
===============
___ 10:00PM BLOOD WBC-5.1 RBC-3.36* Hgb-8.7* Hct-28.5*
MCV-85 MCH-26.0* MCHC-30.6* RDW-19.6* Plt ___
___ 07:00AM BLOOD ___ PTT-32.6 ___
___ 10:00PM BLOOD Glucose-98 UreaN-13 Creat-0.9 Na-146*
K-3.8 Cl-105 HCO3-28 AnGap-17
___ 10:00PM BLOOD ALT-52* AST-92* AlkPhos-83 TotBili-0.1
___ 10:00PM BLOOD Lipase-199*
___ 10:00PM BLOOD Albumin-4.8
___ 06:10PM BLOOD Calcium-7.9* Phos-1.9* Mg-0.9*
PERTINENT IMAGING:
==================
CXR ___:
IMPRESSION:
1. No acute cardiac or pulmonary findings. Right mid and lower
lung
subsegmental atelectasis, not significantly changed.
2. Unchanged mild cardiomegaly
PERTINENT MICRO:
================
___ 8:25 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
DISCHARGE LABS:
===============
___ 07:10AM BLOOD WBC-4.5 RBC-3.90* Hgb-10.2* Hct-32.8*
MCV-84 MCH-26.1* MCHC-31.0 RDW-18.6* Plt ___
___ 07:10AM BLOOD Glucose-97 UreaN-10 Creat-0.6 Na-135
K-4.2 Cl-97 HCO3-29 AnGap-13
___ 07:10AM BLOOD ALT-63* AST-123* AlkPhos-87 TotBili-0.2
___ 07:10AM BLOOD Calcium-10.6* Phos-4.7* Mg-1.2*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Mirtazapine 15 mg PO HS
3. TraZODone 100-200 mg PO HS:PRN insomnia
4. Vitamin B Complex 1 CAP PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. Citalopram 20 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Mirtazapine 15 mg PO HS
5. TraZODone 100-200 mg PO HS:PRN insomnia
6. Multivitamins 1 TAB PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
8. Magnesium Oxide 400 mg PO BID
Take with food, discontinue if your diarrhea gets worse
RX *magnesium oxide 400 mg 1 capsule(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Recurrent EtOH Pancreatitis
Secondary: Chronic EtOH abuse, crack cocaine use, heroin use,
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ETOH abuse and pancreatitis, presenting with cough. Evaluate for
pneumonia.
COMPARISON: Chest radiograph from ___.
FINDINGS: Heterogeneous right lower lung opacities are not significantly
changed compared to the prior study from ___, likely subsegmental
atelectasis. There is also an area of atelectasis in the right mid lung, not
significantly changed. The left lung is clear. Mild cardiomegaly is
unchanged. The mediastinal contours are normal. There are no pleural
effusions. No pneumothorax is seen. Healing right-sided rib fractures are
noted. Deformity of the manubrium is redemonstrated.
IMPRESSION:
1. No acute cardiac or pulmonary findings. Right mid and lower lung
subsegmental atelectasis, not significantly changed.
2. Unchanged mild cardiomegaly.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with ACUTE PANCREATITIS
temperature: 97.6
heartrate: 103.0
resprate: 18.0
o2sat: 96.0
sbp: 127.0
dbp: 89.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ w/ Hx of EtOH abuse (prior admissions for
withdrawal, DTs), Hx of EtOH pancreatitis, GERD, depression,
polysubstance abuse, and other issues who presented w/ recurrent
EtOH pancreatitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ambien
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
FROM ADMISSION NOTE
___ is a ___ year old man with h/o PA sarcoma s/p L
lung resection and RUL wedge resection (no evidence of
recurrence), intraparenchymal hemorrhage from radiation necrosis
in ___, recurrent PE on anticoagulation, right heart failure,
and pulmonary hypertension who presented to the ED with
progressive dyspnea and weight gain. He was stable on
alternating
20mg/10mg daily until about 3 weeks ago when he started the new
medication. Due to decreased appetite, dyspnea, worsening edema
he was increased to 40 mg daily of furosemide by Dr. ___. Today
he was increased to furosemide 80 mg BID given that he has
gained
3 lb in the last couple of days. He has not had any fevers,
chills, or felt systemically ill. He is now short of breath
while
sitting and severely dyspnea with only a few steps. Of note, he
also has a history of pulmonary embolisms even while on
anticoagulation.
In the ED, initial VS were: T 98.0 HR 102 BP 117/81 RR 22 99% RA
Exam notable for:
POCUS with RV:LV ratio nearly 2:1
TAPSE 0.7cm
Diastology c/f pseudonormal to restrictive
Worsening ___ edema, abdominal distention
ECG: NSR 97, RVH with TWI V2-V5.
Labs showed:
136 | 95 | 15
6.9 > 15.0 < 150 ---------------< 114
4.1 | 20 | 1.1
Lactate 2.0 VBG pH 7.47 / pCO2 33 / pO2 39
Chest ___
Cardiology was consulted. Thought his bedside echo looked worse
compared to ___, RV larger though the RV dilatation is not
new.
Patient received:
___ 23:35 IV Furosemide 60 mg
___ 23:35 SC Enoxaparin Sodium 60 mg
Transfer VS were: T 98.6 HR 98 BP 113/78 RR 30 O2 98% RA
On arrival to the floor, patient reports that he feels better
after receiving an albuterol neb. He thinks that he urinated
more
to the 80 mg dose of furosemide that he started today. Confirms
that his leg swelling and decreased appetite all started when he
started taking Optima. He confirms that he is DNR/DNI, but ok
for
bipap.
Past Medical History:
FROM ADMISSION NOTE
Pulmonary artery intimal sarcoma, high grade
- Diagnosed ___ with biopsy from the left pulmonary artery
- L pneumonectomy ___
- Adjuvant radiation therapy
- R craniotomy ___ for brain metastasis
- Completed 4 cycles of temozolomide
- RUL wedge resection to remove 3.8 cm met
- He was noted to have a chronic thrombus in the R-sided
pulmonary arteries in ___ rivaroxaban was initiated.
- In ___ he had a cerebral bleed from the rivaroxaban
without any deficits; he was also on a baby aspirin at this time
and Adempas (PH medication). MRI revealed enhancement w/ concern
for tumor recurrence. Resection was performed and revealed
necrotic tissue from radiation treatment. For further
anticoagulation, he was started on enoxaparin 40 mg BID in late
___ to prevent further PEs. In ___, he had worsening
dyspnea and CT chest w/ contrast showed new PE as well as
findings c/f recurrence of his sarcoma. Because of this, his
enoxaparin was increased to 60 mg BID and benefit felt to
outweigh risk of CNS bleeding.
Social History:
___
Family History:
FROM ADMISSION NOTE
Father died age ___ of breast cancer, paternal grandmother died
of
ovarian cancer. Brother has prostate cancer. Both the patient
and
his daughter have been tested for BRCA mutations and are
negative.
Physical Exam:
ADMISSION PHYSICAL EXAM
=====================
VS: T 98.3 BP 102/70 HR 101 RR 20 O2 97% 3L NC
I/O (since receiving IV furosemide in the ED): ___
GENERAL: Anxious, dyspneic while speaking
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, JVD to mid-neck at 90 degrees
HEART: Tachycardia, regular rhythm, S1/S2, ___ systolic murmur
loudest at the LUSB.
LUNGS: Right lung CTAB. Absent L lung sounds. Tachypneic.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: no cyanosis, clubbing. Warm and well perfused. 2+
pitting edema bilaterally to the knees.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: Ecchymoses at sites of enoxaparin injections on the
abdomen.
DISCHARGE PHYSICAL EXAM
======================
VITALS: T 97.3, HR 100, BP 93/61, RR 20, O2 98% RA
GENERAL: NAD, lying flat
HEENT: anicteric sclerae, oropharynx clear, MMM
NECK: supple, prominent EJ, dynamic JVP improved to ___orderline tachycardic, S1/split S2, IV/VI systolic murmur
loudest at the LUSB
PULM: conversational dyspnea improved, absent left lung sounds,
right lung clear
ABD: soft, normoactive, non-distended, non-tender
EXT: warm, well perfused, lower extremity edema resolved
NEURO: non-focal
Pertinent Results:
ADMISSION LABS
=============
___ 10:30PM BLOOD WBC-6.9 RBC-5.10 Hgb-15.0 Hct-44.8 MCV-88
MCH-29.4 MCHC-33.5 RDW-16.5* RDWSD-52.0* Plt ___
___ 10:30PM BLOOD Neuts-81.8* Lymphs-8.2* Monos-9.0
Eos-0.4* Baso-0.3 Im ___ AbsNeut-5.62 AbsLymp-0.56*
AbsMono-0.62 AbsEos-0.03* AbsBaso-0.02
___ 10:30PM BLOOD ___ PTT-35.5 ___
___ 01:50PM BLOOD LMWH-0.61
___ 10:30PM BLOOD Glucose-114* UreaN-15 Creat-1.1 Na-136
K-4.1 Cl-95* HCO3-20* AnGap-21*
___ 06:50AM BLOOD ALT-16 AST-22 AlkPhos-127 TotBili-1.3
___ 10:30PM BLOOD proBNP-4961*
___ 10:30PM BLOOD cTropnT-0.02*
___ 06:50AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.8
___ 10:41PM BLOOD ___ pO2-39* pCO2-33* pH-7.47*
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
___ 10:41PM BLOOD Lactate-2.0
DISCHARGE LABS
=============
___ 09:06AM BLOOD WBC-6.6 RBC-4.95 Hgb-14.6 Hct-43.7 MCV-88
MCH-29.5 MCHC-33.4 RDW-15.9* RDWSD-50.8* Plt ___
___ 09:06AM BLOOD Glucose-120* UreaN-20 Creat-1.2 Na-136
K-3.8 Cl-96 HCO3-25 AnGap-15
___ 09:06AM BLOOD CK-MB-3 cTropnT-0.02*
STUDIES
=======
CXR (___)
IMPRESSION:
1. New right lower lung zone opacities concerning for multifocal
pneumonia.
2. Stable left pneumonectomy changes.
TTE (___):
CONCLUSION:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is >15mmHg. There is normal left ventricular
wall thickness with a small cavity. There is normal regional
left ventricular systolic function. Global left ventricular
systolic function is normal. The visually estimated left
ventricular ejection fraction is >=55%. There is no resting left
ventricular
outflow tract gradient. SEVERELY dilated right ventricular
cavity with moderate global free wall hypokinesis. Intrinsic
right ventricular systolic function is likely lower due to the
severity of tricuspid regurgitation. There is abnormal
interventricular septal motion c/w right ventricular pressure
and volume overload. The aortic sinus diameter is normal for
gender with normal ascending aorta diameter for gender. The
aortic arch diameter is
normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. There is mild [1+] aortic
regurgitation. The mitral leaflets are mildly thickened with no
mitral valve prolapse. There is trivial mitral regurgitation.
The tricuspid valve leaflets appear structurally normal with
leaflets that fail to fully coapt.
There is severe [4+] tricuspid regurgitation. There is SEVERE
pulmonary artery systolic hypertension. In the setting of at
least moderate to severe tricuspid regurgitation, the pulmonary
artery systolic pressure may be UNDERestimated. There is no
pericardial effusion.
IMPRESSION: Adequate image quality. Severe right ventricular
cavity dilation with moderate global systolic dysfunction.
Normal left ventricular wall thickness with unusually small
cavity size and normal global systolic function. Severe
tricuspid regurgitation. Mild aortic regurgitation. Severe
pulmonary artery systolic hypertension.
Compared with the prior TTE (images reviewed) of ___ ,
the right ventricle is more dilated and the degree of tricuspid
regurgitation and pulmonary systolic pressure have increased.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 500 mg PO BID
2. Benzonatate 100 mg PO TID
3. Guaicon DMS (dextromethorphan-guaifenesin) 600 mg-30 mg oral
BID:PRN
4. Enoxaparin Sodium 60 mg SC Q12H
5. Pravastatin 20 mg PO QPM
6. Furosemide 80 mg PO BID
7. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous
gluconat;<br>multivitamin-iron-folic acid) 3,500-18-0.4
unit-mg-mg oral DAILY
8. rOPINIRole 0.75 mg PO TID
9. albuterol sulfate 90 mcg/actuation inhalation ___ puffs every
___ hours
10. TraZODone 25 mg PO QHS:PRN insomnia
11. macitentan 10 mg oral DAILY
12. Vitamin D ___ UNIT PO DAILY
13. budesonide-formoterol 160-4.5 mcg/actuation inhalation 2
buffs BID
14. Sildenafil 20 mg PO TID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides 8.6 mg 1 tablet by mouth twice daily Disp #*45
Tablet Refills:*0
4. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth daily Disp #*45 Tablet
Refills:*1
5. albuterol sulfate 90 mcg/actuation inhalation ___ puffs
every ___ hours
6. Benzonatate 100 mg PO TID
7. budesonide-formoterol 160-4.5 mcg/actuation inhalation 2
buffs BID
8. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous
gluconat;<br>multivitamin-iron-folic acid) 3,500-18-0.4
unit-mg-mg oral DAILY
9. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
10. Guaicon DMS (dextromethorphan-guaifenesin) 600 mg-30 mg
oral BID:PRN
11. LevETIRAcetam 500 mg PO BID
12. macitentan 10 mg oral DAILY
13. Pravastatin 20 mg PO QPM
14. rOPINIRole 0.75 mg PO TID
15. Sildenafil 20 mg PO TID
16. TraZODone 25 mg PO QHS:PRN insomnia
17. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Acute on chronic right heart failure
SECONDARY:
-Pulmonary hypertension
-Recurrent pulmonary embolism
-Metastatic pulmonary angiosarcoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with RV failure and progressive SOB// eeffusion?
edema?
COMPARISON: Chest CT ___
Chest radiograph ___
FINDINGS:
Portable upright AP view of the chest provided.
Status post left pneumonectomy with complete opacification of the left
hemithorax similar prior. Multiple left-sided surgical clips are again noted.
New subtle rounded opacities in the right lower lung zones are concerning for
pneumonia. No right-sided pleural effusion or pneumothorax. Mediastinal
structures are shifted towards the left and poorly evaluated.
IMPRESSION:
1. New right lower lung zone opacities concerning for multifocal pneumonia.
2. Stable left pneumonectomy changes.
Radiology Report
INDICATION: ___ male with history of PA intimal sarcoma s/p left
pneumonectomy and RUL wedge resection, pulmonary hypertension, CTEPH admitted
for acute on chronic RV failure.// Evaluate for interval evolution of
multi-focal opacities on prior CXR.
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs, most recent dated ___.
Chest CT ___.
FINDINGS:
There is complete opacification of the left lung with leftward deviation of
the trachea consistent with pneumonectomy with postsurgical changes. The
right lung is well aerated. Right lower and upper lung opacities have
increased. Scattered subsegmental atelectasis is persistent. No right
pleural effusion. No evidence of pneumothorax.
IMPRESSION:
Interval worsening of right upper and right lower lobe opacities which may
represent pneumonia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified
temperature: 98.0
heartrate: 102.0
resprate: 22.0
o2sat: 99.0
sbp: 117.0
dbp: 81.0
level of pain: 0
level of acuity: 2.0 | ___ male with a history of high-grade pulmonary artery
intimal sarcoma s/p left pneumonectomy and RUL wedge resection
metastatic to brain s/p craniotomy/chemoradiation, pulmonary
arterial hypertension on sildenafil and macitentan, recurrent
PE/CTEPH on Lovenox, ensuing chronic right heart failure who
presents with subacute, progressive dyspnea with
echocardiographic evidence of worsening RV dilatation and
pulmonary arterial hypertension. Symptoms much improved after
volume optimization.
ACTIVE ISSUES
#) Recurrent PE/CTEPH
#) Pulmonary arterial hypertension
#) Acute on chronic right heart failure
Patient presented with subacute, progressive exertional dyspnea,
conversational dyspnea, and lower extremity edema. Never with
features of cardiogenic or obstructive shock. TTE revealed RV
diameter 5.2 -> 6.2 cm (i.e., severe dilitation) with moderate
RV free wall hypokinesis, PASP 84 -> 112 mmHg, TR 2+ -> 4+, as
well as incompressible IVC all suggestive of volume overload.
Symptoms seemingly parallel initiation of endothelin antagonist,
which could have precipitated fluid retention. Probable
component of progressive intrinsic pulmonary arterial
hypertension too. Per radiation oncology, last PET not
compelling for disease recurrence, though overall equivocal. New
pulmonary embolism conceivable deemed unlikely on therapeutic
anticoagulation. His hematologist, Dr. ___ anti-Xa
assay was indeed acceptable at 0.61. His symptoms rapidly
improved with gentle IV diuresis (i.e., Lasix 40-60 mg), which
was then tapered to torsemide alternating ___ mg daily to
maintain euvolemia. His weight at discharge is 54.5 kg. His
macitentan 10 mg daily was resumed on ___ in consultation with
his pulmonologist, Dr. ___. Home sildenafil 20 mg TID was
continued. Baseline systolic blood pressure in 90-range to low
100-range would not tolerate dose escalation. Home
bronchodilators were likewise continued. Patient declined speech
and swallow evaluation for possible aspiration events.
Of note, on day prior to discharge, patient triggered for
asymptomatic hypotension in the 70-range, which spontaneously
resolved. ECG demonstrated new TWI in V1-V4, though cardiac
enzymes were undetectable. Torsemide was amended to alternating
___ mg daily. Unlikely to tolerate maintenance diuretic at
higher dose or other antihypertensive. Remained normotensive
thereafter.
#) Goals of care: while advanced directives are clear, other
terminal care preferences remain to be clarified. Patient and
family are realistic and understand his prognosis is guarded.
Previously declined palliative care, but now amenable to
introduction and probable transition to outpatient palliative
care.
CHRONIC/STABLE ISSUES
#) Metastatic PA intimal sarcoma: s/p left pneumonectomy and RUL
wedge resection (___). Metastatic brain lesion s/p
craniotomy/chemoradiation c/b intracranial hemorrhage. Local
recurrence improbable, as above. Home Keppra 500 mg BID
continued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / bacitracin / vancomycin
Attending: ___.
Chief Complaint:
Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with SCD (not on hydroxyurea) who presents
with extreme back pain requiring ICU admission for SVT to 160s
and Ketamine gtt and found to have acute chest syndrome during
his inpatient stay.
He reported to the ED that he began to experience lower back
pain one day prior to admission. It then spread to multiple
joints, most prominently his knees. Of note, on arrival to ___,
he only reported having had pain in back. Pain was ___. He
takes dilaudid 4mg 10x/day at home for his pain, and per review
of outpatient records, this has not been providing him with
adequate pain relief. He denies any shortness of breath, chest
pain, or fevers. He has had chronic lower extremity ulcers and
was seen by dermatology ___ who prescribed dicloxacillin 500mg
q6h x7 days for infection.
Of note, he has had inconsistent follow-up with hematology and
is not on hydroxyurea as an outpatient due to concerns regarding
side effects, and per chart review, believes his brother (who
had received a BM transplant) may have died from a hydroxyurea
complication. He is prescribed deferasirox for iron overload
from numerous transfusions. Per chart review, he has also been
having housing difficulties recently, and it appears he may be
inconsistently filling his medications.
In ED initial VS: 97.1, 88, 142/77, 24, 93% RA, had reported
runs of SVT to 170
Labs significant for: WBC 30.5, Hgb 5.9, Plt 201, Trp <0.01, Cr
0.8, LDH 1496, TB 4.8, Lactate 1.3
He received: 5mg IV dilaudid, 30mg ketorolac, 1L LR, 500mg
azithromycin, and was started on a ketamine gtt.
He was started on O2 for a pulse ox reading of 84 on room air
and admitted to the MICU with concern for acute chest syndrome.
Imaging notable for:
- CXR: No acute intrathroacic process. Stable moderate
cardiomegaly
Consults: None
VS prior to transfer: 98.2, 88, 127/71, 16, 99% 5L NC
On arrival to the MICU, he was in visible pain and unable to
provide much history. He denied any chest pain and endorsed low
and mid back pain.
Past Medical History:
- Sickle Cell disease (Hgb SS), c/b priapism - followed at ___
- History of NSTEMI, ___
- Iron overload, on deferasirox
- History of multiple pneumonias, with history of ICU stays,
though no intubations
- History of childhood asthma
- Vitamin D deficiency
Social History:
___
Family History:
Brother - died at age ___ from complications of BM transplant.
Father - sickle cell trait.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VITALS: Reviewed in metavision
GENERAL: Alert, appears in pain, answers questions with one word
answers
HEENT: Sclera anicteric
NECK: supple
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, ___ systolic murmur
at base
ABD: Soft, nt, nd
EXT: Warm, well perfused, no clubbing, cyanosis or edema.
SKIN: RLE ulcer wrapped in clean, dry bandage
NEURO: Alert
DISCHARGE PHYSICAL EXAM
=======================
VITALS: Temp: 98.7 PO BP: 152/77 HR: 63 RR: 18 O2 sat: 98% O2
delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: Alert, lying in bed, talkative.
HEENT: Sclera anicteric.
NECK: Supple, no JVD.
CHEST: No TTP to anterolateral chest wall.
CV: Regular rate and rhythm, normal S1 S2, ___ systolic murmur
at
apex, without appreciable radiation.
PULM: Decreased breath sounds at bases, no crackles noted.
ABD: Soft, non tender, non distended, normoactive bowel sounds.
EXT: Warm and well perfused; no clubbing, cyanosis or edema.
SKIN: RLE ulcer wrapped in bandage, CDI.
NEURO: Alert, oriented, no gross focal deficits.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:50AM BLOOD WBC-30.5* RBC-1.82* Hgb-5.9* Hct-16.7*
MCV-92 MCH-32.4* MCHC-35.3 RDW-27.2* RDWSD-82.1* Plt ___
___ 01:50AM BLOOD Neuts-75.9* Lymphs-13.8* Monos-6.1
Eos-0.2* Baso-0.5 NRBC-7.3* Im ___ AbsNeut-23.16*
AbsLymp-4.19* AbsMono-1.86* AbsEos-0.05 AbsBaso-0.14*
___ 01:50AM BLOOD Hypochr-NORMAL Anisocy-3+* Poiklo-3+*
Macrocy-1+* Microcy-1+* Polychr-2+* Ovalocy-1+* Target-1+*
Sickle-3+* Schisto-1+* How-Jol-1+*
___ 01:50AM BLOOD Plt Smr-NORMAL Plt ___
___ 01:50AM BLOOD Ret Man-25.0* Abs Ret-0.46*
___ 01:50AM BLOOD Glucose-191* UreaN-11 Creat-0.8 Na-137
K-4.7 Cl-100 HCO3-22 AnGap-15
___ 01:50AM BLOOD ALT-51* AST-200* LD(LDH)-1496* AlkPhos-97
TotBili-4.8* DirBili-0.9* IndBili-3.9
___ 01:50AM BLOOD cTropnT-<0.01
___ 02:55PM BLOOD Calcium-8.3* Phos-4.3 Mg-2.1
___ 01:50AM BLOOD Hapto-<10*
___ 03:17AM BLOOD Lactate-1.3
DISCHARGE LABS:
==============
___ 06:15AM BLOOD WBC: 12.7* RBC: 3.38* Hgb: 9.9* Hct:
28.7*
MCV: 85 MCH: 29.3 MCHC: 34.5 RDW: 18.6* RDWSD: 56.9* Plt Ct:
503*
___ 06:15AM BLOOD Glucose: 105* UreaN: 10 Creat: 0.5 Na:
139
K: 4.3 Cl: 104 HCO3: 21* AnGap: 14
___ 06:15AM BLOOD Calcium: 8.5 Phos: 4.8* Mg: 2.1
IMAGING:
==========
___ CHEST (PORTABLE AP)
In comparison with the study ___, the there is little
change.
Continued enlargement of the cardiac silhouette with
indistinctness of
pulmonary vessels consistent with elevated pulmonary venous
pressure.
Retrocardiac opacification with obscuration of the hemidiaphragm
is consistent with substantial volume loss in the left lower
lobe and probable pleural effusion. There is probably also a
small effusion at the right base. Although no focal
consolidation is identified, given the changes described above
would be extremely difficult to exclude superimposed
aspiration/pneumonia in the appropriate clinical setting,
especially in the absence of a lateral view.
___ CTA CHEST
1. No evidence of pulmonary embolism in the main, right, left,
lobar or
segmental pulmonary arteries.
2. Small bilateral pleural effusions.
3. Opacification of the lung parenchyma in the lower lobes may
be secondary to compressive atelectasis although acute chest
syndrome cannot be excluded.
4. Global cardiomegaly, bony sclerosis, H-shaped vertebral
bodies and absence of the spleen consistent with sequela of
sickle cell disease.
MICRO:
=====
No pertinent culture data; UCx and Blood Cx negative
MRSA swab nares negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. HYDROmorphone (Dilaudid) 4 mg PO 10X/DAY
4. Jadenu (deferasirox) 360 mg oral BID
Discharge Medications:
1. FoLIC Acid 5 mg PO DAILY
RX *folic acid 1 mg 5 tablet(s) by mouth daily Disp #*150 Tablet
Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. HYDROmorphone (Dilaudid) 4 mg PO 10X/DAY
RX *hydromorphone 4 mg 1 tablet(s) by mouth every three (3)
hours Disp #*20 Tablet Refills:*0
5. Jadenu (deferasirox) 360 mg oral BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
# Moderate type, acute chest syndrome
# Acute hypoxic respiratory failure
# Sickle cell disease
# Acute pain crisis
SECONDARY
=========
# RLE ulcer
# Anemia
# Leukocytosis
# Iron Overload
# Malnutrition
Discharge Condition:
Mr. ___ was alert, talkative, and at his usual state of health
upon discharge. He was able to ambulate well and had no
difficulties with his ADLs.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with pain// ?acute chest
COMPARISON: Multiple prior chest radiographs with the most recent dated ___
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is unchanged with moderate cardiomegaly.
Multilevel chronic thoracic spine deformity is re-demonstrated and may relate
to known history of sickle cell disease.
IMPRESSION:
1. No acute intrathoracic process.
2. Stable moderate cardiomegaly.
Radiology Report
INDICATION: ___ year old man with picc// r dl picc 41cm iv ping ___
Contact name: ping, ___: ___
COMPARISON: Radiographs from ___
IMPRESSION:
There is a new right-sided PICC line with distal tip in the proximal right
atrium/cavoatrial junction. Heart size is within normal limits. There is
minimal bibasilar atelectasis. There are no pneumothoraces.
Radiology Report
INDICATION: ___ year old man with acute sickle cell pain crisis.// Evaluate
for interval change, acute chest syndrome.
COMPARISON: Radiographs from ___
IMPRESSION:
There is a right-sided PICC line with the distal tip at the cavoatrial
junction. Heart size is prominent but stable. There are no focal
consolidations, pleural effusion, or pulmonary edema. There are no
pneumothoraces.
Radiology Report
INDICATION: ___ year old man with sickle cell disease, pain crisis.// Evaluate
for acute chest syndrome.
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: Radiograph of the chest performed 1 day prior
FINDINGS:
Moderate cardiomegaly is unchanged compared to the prior exam. Hilar and
mediastinal contours are stable. There appears to be subtle increased opacity
at the right lung base. There is no large pleural effusion or pneumothorax.
Visualized osseous structures are grossly unremarkable.
IMPRESSION:
Subtle increase in opacity seen at the right lung base, which could be
secondary to an infectious process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with sickle cell, c/f acute chest syndrome.//
?any infiltrations?
IMPRESSION:
In comparison with the study ___, the there is little change.
Continued enlargement of the cardiac silhouette with indistinctness of
pulmonary vessels consistent with elevated pulmonary venous pressure.
Retrocardiac opacification with obscuration of the hemidiaphragm is consistent
with substantial volume loss in the left lower lobe and probable pleural
effusion. There is probably also a small effusion at the right base.
Although no focal consolidation is identified, given the changes described
above would be extremely difficult to exclude superimposed
aspiration/pneumonia in the appropriate clinical setting, especially in the
absence of a lateral view.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: Mr. ___ is a ___ year old gentleman with SCD (not on
hydroxyurea) c/b NSTEMI, priapism and frequent pain crises who presented to
the ED with low and mid back pain consistent with acute pain crisis now with
chest pain and hypoxemia// Rule out PE and evaluate for lobar infiltrate that
would suggest acute chest pain sx
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.0 s, 26.9 cm; CTDIvol = 5.4 mGy (Body) DLP = 146.0
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
3) Stationary Acquisition 1.8 s, 0.5 cm; CTDIvol = 9.1 mGy (Body) DLP = 4.5
mGy-cm.
Total DLP (Body) = 152 mGy-cm.
COMPARISON: CT dated ___
FINDINGS:
HEART/VASCULATURE:
Assessment of the pulmonary vasculature is partially degraded by motion
artifact. The pulmonary arteries are well opacified to the segmental level
with no evidence of filling defect within the main, right, left, lobar or
segmental pulmonary arteries. Subsegmental arteries are inadequately
assessed. The main and right pulmonary arteries are normal in caliber.
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. No other acute
aortic abnormality or significant aortic atherosclerosis evident.
There is moderate global cardiomegaly. There is no evidence of right
ventricular strain. There is no pericardial effusion.
AIRWAYS/LUNGS:
The airways are patent to the subsegmental level.
Lung apices are excluded from the field of view. There is opacification of
the lung parenchyma in the of lower lobes bilaterally which demonstrate
adequate enhancement. There is small bilateral pleural effusions.
MEDIASTINUM/LYMPH NODES:
No mediastinal, or hilar lymphadenopathy. No other mediastinal abnormality.
BONES/CHEST WALL:
Note is again made of H-shaped vertebral bodies and patchy sclerosis
throughout the vertebra, sternum and bilateral ribs in keeping with history of
sickle cell disease. There is no destructive bone lesion.
UPPER ABDOMEN:
Limited images of the upper abdomen demonstrates hepatomegaly and absence of
the spleen consistent with sickle cell disease.
IMPRESSION:
1. No evidence of pulmonary embolism in the main, right, left, lobar or
segmental pulmonary arteries.
2. Small bilateral pleural effusions.
3. Opacification of the lung parenchyma in the lower lobes may be secondary to
compressive atelectasis although acute chest syndrome cannot be excluded.
4. Global cardiomegaly, bony sclerosis, H-shaped vertebral bodies and absence
of the spleen consistent with sequela of sickle cell disease.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: Mr. ___ is a ___ year old gentleman with SCD (not on hydroxyurea
given personal preference) c/b NSTEMI, priapism and frequent pain crises who
presented to the ED with low and mid back pain consistent with acute pain
crisis requiring ICU admission for SVT to 160s and Ketamine gtt. Called out
to floor ___ overnight, now with pleuritic chest pain diagnosed with acute
chest of moderate severity.// Worsening chest pain. Assess interval
COMPARISON: Chest radiograph ___.
FINDINGS:
PA and lateral views of the chest provided.
Right-sided PICC terminates overlying the superior cavoatrial junction. Right
lower lobe consolidation is worse as compared to chest CT head ___.
Small bilateral pleural effusions are mildly increased in size.. Mild
cardiomegaly is unchanged.
IMPRESSION:
1. Right lower lobe opacity appears worse as compared to chest CT ___
and could represent atelectasis or infection
2. Small bilateral pleural effusions are increased in size.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Sickle cell crisis
Diagnosed with Hb-SS disease with crisis, unspecified
temperature: 97.1
heartrate: 88.0
resprate: 24.0
o2sat: 93.0
sbp: 142.0
dbp: 77.0
level of pain: 10
level of acuity: 2.0 | ___ with SCD not on hydroxyurea due to patient preference who
presented with low and mid back pain consistent with acute pain
crisis. He was admitted to the MICU for pain control. Upon
arrival to the floor, patient developed severe right-sided chest
pain and back pain with O2 sat <90%. CT chest showed bilateral
lower lobe consolidations, and he met criteria for moderate
severity acute chest syndrome.
ACUTE ISSUES
#CHEST PAIN
#ACUTE CHEST SYNDROME, MODERATE SEVERITY
Patient complaining of new onset of sharp pleuritic pain on
___. CTA notable for focal b/l lower lobe consolidations. Given
CTA findings and clinical status (chest pain, dyspnea,
hypoxemia), patient met criteria for acute chest syndrome of the
moderate type. From ___, patient received 2g IV
ceftriaxone and 250mg PO azithromycin. From ___, patient
received 2g IV cefepime (after spiking a fever) and 250mg PO
azithromycin. He received 2U PRBCs on ___ and 2U PRBCs on ___
with marked improvement in his symptoms. He was stable on room
air with improvement in his pain to baseline on ___.
#ACUTE PAIN CRISIS, SICKLE CELL DISEASE:
On admission, he had significant back pain consistent with acute
pain crisis. His pain was managed initially with dilaudid PCA
and ketamine gtt, but he was able to wean off the ketamine while
in ICU. He was weaned off PCA dilaudid on ___. At time of
discharge, he was only requiring PO dilaudid. He also received
Tylenol and toradol during his hospital course.
#LEUKOCYTOSIS: Suspect reactive in setting of acute pain crisis.
Culture data was negative.
#ANEMIA: Patient received 4 total simple transfusions of pRBC
after Hgb fell to 4.6. Patient's Hgb 9.9 at time of discharged.
#HYPOXEMIA (RESOLVED):
The patient had O2 sats <90% and was put on 2L NC. At time of
discharge, the patient was sat 97-99% on room air.
CHRONIC ISSUES
#RLE ULCER:
Has a history of chronic ulcers. He was seen by dermatology
___ and prescribed dicloxacillin for 7 days for infection.
Outpatient culture from wound grew MSSA. Dicloxacillin was
discontinued on ___ as the patient was on treatment on
ceftriaxone and azithromycin for PNA.
#H/O NSTEMI: Years ago due to SCD. He is continuing to take his
home aspirin and atorvastatin.
#Malnutrition: He is clinically malnourished and needs to be
encouraged to keep up with his caloric and protein requirements
during his acute hospitalization.
TRANSITIONAL ISSUES:
======================
- ___ checked, no concerning prescription patterns. Provided
dilaudid refill prescription for two days of pain medications.
Patient will call primary care provider on ___ for follow up
appointment and prescription refill.
- Hematology oncology will arrange for follow up after
discharge. They will address chronic issues including
hydroxyurea and PO iron chelation.
- Patient has dermatology follow up after discharge for care of
his RLE ulceration.
- Consider outpatient liver MRI to quantify his iron overload. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old man with past medical history of atrial fibrillation
s/p multiple cardioversions, hypertension, COPD, hyperlipidemia,
and recent COPD flare who presents today after a syncopal event.
He had an episode of chest pain about 3 weeks ago. The pain was
substernal, "grasping" pain that radiated into his jaw and
resolved after 20 minutes. The pain felt like chest pain that he
has experienced in the past during episodes of stress. He has
nitroglycerine prescribed but has never used it.
Last week, he developed a sore throat, cough and dyspnea on
exertion concerning for URI or COPD exacerbation. He was seen at
___ where prescribed a 5 day course of prednisone
40mg.
He continues to have coughing "fits" and endorses chills and
sweats over the past few days but was overall feeling better
yesterday. He endorses poor oral intake over the past few days.
Of note, he reports that his breathing has improved after the
Prednisone course and that his cough is not bothersome like it
had been previously.
Today he felt fine at home, then walking from the parking lot
into work he felt winded, lightheaded, fatigued, and general
malaise. The lightheadedness continued during the morning. He
then had an episode of syncope. Prior to the episode, he
describes standing up suddenly from sitting. He also possibly
was
coughing directly prior to the episode. Directly before he lost
consciousness, he experienced worsening tunnel vision. He denies
prodromal symptoms of palpitations, angina, nausea, sweating,
feeling hot, or feeling cold. He says that witnesses said that
the episode lasted a few seconds. He endorses immediately
regaining consciousness with no confusion. He also denies
urinary
or fecal incontinence, jerking movements and tongue biting.
He has had ___ prior episodes of passing out over his life time.
He has noticed no clear pattern. One instance occurred about ___
years ago immediately following discharge after a cardioversion.
During that time, he stopped at a restaurant, had not yet
started eating and passed out. He fell out of his chair and
became incontinent of urine. Another episode occurred
surrounding a blood draw. Another happened when he stood up
suddenly to go to the bathroom and passed out in the bathroom,
unclear if prior to or after urinating.
Past Medical History:
Atrial fibrillation with multiple cardioversions (most recently
___, ___
Hypertension
COPD
Hyperlipidemia
Tobbacco use (current smoker)
Social History:
___
Family History:
Father - died of prostate cancer; had a fib and stroke
Mother - died of CHF; kidney disease - never on dialysis
Oldest brother - died at age ___ of sudden cardiac death after
___
MI, had morbid obesity and hx of cocaine use
Older brother - living, estranged, diagnosed with prostate
cancer
Sister - living, lung cancer /___ s/p resection
Younger brother - living, renal cancer, asthma, afib,
hypertension
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: ___ Temp: 97.8 PO BP: 117/71 HR: 68 RR: 18 O2
sat: 95% O2 delivery: ra
ORTHOSTATIC VITALS:
___ BP: 111/70 R Lying
___ BP: 116/75 R Sitting
___ BP: 122/74 R Standing
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. Sclera anicteric and without injection. MMM.
CARDIAC: RRR, normal S1 S2, no audible M/R/G
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales.
ABDOMEN: Soft, non distended, non-tender to deep palpation in
all
four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP 2+
bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: ___ strength throughout. Grossly normal sensation.
Pertinent Results:
ADMISSION LABS:
==================
___ 11:20AM BLOOD WBC-16.3* RBC-4.53* Hgb-14.7 Hct-42.4
MCV-94 MCH-32.5* MCHC-34.7 RDW-13.5 RDWSD-45.9 Plt ___
___ 11:20AM BLOOD Glucose-88 UreaN-27* Creat-1.4* Na-139
K-4.1 Cl-100 HCO3-19* AnGap-20*
___ 11:20AM BLOOD Calcium-9.1 Phos-5.1* Mg-2.4
DISCHARGE LABS:
=================
___ 06:17AM BLOOD WBC-9.0 RBC-4.13* Hgb-13.2* Hct-38.4*
MCV-93 MCH-32.0 MCHC-34.4 RDW-12.9 RDWSD-43.9 Plt ___
___ 06:17AM BLOOD Glucose-111* UreaN-15 Creat-0.9 Na-143
K-3.6 Cl-103 HCO3-22 AnGap-18
___ 06:17AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.2
IMAGING:
==========
CARDIAC PERFUSION PHARMACOLOGICAL:
SUMMARY FROM THE EXERCISE LAB:
For pharmacologic stress 0.4 mg of regadenoson (0.08 mg/ml) was
infused
intravenously over 20 seconds followed by a saline flush.
FINDINGS: Left ventricular cavity size has increased since ___, and is now
top-normal in size an end-diastolic volume 118 mL.
Similar to prior, there is a moderate, fixed inferior wall
defect.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 64%.
IMPRESSION: 1. Moderate predominantly fixed inferior wall
defect, unchanged
compared to ___. 2. Interval increase in left ventricular
cavity size,
which is now top-normal. 3. Normal systolic function.
STRESS TEST:
INTERPRETATION: This ___ yo man with h/o atrial fibrillation, s/p
DCCV's ___ and ___, HTN, HLD, smoking, BMI of ___, family h/o
premature
CAD, and COPD exacerbation was referred to the lab from the
inpatient
floor following negative serial cardiac enzymes for evaluation
of chest
discomfort. Prior to the test, the patient was administered 2
puffs of
90 mcg/actuation albuterol, followed by 0.4 mg of Regadenoson
(Lexiscan)
IV Bolus over 20 seconds. There were no reports of chest, back,
neck, or
arm discomforts during the study. There were no significant ST
changes
noted during infusion or recovery. Rhythm was sinus with one
VPB.
Resting systolic hypertension with an appropriate blood pressure
and
heart rate response to the infusion.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Resting
systolic hypertension. Nuclear report sent separately.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with DOE and cough x7 days// eval for PNA
COMPARISON: Chest x-ray ___, CT of the chest dated ___
FINDINGS:
PA and lateral views of the chest provided. Lungs are clear. There is no
focal consolidation, effusion, or pneumothorax. No signs of congestion or
edema. Again seen are surgical clips at the base of the right neck and
calcification of the aortic arch. 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: CT HEAD W/O CONTRAST
INDICATION: ___ with syncope and fall// 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: Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute territorial infarction,hemorrhage,edema,or
discrete mass. Mild periventricular white matter hypodensities are
nonspecific, but likely represent the sequela of chronic microvascular
ischemia. The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. There is partial opacification of the left
maxillary sinus with an air-fluid level. There is also partial opacification
of the posterior ethmoid air cells on the left. Mild mucosal thickening
within the right sphenoid sinus. The visualized portion of the mastoid air
cells and middle ear cavities are clear. The visualized portion of the orbits
are unremarkable.
IMPRESSION:
1. No evidence of fracture or intracranial hemorrhage.
2. Mild paranasal sinus opacification with an air-fluid level in the left
maxillary sinus. Please correlate for any clinical signs of acute sinusitis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Syncope
Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation, Shortness of breath, Syncope and collapse, Cough
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: crit
level of acuity: 2.0 | PATIENT SUMMARY:
==================
___ year-old man with hx of atrial fibrillation s/p multiple
cardioversions, hypertension, and COPD s/p recent prednisone
course for COPD exacerbation, who initially presented to ___
s/p syncopal event, felt to be secondary to orthostatic
hypotension and improved with IVF resuscitation, course
complicated by worsening cough concerning for COPD exacerbation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Persistent disequilibrium
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo man with multiple vascular risk factors
and significant peripheral vascular disease who presents with
persistent disequilibrium.
Yesterday morning he felt sensation of imbalance, lasting 15
minutes before resolving. He then felt normal rest of the day.
On awakening this morning, he again felt a sensation of
imbalance, but this has persisted throughout the day. He tried
drinking water to help alleviate the symptoms, thinking that sx
were due to dehydration, and he drank a total of 3 bottles of
water with minimal effect. Overall his symptoms have improved
slightly since onset.
Past Medical History:
Past Medical History:
- CAD s/p CABG ___ w/ 3 stents at ___ & ___
--___: CABG (LIMA-LAD, SVG-OM1 and OM2, SVG-rPDA)
--___: IMI, BMS to SVG-OM c/b ISR s/p 3 DES to SVG-OM
--___: MI s/p thrombectomy and BMS to SVG-OM
- Peripheral Arterial disease s/p right SFA PTA/stent ___
- Hypertension
- Hyperlipidemia
- CKD
- BPH, s/p Transurethral photovaporization of the prostate using
GreenLight laser in ___
- Hx ventral hernia
- Hx ampullary adenoma s/p endoscopic resection in ___, repeat
ampullectomy for focal recurrence (___)
- S/p colectomy in ___ (performed prophylactically due to
attenuated FAP)
- Mesenteric ischemia s/p PTA & stenting of SMA and Celiac
Past Surgical History:
-CABG (LIMA-LAD, SVG-OM1 and OM2, ___
-IMI, BMS to SVG-OM c/b ISR s/p 3 DES to SVG-OM (___)
-MI s/p thrombectomy and BMS to SVG-OM (___)
-Right SFA PTA/stent ___
-Transurethral photovaporization of the prostate using
GreenLight laser in ___
-Endoscopic resection ampullary adenoma ___
-Repeat endoscopic resection for recurrence ___
-Colectomy in ___ (performed prophylactically due to
attenuated FAP)
-Celiac artery PTA/Stent & SMI PTA/Stent ___
Social History:
Lives w/ wife, daughter, granddaughter. Previous smoker (quit at
age ___, smoked ___ ppd for ___ years), social drinker
(___), Denies recreational drug use.
- Modified Rankin Scale:
[] 0: No symptoms
[x] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
- Multiple family members with ___ cancer
- Father ___ Disease, polyps -> died of an MI
- Multiple Maternal Aunts with ___ Cancer
- Mother ___ Cancer; Multiple polyps (no formal dx of ___
cancer per patient); Coronary Artery Disease; ?Gynecologic
Cancer -> died of an MI
- Sister ___ Cancer(2), s/p resection, both doing well;
brother died in ___ of mesothelioma (former smoker and
+asbestos exposure)
Physical Exam:
ADMISSION EXAMINATION
=====================
Vitals: T: 97.6 HR: 75 BP: 152/98 RR: 16 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions.
Pulmonary: Breathing comfortably, no tachypnea nor increased
WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive to exam. Speech is fluent
with normal grammar and syntax. No paraphasic errors.
Comprehension intact to complex, cross-body commands. Normal
prosody.
-Cranial Nerves: PERRL 2->1.5. VFF to confrontation. EOMI
without
nystagmus. Head impulse without corrective saccade. ___
unremarkable to R, torsional and upbeating nystagmus to the L.
Facial sensation intact to light touch. Face symmetric at rest
and with activation. Hearing intact to conversation. Palate
elevates symmetrically. ___ strength in trapezii bilaterally.
Tongue protrudes in midline and moves briskly to each side. No
dysarthria.
- Motor: Normal bulk and tone. No drift. No tremor nor
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Adductors
L 2 2 3 2 2
R 2 2 3 2 2
-Sensory: Intact to LT, temp throughout.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: Wide base, loses balance ___ times during a 20 foot
walk.
Romberg with sway without stepoff.
DISCHARGE EXAMINATION
=====================
Vitals: Temp: 97.8 (Tm 98.1), BP: 127/75 (122-152/63-75), HR: 61
(61-67), RR: 18, O2 sat: 97% (95-97), O2 delivery: RA
General: Awake, cooperative, NAD.
HEENT: No scleral icterus, MMM, no oropharyngeal lesions.
Decreased active range of motion bilaterally.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: Skin warm, well-perfused.
Abdomen: Soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Speech is fluent with normal grammar
and syntax. No paraphasic errors. Comprehension intact to
complex, cross-body commands. Normal prosody.
-Cranial Nerves: PERRL 2->1.5. VFF to confrontation. EOMI
without
nystagmus. Head impulse without corrective saccade. ___
unremarkable to R, patient reports room spinning to L but no
visualized nystagmus. Facial sensation intact to light touch.
Face symmetric at rest and with activation. Hearing intact to
conversation. Palate elevates symmetrically. ___ strength in
trapezii bilaterally. Tongue protrudes in midline and moves
briskly to each side. No dysarthria.
- Motor: Normal bulk and tone. No drift. No tremor nor
asterixis. Neck flexion and extension strength ___.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-DTRs: ___ adductors bilaterally, negative ___.
Bi Tri ___ Pat Ach
L 3 2 2 3 2
R 3 2 2 3 2
Plantar reflex was equivocal bilaterally.
-Sensory: Intact to light touch throughout. Vibratory sensation
intact in lower extremities. Proprioception testing with ___
incorrect on right toe and ___ incorrect on left finger.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: Narrow base, no loss of balance during 20 ft unassisted
walk. Romberg with sway without stepoff.
Pertinent Results:
___ 04:20AM BLOOD WBC-5.6 RBC-4.18* Hgb-13.0* Hct-38.8*
MCV-93 MCH-31.1 MCHC-33.5 RDW-13.2 RDWSD-45.1 Plt ___
___ 04:20AM BLOOD ___ PTT-29.3 ___
___ 04:20AM BLOOD Glucose-101* UreaN-17 Creat-1.0 Na-144
K-4.3 Cl-105 HCO3-23 AnGap-16
___ 04:20AM BLOOD Albumin-3.9 Calcium-9.0 Phos-3.6 Mg-2.0
Cholest-154
___ 04:20AM BLOOD ALT-14 AST-16 AlkPhos-59 TotBili-1.0
___ 04:20AM BLOOD VitB12-500 Folate-11
___ 04:20AM BLOOD %HbA1c-5.5 eAG-111
___ 04:20AM BLOOD Triglyc-281* HDL-39* CHOL/HD-3.9
LDLcalc-59
___ 04:20AM BLOOD TSH-4.6*
___ 12:12PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 12:38 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 12:35 ___ CT HEAD W/O CONTRAST
1. No acute hemorrhage. No evidence for an acute major vascular
territorial infarction.
2. Left greater than right confluent parietal white matter
hypodensities are nonspecific but likely sequela of chronic
small vessel ischemic disease in this age group. MRI would be
more sensitive for an acute infarction or other acute pathology,
if clinically warranted.
___ 1:45 ___ CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC &
RECONS
1. Approximately 75-80% stenosis of the proximal right internal
carotid artery and approximately 40% stenosis of the proximal
left internal carotid artery by NASCET criteria.
2. Moderate stenosis of the left vertebral artery origin. Areas
of mild
narrowing in the distal left V2 segment. Short segment of
moderate to severe stenosis in the proximal left V4 segment.
3. Atherosclerosis of bilateral carotid siphons with mild
supraclinoid right ICA narrowing and moderate cavernous left ICA
narrowing.
4. Extensive atherosclerosis in the visualized aorta, with 2
penetrating
ulcers in the proximal descending aorta measuring 7 mm each.
5. Enlarged main pulmonary artery, suggesting pulmonary arterial
hypertension. Please correlate clinically.
Portable TTE (Complete) Done ___ at 9:17:56 AM
Mild regional left ventricular systolic dysfunction, c/w CAD.
Mild mitral regurgitation.
___ 4:38 AM MR HEAD W/O CONTRAST
No acute infarction.
___ 4:39 AM MR CERVICAL SPINE W/O CONTRAST
1. Motion limited exam.
2. Multilevel degenerative disease.
3. Moderate to severe spinal canal stenosis at C4-C5 with
abutment of the
spinal cord. Moderate spinal canal narrowing at at C5-C6 with
minimal
remodeling of the spinal cord.
4. Motion artifact limits evaluation of spinal cord signal.
Questionable
linear T2 hyperintensity in the central cord at the level of
C5-C6 is most
likely artifactual, and less likely secondary to myelomalacia,
as there is no evidence for associated volume loss.
5. Advanced multilevel neural foraminal narrowing, as detailed
above.
Medications on Admission:
1. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
2. Losartan Potassium 12.5 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Ranexa (ranolazine) 500 mg oral BID
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough/wheeze
8. Tamsulosin 0.4 mg PO BID
9. Pantoprazole 40 mg PO Q24H
10. Aspirin EC 81 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough/wheeze
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Losartan Potassium 12.5 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
9. Ranexa (ranolazine) 500 mg oral BID
10. Tamsulosin 0.4 mg PO BID
11.Outpatient Physical Therapy
Evaluate and treat for disequilibrium, cervical spondylosis
Discharge Disposition:
Home
Discharge Diagnosis:
1. Cervicogenic disequilibrium
2. Vestibulopathy, likely multifactorial
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with dizziness, evaluate for acute intracranial process.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.7 cm; CTDIvol = 48.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no acute intracranial hemorrhage, mass effect, or evidence for an
acute major vascular territorial infarction. Confluent hypodensities in left
greater than right parietal white matter, periventricular and, deep, and
subcortical, are nonspecific but likely sequela of chronic small vessel
ischemic disease in this age group. There is global parenchymal volume loss
with prominent ventricles and sulci, likely age-related.
Status post bilateral cataract surgery. No evidence for suspicious bone
lesions. Minimal mucosal thickening in the ethmoid air cells and partially
visualized maxillary sinuses. Ethmoid air cells are well aerated.
IMPRESSION:
1. No acute hemorrhage. No evidence for an acute major vascular territorial
infarction.
2. Left greater than right confluent parietal white matter hypodensities are
nonspecific but likely sequela of chronic small vessel ischemic disease in
this age group. MRI would be more sensitive for an acute infarction or other
acute pathology, if clinically warranted.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with dizziness. Evaluate for posterior stroke.
TECHNIQUE: 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) Stationary Acquisition 8.0 s, 0.5 cm; CTDIvol = 87.1 mGy (Head) DLP =
43.6 mGy-cm.
2) Spiral Acquisition 5.6 s, 44.0 cm; CTDIvol = 31.1 mGy (Head) DLP =
1,369.8 mGy-cm.
Total DLP (Head) = 1,413 mGy-cm.
COMPARISON: CT head ___
Chest CT from ___.
FINDINGS:
CTA NECK:
There is a 3 vessel aortic arch. There is mild mixed plaque at the origin and
proximal portion of the left subclavian artery without evidence for
flow-limiting stenosis. There is calcified plaque at the origins of the left
common carotid and innominate arteries, and, to a lesser extent, at the
origins of the right common carotid and subclavian arteries, without evidence
for flow-limiting stenosis.
Calcified plaque in the proximal right internal carotid artery causes
approximately 75-80% stenosis by NASCET criteria. Smooth mixed plaque in the
proximal left internal carotid artery causes approximately 40% stenosis by
NASCET criteria.
Right vertebral artery origin appears widely patent, though there is adjacent
plaque in the subclavian artery. There is a small focus of calcified plaque
in the distal right V1 segment without evidence for significant luminal
narrowing. V2 and V3 segments appear widely patent.
Calcified plaque at the left vertebral artery origin causes moderate stenosis.
Calcified plaque in the distal left P1 segment causes mild stenosis. Small
foci of calcified plaque in the distal left V2 segment at the levels of C4-C5
and at the level of C3 cause mild luminal narrowing.
CTA HEAD:
There is calcified plaque within bilateral carotid siphons, with mild
narrowing of the supraclinoid right internal carotid artery, and moderate
narrowing of the distal cavernous left internal carotid artery. There is a
focus of calcified plaque in the intracranial right vertebral artery without
evidence for flow-limiting stenosis. There is a short-segment of mixed plaque
in the proximal intracranial left vertebral artery causing moderate to severe
stenosis. Hypoplasia of the A1 segment of the left anterior cerebral artery
is a normal variant. No evidence for an aneurysm. The dural venous sinuses
are patent.
OTHER:
This exam is not technically optimized for evaluation of the brain parenchyma,
which are better assessed on the same-day noncontrast head CT. There is
evidence of bilateral cataract surgery. There is minimal mucosal thickening
in the ethmoid air cells and right maxillary sinus. There is a small mucous
retention cyst along the floor of the left maxillary sinus. Mastoid air cells
appear well-aerated.
There are degenerative changes in the cervical spine. The thyroid is
unremarkable.
Evaluation of the included upper lungs is limited by respiratory motion
artifact. Dependent atelectasis is present. There is a 6 mm ground-glass
right upper lobe pulmonary nodule on image 2:48, unchanged compared to the ___ chest CT, which does not require follow-up.
Cardiomegaly and evidence of CABG are partially visualized. Main pulmonary
artery is enlarged, 3.8 cm, indicating pulmonary arterial hypertension.
Ascending aorta is at the upper limit of normal caliber. There is extensive
mixed plaque in the visualized ascending aorta, aortic arch, and proximal
descending aorta, including 2 penetrating ulcers in the proximal descending
aorta measuring 7 mm each on image 2:57.
IMPRESSION:
1. Approximately 75-80% stenosis of the proximal right internal carotid artery
and approximately 40% stenosis of the proximal left internal carotid artery by
NASCET criteria.
2. Moderate stenosis of the left vertebral artery origin. Areas of mild
narrowing in the distal left V2 segment. Short segment of moderate to severe
stenosis in the proximal left V4 segment.
3. Atherosclerosis of bilateral carotid siphons with mild supraclinoid right
ICA narrowing and moderate cavernous left ICA narrowing.
4. Extensive atherosclerosis in the visualized aorta, with 2 penetrating
ulcers in the proximal descending aorta measuring 7 mm each.
5. Enlarged main pulmonary artery, suggesting pulmonary arterial hypertension.
Please correlate clinically.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man with multiple vascular risk factors, new vertigo.
Evaluate for infarct.
TECHNIQUE: Sagittal T1 weighted, and axial T2 weighted, FLAIR, gradient echo,
and diffusion-weighted images of the brain were obtained.
COMPARISON: ___ head CT, head/neck CTA.
FINDINGS:
There is no acute infarction. There is no edema, mass effect, or evidence for
blood products. T2 hyperintensities in the periventricular, deep, and
subcortical white matter of the cerebral hemispheres, most extensive within
bilateral lower parietal regions, are nonspecific but likely sequela of
chronic small vessel ischemic disease in this age group. There is mild
age-related parenchymal volume loss with associated prominence of the
ventricles and sulci. Atherosclerosis of the intracranial left vertebral
artery is better seen on the preceding CTA. Major vascular flow voids are
otherwise grossly preserved.
Status post bilateral cataract surgery. Minimal mucosal thickening in the
ethmoid air cells.
IMPRESSION:
No acute infarction.
Radiology Report
EXAMINATION: MRI CERVICAL SPINE WITHOUT CONTRAST
INDICATION: ___ year old man with multiple vascular risk factors, new vertigo.
Evaluate for cervical stenosis.
TECHNIQUE: Sagittal T1 weighted, T2 weighted, and STIR images of the
cervical spine with axial gradient echo and T2 weighted images.
COMPARISON: No prior spine MRI.
___ CTA head and neck.
FINDINGS:
Motion artifact limits evaluation.
Vertebral body heights are preserved. No suspicious bone marrow signal
abnormalities are seen. Discogenic bone marrow changes are present at
multiple levels. There is mild anterolisthesis of C4 on C5, mild
retrolisthesis of C5 on C6, and mild anterolisthesis of C7 on T1.
The cerebellar tonsils are normally positioned. Concurrent brain MRI is
reported separately.
C2-C3: Possible shallow central disc protrusion without spinal canal
narrowing. Mild right and moderate to severe left neural foraminal narrowing
by uncovertebral and facet osteophytes.
C3-C4: Broad-based central disc protrusion indents the ventral thecal sac
without spinal cord contact. Severe right and moderate left neural foraminal
narrowing by uncovertebral and facet osteophytes.
C4-C5: Mild anterolisthesis, shallow broad-based central disc protrusion, and
endplate osteophytes, as well as infolding of the ligamentum flavum, cause
moderate to severe spinal canal stenosis with abutment of the spinal cord.
Moderate to severe right and moderate left neural foraminal narrowing by
uncovertebral and facet osteophytes.
C5-C6: Mild retrolisthesis and posterior endplate osteophytes abut and
minimally remodel the ventral spinal cord, causing moderate spinal canal
narrowing. Severe bilateral neural foraminal narrowing by uncovertebral and
facet osteophytes.
C6-C7: Left paracentral posterior endplate osteophytes indent the ventral
thecal sac without spinal cord contact. Severe bilateral neural foraminal
narrowing by uncovertebral and facet osteophytes.
C7-T1: Mild anterolisthesis. Thickening of the ligamentum flavum minimally
indents the dorsal thecal sac without spinal cord contact. Mild right and
moderate left neural foraminal narrowing by facet osteophytes.
Evaluation of spinal cord signal is limited by artifacts. There is
questionable linear T2 hyperintensity in the central cord at the level of
C5-C6, most likely artifactual.
IMPRESSION:
1. Motion limited exam.
2. Multilevel degenerative disease.
3. Moderate to severe spinal canal stenosis at C4-C5 with abutment of the
spinal cord. Moderate spinal canal narrowing at at C5-C6 with minimal
remodeling of the spinal cord.
4. Motion artifact limits evaluation of spinal cord signal. Questionable
linear T2 hyperintensity in the central cord at the level of C5-C6 is most
likely artifactual, and less likely secondary to myelomalacia, as there is no
evidence for associated volume loss.
5. Advanced multilevel neural foraminal narrowing, as detailed above.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness
Diagnosed with Dizziness and giddiness
temperature: 97.6
heartrate: 75.0
resprate: 16.0
o2sat: 100.0
sbp: 152.0
dbp: 98.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ man with history notable for CAD
s/p CABG s/p DES and BMS placement, PAD s/p R SFA stent, HTN,
HLD, CKD, BPH, and mesenteric ischemia s/p celiac and SMA
stenting presenting with one day of persistent disequilibrium.
Head and neck imaging with CT and MRI did not demonstrate
evidence of acute stroke, hemorrhage, large vessel occlusion, or
mass to account for Mr. ___ symptoms. MRI of the cervical
spine, however, did demonstrate significant multilevel spinal
canal and neural foraminal stenosis, with examination also
demonstrating subtle impairment of joint position sense in the
extremities; overall, findings were concerning for cervicogenic
disequilibrium with a potential underlying component of dorsal
column or large fiber neuropathy. Additionally, initial
examination was notable for vertigo with positive ___
maneuver on the left, suggestive of a superimposed component of
BPPV or other vestibulopathy, though these findings resolved on
subsequent examination. As Mr. ___ was noted to ambulate
without assistance or significant disequilibrium on follow-up
examination, he was discharged home with outpatient physical
therapy. A recommendation was also made to wear a soft cervical
collar at bedtime.
TRANSITIONAL ISSUES
1. Outpatient ___ for disequilibrium.
2. Consider rechecking TSH, free T4 and evaluating for
hypothyroidism. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Augmentin
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
intubation ___
extubation ___
ICP bolt placement ___
ICP bolt removed ___
Lumbar puncture ___
History of Present Illness:
Ms. ___ is a ___ year old female with uncertain PMHx who
presents as a transfer from ___ for multi-organ failure.
By ED report, she was recently treated for a pneumonia. Based on
a medication history review she was prescribed Augmentin x 7
days. She was doing better but remained slightly dyspneic, which
began worsening the day prior to admission. She went to ___.
___ and was found to have grossly abnormal labs
prompting transfer to ___.
According to their records, she had new onset bilateral
peripheral edema.
In our ED, her initial vitals were: T 100, HR 112, BP 120/91, RR
28, O2 100% RA. She had progressively increased work of
breathing and was intubated. After intubation she was started on
norepinephrine for hypotension.
Her labs were notable for:
131 | 90 | 33
---------------< 63 AG = 33
4.4 | 12 | 1.7
23.7 > 5.2/18.4 < 188 MCV 76, N 86.8
INR 3.1, PTT 33.3, Fibrinogen 130
BNP 28409, Trop-T 0.60
AST ___ ALT 8270 AP 116 TBili 1.6 Lip 61 Alb 3.5
Negative serum tox screen. Urine tox positive for
benzodiazepines. Negative HCG.
VBG: ___ with lactate 7.3
POCUS: "no effusion, LVEF ~45%, no noted RWMA, RV dilatation
(1:1) with hypokinesis, plethoric IVC. c/w toxic-metabolic biV
dysfunction, less so PE"
She was given:
___ 00:54 IV DRIP Acetylcysteine (IV) (3000 mg ordered)
Started 62.5 mL/hr
___ 01:24 IV Ketamine (For Intubation) 100 mg
___ 01:24 IV Succinylcholine 100 mg
___ 01:24 IV DRIP Midazolam ___ mg/hr ordered) Started 2
mg/hr
___ 01:57 IV Dextrose 50% 25 gm
___ 02:22 IVF D5NS ( 1000 mL ordered) Started 125 mL/hr
___ 02:35 IV Vecuronium Bromide 10 mg
___ 02:39 IV DRIP Midazolam Confirmed Rate Changed to 4
mg/hr
___ 02:39 IV DRIP Fentanyl Citrate (100-200 mcg/hr
ordered)Started 100 mcg/hr
___ 02:39 IVF NS ( 500 mL ordered)
___ 02:39 IV DRIP NORepinephrine (0.03-0.25 mcg/kg/min
ordered) Started 0.12 mcg/kg/min
On arrival to the MICU, the patient was intubated and sedated.
Review of systems: See HPI. Otherwise unable to obtain.
Past Medical History:
-allergies
-asthma
-depression
-history of hospitalizations: anorexia as a teenager
-anorexia with laxative use
-no history of drug overdose
-no history of alcohol abuse
Social History:
___
Family History:
-mom: breast cancer
-father: healthy
no know family history of hepatitis, cirrhosis, need for
transplantation, gastrointestinal or liver malignancies
Physical Exam:
ADMISSION EXAM
==============
Vitals: T: 100.7 BP: 116/80 P: 107 R: 28 O2: 100% on ventilator
GENERAL: Intubated and sedated
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear
NECK: R IJ CVL in place
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended
EXT: Warm, well perfused, 2+ edema bilaterally
SKIN: No rashes or bruising
DISCHARGE EXAM
==============
Pertinent Results:
ADMISSION LABS
==============
___ 12:16AM BLOOD WBC-23.7* RBC-2.42* Hgb-5.2* Hct-18.4*
MCV-76* MCH-21.5* MCHC-28.3* RDW-19.9* RDWSD-54.3* Plt ___
___ 12:16AM BLOOD ___ PTT-33.3 ___
___ 12:16AM BLOOD ___
___ 01:50PM BLOOD Fibrino-97*
___ 12:56PM BLOOD Parst S-NEGATIVE
___ 12:16AM BLOOD Glucose-63* UreaN-33* Creat-1.7* Na-131*
K-4.4 Cl-90* HCO3-12* AnGap-33*
___ 12:16AM BLOOD ALT-8270* ___ AlkPhos-116*
TotBili-1.6*
___ 12:16AM BLOOD Lipase-61*
___ 12:16AM BLOOD ___
___ 02:15AM BLOOD UricAcd-16.9* Iron-24*
___ 02:15AM BLOOD HBsAg-Negative HBsAb-Negative HAV
Ab-Negative IgM HBc-Negative IgM HAV-Negative
___ 12:16AM BLOOD HCG-<5
___ 04:49AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 11:51AM BLOOD CEA-2.0 AFP-2.3
___ 04:49AM BLOOD ___
___ 12:56PM BLOOD HIV Ab-Negative
___ 02:15AM BLOOD HCV Ab-Negative
___ 02:15AM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT
___ 12:22AM BLOOD Type-CENTRAL VE Temp-37.8 pO2-33*
pCO2-25* pH-7.37 calTCO2-15* Base XS--9 Intubat-NOT INTUBA
___ 12:22AM BLOOD Lactate-7.3* K-4.2
IMAGING
=======
RUQ US ___. Patent hepatic vasculature and IVC.
2. Slightly echogenic liver and gallbladder wall edema without
gallbladder
distention are compatible with provided history of liver
failure.
CT CHEST ___. Mild cardiomegaly without pericardial effusion. Suggestion
of anemia.
2. Suggestion of pulmonary hypertension.
3. Moderate bibasilar atelectasis and mild mucous plugging,
right greater than left. An underlying infection or aspiration
cannot be excluded in the proper clinical setting.
4. Subpleural posterior consolidation in the left upper lobe
could reflect
atelectasis but warrants follow-up in 3 months to exclude an
underlying
malignancy.
5. No acute abnormality in the abdomen. Nondistended
gallbladder with
gallbladder wall thickening likely related to to clinical
history of liver
disease, or systemic causes ; cholecystitis is unlikely.
ECHO ___
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses and
cavity size are normal. Overall left ventricular systolic
function is moderately depressed (LVEF= 35 %). There is no
ventricular septal defect. The right ventricular free wall is
hypertrophied. The right ventricular cavity is mildly dilated
with moderate global free wall hypokinesis (fractional area
change = 25%). There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild to moderate (___) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen (may be underestimated due to suboptimal imaging). There is
mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
ECHO ___
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is severely depressed (LVEF=
20 %). The right ventricular free wall thickness is normal.
Right ventricular chamber size is normal with depressed free
wall contractility. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. Moderate (2+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
ECHO ___
Left ventricular wall thicknesses and cavity size are normal.
There is moderate global left ventricular hypokinesis (biplane
LVEF = 33 %). The right ventricular cavity size is milldy
increased with low normal free wall motino. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate (___) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with moderate
global hypokinesis in a pattern most c/w a non-ischemic
cardiomyopathy. Mild-moderate mitral regurgitation. Mild
pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
global left ventricular systolic function has improved. The
severity of mitral regurgitation, tricuspid regurgitation and
the estimated PA systolic pressure are now slightly lower. The
heart rate is also now lower.
VQ Scan ___. Low likelihood ratio for pulmonary embolism.
NCCT Head ___. Suggestion of early global cerebral swelling. No evidence of
hemorrhage or infarction.
NCCT HEAD ___
No acute intracranial process.
CT Abd/pelvis ___
Suggestion of acute pancreatitis involving pancreatic tail.
Diffuse soft tissue edema.
CT Chest
1. Proximal right mainstem bronchus intubation, endotracheal
tube should be pulled back.
2. Consolidation, adjacent nodularity in the posterior left
upper lobe is
unchanged, is indeterminate, follow-up exam is recommended.
3. Improvement in bibasilar atelectasis ; residual ground-glass
opacities may be sequela of re-expansion; infection is less
likely. .
4. No new acute abnormality in the chest.
RECOMMENDATION(S): Follow-up of left upper lobe consolidation
with CT in 3 months time.
CSF:
NEGATIVE FOR MALIGNANT CELLS.
Lymphocytes and monocytes.
MRI HEAD ___
There is no evidence of intracranial hemorrhage, mass, mass
effect or shifting of the normally midline structures. The
ventricles and sulci are normal in size and configuration for
the patient's age. No diffusion abnormalities are detected.
Small subependymal hyperintense areas are noted adjacent to the
left ventricular horns (for example image 14, series 10), which
are nonspecific and may represent some gliotic areas and of
doubtful clinical significance. The major vascular flow voids
are present and demonstrate normal distribution. The orbits are
unremarkable, the paranasal sinuses are notable for mucosal
thickening in the maxillary sinuses, more significant on the
right, frontoethmoidal recesses, frontal sinus, sphenoid sinus.
Bilateral mucosal thickening is present mastoid air cells, more
significant on the left.
___ U/S ABD/PELVIS
1. Patent hepatic vasculature. Pulsatile waveforms within the
portal veins could be due to right heart failure.
2. Small stones and sludge noted in the gallbladder. There is
no sonographic sign of cholecystitis and there is no biliary
dilation.
3. Scant trace ascites seen only in the perihepatic space.
4. Normal sonographic appearance of the pancreas with no
evidence of secondary sequelae of acute pancreatitis.
OTHER LABS/STUDIES
==================
HIV-Ab: Negative
RPR: Negative
FluAPCR: Negative
FluBPCR: Negative
Hepatitis B Surface Antigen Negative
Hepatitis B Surface Antibody Negative
Hepatitis A Virus Antibody Negative
Hepatitis B Core Antibody, IgM Negative
Hepatitis A Virus IgM Antibody Negative
Hepatitis C Virus Antibody Negative
HBV VL undetectable
HCV VL undetectable
immunogloblulins relatively normal
tox neg
___ VIRUS: RESULTS INDICATIVE OF PAST EBV INFECTION.
CA ___: 20 (<34)
Anti-Mitochondrial Antibody NEG
Anti-Smooth Muscle Antibody NEG
Anti-Nuclear Antibody NEG
Herpesvirus 6 Antibody, IgG and IgM: PAST INFECTION
Hepatitis E Antibody (IgG) NEG
Parvovirus B19 Antibodies: IgG positive, IgM NEG
CMV IgG ANTIBODY: Neg
CMV IgM ANTIBODY: Neg
VARICELLA-ZOSTER IgG SEROLOGY: Neg
___: negative
Paraneoplastic panel: negative
DISCHARGE LABS
==============
___ 07:26AM BLOOD WBC-8.4 RBC-3.23* Hgb-8.3* Hct-28.2*
MCV-87 MCH-25.7* MCHC-29.4* RDW-30.2* RDWSD-92.0* Plt ___
___ 08:06AM BLOOD ___ PTT-28.4 ___
___ 07:26AM BLOOD Plt ___
___ 03:02AM BLOOD ___
___ 03:24AM BLOOD QG6PD->19.5*
___ 05:21AM BLOOD Ret Aut-5.0* Abs Ret-0.16*
___ 07:26AM BLOOD Glucose-80 UreaN-9 Creat-1.1 Na-139 K-4.4
Cl-100 HCO3-23 AnGap-20
___ 07:26AM BLOOD ALT-69*
___ 07:26AM BLOOD Calcium-9.0 Phos-4.7* Mg-1.5*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ALPRAZolam 1 mg PO TID
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Amitriptyline 75 mg PO QHS:PRN per instruction
4. Mirtazapine 45 mg PO QHS
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Omeprazole 20 mg PO DAILY
7. Montelukast 10 mg PO DAILY
8. Pravastatin 20 mg PO QPM
9. Venlafaxine XR 300 mg PO DAILY
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
3. LevETIRAcetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. HELD- Montelukast 10 mg PO DAILY This medication was held.
Do not restart Montelukast until told to do so by your doctor
9. HELD- Trivora (28) (levonorg-eth estrad triphasic) ___
(6)/75-40 (5)/125-30(10) oral daily This medication was held.
Do not restart Trivora (28) until told to do so by your doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
acute systolic CHF
acute liver failure
acute tubular necrosis
toxic metabolic encephalopathy
SECONDARY DIAGNOSIS
===================
depression
anorexia
microcytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST
INDICATION: ___ year old woman admitted to ICU for acute liver failure,
developed respiratory distress and has evidence of RV dysfunction. Has
worsening ___ with up trending Cr. // Evaluate for intrathoracic pathology.
TECHNIQUE: Contiguous helical MDCT images were obtained through the chest and
abdomen without IV contrast. Multiplanar axial, coronal in sagittal images
were generated and reviewed. Enteric contrast was administered.
DOSE: Total DLP (Body) = 723 mGy-cm.
COMPARISON: Chest radiographs ___ and ___. Abdominal
ultrasound ___.
FINDINGS:
CT CHEST: ET tube terminates approximately 2.5 cm from the carina. Right
internal jugular central venous catheter terminates in mid SVC. Enteric tube
courses through the esophagus and into the stomach.
The thyroid is grossly normal. There is no supraclavicular, axillary,
mediastinal or hilar lymphadenopathy within the limitations of a noncontrast
enhanced study.
There is mild cardiomegaly without pericardial effusion. Hyperattenuation of
cardiac myocardium relative to blood pool may be seen in the setting of
anemia. The thoracic aorta and proximal great vessels are normal in caliber.
The main pulmonary artery is mildly dilated measuring 3.1 cm.
The central airways are patent. Upper lobe bronchi are normal in caliber
without wall thickening. There is mild mucous plugging at the lung bases
(4:157). There is no pneumothorax. There is moderate bibasilar atelectasis,
right greater than left. There is an irregularly shaped subpleural posterior
consolidation in the left upper lobe measures 3 x 1.4 cm (04:47). There is
minimal, nonspecific, pleural thickening or scarring at the right apex
(___). There are small pleural effusions.
CT ABDOMEN:
HEPATOBILIARY: The liver is suboptimally evaluated on this noncontrast
enhanced study. Within these limitations there is no evidence of intrahepatic
biliary duct dilation. The liver contour is smooth. No large hepatic mass is
detected. The portal vein cannot be evaluated.
GALLBLADDER: There is gallbladder wall edema in a nondistended gallbladder
which can be seen with systemic causes, chronic liver disease, chronic or
acute cholecystitis are less likely.
SPLEEN: Normal in size and attenuation
ADRENAL GLANDS: Normal
PANCREAS: Normal in size and attenuation without peripancreatic stranding.
KIDNEYS: Kidneys are normal in size without hydronephrosis. The proximal
ureters are normal in caliber.
STOMACH AND BOWEL: The stomach is normal in caliber containing enteric
contrast. Enteric tube terminates in the gastric antrum. Included loops of
small and large bowel are normal in caliber without evidence obstructs of
obstruction. Enteric contrast is seen to the level of the mid small bowel.
Fatty infiltration in the wall of the descending colon may reflect sequela of
previous inflammation, no definite evidence of acute process. Normal
appendix.
LYMPH NODES: There is no mesenteric or retroperitoneal lymphadenopathy.
Small porta hepatic lymph nodes are not pathologically enlarged by CT size
criteria measuring up to 9 mm (02:54).
VASCULAR: The abdominal aorta is normal in caliber but cannot be further
evaluated. The hepatic vasculature cannot be evaluated.
OSSEOUS STRUCTURES: There is no worrisome sclerotic or lytic lesion. There
is no significant degenerative change in the thoracic or lumbar spine. There
is diffuse subcutaneous edema.
IMPRESSION:
1. Mild cardiomegaly without pericardial effusion. Suggestion of anemia.
2. Suggestion of pulmonary hypertension.
3. Moderate bibasilar atelectasis and mild mucous plugging, right greater than
left. An underlying infection or aspiration cannot be excluded in the proper
clinical setting.
4. Subpleural posterior consolidation in the left upper lobe could reflect
atelectasis but warrants follow-up in 3 months to exclude an underlying
malignancy.
5. No acute abnormality in the abdomen. Nondistended gallbladder with
gallbladder wall thickening likely related to to clinical history of liver
disease, or systemic causes ; cholecystitis is unlikely. .
RECOMMENDATION(S): Follow-up chest CT in 3 months after resolution of acute
illness.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST
INDICATION: ___ year old woman admitted to ICU for acute liver failure,
developed respiratory distress and has evidence of RV dysfunction. Has
worsening ___ with up trending Cr. // Evaluate for intrathoracic pathology.
TECHNIQUE: Contiguous helical MDCT images were obtained through the chest and
abdomen without IV contrast. Multiplanar axial, coronal in sagittal images
were generated and reviewed. Enteric contrast was administered.
DOSE: Total DLP (Body) = 723 mGy-cm.
COMPARISON: Chest radiographs ___ and ___. Abdominal
ultrasound ___.
FINDINGS:
CT CHEST: ET tube terminates approximately 2.5 cm from the carina. Right
internal jugular central venous catheter terminates in mid SVC. Enteric tube
courses through the esophagus and into the stomach.
The thyroid is grossly normal. There is no supraclavicular, axillary,
mediastinal or hilar lymphadenopathy within the limitations of a noncontrast
enhanced study.
There is mild cardiomegaly without pericardial effusion. Hyperattenuation of
cardiac myocardium relative to blood pool may be seen in the setting of
anemia. The thoracic aorta and proximal great vessels are normal in caliber.
The main pulmonary artery is mildly dilated measuring 3.1 cm.
The central airways are patent. Upper lobe bronchi are normal in caliber
without wall thickening. There is mild mucous plugging at the lung bases
(4:157). There is no pneumothorax. There is moderate bibasilar atelectasis,
right greater than left. There is an irregularly shaped subpleural posterior
consolidation in the left upper lobe measures 3 x 1.4 cm (04:47). There is
minimal, nonspecific, pleural thickening or scarring at the right apex
(___). There are small pleural effusions.
CT ABDOMEN:
HEPATOBILIARY: The liver is suboptimally evaluated on this noncontrast
enhanced study. Within these limitations there is no evidence of intrahepatic
biliary duct dilation. The liver contour is smooth. No large hepatic mass is
detected. The portal vein cannot be evaluated.
GALLBLADDER: There is gallbladder wall edema in a nondistended gallbladder
which can be seen with systemic causes, chronic liver disease, chronic or
acute cholecystitis are less likely.
SPLEEN: Normal in size and attenuation
ADRENAL GLANDS: Normal
PANCREAS: Normal in size and attenuation without peripancreatic stranding.
KIDNEYS: Kidneys are normal in size without hydronephrosis. The proximal
ureters are normal in caliber.
STOMACH AND BOWEL: The stomach is normal in caliber containing enteric
contrast. Enteric tube terminates in the gastric antrum. Included loops of
small and large bowel are normal in caliber without evidence obstructs of
obstruction. Enteric contrast is seen to the level of the mid small bowel.
Fatty infiltration in the wall of the descending colon may reflect sequela of
previous inflammation, no definite evidence of acute process. Normal
appendix.
LYMPH NODES: There is no mesenteric or retroperitoneal lymphadenopathy.
Small porta hepatic lymph nodes are not pathologically enlarged by CT size
criteria measuring up to 9 mm (02:54).
VASCULAR: The abdominal aorta is normal in caliber but cannot be further
evaluated. The hepatic vasculature cannot be evaluated.
OSSEOUS STRUCTURES: There is no worrisome sclerotic or lytic lesion. There
is no significant degenerative change in the thoracic or lumbar spine. There
is diffuse subcutaneous edema.
IMPRESSION:
1. Mild cardiomegaly without pericardial effusion. Suggestion of anemia.
2. Suggestion of pulmonary hypertension.
3. Moderate bibasilar atelectasis and mild mucous plugging, right greater than
left. An underlying infection or aspiration cannot be excluded in the proper
clinical setting.
4. Subpleural posterior consolidation in the left upper lobe could reflect
atelectasis but warrants follow-up in 3 months to exclude an underlying
malignancy.
5. No acute abnormality in the abdomen. Nondistended gallbladder with
gallbladder wall thickening likely related to to clinical history of liver
disease, or systemic causes ; cholecystitis is unlikely. .
RECOMMENDATION(S): Follow-up chest CT in 3 months after resolution of acute
illness.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old woman with acute liver and kidney failure, no bowel
movements on lactulose // Assess for ileus or obstruction
TECHNIQUE: Abdomen single view
COMPARISON: CT abdomen ___
FINDINGS:
Mild gastric distention. Few mildly distended loops of colon. Residual
contrast in the bowel loops. No evidence of obstruction. There is contrast
at the rectosigmoid. Bibasilar opacities are suboptimally seen, consider
atelectasis, infiltrate. Probable cardiomegaly.
IMPRESSION:
Few mildly distended loops of colon, contrast is seen to the level of
rectosigmoid. No evidence of obstruction. Basilar opacities, consider
atelectasis, infiltrate, suboptimally evaluated
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with fulminant liver and renal failure with
increasing lethargy // Assess for intracranial hemorrhage or other etiology of
obtundation
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.8 s, 16.1 cm; CTDIvol
= 52.7 mGy (Head) DLP = 848.0 mGy-cm. Total DLP (Head) = 848 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. Diminutive
appearance of the ventricles and minimal sulcal effacement could suggest early
global cerebral swelling. Gray-white matter differentiation is preserved.
The basal cisterns are patent. Periventricular white matter hypodensities
likely reflect sequela of chronic small vessel ischemic disease.
There is no evidence of fracture. There is opacification of some anterior
ethmoidal air cells and mucosal thickening of the sphenoid sinus bilaterally,
otherwise visualized portion of the paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. Suggestion of early global cerebral swelling. No evidence of hemorrhage or
infarction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with fulminant hepatorenal failure, new fever
// Assess for pneumonia Assess for pneumonia
IMPRESSION:
Compared to chest radiographs ___ and ___.
Moderate enlargement of the cardiac silhouette has increased due to
cardiomegaly and/or pericardial effusion. Pulmonary vascular congestion has
worsened. Opacification at the right lung base could be a combination of
atelectasis, following tracheal extubation, and vascular engorgement, but
should be followed for early pneumonia with conventional radiographs if
feasible.
Right jugular line ends in the mid SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p intubation // placement of ET tube
TECHNIQUE: Single frontal view of the chest.
COMPARISON: Same-day chest radiographs.
FINDINGS:
Compared to chest radiographs from a few hours earlier, pulmonary edema has
resolved. There has been interval placement of a endotracheal tube, which
terminates approximately 3.3 cm above the carina. Lungs are grossly clear
without focal consolidation, effusion or pneumothorax. Retrocardiac and
bibasilar opacities are unchanged and likely represent atelectasis. Moderate
cardiomegaly is stable.
New nasogastric tube descends below level of diaphragm with side ports beyond
the level of the gastroesophageal junction. Right IJ central venous catheter
tip terminates in the mid SVC.
IMPRESSION:
1. Endotracheal tube terminates approximately 3.3 cm above the carina.
2. Resolved pulmonary edema.
3. Unchanged retrocardiac and bibasilar opacities, likely reflecting
atelectasis.
4. Stable moderate cardiomegaly.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ year old woman with acute hepatorenal failure now with rising
lactate and newly tender abdomen // Assess for infectious source or evidence
of mesenteric ischemia
TECHNIQUE: Multidetector CT of the abdomen and pelvis was performed without
contrast. Multiplanar reformations were provided.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.5 s, 71.4 cm; CTDIvol = 15.0 mGy (Body) DLP =
1,072.4 mGy-cm.
Total DLP (Body) = 1,072 mGy-cm.
COMPARISON: CT abdomen ___
FINDINGS:
Lower Chest: Please see separately dictated CT chest from today
Abdomen and Pelvis:
Hepatobiliary: There are no hepatic abnormalities. Previously seen
gallbladder wall below team a has resolved. There is no pericholecystic
stranding. No evidence of bile duct dilatation.
Spleen: Normal
Adrenals: Normal
Kidneys, Bladder, Ureters: Normal kidneys. No hydronephrosis. Foley catheter
in the bladder.
Pancreas: While there is diffuse subcutaneous edema suggesting fluid overload,
there is suggestion of mild peripancreatic edema about pancreatic tail,
clinically correlate as findings may represent acute pancreatitis. No
peripancreatic organized fluid collection.
Gastrointestinal: Enteric tube tip is in the distal stomach. There is rectal
tube in place. There is stable fatty infiltration of the wall of the
descending, rectosigmoid colon, likely sequela of prior inflammatory or
infectious colitis, no definite evidence of acute process. . Normal
appendix. No bowel dilatation. No free air, no free fluid.
Lymph Nodes: No adenopathy
Pelvis: No free fluid
Reproductive Organs: No abnormality
Vascular: Minimal atherosclerotic changes
Soft Tissues: Diffuse soft tissue edema
Bones: There are mild degenerative changes in the lumbar spine. There is
benign bone island in the left hip.
IMPRESSION:
Suggestion of acute pancreatitis involving pancreatic tail.
Diffuse soft tissue edema.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST.
INDICATION: ___ year old woman with acute liver failure and acute renal
failure, AMS with CT Head showing early global cerebral swelling // cerebral
swelling, acute findings.
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: Head CT dated ___.
FINDINGS:
There is no evidence of intracranial hemorrhage, mass, mass effect or shifting
of the normally midline structures. The ventricles and sulci are normal in
size and configuration for the patient's age. No diffusion abnormalities are
detected. Small subependymal hyperintense areas are noted adjacent to the
left ventricular horns (for example image 14, series 10), which are
nonspecific and may represent some gliotic areas and of doubtful clinical
significance. The major vascular flow voids are present and demonstrate
normal distribution. The orbits are unremarkable, the paranasal sinuses are
notable for mucosal thickening in the maxillary sinuses, more significant on
the right, frontoethmoidal recesses, frontal sinus, sphenoid sinus. Bilateral
mucosal thickening is present mastoid air cells, more significant on the left.
IMPRESSION:
1. There is no evidence acute or subacute intracranial process, there is no
evidence of intracranial hemorrhage.
2. Paranasal sinus disease as described above.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ woman with acute hepatopetal failure, now with rising
lactate and new leak tender abdomen. Assess for infectious source or evidence
of mesenteric ischemia.
TECHNIQUE: Contiguous helical multi detector CT images were obtained through
the chest without intravenous contrast.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: CT chest performed ___.
FINDINGS:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Endotracheal tube tip is in the
proximal right mainstem bronchus. NG tube is noted with tip in the stomach.
A right internal jugular central venous line is noted with tip in the upper
superior vena cava. Thyroid is unremarkable. No supraclavicular or axillary
lymphadenopathy.
UPPER ABDOMEN: Please refer to separate report of CT abdomen and pelvis
performed the same day for description of the findings.
MEDIASTINUM: There is no mediastinal lymphadenopathy.
HILA: There is no hilar lymphadenopathy.
HEART and PERICARDIUM: Cardiomegaly is again noted. Suggestion of anemia. No
pericardial effusion. The visualized thoracic aorta and great vessels are
unremarkable. The main pulmonary artery is dilated measuring 3.5 cm,
previously measuring 3.1 cm.
PLEURA: No pleural effusion.
LUNG:
-PARENCHYMA: Focal consolidation and adjacent nodularity in the posterior
aspect of the left upper lobe is not significantly changed compared to the
prior exam. Linear and ground-glass opacities noted in both lung bases have
improved, consistent with atelectasis ; infection, should be considered.
Pattern not typical of pulmonary hemorrhage. .
-AIRWAYS: Motion artifact in the lung bases is demonstrated but there appears
to be improvement in mucus plugging compared to the prior.
-
CHEST CAGE: No acute osseous or abnormality.
IMPRESSION:
1. Proximal right mainstem bronchus intubation, endotracheal tube should be
pulled back.
2. Consolidation, adjacent nodularity in the posterior left upper lobe is
unchanged, is indeterminate, follow-up exam is recommended.
3. Improvement in bibasilar atelectasis ; residual ground-glass opacities may
be sequela of re-expansion; infection is less likely. .
4. No new acute abnormality in the chest.
RECOMMENDATION(S): Follow-up of left upper lobe consolidation with CT in 3
months time.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 6:37 ___, 10 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with acute liver and renal failure,
pancreatitis // pna, pulm edema pna, pulm edema
IMPRESSION:
Comparison to ___. The monitoring and support devices are
stable. Stable retrocardiac atelectasis. Moderate cardiomegaly and minimal
elevation of the left hemidiaphragm persists. No overt pulmonary edema. No
new focal parenchymal opacities.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old woman with acute liver failure, acute pancreatitis,
now worsening LFT's; would prefer portable as patient's status is very tenuous
// PV thrombus, any stones; please assess with Doppler; would prefer portable
as patient's status is very tenuous
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdomen CT ___, abdomen CT ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. There is no focal liver mass. There is scant trace
ascites seen only in the perihepatic space.
A small oval hypoechoic structure is adjacent to the anterior margin of the
liver, near the gallbladder, measuring 1.5 x 2.2 x 2.6 cm. Referring back to
the Abdomen CT of ___ this structure is a lobule of fatty tissue
either representing an omental lipoma or torsed epiploic appendage.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 2 mm.
GALLBLADDER: Small stones and sludge are noted in the gallbladder. The
gallbladder wall is not edematous and no pericholecystic fluid is seen.
PANCREAS: The head, body, and proximal tail of the pancreas are within normal
limits, without masses or pancreatic ductal dilatation.The distal tail is not
well seen. No peripancreatic fluid collections identified.
DOPPLER EXAMINATION: The main, right and left portal veins are patent with
hepatopetal flow. Pulse subtle waveforms within the portal veins are noted
which could be due to right heart failure. The hepatic veins and IVC are
patent. Appropriate arterial waveforms are seen in the main, right and left
hepatic arteries.
IMPRESSION:
1. Patent hepatic vasculature. Pulsatile waveforms within the portal veins
could be due to right heart failure.
2. Small stones and sludge noted in the gallbladder. There is no sonographic
sign of cholecystitis and there is no biliary dilation.
3. Scant trace ascites seen only in the perihepatic space.
4. Normal sonographic appearance of the pancreas with no evidence of secondary
sequelae of acute pancreatitis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with hepatorenal failure, AMS and CNS opening
pressure 34. Evaluate for cerebral edema or herniation.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.2 cm; CTDIvol = 52.2 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: CT head from ___ and MR brain performed earlier on
the same day at 01:40
FINDINGS:
The study is slightly limited due to patient positioning. Allowing for this,
there is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration. Intracranial
findings are stable compared with brain MRI from earlier today, and CT from
yesterday. No herniation.
There is no evidence of fracture. An enteric tube is partially visualized at
the nasopharynx. Patient is status post prior right sinus surgery. There is
moderate paranasal sinus opacification, likely due to intubation. Mastoid air
cells and middle ear cavities are clear. The visualized portion of the orbits
are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with acute liver failure and AMS // pna, pulm
edema pna, pulm edema
IMPRESSION:
In comparison with the study of ___, the monitoring support devices
are essentially unchanged. Continued retrocardiac opacification consistent
with volume loss in the left lower lobe and pleural effusion. Cardiac
silhouette remains enlarged with mild elevation in pulmonary venous pressure.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with acute liver failure and acute systolic CHF
EF 20%; please perform by 9:30 am // pna, pulm edema; please perform by 9:30
am pna, pulm edema; please perform by 9:30 am
IMPRESSION:
ET tube tip is 4 cm above the carinal. NG tube tip is in the stomach. Right
internal jugular line tip at the level of mid SVC. Heart size and mediastinum
are stable. Bibasal consolidations, left more than right are similar to
previous study there is minimal improvement in vascular congestion.
Radiology Report
INDICATION: History: ___ with acute liver failure, unclear cause. //
***PORTABLE*** eval for portal thrombosis, include Dopplers
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: None available
FINDINGS:
Liver: The hepatic parenchyma is slightly echogenic. No focal liver lesions
are identified. There is no ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 2 mm.
Gallbladder: There is cholelithiasis without gallbladder distention. There
is moderate wall edema.
Pancreas: The imaged portion of the pancreas appears within normal limits,
with portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 8.6 cm.
Kidneys: No hydronephrosis in the right kidney.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 24 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.
The IVC is patent.
IMPRESSION:
1. Patent hepatic vasculature and IVC.
2. Slightly echogenic liver and gallbladder wall edema without gallbladder
distention are compatible with provided history of liver failure.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with ETT placement // ETT placement
COMPARISON: Chest radiograph ___
FINDINGS:
ET tube tip is approximately 2.4 cm above the carina. Right jugular line tip
projects over the mid SVC. There is no focal consolidation, effusion, or
pneumothorax. Heart size is mildly enlarged and there is vascular congestion
but no oevert edema. The mediastinal silhouette is normal. No free air below
the right hemidiaphragm is seen.
IMPRESSION:
ET tube tip is approximately 2.4 cm above the carina.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with right heart strain, acute liver failure
// eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Transfer
Diagnosed with Acute respiratory failure, unsp w hypoxia or hypercapnia
temperature: 100.0
heartrate: 112.0
resprate: 28.0
o2sat: 100.0
sbp: 120.0
dbp: 91.0
level of pain: 0
level of acuity: 2.0 | Ms ___ is a ___ with h/o asthma, depression, anorexia w/
laxative abuse who was recently treated for PNA with Augmentin
initially went to her PCP and then an outside hospital for
shortness of breath and new peripheral edema. Her work up at the
OSH showed a Troponin of 7, BNP of 30000, Creat of 1.35, and a
marked transaminitis concerning for acute liver failure. She was
transferred to ___ for further care and eval for liver
transplant.
Tox screen negative, but she was empirically given NAC given
abnormal LFTs and concern for drug toxicity. She also had an
ECHO which showed an EF of 35% consistent with new systolic
heart failure. She was also found to have ATN, with Cr peaking
at 7.2; ALT/AST 8000s/12000s. She was intubated ___ mental
status change thought to be due to hepatic encephalopathy. A
head CT was obtained which demonstrated early global cerebral
swelling. Pt was started on EEG and neurology was consulted. EEG
showed irritability but no frank seizures; she was started on
keppra. LP done on ___ which showed elevated opening pressure,
but negative otherwise. Patient was extubated ___ with
improved mental status. She was transferred to the floor. LFTs,
renal function improved. Repeat echos with nadir at 25%, though
EF improved to 33% prior to DC. Patient worked with ___. She
was seen by psych in the setting of significant h/o depression,
anorexia and laxative abuse. They did not feel she was SI/HI or
had a purposeful ingestion.
Pt's mental status continued to improve prior to discharge,
A+Ox3, without asterixis. She was on rifaximin and lactulose per
Hepatology, but this was discontinued once her LFTs and mental
status normalized. Heme-Onc was consulted for severe anemia on
presentation, along with questionable hyper-coaguable state, pt
will f/u with Hematology as outpatient. She will also follow-up
with cardiology upon discharge for her new heart failure with
systolic dysfunction.
#Acute respiratory failure:
Patient was intubated x 2 during MICU course. Initial intubation
was in ED for unclear reasons, and patient weaned off ventilator
in a few days. Patient then became increasingly altered and
tachypneic, with sustained RR in ___. Imaging showed possible
evidence of pneumonia and she was treated with antibiotics. Also
attributed to possible encephalopathy. As mental status improved
she was able to be weaned from the vent and was extubated on
___.
#Acute liver failure:
Her initial lab work showed AST > 12k and ALT > 8k with elevated
INR and Tbili. ALT/LDH ratio <1.5 and rapid rise of LDH with
associated ATN point to possible ischemic etiology. Serum
acetaminophen and ETOH negative. Broad workup initiated which
was mostly unremarkable for causes of acute liver failure.
Patient does have known history of laxative abuse and was
reportedly taking "handfuls" of bisacodyl which could have
contributed. She was treated with NAC until INR downtrended
below 2. She did have evidence of cerebral edema on CT Head and
patient had altered mental status and was treated with
lactulose/rifaximin. LFTs trended down during hospital course
and coags normalized. Her lactulose/rifaximin were discontinued
after her mental status and LFTs normalized.
#Acute renal failure, acute tubular necrosis:
Her creatinine peaked in the 7's, though patient never lost the
ability to make urine. Consideration was given for dialysis for
uremia/altered mental status but deferred as UOP picked up and
encephalopathy improved. Cr 1.1 on discharge.
#Toxic metabolic encephalopathy:
After initial extubation, patient became increasingly altered
and would not follow commands and would not speak. With
concomitant tachypnea, she was intubated. CT Head showed
possible early global cerebral edema. LP performed had elevated
opening pressure to 34. CSF studies unremarkable. EEG with
generalized cortical irritability, and neurology recommended
starting her on Keppra. Neurosurgery placed an intracranial bolt
for ICP monitoring and this was normal. Lactulose/rifaximin
continued in case hepatic encephalopathy. Abx given at
meningitic doses, with ___ompleted. Her
encephalopathy improved throughout hospital course and she
became more responsive and oriented. She had some asterixis, but
upon discharge this was gone and she was A+Ox3 and able to say
days of week backwards.
#Acute systolic CHF:
Patient's initial echo showed EF 35% with global hypokinesis.
As patient worsened, repeat echo showed EF 20% with again global
hypokinesis. Cardiology consulted for questionable cardiac
biopsy but deferred as thought to be low-yield in terms of
providing info for overall picture of patient and in setting of
___. Patient will have follow-up with heart failure specialist
who can consider MR vs. biopsy. Repeat echo prior to d/c with EF
33%. Patient was started on coreg 12.5 mg BID and lisinopril 2.5
mg qd.
#Microcytic Anemia:
From collateral from PCP prior labs ___/ MCV 83, H&H ___
(normocytic anemia). No Fe studies per outpt PCP. RI on ___
with RI<2% likely rep of underproduction. However, repeat RI >
2% w/ normal hapto and no evidence of acute blood loss. Fe snl,
TIBC wnl and ferritin normal. Fe/TIBC 21% which is not c/w Fe
def anemia. Fe/TIBC 21% could be c/w anemia of chronic
inflammation, but ferritin nrm and Fe and TIBC wnl. Started Fe
supplement per heme-onc.
# h/o Depression
# h/o Anorexia/bulimia w/ laxative use
On disability for depression and anorexia. Collateral from
family indicates she may have been using at home. Unclear if
possible ingestion contributed to presentation and multi-organ
failure. Patient denies SI/HI prior to hospitalization. Does
report large ingestions of laxatives. Psych consulted and
strongly advises patient to have psych/SW follow-up for rehab.
She also recs DMH referral. Held home mirtazapine,
amitriptyline, alprazolam, venlafaxine, sertraline per
psychiatry.
# h/o anorexia w/ laxative abuse and depression. Per her
parents/patient, was abusing bisacodyl prior to presentation
# Pancreatitis: Unknown etiology. Abdomen has remained
non-tender.
# Nutrition
continued S/S eval as patient transitions to rehab and consider
DMP as part of dc planning.
# Elevated intracranial pressure- resolved: Discovered on LP w/
some evidence of cerebral edema on CT head. Initially had ICP
monitoring w/ normal pressures. D/c bolt on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Ibuprofen
Attending: ___.
Chief Complaint:
Transient slurring of speech, right eye visual changes, left
hand numbness -- R ICA occlusion and R fronto-parietal infarct
Major Surgical or Invasive Procedure:
None
History of Present Illness:
NIHSS Total Score: 0
HISTORY OF PRESENT ILLNESS:
Mr. ___ is a ___ y/o right-handed man with a history of
paroxysmal A-fib (not on anticoagulation), HTN, HLD who presents
after transient episodes of visual changes, slurred speech and
left-sided numbness.
His symptoms began 3 days before admission. He was rowing at the
gym when he suddenly saw white, fluffy spots appear in the
___ his right eye visual field, which turned purple after
20 minutes. ___ hours later, his right eye became clouded over.
There was no lightheadness or diplopia, and these symptoms
lasted for approximately 1 day.
The day of admission, he was visiting his PCP with regards to
his visual changes. His PCP recommended he start anticoagulation
therapy with apixaban for his A-fib, given concern for a right
ophthalmic embolus. While driving home around 3:30 pm with his
wife, she noted slurred speech and asked him to pull over. This
lasted approximately 30 minutes
and now is fully resolved. Patient denies word finding
difficulty and states that comprehension was intact. He denies
focal weakness, numbness, ataxia, vision changes, gait
instability. He denies recent infectious symptoms, headache,
neck pain. He does
not recall any recent head trauma or strain.
On neuro ROS, the pt denies headache, loss of vision, diplopia,
dysarthria, dysphagia, vertigo. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or
retention.Denies difficulty with gait.
On general review of systems, 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 rash.
Past Medical History:
- Paroxysmal A-fib (only on full-dose aspirin, not
anti-coagulated)
- Hypertension
- Hyperlipidemia
- Sleep apnea (uses CPAP)
Social History:
___
Family History:
- Father: ___ MIs, deceased at age ___ from MI
- Paternal uncle: heart disease
- Mother: alcohol use, deceased in early ___
Physical Exam:
Physical Exam:
Vitals: T 98.2 HR 80 BP 80/101 RR 15 O2 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: Anisocoria--R pupil 2-->1mm, L 3-->2mm; mild ptosis on R.
VFF to confrontation. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages.
III, IV, VI: EOMI with sustained left beating horizontal
nystagmus on left gaze. Normal saccades.
V: Facial sensation intact to light touch.
VII: Right ptosis.
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 but does have upward drift on the Left. No
adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ ___ 5 5
R ___ ___ ___ ___ 5 5
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. + extinction to DSS on left and agraphesthesia on L.
-DTRs:
Bi Tri ___ Pat Ach
L ___ 2 0
R ___ 2 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
Discharge exam:
Sensation to light touch and pin is improved. Still neglecting
left side in visual and tactile modalities.
Pertinent Results:
ADMISSION LABS:
WBC-8.9 RBC-5.00 HGB-15.8 HCT-43.5 MCV-87 MCH-31.5 MCHC-36.3*
RDW-13.4 PLT COUNT-239
___ PTT-32.1 ___
GLUCOSE-157* NA+-141 K+-4.4 CL--103 TCO2-26 UREA N-18 CREAT-0.9
ALT(SGPT)-88* AST(SGOT)-48* ALK PHOS-85 TOT BILI-0.6
STROKE WORKUP:
%HbA1c-5.6 eAG-114
Cholest-199 Triglyc-216* HDL-46 CHOL/HD-4.3 LDLcalc-110
IMAGING:
MRI/MRA head
1. Acute/subacute infarction in the right frontal parietal lobe
in the right MCA territory. No evidence of hemorrhage.
2. Occlusion of the right ICA beginning at the level of the
carotid
bifurcation with reconstitution of flow at the distal right
carotid terminus with decreased flow related enhancement in the
right MCA and right ACA and the right MCA territory compared to
the left.
3. Focal stenosis with poststenotic dilatation involving the
distal right vertebral artery.
CTA head
1. Complete occlusion of the right internal carotid artery,
beginning its
proximal aspect with distal reconstitution within its proximal
cavernous
segment, likely retrograde flow via the circle ___.
2. Right vertebral artery stenosis with poststenotic dilatation,
measuring up to 4.7 mm.
Medications on Admission:
Atorvastatin 80mg qd
Flecainide 150mg bid
Metoprolol ER 100mg qd
Aspirin 325mg qd
Vitamin C daily
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Flecainide Acetate 150 mg PO Q12H
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 5 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
5. Ascorbic Acid 0 mg PO DAILY
6. Outpatient Occupational Therapy
Diagnosis ischemic stroke ___
Discharge Disposition:
Home
Discharge Diagnosis:
- Right internal carotid artery occlusion
- Right fronto-parietal lobe infarct
ACUTE ISCHEMIC STROKE
RIGHT INTERNAL CAROTID OCCLUSION
ATRIAL FIBRILLATION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS
INDICATION: History: ___ with slurred speech // eval for ICH
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. Three-dimensional angiographic volume rendered, curved
reformatted and segmented images were generated on a separate workstation and
reviewed. This report is based on interpretation of all of these images.
DOSE: This study involved 5 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
1,009.3 mGy-cm.
4) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
5) Spiral Acquisition 5.3 s, 41.4 cm; CTDIvol = 35.5 mGy (Head) DLP =
1,471.1 mGy-cm.
Total DLP (Head) = 2,502 mGy-cm.
COMPARISON: CTA head ___.
FINDINGS:
Head CT: There is no evidence of acute intracranial hemorrhage or mass
effect. The ventricles and basal cisterns appear normal. The brain
parenchymal volume is within normal limits. The orbits and skull base are
unremarkable. There is right maxillary sinus mucosal thickening.
Head CTA: Anterior cerebral arteries, middle cerebral arteries, posterior
cerebral arteries appear patent. There is no stenosis or occlusion.
Neck CTA: The aortic arch demonstrates a common origin of the brachiocephalic
artery in common carotid artery. The origin of the right subclavian artery is
tortuous. The left vertebral artery is slightly dominant. The vertebral
arteries are patent throughout their course within the neck there is focal
stenosis of the V4 segment of the right vertebral artery with poststenotic
dilatation, measuring 4.7 mm. The common carotid arteries appear normal. The
right internal carotid artery is completely occluded, beginning in its origin,
with distal reconstitution in its proximal cavernous portion likely via
retrograde flow from Circle ___.
The lung apices appear normal. The thyroid gland, submandibular glands, and
parotid glands appear normal.
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Complete occlusion of the right internal carotid artery, beginning its
proximal aspect with distal reconstitution within its proximal cavernous
segment, likely retrograde flow via the circle ___.
3. Right vertebral artery stenosis with poststenotic dilatation, measuring up
to 4.7 mm.
NOTIFICATION:
The findings were discussed by Dr. ___ with Dr. ___ on the telephone
on ___ at 5:52 ___, 5 minutes after discovery of the findings.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with AMS // eval for PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
There are relatively low lung volumes. The lungs are clear without focal
consolidation. No pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ year old man with like stroke // please assess for ischemic
stroke
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with MIP reconstructions. Dynamic MRA of the neck was
performed during administration of 15cc of Multihance intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
COMPARISON: No prior MRI available for comparison. Prior CT and CTA dated ___.
FINDINGS:
MRI Brain: There is slow diffusion in the right frontal and parietal lobe
with involvement of both the precentral gyrus and postcentral gyrus noted.
There is T2/FLAIR signal hyperintensity within this region. Findings are
consistent with late acute/ early subacute infarction. There are a few
additional foci of T2/FLAIR signal hyperintensity in the subcortical white
matter which are nonspecific but may reflect the sequela of chronic small
vessel ischemic disease. There is no evidence of extra-axial collection,
acute hemorrhage, or midline shift. Ventricles and sulci are normal in
caliber and configuration. The orbits are unremarkable. There is mild
mucosal thickening within the ethmoid air cells. The remaining paranasal
sinuses and mastoid air cells are clear.
MRA brain: There is no flow related enhancement in the proximal intracranal
portion of the right ICA. There is reconstitution of flow seen in the the
distal right carotid terminus with flow in the right MCA and right ACA. Flow
related contrast enhancement is decreased in the right MCA and right ACA
compared to the left. There is also decreased distal perfusion noted within
the right MCA territory compared to the left MCA territory. The left MCA,
ACA, and internal carotid artery are normal. There is focal fusiform
aneurysmal dilatation of the right vertebral artery just proximal to the
vertebrobasilar junction which appears similar to prior CTA. The left
vertebral artery and basilar artery are normal.
MRA neck: There is complete occlusion of the right ICA beginning at the
bifurcation with reconstitution of flow not apparent to the level of the
carotid terminus. The common, left internal and external carotid arteries
appear normal. There is no evidence of stenosis by NASCET criteria. The
origins of the great vessels, subclavian and vertebral arteries appear normal
bilaterally. There is no evidence of dissection.
IMPRESSION:
1. Acute/subacute infarction in the right frontal parietal lobe in the right
MCA territory. No evidence of hemorrhage.
2. Occlusion of the right ICA beginning at the level of the carotid
bifurcation with reconstitution of flow at the distal right carotid terminus
with decreased flow related enhancement in the right MCA and right ACA and the
right MCA territory compared to the left.
3. Focal stenosis with poststenotic dilatation involving the distal right
vertebral artery. .
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with OCCLUS CAROTID ART W/INFARCT, ATRIAL FIBRILLATION
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | On presentation, Mr. ___ had a ___ Horner's,
left-sided deficits to light touch and pin and left-sided
neglect in multiple sensory modalities. His NIHSS score was 0,
and tPA was not given as his symptoms were resolving. CTA
revealed total occlusion of right internal carotid artery, with
distal reconstitution of flow. MRI showed acute infarct in the
right fronto-parietal lobe in the distribution of inferior
division of the right MCA. There was no evidence of carotid
artery dissection by fat sat MRA. Given the robust collateral
flow, the differential was thought to be infarct due to
thrombosis vs. cardio-embolus, and included the possibility of a
cardio-embolus acutely occluding a chronically stenosed right
ICA from atherosclerosis or prior dissection. His stroke workup
was otherwise notable for LDL 110, HDL 46, ___ 216 (elevated) and
HbA1c 5.6%. No echocardiogram was obtained as it would not
change his management. He had been started on heparin gtt on
admission, which was changed to apixaban 5 mg BID and his
aspirin was stopped. His statin was continued.
On his CTA there was an incidental finding of a 5 mm fusiform
aneurysm in the right vertebral artery for which he should
follow up in ___ clinic.
================================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient
Ischemic Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No
4. LDL documented? (x) Yes (LDL = PND) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
___: VP Shunt insertion
History of Present Illness:
This is a ___ y.o. male with history of multiple metastatic
melanoma to multiple areas of the brain who underwent a
cyberknife treatment yesterday. Apparently, patient went back
to nursing home in normal state of health. He began to
decompensate and became lethargic with projectile vomiting.
Patient
transported to ___ where a head CT showed posterior fossa
showed increase cerebral edema. Neurosurgery consulted for
further management.
Past Medical History:
metastatic melanoma, hypertension, allergic rhinitis, b12
deficiency
Social History:
___
Family History:
Brother may have had melanoma
Physical Exam:
O: AF 156/78 65 12 98% 4L NC
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
AOx1, PERRL ___, + papilledema bilaterally, right lateral gaze
defect. dysphasic, follows simple commands with significant
encouragement. moves ___ L>R.
+ clonus 2-beats b/l, Babinski is extensor bilaterally
Sensation: Intact to light touch
Toes downgoing bilaterally
On Discharge:
Patient is oriented x 2, + simple commands, rightward gaze
slightly limited but nearly full, verbalizes at times, left
ptosis
Pertinent Results:
___ CXR- IMPRESSION: Stable findings consistent with
metastatic disease.
___ ___- IMPRESSION:
1. Multiple supra- and infra-tentorial metastatic lesions
either stable or enlarged since most recent exam. Most notably,
there is enlargement of the right cerebellar lesion with
increased surrounding vasogenic edema. New effacement of fourth
ventricle which is shifted to the left and progressive
effacement of the prepontine cistern and crowding at the foramen
magnum. Progressive enlargement of the lateral and third
ventricles concerning for developing hydrocephalus.
___ ___-
Interval placement of a left frontal approach ventricular shunt.
Degree of hydrocephalus appears minimally decreased compared to
recent prior examination. Expected postoperative changes without
other significant change compared to recent prior.
Medications on Admission:
1. Cyanocobalamin 500 mcg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Sertraline 200 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
6. LeVETiracetam 500 mg PO BID
7. traZODONE 25 mg PO HS:PRN sleep
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*15 Tablet Refills:*0
8. Dexamethasone 4 mg PO Q8H
9. Insulin SC Sliding Scale
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN temp; pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
3. Cyanocobalamin 500 mcg PO DAILY
4. Dexamethasone 6 mg IV Q8H
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
8. Heparin 5000 UNIT SC TID
9. HydrALAzine ___ mg IV Q6H:PRN SBP >160
10. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using REG Insulin
11. LeVETiracetam 500 mg IV BID
12. Milk of Magnesia 30 mL PO Q6H:PRN constipation
13. Morphine Sulfate ___ mg IV Q4H:PRN pain
14. Ondansetron 4 mg IV Q8H:PRN nausea; vomiting
15. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
16. Pantoprazole 40 mg PO Q24H
17. Senna 1 TAB PO BID:PRN constipation
18. Sertraline 200 mg PO DAILY
19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
20. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hydrocephalus
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
CHEST RADIOGRAPH PERFORMED ON ___
___.
CLINICAL HISTORY: Altered mental status, history of melanoma with brain
metastasis, patient altered with vomiting.
FINDINGS: AP upright portable chest radiograph obtained. There is a large
mass in the left lower lung accounting simulating an elevated hemidiaphragm.
Also noted is stable left upper lobe perihilar opacity compatible with known
metastasis. The right lung is clear. Cardiomediastinal silhouette appears
grossly unremarkable, though left heart border is partially obscured. No free
air below the right hemidiaphragm. Bony structures appear grossly intact.
IMPRESSION: Stable findings consistent with metastatic disease.
Radiology Report
HEAD CT WITHOUT CONTRAST: ___.
HISTORY: ___ male with known brain metastasis due to melanoma, now
with altered mental status and vomiting. Question intracranial hemorrhage or
bleed into metastases.
TECHNIQUE: Contiguous axial images were obtained from skull base to vertex
without intravenous contrast. Coronal and sagittal reformats were reviewed.
COMPARISON: Head CTs from ___ and ___ and brain MR
from ___.
FINDINGS: Again seen are multiple relatively hyperdense supra- and
infratentorial lesions compatible with patient's known metastatic melanoma.
There is no definite evidence of hemorrhage. There has, however, been
interval enlargement of several of these metastases. The largest of which in
the cerebellum on the right measures 2.6 x 2.4 cm, previously 2.4 x 2.1 cm on
prior. Additional lesion in the right frontal lobe (series 2, image 13) which
measures 11 mm, approximately 10 on prior, but this lesion was only 4 mm on
___. Additional lesions are seen in the left middle cerebellar
peduncle and the right frontal lobe at the vertex, similar to prior.
Additional lesion also in the left frontal lobe (series 2, image 23). In
addition, there is apparent new hyperdensity in the left frontal lobe (image
17) potentially metastatic lesion.
When compared to prior, there is increased vasogenic edema surrounding these
lesions most notably surrounding the right cerebellar lesion. There is new
effacement of the fourth ventricle which is displaced to the left, which is
new compared to prior. There is also near complete effacement of the
prepontine cistern. There is crowding at the foramen magnum without frank
tonsillar herniation. These findings all have progressed since most recent
exam. There is also ventriculomegaly with enlargement of the temporal horns.
This demonstrates progressive interval dilatation over the course of this
month and is worrisome for developing hydrocephalus.
There is no evidence of intra-axial or extra-axial hemorrhage. There is no
supratentorial midline shift. The suprasellar cisterns are maintained.
The mastoid air cells are clear. Mucus retention cyst seen in the left
sphenoid sinus. Other paranasal sinuses and mastoids are clear. The orbits,
skull and extracranial soft tissues are unremarkable.
IMPRESSION:
1. Multiple supra- and infra-tentorial metastatic lesions either stable or
enlarged since most recent exam. Most notably, there is enlargement of the
right cerebellar lesion with increased surrounding vasogenic edema. New
effacement of fourth ventricle which is shifted to the left and progressive
effacement of the prepontine cistern and crowding at the foramen magnum.
Progressive enlargement of the lateral and third ventricles concerning for
developing hydrocephalus.
Findings of mass effect on the posterior fossa were discussed with the
neurosurgical ___ at the time of discovery at approximately 12:30 p.m. on
___.
Radiology Report
HISTORY: ___ male with history of metastatic brain lesions and
hydrocephalus. Patient is now status post ventricular shunt placement.
Assess for postoperative change.
COMPARISON: Preoperative head CT from ___, at 11:40 a.m.
TECHNIQUE: MDCT axial images of the brain were obtained without intravenous
contrast.
NON CONTRAST HEAD CT: There has been interval placement of a left frontal
approach ventricular catheter. The catheter tip terminates in the third
ventricle. No hemorrhage is seen along the catheter tract. There is a
moderate amount of pneumocephalus in the left frontal region. Ventricular
dilatation is minimally improved as compared to recent prior examination. The
lateral ventricles now measure 4.6 cm in transverse dimension as compared to
4.7 cm on recent prior (3A:17). Numerous hyperdense metastases (detailed on
recent prior examination) appeared unchanged compared to recent prior and are
not fully evaluated due to motion artifact. Local mass effect with crowding
of the foramen magnum is unchanged. No new intra- or extra-axial hemorrhage
is identified. There is no acute large territorial infarction. There is no
shift of the usually midline structures. Expected post-surgical changes are
seen within the left frontal bone. Air and small amount of fluid are seen
within the left frontal scalp. Visualized paranasal sinuses and mastoid air
cells are well aerated.
IMPRESSION: Interval placement of a left frontal approach ventricular shunt.
Degree of hydrocephalus appears minimally decreased compared to recent prior
examination. Pneumocephalus is expected post procedure.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CODE STROKE
Diagnosed with SEC MAL NEO BRAIN/SPINE
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ gentleman was admitted to neurosurgery and emergently taken
to the OR for the placement of a VP Shunt. He was given Decadron
10mg x1 and 25g of Mannitol. Surgery was performed without
complication. He was extubated and transferred to the PACU. He
remained neurologically stable overnight. Post op CT revealed
post op changes. Radiation oncology was consulted for assistance
with plan of care. He remained stable on the floor on ___
while awaiting disposition plan. He continued to improve
neurologically and the decision was made on ___ to have him
discharged back to his rehab facility. He was seen by a screener
from his facility and he was accepted to go back to his rehab.
Discussion was had with patient and daughter regarding plan
going forward, they were in agreement with this plan and he was
discharged to rehab at 4pm. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
hydromorphone / morphine / oxycodone / Phenergan / ciprofloxacin
/ ceftriaxone / azithromycin
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___, generally healthy with 5 prior C-sections, h/o laparoscopy
for endometriosis c/b bowel perforation and resection in ___
followed by SBO, Cdiff, and enterocutaneous fistula now
resolved; and cholecystectomy now p/w abd pain and CT showing
SBO.
.
Pt developed severe abdominal pain primarily in the RUQ and LUQ
shortly after eating lunch at noon today. She drank water and
walked around, as she intermittently has episodes of abdominal
pain that resolve with these activities. She has had 4 BMs today
including watery stools, which differs significantly from her
baseline of BMs every ___ days with hard stools. As her
abdominal pain did not resolve, she chose to present to the
___ ED.
.
On interview, the patient is s/p IV ketorolac and acetaminophen,
and she reports that she has no pain. She denies fever, nausea,
vomiting, bloody or black stools.
Past Medical History:
PMH:
Enterocutaneous fistula, resolved
Endometriosis
___'s Thyroiditis
Oral Herpes
Recurrent Cdiff
PSH:
Cholecystectomy, ___
Endometriosis laparoscopy ___
Laparotomy for SBO, with SBR, ___
Cesarean section x5
Social History:
___
Family History:
Mother: BREAST CANCER, THYROID CANCER
Father: THYROID CANCER. MYOCARDIAL INFARCTION
___, Deceased: BREAST CANCER
PGM, Deceased: BREAST CANCER
Brother: ARRHYTHMIA
Sister: HEALTHY
Physical Exam:
Admission Physical Exam:
.
VS: T: 97.9 P: 84 BP: 138/84 RR: 18 O2sat: 100% RA
GEN: Well-nourished woman, appears uncomfortable
HEENT: NCAT, EOMI, anicteric
CV: RR
PULM: normal excursion, no respiratory distress
ABD: mildly distended, soft, tender to palpation at LUQ and
periumbilical region, no rebound/guarding, no mass, no hernia,
well-healed scars consistent with multiple surgeries
EXT: WWP, no CCE
NEURO: A&Ox3, no focal neurologic deficits
DERM: no rashes/lesions/ulcers
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
.
Discharge Physical Exam:
VS: T: 98.2 PO BP: 110/61 HR: 73 RR: 18 O2: 95% Ra
GEN: A+Ox3, NAD
HEENT: MMM
PULM: No respiratory distress, breathing comfortably on room air
ABD: soft, mildly distended, non-tender to palpation
EXT: wwp, no edema b/l
Pertinent Results:
IMAGING:
___: CT Abdomen/Pelvis:
Small bowel obstruction, with transition point in a mid ileal
loop the right lower quadrant, which courses adjacent to a
distal ileal enteroenteric anastomosis, likely secondary to an
adhesion. No pneumatosis, portal venous gas or differential
bowel wall enhancement. Small amount of scattered mesenteric
fluid, therefore early ischemic change is unable to be excluded.
___: KUB:
Enteric tube courses below the diaphragm, with tip terminating
outside the
field of view.
___: KUB:
Contrast reaches left hemicolon.
LABS:
___ 09:31AM GLUCOSE-109* UREA N-5* CREAT-0.5 SODIUM-141
POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-22 ANION GAP-9*
___ 09:31AM CALCIUM-7.5* PHOSPHATE-2.5* MAGNESIUM-1.8
___ 09:31AM WBC-6.5 RBC-3.07* HGB-8.6* HCT-26.8* MCV-87
MCH-28.0 MCHC-32.1 RDW-14.4 RDWSD-45.6
___ 09:31AM PLT COUNT-236
___:00PM URINE UCG-NEG
___ 11:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:00PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 11:00PM URINE RBC-3* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 09:44PM LACTATE-1.8
___ 09:30PM GLUCOSE-104* UREA N-8 CREAT-0.7 SODIUM-141
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-22 ANION GAP-17
___ 09:30PM ALT(SGPT)-12 AST(SGOT)-18 ALK PHOS-60 TOT
BILI-1.1
___ 09:30PM LIPASE-24
___ 09:30PM cTropnT-<0.01
___ 09:30PM ALBUMIN-4.1
___ 09:30PM HCG-<5
___ 09:30PM WBC-10.0 RBC-3.74* HGB-10.5* HCT-31.9* MCV-85
MCH-28.1 MCHC-32.9 RDW-14.1 RDWSD-43.9
___ 09:30PM NEUTS-78.1* LYMPHS-12.4* MONOS-7.2 EOS-1.4
BASOS-0.5 IM ___ AbsNeut-7.84* AbsLymp-1.24 AbsMono-0.72
AbsEos-0.14 AbsBaso-0.05
___ 09:30PM PLT COUNT-279
___ 09:30PM ___ PTT-27.4 ___
MICROBIOLOGY:
___ 11:00 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
Medications on Admission:
1. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 25 mcg 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
EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST
INDICATION: ___ with abdominal pain, previous SBO//? eval for 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) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 50.5 mGy (Body) DLP =
25.3 mGy-cm.
2) Spiral Acquisition 6.5 s, 51.1 cm; CTDIvol = 24.3 mGy (Body) DLP =
1,242.1 mGy-cm.
Total DLP (Body) = 1,267 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There are multiple hypodense lesions throughout the liver, measuring up to 2.3
cm, likely representing cysts. Additional subcentimeter hypodensities are too
small to characterize by CT. There is mild central intrahepatic and
extrahepatic biliary ductal dilatation, with the common bile duct measuring up
to 7 mm, within expected limits of postcholecystectomy state. The gallbladder
is not visualized, presumably surgically absent.
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 distended with contrast material, which does
not progress beyond the pylorus. The there is an enteroenteric anastomosis in
the distal ileum in the right lower quadrant. Proximal small bowel loops are
dilated, with a small amount of fecalized material mixed with fluid, measuring
up to 3.6 cm, with surrounding stranding. There is a transition point within
a mid ileal loop in the right lower quadrant which courses adjacent to the
anastomosis (02:55), presumably secondary to an adhesion. The small bowel
wall enhances normally, there is no pneumatosis or portal venous gas. However
there is a small amount of scattered mesenteric fluid, therefore early
ischemic change is unable to be excluded.
The colon and rectum are decompressed. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
Small bowel obstruction, with transition point in a mid ileal loop the right
lower quadrant, which courses adjacent to a distal ileal enteroenteric
anastomosis, likely secondary to an adhesion. No pneumatosis, portal venous
gas or differential bowel wall enhancement. Small amount of scattered
mesenteric fluid, therefore early ischemic change is unable to be excluded.
Radiology Report
EXAMINATION: Portable AP chest
INDICATION: History: ___ with NGT// eval NGT placement
TECHNIQUE: Portable AP chest
COMPARISON: None.
FINDINGS:
Status post placement of enteric tube, with tip coursing below the diaphragm
and terminating outside the field of view.
Lungs are clear. Cardiomediastinal and hilar silhouettes are within normal
limits. No pleural effusions. No pneumothorax.
IMPRESSION:
Enteric tube courses below the diaphragm, with tip terminating outside the
field of view.
Radiology Report
INDICATION: ___ year old woman with SBO.// Evaluate contrast transit iso of
SBO. Please obtain precisely 6 hours after oral contrast consumption.
TECHNIQUE: Portable supine abdominal radiographs obtained 6 hours after the
small-bowel follow-through.
COMPARISON: CT abdomen/pelvis ___.
FINDINGS:
NG tube projects over the stomach. Oral contrast is noted in the right
hemicolon and transverse colon to the splenic flexure. There is unremarkable
small bowel gas pattern.
Osseous structures appear unremarkable. Soft tissues are unremarkable.
IMPRESSION:
Oral contrast reaches large bowel after 6 hours of oral contrast
administration.
Radiology Report
INDICATION: ___ year old woman with SBO.// Evaluate contrast transit iso of
SBO. Please obtain precisely 12 hours after oral contrast consumption.
TECHNIQUE: Portable supine abdominal radiograph
COMPARISON: Abdominal radiograph of the same day.
FINDINGS:
Oral contrast reaches the descending colon. Small bowel gas pattern remains
unremarkable. Esophageal tube projects over the stomach region..
No free air noted.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Contrast reaches left hemicolon.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Abd pain, Abdominal distention
Diagnosed with Unsp intestnl obst, unsp as to partial versus complete obst
temperature: 97.9
heartrate: 87.0
resprate: 18.0
o2sat: 100.0
sbp: 126.0
dbp: 86.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is a ___ y/o F, generally healthy with 5 prior
C-sections, h/o cholecystectomy, laparoscopy for endometriosis
c/b bowel perforation and resection in ___ followed by SBO,
Cdiff, and enterocutaneous fistula now resolved; who presented
to ___ on ___ with abdominal pain and CT imaging
demonstrating SBO. It was believed that the SBO was likely due
to adhesions from her extensive history of abdominal surgeries,
and that this obstruction may resemble a partial SBO as she
continued to have bowel movements. The patient was admitted to
the Acute Care Surgery service for non-operative management. A
NGT was placed in the ED, IVF were administered and she was made
NPO with serial abdominal exams.
.
Gastrograffin follow through study with abdominal x-rays were
ordered to determine resolution of SBO. Contrast was ultimately
seen in the left hemicolon. NGT was clamped. On HD3, the NGT was
removed and she had flatus and multiple loose bowel movements. A
C.diff was ordered which was negative. Diet was gradually
advanced to regular which she tolerated. Her loose bowel
movements improved after eating a regular diet.
.
The patient was alert and oriented throughout hospitalization.
She remained stable from a cardiovascular and pulmonary
standpoint. Intake and output were closely monitored. The
patient received subcutaneous heparin and ___ dyne boots were
used during this stay and was encouraged to get up and ambulate
as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
hand infection
Major Surgical or Invasive Procedure:
___ I&D of right digit
History of Present Illness:
___ with no medical problems transferred from ___ for
right hand infection. Patient had cryotherapy for a wart on her
right fourth finger 2 weeks ago. On ___ (4 days ago) she
developed pain, erythema, and edema at the site. She presented
to her PCP who prescribed cephalexin 500mg BID. The lesion later
turned black, and yesterday the erythema and pain began to
spread up her hand and arm. Her PCP instructed her to go the
___
for further evaluation.
At ___, she was afebrile and hemodynamically stable with
normal labs. On exam she had a small area of black necrotic
tissue with edema and erythema throughout the finger and
streaking redness up the hand and arm. X-ray showed no bony
abnormality. She was transferred to ___ because ___ has
no hand surgery coverage on the weekend. She was started on IV
vancomycin but developed erythema and itching at the IV site and
the infusion was stopped early.
At ___, the patient remained afebrile and hemodynamically
stable with normal labs. Hand Surgery was consulted and found no
drainable collection on exam (ultrasound was not performed), and
recommended admission to Medicine for IV antibiotics. Patient
was
given IV ceftriaxone 1g and IV morphine 2g.
Past Medical History:
Cutaneous warts
No other medical problems
Social History:
___
Family History:
Reviewed, not relevant to current hospitalization.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
============================
VITALS: 24 HR Data (last updated ___ @ 724)
Temp: 98.2 (Tm 98.3), BP: 100/61 (94-109/56-68), HR: 64
(62-72), RR: 18 (___), O2 sat: 97% (95-97), O2 delivery: RA
GENERAL: Well appearing middle-aged woman.
HEENT: No icterus or injection. MMM.
CARDIAC: RRR, no murmurs
LUNGS: CTAB.
ABDOMEN: Soft, NDNT.
EXTREMITIES: Black necrotic appearing lesion at right fourth PIP
with marked surrounding edema and erythema, improving. Faint
streaky erythema extending proximally up hand and forearm,
outlined with marker, also improving.
NEUROLOGIC: Normal mental status.
DISCHARGE PHYSICAL EXAMINATION:
=============================
24 HR Data (last updated ___ @ 909)
Temp: 97.8 (Tm 98.2), BP: 97/59 (97-114/59-71), HR: 73
(69-73), RR: 18, O2 sat: 97% (97-100), O2 delivery: RA, Wt:
153.7
lb/69.72 kg
GENERAL: Well appearing middle-aged woman.
HEENT: No icterus or injection. MMM.
CARDIAC: RRR, no murmurs
LUNGS: CTAB.
ABDOMEN: Soft, NDNT.
EXTREMITIES: right ___ finger with dressing applied. cellulitis
on the right forearm improved.
NEUROLOGIC: Normal mental status.
Right hand examination:
-Right RF lesion without purulence or surrounding erythema
-A/PROM of RF PIP remains minimal, but improved
-Fires EPL, FPL, DIO
-SILT r/m/u
-Palpable radial artery
Pertinent Results:
ADMISSION LABS:
==============
___ 02:49AM BLOOD WBC-8.7 RBC-3.96 Hgb-12.6 Hct-38.4 MCV-97
MCH-31.8 MCHC-32.8 RDW-11.9 RDWSD-42.9 Plt ___
___ 05:22AM BLOOD ___ PTT-26.6 ___
___ 02:49AM BLOOD Glucose-96 UreaN-5* Creat-0.6 Na-140
K-3.9 Cl-106 HCO3-22 AnGap-12
___ 05:22AM BLOOD ALT-20 AST-23 TotBili-0.7
___ 05:22AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1
DISCHARGE LABS:
==============
___ 05:38AM BLOOD WBC-5.5 RBC-3.94 Hgb-12.6 Hct-39.1
MCV-99* MCH-32.0 MCHC-32.2 RDW-11.6 RDWSD-42.7 Plt ___
___ 05:38AM BLOOD ___ PTT-27.2 ___
___ 05:38AM BLOOD Glucose-74 UreaN-8 Creat-0.7 Na-142 K-4.7
Cl-105 HCO3-27 AnGap-10
___ 05:38AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.2
MICROBIOLOGY:
=============
___ 2:49 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
IMAGING:
=======
HAND U/S - ___
Marked soft tissue edema and hyperemia with trace fluid in the
dorsal aspect
of the proximal right ring finger, without drainable fluid
collection.
TTE - ___
EF: 60%. Normal study. Normal biventricular cavity sizes and
regional/global biventricular systolic function. No valvular
pathology or pathologic flow identified. Normal estimated
pulmonary artery systolic pressure.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*84 Tablet Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD ONCE Duration: 1 Dose
RX *lidocaine 5 % Keep on for only 12 hours with 12-hour free
interval once a day Disp #*14 Patch Refills:*0
3. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tab-cap by mouth twice a day Disp #*18 Tablet Refills:*0
4. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Right upper extremity cellulitis
Right fourth PIP abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT
INDICATION: ___ year old woman status post liquid nitrogen treatment of a wart
in the right ring finger, now with finger eschar tissue and swelling.
Evaluate for collection.
TECHNIQUE: Grayscale, color and Doppler images were obtained of the ring
finger of the right hand.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the region of clinical concern
on the dorsal aspect of the right ring finger at the level of the proximal
interphalangeal joint.
There is subcutaneous edema and trace fluid surrounded by prominent vascular
flow, without suspicious soft tissue mass or organized fluid collections.
Scratch
IMPRESSION:
Marked soft tissue edema and hyperemia with trace fluid in the dorsal aspect
of the proximal right ring finger, without drainable fluid collection.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Finger injury, Transfer
Diagnosed with Cellulitis of right finger
temperature: 98.5
heartrate: 79.0
resprate: 18.0
o2sat: 98.0
sbp: 109.0
dbp: 61.0
level of pain: 7
level of acuity: 2.0 | SUMMARY:
========
Ms. ___ is a ___ year-old healthy woman, presents with
necrotic-appearing right fourth finger SSTI and lymphangitic
spread after wart cryotherapy two weeks prior to admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ with PMH of R papillary urothelial
carcinoma s/p stent placemen and removal, colon cancer s/p
colectomy and chemotherapy ___, MGUS, HFpEF, chronotropic
incompetence s/p PPM, severe TF s/p repair (___), PFO s/p
repair (___), MR, AF on warfarin (s/p ___ stapling), h/o TIA,
cardiac cirrhosis, CKD stage III, DVT on warfarin, MGUS, who
presents with R sided flank pain.
Patient reports worsening R sided back pain over the past 3
weeks, which increased in intensity and migrated to his right
lower flank on the day of presentation. He states the pain is
constant and worsens with any movement. He denies any
association with eating. Denies difficult with urination. Denies
fevers, chills. States pain is different in character than prior
symptoms associated with h/o hydronephrosis.
In terms of his more recent medical history, pt was diagnosed
with papillary urothelial carcinoma in ___, deemed non-surgical
candidate given medical comorbidities. He developed
hydronephrosis of R kidney, managed with ureteral stent, which
was exchanged every 3 months. On ___, at the time of stent
removal, was noted to have adequate drainage w/o obstruction, so
no stent was replaced at that time.
Regarding his heart failure, patient followed by Dr. ___ in
___ clinic, noted to be ___ II. He was noted to be volume
overloaded at last appointment in ___, treated with
increased dose of torsemide (40mg daily). Repeat labs from ___
notable for Cr 2.3, Na 127 on ___, recommended to decrease
torsemide to 10mg daily x2 days, and restart 20mg daily
thereafter. Repeat labs ___ with Cr 2.2, Na 127.
Patient followed by nephrology for CKD and has some degree of
hyponatremia at baseline, thought to be related to ADH in the
setting of CHF and cirrhosis, maintained on ___ fluid
restriction to which he reports adherence.
Patient presented to the ED on the day prior to admission with
worsening R flank pain, migrating lower on his R flank.
In the ED, initial VS were: T 97 HR 85 BP 116/67 RR 15 O2 94%RA
- Exam notable for: R flank tenderness
- Labs notable for: Na 125, Cr 1.9, UA negative. UNa < 20, Uosm
325. Hgb 10.6,
- Imaging showed: Renal US w/mild right hydronephrosis and 1.2cm
hypoechoic lesion in left hepatic lobe. CXR w/RLL opacity
similar to prior and new nodular opacities in RUL and L midlung
c/f multifocal PNA, pulmonary vascular congestion.
- Urology consulted who recommended no urgent surgical
intervention. Recommended monitor PVR.
On arrival to the floor, patient reports some persistent R flank
pain, worse with movement. He denies fevers, chills. Denies
dysuria, hematuria. Denies orthopnea, PND. Endorses ___ edema
right > left, stable from prior.
Past Medical History:
- Pacemaker Dual-Chamber: placed for chronotropic incompetence
in ___ battery replacement in ___
- Severe Tricuspid Regurgitation: s/p TV repair on ___.
___ at ___ with 36 mm CarboMedics partial ring
annuloplasty repair
- Patent foramen ovale: s/p surgical repair at the time of his
tricuspid valve surgery
- Mitral Regurgitation
- Atrial Fibrillation: anticoagulated on warfarin; of note he is
status post external stapling of the left atrial appendage in
___ at the time of his tricuspid valve ring repair
- History of TIA in ___ but no prior stroke
- Cirrhosis: attributed to cardiac congestion; per his wife the
patient has had mild encephalopathy in the past
- Alpha-1 antitrypsin deficiency
- Chronic Kidney Disease: Stage III
- Nephrolithiasis
- DVT: anticoagulated on coumadin
- Colon cancer, status post colectomy and chemotherapy in ___
- Osteoporosis: he was on reclast in the past
- Monoclonal gammopathy of undetermined significance (followed
by Dr. ___ - diagnosed in ___
- Urothelial carcinoma of the right ureter (with recent hx of
right ureteral stent placement)
- TV ring repair (36mm Carbomedics ring) with PFO closure and
___ stapling
- Partial colectomy
- Cholecystectomy
- Basal cell skin cancer removed from behind his knee
- Tonsillectomy
Social History:
___
Family History:
Reviewed and no significant changes.
Father: died of MI at age ___ also had strokes
Mother: ? endometrial cancer, breast cancer
No significant history of cardiomyopathy or sudden cardiac
death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: Temp: 97.9 PO BP: 111/75 HR: 76 RR: 18 O2 sat: 95% O2 RA
GENERAL: NAD
HEENT: MMM
NECK: supple
CV: regular, nl S1 S2, systolic murmur LLSB, no rubs, gallops
LUNGS: CTA anteriorly
ABD: soft, NT, ND, NABS.
BACK: TTP of R flank,
EXT: 1+ ___ edema R > L
PULSES: DP 2+ bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: No rash
DISCHARGE PHYSICAL EXAM:
=======================
24 HR Data (last updated ___ @ 846)
Temp: 98.7 (Tm 98.7), BP: 115/78 (103-125/71-81), HR: 74
(74-81), RR: 18 (___), O2 sat: 95% (92-95), O2 delivery: Ra
GENERAL: Laying comfortably in bed.
CV: Irregular irregular rhythm with nl S1 & S2, I/VI systolic
murmur over RUSB/LUSB and IV/VI over LLSB and apex. No rubs or
gallops.
LUNGS: Normal respiratory effort. No crackles present.
ABD: soft, NT, ND, NABS. No masses.
GU: Slight CVA tenderness on the right. No left CVA TTP or
suprapubic pain.
EXT: Warm, well perfused. 1+ ___ edema R > L. No erythema.
PULSES: DP 2+ bilaterally
Pertinent Results:
ADMISSION LABS:
==============
___ 02:20AM BLOOD WBC-11.8* RBC-3.10* Hgb-10.6* Hct-30.4*
MCV-98 MCH-34.2* MCHC-34.9 RDW-14.4 RDWSD-51.8* Plt ___
___ 02:20AM BLOOD Neuts-81.8* Lymphs-3.6* Monos-12.2
Eos-1.0 Baso-0.5 Im ___ AbsNeut-9.62* AbsLymp-0.42*
AbsMono-1.44* AbsEos-0.12 AbsBaso-0.06
___ 02:20AM BLOOD Glucose-100 UreaN-33* Creat-1.9* Na-125*
K-5.0 Cl-86* HCO3-26 AnGap-13
___ 02:20AM BLOOD ALT-19 AST-38 AlkPhos-196* TotBili-0.4
___ 02:20AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.3
PERTINENT LABS/MICRO:
====================
___ 08:48AM BLOOD proBNP-6937*
___ 02:20AM BLOOD Osmolal-269*
___ 08:48AM BLOOD AFP-2.3
___ 03:30AM URINE Color-Yellow Appear-Clear Sp ___
___ 03:30AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 03:30AM URINE RBC-1 WBC-1 Bacteri-FEW* Yeast-NONE
Epi-<1 TransE-<1
___ 03:30AM URINE Hours-RANDOM Creat-69 Na-<20
___ 03:30AM URINE Osmolal-325
___ Urine culture: Negative
DISCHARGE LABS:
==============
___ 04:50AM BLOOD WBC-10.5* RBC-3.09* Hgb-10.5* Hct-30.4*
MCV-98 MCH-34.0* MCHC-34.5 RDW-14.6 RDWSD-52.5* Plt ___
___ 04:50AM BLOOD Glucose-85 UreaN-27* Creat-1.8* Na-128*
K-5.3 Cl-91* HCO3-25 AnGap-12
___ 04:50AM BLOOD Calcium-7.8* Phos-3.5 Mg-2.2
PERTINENT IMAGING:
=================
___ Renal Ultrasound:
1. Mild right hydronephrosis. Calices are more dilated in the
lower pole and contain echogenic material, which could be
residual debris status post recent stent removal, with infection
unable to be excluded. Correlation with urinalysis is
recommended.
2. 1.2 cm hypoechoic lesion in the left hepatic lobe is new
compared to prior liver ultrasound. Dedicated contrast enhanced
CT or MRI of the liver on a nonemergent basis is recommended for
further characterization.
___ CXR:
1. Right lower lobe opacity appears similar to ___,
however there are new nodular opacities in the right upper lobe
and left midlung, raising concern for multifocal pneumonia.
2. Moderate cardiomegaly with pulmonary vascular congestion.
3. Small right and trace left pleural effusions.
___ CT Abd/pelvis w/o Contrast:
1. Moderate right hydronephrosis, with irregular soft tissue
thickening of the renal pelvis and proximal right ureter.
Ill-defined spiculated lesion encasing the proximal-mid right
ureter, with increased attenuation of the distal right ureter.
The appearances are compatible with progression of the patient's
urothelial carcinoma.
2. Cirrhotic liver. The hypoechoic lesion seen on ultrasound is
not visualized on this noncontrast study.
3. Please refer to the separate report for intrathoracic
findings.
___ CT Chest w/o Contrast:
Innumerable bilateral pulmonary nodules, compatible with
metastatic disease.
No evidence of pneumonia.
Well-circumscribed high attenuation lesion in the middle
mediastinum measuring up to 7.3 cm. This lesion has a benign
appearance, possibly representing a large bronchogenic cyst.
Its appearance is not significantly changed since the CT scan of
the abdomen and pelvis dated ___.
Calcified mediastinal and hilar lymph nodes, sequelae of
previous granulomatous disease.
Please refer to the separate CT abdomen report for description
of intra-abdominal findings.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO TID
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Rifaximin 550 mg PO BID
4. Rosuvastatin Calcium 2.5 mg PO QPM
5. Tamsulosin 0.4 mg PO QHS
6. Torsemide 20 mg PO DAILY
7. calcium citrate (calcium carbonate-vit D3-min) 200 mg (950
mg) oral BID
8. vit C,E-Zn-coppr-lutein-zeaxan 250-200-40-1 mg-unit-mg-mg
oral BID
9. Fish Oil (Omega 3) 1000 mg PO BID
10. Acidophilus (Lactobacillus acidophilus) oral DAILY
11. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Acidophilus (Lactobacillus acidophilus) oral DAILY
3. calcium citrate (calcium carbonate-vit D3-min) 200 mg (950
mg) oral BID
4. Ferrous Sulfate 325 mg PO BID
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Lactulose 30 mL PO TID
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Rifaximin 550 mg PO BID
9. Rosuvastatin Calcium 2.5 mg PO QPM
10. Tamsulosin 0.4 mg PO QHS
11. Torsemide 20 mg PO DAILY
12. vit C,E-Zn-coppr-lutein-zeaxan 250-200-40-1 mg-unit-mg-mg
oral BID
Discharge Disposition:
Home
Discharge Diagnosis:
#Primary:
Papillary Urothelial Carcinoma
#Secondary:
Right moderate hydronephrosis
Lung nodules concerning for metastatic disease
Acute on chronic hyponatremia
Hepatic Lesion
Chronic kidney disease
Cardiac cirrhosis
Chronic heart failure with preserved ejection fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S. PORT
INDICATION: History: ___ with R renal tumor, s/p stent removal, with R flank
pain// eval for hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Abdominal ultrasound ___
Outside CT abdomen and pelvis ___
FINDINGS:
The right kidney measures 10.7 cm. There is mild right hydronephrosis.
Calices are more dilated in the right lower pole and contain echogenic
material, which could be residual debris status post recent stent removal,
with infection unable to be excluded. The left kidney measures 10.7 cm.
There is no left right hydronephrosis. The renal cortices are mildly
echogenic but normal in thickness. There is no solid renal mass. No renal
stones are detected.
Incidentally noted is a heterogeneously hypoechoic 1.1 x 1.0 x 1.2 cm lesion
in the left hepatic lobe, which was not seen on prior liver ultrasound.
Visualized portions of the liver are nodular contour.
The bladder is underdistended and suboptimally evaluated. Bilateral ureteral
jets are present.
IMPRESSION:
1. Mild right hydronephrosis. Calices are more dilated in the lower pole and
contain echogenic material, which could be residual debris status post recent
stent removal, with infection unable to be excluded. Correlation with
urinalysis is recommended.
2. 1.2 cm hypoechoic lesion in the left hepatic lobe is new compared to prior
liver ultrasound. Dedicated contrast enhanced CT or MRI of the liver on a
nonemergent basis is recommended for further characterization.
RECOMMENDATION(S): Nonemergent contrast-enhanced CT or MRI of the liver.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with R flank pain// eval for rib fracture
TECHNIQUE: Chest AP upright and lateral
COMPARISON: Outside chest radiographs ___
FINDINGS:
A left chest wall pacemaker is in place with leads terminating in the right
atrium and right ventricle. Patient is status post median sternotomy. A
right lower lobe opacity appears similar to ___, however there are
additional nodular opacities seen in the right upper lung as well, making it
very difficult to exclude acute infection. There is also a peripheral left
lung opacity. Moderate cardiomegaly is unchanged. There is pulmonary
vascular congestion. Small right and trace left pleural effusion. No
pneumothorax.
IMPRESSION:
1. Right lower lobe opacity appears similar to ___, however there
are new nodular opacities in the right upper lobe and left midlung, raising
concern for multifocal pneumonia.
2. Moderate cardiomegaly with pulmonary vascular congestion.
3. Small right and trace left pleural effusions.
Radiology Report
EXAMINATION: CT scan of the abdomen and pelvis without contrast
INDICATION: ___ with PMH of R papillary urothelial carcinoma s/p stent
placemen and removal, colon cancer s/p colectomy and chemotherapy ___, MGUS,
HFpEF, chronotropic incompetence s/p PPM, severe TF s/p repair (___), PFO s/p
___, MR, AF on warfarin (s/p ___ stapling), h/o TIA, cardiac
cirrhosis, CKD stage III, DVT on warfarin, MGUS, who presents with R sided
flank pain.// CT chest, abdomen, pelvis for evaluation of ?multifocal PNA on
CXR, and evaluation of hepatic lesion noted on renal US, and mild
hydronephrosis on R sp
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 4.9 s, 65.2 cm; CTDIvol = 7.8 mGy (Body) DLP = 509.7
mGy-cm.
Total DLP (Body) = 510 mGy-cm.
COMPARISON: Ultrasound from ___ and CT scan from ___.
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 is cirrhotic. There is no evidence of focal lesions
within the limitations of an unenhanced scan. The lesion seen on ultrasound
is not seen on this unenhanced study. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder absent.
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: There is moderate right hydronephrosis, with irregular soft tissue
thickening at the renal pelvis, extending into the proximal right ureter.
There is an ill-defined, spiculated lesion medial to the right psoas muscle,
encasing the proximal right ureter and right common iliac vessels, measuring
approximately 3.3 x 3.1 cm. In addition, there is increased attenuation of
the distal right ureter (2:90). The findings are compatible with progression
of the patient's urothelial carcinoma.
The left kidney is unremarkable.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. Previous ileocolic resection,
with unremarkable appearance of the anastomosis.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
IMPRESSION:
1. Moderate right hydronephrosis, with irregular soft tissue thickening of the
renal pelvis and proximal right ureter. Ill-defined spiculated lesion
encasing the proximal-mid right ureter, with increased attenuation of the
distal right ureter. The appearances are compatible with progression of the
patient's urothelial carcinoma.
2. Cirrhotic liver. The hypoechoic lesion seen on ultrasound is not
visualized on this noncontrast study.
3. Please refer to the separate report for intrathoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: Rule out multifocal pneumonia
TECHNIQUE: MDCT of the chest was performed without intravenous contrast.
Coronal and sagittal reformats were sent to PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.9 s, 65.2 cm; CTDIvol = 7.8 mGy (Body) DLP = 509.7
mGy-cm.
Total DLP (Body) = 510 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: No prior chest CTs. CT abdomen and pelvis ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: there is no supraclavicular,
axillary or internal mammary lymphadenopathy
UPPER ABDOMEN: Please refer to the separate CT report for the intra-abdominal
findings.
MEDIASTINUM: Calcified mediastinal lymph nodes, measuring up to 1.2 cm in
short axis. There is a homogeneous well-circumscribed lesion in the middle
mediastinum measuring 4.2 x 4.1 x 7.3 cm,, which was previously present but
incompletely evaluated on the CT scan of the abdomen pelvis dated ___
HILA: Calcified hilar lymph nodes.
HEART and PERICARDIUM: The heart is enlarged. Dual lead pacemaker in situ.
Calcification of the coronary arteries.
PLEURA: Small bilateral pleural effusions.
LUNG:
1. PARENCHYMA: There are innumerable bilateral pulmonary nodules, measuring
up to 1.8 cm in the right lower lobe, compatible with metastatic disease.
Subsegmental atelectatic changes at both lung bases.
2. AIRWAYS: The central airways are patent.
3. VESSELS: Thoracic aorta and pulmonary arteries are normal in caliber.
CHEST CAGE: Post median sternotomy. No suspicious bone lesions.
IMPRESSION:
Innumerable bilateral pulmonary nodules, compatible with metastatic disease.
No evidence of pneumonia.
Well-circumscribed high attenuation lesion in the middle mediastinum measuring
up to 7.3 cm. This lesion has a benign appearance, possibly representing a
large bronchogenic cyst. Its appearance is not significantly changed since
the CT scan of the abdomen and pelvis dated ___.
Calcified mediastinal and hilar lymph nodes, sequelae of previous
granulomatous disease.
Please refer to the separate CT abdomen report for description of
intra-abdominal findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Flank pain
Diagnosed with Unspecified abdominal pain, Abn lev hormones in specimens from female genital organs
temperature: 97.0
heartrate: 85.0
resprate: 15.0
o2sat: 94.0
sbp: 116.0
dbp: 67.0
level of pain: 4
level of acuity: 3.0 | Mr. ___ is an ___ y/o male with a history of right papillary
urothelial carcinoma s/p stent placement and removal, colon
cancer s/p colectomy and chemotherapy (___), HFpEF,
chronotropic incompetence s/p PPM, severe TF s/p repair (___),
PFO s/p repair (___), MR, AF not on anticoagulation (s/p ___
stapling), h/o TIA, cardiac cirrhosis, CKD stage III, and MGUS
who presented with R sided flank pain, found to have worsening
urothelial carcinoma with moderate hydronephrosis and likely
pulmonary metastases. Urology was consulted and recommended
percutaneous nephrostomy tube for palliation. The patient
ultimately chose to pursue outpatient stenting.
# Right Flank Pain
Presented with right-sided flank pain described as a dull ache
with episodes of sharp pain with movement. His pain felt
different from prior pain associated with hydronephrosis. A
renal ultrasound showed mild hydronephrosis and then a follow up
CT abd/pelvis demonstrated progression of his known urothelial
carcinoma with encasement of the right ureter and associated
moderate hydronephrosis. It was felt that his pain was due to
his disease progression with some contribution from the
hydronephrosis. Urology was consulted and recommended placing a
percutaneous nephrostomy tube as a palliative measure. The
patient decided to pursue outpatient stenting with his
urologist. Additionally, his pain was managed with Tylenol prn
and a lidocaine patch.
# Right Hydronephrosis
# R Papillary Urothelial Carcinoma
The patient had been followed by urology for urothelial
carcinoma managed with stent exchanges. Most recently his stent
was removed and not replaced given adequate urine output. Repeat
imaging as described above showed progression of his malignancy
with encapsulation of the ureter and moderate hydronephrosis.
Additionally, CT chest showed multiple bilateral pulmonary
nodules concerning for metastases. Etiology was unclear though
differential included metastatic disease from his known
urothelial cancer. Urology was consulted recommended either PCN
versus stent. Patient chose stent, to be done as outpatient.
His home tamsulosin was also continued. He should follow up with
urology as an outpatient for further management and for stent
placement. The patient was also scheduled for outpatient
Oncology follow-up.
# Acute on Chronic Hyponatremia
The patient's recent baseline had been between 128-130. Sodium
on admission was 125 without associated symptoms. Etiology was
unclear but felt to be multifactorial from several medical
comorbities. Exam was difficult but appeared to be mildly volume
overloaded with trace ___ edema and JVP elevation (though in the
setting of known valvular disease). Additionally, BNP was
elevated to ~6000, concerning for volume overload. However, the
patient's weight has been at baseline and his creatinine had
actually improved over the prior few weeks with decreasing doses
of torsemide. Urine lytes were consistent with a sodium avid
state, which could have been hyper or hypovolemic in nature.
Decision was made to hold home torsemide and monitor. His Na
improved and torsemide was restarted. His discharge Na was 128.
# Lung Opacities c/f Metastatic Disease
Noted to have bilateral opacities on CXR; follow up CT chest
showed many nodules bilaterally concerning for metastatic
disease. Etiology was unclear though there was concern for
progression of his known urothelial carcinoma vs less likely due
to recurrent colon cancer or an additional primary. Patient will
follow up with oncology as an outpatient.
# Liver Lesion
Noted to have 1.1 x 1.0 x 1.2 hypoechoic lesion in the left
hepatic lobe on ultrasound, though the lesion was not present on
repeat CT scan w/o contrast. There was concern for further
metastatic disease (urothelial, less likely colon cancer
recurrence) vs primary liver malignancy in the setting of his
cirrhosis. AFP was normal pointing against ___. Discussed with
radiology who recommended triphasic MRI for further
characterization as an outpatient.
# Chronic Anemia
Hemoglobin around ___ at baseline, presented with a Hgb of 9.
Prior iron studies were normal. Blood counts were monitored
daily without much change.
# Chronic Stage III CKD
Followed by Dr. ___ as an outpatient. Baseline Cr 1.5-1.7.
Cr 1.9 on admission and improved to baseline with holding
torsemide.
# Atrial Fibrillation
# Chronotropic Incompetence s/p PPM
The patient has a history of atrial fibrillation, on metoprolol
at home. He was not on anticoagulation per outpatient providers
given recurrent bleeding. He was continued on his home regimen
without any issues.
# Cardiac Cirrhosis
History of cirrhosis 2/p HFpEF. Childs B. He had no signs of
hepatic encephalopathy, varices or ascites. He was continued on
his home lactulose and rifaximin. Last EGD in ___ showed no
varices. He should follow up with GI for management and possible
repeat EGD.
# Chronic Diastolic Heart Failure
# Severe TR s/p Repair, MR, PFO s/p Closure:
Followed by Dr. ___. Last TTE on ___ notable for EF
>60%, 4+ mitral regurgitation and 4+ tricuspid regurgitation,
with dilated LA and RA. JVP elevated on exam though likely in
the setting of valvular dysfunction. The remained of his volume
status was difficult as he had trace edema though improvement in
Cr with holding torsemide. Decision was made to hold home
torsemide and monitor given hyponatremia. He was ultimately
discharged on his home dose of torsemide. He should follow up
with his primary care provider for further management.
# Coronary Artery Disease
The patient was continued on his home statin and metoprolol
dosing. He was not given aspirin as no longer needed per
outpatient providers notes.
# H/o Colon Cancer s/p Resection & Chemotherapy
Unknown treatment history. Last colonscopy in ___ was normal.
CT abd/pelvis without contrast did not find a malignancy though
the study was limited and the likely metastases in the lungs was
concerning for possible recurrence vs disease progression of his
known urothelial carcinoma. He should consider outpatient
colonoscopy/imaging pending results of pulmonary nodule biopsy
(if within goals of care). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
citalopram / iron
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
DISCHARGE LABS:
___ 07:03AM BLOOD WBC-4.8 RBC-4.15 Hgb-8.4* Hct-29.0*
MCV-70* MCH-20.2* MCHC-29.0* RDW-18.8* RDWSD-46.3 Plt ___
___ 07:03AM BLOOD Glucose-85 UreaN-8 Creat-0.6 Na-142 K-4.0
Cl-106 HCO3-24 AnGap-12
___ 07:03AM BLOOD ALT-15 AST-16 AlkPhos-77 TotBili-0.2
___ 11:15PM BLOOD cTropnT-<0.01
___ 07:03AM BLOOD Lipase-67*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion XL (Once Daily) 150 mg PO DAILY
2. Diazepam ___ mg PO DAILY:PRN anxiety
3. Omeprazole 40 mg PO BID
4. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
5. OxyCODONE (Immediate Release) 10 mg PO Q 4 - 6 HOURS
6. Acetaminophen Dose is Unknown PO Frequency is Unknown
7. Promethazine 12.5 mg PO Q6H:PRN nausea
8. Vitamin D ___ UNIT PO 1X/WEEK (___)
9. Ustekinumab 390 mg IV Q8 WKS
10. OxyCODONE SR (OxyCONTIN) 10 mg PO Q12H
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 1 syringe injection every twelve
(12) hours Disp #*14 Syringe Refills:*0
2. Warfarin 3 mg PO DAILY16
RX *warfarin 3 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. BuPROPion XL (Once Daily) 150 mg PO DAILY
5. Diazepam ___ mg PO DAILY:PRN anxiety
6. Omeprazole 40 mg PO BID
7. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
8. OxyCODONE (Immediate Release) 10 mg PO Q 4 - 6 HOURS
9. OxyCODONE SR (OxyCONTIN) 10 mg PO Q12H
10. Promethazine 12.5 mg PO Q6H:PRN nausea
11. Ustekinumab 390 mg IV Q8 WKS
12. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Common iliac DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST AND CT ABDOMEN AND PELVIS
INDICATION: History: ___ with hx right subphrenic abscess, presenting with
dyspnea, nausea, abdominal pain, positive D dimer, need to rule out PE and
assess for intra-abdominal infection. // rule out PE, assess for
intra-abdominal infection, assess size of right subphrenic abscess
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) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.5 mGy (Body) DLP = 0.8
mGy-cm.
2) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 4.6 mGy (Body) DLP = 2.3
mGy-cm.
3) Spiral Acquisition 3.7 s, 28.8 cm; CTDIvol = 11.0 mGy (Body) DLP = 316.2
mGy-cm.
4) Spiral Acquisition 6.7 s, 53.1 cm; CTDIvol = 15.5 mGy (Body) DLP = 821.3
mGy-cm.
Total DLP (Body) = 1,140 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
CHEST:
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. A left central venous
catheter terminates near the cavoatrial junction.
AXILLA, HILA, AND MEDIASTINUM: Multiple mediastinal and hilar nodes are
prominent, but not pathologically enlarged by CT size criteria. No axillary
lymphadenopathy. Soft tissue within the anterior mediastinum likely reflects
residual thymic tissue.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: A pleural based pulmonary nodule within the right lower lobe
measures 3 mm (4:127). Micronodule within the left lower lobe (4:113). Mild,
dependent atelectasis. Mild diffuse bronchial wall thickening most pronounced
within the bilateral lower lobes. Otherwise, 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 TISSUE: No suspicious osseous lesions. No abnormalities of the
soft tissues of the chest cage.
ABDOMEN:
HEPATOBILIARY: A subdiaphragmatic collection along the hepatic dome measures
approximately 5.0 x 1.5 cm, similar in extent to the most recent prior study.
Mild overlying thickening of the right hemidiaphragm appears unchanged. No
new collections are identified. The liver otherwise demonstrates homogeneous
attenuation throughout. A hypodense left hepatic lesion measuring 1.4 cm
appears unchanged, compatible with a cyst. Mild intrahepatic biliary
dilatation within the right hepatic lobe has not substantially changed. No
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 patient is status post gastrojejunostomy and total
colectomy. Anastomotic sutures are seen within the left hemiabdomen. A left
lower quadrant ostomy appears unchanged. No bowel obstruction.
PELVIS:
The bladder appears unremarkable. There is no free fluid in the pelvis. A
large peritoneal inclusion cyst within the pelvis measuring up to 13.1 cm has
not substantially changed.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexa appear within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: A focal, central filling defect with mild vascular expansion is seen
within the right common iliac vein and proximal right external iliac vein
(5:61, 607:27), new from the prior study. There is no abdominal aortic
aneurysm. No atherosclerotic disease is noted.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. Levoconvex curvature of the thoracolumbar spine.
Postsurgical changes are seen within the anterior abdominal wall. Soft tissue
scarring in the right ischiorectal fossa is non specific.
IMPRESSION:
1. New focal, central filling defect within the right common iliac and
proximal external iliac veins, concerning for partially occlusive thrombus.
2. No substantial change in a 5.0 cm subdiaphragmatic fluid collection with
overlying right hemidiaphragmatic thickening. No new fluid collections
identified.
3. No substantial change in mild intrahepatic biliary dilatation within the
right hepatic lobe.
4. No evidence of pulmonary embolism to the subsegmental level.
5. Bilateral pulmonary nodules measuring up to 3 mm, for which no dedicated CT
follow-up is recommended in a low risk patient, and an optional CT follow-up
in 12 months is recommended in a high risk patient.
6. No substantial change in a large pelvic peritoneal inclusion cyst.
RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules
smaller than 6mm, no CT follow-up is recommended in a low-risk patient, and an
optional CT follow-up in 12 months is recommended in a high-risk patient.
See the ___ ___ Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ with crohn's, pelvic DVT on CT; also RLE pain, c/f clot
extension // RLE DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: CT torso performed on ___.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the right
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Lightheaded, Nausea
Diagnosed with Dyspnea, unspecified
temperature: 97.5
heartrate: 110.0
resprate: 15.0
o2sat: 100.0
sbp: 122.0
dbp: 82.0
level of pain: 5
level of acuity: 3.0 | TRANSITIONAL ISSUES:
- consider transition onto DOAC, though this will require prior
auth per my discussion with outpatient pharmacy
- intake into ___ clinic with monitoring for therapeutic
INR and DC of lovenox
- consider indefinite anticoagulation given her recurrent
thromboembolic disease
- lung nodules seen incidentally but unclear whether she would
need repeat imaging f/u
- should consider hematology referral outpatient for microcytic
anemia
HOSPITAL COURSE:
# DVT: The patient presents with several days of progressive DOE
as well as exertional lightheadedness and dizziness. Imaging in
the ED notable for "New focal, central filling defect within the
right common iliac and proximal external iliac veins, concerning
for partially occlusive thrombus." She was started on heparin
gtt
in the ED. As this would be patient's ___ VTE at this point, she
would likely benefit from lifelong a/c. She could also be
referred for possible hypercoagulability eval. Trop neg and EKG
unremarkable. Tele unremarkable. Pt with some transient pain in
right leg but no DVT on ___. Sent in DOAC scripts for possible
transition but will require a PA and pt elected not to wait.
Started on lovenox/warfarin prior to ___; unable to set up her
first ___ clinic visit but pt felt she could arrange this
herself. Brief teaching on SQ admin given prior to DC.
Tolerating ambualation and feeling ready for DC.
# ABDOMINAL ABSCESS: S/p abx, stable on repeat imaging here. ID
aware of pt but felt no need to see her.
# LUNG NODULES: Incidental finding on CT. F/u imaging
recommended
only if patient high risk.
# MICROCYTIC ANEMIA: H/H stable from prior admission values. Per
prior d/c summary, "Iron studies previously consistent with iron
def anemia however without e/o blood loss currently and stable
from prior. She has had multiple endoscopies with no evidence
of
bleeding (however anastomotic erosions which could be the source
of a slow bleed) and is not a candidate for IV iron given
reported allergy. No urgent indication for further inpatient
w/u
and no clear source of blood loss but should follow up with
hematology as an outpatient."
# CROHN'S DISEASE: S/p complicated abdominal surgical history.
Currently on Stelara. Followed by Dr. ___. Pain stable on home
regimen, b/l GI output.
# DEPRESSION/ANXIETY: stable
- continue home buproprion, diazepam
# GERD: continue home PPI
>30 minutes spent on day of DC planning |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lithium / Codeine
Attending: ___.
Chief Complaint:
Worsening renal failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with COPD/asthma and recent hospitalization requiring
admission to the FICU for exudative pleural effusion, s/p vats
decortication, hospitalization complicated by acute renal
failure, seen in follow-up at ___ with worsening renal failure
2.5--> ___ yesterday, massive ___ edema and scrotal edema.
The patient states that he was doing well at home until about
one week ago when he noticed that his left leg began to swell
and become painful. He also noted that his scrotum began to
swell, though the pain at this site was minimal. He was hesitant
to see his PCP but finally decided to come in because it was
becoming difficult to ambulate. He denies any changes to his
diet or medications but does endorse dribbling and poor stream
when urinating which he says is not new for him. He states that
the frequency of urination has decreased recently and that his
urine is dark brown despite drinking more water than usual. He
complains of chills but states that this is chronic. Endorses a
30 lb weight gain over several months as well as reflux. Also
complains of pain at the chest tube site.
.
ROS: + per HPI, otherwise negative for fever, chills, sick
contacts, headaches, visual changes, diarrhea, constipation,
melena, cough, SOB, chest pain, hemoptysis.
.
___: negative for DVT
In the ED: 97.8 87 120/81 16 97%. Received dilaudid for pain.
Past Medical History:
#COPD/asthma - 60 pack year smoking hx, uses advair & albuterol
#Hepatitis C, in remission after interferon rx
#Atopic dermatitis, seborrheic dermatitis
#h/o alcohol use, now sober
#Lower back pain
#Extensive burns after being burned and tortured in ___
#PTSD after being tortured and burned in ___, had paranoia
preceding this event, however
#Depression, prior hx of suicide attempt on bottle of pills
#Schizoaffective disorder
-Sporadically attends the chronic mental illness group here at
___. Has been involved with ___ in the past.
-Multiple medication trials,including Celexa, Remeron,
Klonopin, Zyprexa, Prozac.
Social History:
___
Family History:
Father with schizophrenia and EtOH abuse.
Mother died of lung cancer at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.8 BP: 126/76 P: 98 R: 20 O2: 100%RA
GENERAL: Alert, oriented, pleasant middle-aged Caucasian male in
no acute distress
SKIN: Diffuse seborrheic dermatitis on face, scalp, trunk, upper
and lower extremities. Patient is actively scratching. Diffuse
scaling.
HEENT: Sclera anicteric, PERRLA, EOMI, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds on left ___ way up with
occasional crackles, no wheezes or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABDOMEN: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Scrotum is edematous without tenderness to palpation, warmth
or erythema. Foley catheter in place.
EXTREMITIE: Warm, well perfused. Extensive skin grafts present
on lower exremities. LLE > RLE, tender to palpation. Pulses not
appreciated. No clubbing or cyanosis. Edema is nonpitting but
skin is very tight ___ grafts.
NEURO: A&O x3, CNs II-XII intact, no focal deficits. Gate not
assessed.
.
DISCHARGE PHYSICAL EXAM:
Vitals:Tc: 98.5 BP: 138/92 (106-151/63-89) P: 93 (63-93) R: 18
O2: 92%RA
GENERAL: Alert, oriented, pleasant middle-aged Caucasian male in
no acute distress
SKIN: Diffuse seborrheic dermatitis on face, scalp, trunk, upper
and lower extremities.
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: Decreased breath sounds on left ___ way up with
occasional crackles, no wheezes or rhonchi. Pleurex catheter in
place under dressing, area is nonpainful to palpation
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABDOMEN: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Scrotum is edematous without tenderness to palpation, warmth
or erythema. Foley catheter in place.
EXTREMITIES: Warm, well perfused. Extensive skin grafts present
on lower exremities. LLE > RLE, tender to palpation. Pulses not
appreciated. Edema is nonpitting but skin is very tight ___
grafts. Edema improved since previous exam
NEURO: A&O x3, CNs II-XII intact, no focal deficits. Gate not
assessed.
Pertinent Results:
___ 12:20PM BLOOD WBC-11.8* RBC-3.64* Hgb-10.2* Hct-31.6*
MCV-87 MCH-28.1 MCHC-32.3 RDW-15.2 Plt ___
___ 08:20AM BLOOD WBC-7.7 RBC-3.54* Hgb-9.8* Hct-30.9*
MCV-87 MCH-27.6 MCHC-31.6 RDW-15.3 Plt ___
___ 12:20PM BLOOD Glucose-73 UreaN-14 Creat-2.5*# Na-142
K-3.7 Cl-103 HCO3-26 AnGap-17
___ 08:20AM BLOOD Glucose-80 UreaN-13 Creat-2.2* Na-146*
K-3.6 Cl-107 HCO3-30 AnGap-13
___ 07:20AM BLOOD Glucose-96 UreaN-15 Creat-2.0* Na-147*
K-3.4 Cl-108 HCO3-32 AnGap-10
___ 08:20AM BLOOD proBNP-993*
___ 08:20AM BLOOD ALT-14 AST-17 LD(LDH)-193 AlkPhos-82
TotBili-0.2
___ 07:20AM BLOOD TotProt-5.6* Calcium-8.6 Phos-4.4 Mg-1.3*
___ 08:20AM BLOOD Albumin-2.6* Calcium-8.9 Phos-4.5 Mg-1.6
RENAL ULTRASOUND ___
INDICATION: ___ male with acute kidney injury and
rising creatinine.
Evaluate for an obstructive process to account for worsening
renal function.
COMPARISON: Renal ultrasound of ___.
TECHNIQUE: Multiple sonographic grayscale images were obtained
of the kidneys
with color Doppler evaluation.
FINDINGS: The right kidney measures 11.9 cm and contains a
simple cyst in the
lower pole measuring 1.5 x 1.3 x 1.2 cm. The left kidney
measures 12.3 cm.
Both kidneys demonstrate normal echogenicity and
corticomedullary
differentiation without shadowing stones, suspicious renal
lesions, or
hydronephrosis. There is no cortical thinning. Both kidneys
demonstrate
normal vascularity.
The urinary bladder is decompressed with a Foley catheter.
IMPRESSION:
Simple right renal cyst. Otherwise, normal appearance of both
kidneys without
hydronephrosis.
ECHOCARDIOGRAM:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF 60%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is no
pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review) of ___, no major change.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Desonide 0.05% Cream 1 Appl TP BID eczema
2. Amantadine 100 mg PO BID
3. Amlodipine 10 mg PO DAILY
4. Clobetasol Propionate 0.05% Soln 1 Appl TP BID
5. Diazepam 5 mg PO QAM
6. Diazepam 2 mg PO QHS
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Mirtazapine 15 mg PO HS
10. OLANZapine 30 mg PO HS
11. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
12. HydrOXYzine 10 mg PO BID:PRN itching
13. Fluvoxamine Maleate 100 mg PO BID
14. mineral oil *NF* Topical prn dry skin
15. Cetaphil *NF* (cetyl & ste alcoh-prop
___ alc-pro
gl-sls;<br>soap;<br>sunscreen) 15 SPF Topical prn
16. Naproxen 500 mg PO Q12H:PRN pain
17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY
18. Ziprasidone Hydrochloride 60 mg PO HS
19. Acetaminophen 650 mg PO Q6H:PRN pain
20. Calcium Acetate 1334 mg PO TID W/MEALS
21. Docusate Sodium 100 mg PO BID
22. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
through ___
23. Polyethylene Glycol 17 g PO DAILY:PRN constipation
24. Senna 1 TAB PO BID:PRN constipation
25. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
26. Levofloxacin 250 mg PO DAILY
through ___
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
3. Amlodipine 10 mg PO DAILY
4. Calcium Acetate 1334 mg PO TID W/MEALS
5. Clobetasol Propionate 0.05% Soln 1 Appl TP BID
6. Desonide 0.05% Cream 1 Appl TP BID eczema
7. Diazepam 5 mg PO QAM
8. Diazepam 2 mg PO QHS
9. Docusate Sodium 100 mg PO BID
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Fluvoxamine Maleate 100 mg PO BID
12. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
13. HydrOXYzine 10 mg PO BID:PRN itching
14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
through ___
15. Mirtazapine 15 mg PO HS
16. OLANZapine 30 mg PO HS
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Senna 1 TAB PO BID:PRN constipation
19. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY
20. Ziprasidone Hydrochloride 60 mg PO HS
21. Cetaphil *NF* (cetyl & ste alcoh-prop
___ alc-pro
gl-sls;<br>soap;<br>sunscreen) 15 SPF Topical prn
22. Hydrochlorothiazide 12.5 mg PO DAILY
23. Mineral Oil *NF* 0 TOPICAL PRN dry skin
24. Amantadine 100 MG PO DAILY
RX *amantadine 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
25. Levofloxacin 500 mg PO DAILY
through ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Left lower extremity edema. Prolonged hospital admission.
COMPARISONS: None.
FINDINGS: The bilateral common femoral veins are patent with symmetric
response to Valsalva. The left common femoral vein, superficial femoral vein,
popliteal vein, peroneal veins, and posterior tibial veins are patent with
normal compressibility. There is significant subcutaneous edema overlying the
entire left lower extremity. A prominent, but normal appearing, lymph node is
noted in the left groin measuring 3.6 x 0.9 cm. There is no thickening of the
cortex, and there is normal fatty hilum.
IMPRESSION:
1. No evidence of left lower extremity deep vein thrombosis.
2. Significant subcutaneous edema.
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Recent exudate and effusion, status post VATS decortication,
presenting with new left lower extremity edema.
COMPARISONS: ___.
TECHNIQUE: Chest, AP and lateral.
FINDINGS: A PICC line has been removed. A chest tube again projects over the
left lower chest wall, although its sidehold again lies outside the left
hemithorax. There is persistent volume loss with mild leftward mediastinal
shift and a moderate suspected pleural effusion in the left lower hemithorax.
A focus of band-like atelectasis in the left mid lung has partly resolved.
The lateral view suggests persistent consolidation with air bronchograms in
the left lower lobe, again without clear change.
IMPRESSION: Similar persistent loculated left-sided pleural effusion and
consolidation. Chest tube terminating in the left lower hemithorax, although
the sidehole again lies outside the pleural cavity.
Radiology Report
RENAL ULTRASOUND
INDICATION: ___ male with acute kidney injury and rising creatinine.
Evaluate for an obstructive process to account for worsening renal function.
COMPARISON: Renal ultrasound of ___.
TECHNIQUE: Multiple sonographic grayscale images were obtained of the kidneys
with color Doppler evaluation.
FINDINGS: The right kidney measures 11.9 cm and contains a simple cyst in the
lower pole measuring 1.5 x 1.3 x 1.2 cm. The left kidney measures 12.3 cm.
Both kidneys demonstrate normal echogenicity and corticomedullary
differentiation without shadowing stones, suspicious renal lesions, or
hydronephrosis. There is no cortical thinning. Both kidneys demonstrate
normal vascularity.
The urinary bladder is decompressed with a Foley catheter.
IMPRESSION:
Simple right renal cyst. Otherwise, normal appearance of both kidneys without
hydronephrosis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: WORSENING RENAL FAILURE
Diagnosed with RENAL FAILURE, UNSPECIFIED, EDEMA
temperature: 97.8
heartrate: 87.0
resprate: 16.0
o2sat: 97.0
sbp: 120.0
dbp: 81.0
level of pain: 7
level of acuity: 3.0 | ___ with recent hospitalization and stay in the ___ for
exudative pleural effusion, s/p vats decortication,
hospitalization complicated by acute renal failure, seen by PCP
with worsening renal failure, massive ___ edema and scrotal
edema.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
metoclopramide
Attending: ___
Chief Complaint:
Diabetic foot ulcer
Major Surgical or Invasive Procedure:
-PICC line placement on ___
-Excisional debridement down to and including bone with wound
vac placement, Left foot on ___
-Angiogram of the left leg on ___
History of Present Illness:
HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ yo woman
with longstanding T1DM c/b Charcot joints, diabetic retinopathy,
neuropathy and gastroparesis, end-stage renal disease s/p DDRT
___ ___ ___s recent right great toe fracture ___ who
presents with left foot pain.
Patient states that she noted dry skin and 'a crack' over her
left heel about 1 week prior to presentation but she held off on
presenting as she did not have scheduled podiatry follow-up for
some time. On ___ or ___ she started to notice burning and
slight redness traveling up her left calf at which point she
presented to the ED. She denies associated fevers, chills,
numbness, tingling, nausea, vomiting diarrhea, headache, eye
pain, blurry vision.
___ the ED T-max 101.1, SBP 107-110. vitals otherwise
unremarkable. Labs notable for WBC 20.8, Na 132, lactate 1.3.
Patient given IV ciprofloxacin 400 mg ×1 ___s Flagyl 500
mg
×1. Given 1 L NS. Heel XR showed 'a 5 x 3 mm radiopaque
structure projecting over the superficial soft tissues plantar
to the posterior calcaneus is new since ___.
Unclear whether this represents a foreign body or other soft
tissue calcification. No definite cortical destruction seen to
suggest acute osteomyelitis radiographically.'
Seen by podiatry consult service:
'Patient seen and evaluated. Wound to plantar left heel probes
deep but not to bone. There is no purulent drainage, however
elevated white count of 20 is concerning. There are no bony
changes on x-ray to suggest osteomyelitis or any soft tissue
gas.
Patient would benefit from IV abx for treatment of cellulitis
and
we will to follow closely while ___.
-Admit to medicine for IV abx (v/c/f)
-Betadine dressing L heel
-F/u micro
-Multipodus boot to L foot'
On arrival to the medicine ward, patient reports the above
history. He feels that redness is almost completely resolved
with antibiotics administer ___ the ED. Currently pain is ___, though she has almost no feeling ___ her legs at baseline.
ROS as above.
Past Medical History:
- kidney transplant on ___
- hypertension
- autonomic instability w/ labile BP
- T1DM c/b Charcot joints, diabetic retinopathy, neuropathy,
gastroparesis
- UGIB (admitted ___
- H/o adenomatous colonic polyps by colonoscopy ___ ___.
- Minimally displaced right proximal humerus fracture ___
- Gastroesophageal reflux
- Hyperlipidemia
- TIA ___ ___
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.3 BP12 69 HR72 RR 1895%RA
GENERAL: Thin, chronically ill-appearing woman ___ no distress.
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Left foot with healed, partially amputated ___ and
third digits. ~ 2 x 3 cm ulcer with surrounding erythema and
maceration. Minimal surrounding cellulitis posterior calf (see
OMR note)
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 824)
Temp: 98.3 (Tm 99.1), BP: 138/45 (98-138/37-67), HR: 62
(62-69), RR: 18 (___), O2 sat: 95% (94-96), O2 delivery: RA,
Wt: 160 lb/72.58 kg (160-161)
GENERAL: Thin, chronically ill-appearing woman ___ no distress.
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Left foot with healed, partially amputated ___ and
third digits. wound vac and multipodus boot ___ place.
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric. No asterixis.
SKIN: rash on extremities resolved, but continues to be
intermittently pruritic.
Pertinent Results:
ADMISSION LABS:
___ 10:25PM LACTATE-1.3
___ 09:07PM GLUCOSE-241* UREA N-22* CREAT-1.2*
SODIUM-132* POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-20* ANION GAP-16
___ 09:07PM CRP-260.6*
___ 09:07PM WBC-20.8* RBC-3.69* HGB-11.3 HCT-34.7 MCV-94
MCH-30.6 MCHC-32.6 RDW-13.3 RDWSD-46.1
___ 09:07PM NEUTS-83.9* LYMPHS-3.8* MONOS-7.8 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-17.45* AbsLymp-0.78*
AbsMono-1.62* AbsEos-0.01* AbsBaso-0.06
___ 09:07PM PLT COUNT-207
INTERVAL & DISCHARGE LABS/STUDIES:
___ 03:46AM BLOOD WBC-15.8* RBC-3.59* Hgb-10.6* Hct-32.4*
MCV-90 MCH-29.5 MCHC-32.7 RDW-13.2 RDWSD-44.1 Plt ___
___ 07:04AM BLOOD WBC-12.1* RBC-3.79* Hgb-10.9* Hct-35.0
MCV-92 MCH-28.8 MCHC-31.1* RDW-13.8 RDWSD-46.9* Plt ___
___ 05:12AM BLOOD WBC-15.0* RBC-3.57* Hgb-10.3* Hct-32.7*
MCV-92 MCH-28.9 MCHC-31.5* RDW-13.6 RDWSD-46.0 Plt ___
___ 05:25AM BLOOD WBC-13.3* RBC-3.45* Hgb-10.3* Hct-32.3*
MCV-94 MCH-29.9 MCHC-31.9* RDW-13.8 RDWSD-46.8* Plt ___
___ 05:06AM BLOOD WBC-9.9 RBC-3.36* Hgb-10.0* Hct-31.8*
MCV-95 MCH-29.8 MCHC-31.4* RDW-13.9 RDWSD-47.6* Plt ___
___ 05:10AM BLOOD Neuts-76.1* Lymphs-12.2* Monos-6.6
Eos-2.9 Baso-0.5 Im ___ AbsNeut-10.11* AbsLymp-1.62
AbsMono-0.87* AbsEos-0.39 AbsBaso-0.06
___ 05:06AM BLOOD Plt ___
___ 05:06AM BLOOD ___ PTT-27.9 ___
___ 05:06AM BLOOD Glucose-257* UreaN-18 Creat-0.8 Na-139
K-5.2 Cl-100 HCO3-28 AnGap-11
___ 05:12AM BLOOD ALT-20 AST-27 AlkPhos-121* TotBili-0.3
___ 05:06AM BLOOD Calcium-9.8 Phos-3.8 Mg-1.8
___ 05:33AM BLOOD %HbA1c-12.0* eAG-298*
___ 09:07PM BLOOD CRP-260.6*
___ 06:35AM BLOOD CRP-173.4*
___ 04:42AM BLOOD tacroFK-7.9
___ MR FOOT
1. No MR evidence of osteomyelitis or abscess. Skin defect
overlying the
posterior plantar calcaneus does not extend to the bone.
2. Degenerative changes as described above.
3. Tenosynovitis of the posterior tibialis tendon.
4. Remote sprain of the tibial spring ligament.
5. Chronic plantar fasciitis.
6. Fatty atrophy and edema of the muscles within the tarsal
tunnel are likely denervation changes.
7. Small bone fragments adjacent to the medial cuneiform at the
site of
attachment of the Lisfranc ligament however the Lisfranc
ligament appears to be intact.
Blood cultures: ___ x2 no growth, ___ x2 no growth, ___ no
growth
WOUND CULTURE ___:
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. HEAVY GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN G---------- =>64 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 7:01 pm SWAB Source: Left heel wound.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Susceptibility testing performed on culture # ___
___.
ENTEROCOCCUS SP.. SPARSE GROWTH.
Susceptibility testing performed on culture # ___
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 10:55 am TISSUE SOFT TISSUE LEFT FOOT.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
ENTEROCOCCUS SP..
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
Identification and susceptibility testing performed on
culture #
___ ___.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):
___ 11:00 am TISSUE LEFT CALCANEUS BONE.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
ENTEROCOCCUS SP.. SPARSE GROWTH.
ENTEROCOCCUS SP.. RARE GROWTH. SECOND MORPHOLOGY.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
___ 06:04AM BLOOD WBC-9.3 RBC-3.36* Hgb-10.0* Hct-31.7*
MCV-94 MCH-29.8 MCHC-31.5* RDW-13.9 RDWSD-47.2* Plt ___
___ 06:04AM BLOOD Plt ___
___ 06:04AM BLOOD Glucose-152* UreaN-16 Creat-0.8 Na-144
K-4.9 Cl-103 HCO3-26 AnGap-15
___ 06:04AM BLOOD Calcium-9.6 Phos-3.9 Mg-1.9
___ 05:06AM BLOOD CRP-39.3*
___ 06:04AM BLOOD Vanco-25.3*
___ 05:06AM BLOOD Vanco-23.2*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. ClonazePAM 0.5 mg PO QHS:PRN anxiety
5. Enalapril Maleate 2.5 mg PO DAILY
6. Mycophenolate Mofetil 500 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. PARoxetine 20 mg PO DAILY
9. PredniSONE 2.5 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. Tacrolimus 1.5 mg PO Q12H
12. dextran 70-hypromellose 0.1-0.3 % ophthalmic (eye) TID PRN
dry eyes
13. Glargine 36 Units Breakfast
Insulin SC Sliding Scale using ___ four times a day As per
___ sliding scale; 2 to 16 units with meals; 0 to 8 units at
bedtime Insulin
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone ___ dextrose,iso-os 2 gram/50 mL 2 g IV q24h Disp
#*68 Intravenous Bag Refills:*0
3. DiphenhydrAMINE 25 mg PO DAILY:PRN itching
RX *diphenhydramine HCl [Allergy (diphenhydramine)] 25 mg 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*120 Tablet Refills:*0
5. Sarna Lotion 1 Appl TP QID:PRN itch
RX *camphor-menthol [Anti-Itch (menthol/camphor)] 0.5 %-0.5 %
apply to itchy areas on skin four times a day Disp #*1 Bottle
Refills:*0
6. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 1 gram 1 g IV every twelve (12) hours Disp #*136
Vial Refills:*0
7. toujeo 42 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
8. Aspirin 325 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. ClonazePAM 0.5 mg PO QHS:PRN anxiety
11. dextran 70-hypromellose 0.1-0.3 % ophthalmic (eye) TID PRN
dry eyes
12. Mycophenolate Mofetil 250 mg PO BID
RX *mycophenolate mofetil 250 mg 1 capsule(s) by mouth twice a
day Disp #*60 Capsule Refills:*0
13. Omeprazole 20 mg PO DAILY
14. PARoxetine 20 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY
16. PredniSONE 2.5 mg PO DAILY
17. Tacrolimus 1 mg PO Q12H
18.Outpatient Lab Work
ICD-10: E11.621. Please obtain weekly (starting ___:
CBC with differential, BUN, Cr, Vancomycin trough, AST,
ALT, Total Bili, ALK PHOS. Please fax results to ___
CLINIC (___).
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY:
Diabetic foot ulcer, status post debridement and wound vac
placement
History of end stage renal disease, status post deceased donor
renal transplant (___)
SECONDARY:
Hyperglycemia
Pruritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with left heel pain, redness, fever// evaluate for
foreign body, osteo
TECHNIQUE: Three views of the left foot
COMPARISON: ___, left toes and left foot radiographs from ___
FINDINGS:
Chronic deformities of the first and fifth metatarsals are re-demonstrated.
Again seen finding of the head of the second metatarsal in degenerative
changes about the second MTP joint. Re-demonstrated diminutive appearance of
the distal phalanx of the second toe. Third digit status post amputation at
the level of the PIP joint.
Projecting over the superficial soft tissue plantar to the calcaneus is a 5 mm
x 3 mm radiopaque structure, unclear whether this represents a foreign body or
other soft tissue calcification.
No definite cortical destruction seen to suggest acute osteomyelitis
radiographically.
Vascular calcifications are seen.
IMPRESSION:
5 x 3 mm radiopaque structure projecting over the superficial soft tissues
plantar to the posterior calcaneus is new since ___. Unclear
whether this represents a foreign body or other soft tissue calcification.
No definite cortical destruction seen to suggest acute osteomyelitis
radiographically.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ year old woman with T1DM on immunosuppression with foot ulcer
s/p debridement// osteo?
TECHNIQUE: Three views of left foot.
COMPARISON: Left foot radiograph ___, ___
FINDINGS:
Previously described 5 mm radiodense foreign body in the soft tissue overlying
the posterior plantar aspect of the calcaneus is no longer visualized. Area
of lucency is demonstrated in the soft tissue at this site, likely reflecting
soft tissue defect, possibly related to debridement. No notable change is
identified in the bones compared to 1 day ago. No cortical destruction or
erosive changes are identified to suggest osteomyelitis.
No acute fractures or dislocation are present. Chronic deformities of the
bones are again demonstrated, including proximal phalanx and metatarsal of the
first and fifth toes and flattened second metatarsal head. Third toe middle
and distal phalanges are absent. Valgus alignment of second toe DIP joint is
unchanged. Heavy vascular calcifications are noted.
IMPRESSION:
Previously described 5 mm radiodense object in the soft tissues overlying the
posterior plantar calcaneus has been removed. Soft tissue defect at this
location is likely related to debridement. Otherwise, no notable change is
identified compared to 1 day ago.
Radiology Report
EXAMINATION: MR FOOT ___ CONTRAST LEFT
INDICATION: ___ year old woman with T1DM and ESRD s/p DDRT p/w diabetic foot
ulcer// rule out osteo
TECHNIQUE: Multiplanar images of the left foot were performed with and
without the administration of intravenous contrast using a routine MR ankle
protocol.
COMPARISON: Left foot radiographs ___
FINDINGS:
Study is optimized for detection of infection or mass, therefore the
assessment of intra-articular structures, tendons and ligaments is somewhat
limited.
Soft tissue edema and focal skin defect is identified in the area of posterior
plantar calcaneus. The defect is superficial and does not extend to the bone.
No sinus tract is identified. Variable enhancement of the surrounding soft
tissue is noted which can be seen with peripheral vascular disease.
Small area of bone marrow edema in the posterior calcaneus is nonspecific and
likely reactive. Bone marrow signal intensity is relatively preserved on T1
weighted images, therefore this appearance is not diagnostic of osteomyelitis.
Achilles tendon: Multiple areas of alternating the thickening and thinning of
the tendon is identified, likely reflecting prior episodes of tendinosis.
Posterior tibial tendon: Fluid surrounding the tendon is consistent with
tenosynovitis.
Flexor digitorum tendon: Unremarkable.
Flexor hallucis tendon: Unremarkable.
Peroneal tendons: Unremarkable.
Anterior tibialis tendon: Unremarkable.
Extensor digitorum tendon: Unremarkable.
Extensor hallucis longus: Unremarkable.
Anterior tibiofibular ligament: Unremarkable.
Posterior tibiofibular ligament: Unremarkable.
Anterior talofibular ligament: Unremarkable.
Posterior talofibular ligament: Unremarkable.
Calcaneofibular ligament: Not well visualized.
Tibiotalar ligament: Unremarkable.
Tibiospring Ligament: Thickened but low in signal intensity on fluid sensitive
sequences likely reflecting a remote sprain.
Spring ligament: Unremarkable.
Sinus tarsi: Normal.
Plantar fascia: Central cord is thickened, most notably at the distal portion,
measuring 6 mm in thickness but without surrounding edema consistent with
chronic plantar fasciitis.
Tibiotalar joint space: There is no joint effusion. Full-thickness loss of
cartilage is identified in the lateral gutter and lateral talar dome with
multiple foci of subchondral bone marrow edema.
Marrow signal: As above.
Other findings: STIR hyperintensity and fatty atrophy of the muscles in the
tarsal tunnel are compatible with denervation.
A millimetric bone fragment is identified near the site of Lisfranc ligament
attachment at the medial cuneiform, likely reflecting a old injury (03:18).
Visualized fibers of the Lisfranc ligament are visualized however.
IMPRESSION:
1. No MR evidence of osteomyelitis or abscess. Skin defect overlying the
posterior plantar calcaneus does not extend to the bone.
2. Degenerative changes as described above.
3. Tenosynovitis of the posterior tibialis tendon.
4. Remote sprain of the tibial spring ligament.
5. Chronic plantar fasciitis.
6. Fatty atrophy and edema of the muscles within the tarsal tunnel are likely
denervation changes.
7. Small bone fragments adjacent to the medial cuneiform at the site of
attachment of the Lisfranc ligament however the Lisfranc ligament appears to
be intact.
Radiology Report
EXAMINATION: ART EXT (REST ONLY)
INDICATION: ___ year old woman with T1DM and diabetic foot ulcer// bilateral
lower extremity non invasive arterial study
TECHNIQUE: Noninvasive evaluation of the arterial system of the lower
extremities was performed with Doppler signal recordings, pulse volume
recordings and segmental limb the pressure measurements at rest.
COMPARISON: None
FINDINGS:
On the right-side, triphasic Doppler waveforms were seen at the right femoral,
popliteal, posterior tibial, and dorsalis pedis arteries. The right ABI 1.20
at rest. The right TBI is 0.82. Pulse volume recordings demonstrate normal
waveforms at the low thigh, calf, ankle, metatarsal, and digit.
On the left-side, triphasic Doppler waveforms were seen at the right femoral,
popliteal arteries. Waveform is uninterpretable at the posterior tibial
artery. Monophasic waveform of the dorsalis pedis artery. The left ABI
uninterpretable at rest. The left TBI is 0.56. Pulse volume recordings
demonstrate normal waveforms at the low thigh, calf, ankle, moderately
abnormal at the metatarsal, and normal at the digit.
IMPRESSION:
Noncompressible left posterior tibial artery consistent arterial calcification
artifact. Abnormal left TBI consistent with mild distal arterial obstructive
disease.
Normal right ABI and TBI.
Radiology Report
INDICATION: ___ year old woman with picc// r picc 47cm iv ping ___ Contact
name: ping, ___: ___
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
There are multiple bilateral rib fractures. Right-sided PICC line projects to
the subclavian vein. Cardiomediastinal silhouette is stable. There is no
pleural effusion. No pneumothorax is seen.
Radiology Report
INDICATION: ___ year old woman with RUE PICC line that is malpositioned in the
subclavian vein.// Please reposition or replace RUE PICC line.
COMPARISON: X-ray from 1 day prior
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: None
MEDICATIONS: None
CONTRAST: 0 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 0.1, 1 mGy
PROCEDURE: 1. Fluoroscopic image of the chest.
PROCEDURE DETAILS: The patient was brought down to the angiography suite for
repositioning of the PICC line. Initial fluoroscopic image demonstrated that
the PICC line and artery reposition itself, now located in the mid SVC and
ready to use.
.
FINDINGS:
PICC line in appropriate position in the mid SVC.
IMPRESSION:
PICC line in mid SVC. Ready to use.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ year old woman s/p partial calcanectomy// post-op eval
IMPRESSION:
In comparison with the study ___, extensive postsurgical changes are
again seen in the foot. Following surgical procedure, there is no evidence of
complication. Further information can be gathered from the operative report.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Foot pain
Diagnosed with Cellulitis of left lower limb
temperature: 98.2
heartrate: 90.0
resprate: 18.0
o2sat: 96.0
sbp: 107.0
dbp: 58.0
level of pain: 9
level of acuity: 3.0 | Brief hospital course:
This is a ___ woman with type 1 diabetes (complicated by
Charcot joints, diabetic retinopathy, diabetic neuropathy,
gastroparesis) and end-stage renal disease (status post deceased
donor renal transplant ___ ___ who presented to the hospital
on ___ with a chief complaint of left heel pain, found to
have a left heel diabetic ulcer. Initially the area appeared not
to involve bone, with MRI showing only left foot tenosynovitis;
however, the wound had progressively necrotic tissue, requiring
multiple episodes of debridement with the assistance of
podiatric surgery. Eventually, the wound extended down to the
level of bone with concern for empiric osteomyelitis of the left
foot. Podiatric surgery performed serial debridements of the
foot. She went for OR debridement and placement of wound VAC on
___. Vascular surgery evaluated the blood flow to the area
with a left lower extremity angiogram on ___ this found
generally good blood flow to the affected area. The patient was
discharged with IV antibiotics, ___ for wound VAC nursing care.
Her blood sugars were also very labile ___ the setting of
infection; insulin was titrated with the assistance ___
diabetes service. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
amoxicillin
Attending: ___
Chief Complaint:
RLQ abdominal pain
Major Surgical or Invasive Procedure:
diagnostic laparoscopy, right salpingectomy and left ovarian
cystectomy
History of Present Illness:
___ is a ___ G0 who presents for RLQ pain since
this AM. She reports she awoke this am with mild right back
pain. She then experienced an episode of severe, sharp RLQ pain
at 7am. She also felt nauseated, dizzy, and experienced 4
episodes of diarrhea at the onset of her severe pain. Did not
get relief with diarrhea and has had no further episodes.
Received ibuprofen without relief. Stretching her legs would
briefly reduce the pain but she did not get any relief until she
received morphine in the ED.
PUS in the ED showed: 1. Two right adnexal cysts, measuring 10cm
and 5cm which are either exophytic from the ovary or
paraovarian. Doppler signal is present within the right ovary,
however given the size of the cysts intermittent torsion cannot
be completely excluded based on this study alone. MRI is
recommended to more completely evaluate these cysts.
CT showed:
1. Normal appendix.
2. Two large simple fluid-containing adnexal cysts, measuring
10cm and 5.7cm, are seen in the pelvis, as seen on ultrasound.
These cysts are causing mass effect on surrounding structures,
notably the rectum and bladder. Torsion is better assessed on
ultrasound.
3. There are findings suggestive of aggressive fluid hydration,
including periportaland upper abdominal perivascular edema. The
IVC is also distended.
Experienced 'intense chills' with onset of severe pain, but o/w
no fevers or chills. Denies dysuria, abnormal vaginal discharge,
vaginal bleeding, recent GI symptoms. No possibility of
pregnancy
as she has never had intercourse.
Past Medical History:
Obstetrical History: G0
Gynecologic History:
- LMP ___
- Menses previously regular until she moved to ___ 2months
ago. Denies history of menorrhagia or dysmenorrhea.
- Last Pap: never
- Not sexually active, denies exposure to STIs and h/o STIs.
Past Medical History: Denies
Past Surgical History:
- Cleft lip surgery x 2
Social History:
___
Family History:
non contributory
Physical Exam:
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, appropriately tender, no rebound/guarding, incision
c/d/i
Ext: no TTP
Pertinent Results:
LABS:
====
___ 12:29PM LACTATE-1.7
___ 12:00PM GLUCOSE-125* UREA N-15 CREAT-0.7 SODIUM-138
POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-22 ANION GAP-23*
___ 12:00PM estGFR-Using this
___ 12:00PM ALT(SGPT)-13 AST(SGOT)-28 ALK PHOS-64 TOT
BILI-0.5
___ 12:00PM LIPASE-37
___ 12:00PM ALBUMIN-5.0
___ 12:00PM WBC-11.3* RBC-4.28 HGB-12.6 HCT-39.8 MCV-93
MCH-29.4 MCHC-31.7* RDW-13.2 RDWSD-45.0
___ 12:00PM NEUTS-89.9* LYMPHS-6.5* MONOS-2.8* EOS-0.0*
BASOS-0.4 IM ___ AbsNeut-10.14* AbsLymp-0.73* AbsMono-0.31
AbsEos-0.00* AbsBaso-0.04
___ 12:00PM PLT COUNT-229
___ 11:58AM URINE HOURS-RANDOM
___ 11:58AM URINE UCG-NEG
___ 11:58AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 11:58AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:58AM URINE RBC-4* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-9
___ 11:58AM URINE MUCOUS-MOD
MICRO:
=====
___ - UCx contaminated
___ - BCx pending
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*50 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*40 Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp
#*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
right adnexal torsion and left ovarian cyst
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. Evaluate for appendicitis.
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right lower quadrant in the region of the patient's tenderness.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right lower quadrant in the region of the patient's tenderness.
A small amount of free fluid is seen in the right lower quadrant. The
appendix is not identified.
IMPRESSION:
1. The appendix is not identified.
2. Small amount of free fluid in the right lower quadrant.
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: ___ with rt lq pain. Evaluate for torsion?
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach. A transvaginal approach was not performed as patient
has never been sexually active.
COMPARISON: None.
FINDINGS:
The uterus is anteverted and measures 8.0 x 3.0 x 4.5 cm. The endometrium is
homogenous and measures 9 mm.
There are 2 large cystic structures in the right adnexa, which are either
exophytic from the ovary or paraovarian. Hydrosalpinx cannot be entirely
excluded. The largest of these cystic structures measures 10.0 x 8.7 x 8.4 cm
and contains low-level internal echoes. The smaller cyst measures 5.8 x 5.4 x
5.8 cm. Although arterial and venous waveforms are seen in the right ovary,
intermittent torsion cannot be entirely excluded. The left ovary is normal.
There is a trace amount of free fluid.
IMPRESSION:
1. Two right adnexal cysts, measuring 10 cm and 5 cm which are either
exophytic from the ovary or extra-ovarian. Ovarian tissue itself is not
thinned in appearance and the cystic structures may be extra-ovarian Doppler
signal is present within the right ovary, however given the size of the cysts
intermittent torsion cannot be completely excluded based on this study alone.
MRI is recommended to more completely evaluate these findings. GYN
consultation/evaluation also recommended.
RECOMMENDATION(S): MRI is recommended to more completely evaluate the large
right-sided adnexal cysts. GYN consultation.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ with rt lq pain. Evaluate for appendicitis.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 518 mGy-cm.
COMPARISON: Pelvic ultrasound from ___.
FINDINGS:
LOWER CHEST: There is minimal right basilar atelectasis. There is no evidence
of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is periportal edema, likely related to fluid administration. 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.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
trace free fluid in the pelvis.
REPRODUCTIVE ORGANS: 2 large simple appearing cysts are seen within the
pelvis. The air positioned at the midline with the smaller anterior cyst
measuring 5.5 x 5.4 x 5.7 cm (2:73, 601b:23 and the larger to posterior cyst
measuring 10.0 x 9.0 x 7.8 cm (2:75, 601b:35). The cysts appear to arise from
the right ovary. There is associated mass effect on adjacent structures,
including the rectum and bladder. Ovarian torsion is better evaluated for on
ultrasound. The uterus is unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No 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. Normal appendix.
2. Two large pelvic cysts, measuring 10 cm and 5.7 cm, likely rising from the
right ovary. Significant mass-effect on the surrounding structures most
notably, rectum and bladder. Torsion better assessed on same-day pelvic
ultrasound.
3. Stigmata of aggressive fluid resuscitation.
RECOMMENDATION(S): Given size of large pelvic cysts, gyn consultation
advised.
Gender: F
Race: NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
Arrive by WALK IN
Chief complaint: Lower back pain, RLQ abdominal pain
Diagnosed with Torsion of right ovary and ovarian pedicle
temperature: 97.8
heartrate: 48.0
resprate: 18.0
o2sat: 100.0
sbp: 124.0
dbp: 69.0
level of pain: 6
level of acuity: 3.0 | On ___, Ms. ___ was admitted to the gynecology
service after undergoing diagnostic laparoscopy, right
salpingectomy and left ovarian cystectomy. Please see the
operative report for full details.
Her post-operative course was uncomplicated. Her foley catheter
was removed post operatively and she voided spontaneously.
Immediately post-op, her pain was controlled with PO oxycodone,
acetaminophen, and ibuprofen. Her diet was advanced without
difficulty.
By post-operative day 1, she was tolerating a regular diet,
voiding spontaneously, ambulating independently, and pain was
controlled with oral medications. She was then discharged home
in stable condition with outpatient follow-up scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
ETOH intoxication
Major Surgical or Invasive Procedure:
intubation ___ (subsequently extubated shortly thereafter same
day)
History of Present Illness:
Ms. ___ is a ___ woman with T2DM,
depression/anxiety, seizure disorder, ETOH cirrhosis (history
not confirmed) presenting for agitation and suspected
polysubstance ingestion.
She was evaluated by EMS in the community. Her boyfriend
(___?) reported to EMS that the patient took too much of her
medications. At time of EMS arrival, the patient endorsed that
she drank 6 beers, took extra medications, and took suboxone in
an effort to sleep.
At ___, patient again endorsed the above but denied any
intentional overdose or thoughts of hurting herself. She arrived
with multiple pill bottles, including clonidine, Wellbutrin,
topiramate, lamotrigine, and clonazepam. Patient reported
feeling anxious and
denied any fever, headache, vision or speech change, weakness or
numbness, neck pain, chest pain, back pain, difficulty
breathing, abdominal pain nausea or vomiting or any other
symptoms.
In the OSH ED, she was agitated and reportedly talking in
multiple languages. Thought pattern was nonlinear and she became
violent, and reportedly was hitting the OSH ED staff. She was
given multiple doses of Haldol (15mg total)/Ativan (8mg total)
and was ultimately intubated. She was given a dose of Zosyn for
question of pneumonia. No reported fevers. She remained agitated
post-intubation and received vecuronium for paralysis.
In ___ ED, initial VS were:
98.4 66 99/51 23 100% Intubation
Patient was agitated in the ED.
Patient was given:
___ 05:36 IV DRIP Propofol ___ mcg/kg/min ordered)
Started 40
___ 05:36 IV DRIP Fentanyl Citrate ___ mcg/hr
ordered) Started 50
___ 05:36 IV DRIP Midazolam (0.5-2 mg/hr ordered)
___ 06:25 IV Ondansetron 4 mg
___ 06:41 IV DRIP Fentanyl Citrate 100 mcg/hr
___ 06:42 IV DRIP Propofol 50 mcg/kg/min
___ 07:45 IV DRIP Midazolam 6mg/hr
___ 07:51 IV Vecuronium Bromide 10 mg
Past Medical History:
Hx Diabetes Type 2, untreated
Hypertension
Depression, anxiety
Agoraphobia
Seizure
ETOH cirrhosis
Social History:
___
Family History:
unknown
Physical Exam:
ADMISSION PHYSCIAL EXAM:
========================
Ventilator: CMV RR 14, Tv450cc, 5PEEP, FiO2 40%
VITALS: 98.3 80 131/65 20 99% (on ventilator)
GENERAL: Intubated/sedated, intermittently arousable and follows
some commands. +Myoclonic jerks.
HEENT: Pupils 3mm and reactive bilaterally. Extraocular
movements grossly intact.
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally in anterior fields, no
wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: Intubated/Sedated.
DISCHARGE PHYSCIAL EXAM:
========================
Vitals: 97.8
PO 113 / 76
R Lying 61 18 98 Ra
Consitutional: anxious, "how long am I sectioned?"
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: obese, soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice. neck is supple
Neuro: AAOx3. CNs II-XII intact. MAEE.
Psych: denies SI/HI, full range of affect
Pertinent Results:
Admission Labs:
===============
- Lactate 2.2
- VBG with pH 7.29, pCO2 49, HCO3 25
- Electrolytes, LFTs, CBC, coags otherwise unremarkable
- OSH CT head with no acute intracranial process.
- Tox screen positive for benzodiazepines and buprenorphine from
OSH
Imaging:
========
CXR:
1. Endotracheal tube in appropriate position.
2. Retrocardiac and right lower lung opacities likely represent
atelectasis although aspiration could have this appearance.
EKG:
====
___ NSR. +S1Q3T3. Otherwise PR 161, narrow QRS, normal
appearance of T waves.
___ normal sinus rhythm rate 60 previously seen S1 wave is still
present (although smaller) and previously seen Q in lead III and
TWI in lead III are no longer seen. No other signs of R heart
strain or evidence of ischemia. QTc is 440.
DISCHARGE LABS:
==============
___ 07:15AM BLOOD WBC-6.8 RBC-3.59* Hgb-10.8* Hct-31.2*
MCV-87 MCH-30.1 MCHC-34.6 RDW-12.8 RDWSD-40.3 Plt ___
___ 02:52AM BLOOD WBC-7.8 RBC-3.78* Hgb-11.3 Hct-32.8*
MCV-87 MCH-29.9 MCHC-34.5 RDW-12.9 RDWSD-40.1 Plt ___
___ 07:15AM BLOOD Glucose-107* UreaN-6 Creat-0.8 Na-141
K-3.3 Cl-110* HCO3-18* AnGap-16
___ 02:52AM BLOOD Glucose-112* UreaN-5* Creat-0.8 Na-141
K-3.3 Cl-111* HCO3-18* AnGap-15
___ 07:15AM BLOOD ALT-23 AST-16 AlkPhos-50 TotBili-0.3
___ 02:52AM BLOOD ALT-28 AST-20 LD(LDH)-191 AlkPhos-50
TotBili-0.4
___ 07:15AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.7
___ 02:52AM BLOOD Albumin-3.6 Calcium-8.4 Phos-3.2 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO BID:PRN anxiety
2. HydrOXYzine 50 mg PO TID
3. CloNIDine 0.2 mg PO TID
4. TraZODone 100 mg PO QHS
5. Sertraline 200 mg PO DAILY
6. Amphetamine-Dextroamphetamine Dose is Unknown PO BID
7. Gabapentin 400 mg PO TID
8. Buprenorphine-Naloxone (2mg-0.5mg) Dose is Unknown SL DAILY
9. ARIPiprazole 20 mg PO DAILY
10. BuPROPion (Sustained Release) 150 mg PO QAM
11. Topiramate (Topamax) 200 mg PO BID
12. LamoTRIgine 25 mg PO BID
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY:PRN constipation
2. QUEtiapine Fumarate 50 mg PO QPM:PRN sleep
3. Senna 8.6 mg PO DAILY
4. ClonazePAM 1 mg PO BID:PRN anxiety
5. LamoTRIgine 25 mg PO BID
6. Topiramate (Topamax) 200 mg PO BID
7. ___- BuPROPion (Sustained Release) 150 mg PO QAM This
medication was ___. Do not restart BuPROPion (Sustained
Release) until it is restarted by psychiatry
8. ___- CloNIDine 0.2 mg PO TID This medication was ___. Do
not restart CloNIDine until it is restarted by psychiatry
9. ___- Gabapentin 400 mg PO TID This medication was ___. Do
not restart Gabapentin until it is restarted by psychiatry
10. ___- HydrOXYzine 50 mg PO TID This medication was ___. Do
not restart HydrOXYzine until it is restarted by psychiatry
11. ___- TraZODone 100 mg PO QHS This medication was ___. Do
not restart TraZODone until it is restarted by psychiatry
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Suspected multisubstance ingestion
#Alcohol Intoxication
#Agitation
#Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with intubated// confirm ETT
TECHNIQUE: Portable AP chest
COMPARISON: None
FINDINGS:
Endotracheal tube terminates 4.2 cm above the carina, in appropriate position.
Enteric tube courses beyond the diaphragm and inferiorly out of view. Lung
volumes are low. Retrocardiac and right lower lung opacities present. No
pneumothorax or pleural effusion. Cardiomediastinal silhouette is within
normal limits. Metallic coil overlies the right mediastinum.
IMPRESSION:
1. Endotracheal tube in appropriate position.
2. Retrocardiac and right lower lung opacities likely represent atelectasis
although aspiration could have this appearance.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: INTUBATED TRANSFER
Diagnosed with Altered mental status, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: UTA
level of acuity: 1.0 | SUBJECTIVE: Overnight, pt requested something for sleep however
was refusing her other medications as prescribed. She agreed to
take her other meds and overnight MD prescribed ___ and she
did sleep a few hours. This morning, she asked when she was
going to be able to go home. She asked if she was "sectioned"
and I said yes. She said, "well that means I will go to a psych
hospital like ___. The psychiatry doctor ___ say that I'm
not rational."
overall feeling well. denies chest pain, nausea, vomiting,
diarrhea. Reported no bowel movement for 5 days so bowel regimen
was ordered. otherwise no specific medical complaints. Denies
SI/HI this morning.
no events on telemetry overnight. her EKG yesterday morning
demonstrated normalization of previously seen TWI and Q waves.
No events were seen on telemetry and it was discontinued.
Psychiatry recommended inpatient psychiatric hospitalization for
further stabilization and I was informed that a bed is available
at ___ HRS inpatient psychiatric unit ___. accepting physician ___. Expected transfer at
9AM).
Rest of hospital course and plan are outlined below by issue:
#Suspected multisubstance ingestion:
#Agitation:
Patient endorsed taking multiple medications to fall asleep/get
high, but denied any intentional overdose or thoughts of hurting
herself. She arrived with multiple pill bottles, including
clonidine, wellbutrin, topiramate, lamotrigine, and clonazepam.
No anion gap, ASA and Tylenol serum levels negative. Tox screen
positive for benzodiazepines and buprenorphine. Toxicology
consulted, existing who suggested continuing supportive care
until her ingestion clears. Initially intubated at OSH for being
violent to ED staff and requiring large doses of Haldol (15mg
total) and Ativan (8mg total). She remained agitated
post-intubation and received vecuronium for paralysis. The
patient was taken off vecuronium and maintained on
midazolam/fentanyl for sedation. Required Precedex
intermittently the following night. Extubated in the morning of
___ with good oxygenation on room air. There was no anion gap,
ASA and Tylenol serum levels were negative.
-Differential diagnosis: Serotonin syndrome was less likely in
absence of fever. CK 324. In discussion with toxicology ,
existing workup was adequate and goal was to continue supportive
care until her ingestion cleared
-continuing topiramate, lamotrigine, and clonazepam continued
1mg BID per psych
-other psych medications have been ___ including the
following:
HydrOXYzine 50 mg PO TID, CloNIDine 0.2 mg PO BID:PRN, TraZODone
100 mg PO QHS, and buproprion (sustained) 15mg qAM (these may
be sequentially resumed per psychiatry recommendations.
-The following meds were listed in med rec from OSH but pt
currently denies taking the following at least since ___:
Sertraline 200 mg PO DAILY, Amphetamine-Dextroamphetamine,
aripiprazole 20mg qd
-Seroquel 50 nightly PRN for sleep as suggested by psych
-patient is under ___ and cannot leave AMA
-1:1 sitter
#Bipolar disorder II:
#Depression, anxiety:
#Elopement:
Per ___ records, has a history of suicidal ideation and
wrist cutting. Denied suicidal ideation at OSH, but intubated
and sedated on arrival so interview not done on arrival.
Psychiatry consulted for evaluation of suicidality and capacity.
After patient was interviewed by psychiatry, the psychiatry team
exited the room to discuss plan of care with primary team.
During interdisciplinary discussion, patient eloped with two
companions. Security was called and patient description was
provided. Security team in the lobby was similarly notified and
requested to stop the patient if she tried to exit the building.
Psychiatry felt that patient is not currently suicidal but
should be placed under a ___ for her safety. Patient was
found and was returned to her room and a ___ was filled.
#Myoclonus:
Unclear etiology, but Sertraline and Adderall were ?
contributing vs other ingestion.
-Continue to monitor
#Constipation: bowel regimen
#Reported ETOH abuse:
-no significant withdrawal at this time.
#Abnormal EKG Findings:
S1Q3T3 was noted on EKG while in ICU however overall picture was
felt not suggestive of pulmonary embolus. Not tachycardic and
without evidence of difficulty oxygenating on ventilator. No
previous EKG available for comparison and her repeat EKG on ___
demonstrated normalization of previously seen TWI and Q waves,
Qtc 440.
#Vomiting:
She had nausea/vomiting and possible aspiration on CXR. No
fevers.
#T2DM:
Not on medications at baseline.
-Insulin sliding scale while inpatient
#Chronic pain:
-Holding gabapentin
#Seizure disorder:
Reportedly on topiramate, lamotrigine. Intermittent clonus noted
in the ICU, which has now resolved. topiramate and lamotrigine
were confirmed that she was taking and have been resumed.
#Transitional Issues:
-needs new PCP ___
#CONTACTS:
-?Mother ___ ___ (attempted to call but no answer
and voicemail not set up)
-PCP: ___. Listed as Dr. ___ (had appointment with
him for ___ but didn't show, never actually saw him). staff
left message with Dr. ___ (psychiatry) ___
who most recently wrote her medications.
#Consults: Psych
#Disposition: was at home with boyfriend prior to admission.
Reviewed by physical therapy and no acute ___ needs were
identified. Medically ready for discharge to inpatient
psychiatric facility (___). ___
spent > 30 minutes seeing the patient and organizing her
transfer. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
EGD x 4 (___)
Left Hip Girdlestone (___)
Endotracheal Intubation (___)
___ embolization (___)
History of Present Illness:
Mr. ___ is a ___ year-old man with schizoaffective disorder
who presents after being found down at home. Patient lives alone
in independent living facility but has intermittent home visits
by psych social worker. The last visit was 5 days prior to
admission. On the day of admission, pt. was found down on the
floor by EMS.
In the ED, initial vitals 98.2 110 173/78 20 98%RA.
- Labs were significant for Chem-7 with Na 154 K 5.5 CO2 17
BUN/Cr 105/1.7, CBC with WBC 22.6, LFTs with ALT 180 AST 2209,
CK 2938, lactate 2.7, coags with INR 1.2.
- UA with mod blood. STox/UTox negative. BCx x2 and UCx sent and
pending.
- CXR without acute intrathoracic process. L hip X-ray showing
fracture at mid-cervical level. Noncon CT head with small
subgaleal hematoma without underlying fracture or intracranial
hemorrhage. CT C-spine with no acute fracture or malalignment
but multilevel degenerative changes.
- The patient was administered 1L IVF with improvement in Cr
1.4. In addition was administered 3 amps bicarb with D5W.
Orthopedics team was consulted and recommended admission to
medicine for medical optimization prior to planned OR tomorrow
___. Vitals prior to transfer 98.1 108 159/65 18 99% RA.
Upon arrival to the floor, patient reports significant left hip
pain with movement. He other has no complaints.
ROS:
Per HPI. In addition, pt. denies fevers, chills, night sweats,
or weight changes. No cough, no shortness of breath, no dyspnea
on exertion. No chest pain or palpitations. No nausea or
vomiting. No diarrhea or constipation.
Past Medical History:
- Schizoaffective disorder (auditory hallucinations; followed by
Dr. ___ at ___)
- GERD
- BPH
- Elevated PSA
- Inguinal hernia
- Pt. does report he has been hospitalized several times for
inability to care for himself.
Social History:
___
Family History:
Unknown.
Physical Exam:
On Admission:
VS: 98.6, 111, 145/88, 18, 98% on RA
GEN: A and O x2 (self, hospital, ___ elderly
chronically ill appearing gentleman
HEENT: Sclera anicteric, dry mucous membranes, poor dentition,
superficial bruise/hematoma on skullEOMI; tacky MM; poor
dentition
NECK: Supple, nontender
PULM: CTAB w/o wheezes or crackles, though poor inspiratory
effort
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, normoactive bowel sounds
EXT: Warm, well-perfused 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Eschars on right lateral hip, knee, shoulder, and elbow;
superficial abrasion posterior skull, nonstageable large ulcer
on coccyx
NEURO: Face is symmetric, moves all 4 extremities equally,
sensation intatct to light touch throughout
Discharge Exam:
Vitals: 98, 143/53, 76, 20, 97%RA
General: alert, dysarthric, answers questions appropriately,
oriented to self; generally edematous
HEENT: Sclera anicteric, MMM, poor dentition
Neck: supple, JVP not elevated, no LAD
Lungs: limited, clear to auscultation bilaterally on
anterolateral exams, no wheezes, rales, rhonchi
CV: Regular rate, no m/r/g
Abdomen: soft, distended, tympanitic to percussion, + bowel
sounds
GU: Foley
Ext: Warm, well perfused. 2+ LLE pitting edema with edema also
in UE b/l
Neuro: can repeat name, mildly dysarthric speech
Skin: sacral ulcers as well as multiple abrasions with dressing
c/d/i
Pertinent Results:
***ADMISSION LABS
___ 02:15PM BLOOD WBC-22.6*# RBC-4.77 Hgb-15.0 Hct-46.2
MCV-97 MCH-31.4 MCHC-32.5 RDW-13.1 RDWSD-46.5* Plt ___
___ 02:15PM BLOOD Neuts-86.5* Lymphs-2.8* Monos-9.9
Eos-0.0* Baso-0.2 Im ___ AbsNeut-19.54* AbsLymp-0.63*
AbsMono-2.23* AbsEos-0.00* AbsBaso-0.04
___ 04:20PM BLOOD ___ PTT-25.4 ___
___ 02:15PM BLOOD Glucose-135* UreaN-105* Creat-1.7*
Na-154* K-5.5* Cl-110* HCO3-17* AnGap-33*
___ 02:15PM BLOOD ALT-180* AST-209* CK(CPK)-3938*
AlkPhos-60 TotBili-0.9
___ 02:15PM BLOOD Albumin-4.0 Calcium-9.4 Phos-5.4*#
Mg-3.6*
___ 04:00PM BLOOD Lipase-21
___ 02:15PM BLOOD cTropnT-<0.01
___ 02:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:35PM BLOOD Lactate-2.7*
___ 02:50PM BLOOD WBC-36.4*# RBC-2.21* Hgb-6.4* Hct-20.1*
MCV-91 MCH-29.0 MCHC-31.8* RDW-17.7* RDWSD-56.0* Plt ___
___ 04:03AM BLOOD Neuts-96* Bands-0 Lymphs-2* Monos-2*
Eos-0 Baso-0 ___ Myelos-0 NRBC-3* AbsNeut-28.03*
AbsLymp-0.58* AbsMono-0.58 AbsEos-0.00* AbsBaso-0.00*
___ 04:03AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-1+
___ 02:50PM BLOOD ___ PTT-31.0 ___
___ 02:50PM BLOOD ___
___ 02:50PM BLOOD Glucose-163* UreaN-45* Creat-1.2 Na-150*
K-4.2 Cl-119* HCO3-19* AnGap-16
___ 11:00PM BLOOD CK(CPK)-96
___ 11:00PM BLOOD CK-MB-5 cTropnT-0.04*
___ 11:00PM BLOOD Calcium-7.1* Phos-4.0 Mg-2.2
___ 04:03AM BLOOD Vanco-32.0*
___ 11:00PM BLOOD Type-CENTRAL VE pO2-49* pCO2-35 pH-7.38
calTCO2-22 Base XS--3
___ 11:38AM BLOOD Lactate-1.7 Na-144 K-4.0 Cl-118*
___ 11:38AM BLOOD Hgb-7.1* calcHCT-21
================
MICROBIOLOGY
___ Blood Cx: Proteus mirabilis and Alloicoccus Otitis
___ Joint Fluid: Gram stain with PMNs but no organisms; Cx with
no growth
___ Tissue/Bone Culture: Proteus Mirabilis
___ Urine Culture: negative
___ Sputum Culture: <10 PMNs and >10 epithelial cells/100X
field. Gram stain indicates extensive contamination with upper
respiratory secretions
___ C. Diff toxin assay: negative
=================
IMAGING
___ CT C-Spine: 1. No acute cervical spinal fracture or
malalignment.
2. Multilevel degenerative changes, as described above.
___ CT Head: Small subgaleal hematoma overlying the vertex,
without underlying fracture or intracranial hemorrhage.
___ CXR Portable: No acute intrathoracic process.
___ Left Hip XR: AP pelvis and two views left hip were
provided. The bony pelvic ring is intact. There is an acute
fracture involving the left femoral neck. The fracture involves
the mid cervical level and the distal shaft is varus angulated.
Mild spurring at the hip joints noted. SI joints are symmetric.
___ RUQ US: Limited views of the liver due to overlying bowel
gas and patient's inability to cooperate with the exam. Within
these limitations, normal abdominal ultrasound.
___ CT Abd/Pelv: 1. Stranding and mild wall thickening around
the duodenum suggest duodenitis. This could be inflammatory,
infectious, or ischemic. 2. Large right inguinal hernia
containing multiple loops of bowel. There is mild dilation of
small bowel proximal to this with transition point at the entry
site to the hernia, suggesting a partial or early small bowel
obstruction. 3. Left femoral neck fracture. 4. Small left
inguinal hernia. 5. Retained contrast in the kidneys, suggestive
of acute or chronic kidney
disease. 6. Enlarged prostate. 7. Subcentimeter right adrenal
lesion, likely adenoma.
___ Pathology investigation of transfusion: Mr. ___
multiple underlying medical issues most likely contributed to
the fever in question, as he has been having fevers throughout
his hospital stay, including prior to the transfusion. No
changes in standard transfusion practices are recommended in
this patient at this time.
___ EKG: Sinus rhythm with underlying A-V conduction delay and
right bundle-branch block. There are Q waves in leads I, aVL,
and V5-V6 consistent with an old lateral myocardial infarction.
Compared to the previous tracing of ___ there is now T wave
inversion in leads V2-V3 of unclear significance. Rate 90, PR
214, QRS 138, QT 398, QTc 450
___ ABD XRAY: Dilated loops of large and small bowel. Lucency
in the right upper quadrant on lateral view likely due to
artifact. Further examination with CT should be considered to
rule out small bowel obstruction
___ ABD CT w/ and w/o contrast: 1. No evidence for free air.
Stranding and mild thickening around the duodenum significantly
improved from prior examination, could reflect residual
duodenitis. 2. Large right inguinal hernia containing multiple
loops of collapsed small bowel. There is no evidence of small
bowel obstruction. 3. Redemonstration of a right adrenal lesion,
likely adenoma. 4. Fluid filled large bowel, correlate with any
history of diarrhea.
___ CT ABD/PELV: 1. Intramuscular hematoma at the site of left
femoral head osteotomy, with increased density and expansion of
left gluteal musculature, suggestive of a growing hematoma. 2.
Increased bilateral simple pleural effusions. 3. Large bowel
containing right inguinal hernia, without evidence of bowel
obstruction or inflammation. 4. Unchanged right adrenal lesion,
incompletely characterized but likely an adenoma. 5. Findings
suspicious for active duodenal bleed (Not on report,
communicated by ___ upon review of imaging)
___ Hip X-ray: Moderate degenerative changes of the right hip
and lower lumbar spine. No interval changes s/p antibiotic
spacer placement in left hip.
DISCHARGE LABS:
___ 05:57AM BLOOD WBC-8.4 RBC-2.78* Hgb-8.3* Hct-26.6*
MCV-96 MCH-29.9 MCHC-31.2* RDW-16.4* RDWSD-57.2* Plt ___
___ 05:57AM BLOOD Plt ___
___ 05:57AM BLOOD ___ PTT-31.4 ___
___ 05:57AM BLOOD Glucose-78 UreaN-8 Creat-0.6 Na-138 K-3.3
Cl-100 HCO3-27 AnGap-14
___ 06:48AM BLOOD ALT-29 AST-34 LD(LDH)-250 AlkPhos-97
TotBili-0.3
___ 05:57AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 20 mg PO DAILY
2. OLANZapine 20 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Vitamin E 400 UNIT PO DAILY
5. Calcium Carbonate 500 mg PO QID:PRN dyspepsia
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY Duration: 14 Days
Last dose on ___
2. CeftriaXONE 1 gm IV Q24H
Please continue taking for total of 6 week course (last dose
___
3. Collagenase Ointment 1 Appl TP DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Vitamin E 400 UNIT PO DAILY
7. Calcium Carbonate 500 mg PO QID:PRN dyspepsia
8. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
Last dose ___
9. Docusate Sodium 100 mg PO BID
Please continue taking until you are no longer taking pain
medication
10. Senna 8.6 mg PO BID:PRN constipation
Please stop taking when you stop taking narcotic pain
medications.
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain
Please hold for decreased respiratory rate and sedation.
12. Acetaminophen 650 mg PO Q6H
Please do not take more than 3 grams in one day
13. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
14. ARIPiprazole 10 mg PO DAILY
Please follow up on long term dosing with your outpatient
psychologist
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis/es:
-Upper Gastrointestinal Bleed from Duodenal Ulcers
-Osteomyelitis of Left Femur
-Septic Arthritis of Left Hip
-Left Hip Fracture
-Multiorganism bacteremia (Proteus Mirabilis and Alloiococcus
Otitis)
Secondary Diagnosis/es:
-Rhabdomyolysis
-Acute Kidney Injury
-Multiple decubitus ulcers
-Hypoxemic Respiratory Failure
-Schizoaffective Disorder
-Anemia (due to intestinal bleeding)
-Encephalopathy due to hemodynamic and metabolic instability
-Hypernatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ found down x several days now w/ r sided and sacral decub
wounds
COMPARISON: None
FINDINGS:
AP portable supine view of the chest. There is no focal consolidation or
supine evidence for pleural effusion, or pneumothorax. The cardiomediastinal
silhouette is normal. Imaged osseous structures are intact.
IMPRESSION:
No acute intrathoracic process
Radiology Report
INDICATION: ___ found down, L hip externally rotated and foreshortened //
eval ? L hip fracture
COMPARISON: None
FINDINGS:
AP pelvis and two views left hip were provided. The bony pelvic ring is
intact. There is an acute fracture involving the left femoral neck. The
fracture involves the mid cervical level and the distal shaft is varus
angulated. Mild spurring at the hip joints noted. SI joints are symmetric.
IMPRESSION:
Left hip fracture, mid cervical level.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ found down, AMS, unknown LOC // eval ? ICH, cerivcal spinal
injury
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 1,003 mGy-cm
COMPARISON: None.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, mass, midline shift, or
acute major vascular territorial infarct. Gray-white matter differentiation
is preserved. Mild periventricular white matter hypodensities are
nonspecific, but may be a sequela of chronic small vessel ischemic changes.
Prominent ventricles and sulci are likely due to age-related volume loss.
Basilar cisterns are patent.
Minimal mucosal thickening is noted within the anterior ethmoid air cells.
Remainder of the included paranasal sinuses and mastoids are clear. Skull and
extracranial soft tissues are unremarkable. A small subgaleal hematoma is
noted along the vertex (___).
IMPRESSION:
Small subgaleal hematoma overlying the vertex, without underlying fracture or
intracranial hemorrhage.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ found down, AMS, unknown LOC. Evaluate for cervical spinal
injury.
TECHNIQUE: Noncontrast CT cervical spine with axial, coronal, sagittal
reformations.
COMPARISON: None
FINDINGS:
There is no acute fracture or malalignment in the cervical spine. Multilevel
degenerative changes of the cervical spine are identified, worst at C4-C5,
C5-C6, and C6-C7 with disc height loss, uncovertebral joint hypertrophy and
posterior osteophytes. There is at least moderate canal narrowing which is
worse at the C3-4 and C4-5 levels. There is ossification of the nuchal
ligament. No prevertebral edema.
The aerodigestive tract appears patent. Lobulated slightly hyperdense
structure seen in close association to the infrahyoid strap muscles (03:40)
which could represent a thyroglossal duct cyst. Mild left apical pulmonary
scarring is identified. Thyroid gland appears normal.
IMPRESSION:
1. No acute cervical spinal fracture or malalignment.
2. Multilevel degenerative changes, as described above.
Radiology Report
INDICATION: ___ with L hip fx // eval ? distal femur injury
COMPARISON: Same-day left hip radiograph
FINDINGS:
Views of the left distal femur demonstrate no fracture. An ossific density
projecting over the inferior aspect of the patella may represent a congenital
fusion anomaly. No joint effusion at the left knee. Soft tissues appear
unremarkable.
IMPRESSION:
No fracture in the distal femur.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with transaminitis and gram negative bacteremia
// Evidence of biliary pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: Very limited views of the liver were obtained due to overlying bowel
gas and patient's inability to cooperate with the exam. Within these
limitations, no focal hepatic lesion is seen. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized on this exam due to overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 9.6 cm.
KIDNEYS: The right kidney measures 10.5 cm. The left kidney measures 11.2 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones, or hydronephrosis in the
kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Limited views of the liver due to overlying bowel gas and patient's inability
to cooperate with the exam. Within these limitations, normal abdominal
ultrasound.
Radiology Report
INDICATION: ___ year old man with sacral decubitus ulcer, GNR bacteremia,
hypernatremia, now with rigors, new O2 requirement. // aspiration pneumonitis
vs PNA
COMPARISON: Radiographs from ___
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. Mild subsegmental
atelectasis is seen at the lung bases. There are no focal consolidations,
pleural effusion, or pulmonary edema. There are no pneumothoraces.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man admitted after being found down, has left femur
fracture, now transferred to ICU for acute hypoxia and tachypenia, has
worsening mental status. CT head on admission negative. // Evaluate for any
interval change, particularly any subdural 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.
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 = 55.0 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: Head CT on ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are enlarged consistent with age related atrophy.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable. The small
subgaleal hematoma at the vertex is again demonstrated.
IMPRESSION:
1. No acute intracranial process.
Radiology Report
EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY
INDICATION: ___ year old man admitted after being found down, has left femur
fracture, now transferred to ICU for acute hypoxia and tachypenia, has
persistent tachcyardia. // Please r/o PE
TECHNIQUE: MDCT images were obtained from the thoracic inlet to the upper
abdomen. IV contrast was administered. Axial images were interpreted in
conjunction with sagittal and coronal reformats.
DLP: 216 mGy-cm
COMPARISON: None
FINDINGS:
The thyroid is normal.
Axillary, supraclavicular, mediastinal, and hilar lymph nodes are not
pathologically enlarged.
The aorta is normal in caliber. There is moderate atherosclerosis of the
thoracic aorta. The right main pulmonary artery measures 3 cm in diameter.
There is no evidence of pulmonary embolism to the subsegmental level.
The heart size is normal. No pericardial effusion.
The airways are patent to subsegmental levels.
There is bibasilar atelectasis. No focal consolidation, effusion or
pneumothorax is seen.
The esophagus and visualized upper abdominal organs are unremarkable.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy.
There is a 3.0 x 3.7 cm subcutaneous ovoid lesion which is low density, likely
a cyst in the anterior superior chest wall, just below the level of the
sternoclavicular joint.
IMPRESSION:
No evidence of pulmonary embolism to the subsegmental level. Bibasilar
atelectasis.
Likely large subcutaneous sebaceous cyst along the anterior superior chest
wall, recommend clinical correlation.
Radiology Report
INDICATION: ___ year old man with found down at home now with altered mental
status in need of MRI scan // Please assess for intra-abomdinal metal prior
to MRI scan
COMPARISON: Compared to radiographs from ___ of the left hip.
IMPRESSION:
There is no metallic densities identified within the abdomen. EKG leads are
seen. The bowel gas pattern is nonspecific, without signs for bowel
obstruction. Air is seen throughout the stomach and nondilated loops of
colon.There is a fracture involving the left femoral neck.
Radiology Report
INDICATION: Found down at home with altered its mental status and gram
negative rod bacteremia. Evaluate for cause of infection.
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.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was not administered.
DOSE: DLP: 1118.17 mGy-cm (abdomen and pelvis).
COMPARISON: CT of the chest from ___.
FINDINGS:
LOWER CHEST: There is bibasilar atelectasis. No discrete nodule or pleural
effusion is identified. Base the heart is normal in size. There is no
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions on this limited noncontrast exam. There
is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits, without CT evidence of cholecystitis.
PANCREAS: There is mild pancreatic atrophy. The pancreas otherwise has normal
attenuation throughout, without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen is normal in size, measuring 11.5 cm. There are no focal
lesions.
ADRENALS: In the right adrenal gland, there is a 9 mm nodule which measures 7
hounsfield units. The left adrenal gland is mildly thickened, though no
discrete nodule is identified.
URINARY: The kidneys are of normal and symmetric size. In the right kidney,
there is a 11 mm cyst (601 B, 44). There is no evidence of a worrisome focal
renal lesion or hydronephrosis. There is no nephrolithiasis. The kidneys
have a striated enhancement pattern, likely due to residual contrast from the
prior CTA. This suggests renal insufficiency. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is normal in caliber and filled with fluid.
There is some stranding around the first and second portions of the duodenum,
as well as possible mild wall thickening with thickening of the adjacent
mesentery. There is no free air or free fluid. This likely represents a
duodenitis.
There is a large right inguinal hernia, which contains multiple loops of small
bowel. The small bowel proximal to the hernia is mildly dilated and
fluid-filled, measuring up to its 3.1 cm. The loops distal to the hernia are
collapsed. Transition point is likely at the entry site to the hernia, series
2, image 69. There is no wall edema or significant stranding around any of
the dilated loops. There is no free fluid.
There is a small left inguinal hernia appears to contain a small collapsed
loop of bowel, though there is no evidence of obstruction or strangulation.
The large bowel is normal in course and caliber without evidence of
inflammatory changes or mass. The appendix is not definitely visualized,
though there no secondary signs of appendicitis.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. No
retroperitoneal hematoma is identified.
VASCULAR: There is no abdominal aortic aneurysm. There is a moderate calcium
burden in the abdominal aorta and great abdominal arteries. Note, evaluation
is limited given the noncontrast technique.
PELVIS: A Foley catheter is present within a collapsed urinary bladder. Air
within the bladder is likely from this recent instrumentation. The prostate
is enlarged, measuring 6.1 cm in the transverse dimension. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
BONES AND SOFT TISSUES: There is a subacute appearing left femoral neck
fracture which extends to the subcapital region. Tiny bone fragments are
noted around the fracture line. There is surrounding air in the soft tissues
from vacuum phenomenon. Additionally there is stranding in the surrounding
musculature and soft tissues. There is no large focal hematoma. No other
fracture is identified. There are moderate degenerative changes in the lumbar
spine.
IMPRESSION:
1. Stranding and mild wall thickening around the duodenum suggest duodenitis.
This could be inflammatory, infectious, or ischemic.
2. Large right inguinal hernia containing multiple loops of bowel. There is
mild dilation of small bowel proximal to this with transition point at the
entry site to the hernia, suggesting a partial or early small bowel
obstruction.
3. Left femoral neck fracture.
4. Small left inguinal hernia.
5. Retained contrast in the kidneys, suggestive of acute or chronic kidney
disease.
6. Enlarged prostate.
7. Subcentimeter right adrenal lesion, likely adenoma.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the
telephone on ___ initiallyat 5 ___, and then again at 7 ___ after the
attending review.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man found down at home here with altered mental
status and GNR bacteremia // Assess for intracranial cause of AMS, evidence
of stroke
TECHNIQUE: MRI of the brain is performed and includes the following
sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial flair,
axial diffusion weighted and axial gradient echo images . Gadolinium enhanced
MRA of the neck was acquired.
COMPARISON: No prior similar examinations.
FINDINGS:
There is no acute infarction, intracranial hemorrhage, extracerebral fluid
collection, midline shift or mass effect. Mild brain atrophy is seen. There
is also mild medial temporal atrophy identified. No evidence of significant
subcortical white matter ischemic disease. Flow voids are maintained.
Suprasellar and craniocervical regions are unremarkable. Incidentally noted
is a small left anterior temporal fossa arachnoid cyst.
MRA of the neck shows normal flow in the carotid and vertebral arteries
without stenosis or occlusion.
IMPRESSION:
No acute infarcts mass effect or hydrocephalus. Mild to moderate brain and
medial temporal atrophy. Normal MRA of the neck. .
Radiology Report
INDICATION: ___ year old man with respiratory failure, intubated // Assess ET
tube position
COMPARISON: Radiographs from ___
IMPRESSION:
There is an endotracheal tube whose tip is 6 cm above the carina. There is a
nasogastric tube whose sideport is just past the GE junction. There are low
lung volumes with atelectasis at the lung bases. There is a left retrocardiac
opacity and left-sided pleural effusion. No pneumothoraces are identified.
Radiology Report
INDICATION: ___ year old man with respiratory failure, altered mental status
and sepsis now intubated // Please assess for interval change
COMPARISON: Radiographs from ___
IMPRESSION:
Endotracheal tube and feeding tube are unchanged position. Cardiomediastinal
silhouette is within normal limits. There is atelectasis at the lung bases.
There is no signs for overt pulmonary edema or focal consolidation. There is
improved aeration at the left base since prior. There are no pneumothoraces.
Radiology Report
EXAMINATION:
MRI OF THE CERVICAL SPINE
INDICATION: ___ year old man with altered menal status, bilateral upper
extremity weakness, polymicrobial bacteremia // Please assess for cervical
spine abnormality
TECHNIQUE: T1, T2 and inversion recovery sagittal and gradient sequence T2
axial images of cervical spine obtained.
COMPARISON: Cervical spine CT ___.
FINDINGS:
At the craniocervical junction and C2-3 level, mild degenerative changes
identified.
At C3-4 level, there is posterior disk bulge mild to moderate spinal stenosis
seen with mild to moderate foraminal narrowing.
At C4-5 disc bulging and posterior ridging identified with moderate spinal
stenosis and deformity of the spinal cord. Moderate to severe right-sided and
mild-to-moderate left-sided foraminal narrowing is seen.
At C5-6 level, posterior disc osteophyte results in moderate spinal stenosis
with moderate to severe bilateral foraminal narrowing.
At C6-7 level, disc bulging and mild spinal canal narrowing seen with mild to
moderate bilateral foraminal narrowing.
At C7-T1 level, mild anterolisthesis due to degenerative changes identified.
There is no spinal stenosis or foraminal narrowing.
At T1-2 and T2-3 mild degenerative change seen.
The spinal cord shows normal intrinsic signal.
The patient has endotracheal intubation with retained secretions within the
nasopharynx.
IMPRESSION:
Multilevel changes of cervical spondylosis are identified with moderate spinal
stenosis at C4-5 and C5-6 and mild to moderate spinal stenosis at C3-4 and
mild spinal stenosis at see C6-7 levels. Multilevel foraminal changes as
described above. Mild extrinsic deformity of the spinal cord is seen at C4-5
and C5-6 levels but no evidence of intrinsic spinal cord signal abnormalities.
No signs of ligamentous disruption seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure, intubated, has had
atelectasis at the bases. // Evaluate for interval change. Evaluate for
interval change.
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
remain in place. The cardio mediastinal silhouette is stable and there is no
evidence of vascular congestion or pleural effusion. Minimal atelectatic
changes in the retrocardiac region, with no evidence of acute focal pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with left hip fracture and altered mental status
with GNR/GPC bacteremia, also intubated // Assess for interval change
Assess for interval change
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices are
unchanged. Cardiomediastinal silhouette is stable and there is no evidence of
vascular congestion, pleural effusion, or acute focal pneumonia.
Radiology Report
INDICATION: ___ year old man with sepsis, respiratory failure, intubated for
airway protection // Assess for interval change
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
he monitoring and support devices are unchanged in standard position. The tip
of the nasogastric tube is in the first portion of the duodenum. Interval
worsening of asymmetric left-sided pulmonary edema. No significant pleural
effusions or pneumothorax. The cardiomediastinal silhouette is compared well.
IMPRESSION:
Mild worsening of the asymmetric left-sided interstitial edema.
Radiology Report
INDICATION: ___ year old man with bacteremia s/p R hip fracture // please
evaluate for evidence of pneumonia
TECHNIQUE: Portable
COMPARISON: ___
FINDINGS:
The nasogastric tube has been removed. The ET tube is in good position. The
left-sided asymmetric pulmonary edema has improved. Minimal left residual
basal atelectasis. No pneumothorax. The cardiomediastinal silhouette is
compared with the prior. There is barium seen within the stomach.
IMPRESSION:
Interval improvement, of the left pulmonary edema and atelectasis. The ET
tube remains in good position.
Radiology Report
INDICATION: ___ year old man currently intubated with OG tube // Please
evaluate placement of OG tube; ETT
TECHNIQUE: Chest portable
COMPARISON: ___
FINDINGS:
The enteric feeding tube is coiled in the stomach, with the tip at the gastric
fundus. The endotracheal tube ends 5.9 cm from the carina.
The lungs are clear. Cardiomediastinal silhouette is not enlarged. No
pneumothorax an check a trace left-sided effusion is suspected.
IMPRESSION:
No acute interval change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man w/resp failure currently intubated with ET/OG
tube // check ET/OG tube placement check ET/OG tube placement
IMPRESSION:
The endotracheal tube remains in good position. Nasogastric tube extends to
the mid body of the stomach, before coiling upon itself so that the tip lies
close to the esophagogastric junction and pointing upwards. No evidence of
acute pneumonia or vascular congestion.
Multiple punctate opacifications are seen in the right mid to upper abdomen.
However, these are not appreciated on a CT examination on the following day
and could well be artifactual.
Radiology Report
INDICATION: ___ year old man with femur fracture; bacteremia; and upper GI
bleed with diffuse duodenal ulceration and now with increased abdominal
distention // Please evaluate for air under diaphragm; also for evidence of
SBO
TECHNIQUE: Supine and left lateral decubitus abdominal radiographs were
obtained.
COMPARISON: CT abdomen dated ___.
FINDINGS:
There are dilated loops of large and small bowel with the large bowel
measuring up to 6.3 cm, and the small bowel measuring up to 5.1 cm. There are
multiple air-fluid levels seen on the left lateral decubitus view. The right
upper quadrant lucency on the left lateral decubitus view is thought to be
artifactual without any other evidence of pneumoperitoneum. The bony
structures are unremarkable. The rectangular density in the mid abdomen is
thought to be external to the patient as this density is not present on the
following images. There are multiple skin staples overlying the left lower
abdomen.
IMPRESSION:
Dilated loops of large and small bowel. Lucency in the right upper quadrant
on lateral view likely due to artifact. Further examination with CT should be
considered to rule out small bowel obstruction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure s/p intubation with
distended abdomen // please evaluate ETT and OGT placement please
evaluate ETT and OGT placement
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are unchanged. No evidence of acute pneumonia or vascular congestion. The
abdomen has been excluded from the image, so that the degree of bowel
dilatation cannot be assessed on this study.
Radiology Report
EXAMINATION: Abdominal and pelvic CT.
INDICATION: ___ year old man with UGIB with evidence of increased abdominal
distention. Also with bacteremia and recent left femur fracture // Please
evaluate for evidence of perforation
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
without intravenous contrast administration.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was not administered.
DOSE: DLP: 894 mGy-cm (abdomen and pelvis).
COMPARISON: Abdominal/pelvic CT from ___.
FINDINGS:
LOWER CHEST: There is mild bibasilar atelectasis. Visualized portions of the
heart are within normal limits.
Evaluation of solid abdominal viscera is limited by lack of IV contrast.
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,
without stones or gallbladder wall thickening.
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: 10 mm right hypodense lesion in the adrenal gland is statistically
an adenoma (series 2, image 25). The left adrenal gland is normal.
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: The stomach is normal in caliber and contains an orogastric
tube. Stranding around the first and second portions of the duodenum has
significantly improved since prior study, but could reflect residual
duodenitis. Small bowel loops otherwise demonstrate normal caliber, wall
thickness and enhancement throughout. There is a large right inguinal hernia,
which contains multiple loops of small bowel, which are not distended. The
colon and rectum are fluid-filled. Appendix is not visualized. There is no
evidence of mesenteric lymphadenopathy. There is no free air.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium
burden in the abdominal aorta and great abdominal arteries.
PELVIS: Foley catheter seen within a predominantly collapsed urinary bladder.
Air within the urinary bladder is likely related to recent instrumentation.
There is no evidence of pelvic or inguinal lymphadenopathy. There is no free
fluid in the pelvis. There is a small fat containing left inguinal hernia.
REPRODUCTIVE ORGANS: Reproductive organs are within normal limits.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions.
Abdominal and pelvic wall is within normal limits. Patient is status post
left femoral head ostectomy. Small pockets of air still remain within the
surrounding soft tissues. Moderate multilevel degenerative changes are noted
throughout the thoracolumbar spine.
IMPRESSION:
1. No evidence for free air. Stranding and mild thickening around the
duodenum significantly improved from prior examination, could reflect residual
duodenitis.
2. Large right inguinal hernia containing multiple loops of collapsed small
bowel. There is no evidence of small bowel obstruction.
3. Redemonstration of a right adrenal lesion, likely adenoma.
4. Fluid filled large bowel, correlate with any history of diarrhea.
NOTIFICATION: Findings ___ were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 4:40 AM, 15 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure s/p intubation //
interval change interval change
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
have been removed. The patient has taken a better inspiration. The cardiac
silhouette is at the upper limits of normal in size or mildly enlarged. Some
indistinctness of pulmonary vessels suggest elevated pulmonary venous
pressure. No evidence of acute focal pneumonia or pleural effusion
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with PICC. // Pt had a left picc,48cm ___
___ Contact name: ___: ___ Pt had a left picc,48cm ___
___
COMPARISON: Prior chest radiographs ___ through ___.
IMPRESSION:
Mild pulmonary edema and small bilateral pleural effusions have both
increased. Top- normal heart size is unchanged. Left PIC line ends in upper
SVC.
NOTIFICATION: Dr. ___ reported the findings to IV Nurse, ___ by
telephone on ___ at 12:38 ___, 2 minutes after discovery of the findings.
She will relay findings relating to congestive heart failure to the clinical
care team.
Radiology Report
INDICATION: Evaluate for source of bleed in a patient with anemia and
recurrent transfusions.
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
No oral contrast was administered.
DOSE: This study involved 5 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
4) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
5) Spiral Acquisition 5.2 s, 56.5 cm; CTDIvol = 15.9 mGy (Body) DLP = 898.3
mGy-cm.
Total DLP (Body) = 912 mGy-cm.
IV Contrast: 130 mL Omnipaque
COMPARISON: CT abdomen/ pelvis from ___.
FINDINGS:
LOWER CHEST:
There are bilateral small simple pleural effusions, increased compared to
prior exam, with associated compressive atelectasis. No pericardial effusion
is seen.
ABDOMEN:
HEPATOBILIARY: The liver is homogeneous in attenuation, without focal mass or
intrahepatic biliary duct dilation. The portal vein is patent. The
gallbladder is within normal limits, without stones or gallbladder wall
thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is homogeneous and normal in size.
ADRENALS: A 1.2 x 1.7 cm nodule in the right adrenal gland (02:19) is again
seen, incompletely characterized but likely representing an adenoma. There is
thickening of the left adrenal glands, without discrete nodule.
URINARY: The kidneys are symmetric and normal in size, demonstrating normal
nephrograms and excreting contrast promptly. A 1.4 cm hypodensity in the
interpolar region of the right kidney is slightly hyperdense, and may
represent a hemorrhagic or proteinaceous cyst.
GASTROINTESTINAL: Small and large loops of bowel are normal in caliber,
without wall thickening or evidence of obstruction. A normal air-filled
appendix is visualized.
RETROPERITONEUM: Retroperitoneal lymph nodes are prominent, but not
pathologically enlarged by CT size criteria. There is no mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is mild to moderate
calcium burden in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder is partially decompressed by a Foley catheter. There is
no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in
the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged.
BONES AND SOFT TISSUES:
The patient is status post left femoral head osteotomy, with the expected
postsurgical changes. In the left gluteal musculature at the surgical site,
there is increased density, suggestive of a growing hematoma. The involved
area of hematoma, including the musculature, measures 12.7 x 9.7 cm (2:64,
previously 11.5 x 9.1 cm). Fluid tracks down the lateral aspect of the
femoral neck and proximal shaft. There is also a large bowel containing right
inguinal hernia, as seen on prior exam. There is no evidence of obstruction
or surrounding inflammatory changes.
IMPRESSION:
1. Intramuscular hematoma at the site of left femoral head osteotomy, with
increased density and expansion of left gluteal musculature, suggestive of a
growing hematoma.
2. Increased bilateral simple pleural effusions.
3. Large bowel containing right inguinal hernia, without evidence of bowel
obstruction or inflammation.
4. Unchanged right adrenal lesion, incompletely characterized but likely an
adenoma.
NOTIFICATION: Findings were communicated to Dr. ___ at 5:03 a.m. on ___ via phone by Dr. ___.
Radiology Report
INDICATION: ___ year old man with UGIB now intubated for EGD // ? ET tube
placement
TECHNIQUE: Chest PA
COMPARISON: ___
FINDINGS:
The endotracheal tube is in good position m from the carina. The left-sided
PICC line is in similar position in the mid SVC.
The lung volumes remain low with bibasal atelectasis. No pneumothorax. Small
bilateral effusions layering effusions persist.
IMPRESSION:
The endotracheal tube is approximately 5 cm from the carina.
Small layering effusions persist.
Radiology Report
INDICATION: ___ year old man with recurrent GI Bleeds. GDA embolization
COMPARISON: CT abdomen with contrast dated ___
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr.
___, attending radiologist performed the procedure. Dr. ___
personally supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Sedation was provided by continuous administration of intravenous
propofol, monitored by the ICU and radiology nursing staff. 1% lidocaine was
injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Propofol
CONTRAST: 104 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 38.2 min, 180 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Right common femoral arteriogram.
3. Common hepatic arteriogram.
4. Pre and post coil embolization arteriogram of the gastroduodenal artery.
5. Superior mesenteric arteriogram.
6. Pre and post coital embolization arteriogram of the supra
pancreaticoduodenal arteriogram.
7. Angio-Seal closure of right common femoral access.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. Both groins were
prepped and draped in the usual sterile fashion.
Using palpatory and fluoroscopic guidance, the right common femoral artery was
punctured using a micropuncture set at the level of the mid-femoral head. A
0.018 wire was passed easily into the vessel lumen. A small skin incision was
made over the needle. Then the inner dilator and wire were removed and a
___ wire was advanced under fluoroscopy into the aorta. The micropuncture
sheath was exchanged for a 5 ___ sheath which was attached to a continuous
heparinized saline side arm flush.
A C2 Cobra catheter was advanced over ___ wire into the aorta. The wire
was removed and the celiac artery was selectively cannulated and a small
contrast injection was made to confirm position. With a Glidewire, the C2
Cobra catheter was then advanced into the common hepatic artery. Contrast was
injected to confirm position. At arteriogram was performed.
A renegade ___ micro catheter was then advanced with a preloaded Transcend
wire, and was used to select the gastroduodenal artery. An arteriogram was
performed.
Multiple coils were deployed, specifically five 4 mm x 2 cm and four 5 mm x 6
cm Hilal coils were deployed within the gastroduodenal artery. Gel-Foam
slurry was then injected into the gastroduodenal artery. The micro catheter
was then retracted into the common hepatic artery and an arteriogram was
performed.
The micro catheter and wire were then advanced into the un-thrombosed proximal
segment of the gastroduodenal artery and into the supra pancreaticoduodenal
artery. An arteriogram was performed. Two 2 mm x 2 cm coils were then
deployed. The micro catheter was then retracted back into the common hepatic
artery and there arteriogram was performed.
Catheter and Transcend wire were then removed and the C2 Cobra catheter was
repositioned into the superior mesenteric artery. Contrast was injected to
confirm position. An arteriogram was performed.
The catheter was then removed over the wire and the sheath was removed. An
Angioseal closure device was deployed and manual pressure was held until
hemostasis was achieved. Sterile dressings were applied. The patient
tolerated the procedure well.
FINDINGS:
1. Celiac angiogram demonstrates conventional hepatic anatomy. No contrast
extravasation.
2. Common hepatic angiogram demonstrates a patent gastroduodenal artery
without pseudoaneurysm or contrast extravasation. There is irregularity of
the distal portion of the gastroduodenal artery.
3. Post embolization of the gastroduodenal and superior pancreaticoduodenal
arteriogram demonstrates complete occlusion.
4. Normal superior mesenteric anatomy without dominant inferior
pancreaticoduodenal branch.
5. Angio-Seal closure of the right common femoral artery.
IMPRESSION:
Successful embolization of gastroduodenal and superior pancreaticoduodenal
arteries
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respitaory failre and NG tube confirmation
// ___ year old man with respitaory failre and NG tube confirmation
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the patient has received a nasogastric
tube. The course of the tube is unremarkable, the tip of the tube is not
visible, but the side-hole is positioned at the level of the gastroesophageal
junction. No complications, notably no pneumothorax. Otherwise unchanged
radiograph.
Radiology Report
EXAMINATION: Oropharyngeal swallowing video fluoroscopy.
INDICATION: ___ year old man with complex admission, now with ongoing
aspiration risk, getting TPN. // eval for aspiration
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 1.5 min.
COMPARISON: None.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There was aspiration with thin liquids.
IMPRESSION:
Aspiration with thin liquids.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: DX PELVIS AND HIP UNILATERAL
INDICATION: ___ year old man with hip fracture, bacteremia and GI bleed //
?interval change s/p hip fracture fixation?
TECHNIQUE: AP view of the pelvis and two views of the left hip.
COMPARISON: ___
FINDINGS:
The patient is status post placement of a methylmethacrylate antibiotic spacer
in the left acetabular fossa . There has been slight subluxation of the femur
superiorly. There is heterotopic bone formation. There are moderate
degenerative changes of the lumbar spine and right hip. No suspicious osseous
lesions.
IMPRESSION:
Status post placement of a methylmethacrylate antibiotic spacer in the left
hip.
Moderate degenerative changes of the right hip and lower lumbar spine.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Found down
Diagnosed with FX NECK OF FEMUR NOS-CL, RHABDOMYOLYSIS, UNSPECIFIED FALL
temperature: 98.2
heartrate: 110.0
resprate: 20.0
o2sat: 98.0
sbp: 173.0
dbp: 78.0
level of pain: nan
level of acuity: 1.0 | This is a ___ with a PMHx of schizoaffective disorder who
presented after being found down and found to have left femur
fracture, rhabdomyolysis with ___, GNR bacteremia of unclear
source, and multiple right-sided pressure ulcers. Course
subsequently complicated by septic arthritis of fractured L hip
as well as multiple MICU stays for hypoxic respiratory distress
and UGI bleed requiring 21 units of pRBC transfusion, stabilized
s/p GDA and superior pancreaticoduodenal artery embolization on
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
Shortness of breath, leg swelling, weight gain
Major Surgical or Invasive Procedure:
___ Placed: ___
History of Present Illness:
___ female with history of dilated cardiomyopathy
secondary to TTN mutation with most recent LVEF in ___ of
___, status post single-chamber primary prevention ICD
(___), with recent hospitalization for fevers 2
weeks ago, who presents with weight gain, hemoptysis,
progressive DOE x6 days, PND last night, in the setting of
holding CHF medications since last hospitalization in ___.
Patient endorses continued cyclic fevers since her discharge in
___. She's been taking Tylenol TID. On ___, she started to
present with some SOB. On ___, she started coughing with
intermittently productive white sputum (and once or twice
green-tinged sputum). Last evening, she had severe coughing +
two
"quarter-sized amount of blood." She also says endorses dry
heaving in the setting of severe coughing fits. (Of note, in
___, she was hospitalized for PNA + hemoptysis.) She also
endorses PND. She needs to sleep lying >45 degree angle to feel
comfortable. She also noticed feet swelling. She reports a poor
appetite since ___ and increased lethargy.
Past Medical History:
Non-ischemic dilated cardiomyopathy s/p ICD
Mild obesity
Persistently elevated serum CK
History of asthma
Right femur fracture in ___
Congenital cataracts
Social History:
___
Family History:
Grandfather with CHF (in ___
Arthritis
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
VS: T 99.1 BP 101/52 HR132 RR20 O2 SAT 94 RA
Weight: 89.1kg
Dry weight: 84 Kg (RHC ___ showed a cardiac index (2.5
L/min/m2) and PCW 9.
Last discharge weight: 87kg (looked euvolemic)
GEN: NAD, sitting in bed at 45 degrees + non-productive coughing
intermittently
HEENT: conjunctiva pink; sclera anicteric; oropharynx is clear
with moist mucous membranes.
NECK: supple; trachea midline; JVP 9cm
CV: PMI is not readily palpable; the precordium is quiet without
RV heave; there is a regular but fast rate and rhythm
(tachycardic); normal S1 with physiologically split S2;there is
a II/VI holosystolic murmur appreciated at the left lower
sternal border and apex radiating to the axilla.
PULM: normal chest wall excursion; clear to auscultation
bilaterally, some mild crackles at bases that clear with
coughing.
ABD: non-distended; normoactive bowel sounds; soft and
non-tender to palpation; there is no appreciable organomegaly or
mass
EXT: warm; no cyanosis, or clubbing, trace edema bilateral feet
SKIN: warm, dry, there are no venous stasis changes
========================
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T 98.3 BP 92/57 HR 116 RR 18 O2 99% on RA
GEN: NAD, asleep on my entry but rouses to light voice.
HEENT: Sclerae anicteric, MMM.
NECK: Supple, JVP flat at the clavicle at 30 degrees.
CV: RRR, ___ holosystolic murmur heard best at the apex. No
gallops/rubs.
PULM: No crackles on auscultation
ABD: normoactive bowel sounds; soft, ND, nontender to palpation
this morning. No rebound or guarding.
EXT: warm; no cyanosis, or clubbing, no edema
SKIN: warm, dry, no venous stasis changes
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 04:00AM BLOOD WBC-8.0# RBC-3.28* Hgb-8.7* Hct-28.6*
MCV-87 MCH-26.5 MCHC-30.4* RDW-15.1 RDWSD-47.2* Plt ___
___ 04:00AM BLOOD Glucose-101* UreaN-9 Creat-0.9 Na-135
K-5.3* Cl-102 HCO3-21* AnGap-12
___ 06:18AM BLOOD ALT-88* AST-105* LD(LDH)-659*
CK(CPK)-2345* AlkPhos-46 TotBili-0.5
___ 04:00AM BLOOD proBNP-2923*
___ 04:00AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.1
===============
PERTINENT MICRO
===============
___ 03:20PM BLOOD CMV VL-2.4*
___ 04:37AM BLOOD CMV VL-DETECTED
===============
DISCHARGE LABS:
===============
___ 05:30AM BLOOD WBC-4.9 RBC-3.37* Hgb-9.0* Hct-28.7*
MCV-85 MCH-26.7 MCHC-31.4* RDW-14.3 RDWSD-43.8 Plt ___
___ 05:30AM BLOOD Glucose-88 UreaN-20 Creat-0.9 Na-142
K-4.3 Cl-103 HCO3-27 AnGap-12
___ 05:30AM BLOOD Calcium-9.1 Phos-4.5 Mg-1.9
___ 05:42PM BLOOD CMV VL-DETECTED
=========
IMAGING:
=========
ECHO ___
Severely depressed left ventricular systolic function. Moderate
to severe mitral regurgitation. Indeterminate pulmonary artery
systolic hypertension. Compared with the prior study (images
reviewed) of ___, the severity of mitral regurgitation has
decreased.
CT CHEST ___
1. No convincing evidence of pneumonia. Interlobular septal
thickening is compatible with mild edema.
2. Stable, enlarged mediastinal lymph nodes.
3. Cardiomegaly.
CT ABD/PEL ___
1. Fluid opacification of the large bowel without dilatation or
wall
abnormality, which can be seen in the setting of a nonspecific
diarrheal
entity.
2. Otherwise no acute findings or infectious source in the
abdomen or pelvis. No abscess.
3. IUD appears appropriately positioned without gross
complication.
4. 2 mm right lower lobe nodule requires no further evaluation.
RUQUS ___
1. Echogenic liver consistent with steatosis. Other forms of
liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded
on the basis of this examination.
2. No evidence of cholelithiasis or cholecystitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
Daily Disp #*15 Tablet Refills:*0
2. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth Daily
Disp #*15 Tablet Refills:*0
3. Torsemide 80 mg PO DAILY
RX *torsemide 20 mg 4 tablet(s) by mouth Daily Disp #*120 Tablet
Refills:*0
4. ValGANCIclovir 900 mg PO DAILY
Day 1 ___.
RX *valganciclovir 450 mg 2 tablet(s) by mouth Daily Disp #*60
Tablet Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute on chronic systolic heart failure
Dilated cardiomyopathy
Cytomegalovirus Viremia
Secondary:
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fever and cough, hx of CHF// please eval for pna, pulm
edema
TECHNIQUE: Frontal and lateral views the chest.
COMPARISON: Chest x-ray from ___ and ___.
FINDINGS:
Cardiac silhouette is slightly enlarged, similar compared to prior exam from
___. Left chest wall single lead pacing device is noted with lead tip at the
right ventricular apex. Interstitial edema is noted with mild thickening of
the fissures. No large pleural effusion although blunting of the left
posterior costophrenic angle may represent a small effusion. No focal
consolidation or acute osseous abnormality.
IMPRESSION:
Interstitial edema with probable small left pleural effusion. No focal
consolidation.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ female with history of dilatedcardiomyopathy
secondary to TTN mutation with most recent LVEF ___ of ___, status
post single-chamber primaryprevention ICD (___), with recent hospitalization
for fevers 2weeks ago, who presents with weight gain, hemoptysis,
progressiveDOE x6 days, PND last night, in the setting of holding
CHFmedications since last hospitalization in ___// eval for FUO, pt has
IUD in, any e/o complications? any abscesses? please do w/ IV and PO contrast
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.1 s, 49.7 cm; CTDIvol = 16.5 mGy (Body) DLP = 817.7
mGy-cm.
2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.8 mGy (Body) DLP = 1.4
mGy-cm.
3) Stationary Acquisition 4.7 s, 0.5 cm; CTDIvol = 25.6 mGy (Body) DLP =
12.8 mGy-cm.
Total DLP (Body) = 832 mGy-cm.
COMPARISON: Renal ultrasound ___.
FINDINGS:
LOWER CHEST: Pacer leads are partially identified. Heart size is mildly
enlarged without significant pericardial effusion. There is mild linear
atelectasis in the left lung base. A 2 mm perifissural nodule is noted in the
right lung base (3:3). This likely represents an intrapulmonary lymphoid
aggregate. The lung bases are otherwise grossly clear.
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.
The portal vein is patent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is borderline prominent in size, without focal lesion.
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. There are
nonspecific fluid levels within the large bowel without wall abnormality. The
large bowel and rectum are otherwise unremarkable. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: IUD appears appropriately positioned within otherwise
unremarkable uterus. There is normal physiologic follicular activity of the
ovaries. There is trace likely physiologic free pelvic fluid.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy by size
criteria. There are a few mildly prominent though nonenlarged mesenteric
lymph nodes measuring up to 8 mm in short axis in the right hemiabdomen..
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.
There is transitional vertebral anatomy with partial lumbarization of S1. The
superior most portion of a right femoral intramedullary rod is partially
visualized.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits. There is
no organizing fluid collection.
IMPRESSION:
1. Fluid opacification of the large bowel without dilatation or wall
abnormality, which can be seen in the setting of a nonspecific diarrheal
entity.
2. Otherwise no acute findings or infectious source in the abdomen or pelvis.
No abscess.
3. IUD appears appropriately positioned without gross complication.
4. 2 mm right lower lobe nodule requires no further evaluation.
RECOMMENDATION(S): For incidentally detected nodules smaller than 6mm in the
setting of an incomplete chest CT, no CT follow-up is recommended.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ female with complicated past medical history.
Evaluate for infection.
TECHNIQUE: CT chest was obtained without the administration of intravenous
contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.2 s, 35.2 cm; CTDIvol = 11.8 mGy (Body) DLP = 413.4
mGy-cm.
Total DLP (Body) = 413 mGy-cm.
COMPARISON: CTA chest dated ___, chest radiograph dated ___
FINDINGS:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The thyroid is unremarkable. There
are scattered prominent subpectoral lymph nodes, bilateral, measuring up to 1
cm in short axis, also noted on the prior study. Prominent axillary lymph
nodes are also noted, also seen on prior images.
UPPER ABDOMEN: Limited evaluation of the upper abdomen shows no significant
abnormalities. Please see report from dedicated CT of the abdomen and pelvis
from 1 day prior for further findings.
MEDIASTINUM: Prominent mediastinal lymph nodes are demonstrated, largely
similar to the prior examination. A prominent prevascular lymph node measures
up to 1 cm in short axis (302:54). A right pretracheal lymph node measures up
to 9 mm in short axis (302:44), also unchanged in an enlarged subcarinal lymph
node measures up to 1.7 cm in short axis, also stable since ___.
HILA: There is no definite hilar lymphadenopathy.
HEART and PERICARDIUM: The heart is enlarged, compatible with the patient's
diagnosis of dilated cardiomyopathy. An AICD is noted in the left chest wall,
with the lead terminating in the right ventricle.
PLEURA: There is no pleural effusion
LUNG:
1. PARENCHYMA: Left basilar scarring/atelectasis is noted. Previously seen
left lower lobe consolidation has resolved. No findings of pneumonia.
Interlobular septal thickening, particularly at the bases, is compatible with
edema. 0.3 cm left upper lobe nodule, series 302, image 86 is unchanged
compared to the prior exam.
2. AIRWAYS: The airways are patent to the subsegmental level, but diffusely
thickened, comparable to the prior examination.
3. VESSELS: The main pulmonary artery is dilated, measuring up to 3.1 cm,
previously 2.5 cm in. The thoracic aorta is normal in caliber.
CHEST CAGE: No acute fracture or suspicious bony abnormality is identified.
IMPRESSION:
1. No convincing evidence of pneumonia. Interlobular septal thickening is
compatible with mild edema.
2. Stable, enlarged mediastinal lymph nodes.
3. Cardiomegaly.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new R PICC// R SL Power PICC 40cm out 1cm
___ ___ Contact name: ___: ___ R SL Power PICC 40cm out 1cm
___ ___
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
New right PIC line ends at the origin of the SVC.
Moderate moderate cardiomegaly and mild central pulmonary vascular dilatation
are chronic. No pulmonary edema, pleural effusion, or pneumothorax.
Transvenous right ventricular pacer defibrillator lead follows expected course
from the left pectoral generator.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with cardiomyopathy, heart failure, new onset
RUQ pain, nausea// Cholecystitis, congestive hepatopathy, cholelithiasis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
LIVER: The liver is heterogeneously echogenic. The contour of the liver is
smooth. There is no focal liver mass. The main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 2 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 8.1 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. Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
2. No evidence of cholelithiasis or cholecystitis.
Gender: F
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: Dyspnea on exertion, Fever, Leg swelling
Diagnosed with Sepsis, unspecified organism, Severe sepsis with septic shock, Hypotension, unspecified
temperature: 101.6
heartrate: 124.0
resprate: 22.0
o2sat: 100.0
sbp: 107.0
dbp: 59.0
level of pain: 5
level of acuity: 2.0 | ======================
PATIENT SUMMARY
======================
Ms. ___ is a ___ woman with non-ischemic dilated
cardiomyopathy w/single chamber ICD who presents with CHF
exacerbation and cyclic fevers of unknown origin, who was found
to have CMV viremia.
=======================
ACUTE ISSUES
=======================
# Acute on chronic systolic HF reduced EF ___:
Patient has a TTN mutation that is the etiology of her
cardiomyopathy. She appeared overloaded on exam at admission
with elevated JVP, and high BNP in the setting of holding her
home medication for 2 weeks. She was treated with Lasix gtt and
then transitioned to po torsemide. She was also started back on
her home lisinopril and metoprolol. She was started on
Spironolactone. At discharge, her weight was 83.19kg (previously
recorded dry weight of 84kg), she was net negative 14L since
admission, and she was discharged on the following diuretics:
torsemide 80mg daily.
- Discharge Creatinine: 0.9
- PRELOAD: Torsemide 80mg daily
- NHBK: Metoprolol succinate 12.5mg daily, spironolacteon
12.5mg daily
- AFTERLOAD: Initially had lisinopril 2.5mg daily; stopped on
___ given borderline hypotension.
- DIET: Because of poor PO intake, diet liberalized from < 2g
Na to ___ Na. Still on 2L PO fluid restriction.
#CMV Viremia with
#Blurry vision:
She had an extensive workup during her previous hospitalization
for fever of unknown origin that yielded no significant positive
results. Given her (mild) hemoptysis, productive cough, fevers
and lethargy, and travel to ___, sputum cultures were
sent for TB rule out. TB is less likely given acute onset of
cough and negative CXR (although could be obscured given CHF).
GeneExpert PCR for Tb was negative X1. ID and rheumatology were
consulted during this hospitalization and a number of labs were
sent, many of which are still pending at the time of her
discharge. However, she had a positive CMV viral load and her
symptoms were thought to be consistent with CMV viremia. She was
started on IV Gancyclovir and a PICC was placed. Ophthalmology
was involved given concern for blurry vision, and she was
determined not to have CMV retinitis - with follow up dilated
eye exam showing no CMV retinitis. She completed a 2 week
course of IV ganciclovir from ___, and then was
transitioned to PO valganciclovir 900mg daily starting ___.
She will f/u with ID outpatient, rheumatology, and
ophthalmology. She is to call and schedule an ophthalmology
appointment after her discharge.
- Weekly CMV viral load draws (next on ___.
=======================
CHRONIC ISSUES
=======================
#Normocytic anemia: Likely iron deficiency anemia with some
component of anemia of inflammation. Ferritin elevated to 418.
Hemolysis unlikely given elevated haptoglobin and normal Tbili
checked. Iron/TIBC very low ~8%, so patient may benefit from IV
iron after there is no longer a question of ongoing infection.
#Persistently elevated serum CK with a normal ESR.
This seems to be a chronic issue for the patient given her past
trends. We continued to monitor labs during this
hospitalization, with plan to follow up with Rheumatology as an
outpatient to discuss muscle biopsy further.
# ABDOMINAL PAIN:
Longstanding, chronic, months-to-years of abdominal pain that is
diffuse or poorly localized and not worse in this admission.
Offered uptitrated bowel regimen, to some improvement of her
pain. RUQUS was notable for steatosis of the liver, without
cholelithiasis. bHCG negative. LFT's normal.
========================
TRANSITIONAL ISSUES
========================
# CODE STATUS: FULL
# CONTACT ___
___: sister
Cell phone: ___
[ ] DISCHARGE WEIGHT: 83.19 kg (prior dry weight 84kg)
[ ] DISCHARGE DIURETIC: 80mg torsemide daily
[ ] MEDICATIONS RESTARTED: Metoprolol Succinate XL 12.5 mg,
Spironolactone 12.5 mg. Lisinopril 2.5mg initially restarted,
but discontinued due to borderline blood pressures.
[ ] CMV VIREMIA:
- IV gancicylovir given from ___. CMV viral load was
detectable < 2.1 as of ___.
- Pt to continue on valganciclovir 900mg PO daily.
- Weekly CMV VL draws, starting ___.
[ ] follow up with rheumatology established to consider muscle
biopsy and to follow up on serology testing for autoimmune
diseases
[ ] follow up with Infectious Diseases re: CMV viremia
[ ] follow up ophtho for dilated exams to r/o CMV retinitis
[ ] pt will need hepatitis B vaccination
[ ] Iron/TIBC very low ~8%, so patient may benefit from IV iron
after there is no longer a question of ongoing infection.
[ ] repeat chemistries at next PCP/cardiology appointment to
ensure electrolytes stable on torsemide 80mg daily
[ ] pt has nodular lesions in armpits bilaterally that do not
appear to track along lyphatic chain. Per her, there has been
drainage of blood/pus. Derm follow-up scheduled. These do not
appear infected on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
S/P fall, AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ y/o female with no past medical history
who presents as a transfer from ___ with imaging demonstrating
small SAH after witnessed fall.
Day of admission, she was noted to have unsteady gait before
falling onto her face outside of the store (witnessed by a
stranger from whom collateral could not be obtained). Per
report, it was unclear whether she lost consciousness.
Immediately after, she was noted to be confused and agitated.
Patient was taken by EMS to ___. Initial vitals at ___ were
T97.4F, HR 78, BP 119/78, RR 18, FSBG 131. Patient was noted to
be A&Ox0 though she was moving all extremities spontaneously.
WBC 10.2, trop negative, CPK 67, Lactate 3.7. where NCHCT
revealed possible R temporal SAH. She was transferred to ___
for further management.
In the ___ ED,
- Initial Vitals: T 98.1F, HR 93, BP 137/83, RR 17, SaO2 100%
(intubated)
- Exam: limited given patient's agitation (not obeying commands
or answering questions), GCS 13 (E4, V4, M5)
- Labs:
-VBG (___) 7.30/48/29, HCO3 25
-ABG (___) 7.38/41/431, HCO3 25
-CBC/Diff 15.8>12.0/37.1<210 PMNs 89%, Lymphs 6%
-BMP:
137 | 104 | 14
---------------<178
3.4 | 19 |0.7
-Lactate 5.3
-LFTs: ALT 26, AST 33, ALP 68, Tbili 0.4, Lipase 38, Albumin
4.1
-Coags: ___ 10.7, INR 1.0, PTT 24.5
-STox: ASA, EtOH, APAP, TCA negative
-UTox: Benzos, Barbs, Opiates, Cocaine, Amphetamines,
Methadone,
Oxycodone negative
-U/A: wnl
- Imaging:
-NCHCT: subtle minimal R frontal SAH (unchanged from prior)
and
questionable R temporal lobe SAH
-CTA Head/neck: no e/o stenosis, occlusion, or aneurysm of
subclavian, common carotid, ICA, and vertebral arteries; patent
vessels of circle of ___ dural venous sinuses are patent
-CT Chest/Abd/Pelvis: no acute traumatic injury, bilateral
lower lobe atelectasis, presacral stranding and fluid ?due to
___ spacing from IV fluids, 2.5 cm R simple adnexal cyst
-CXR: Patchy left basilar opacification could reflect
atelectasis, with pneumonia or aspiration not excluded in the
correct clinical setting.
- Consults:
-NSGY - no acute NSGY intervention, no need for repeat CT,
SBP<160
-Neuro - unrevealing neuro exam; LP given WBC with left
shift, rec initiation of meningitic abx + acyclovir, cEEG to r/o
seizures, non-urgent MRI while inpatient, TTE to r/o cardiac
dysfunction, will follow
- Interventions:
-Intubated @1927 with Vecuronium 10mg for airway protection
-IV Levetiracetam 500mg
-IV MgSO4 4gm
-LR 1L
-LP: glucose 72, protein pnd, cell counts pnd
-IV Ceftriaxone 2gm + IV Acyclovir 500mg
Upon arrival to the ICU, patient was noted to be
shaking/shivering with question of preference for her right
side. Patient was started on propofol and fentanyl drips for
sedation and comfort. Patient's husband noted that patient was
not complaining of any fever, cough, rhinorrhea, or myalgias and
was mentating fine prior to leaving for ___ to return some
clothes. Neither he nor his daughter were with the patient when
she fell. She has no personal or family history of seizures. As
far as her husband knows, she has not been taking any
medications, either prescribed or over-the-counter.
Past Medical History:
None
Social History:
___
Family History:
Per chart, patient's father died of pancreatic cancer and
history of lung cancer in the family.
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM:
=========================
VS: T98.5, HR 76, BP 93/56(MAP 67), RR 10 (PSV ___ FiO2 50%),
SaO2 100%, FSBG 105
GEN: sedated and intubated
EYES: PERRLA 4->2mm
HEENT: 2 ecchymoses over L lateral eyebrow, no LAD, no apparent
meningismus though difficult to assess given sedation
CV: sinus rhythm, nl S1/S2, no murmurs/rubs/gallops
RESP: ventilated patient, no rales/rhonchi
GI: soft, nontender/nondistended
MSK: no paratonias
SKIN: no rashes, warm and well perfused
NEURO: sedated
PSYCH: unable to assess
=========================
DISCHARGE PHYSICAL EXAM:
=========================
VS: ___ 0725 Temp: 99.1 PO BP: 114/69 R Lying HR: 73 RR: 18
O2 sat: 97% O2 delivery: Ra
GENERAL: Obviously uncomfortable, eyes closed throughout
encounter.
HEENT: EOMI. Oropharynx clear, mucous membranes moist. Swelling
over her left eye, with overlying ecchymoses over eye and on
forehead.
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops.
No bruits heard on auscultation.
LUNG: Appears in no respiratory distress, only able to listen in
the front, but CTAB.
ABD: Normal bowel sounds, soft, nondistended.
EXT: Warm, well perfused, no lower extremity edema.
PULSES: 2+ ___ pulses
NEURO: AxO X3. Attentive to days of week backwards and able to
follow midline and appendicular commands. No left/right
confusion
observed. Hearing in tact to conversation. Facial sensation in
tact, symmetric at rest and with activation. Tongue protrudes
midline. Moves all extremities against gravity. Sensation
grossly
in tact bilaterally in UE and ___.
SKIN: No significant rashes.
Pertinent Results:
================
ADMISSION LABS:
================
___ 05:01AM VIT B12-240
___ 05:01AM TSH-1.3
___ 02:47AM CEREBROSPINAL FLUID (CSF) PROTEIN-34
GLUCOSE-72
___ 02:47AM CEREBROSPINAL FLUID (CSF) TNC-63* RBC-8959*
POLYS-78 ___ ___ 02:47AM CEREBROSPINAL FLUID (CSF) TNC-109* RBC-___*
POLYS-53 ___ MACROPHAG-1
___ 12:14AM LACTATE-2.0
___ 09:36PM TYPE-ART PEEP-5 PO2-431* PCO2-41 PH-7.38
TOTAL CO2-25 BASE XS-0 INTUBATED-INTUBATED VENT-SPONTANEOU
___ 09:36PM O2 SAT-99
___ 09:07PM ___ PO2-32* PCO2-59* PH-7.23* TOTAL
CO2-26 BASE XS--4
___ 09:07PM LACTATE-3.5*
___ 09:07PM O2 SAT-48 CARBOXYHB-0
___ 09:07PM O2 SAT-48 CARBOXYHB-0
___ 09:00PM GLUCOSE-123* UREA N-14 CREAT-0.7 SODIUM-137
POTASSIUM-3.4* CHLORIDE-104 TOTAL CO2-19* ANION GAP-14
___ 09:00PM estGFR-Using this
___ 07:55PM URINE HOURS-RANDOM
___ 07:55PM URINE UCG-NEGATIVE
___ 07:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 07:55PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 07:39PM ___ PO2-29* PCO2-48* PH-7.30* TOTAL
CO2-25 BASE XS--3
___ 07:21PM GLUCOSE-178* LACTATE-5.3* CREAT-0.65 NA+-136
K+-3.4 CL--104 TCO2-24
___ 07:21PM HGB-12.4 calcHCT-37
___ 07:00PM UREA N-15
___ 07:00PM ALT(SGPT)-26 AST(SGOT)-33 ALK PHOS-68 TOT
BILI-0.4
___ 07:00PM LIPASE-38
___ 07:00PM ALBUMIN-4.1
___ 07:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 07:00PM WBC-15.8* RBC-4.04 HGB-12.0 HCT-37.1 MCV-92
MCH-29.7 MCHC-32.3 RDW-11.9 RDWSD-40.7
___ 07:00PM NEUTS-88.5* LYMPHS-6.1* MONOS-4.4* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-13.98* AbsLymp-0.97* AbsMono-0.70
AbsEos-0.02* AbsBaso-0.05
___ 07:00PM PLT COUNT-210
___ 07:00PM ___ PTT-24.5* ___
===============
DISCHARGE LABS
===============
___ 06:30AM BLOOD WBC-5.5 RBC-3.23* Hgb-9.6* Hct-28.6*
MCV-89 MCH-29.7 MCHC-33.6 RDW-11.7 RDWSD-37.6 Plt ___
___ 06:30AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-94 UreaN-11 Creat-0.7 Na-139
K-3.6 Cl-103 HCO3-25 AnGap-11
___ 05:45AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.7 Iron-55
___ 05:45AM BLOOD calTIBC-263 Ferritn-230* TRF-202
============
MICROBIOLOGY
============
___ 7:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 2:47 am CSF;SPINAL FLUID # 3.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
___
HSV: NEGATIVE
============
IMAGING:
============
TRAUMA CXR ___
IMPRESSION:
1. Standard positioning of the endotracheal and enteric tubes.
2. Patchy left basilar opacification could reflect atelectasis,
with pneumonia or aspiration not excluded in the correct
clinical setting.
CT HEAD ___
IMPRESSION:
1. Subtle minimal right frontal subarachnoid hemorrhage,
unchanged from prior head CT, and questionable minimal right
temporal lobe subarachnoid hemorrhage.
2. No acute fracture.
CT CHEST/A/P ___
IMPRESSION:
1. No acute traumatic injury identified within the torso. No
fractures.
2. Bilateral lower lobe atelectasis.
3. Presacral stranding and fluid may be due to third spacing
from aggressive volume resuscitation.
4. 2.5 cm right simple adnexal cyst. For asymptomatic
incidental simple cysts (thin-walled, no enhancement, water
intensity/density, round or oval) less than 3 cm, follow up is
not required.
CTA HEAD/NECK ___
IMPRESSION:
1. Examination is limited due to timing of the contrast bolus
and streak
artifact from dental amalgam.
2. Prominent, somewhat serpiginous vessels in the right
frontoparietal region likely correspond to the areas of
hyperdensity identified on the prior noncontrast CT head. The
findings are likely within normal limits. If there is
persistent clinical concern, consider further evaluation with
MRI brain.
3. Patent circle of ___ with no evidence of focal stenosis or
aneurysm.
4. Patent neck vasculature with no evidence of internal carotid
artery
stenosis by NASCET criteria.
TTE ___
IMPRESSION: No structural cardiac cause of syncope identified.
Normal left ventricular wall thickness, cavity size, and
regional/global systolic function. Mild tricuspid regurgitation.
Right pleural effusion.
EKG ___ 06:15:19
Normal sinus rhythm
Normal ECG
No previous ECGs available
MRI BRAIN ___
IMPRESSION:
1. No evidence of intracranial hemorrhage. Specifically, no
findings to
suggest subarachnoid hemorrhage.
2. No evidence of acute infarction.
3. No evidence of abnormal leptomeningeal enhancement to suggest
meningitis.
4. Mild smooth with pachymeningeal thickening and enhancement is
nonspecific however could be secondary to reaction from a lumbar
puncture with collection of CSF if recently performed. Please
correlate clinically as infection cannot entirely be excluded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth Every 8 hours Disp #*60 Tablet Refills:*0
2. Gabapentin 200 mg PO TID
RX *gabapentin 100 mg 2 capsule(s) by mouth Three times daily
Disp #*180 Capsule Refills:*2
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
RX *ibuprofen 400 mg 1 tablet(s) by mouth Every 8 hours Disp
#*90 Tablet Refills:*0
4. LevETIRAcetam 1000 mg PO Q12H
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth Every
12 hours Disp #*5 Tablet Refills:*0
5. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth Every 8 hours Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-TBI
-Traumatic SAH
-Leukocytosis
-Fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ female with fall and altered mental status. Intubated
due to agitation and airway protection. Evaluation of subarachnoid
hemorrhage, meningeal enhancement c/f meningitis.
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 ___.
CTA head and neck with contrast dated ___.
FINDINGS:
There is no evidence of restricted diffusion to suggest acute infarction. No
evidence of acute intracranial hemorrhage. Specifically, no findings to
suggest subarachnoid hemorrhage. The ventricles and sulci are
age-appropriate. No mass effect or midline shift.
Scattered T2 and FLAIR hyperintense foci in the periventricular and
subcortical white matter are nonspecific, but likely reflect chronic small
vessel ischemic changes.
There is mild smooth pachymeningeal thickening and enhancement, a nonspecific
finding. No evidence of abnormal leptomeningeal enhancement.
The major intracranial arterial and venous flow voids are preserved.
Mild mucosal thickening of the ethmoid and sphenoid sinuses. Mild
opacification of the right mastoid air cells. Unremarkable intraorbital
contents.
IMPRESSION:
1. No evidence of intracranial hemorrhage. Specifically, no findings to
suggest subarachnoid hemorrhage.
2. No evidence of acute infarction.
3. No evidence of abnormal leptomeningeal enhancement to suggest meningitis.
4. Mild smooth with pachymeningeal thickening and enhancement is nonspecific
however could be secondary to reaction from a lumbar puncture with collection
of CSF if recently performed. Please correlate clinically as infection cannot
entirely be excluded.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Altered mental status, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Mrs. ___ is a ___ year-old woman with no significant PMH
admitted to ___ with altered mental status after a witnessed
fall of unclear cause, found to have a subarachnoid hemorrhage
on imaging. In the hospital, she was intubated for airway
protection and admitted to the ICU due to her altered mental
status, then extubated and transferred to the medicine floor.
Neurosurgery was consulted, did not recommend surgical
intervention. No clear cardiac or neurologic cause of her fall
was identified, and she was placed on one week of anti-epileptic
medication for seizure prophylaxis. Patient remained in the
hospital until she was able to ambulate, eat, and use the
bathroom independently.
=================================
PROBLEM-BASED SUMMARY
=================================
#Traumatic ___
Patient presented from OSH ___ after a fall of unknown
cause (see below). OSH NCHCT showed SAH in right temporal lobe,
since resolved on MRI head ___. Patient was unable to recall
events prior to fall or the fall itself, as well as events after
the fall until intubation at ___. CTA/CT showed SAH
distribution unlikely to be of vascular origin, making ruptured
aneurysm less likely. No acute interventions were recommended
per neurosurgery, and neurology saw the patient during her stay.
Patient was started on a 1 week course of Keppra for seizure
prophylaxis (___). Per discussion with neurology, she
will follow up in neurology clinic (not ___ clinic).
#Fall
#TBI
It is unclear whether the patient lost consciousness and whether
there was a preceding prodrome. Of note, the patient's family
reports that she has a remote history of vertigo, for which she
has not received treatment. Patient reported to be disoriented
after fall and was confused, agitated, and unable to follow
commands upon arrival to ED (___ 13). Patient was intubated
given concern for inability to protect airway. CTA showed no
signs of vascular stenosis or aneurysm. Syncopal work-up for
cardiogenic cause including telemetry, EKG, and TTE all
unremarkable. Toxic-metabolic work-up, including urine
toxicology screen, LP with CSF analysis, and urine culture were
all negative, and TSH/B12 were also normal. EEG showed diffuse
slowing, consistent with TBI, with no suggestion of epileptiform
activity. Patient endorsed headache, dizziness, photophobia, and
phonophobia, consistent with a post-concussive syndrome. Patient
was given Tylenol/ibuprofen/gabapentin for headache treatment,
and Ondansetron for nausea to prevent strain and to address
symptoms.
#Leukocytosis
Per patient's husband, patient did not complain of any
localizing infectious symptoms, and there no localizing signs on
exam. WBC notably normal (10.2) at ___ prior to transfer, but
was WBC 15.8 with left shift upon arrival to ___. Leukocytosis
resolved within two days of admission, patient remained
afebrile, and cultures were unremarkable. Due to some initial
concern for meningitis, she underwent LP, which was not
concerning for infection, though she briefly was on empiric
coverage with vancomycin, ampicillin, ceftriaxone, and
acyclovir. CSF studies were negative. Suspect leukocytosis was
reactive in the setting of SAH.
#Episodes of apnea
Noted to have apnea while intubated, thought to be sedation
related, resolved after extubation. Patient was monitored on
continuous O2.
#Normocytic anemia
Patient's Hb fell from Hb 12 on presentation to <10 throughout
stay. Given lack of PMH, hard to know if chronic anemia or new
process. Monitored CBC throughout stay, iron studies with
transferrin saturation of 21%, ferritin 230.
=====================
TRANSITIONAL ISSUES
=====================
[ ] Follow up with PCP to discuss fall. Patient and family
counseled to pay attention to any changes in gait, weakness, or
concerning palpitations that could be precipitant for fall.
[ ] Follow up with neurology clinic for TBI: ___
[ ] Keppra for one week: ___
[ ] Followup anemia, consider repeat CBC and iron
supplementation
# CODE: Full, presumed
# CONTACT: ___ (husband), p ___
I have seen and examined the patient and she is stable for
discharge. Greater than 30 minutes were spent in discharge
planning and coordination. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal swelling and pain
Major Surgical or Invasive Procedure:
Paracentesis ___
Paracentesis ___
Paracentesis ___
History of Present Illness:
___ yo M with h/o HBV/HCV cirrhosis c/b varices (last banding
___ and ascites requiring frequent large-volume paras,
lymphoplasmacytic lymphoma, Waldenstrom's macroglobulinemia,
HIV, IVDU (cocaine), and anal cancer who presents with abdominal
distention and pain.
Patient has a recent admission on ___ with a similar
presentation, presenting with abdominal distention and shortness
of breath (though did not have pain on prior admission). At that
time he was admitted for paracentesis and had 5.2L removed. Was
discharged with recommendation to f/u with hepatologist. 3 days
ago however he began to again experience abdominal distention
and early satiety.
He then began to experience ___ lower abdominal pain last
night. Per his wife, he was also a little confused last night
but now clearer again.
He reports compliance with diuretics and low-salt diet.
He presents to the ___ ED today for paracentesis. Denies any
fevers, chills, n/v, changes in diet.
In the ED, initial vitals were:
- Exam notable for: Bibasilar crackles, +BS, bulging flanks,
abd distended, mild tenderness to palpation in R and L lower
quadrants. Dressing in LLQ over prior paracentesis site. No
asterixis.
- Labs notable for:
139 ___ AGap=14
-------------
3.8 22 1.0
91
2.9 12.5 41
38.5
N:55.5 L:25.5 M:14.6 E:3.1 Bas:1.0 ___: 0.3 Absneut: 1.63
Abslymp: 0.75 Absmono: 0.43 Abseos: 0.09 Absbaso: 0.03
ALT: 25 AP: 163 Tbili: 2.0 Alb: 3.3
AST: 34 LDH: Dbili: TProt:
___: Lip: 75
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Lactate:2.9
___: 17.9 PTT: 32.8 INR: 1.6
Trop-T: <0.01
- Imaging was notable for:
RUQ ultrasound ___
1. Nonocclusive clot in the left portal vein with slow
hepatopetal flow. No evidence of clot in the main, right
anterior, or right posterior portal veins, with hepatopetal flow
in all 3 veins.
2. Re-demonstration of cirrhotic liver. Unchanged splenomegaly,
measuring 21 cm.
VS were stable on transfer to Medicine for further workup.
Upon arrival to the floor, patient was interviewed with a
___ telephone interpreter. He reports feeling relatively
well. He reports he returned due to worsening abdominal
distension, as well as due to leakage from his prior
paracentesis site.
Past Medical History:
Lymphoplasmacytic lymphoma complicated by Waldenstrom's
macroglobulinemia and hyperviscosity syndrome
HIV (HAART)
Squamous cell rectal cancer ___, excision and radiation)
Hepatitis C genotype 1b (ribavirin and IFN)
Hepatitis B
Cerebral/cerebellar microvascular ischemic changes
Cirrhosis c/b grade III varices s/p banding on ___
Splenomegaly and small liver cysts
Asthma
Lumbar disk disease
Hearing loss; deafness
SURGICAL HISTORY:
Rectal surgery
Surgical repair of umbilical hernia
Social History:
___
Family History:
No CAD, MI
Mother with stroke at ___
Father died of prostate cancer.
Physical Exam:
ADMISSION:
=========
Vitals: 97.5PO 116 / 72L Lying 62 20 95 Ra
Genl: chronically ill appearing NAD
HEENT: PERRLA no icterus MMM
Cor: RRR NMRG
Pulm: CTAB
Abd: distended, LLQ dressing in place from prior para. s/nt.
Neuro: Alert, oriented to person, ___ and ___ No asterixis.
Psych: calm and appropriate.
DISCHARGE:
===========
Vitals: 98.9 107 / 64 85 20 95 Ra
General: Alert, oriented, NAD; severe temporal wasting
Lungs: CTAB without wheezes or rales
CV: RRR, normal S1, S2, no m/r/g
Abdomen: Soft, mildly tender in all quandrants, moderately
distended with positive fluid wave
Ext: WWP, no edema; no asterixis
Neuro: Alert, oriented to person, hospital and date; moving all
extremities with purpose, fluent speech
Pertinent Results:
Admission:
___ 04:35PM BLOOD WBC-2.9* RBC-4.23* Hgb-12.5* Hct-38.5*
MCV-91 MCH-29.6 MCHC-32.5 RDW-20.9* RDWSD-70.1* Plt Ct-41*
___ 04:35PM BLOOD Neuts-55.5 ___ Monos-14.6*
Eos-3.1 Baso-1.0 Im ___ AbsNeut-1.63 AbsLymp-0.75*
AbsMono-0.43 AbsEos-0.09 AbsBaso-0.03
___ 04:39PM BLOOD ___ PTT-32.8 ___
___ 04:35PM BLOOD Glucose-89 UreaN-15 Creat-1.0 Na-139
K-3.8 Cl-107 HCO3-22 AnGap-14
___ 04:35PM BLOOD ALT-25 AST-34 AlkPhos-163* TotBili-2.0*
___ 04:35PM BLOOD Lipase-75*
___ 04:35PM BLOOD cTropnT-<0.01
___ 04:35PM BLOOD Albumin-3.3*
___ 08:15AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.1
___ 04:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:35PM BLOOD Lactate-2.9*
NOTABLE:
___ 08:15AM BLOOD AFP-2.5
___ 10:00AM BLOOD HBV VL-NOT DETECT
___ 10:00AM BLOOD HIV1 VL-DETECTED
___ 08:35AM BLOOD HCV VL-NOT DETECT
___ 10:15AM BLOOD ___ pO2-55* pCO2-31* pH-7.44
calTCO2-22 Base XS--1 Comment-GREEN TOP
DISCHARGE:
___ 07:55AM BLOOD WBC-3.5* RBC-3.97* Hgb-11.7* Hct-35.0*
MCV-88 MCH-29.5 MCHC-33.4 RDW-20.5* RDWSD-65.4* Plt Ct-27*
___ 07:55AM BLOOD ___ PTT-30.4 ___
___ 07:55AM BLOOD Glucose-117* UreaN-20 Creat-0.9 Na-134
K-4.0 Cl-100 HCO3-19* AnGap-19
___ 07:55AM BLOOD ALT-21 AST-37 LD(LDH)-225 AlkPhos-136*
TotBili-1.5
___ 07:55AM BLOOD Albumin-3.3* Calcium-8.5 Phos-2.2* Mg-2.3
Ascitic fluid:
___ 11:58AM ASCITES TNC-266* RBC-4674* Polys-0 Lymphs-76*
___ Mesothe-2* Macroph-22* Other-0
___ 03:49PM ASCITES TNC-189* RBC-2836* Polys-7* Lymphs-81*
___ Macroph-12*
___ 08:43PM ASCITES TNC-43* RBC-___* Polys-8* Lymphs-62*
___ Mesothe-6* Macroph-24*
___ 08:43PM ASCITES TotPro-0.7 Glucose-123
IMAGING/STUDIES:
___ DOP ABD/PEL LIMI
1. Nonocclusive clot in the left portal vein. No evidence of
clot in the
main, right anterior, or right posterior portal veins, with
hepatopetal flow
in all 3 veins.
2. Re-demonstration of cirrhotic liver. Unchanged splenomegaly,
measuring 21
cm.
___: immunophenotyping specimen
INTERPRETATION
Nonspecific CD8 T cell dominant lymphoid profile; diagnostic
Immunophenoptyic features of involvement by leukemia/lymphoma
are not seen in specimen. No evidence of the ___ known
lymphoplasmacytic lymphoma present. Correlation with clinical
and other ancillary findings is recommended. Flow cytometry
immunophenotyping may not detect all abnormal populations due to
topography, sampling or artifacts of sample preparation.
___
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. Normal left ventricular wall
thickness, cavity size, and regional/global systolic function
(biplane LVEF = 64 %). The estimated cardiac index is normal
(>=2.5L/min/m2). Global longitudinal strain is normal (-24%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Normal study. Normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
No structural heart disease or pathologic flow identified.
___ CHEST/ABD/PELVIS W &
1. Large abdominopelvic ascites without intra-abdominal
hemorrhage.
2. Cirrhotic liver and enlarged spleen with upper abdominal and
esophageal
varices are consistent with portal hypertension.
3. Nonocclusive thrombus within main portal vein, and upper
portion of the
SMV, causing moderate narrowing. Left portal vein is either
completely
occluded or nearly occluded with some peripheral flow versus
collaterals.
Right portal vein is patent. Findings are probably similar
compared with
ultrasound from yesterday, allowing for differences in
technique.
___ FLUID
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, lymphocytes, and histiocytes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB, wheezing
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Gabapentin 100 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Nadolol 20 mg PO DAILY
7. Psyllium Wafer 1 WAF PO DAILY
8. Raltegravir 400 mg PO BID
9. Ranitidine 150 mg PO BID
10. Spironolactone 100 mg PO DAILY
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. Biotene PBF (saliva substitute combo no.9) 15 ml mucous
membrane TID
13. Complera (emtricitab-rilpivirine-tenofov) 200-25-300 mg oral
DAILY
14. diphenoxylate-atropine 2.5-0.025 mg oral BID:PRN
15. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
16. LOPERamide 2 mg PO TID:PRN diarrhea
17. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 mL by mouth three times a day
Disp #*2700 Milliliter Milliliter Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB, wheezing
3. Biotene PBF (saliva substitute combo no.9) 15 ml mucous
membrane TID
4. Complera (emtricitab-rilpivirine-tenofov) 200-25-300 mg oral
DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Gabapentin 100 mg PO BID
8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
9. Multivitamins 1 TAB PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Psyllium Wafer 1 WAF PO DAILY
12. Raltegravir 400 mg PO BID
13. Ranitidine 150 mg PO BID
14. Spironolactone 100 mg PO DAILY
15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
16. HELD- Nadolol 20 mg PO DAILY This medication was held. Do
not restart Nadolol until speaking to your liver doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
HCV cirrhosis
Recurrent ascites
Hepatic encephalopathy
HIV
Secondary:
Lymphoplasmacytic lymphoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with cirrhosis, abd distension// U/S: eval for Portal Vein
thrombosisCXR: eval for pna
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis from ___ liver gallbladder ultrasound
from ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with known cirrhosis. There is no focal liver
mass. There is large volume ascites in all 4 quadrants.
DOPPLER: The main portal vein is patent with hepatopetal flow. Nonocclusive,
echogenic clot is noted within the left portal vein with slow hepatopetal
flow. No evidence of clot in the right anterior or right posterior portal
veins with hepatopetal flow in both.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: The gallbladder demonstrates diffusely thickened wall likely
secondary to underlying liver disease. Gallbladder is nondistended and there
are no visualized stones.
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 21 cm, unchanged.
KIDNEYS: Limited views of the bilateral kidneys show no evidence of
hydronephrosis. The right kidney measures 10.5 cm. The left kidney measures
11 cm.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Nonocclusive clot in the left portal vein. No evidence of clot in the
main, right anterior, or right posterior portal veins, with hepatopetal flow
in all 3 veins.
2. Re-demonstration of cirrhotic liver. Unchanged splenomegaly, measuring 21
cm.
Radiology Report
INDICATION: ___ with cirrhosis, abd distension// U/S: eval for Portal Vein
thrombosisCXR: eval for pna
TECHNIQUE: PA and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
The lungs are clear besides streaky right basilar atelectasis. There is no
consolidation or effusion. The cardiomediastinal silhouette is within normal
limits. Multiple round radiopaque densities project over the left chest and
axillary region as on prior. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT abdomen/pelvis with contrast.
INDICATION: ___ year old man with HCC cirrhosis c/b ascites, varices, PV
thrombus, pw increasing ascites and persistent PV thrombus. S/p 5L
paracentesis ___ ___ with abdominal pain after procedure// **Please perform
triphasic CT A/P**Looking for: HCC progression in liver, bleeding s/p
paracentesis ___ ___, PV thrombus, other hepatic vasculature thrombi
TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen and pelvis 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 and pelvis were scanned in the portal venous phase, followed by a scan
of the abdomen in equilibrium (3-min delay) phase.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 58.0 cm; CTDIvol = 3.3 mGy (Body) DLP = 190.5
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 4.5 s, 35.6 cm; CTDIvol = 12.9 mGy (Body) DLP = 458.8
mGy-cm.
5) Spiral Acquisition 7.3 s, 57.3 cm; CTDIvol = 11.8 mGy (Body) DLP = 677.8
mGy-cm.
Total DLP (Body) = 1,340 mGy-cm.
COMPARISON: ___ ultrasound right upper quadrant. The MRI pelvis ___. CT abdomen ___.
FINDINGS:
LOWER CHEST: The visualized lower lungs demonstrate mild dependent atelectasis
within the lower lobes. There is no pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver is cirrhotic. Upper abdominal varices, including
paraesophageal varices. Enlarged splenic vein. An 8 mm subcapsular focus of
arterial enhancement within segment 5, series 3A image 44 persists on
equilibrium phase imaging, without peripheral show washout, attention to this
area on subsequent followups is recommended. A 7 mm subcapsular cyst within
segment 8 is noted. No suspicious enhancing lesion is seen within the liver.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is decompressed.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: There is severe splenomegaly measuring 19.3 cm. However no focal
lesion is identified. Metallic foreign body is identified in the medial
aspect of the spleen, likely reflecting a BB.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Subcentimeter cysts are noted within the right kidney. There is small scar in
the right kidney. There is otherwise 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. There are large
abdominopelvic ascites. No intra-abdominal hemorrhage is seen. Rectal
varices.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is eccentric thrombus within main portal vein causing moderate
narrowing. Thrombus extends into the upper SMV, causing moderate narrowing.
Remainder of the SMV and its tributaries are patent splenic vein is patent.
Right portal vein and its branches are patent. Left portal vein is either
occluded or nearly occluded with some flow along its periphery versus
collaterals. Findings are probably similar compared ultrasound from
yesterday. Large splenic vein is patent. There are numerous upper abdominal
and lower esophageal varices identified. Note is made of a replaced common
hepatic artery. There is no abdominal aortic aneurysm. Mild atherosclerotic
disease is noted.
BONES: A 5 mm bone island is seen in the left iliac bone. There is no
evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Numerous metallic BBs are noted within the left flank and left
posterior body wall.
IMPRESSION:
1. Large abdominopelvic ascites without intra-abdominal hemorrhage.
2. Cirrhotic liver and enlarged spleen with upper abdominal and esophageal
varices are consistent with portal hypertension.
3. Nonocclusive thrombus within main portal vein, and upper portion of the
SMV, causing moderate narrowing. Left portal vein is either completely
occluded or nearly occluded with some peripheral flow versus collaterals.
Right portal vein is patent. Findings are probably similar compared with
ultrasound from yesterday, allowing for differences in technique.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with HCV cirrhosis, HIV with reduced CD4 count
with recurrent ascites, now with cough// Pneumonia? Atypical pneumonia as
patient with HIV?
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
Mild linear basilar atelectasis, more prominent on the left, improved on the
right. Multiple metallic foreign bodies scattered over left chest, also seen
on prior. Few tiny nodules right costophrenic angle, may be inflammatory or
infectious, more prominent since prior. Normal heart size, pulmonary
vascularity. No pneumothorax. No consolidations.
IMPRESSION:
Few tiny nodules right lateral costophrenic angle, more prominent since prior,
may be infectious.
Radiology Report
INDICATION: ___ year old man with HCV cirrhosis s/p EGD with banding x6 ___
___, now with ___ abdominal pain// perforation/free air?
TECHNIQUE: Portable supine and left lateral decubitus abdominal radiograph
was obtained.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Gaseous
distention of small bowel loops without dilatation, which may be secondary to
endoscopy.
There is no free intraperitoneal air on the left lateral decubitus views.
Osseous structures are unremarkable.
Numerous metallic round densities are noted projecting over the left abdomen
and flank consistent with known metallic BB's in the posterior soft tissues of
the left flank and posterior abdominal wall.
IMPRESSION:
Nonspecific bowel gas pattern. No radiographic evidence of obstruction. No
evidence of free intraperitoneal air on the left lateral decubitus views.
Radiology Report
INDICATION: ___ year old man with HCV cirrhosis with recurrent ascites, HIV//
diagnostic and therapeutic paracentesis
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: Ultrasound-guided paracentesis from ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
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 with a translator
present.
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 4.1 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.
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. 4.1 L of fluid were removed.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with HCV cirrhosis, HIV with cough and wheezing//
PNA? pulmonary edema?
IMPRESSION:
In comparison with the study of ___, there is little interval change. The
multiple opaque metallic foreign bodies overlying the left chest are
consistent with BB pellets.
No convincing evidence of acute focal pneumonia, vascular congestion, or
pleural effusion. If there is strong clinical suspicion for possible
pneumonia, a lateral view of the chest could be obtained.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Abd pain, Abdominal distention
Diagnosed with Other ascites
temperature: 98.2
heartrate: 96.0
resprate: 18.0
o2sat: 99.0
sbp: 123.0
dbp: 80.0
level of pain: 4
level of acuity: 2.0 | ___ with PMH of lymphoplasmacytic lymphoma, Waldenstrom's
macroglobulinemia, HIV on antiviral therapy, HBV/HCV genotype I
cirrhosis c/b varices (last banding ___, anal cancer, IVDU,
cocaine use who presents with recurrent ascites c/f
decompensated cirrhosis.
#Recurrent ascites:
#Portal vein thrombus:
Recurrent ascites likely reflects diuretic refractory ascites.
Serial paracentesis this admission drained several liters of
fluid. Fluid cultures were negative for infection. Ascites cell
differential was negative for infection, though the diff was
unusual as they were zero PMNs on the most recent tap. This may
be an effect of the ___ lymphoplasmacytic lymphoma (see
below), and he will follow-up with oncologist Dr. ___ to
determine if there is any further work-up or management needed.
Home diuretics were initially help due to soft BPs, and some
concern for SBP with rising bili and abdominal pain. After
clinically stable, bili downtrending, and no concern for SBP,
restarted home diuretic regimen of Lasix and spironolactone.
Will see outpatient hepatologist in ___, and likely will
require regular paracenteses.
#Wheezing, SOB: History of asthma. had increased wheezing and
shortness of breath resolved with duonebs. CXR was clear, and
patient was non-toxic, with no suspicion for infection.
#Lymphoplasmacytic lymphoma: Followed by Dr. ___ as outpatient.
Discussed with Dr. ___ any further management necessary
in-patient. After flow cytometry from ascitic fluid showed no
leukemia/lymphoma, Dr. ___ no further management
in-patient. (See above for unusual cell diff count from fluid.)
#HIV: VL reported "detectable" on ___ lab results, though
discussed with Dr. ___ outpatient ID, who explained
that is reported as such, but if <1.3, is undetectable. There
was some concern that ___ PPI may be interfering with
levels of home HIV meds. Discussed this with Dr. ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right Upper Quadrant Pain
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
___ w/ acute onset RUQ pain, awoke from sleep. +nausea/vomiting.
Denies fevers/chills. Similar episode last month, self-resolved.
Denies relation to eating.
Past Medical History:
PAST MEDICAL HISTORY:
None
PAST SURGICAL HISTORY:
None
Social History:
___
Family History:
FAMILY HISTORY:
Non-contributory
Physical Exam:
Physical Exam in Adm:
Vitals: 98.2 89 100/67 18 99% 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, nondistended, RUQ TTP, ___
Ext: No ___ edema, ___ warm and well perfused
Physical Exam in Discharge:
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation
incisionally, non-distended. Incisions: clean, dry and intact,
dressed and closed with steristrips.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
N/A
Medications on Admission:
Denie
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
2. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*45 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with acute onset epigastric/RUQ pain // Eval for
cholecystitis, obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 6 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
The gallbladder contains sludge.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of liver disease
and more advanced liver disease including steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
2. The gallbladder contains sludge. No evidence of cholecystitis.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with epigastric pain,
tendernessNO_PO contrast // pancreatitis?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 5.3 s, 57.5 cm; CTDIvol = 16.7 mGy (Body) DLP = 957.1
mGy-cm.
Total DLP (Body) = 969 mGy-cm.
COMPARISON: Liver ultrasound from earlier the same day
FINDINGS:
LOWER CHEST: There is mild dependent atelectasis bilaterally. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates decreased attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder wall is mildly edematous.
No radiopaque gallstones.
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: There is a small area of nonspecific wall thickening in the
region of the antrum and pylorus. Small bowel loops demonstrate normal
caliber, wall thickness, and enhancement throughout. The colon and rectum are
within normal limits. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and 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.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No CT evidence of pancreatitis or complications from pancreatitis.
2. Mildly edematous gallbladder wall of uncertain significance.
3. Hepatic steatosis is again seen.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Epigastric pain
Diagnosed with Epigastric pain, Right upper quadrant pain, Vomiting without nausea
temperature: 97.7
heartrate: 84.0
resprate: 20.0
o2sat: 100.0
sbp: 144.0
dbp: 89.0
level of pain: 10
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain. The
patient underwent laparoscopic cholecystectomy, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating pain , on IV fluids. The
patient was hemodynamically stable.
.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
exertional dyspnea
Major Surgical or Invasive Procedure:
___ - Aortic valve replacement with a 25 mm ___ valve.
History of Present Illness:
___ y/o F with h/o HTN, HLD, presented to ___ with 2
weeks of exertional dyspnea and chest discomfort/angina after
walking ___ yards, resolved with rest. Prior very active
individual and has been doing 20-mile charity walks for the last
several years. Workup at ___ included negative CTA, echo with
reduced EF and severe AS and cath with normal
coronaries, RHC with slightly elevated filling pressures and
preserved cardiac output. He was given 20mg IV Lasix
prior to transfer and lisinopril was increased from home dose
20mg to 30mg daily. He is transferred for AVR evaluation.
Past Medical History:
Aortic Stenosis
acute, systolic heart failure
Hypertension
Hyperlipidemia
Nephrolithiasis
Social History:
___
Family History:
He has a father who died of an MI at age ___.
His mother has no coronary artery disease- she died at ___.
He has no history of arrhythmia or cardiomyopathy in his family.
Physical Exam:
99.2
PO 110 / 72
R Sitting 98 20 98 RA
Height: 71" Weight: 211 lb
General: NAD, robust male appears stated age
Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade __3/6 systolic_
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _trace_
Varicosities: None [] large varicosities bilaterally, left >
right
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right: 2+ Left:2+
___ Right: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit: Right: Left:
radiation of cardiac murmur
Pertinent Results:
___ 05:52AM BLOOD WBC-6.3 RBC-2.66* Hgb-8.7* Hct-25.6*
MCV-96 MCH-32.7* MCHC-34.0 RDW-13.3 RDWSD-46.5* Plt ___
___ 05:55AM BLOOD ___
___ 05:52AM BLOOD Plt ___
___ 05:52AM BLOOD Glucose-111* UreaN-15 Creat-0.8 Na-133*
K-4.4 Cl-96 HCO3-22 AnGap-15
___ 05:52AM BLOOD Mg-1.8
PRE-BYPASS:
The left atrium is normal in size. Mild spontaneous echo
contrast is present in the left atrial appendage. No thrombus is
seen in the left atrial appendage. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild to moderate global left ventricular
hypokinesis, with severe hypokinesis of the apical segments.
There is dyskinesis throughout the septum consistent with known
left bundle branch block. Estimated EF 35-40% by visual
inspection. Right ventricular chamber size and free wall motion
are normal. There are complex (mobile) atheroma in the aortic
root There are simple atheroma in the descending thoracic aorta.
No thoracic aortic dissection is seen. The aortic valve leaflets
are severely thickened/deformed. There is severe aortic valve
stenosis (valve area <1.0cm2). Trace aortic regurgitation is
seen. Mild (1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
POST-BYPASS:
Rhythm: sinus
Infusions: norepinephrine, vasopressin, epinephrine (weaned off
over the course of the examination).
1. Overall left ventricular contractility is improved on noted
support. Estimated EF > 60%. Abnormal septal motion is
redemonstrated. There are no new wall motion abnormalities.
2. Right ventricular function remains preserved.
3. There is a bioprosthetic valve in the aortic position (25 mm
___ bioprosthetic). The valve is well-seated with
normal trileaflet motion. There is trivial central
regurgitation; there is no paravalvular regurgitation. Peak
gradient across the valve is 24 mmHg, mean gradient is 12 mmHg
at a cardiac output of 12 L/min by thermodilution.
4. Mitral and tricuspid regurgitation are trivial.
5. The thoracic aorta is intact following decannulation. The
complex atheroma in the aorta root is no longer visualized.
6. There is no pericardial effusion.
Dr. ___ was notified in person of the results at the time the
exam was performed in the operating room.
PA and Lateral ___
There are small bilateral pleural effusions, best seen on the
lateral image.
There is no focal consolidation or pneumothorax.
Cardiomediastinal silhouette
is mildly enlarged. There are medial sternotomy wires seen
which are aligned
and intact. There is evidence of aortic valve replacement.
There has been
interval removal of right IJ central venous catheter.
___ 05:28AM BLOOD WBC-5.1 RBC-2.66* Hgb-8.6* Hct-25.3*
MCV-95 MCH-32.3* MCHC-34.0 RDW-13.3 RDWSD-46.4* Plt ___
___ 05:25AM BLOOD Glucose-130* UreaN-20 Creat-0.8 Na-133*
K-4.5 Cl-96 HCO3-29 AnGap-8*
___ 05:25AM BLOOD Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 40 mg PO QPM
2. Lisinopril 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
3. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
4. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 50 mg 1.5 tablet(s) by mouth once a day
Disp #*45 Tablet Refills:*2
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain:
moderate/severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*35 Tablet Refills:*0
6. Potassium Chloride 10 mEq PO DAILY Duration: 7 Days
RX *potassium chloride 10 mEq 1 tablet(s) by mouth once a day
Disp #*7 Tablet Refills:*0
7. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
8. Aspirin 81 mg PO DAILY
9. Pravastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Aortic Stenosis-s/p Tissue AVR
acute, systolic heart failure
Hypertension
Hyperlipidemia
Nephrolithiasis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oxycodone
Incisions:
Sternal - healing well, no erythema or drainage
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p avr and ct removal// r/o ptx
IMPRESSION:
In comparison with study of ___, the mediastinum appears essentially
within normal limits and the outer margin of the aortic arch is more sharply
seen.
The endotracheal tube, nasogastric tube, and right IJ Swan-Ganz catheter been
removed. A right IJ sheath is now in place.
Following chest tube removal, there is no evidence of pneumothorax.
Radiology Report
EXAMINATION: Chest radiograph PA and lateral
INDICATION: ___ year old man s/p AVR// ___ year old man s/p AVR
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
There are small bilateral pleural effusions, best seen on the lateral image.
There is no focal consolidation or pneumothorax. Cardiomediastinal silhouette
is mildly enlarged. There are medial sternotomy wires seen which are aligned
and intact. There is evidence of aortic valve replacement. There has been
interval removal of right IJ central venous catheter.
IMPRESSION:
Small bilateral pleural effusions.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with pre-op AVR// evaluate for acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. There is mild unfolding of the thoracic aorta with knob
calcifications. Hilar contours are preserved. Lungs are clear. Pleural
surfaces are clear without effusion pneumothorax. There is no acute osseous
abnormality. There are bilateral AC joint degenerative changes.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man s/p AVR// FAST TRACK EARLY EXTUBATION CARDIAC
SURGERY Contact name: ___: ___
IMPRESSION:
There has been performance of an aortic valve repair with intact midline
sternal wires. The endotracheal tube tip lies approximately 5 cm above the
carina. Right IJ Swan-Ganz catheter is in the pulmonary outflow tract.
Increased opacification at the left base is consistent with volume loss in the
left lower lobe and there is increasing prominence of the region of the aortic
arch. Although now there is no evidence of postoperative hemorrhage, this
information was discussed with ___ as a region to be closely watched
on subsequent studies.
NOTIFICATION: The indistinctness of the outer aspect of the aortic arch was
discussed ___.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Chest pain, Transfer
Diagnosed with Chest pain, unspecified
temperature: 99.0
heartrate: 85.0
resprate: 16.0
o2sat: 98.0
sbp: 126.0
dbp: 79.0
level of pain: 0
level of acuity: 3.0 | The patient was brought to the Operating Room on ___ where
the patient underwent Aortic valve replacement with a 25 mm ___.
___ valve. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility and
deemed appropriate for discharge home. By the time of discharge
on POD 4 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home in good condition on ___ with
appropriate follow up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Ceclor
Attending: ___.
Chief Complaint:
thunderclap headaches for one week duration
Major Surgical or Invasive Procedure:
___ guided lumbar puncture
History of Present Illness:
The patient is a ___ year old woman with no hx of headache here
with
episodic thunderclap headache occurring at least daily since
___.
Pt notes that she was in normal state of health on ___ when
she had sudden onset ___ pain in the back of her head when on
the toilet and reaching to wipe herself. +nausea, +diaphoresis.
She took motrin as well as Excedrin and lay down. Within 2 hours
her headache had resolved and aside from mild lightheadedness
she
was back to baseline.
Headache is described as - posterior head left more than right
with aching neck in between episodes. +photophobia and
phonophobia. No vertigo. +lightheadedness.
That night she had trouble sleeping which is unusual but there
was no pain involved in preventing her from sleeping.
___ AM, she went to kneel on the couch, and she had another
sudden onset sharp headache as described above. She took 800mg
Ibuprofen with minimal relief. She presented to ___ where
they did NCHCT negative for bleed. After several hours, her
headache resolved. She was given IV Reglan which had minimal
benefit. LP was recommended but she refused as she had been in
the ED for so long and was feeling better.
___ ___, she was in the bathroom urinating and again suddenly
had her severe headache. She took Reglan, ibuprofen, Excedrin,
and returned to ___ where LP was attempted twice and
failed.
This was very uncomfortable and traumatic for her and she now
refuses LP in the ED. Again after several hours, her headache
improved and she was discharged with 10 pills each of Reglan and
Fioricet.
___ she had one sudden onset headache lasting hours.
___ AM, she had a sudden onset headache when just lying in
bed. She took Reglan, Benadryl, fioricet which barely helped.
She
returned to the ED where they got MRI Brain which reportedly
showed sinus infection and she was prescribed augmentin on
discharge. She was also given Percocet and ibuprofen was
recommended.
She had severe sudden onset headaches lasting hours again on
___, ___ AM, and ___ - for each of these she
took many PO meds including combinations of reglan, fioricet,
ibuprofen, percocet, Benadryl. She used all of her reglan and
fioricet that was prescribed.
Today, ___ at 12PM, she had another sudden onset severe
headache that has not resolved since onset despite reglan,
percocet and toradol. She presented to ___ initially where
they obtained CTA H and N concerning for possible vasospasm vs
vasculitis and transferred her here for further management. CT
was negative for bleed.
As noted above, while several episodes occurred with bending
slightly, others occurred at rest without any movement. There is
no positional component to her headache. No transient
obscuration
of vision. No diplopia. No pulsatile tinnitus. No visual
symptoms.
She does not feel that moving her neck brings on her headache.
She denies any recent trauma or car accident prior to onset of
headaches.
She does use marijuana daily and has not recently increased
this.
When seen at 10PM, she still has a severe headache with nausea.
She denies recent prednisone use but has used it previously.
On neurologic review of systems, the patient 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, +Diarrhea from augmentin. She
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,
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
None
Social History:
___
Family History:
Grandmother - brain tumor
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.6F, HR 48-59, BP 152/60, RR 14, 99% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx. With palpation of her b/l trapezius muscles are
tight
but not painful to palpation. There is mild tenderness on
palpation of b/l occipital notches but this is not reproduce her
pain.
Neck: Supple, No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus - several beats of end gaze nystagmus seen but likely
pseudonystagmus as pt trying to blink when seen, not present on
repetition. VFF to confrontation. Fundoscopic exam revealed no
papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii 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, proprioception throughout.
No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 1
R 3 3 3 3 1
Plantar response was flexor bilaterally. No ankle clonus.
+pectoral jerks b/l. +crossed adductors b/l.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
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.
==================================================
DISCHARGE
Vitals: Temp 98.5, BP 136/64, HR 56, RR 18, O2 Sat 100% RA
General: Awake, cooperative, NAD
HEENT: NC/AT, no TTP
Neck: Supple, no TTP
Pulmonary: Breathing comfortably
Cardiac: Well perfused
Extremities: No ___ edema.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty.
-Cranial Nerves:
II, III, IV, VI: PERRL. EOMI without nystagmus
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl IP Ham TA
L 5 ___ ___ 5
R 5 ___ ___ 5
-Sensory: No deficits to light touch, proprioception throughout.
No extinction to DSS.
-Coordination: No intention tremor, no dysmetria on FNF.
Discharge Physical Exam:
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt
Ct
___ 05:50AM 14.0* 4.25 12.2 37.7 89 28.7 32.4 13.2
42.8 334 Import Result
___ 09:05AM 17.0* 3.88* 11.2 34.4 89 28.9 32.6 13.2
42.7 296 Import Result
___ 09:20PM 16.5* 4.18 12.1 37.3 89 28.9 32.4 13.2
42.6 358 Import Result
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Im
___ AbsLymp AbsMono AbsEos AbsBaso
___ 09:20PM 78.5* 16.5* 4.0* 0.3* 0.2 0.5
12.95* 2.72 0.66 0.05 0.04 Import Result
BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___
___ 05:50AM 334 Import Result
___ 01:00PM 12.7* 31.3 1.2* Import Result
___ 09:05AM 296 Import Result
___ 09:05AM 12.8* 29.8 1.2* Import Result
___ 09:20PM 358 Import Result
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 05:50AM ___ 139 3.9 ___ Import Result
___ 09:05AM ___ 137 3.6 ___ Import Result
___ 09:20PM 103* 16 0.7 137 4.4 ___ Import
Result
ESTIMATED GFR (MDRD CALCULATION) estGFR
___ 09:20PM Using this Import Result
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 09:05AM 15 10 201 71 0.5 Import Result
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
___ 05:50AM 8.7 2.4* 2.1 Import Result
___ 09:00PM 6.8 Import Result
___ 09:05AM 3.5 Import Result
___ 09:20PM 8.4 3.4 1.8 Import Result
HEMATOLOGIC Cryoglb
___ 09:00PM PND Import Result
HEPATITIS HBsAg HBsAb HBcAb
___ 09:00PM Negative Positive Negative Import Result
AUTOANTIBODIES ANCA
___ 09:05AM PND Import Result
IMMUNOLOGY ___ CRP
___ 09:05AM PND Import Result
___ 09:05AM <10 Import Result
___ 09:20PM 12.1* Import Result
PROTEIN AND IMMUNOELECTROPHORESIS PEP
___ 09:00PM PND Import Result
COMPLEMENT C3 C4
___ 09:00PM 137 30 Import Result
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbitr Tricycl
___ 09:20PM NEG NEG NEG NEG NEG NEG Import Result
HEPATITIS C SEROLOGY HCV Ab
___ 09:00PM Negative Import Result
LAB USE ONLY
___ 05:50AM Import Result
___ 09:00PM Import Result
___ 09:05AM Import Result
___ 09:20PM Import Result
Miscellaneous
SED RATE
___ 09:05AM Test Import Result
PROCEDURES:
___:
___ Lumbar Puncture
1. Lumbar puncture at L3-L4 without complication.
2. Elevated opening pressure of 38 cm CSF.
I, Dr. ___ supervised the trainee during the key
components of the above procedure and I reviewed and agree with
the trainee's findings and dictation.
IMAGING:
MRI PENDING
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Verapamil 80 mg PO Q8H
RX *verapamil 80 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebral vasospasm /RCVS causing thunderclap headache
Discharge Condition:
Condition: Stable
Mental status: intact, no confusion, patient is alert, language
intact
Ambulates independently
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with white count and elevated cRP //
infectious eval infectious eval
IMPRESSION:
In comparison with the study of ___, there is little change and no
evidence of acute cardiopulmonary disease. The cardiac silhouette is at the
upper limits of normal in size. No vascular congestion, pleural effusion, or
acute focal pneumonia.
Radiology Report
EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE
INDICATION: ___ female with history of recurrent thunderclap
headaches, now presenting for fluoroscopic guided lumbar puncture for the
purpose of obtaining CSF for laboratory evaluation and opening pressure.
___ female with history of recurrent ___ year old woman with recurrent
thunderclap headaches, concerning for intracranial hemorrhage or viral
meningitis, now presenting for fluoroscopic guided lumbar puncture for the
purpose of obtaining CSF for laboratory evaluation and opening pressure.
TECHNIQUE: After informed consent was obtained from the patient explaining
the risks, benefits, and alternatives to the procedure, the patient was laid
in prone position on the fluoroscopic table. A pre-procedure time-out was
performed confirming the patient's identity, relevant history, procedure to be
performed and labs.
Puncture was performed at L3-4.
Approximately 5 cc of 1% lidocaine was administered for local anesthesia.
Under fluoroscopic guidance, a 20 gauge, 15 cm spinal needle was inserted into
the thecal sac. There was good return of clear CSF. 26 mls of CSF were
collected in 4 tubes and sent for requested analysis.
Fluoroscopy time: 2 seconds
Air kerma: 1 mGy
Dose area product: 14.55 uGy m 2
COMPARISON: None.
FINDINGS:
26 mls of CSF were collected in 4 tubes. Opening pressure was measured at 38
cm CSF.
IMPRESSION:
1. Lumbar puncture at L3-L4 without complication.
2. Elevated opening pressure of 38 cm CSF.
I, Dr. ___ supervised the trainee during the key components of
the above procedure and I reviewed and agree with the trainee's findings and
dictation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache, Nausea, Transfer
Diagnosed with Headache
temperature: 97.6
heartrate: 48.0
resprate: 14.0
o2sat: 99.0
sbp: 152.0
dbp: 60.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is an otherwise healthy ___ year old obese woman who
was transferred from ___ after a one week history of
progressively worsening daily "thunderclap" headaches, now
suspicious for vasospasm vs. vasculitis. She was started on
Verapamil prior to transfer.
She underwent LP ___ guided and was found to have in an
increased opening pressure of 38cm on LP in the prone position.
CSF studies did not show any evidence for subarachnoid
hemorrhage. All of her serum and CSF lab studies came back
negative, without any signs of infection, inflammatory processes
or malignancy. Ophthalmology consult revealed no papilledema.
MRI brain without contrast did not show a mass, ischemic
infarct, or intracranial hemorrhage. CTA brain from the OSH
showed mild irregularity of the right M1 segment of the MCA, and
moderate stenosis of the M2 branch of the right MCA - this
imaging plus her history suggested that the likely diagnosis is
reversible cerebral vasoconstriction syndrome. CTA brain did not
show any evidence of aneurysm.
Ms. ___ did not experience further episodes of thunderclap
headaches while inpatient after the Verapamil was started. She
did although occasionally endorse milder pulsing headaches, in
the occipital and temporal regions.
MRI w/thin cuts of orbits, MRA and MRV brain studies were
ordered to assess for other possibilities including idiopathic
intracranial hypertension (IIH) and cerebral venous sinus
thrombosis. IIH was thought to be less likely. Her history and
exam were not suggestive of IIH. Her headaches were actually
improved in the lying down position. Also, she did not have
papilledema on ophtho exam. Although she was found to have an
increased opening pressure of 38cm on LP in the prone position,
it is known that measuring CSF opening pressure in the prone
position may lead to artificially elevated results. After
waiting over a day for the study, Ms. ___ decided to leave
and have the imaging as an outpatient, which is scheduled for
___.
Patient advised to continue Verapamil for 3 months and to
follow-up in clinic with Dr. ___. Patient also advised to
make lifestyle modifications such as decreasing her marijuana
use since it is a known trigger of cerebral vasospasm.
Transitions of care issues:
1. Patient was not able to wait for MRI in the hospital and is
scheduled for outpatient MRI, MRA, and MRV for ___. The patient
has further follow-up with Dr. ___ attending in 3
months.
2. Patient discharged on verapamil PO 80 mg Q8 for a duration of
3 months.
3. Patient advised to follow up with ophthalmologist if she
develops blurry vision or difficulty with vision. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Knee infection
Major Surgical or Invasive Procedure:
Right knee irrigation and debridement
History of Present Illness:
___ s/p R knee arthroscopic debridement & meniscectomy by Dr.
___ at ___ on ___. She reports
persistent bleeding & drainage from the arthroscopic sites, so
she was taken back to OR this past ___ by Dr. ___
arthroscopic I&D & hematoma evacuation. She reports she began
having sxs of fevers to 101, progressive R knee pain & swelling
over the past 24 hrs. She called the office, who informed her to
come to ___ ED for further evaluation given concern for R
septic arthritis. She reports having excruciating R knee pain.
She denies any drainage over arthroscopic sites since her second
surgery. She reports she has been relatively immobilizer over
the past wk after her surgery. She is not on any
anticoagulation. She has been on Keflex ___ QID over the past
week for surgical site infection PPx.
Past Medical History:
R knee OA
Social History:
___
Family History:
Non-contributory
Physical Exam:
Exam on presentation:
RLE:
Arthroscopic sites closed w/ Nylon sutures
Mild erythema around sutures but no drainage
Moderate swelling about R knee
Excruciating R knee pain, mild to moderate calf & thigh pain
Thigh & leg compartments soft
Severe pain w/ limited ROM R knee
Sensation intact to light touch in saphenous, sural, deep
peroneal & superficial peroneal distributions
Motor intact for ___, FHL, GSC, TA
Dorsalis pedis & posterior tibial pulses easily palpable, toes
warm & well perfused
Exam on discharge.
Decreased erythema. Incision c/d/i.
Thigh and leg compartements soft
Some pain with ROM of R knee
Sensation intact to light touch in saphenous, sural, deep
peroneal & superficial peroneal distributions
Motor intact for ___, FHL, GSC, TA
Dorsalis pedis & posterior tibial pulses easily palpable, toes
warm & well perfused
Pertinent Results:
___ 12:50 pm TISSUE RIGHT KNEE,#2.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPHYLOCOCCUS EPIDERMIDIS.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___-___
___.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ 05:27AM BLOOD WBC-5.4 RBC-2.32* Hgb-6.9* Hct-21.0*
MCV-91 MCH-29.7 MCHC-32.9 RDW-12.7 RDWSD-41.7 Plt ___
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth q4hrs Disp #*100
Tablet Refills:*0
2. Daptomycin 350 mg IV Q24H
RX *daptomycin [Cubicin] 500 mg 0.7 units IV Daily Disp #*35
Vial Refills:*0
3. Senna 17.2 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice a day
Disp #*100 Tablet Refills:*0
4. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q3 Disp
#*120 Tablet Refills:*1
6. Docusate Sodium 200 mg PO BID
RX *docusate sodium [Colace] 100 mg 2 capsule(s) by mouth twice
a day Disp #*100 Capsule Refills:*0
7. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
9. Bisacodyl 10 mg PO DAILY:PRN constipation
10. Outpatient Lab Work
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
DAPTOMYCIN: WEEKLY: CBC with differential, BUN, Cr, CPK
11. Crutches
Bilateral axillary crutches for gain training
Dx: S/p Right Knee I+D
Prognosis: Excellent
Duration: 14 months
12. Continuous Passive Motion Machine
Use ___ daily, 2 hours per session
Duration: 2 weeks
Degrees - not limited. Advance as tolerated.
13. Ibuprofen 600 mg PO Q6H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Infected right knee
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with T102.7. // ? infectious process ?
infectious process
IMPRESSION:
In comparison with the study of ___, there is little change and no
evidence of pneumonia or vascular congestion. There is some blunting of the
left costophrenic angle consistent with pleural effusion.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with infection // location of 42 right basilic
picc tip Contact name: ___: ___
COMPARISON: ___
IMPRESSION:
The patient has received a right PICC line. The course of the line is
unremarkable, the tip of the line projects over the lower SVC. No evidence of
complications. Otherwise unchanged radiograph.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: History: ___ with R knee joint infection, pain and swelling to
extremity; // eval for 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.
A fluid collection measuring 5.5 x 0.7 x 1.6 cm is seen in the right popliteal
area.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. A fluid collection measuring 5.5 x 0.7 x 1.6 cm is seen in the right
popliteal area, which could represent a ___ cyst.
Radiology Report
EXAMINATION: MR KNEE WANDW/O CONTRAST RIGHT
INDICATION: ___ year old woman with joint effusion // joint effusion, ?septic
joint w/ negative cultures, determine sequestered focus of fluid
TECHNIQUE: Multiplanar images of the right knee were performed with the
administration of intravenous contrast on a 1.5 T MRI.
COMPARISON: Right knee radiographs ___
FINDINGS:
The study is tailored towards evaluation of the mass or infection and is not a
dedicated examination to evaluate the intra-articular structures of the knee.
Multiple large foci of hypointense signal and blooming seen within the
suprapatellar recess, which corresponds to air on the radiograph and is
presumed secondary to recent aspiration. There is a moderate sized
heterogeneously hyperintense effusion, which may represent a complex effusion
and synovitis with extensive synovial hyperenhancement and thickening on post
contrast imaging. In addition, there is edema and enhancement within ___
fat pad.
Bone marrow edema is seen in the medial tibial plateau and medial femoral
condyle as well as the lateral femoral condyle and at the insertion of the
posterior cruciate ligament. No areas of low signal intensity on T1 weighted
sequences to suggest osteomyelitis are identified however.
Subcutaneous edema is seen surrounding the knee joint with more confluent
areas of fluid in seen along the lateral aspect. In addition, there is edema
and fluid tracking along the posterior aspect of the distal femur. Edema is
noted within the biceps femoris muscle and within the vastus medialis,
lateralis, and intermedius muscles. No rim enhancing fluid collection seen
within the subcutaneous tissues or muscles.
The medial and lateral menisci are grossly intact. The ACL, PCL, medial
collateral ligament, and lateral collateral ligament complex are grossly
intact.
The extensor mechanism is intact. There is a minimal deep infrapatellar
bursitis.
Patellofemoral articular cartilage: Severe thinning of the trochlear
cartilage and superficial fraying of the medial and lateral patellar facet
cartilage.
Medial articular cartilage: Large area of cartilage denudation overlying the
central weight-bearing portion of the femoral condyles with underlying bone
marrow edema pattern. In addition, there is bone marrow edema pattern within
the posterior and medial aspect of the medial tibial plateau.
Lateral compartment cartilage: There is denudation of the cartilage over the
anterior femoral condyle and central weight-bearing femoral condyle with
underlying subchondral bone marrow edema.
Bone marrow edema within the posterior tibia at the insertion of the PCL.
IMPRESSION:
1. Complex joint effusion with synovitis, subcutaneous edema, and muscular
edema. No evidence of osteomyelitis. Findings may represent an inflammatory
arthropathy or infectious etiology. Air within the joint space is presumed to
be related to the recent aspiration.
2. Severe degenerative changes most prominently medial and lateral
compartments with high-grade chondral loss and underlying subchondral bone
marrow edema.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with knee infection. // Pre-op Surg: ___
(R knee I+D)
COMPARISON: No comparison
IMPRESSION:
The lung volumes are normal. Minimal atelectasis at the right lung basis. No
pneumonia, no pulmonary edema, no pleural effusions. Normal size of the
cardiac silhouette. Normal hilar and mediastinal contours.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Knee pain, Fever
Diagnosed with JOINT PAIN-L/LEG
temperature: 99.7
heartrate: 95.0
resprate: 16.0
o2sat: 99.0
sbp: 136.0
dbp: 68.0
level of pain: 10
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 an infected right knee and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for R knee irrigation and
debridement, 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 started on
vancomycin before being switched to daptomycin based on
microbiology sensitivities. A PICC line was placed for
continued antibiotic infusions after discharge. The patient's
home medications were continued throughout this hospitalization.
The patient worked with ___ who determined that discharge to home
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 in the right lower extremity, and
will be discharged on aspirin for DVT prophylaxis. The patient
will follow up with Dr. ___ primary surgeon, after
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: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of morbid obesity, asthma, mild aortic
stenosis presenting with hypotension and shortness of breath.
She has had 2 weeks of increasing cough which is similar to her
past asthma. She took her scooter to her PCP today where she was
seen to be SOB and diffusely wheezy and found to have
hypotension into the ___ systolic. She was then sent to the ED.
In the ED, initial vitals were: T 96, HR 71, BP 77/49, RR 25,
O2 99% NC
- Exam notable for: Pale, morbidly obese. Diffuse inspiratory
and expiratory wheezing on exam
- Labs notable for: Hgb 10.9 (stable from ___, Cr 1.3
(stable from b/l ___, initial lactate 2.4, BNP <500
- Imaging was notable for:
CXR: IMPRESSION: No definite acute cardiopulmonary process.
Increased density at the lung bases only on the lateral view
which could potentially be due to overlying soft tissues as no
clear correlate seen on the frontal view. Underlying
consolidation cannot be entirely excluded.
- Patient was given:
Duonebs x3
IV MethylPREDNISolone 125 mg
PO Azithromycin 500 mg
IVF NS 2.5L
- BP improved to ___, repeat lactate 2.1
By time she left ED her BP was 123/97
Upon arrival to the floor, patient is on nasal cannula, appears
comfortable. She endorses SOB. Denies f/c, CP, leg swelling.
She reports that she has been in her usual state of health over
the last ___ months but decided to stop using her BiPAP around 6
weeks ago. Subsequently ___ weeks ago she started to feel
dyspneic despite having normal (94 %) SPo2 at home. She also
started to get an occasional dry cough as well. She reports
initially not thinking of coming in, feeling she felt just a bit
more tired than normal, but then reports her PCP asked her to
come in. She does endorse eating and drinking less due to
fatigue, but denies fevers or chills.
Past Medical History:
1. depression
2. morbid obesity: referred to gastric bypass program
3. chronic urinary incontinence (overactive)
4. hyperlipidemia
5. tension/migraine headaches
6. chronic insomnia
7. knee degenerative disease s/p TKA
8. HTN
Social History:
___
Family History:
Diabetes mellitus in both parents.
Physical Exam:
ADMISSION:
VS: 97.7
PO 71 22 94 2L
HEENT: EOMI, PERRLA. Pupils are 3 mm, equal and reactive to
light. Extraocular movements without nystagmus. Oropharynx,
moist mucosa without lesions, erythema or exudate seen. sleepy
but aaox3
NECK: JCP elevated 10 cm
LUNGS: Inspiratory and expiratory wheezing on anterior and
posterior chest; mild stertor, bibasilar crackles
CV: RRR, S1, S2, grade ___ early systolic murmur left sternal
border.
ABDOMEN: Obese, soft, nontender, limited by body habitus
EXTREMITIES: WWP, 1+ edema bilaterally. Chronic stasis changes
DISCHARGE:
Vital Signs: 98 124 / 70 78 18 93 ra
General: Obese, alert, interactive, NAD
Lungs: No audible wheezing on inspection, mild diffuse wheezing
on auscultation much improved from prior, adequate air movement
CV: Distant heart sounds, unable to appreciate
Abdomen: obese, soft, ND, NT, NABS
Ext: Chronic venous stasis changes, no edema, WWP
Pertinent Results:
ADMISSION:
___ 10:32AM BLOOD ___
___ Plt ___
___ 10:32AM BLOOD ___
___ Im ___
___
___ 10:32AM BLOOD ___
___
___ 10:32AM BLOOD cTropnT-<0.01 ___
___ 12:45PM BLOOD ___ cTropnT-<0.01
___ 08:30AM BLOOD ___
___ 05:15PM BLOOD ___
___ Base ___
___ 10:44AM BLOOD ___
___ 05:15PM BLOOD ___
NOTABLE:
___ 06:30AM BLOOD ___
___ 08:30AM BLOOD ___
___ 08:48AM BLOOD ___
___ Base ___ TOP
___ 12:54PM BLOOD ___
___ Base ___ TOP
___ 03:19PM BLOOD ___
___ Base ___
___ 06:38AM BLOOD ___
___ Base XS--3 ___ TOP
MICRO:
_______________________________________________________
___ 5:42 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 11:14 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:32 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
___
Poor image quality.The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets are mildly thickened (?#). There is mild aortic valve
stenosis (valve area ___. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, AS
is now mild.
___ (PORTABLE AP)
No definite acute cardiopulmonary process. Increased density at
the lung
bases only on the lateral view which could potentially be due to
overlying
soft tissues as no clear correlate seen on the frontal view.
Underlying
consolidation cannot be entirely excluded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
3. Simvastatin 20 mg PO QPM
4. Lisinopril 2.5 mg PO DAILY
5. Gabapentin 600 mg PO QHS
6. Pramipexole 0.5 mg PO QHS
7. CloNIDine 0.2 mg PO QHS
8. QUEtiapine Fumarate 600 mg PO QHS
9. Sumatriptan Succinate 25 mg PO DAILY:PRN migraines
10. vortioxetine 30 mg oral QHS
11. Calcium 500 With D (calcium ___ D3) 500
mg(1,250mg) -400 unit oral DAILY
12. Multivitamins 1 TAB PO DAILY
13. Ferrous Sulfate 325 mg PO HS
14. Nexium 20 mg Other QHS
15. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. PredniSONE 40 mg PO DAILY
Take 2 tablets ___ through ___
Take 1 tablet ___ through ___
RX *prednisone 20 mg As directed tablet(s) by mouth As directed
Disp #*10 Tablet Refills:*0
2. QUEtiapine Fumarate 300 mg PO QHS
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs IH q6h PRN
Disp #*1 Inhaler Refills:*0
4. Calcium 500 With D (calcium ___ D3) 500
mg(1,250mg) -400 unit oral DAILY
5. Ferrous Sulfate 325 mg PO HS
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 puffs IH twice
a day Disp #*1 Inhaler Refills:*0
8. Gabapentin 600 mg PO QHS
9. Multivitamins 1 TAB PO DAILY
10. Nexium 20 mg Other QHS
11. Pramipexole 0.5 mg PO QHS
12. Simvastatin 20 mg PO QPM
13. Sumatriptan Succinate 25 mg PO DAILY:PRN migraines
14. HELD- CloNIDine 0.2 mg PO QHS This medication was held. ___
not restart CloNIDine until seeing your PCP and rechecking BP
15. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
___ not restart Lisinopril until seeing your PCP and rechecking
blood pressure
16. HELD- vortioxetine 30 mg oral QHS This medication was held.
___ not restart vortioxetine until seeing your PCP or
psychiatrist and restarting this medicaiton slowly
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Asthma
Morbid obesity
Obesity hypoventilation syndrome
Obstructive sleep apnea
Anemia
Hypertension
Secondary:
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with morbid obesity, hypotension, SOB.// pneumonia? pulm
edema?
TECHNIQUE: Frontal lateral views of the chest.
COMPARISON: ___ chest x-ray. CT chest from ___.
FINDINGS:
The lungs are grossly clear on the frontal view. Lung bases are grossly clear
on this view however demonstrate increased density on the lateral. Is
uncertain of this could be due to overlying soft tissues.Cardiomediastinal
silhouette is within normal limits noting possible hiatal hernia, better seen
on prior CT. Right shoulder arthroplasty changes are noted.
IMPRESSION:
No definite acute cardiopulmonary process. Increased density at the lung
bases only on the lateral view which could potentially be due to overlying
soft tissues as no clear correlate seen on the frontal view. Underlying
consolidation cannot be entirely excluded.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Hypotension
Diagnosed with Unspecified asthma with (acute) exacerbation, Hypotension, unspecified
temperature: 96.0
heartrate: 71.0
resprate: 25.0
o2sat: 99.0
sbp: 77.0
dbp: 49.0
level of pain: 0
level of acuity: 1.0 | ___ with history of morbid obesity, asthma, mild aortic
stenosis presenting with hypotension and shortness of breath in
setting of self dc'ing BiPAP last 3 weeks, concerning for Asthma
flare with underlying obesity hypoventilation syndrome.
#Dyspnea: Most likely asthma exacerbation in setting of self
discontinuing home Flovent and acquiring URI. Improved with 60mg
prednisone daily and duoneb treatments inpatient. Discharged on
steroid taper of 40mg pred daily x 4 days, 20 mg daily x 4 days,
off. On RA by discharge. Discharged on her home regimen of
fluticasone inhaler and PRN albuterol inhaler. In the future she
may be a candidate for a ___.
#Hypotension: Improved with IV fluids and holding home
antihypertensives, without other interventions. Ruled out
cardiogenic shock, hemorrhagic shock. Unlikely sepsis as
improved without ABX and was not clinically toxic. Was
normotensive ___ after IVF and off home antihypertensives,
so discharged holding lisinopril and clonidine until PCP ___.
#Restless leg syndrome, insomnia: Was on home Seroquel 600mg
qHS. Had stopped all home medications several weeks prior to
admission. Restarted Seroquel slowly, starting at 50mg qHS and
increasing by 100mg daily.
#Depression: Had stopped all medications several weeks prior to
admission. Was on home vortioxetine, which was not on formulary.
No SSRI was restarted this admission.
#Anemia: Iron studies showing mild iron deficiency. PO iron was
started. Repeat CBC to be checked at ___ appointment to trend. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Leg swelling, diarrhea, fever
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Mr. ___ is a ___ yo M with a PMHx
of intermittent asthma, Syphilis and PCN allergy who presents
with 24 hours of LLE pain, swelling and diarrhea.
Patient lives in ___ but is here for the next year on
sabbatical. He arrived from ___ on ___ and was in normal
state of health until ___ where he describes waking up with
significant LLE swelling and painful rash as well as diarrhea.
Pain is ___ but worse with standing. He denies any trauma to
the
leg recently but has had an area of itching and breaking skin on
his posteromedial calf for at least a few weeks and suffers from
mild athlete's foot at baseline. He had 5 watery, explosive
stools on ___ as well, non-bloody, non-purulent.
He has hx of syphilis treated with non-penicillin abx in ___. He
also has had unprotected sex with men, most recently 10 days
ago.
He tested negative for HIV in ___. He has taken acetaminophen
and
cough drops for his symptoms which he thinks has helped.
In ED initial vitals were temp 98.4 Tm 102.9 HR 120 BP 155/101
RR
20 96% RA
Exam notable for: no wheezing with auscultation, tachycardic
LLE with erythema and edema of right lower leg with erythematous
petechial rash over anterior and posterior lower leg.
Labs showed: WBC 12.5 Cr 1.3
CTA (given tachycardia and leg swelling): No evidence of
pulmonary embolism or acute aortic abnormality.
___: No evidence of deep venous thrombosis in the left lower
extremity veins.
CXR: Patchy left base opacity most likely atelectasis, but
pneumonia is not excluded in the appropriate clinical setting.
Received:
___ 21:38 PO Acetaminophen 1000 mg ___
___ 21:38 IVF NS ___ Started
___ 23:25 IV Vancomycin ___ Started
___ 23:25 IVF NS 1000 mL ___ Stopped (1h ___
___ 23:25 IVF NS 1000 mL ___
___ 23:55 PO Ibuprofen 600 mg ___
___ 00:25 IV Vancomycin 1000 mg ___ Stopped (1h
___
___ 00:48 IV Levofloxacin 750 mg ___
Transfer VS were: Temp 98.0 HR 95 BP 117/79 RR 18 SaO2 99% RA
On arrival to the floor, patient reports the above history. He
continues to have ___ LL pain. Last BM was morning of ___,
diarrhea has slowed down. Denies SOB, cough, sputum production,
HA, visual
Past Medical History:
- Tonsillitis s/p tonsillectomy.
- Intermittent asthma, not currently on rescue inhaler
- Syphilis earlier this year. Thinks "it was caught early."
Prescribed a non-penicillin antibiotic for 28 days in ___
Social History:
___
Family History:
Grandfather with prostate cancer. DM
grandmother. ___ are healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.6 BP 153/86 HR 88 RR 18 94%Ra
GENERAL: Well appearing overweight gentleman NAD. AAOx3.
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: LLE with erythematous rash, TTP, edema. Macerated
tissue between digits LLE consistent with mild tinea pedis
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:
VITALS: 98.9 ___
GENERAL: Well appearing, NAD. AAOx3.
HEENT: Normocephalic, atraumatic.
HEART: Regular rate & rhythm. No murmurs.
LUNGS: CTAB
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: LLE with warm, erythematous rash spanning anterior
shin and extending around leg with moderately defined borders.
Erythema is expanding beyond lines drawn. Mild 1+ pitting edema
of LLE spreading to dorsum of foot. Tender, enlarged left
inguinal LN
Pertinent Results:
ADMISSION LABS:
___ 09:15PM BLOOD WBC-12.5* RBC-4.99 Hgb-14.6 Hct-43.8
MCV-88 MCH-29.3 MCHC-33.3 RDW-13.9 RDWSD-45.1 Plt ___
___ 09:15PM BLOOD Neuts-79.5* Lymphs-13.3* Monos-6.1
Eos-0.2* Baso-0.2 Im ___ AbsNeut-9.90* AbsLymp-1.65
AbsMono-0.76 AbsEos-0.02* AbsBaso-0.03
___ 09:15PM BLOOD Plt ___
___ 09:15PM BLOOD Glucose-123* UreaN-17 Creat-1.3* Na-138
K-4.1 Cl-98 HCO3-23 AnGap-17*
___ 07:15AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9
___ 09:26PM BLOOD Lactate-1.9
PERTINENT LABS:
___ 08:00PM BLOOD HIV1 VL-NOT DETECT
DISCHARGE LABS:
___ 05:42AM BLOOD WBC-10.5* RBC-4.64 Hgb-13.7 Hct-41.7
MCV-90 MCH-29.5 MCHC-32.9 RDW-13.8 RDWSD-44.8 Plt ___
___ 05:42AM BLOOD Plt ___
___ 05:42AM BLOOD Glucose-93 UreaN-16 Creat-1.0 Na-139
K-4.6 Cl-101 HCO3-23 AnGap-15
___ 05:42AM BLOOD Calcium-9.4 Phos-4.9* Mg-2.1
MICRO:
__________________________________________________________
___ 7:53 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
__________________________________________________________
___ 7:53 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
__________________________________________________________
___ 7:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 2:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:00 am BLOOD CULTURE #1.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 7:15 am SEROLOGY/BLOOD
**FINAL REPORT ___
RPR w/check for Prozone (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
__________________________________________________________
___ 1:50 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 11:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
BACILLUS SPECIES; NOT ANTHRACIS.
Isolated from only one set in the previous five days.
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___
AT 0230.
GRAM POSITIVE ROD(S).
IMAGING:
___ Imaging UNILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ Imaging CHEST (PA & LAT)
Patchy left base opacity most likely atelectasis, but pneumonia
is not
excluded in the appropriate clinical setting.
___ Imaging CTA CHEST
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Hepatic steatosis.
___ Imaging CT LOWER EXT W/C LEFT
1. No evidence of subcutaneous tissue gas. No bony destruction.
2. No fluid collection. Edema interdigitating within the
epifascial
subcutaneous fat, worst in the medial aspect of the left foot is
nonspecific,
could represent a mild cellulitis.
3. No acute fracture or dislocation.
___ Imaging CHEST PORT. LINE PLACEM
Compared to chest radiographs ___.
Mild pulmonary vascular congestion and mediastinal venous
engorgement are new.
Even though heart size is normal this could be early cardiac
decompensation.
No pleural effusion or pneumothorax. No evidence of central
lymph node
enlargement.
New right PIC line ends in the low SVC.
___ Cardiovascular ECHO
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. No mass or vegetation is seen on the
mitral valve. The estimated pulmonary artery systolic pressure
is normal. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with SOB, DOE, leg swelling, recent travel// r/o PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 9.1 mGy (Body) DLP = 4.6
mGy-cm.
2) Spiral Acquisition 4.0 s, 31.6 cm; CTDIvol = 14.7 mGy (Body) DLP = 463.8
mGy-cm.
Total DLP (Body) = 468 mGy-cm.
COMPARISON: Chest radiographs ___
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: There is mild-to-moderate streaky bibasilar atelectasis. 4 mm
right ___ fissural triangular opacity likely represents intrapulmonary lymph
tissue. Lungs are otherwise 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 demonstrates hepatic
steatosis.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Hepatic steatosis.
Radiology Report
EXAMINATION: CT left lower extremity
INDICATION: ___ year old man with painful LLE rash, positive BCx//
subcutaneous gas?
TECHNIQUE: MD CT axial images of the left lower extremity were obtained from
above the knee to the foot after administration of intravenous contrast. Soft
tissue and bone algorithm were obtained with coronal and sagittal reformats
and reviewed on PACs.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.7 s, 58.4 cm; CTDIvol = 10.2 mGy (Body) DLP = 595.7
mGy-cm.
Total DLP (Body) = 596 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of subcutaneous tissue gas. Epifascial layer edema,
interdigitating within the subcutaneous fat is noted, worst in the medial
aspect of left foot/ankle. No focal fluid collection is seen. However, there
is no significant skin thickening overlying the areas of subcutaneous edema.
Hazy appearance of 1 of the deep branches of the greater saphenous vein near
the medial malleolus may be secondary to surrounding edema, though
inflammatory reaction around the venule more likely (301:171). There is no
gross evidence of arterial or venous occlusion.
There is moderate degenerative changes in the lateral femoral condyle with
subcondylar sclerosis and cystic changes. There is no evidence of acute
fracture or dislocation. Well corticated ossicle above the tibial tuberosity
may be related to prior injury. Mild enthesophytes are seen in the superior
and inferior patella. Well corticated lucency in the posterior calcaneus may
also be related to degenerative changes, though nonspecific (303:47). There
is no bony destruction. There is no suspicious focal bone lesion.
The muscle bulk is unremarkable. The muscle enhancement is within normal
limits. Evaluation for tendons and ligaments are limited on the current
modality, though overall grossly unremarkable.
IMPRESSION:
1. No evidence of subcutaneous tissue gas. No bony destruction.
2. No fluid collection. Edema interdigitating within the epifascial
subcutaneous fat, worst in the medial aspect of the left foot is nonspecific,
could represent a mild cellulitis.
3. No acute fracture or dislocation.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new line// new right PICC 49 cm ___
___ Contact name: ___: ___ new right PICC 49 cm ___
___
IMPRESSION:
Compared to chest radiographs ___ one.
Mild pulmonary vascular congestion and mediastinal venous engorgement are new.
Even though heart size is normal this could be early cardiac decompensation.
No pleural effusion or pneumothorax. No evidence of central lymph node
enlargement.
New right PIC line ends in the low SVC.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Diarrhea, L Leg swelling
Diagnosed with Cellulitis of left lower limb
temperature: 98.4
heartrate: 120.0
resprate: 20.0
o2sat: 96.0
sbp: 155.0
dbp: 101.0
level of pain: 6
level of acuity: 3.0 | ___ male with PMHx of treated Syhphilis presenting for
LLE rash with associated fevers and diarrhea as well as LLE
rash, with BCx notable for Bacillus in ___ anaerobic bottles.
#LLE rash
Most likely infectious etiology, i.e. cellulitis given
intermittent fevers and positive BCx for Bacillus (not
anthracis). Infectious disease thought that cellulitis and
bacteremia were two seperate processes but possible that
bacteremia seeding his leg leading to cellulitis. Given concern
for deep tissue
infection/necrosis, CT-leg completed ___ which showed no
evidence of gas. Surgery saw the patient and do not think it is
was nec fasc. TTE negative for valvular vegetations. Patient
received vancomycin and levofloxacin (due to concern for Vibrio
as patient from ___ on admission. Levofloxacin was then
d/ced. Due to persistent fevers, high risk sexual history,
petechial regions of the rash inconsistent with cellulitis, and
the prior hx of syphillis, there was concern for a more
insidious process. Therefore, patient broaded to vancomycin,
meropenem, clindamycin, and doxycycline per ID's
recommendations. However, when bacilus grew in the blood, Abx
titrated down to only vancomycin. Pt needed a PICC line ___
given IV access, which was dc'd prior to discharge. On ___, pt
transitioned to linezolid ___ mg PO/NG Q12H until ___ (two
week course) for coverage of bacillus, staph, and strep. Given
patient's documented antibiotic allergy, unclear source of his
infection, potential for multi-organism infection and potential
for more than one infectious process, the decision was made to
provide broad coverage with linezolid per discussion with
Infectious Disease service. ___, ANCA, Gc/C, RPR, and HIV
negative. CRP 136 so evidence of inflammation but CK WNL. ESR
nml. HIV VL undetectable on discharge.
#bloodstream infection, Bacillus non anthracis sps.
Most likely due to either cellulitis (discussed above) in
setting of LLE rash vs. GI source vs. blood culture contaminant.
Treatment as above. TTE ___ was negative for vegetations. ID
recommended treatment as above.
#Congestion on CXR: Pt with mild pulmonary vascular congestion
on CXR ___ and with persistent cough; thought to be secondary
to volume overload in the setting of receiving fluids this
hospitalization. Pt given 20mg IV Lasix ___ and responded
well. Pt had EF >55% on TTE, which was done to r/o endocarditis.
Asthma felt to be unlikely.
#diarrhea: multiple episodes diarrhea. C. diff negative. Likely
___ to infeciton vs. antibiotics. Stool studies (including
salmonella/Yersinia/shigella and vibrio were negative. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal distension, peripheral edema
Major Surgical or Invasive Procedure:
Paracentesis - ___
History of Present Illness:
___ yo M with history of ETOH cirrhosis c/b by varices with prior
GI bleed, ascites, HE, also with history of protein C and
Antithrombin III deficiencies with prior DVT/PE though not on
anticoagulation, who presents with lower extremity edema and a
one-month history of vomiting.
Patient's history is significant for a recent hospitalization
___ for hematemesis. EGD performed showed non-bleeding
medium-sized varices that were indeed banded. During
hospitalization patient's home Lasix was discontinued due to
hypotension; spironolactone was halved to 50mg a day on
discharge. MELD-Na 28 on discharge.
He says since discharge he has continued have nausea, vomiting
about once a day. This comes about randomly and is not
associated with any particular movements, foods, or
environments. No hematemesis since discharge. Over the past few
days he has noticed increased swelling of lower extremities and
abdomen. He presented to HCA today for a PCP visit, but
apparently on arrival he looked quite ill so was sent to ED
instead.
In the ED, initial vitals were 97.5 78 98/62 12 100% RA.
Labs were notable for negative SBP. AST 190 ALT 48 AP 216 Tbili
7.3 Alb 2 Lip 88. Na of 125. Negative trops. Lactate 2.6. UA
negative. D-Dimer positive.
Past Medical History:
ETOH cirrhosis c/b varices (prior bleed, prior banding most
recently ___, ascites, and HE
Bilateral DVTs ___
PE ___
Protein C deficiency
Antithrombin deficiency
Alcohol dependence
Social History:
___
Family History:
Father CAD in his late ___
No history of blood clots, autoimmune diseases, or cancer. No
history of cirrhosis or GI bleeding
Physical Exam:
ADMISSION EXAM
==============
VS: 97.9 99/64 85 18 98 Ra
Weight: (admit wt: 67.99 kg)
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT: + scleral icterus
HEART: RRR, normal S1/S2, no murmurs rubs or gallops.
LUNGS: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: distended, umbilical hernia present, prior
paracentesis site CDI
EXTREMITIES: 2+ pitting edema up to knees
SKIN: Without rash.
NEUROLOGIC: no asterixis, able to say days of week backwards
DISCHARGE LABS
==============
VS: T 98.0, BP 101-113/59-71, HR 66-78, RR 18, SpO2 98/RA
General: very thin, lying in bed, NAD.
HEENT: MMM
Neck: no JVP distension
Lung: CTAB, breath sounds diminished at the bases
Card: RRR, S1+S2, no M/R/G
Abd: distended, soft, non-tender. Normoactive bowel sounds.
Reducible umbilical hernia with ascites in hernia sac.
Ext: 1+ pitting edema in feet and ankles up to mid shin
Neuro: oriented x3. No asterixis.
Pertinent Results:
ADMISSION LABS
=============
___ 11:30AM PLT COUNT-70*#
___ 11:30AM NEUTS-69.3 LYMPHS-11.9* MONOS-17.9* EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-4.44 AbsLymp-0.76* AbsMono-1.15*
AbsEos-0.00* AbsBaso-0.02
___ 11:30AM WBC-6.4 RBC-3.07* HGB-10.6* HCT-29.9* MCV-97
MCH-34.5* MCHC-35.5 RDW-18.2* RDWSD-63.3*
___ 11:30AM ASA-NEG ETHANOL-52* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:30AM OSMOLAL-275
___ 11:30AM ___
___ 11:30AM ALBUMIN-2.0*
___ 11:30AM CK-MB-1 proBNP-147*
___ 11:30AM cTropnT-<0.01
___ 11:30AM LIPASE-88*
___ 11:30AM ALT(SGPT)-48* AST(SGOT)-190* CK(CPK)-124 ALK
PHOS-216* TOT BILI-7.3*
___ 11:30AM estGFR-Using this
___ 11:55AM HGB-11.0* calcHCT-33
___ 11:55AM LACTATE-2.6* NA+-129* K+-3.7 CL--89* TCO2-30
___ 12:33PM ___ PTT-46.3* ___
___ 12:54PM ASCITES TNC-188* RBC-713* POLYS-1* LYMPHS-23*
MONOS-13* MESOTHELI-3* MACROPHAG-60*
___ 12:54PM ASCITES TNC-188* RBC-713* POLYS-1* LYMPHS-23*
MONOS-13* MESOTHELI-3* MACROPHAG-60*
___ 01:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
___ 01:45PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 01:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 01:45PM URINE OSMOLAL-188
___ 01:45PM URINE HOURS-RANDOM CREAT-41 SODIUM-21
POTASSIUM-21 CHLORIDE-23
___ 09:25PM ETHANOL-NEG
___ 09:25PM MAGNESIUM-1.6
___ 09:25PM UREA N-6 CREAT-0.7 SODIUM-130* POTASSIUM-2.6*
CHLORIDE-90* TOTAL CO2-27 ANION GAP-16
MICRO
=====
__________________________________________________________
___ 4:24 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
Fluid Culture in Bottles (Pending):
__________________________________________________________
___ 4:24 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 1:45 pm URINE SOURCE: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 11:53 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:54 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 11:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
DISCHARGE LABS
=============
___ 04:59AM BLOOD WBC-6.4 RBC-2.70* Hgb-9.6* Hct-27.1*
MCV-100* MCH-35.6* MCHC-35.4 RDW-19.0* RDWSD-67.9* Plt Ct-40*
___ 04:59AM BLOOD Plt Ct-40*
___ 04:59AM BLOOD ___ PTT-67.9* ___
___ 12:43PM BLOOD Glucose-122* UreaN-7 Creat-0.5 Na-133
K-3.6 Cl-97 HCO3-28 AnGap-12
___ 04:59AM BLOOD ALT-21 AST-62* AlkPhos-130 TotBili-7.2*
___ 12:43PM BLOOD Calcium-8.3* Phos-3.0 Mg-1.6
IMAGING/STUDIES
==============
___ (PA & LAT)
No acute cardiopulmonary process.
___ OR GALLBLADDER US
1. Cirrhotic liver, without evidence of focal lesion, and
sequelae of portal
hypertension including splenomegaly, moderate ascites, and
edematous
gallbladder wall.
2. Patent hepatic vasculature.
___ CHEST
1. No evidence of pulmonary embolism or aortic abnormality.
2. Large volume ascites.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Nadolol 10 mg PO BID
3. Pantoprazole 40 mg PO Q12H
4. Thiamine 100 mg PO DAILY
5. Spironolactone 50 mg PO DAILY
6. Sucralfate 1 gm PO BID
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg One tablet(s) by mouth Once a day Disp #*60
Tablet Refills:*0
2. TraMADol 50 mg PO Q6H:PRN Pain - Severe
RX *tramadol 50 mg One tablet(s) by mouth Once every 6 (six)
hours Disp #*5 Tablet Refills:*0
3. Multivitamins 1 TAB PO DAILY
4. Nadolol 10 mg PO BID
5. Pantoprazole 40 mg PO Q12H
6. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg One tablet(s) by mouth Once a day Disp
#*60 Tablet Refills:*0
7. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Worsening ascites due to insufficient diuresis
Alcoholic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with rales,// ? Pneumonia, pulmonary edema
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are clear without consolidation, effusion, or edema. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with increasing jaundice and distension// ? Portal vein
thrombosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound from ___
FINDINGS:
LIVER: The hepatic parenchyma appears coarsened. 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 moderate ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There is no evidence of stones with an edematous gallbladder wall
secondary to third spacing.
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 12.2 cm.
KIDNEYS: The right kidney measures 11.6 cm. The left kidney measures 11.9 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, without evidence of focal lesion, and sequelae of portal
hypertension including splenomegaly, moderate ascites, and edematous
gallbladder wall.
2. Patent hepatic vasculature.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with elevated d dimer// ? 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 2.0 s, 0.5 cm; CTDIvol = 6.1 mGy (Body) DLP = 3.0
mGy-cm.
2) Spiral Acquisition 3.9 s, 30.6 cm; CTDIvol = 8.9 mGy (Body) DLP = 272.8
mGy-cm.
Total DLP (Body) = 276 mGy-cm.
COMPARISON: CT 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. Prominence of the soft
tissues adjacent to the distal esophagus is likely due to varices, not well
assessed due to contrast phase of the exam.
PLEURAL SPACES: There is minimal fluid along the right major fissure. There
is no pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. Mild areas of atelectasis at the right lung base. Stable 3 mm
left apical nodule (03:33). Central airways are patent. There is some
bronchial wall thickening and mucous plugging, particularly at the right lung
base.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen demonstrates large volume
ascites and a shrunken nodular liver.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Chronic anterolateral left fourth rib fractures noted. Old anterior right
fourth and fifth rib fractures are noted. There is mild bilateral
gynecomastia.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Large volume ascites.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ yo M with history of ETOH cirrhosis c/b by varices with prior
GI bleed, ascites, HE, also with history of protein C and Antithrombin III
deficiencies with prior DVT/PE though not on anticoagulation, who presents
with lower extremity edema, right leg is larger than left. // any evidence of
clot
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: Bilateral leg ultrasound ___
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow is demonstrated in
the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Abdominal distention, Jaundice, Leg swelling
Diagnosed with Dyspnea, unspecified, Fluid overload, unspecified
temperature: 97.5
heartrate: 78.0
resprate: 12.0
o2sat: 100.0
sbp: 98.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | ___ with EtOH cirrhosis, Childs class C, complicated by ascites,
esophageal varices with history of bleeding s/p banding in
___, and hepatic encephalopathy, as well as a history of
DVT/PE caused by protein c and antithrombin III deficiency (not
on anticoagulation because of bleeding varices in the past). He
presented from PCP office with abdominal distension, peripheral
edema, and nausea.
#ASCITES:
#PERIPHERAL EDEMA: ___ edema and increased ascites from prior.
History of ascites in the past. Recent decrease in diuretic
regimen is likely cause of hypervolemia, with alcohol use
potentially contributing. Initially, ___ edema appears
asymmetrical and patient had h/o DVT, but DVT was ruled out with
Doppler ultrasound. s/p paracentesis on ___, 2L removed, no
evidence of SBP. Ascites and peripheral edema improving with
increased diuretic dose; tolerating the dose from a BP
standpoint. Discharged on 20mg furosemide and 50mg
spironolactone.
#ETOH CIRRHOSIS: currently Childs C, MELD-Na 29. Cirrhosis is
complicated by ascites, esophageal varices with history of
bleeding s/p banding in ___, and hepatic encephalopathy.
Initially (on admission) with transaminases elevated above
baseline, though returned to baseline by discharge. Bilirubin
remains mildly elevated beyond baseline (baseline appears ___,
up to 7.2 at discharge). No leukocytosis, blood/urine cultures
drawn with NGTD. No evidence of SBP on diagnostic paracentesis.
RUQ US done, but without Doppler - not sufficient to evaluate
for a clot. Overall, cirrhosis picture was stable this
admission.
#ESOPHAGEAL VARICES: history of bleeding, most recently banded
on ___. No evidence of bleeding this admission. Continued
nadolol 10mg BID.
#HYPONATREMIA: 125 on admission, up to 135 gradually after
albumin. Likely in the setting of intravascular depletion with
total body volume overload. See above for diuresis.
#ALOHOL USE: no history of withdrawal seizures, no active
symptoms at this time. Last drink evening of ___. Did not
score on CIWA. No evidence of withdrawal this admission. Social
work again consulted for assistance with substance abuse
programs but patient is not interested.
#HEADACHE: reports of headache beginning 1 day after admission.
This happened during previous admission, as well. Reports that
lorazepam is the only medication that works to treat it.
Associated HA with withdrawal, despite no other evidence of
clinical withdrawal from alcohol. Discharged with 5 tabs of
tramadol and instructions to follow-up with PCP.
#NAUSEA/VOMITING: duration >1 month. Potentially due to ascites,
marijuana use. QTc 505 on admission. Persisted throughout
admission, but no episodes of vomiting.
#AT3 vs Protein C deficiency with H/O OF DVT/PE: not on
anticoagulation d/t GIB in ___. Would likely consider
anticoagulation if esophageal varices can be eradicated.
TRANSITIONAL ISSUES
===================
[ ] needs chemistry panel performed in one week (at ___ PCP
___
[ ] diuretics on discharge: 50mg spironolactone, 20mg furosemide
[ ] discharge weight: 69.13kg, 152.4lbs
[ ] may consider up-titration of diuretics as outpatient - next
step would be 40mg furosemide and 100mg spironolactone (can be
done by primary care physician)
[ ] ALCOHOL RELAPSE PREVENTION: pt given contact info for
Adcare, which takes his insurance. Please continue to encourage
patient to partake in relapse prevention, though he is still
pre-contemplative in regards to EtOH cessation.
[ ] VARICES: banded on ___, will need repeat banding in ___
weeks (second half of ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Lactose / Penicillins / adhesive tape / sulfabenzamide / soy /
Wellbutrin / Bactrim / balsam ___ / prednisone /
Norethindrone-Ethinyl Estrad / Norethindrone-Ethinyl Estrad /
Phenylenediamine / latex
Attending: ___.
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
Past Medical History:
Past Medical History:
1. Hypertension.
2. Asthma with a history of steroid use.
3. Gastroesophageal reflux, which is occasional only when she
is on prednisone. She does take omeprazole, which resolves
her symptoms.
4. Osteoarthritis.
5. Chronic low back pain.
6. Hyperlipidemia.
7. Allergic rhinitis.
8. Amblyopia with decreased vision in her left eye.
9. Dyslexia.
10. Hypercalcemia.
11. Hyperuricemia.
12. Fatty liver based on ultrasound.
13. History of H. pylori status post treatment.
14. History of ankle stress fracture.
15. Lipoma.
Past Surgical History:
1. Thymectomy for thymoma in ___.
2. Left oophorectomy in ___.
3. Ovarian cyst surgery in ___ and ___.
4. Appendectomy in ___.
5. Tonsillectomy in ___.
Social History:
___
Family History:
Her family history is noted for lung CA in father; diabetes,
hypertension, CVA and dementia in her mother; sister with
uterine CA.
Pertinent Results:
LABS:
___ 07:01AM BLOOD WBC-7.7 RBC-3.89* Hgb-12.0 Hct-36.2
MCV-93 MCH-31.0 MCHC-33.3 RDW-13.5 Plt ___ Plt ___
Glucose-95 UreaN-6 Creat-0.5 Na-144 K-3.3 Cl-106 HCO3-27
AnGap-14 Calcium-9.1 Phos-3.2 Mg-1.8
___ 03:45PM BLOOD WBC-5.9 RBC-3.98* Hgb-12.8 Hct-37.0
MCV-93 MCH-32.2* MCHC-34.6 RDW-13.2 Plt ___ Neuts-71* Bands-0
Lymphs-17* Monos-12* Eos-0 Baso-0 ___ Myelos-0
___ 03:45PM BLOOD Glucose-117* UreaN-7 Creat-0.5 Na-142
K-3.2* Cl-100 HCO3-30 AnGap-15 03:50PM BLOOD ___ PTT-28.4
___ ___ 03:45PM BLOOD Calcium-9.6 Phos-2.6* Mg-2.0
IMAGING:
___:
ABDOMEN (SUPINE & ERECT)
IMPRESSION: No evidence of obstruction or free air.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Glucosamine Chondroitin MaxStr *NF*
(glucosamine-chondroit-vit C-Mn) 0 Tablets ORAL DAILY
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Docusate Sodium (Liquid) 100 mg PO BID
6. OxycoDONE-Acetaminophen Elixir ___ mL PO Q4H:PRN pain
7. Valsartan 160 mg PO DAILY
please crush
8. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
9. Allegra Allergy *NF* (fexofenadine) 180 mg Oral Daily
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
3. Allegra Allergy *NF* (fexofenadine) 180 mg Oral Daily
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Glucosamine Chondroitin MaxStr *NF*
(glucosamine-chondroit-vit C-Mn) 0 Tablets ORAL DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Valsartan 160 mg PO DAILY
please crush
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea and vomiting
Dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with recent gastric sleeve surgery, presents
with abdominal pain, question perforation, free air, fluid collection or
obstruction.
COMPARISON: Upper GI small bowel follow-through from ___.
TECHNIQUE: Upright and supine views of the abdomen provided.
FINDINGS: There is no evidence of obstruction or free air. There is
high-density contrast material within the colon from recent barium study.
Clips are seen in the left upper quadrant consistent with recent sleeve
gastrectomy. Osseous structures are unremarkable.
IMPRESSION: No evidence of obstruction or free air.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: S/P GASTRIC SLEEVE
Diagnosed with NAUSEA, DEHYDRATION, ABDOMINAL PAIN OTHER SPECIED, BARIATRIC SURGERY STATUS
temperature: 98.1
heartrate: 78.0
resprate: 20.0
o2sat: 98.0
sbp: 123.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | The patient presented to the ___ ED on ___. Patient was
evaluated by physical exam and given IV medications for nausea
as well as IV fluids for resuscitation. An abdominal xray was
ordered, which did not show signs of abdominal free air or a
contrast leak. Patient was then admitted to the ___ surgery
service for further management.
Neurological: Patient was admitted with no neurological
complaints. Her pain was managed with tylenol. She will be given
a prescription for liquid tylenol upon discharge.
Cardiovascular: There were no cardiovascular issues managed
during this hospitalization. The patient's blood pressure and
heart rate were monitored and were within normal limits. Patient
will continue her home anti-hypertensives upon discharge from
the hospital.
Gastrointestinal: The patient was given IV promethazine for
relief of her nausea with good effect. She will be given a
prescription for this medication upon discharge. Patient also
received IV pantoprazole for GI prophylaxis.
Urogynecological: There were no issues during this admission.
Respiratory: There were no issues during this hospitalization.
F/E/N: Patient was kept NPO during her first night of this
hospitalization to allow resolution of her GI complaints. She
was then advanced to a stage 1 bariatric diet the following
morning without incident. She was given IV fluids in the
emergency department and a banana bag on the floor for fluid
resuscitation. Her basic metabolic panel was within normal
limits.
Prophylaxis: Patient was given subcutaneous heparin and venodyne
compression stockings during this hospitalization.
After these interventions, the patient was stable for discharge
home and will follow up with Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Xanax
Attending: ___
Chief Complaint:
Pneumonia, Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Female who pesents with 1 day of cough, fever,
arthralgias, nausea, dysuria who presents with fever of 102,
tachycardia, lethargy found with pneumonia on imaging. Per the
patient she has a history of frequent pneumonias. In the ED she
was found to be markedly lethargic, barely rousable per the ED
notes (she has no memory of all this, and fell apparently per
nursing, although the physician ___ does not mention this).
In the ED initial vitals were 102.1, 120, 121/64, 20, 97%. She
was given 3L of IV fluids, along with ceftriaxone and
azythromycin for CAP. After the fluid boluses she felt dyspneic
and nauseaus.
On arrival to the floor she is much improved, and is not
lethargic at all, although still feels ill. She afebrile at this
time after acetaminophen administration.
Past Medical History:
-Hodgkin's disease IV age ___, s/p ABVD, s/p autoSCT
-Hypertension
-AV block II-III: s/p PPM ___
-Hypothyroidism
-Adrenal adenoma
-Constipation
-CKD (chronic kidney disease), stage III
-Asthma
-Primary ovarian failure
-Immunoglobulin deficiency
-Osteoarthritis
-Obesity
-Pulmonary nodule
-Chronic pain
-IgA nephropathy
-Hyperlipidemia
-Glomus tumor R index finger s/p excision 8d ago
-Hx recurrent PNAs and URIs until ___, has required 7d
admission w/3 unusual organisms isolated (___)
Social History:
___
Family History:
Mother passed away from unknown type of cancer
Physical Exam:
ROS:
GEN: + fevers, + Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: + Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: + Dyspnea, + Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: + Myalgia, + Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 99.3, 116/7, 93, 18, 96%
GEN: NAD, sleepy but fully conversant
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, ___ HSM
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Motor ___ ___ flex/ext/finger spread
On disharge afebrile, lungs remain CTA
Pertinent Results:
___ 12:02PM BLOOD WBC-16.3*# RBC-3.86* Hgb-12.8 Hct-37.9
MCV-98 MCH-33.2* MCHC-33.9 RDW-13.3 Plt ___
___ 12:02PM BLOOD Neuts-89.3* Lymphs-7.8* Monos-2.0 Eos-0.8
Baso-0.1
___ 12:02PM BLOOD Glucose-96 UreaN-29* Creat-1.0 Na-143
K-3.7 Cl-107 HCO3-26 AnGap-14
___ 12:02PM BLOOD HCG-<5
___ 12:07PM BLOOD Lactate-1.7
___ 06:02AM BLOOD WBC-20.7* RBC-3.54* Hgb-11.8* Hct-35.0*
MCV-99* MCH-33.2* MCHC-33.6 RDW-13.2 Plt ___
___ 06:35AM BLOOD WBC-13.4* RBC-3.37* Hgb-11.4* Hct-32.8*
MCV-97 MCH-33.7* MCHC-34.7 RDW-13.8 Plt ___
___ 06:02AM BLOOD Glucose-87 UreaN-19 Creat-1.1 Na-143
K-4.2 Cl-105 HCO3-30 AnGap-12
CHEST (PA & LAT) Study Date of ___ 5:18 ___
IMPRESSION:
Vague opacity in the right mid to lower lung is concerning for
pneumonia.
Blood cultures from ___: NGTD
Urine culture pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
3. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN sore throat
4. Citalopram 20 mg PO DAILY
5. TraZODone 150 mg PO QHS
6. Omeprazole 20 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Simvastatin 20 mg PO QPM
9. DiCYCLOmine 10 mg PO DAILY:PRN spasm
10. Gabapentin 600 mg PO TID
11. Lorazepam 1 mg PO QHS:PRN insomnia
12. Lorazepam 2 mg PO DAILY:PRN anxiety
13. diclofenac sodium 1 % topical BID
14. budesonide-formoterol 160-4.5 mcg/actuation inhalation 2
Puff Daily
15. Ibuprofen 400 mg PO Q8H:PRN pain
16. Levothyroxine Sodium 125 mcg PO DAILY
17. olopatadine 0.1 % ophthalmic BID
18. Prochlorperazine 5 mg PO Q8H:PRN nausea
19. BuPROPion (Sustained Release) 300 mg PO QAM
20. Multivitamins 1 TAB PO DAILY
21. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. Citalopram 20 mg PO DAILY
4. diclofenac sodium 1 % TOPICAL BID
5. DiCYCLOmine 10 mg PO DAILY:PRN spasm
6. Ferrous Sulfate 325 mg PO DAILY
7. Gabapentin 600 mg PO TID
8. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN sore throat
9. Ibuprofen 400 mg PO Q8H:PRN pain
10. Levothyroxine Sodium 125 mcg PO DAILY
11. Lisinopril 40 mg PO DAILY
12. Lorazepam 1 mg PO QHS:PRN insomnia
13. Lorazepam 2 mg PO DAILY:PRN anxiety
14. Multivitamins 1 TAB PO DAILY
15. olopatadine 0.1 % ophthalmic BID
16. Omeprazole 20 mg PO DAILY
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Prochlorperazine 5 mg PO Q8H:PRN nausea
19. Simvastatin 20 mg PO QPM
20. TraZODone 150 mg PO QHS
21. Levofloxacin 500 mg PO DAILY Duration: 4 Days
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth Q24h
Disp #*4 Tablet Refills:*0
Discharge Disposition:
Home
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 (PA AND LAT)
INDICATION: ___ with cough and fever // r/o PNA
COMPARISON: ___.
FINDINGS:
PA and lateral views of the chest provided. Dual lead pacemaker is unchanged
with leads extending to the region the right atrium and right ventricle.
Subtle opacity in the right mid to lower lung is concerning for pneumonia. No
large effusion or pneumothorax is seen. No overt evidence of edema. No
pneumothorax. Cardiomediastinal silhouette appears normal. Bony structures are
intact.
IMPRESSION:
Vague opacity in the right mid to lower lung is concerning for pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, ILI
Diagnosed with FEVER, UNSPECIFIED, OTHER MALAISE AND FATIGUE
temperature: 102.1
heartrate: 120.0
resprate: 20.0
o2sat: 97.0
sbp: 121.0
dbp: 64.0
level of pain: 8
level of acuity: 2.0 | ___ yo women w/ PMHx of Hodgkins disease s/p autologous SCT,
HTN, stage III CKD, IgA nephropathy, immunoglobulin deficiency,
and recurrent pneumonias p/w cough, fever, arthralgias,
headache, found to have right sided pna.
# Bacterial Pneumonia: Patient was initially treated with
Ceftriaxone and Azithromycin given her fever, cough, and
pneumonia on chest X-ray. She remained afebrile with
downtrending white count. She appeared clinically well
throughout her hospitalization. She was switched to levofloxacin
to complete a week long total course of antibiotics. An ECG was
checked and pt's QT was not prolonged so despite being on
citalopram and trazadone, felt as though brief course of
levofloxacin would be relatively low risk. Pt curious as to why
she gets pneumonia so frequently. It appears that she does have
a history of immunoglobulin deficiency and during her last
hospitalization her IgG was mildly low. I advised her to follow
up with immunology. She was given the name of an allergist and
immunologist here ___ or she can follow up at At___.
# Chronic Stable Asthma: Albuterol was continued. Pt should
hold steroid inhaler until pneumonia resolved.
# Hypothyroidism: Patient's home levothyroxine was continue.
# Chronic Pain Syndrome: Gabapentin, Citalopram, and Diclofenac
cream were continued.
# HTN: Lisinopril
# High grade AV block s/p PPM: Recently interrogated. Mostly in
AsVs.
Transitional:
Will need to complete 4 more days of levofloxacin
Will need follow up CXRay in ___ weeks
Will need to see immunology to evaluate for immunodeficiency,
IgG deficiency, etiology of recurrent pnas |
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
Major Surgical or Invasive Procedure:
1. Chest tube placement - right side for his pneumothorax - d/c
on ___
History of Present Illness:
___ year old M adm s/p fall ___ feet from rope swing. +head
strike, +LOC. Pt was admitted ___ and found to have R sided rib
fractures and R small pneumothorax s/p CT placement. Chest tube
now discharged.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
Discharge exam:
Vitals reviewed during discharge exam and WNL
Heart: s1, s2 no m/r/g
Lungs: CTAB
Abdomen: soft, nt, nd. Prior chest tube site healing well, no
erythma or discharge appreciated
Ext: no edema
Pertinent Results:
___ WBC-9.6 RBC-4.37* Hgb-14.1 Hct-41.1 MCV-94 MCH-32.3*
MCHC-34.3 RDW-14.5 Plt ___
___ WBC-7.7 RBC-3.92* Hgb-12.6* Hct-36.5* MCV-93 MCH-32.1*
MCHC-34.5 RDW-14.4 Plt ___
___ ___ PTT-24.8* ___
___ ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ Glucose-87 Lactate-2.9* Na-145 K-4.1 Cl-106 calHCO3-20*
CT head (___)
IMPRESSION:
1. No acute intracranial process.
2. Depressed nasal bone, please correlate for acuity.
CT chest: (___)
IMPRESSION:
1. Right lateral ninth, tenth, and eleventh rib fractures with
associated small right anterior pneumothorax, and air in the
right lateral chest wall. The ninth rib fracture is mildly
displaced, and the tenth and eleventh rib fractures are
nondisplaced.
2. No evidence of solid organ injury in the abdomen or pelvis.
CT C-SPINE W/O CONTRAST (___)
IMPRESSION:
No fracture or traumatic malalignment
CXR ___:
IMPRESSION:
Slight interval increase in the small right pneumothorax.
CRX ___:
IMPRESSION:
No pneumothorax or effusion.
CXR ___:
IMPRESSION:
Status post removal of the right-sided chest tube. There is a 1
cm right
apical lateral pneumothorax without evidence of tension.
Minimal atelectasis at the right lung bases. Unchanged
appearance of the left lung and the heart.
CXR ___
IMPRESSION:
As compared to the previous image, the extent of the known right
pneumothorax is constant. No evidence of tension. Better
apparent than on previous images is a slightly displaced
fracture of the ninth and tenth rib on the right. Normal
appearance of the left lung.
CXR ___
IMPRESSION:
Small right apical pneumothorax, overall unchanged.
Medications on Admission:
not recorded
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
hold for loose stools
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
2. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain
do NOT drive while taking this medication.
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth Q3-6H
Disp #*40 Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM R rib pain
leave on for 12 hours and then remove for 12 hours
RX *lidocaine-menthol [LidoPatch] 4 %-1 % Apply one patch to the
affected area daily Qam Disp #*30 Patch Refills:*0
4. Baclofen 10 mg PO TID
RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp
#*33 Tablet Refills:*0
5. OxyCODONE SR (OxyconTIN) 20 mg PO QAM Duration: 4 Days
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth QAM Disp
#*4 Tablet Refills:*0
6. OxyCODONE SR (OxyconTIN) 10 mg PO QHS Duration: 4 Days
After four days, please take one pill in the morning and one at
night for another week.
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth at bedtime
Disp #*18 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
right-sided rib fractures ___, small right pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: TRAUMA TORSO
INDICATION: ___ with 20-foot fall, right chest and flank pain. Evaluate for
injury.
TECHNIQUE: Contiguous axial MDCT images of the chest abdomen and pelvis were
obtained following the uneventful administration of 130 cc Omnipaque
intravenous contrast. Coronal and sagittal reformations were performed.
DLP: 1150 mGy-cm.
COMPARISON: None
FINDINGS:
CHEST: The thyroid gland is homogeneous. The great vessels of the neck
enhance normally. The heart is normal in size with no pericardial effusion.
There is no axillary, mediastinal, or hilar lymphadenopathy.
Lungs demonstrate moderate dependent bilateral atelectasis with no focal
consolidation or pleural effusion. There are right lateral ninth, tenth, and
eleventh rib fractures with adjacent subcutaneous gas in the right lateral
chest wall (02:56), and a small right anterior pneumothorax. The ninth rib
fracture is mildly displaced, and the tenth and eleventh rib fractures are
nondisplaced. The esophagus follows a normal course and is normal in caliber.
No thoracic spine fractures are seen.
ABDOMEN: The liver is normal in attenuation with no focal hepatic lesions.
The portal and hepatic veins are patent. Gallbladder is within normal limits,
with no stones. The pancreas is normal in attenuation with no duct dilatation
or stranding. Spleen is normal in size and attenuation. The adrenal glands
are morphologically normal bilaterally. The kidneys enhance and excrete
contrast symmetrically. The distal esophagus, stomach, and small bowel are
normal in caliber. Incidentally noted duodenal diverticulum (2:71). The
appendix is normal. The colon is unobstructed with no evidence of colitis.
There is no free fluid in the abdomen.
PELVIS: No free fluid or lymphadenopathy in the pelvis. The bladder,
prostate, and seminal vesicles are normal.
VESSELS: The abdominal aorta demonstrates mild atherosclerotic calcification,
however no aneurysmal dilatation.
OSSEOUS STRUCTURES: Aside from the aforementioned rib fractures, no osseous
injuries detected. Bilateral pars defects are noted at L5-S1, with no
alignment abnormality. Well corticated densities posterior to the left
ischial tuberosity may represent sequela of prior avulsion injury.
IMPRESSION:
1. Right lateral ninth, tenth, and eleventh rib fractures with associated
small right anterior pneumothorax, and air in the right lateral chest wall.
The ninth rib fracture is mildly displaced, and the tenth and eleventh rib
fractures are nondisplaced.
2. No evidence of solid organ injury in the abdomen or pelvis.
NOTIFICATION: The findings were discussed by Dr. ___ with the trauma
team, in person ___ at 4:38 ___, upon discovery of the findings.
Radiology Report
EXAMINATION: PA and lateral chest radiographs
INDICATION: ___ year old man with PTX // interval eval
COMPARISON: Chest radiograph dated ___. CT chest dated ___.
FINDINGS:
A small right pneumothorax persists and was not clearly seen on the prior
radiograph, suggesting interval increase. No evidence of tension. Platelike
atelectasis in the right lower lung is mild. Left infrahilar atelectasis
persists. No focal consolidation, pleural effusion, or pulmonary edema. The
heart size is normal. Multiple right lateral rib fractures are again noted in
better seen on CT. Nonspecific gaseous distension of the imaged bowel without
pneumoperitoneum.
IMPRESSION:
Slight interval increase in the small right pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with right pneumothorax s/p right pigtail
catheter placement // pneumothorax, pigtail placement pneumothorax,
pigtail placement
COMPARISON: Prior chest radiographs ___ and ___ at 10:55.
IMPRESSION:
Right pneumothorax has almost entirely resolved following insertion of a new
pleural drainage catheter. Moderate right basal atelectasis is stable.
Pneumomediastinum may be present. Left lung is clear aside from mild basal
atelectasis. Heart size is normal.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p fall now s/p R chest tube placement // confirm R chest
tube placement confirm R chest tube placement
COMPARISON: Previous chest radiographs ___, most recently 20:37.
IMPRESSION:
There is minimal if any right pneumothorax, and no pleural effusion, following
insertion of a replacement right apical pleural drainage catheter.
Moderate right basal atelectasis has not yet resolved. Left lung is fully
expanded and clear. Heart size is normal.
Radiology Report
EXAMINATION: Portable AP chest radiograph
INDICATION: ___ s/p fall with R rib fx, interval chest tube placement; assess
for interval change // ___ s/p fall with R rib fx, interval chest tube
placement; assess for interval change. please perform at 0600
COMPARISON: Multiple chest radiographs from ___ before and after placement
of the right chest tube.
FINDINGS:
The right chest tube projects over the upper right hemithorax. No
pneumothorax. The lungs are clear. No focal consolidation or pleural
effusion. Elevation of the right hemidiaphragm persists and may suggest some
volume loss. The heart size is normal. Right lateral rib fractures are
incompletely imaged .
IMPRESSION:
No pneumothorax or effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p CT placement for pneumothorax after fall //
eval interval change - chest tube on water seat eval interval change -
chest tube on water seat
COMPARISON: Prior chest radiographs ___.
IMPRESSION:
Left pleural drainage catheter has been withdrawn to the level of the right
third anterior interspace. I cannot be sure it is actually intra thoracic.
Right pneumothorax is tiny. No right pleural effusion. Mild bibasilar
atelectasis, slightly greater on the right, unchanged. Normal
cardiomediastinal and hilar silhouettes.
Radiology Report
EXAMINATION: CHEST (PA, LAT AND OBLIQUES)
INDICATION: ___ year old man s/p fall w pneumothorax s/p CT removal // Please
complete standing end expiratory to eval pneumothorax s/p CT removal
COMPARISON: ___
IMPRESSION:
Status post removal of the right-sided chest tube. There is a 1 cm right
apical lateral pneumothorax without evidence of tension. Minimal atelectasis
at the right lung bases. Unchanged appearance of the left lung and the heart.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p fall w pneumothorax // Please eval inter
change. Complete standing end expiratory
COMPARISON: ___, 22:18
IMPRESSION:
As compared to the previous image, the extent of the known right pneumothorax
is constant. No evidence of tension. Better apparent than on previous images
is a slightly displaced fracture of the ninth and tenth rib on the right.
Normal appearance of the left lung
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p fall w pneumothorax // Please eval interval
change after chest tube removal. Standing end expiratory. Please complete test
at 22pm
COMPARISON: ___, 18:53
IMPRESSION:
As compared to the previous radiograph, there is no substantial change in
appearance of the approximately 1 cm right apical pneumothorax without
evidence of tension.
Radiology Report
EXAMINATION: PA and lateral chest radiograph
INDICATION: ___ year old man w pneumothorax. // Eval interval change Please
standing end expiratory. please complete at 6 am prior to rounds.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The small right apical pneumothorax has not increased in size and is perhaps
minimally decreased from the prior exam. No evidence of tension. The size of
the pneumothorax does not appreciably change with inspiration and expiration.
The lungs are otherwise clear. No focal consolidation, pleural effusion, or
pulmonary edema. The heart is normal in size. The mediastinum is not widened.
Multiple right lateral rib fractures are unchanged.
IMPRESSION:
Small right apical pneumothorax, overall unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ male status post trauma, with pneumothorax.
TECHNIQUE: Portable chest radiograph
COMPARISON: CT of the torso obtained concurrently
FINDINGS:
Aside from bilateral infrahilar opacities likely representing atelectasis,
there is no pleural effusion or focal consolidation. Heart size is within
normal limits given the portable technique. Lung volumes are low. Small
pneumothorax and right lateral rib fractures are better appreciated on the
concurrent CT of the torso.
IMPRESSION:
Traumatic findings of right pneumothorax and right lateral rib fractures are
better seen on the concurrent CT of the torso.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with 20-foot fall, right chest/flank pain.
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: DLP: 891 mGy-cm
CTDI: 40 mGy
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or large mass. The
ventricles and sulci are normal in size and configuration. Compressed nasal
bone is of unclear chronicity. There is moderate mucosal thickening of the
maxillary sinuses and anterior ethmoid air cells bilaterally. The sphenoid
sinuses, frontal sinuses, and mastoid air cells bilaterally are clear. The
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Depressed nasal bone, please correlate for acuity.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with 20-foot fall
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 750 mGy
DLP: 37 mGy-cm
COMPARISON: None
FINDINGS:
Alignment is normal. No fractures are identified. There is no evidence of
spinal canal or neural foraminal narrowing.
IMPRESSION:
No fracture or traumatic malalignment.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: FALL
Diagnosed with FX MULT RIBS NOS-CLOSED, TRAUM PNEUMOTHORAX-CLOSE, FALL-1 LEVEL TO OTH NEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ is a ___ year old M adm s/p fall ___ feet from rope
swing. +head strike, +LOC. Pt was admitted ___ and found to have
R sided rib fractures and R small pneumothorax s/p CT placement.
Chest tube now discharged showing a small apical pneumothorax,
constant over the course of two days s/p CT removal.
Patient main issues during this hospitalization involved:
1. Pain: Patient had a significant amount of pain when he was
lying in bed, but no pain when standing or sitting. Several
attempts of medication/doses were attempted in order to improve
his pain. On HD 6 he was discharge home. By the time of
discharge his pain had improved with a combination of Oxycontin,
Dilaudid, Tylenol, Lidocaine patch and Baclofen. Patient was
discharge home with the following pain meds regimen:
- Oxycontin 20 mg am x 4 days
- Oxycontin 10mg am x 4 days -> Then pt instructed to take
Oxycontin 10mg am/pm for a week.
- Dilaudid 2mg Q3-6h PRN for 5 days. Then pt instructed to take
either OTC tylenol or Advil
- Baclofen 10mg TID for 11 days
- Lidocaine patch
2. R side pneumothorax:
Patient had a chest tube placed as he was noted to have a slight
increase of his right side pneumothorax. His chest tube was
initially put on suction with successful improvement of his
pneumothorax. After his chest tube was removed patient was
noticed to have a small apical pneumothorax, that was closely
observed the next couple of days. His pneumothorax was small and
stable and we felt it was safe to discharge patient home w close
follow up.
On HD 6 patient was discharge home. On discharge he was
tolerating a regular diet, pain was under better control w PO
pain meds, we was ambulating w/o difficult, his chest tube
incision was c/d. Patient will follow up with us in clinic in
the next couple of weeks. Dr. ___ patient to
follow up with oour Nurse ___ in a week but
unfortunately she does not have any availability in the next
couple of weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute mesenteric ischemia
Major Surgical or Invasive Procedure:
___: Thrombolysis of SMA bypass
___: Lysis check
___: Lysis check
History of Present Illness:
We are evaluating this ___ year old female known to our service
with history of chronic mesenteric ischemia with right common
iliac artery to SMA bypass with PTFE in ___ on monoplatelet
therapy with ASA whom is being transferred from outside facility
with clinical and imaging findings concerning for acute
mesenteric ischemia.
.
Her past medical history is notable for hypertension and
hyperlipidemia. She was in her usual state of health until
yesterday morning. Per patient she woke up and developed several
episodes of non-bloody diarrhea. She thought initially this was
related to her underlying IBS so she took 4 mg of Imodium but
did not find any relief. Sometime around 9PM she developed an
acute onset of stabbing pain to her epigatrium associated with
repetitive episodes of NBNB emesis. She presented to the ED at
outside facility with signs of dehydration. Per documentation
the patient was AOx3 on arrival, with VS: BP: 92/60, HR: 106,
RR: 12, O2 sat: 98% room air. Per conversation over the phone
with referring physician her exam was soft, non-peritoneal. Her
labs were notable for leukocytosis of 20.000. She received 2L of
crystalloid. Repeat labs with white count of 15.000. Lactate of
2.4. Imaging with CT abdomen & pelvis concerning for occluded
SMA graft. Patient was referred to ___ for further evaluation.
.
She arrived via EMS to our ED. Upon arrival, patient alert,
oriented. VS: 97.4, 91, 186/61, 14, 96% RA. She has signs of
dehydration. Abdomen is soft, slight tender to left upper
quadrant and lower abdomen with no rebound. Labs here with
leukocytosis to ___. Lactate of 1.9. Imaging from ___
reveals an occluded SMA graft and a severe stenosis of the
celiac axis at its take off. There is evident signs of wall
edema in loops of small bowel in the pelvis and left upper
quadrant. The latter with ___ free fluid.
Past Medical History:
Past Medical History: per HPI. Chronic mesenteric ischemia,
hypertension, hyperlipidemia, IBS.
.
Past Surgical History:
- ___ Right common iliac artery to superior mesenteric
artery bypass with a Distaflo bypass graft
polytetrafluoroethylene (___)
- ___ Abdominal aortogram. SMA catheter placement and
stenting with a balloon expandable 0.518 stent (___)
- ___ redo Right carotid endarterectomy
- ___ Right carotid endarterectomy for asymptomatic disease
Social History:
___
Family History:
NC
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Vitals:
General:
HEENT:
CV:
Pulm:
GI:
Extremities:
Pertinent Results:
ADMISSION LABS:
.
___ 05:36AM BLOOD WBC-17.3* RBC-4.25 Hgb-12.5 Hct-37.7
MCV-89 MCH-29.4 MCHC-33.2 RDW-12.5 RDWSD-40.4 Plt ___
___ 05:36AM BLOOD Neuts-89.9* Lymphs-4.5* Monos-4.6*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-15.52* AbsLymp-0.78*
AbsMono-0.80 AbsEos-0.00* AbsBaso-0.04
___ 07:30AM BLOOD ___ PTT-23.5* ___
___ 05:36AM BLOOD Glucose-175* UreaN-24* Creat-1.0 Na-140
K-5.1 Cl-103 HCO3-18* AnGap-19*
___ 05:36AM BLOOD ALT-30 AST-59* AlkPhos-83 TotBili-0.5
___ 05:36AM BLOOD Albumin-4.1
___ 11:26AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.7
___ 02:20PM BLOOD Lactate-3.0*
.
DISCHARGE LABS:
.
___ 05:20AM BLOOD WBC-16.3* RBC-2.92* Hgb-8.6* Hct-26.9*
MCV-92 MCH-29.5 MCHC-32.0 RDW-15.4 RDWSD-50.3* Plt ___
___ 05:20AM BLOOD Glucose-132* UreaN-11 Creat-0.6 Na-137
K-4.4 Cl-100 HCO3-27 AnGap-10
___ 05:20AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.0
.
KEY IMAGING:
.
___ CTA abdomen and pelvis
IMPRESSION:
1. No evidence of bowel ischemia. No rim-enhancing fluid
collection.
2. Fluid in the right iliacus muscle may be due to evolving
hematoma and/or seroma. Infection is thought to be less likely.
3. Filiform origin of the celiac, but otherwise patent right
CIA-SMA graft and other mesenteric vessels as described above.
4. Distended, fluid-filled loops of small bowel without discrete
transition point.
5. Moderate bilateral nonhemorrhagic pleural effusions and
associated moderate atelectasis.
6. Mild to moderate abdominopelvic ascites.
7. Prominent, fluid-filled endometrial cavity.
.
___ Bilateral lower extremity duplex
IMPRESSION: No evidence of deep venous thrombosis in the right
or left lower extremity veins.
.
___ EGD
Findings: Esophageal hiatal hernia. Normal mucosa in esophagus,
stomach, and duodenum.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. Lisinopril 30 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
4. LORazepam 0.5 mg PO QHS
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day
Disp #*6 Capsule Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM
Place patch on right anterior thigh, remove after 12 hours.
4. LOPERamide 2 mg PO BID:PRN diarrhea
5. Miconazole Powder 2% 1 Appl TP TID:PRN fungal rash
apply to buttocks and abdominal folds
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
decrease frequency and dose as pain level improves
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*12 Tablet Refills:*0
7. Pantoprazole 40 mg PO Q12H
Continue for 30 days
8. Rivaroxaban 15 mg PO BID
continue indefinitaly
9. Aspirin 81 mg PO DAILY
10. Lisinopril 30 mg PO DAILY
11. LORazepam 0.5 mg PO QHS
RX *lorazepam 0.5 mg 1 tablet by mouth at bedtime Disp #*2
Tablet Refills:*0
12. Metoprolol Tartrate 50 mg PO BID
13. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: acute on chronic mesenteric ischemia
Secondary: malnutrition, gastrointestinal bleed, right iliac
hematoma complicated by right lower extremity pain and weakness,
malnutrition
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 SOB// ___ year old woman with SOB
TECHNIQUE: AP portable
COMPARISON: ___
IMPRESSION:
There is mild pulmonary edema with left lower lobe atelectasis. There is
elevation of the right hemidiaphragm and lower volume on the right. There is
mild indentation of the left side of the trachea, being enlargement of the
thyroid the most common cause. There are apical pleural calcifications,
likely degenerative.
Cardiomediastinal and hilar silhouettes are normal. Normal cardiac size.
There is no pleural effusion or pneumothorax.
Radiology Report
EXAMINATION: Chest x-ray
INDICATION: ___ F presenting with occluded R CIA-SMA graft with acute
mesenteric ischemia status post lysis and PTA of the aortic SMA anastomosis.
now with new SOB. Please evaluate for pneumonia, pulmonary edema, pleural
effusion
TECHNIQUE: Portable chest x-ray
COMPARISON: Chest x-ray ___
FINDINGS:
There is pulmonary vascular congestion. There is apical pleural thickening
with calcification. The cardiomediastinal silhouette is normal. There may be
a trace left effusion. The aorta is atherosclerotic
IMPRESSION:
As above
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ F p/w occluded R CIA-SMA graft with acute mesenteric ischemia
s/p lysis and PTA of the aortic SMA anastomosis, now with persistent diarrhea
and leukocytosis// Please evaluate for patency of mesenteric vessels, evidence
of bowel ischemia or infection
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and post-contrast images were
acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.2 s, 51.2 cm; CTDIvol = 3.2 mGy (Body) DLP = 165.3
mGy-cm.
2) Spiral Acquisition 3.9 s, 51.2 cm; CTDIvol = 15.2 mGy (Body) DLP = 779.2
mGy-cm.
Total DLP (Body) = 944 mGy-cm.
COMPARISON: CTA run-off ___
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. The origin of the celiac is filiform,
but there is contrast opacification of the left gastric, common hepatic, and
splenic arteries. The proximal SMA is very attenuated. There is a right
common iliac artery to SMA shunt, which is patent. The SMA is patent
beginning from the insertion of the shunt. The ___, renal and iliac arteries
are patent with no signs of occlusive or aneurysmal disease. The portal system
including SMV, splenic and portal veins is patent. The renal veins, iliac
veins and IVC are patent and demonstrate normal caliber. There is moderate
calcium burden in the abdominal aorta and great abdominal arteries.
LOWER CHEST: Moderate atelectasis is noted in the lung bases. There are
moderate bilateral nonhemorrhagic pleural effusions. There is coronary artery
calcification.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is contains stones, without
evidence of gallbladder wall thickening or pericholecystic fluid.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen 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, concerning renal lesions, or hydronephrosis.
Millimetric hypodensities in the kidneys bilaterally are too small to
characterize. There is no perinephric abnormality.
GASTROINTESTINAL: Hiatal hernia is small. Small bowel loops are fluid-filled
and measure up to 4 cm. There is gradual tapering of the small bowel at the
terminal ileum without discrete transition point. Small bowel loops
demonstrate normal wall thickness and enhancement throughout. No pneumatosis.
Colon and rectum are within normal limits. Appendix is not visualized. There
is no evidence of mesenteric lymphadenopathy.
There is mild to moderate abdominopelvic ascites. No fluid collection.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder contains a catheter tip and some air. The distal
ureters are unremarkable. There is no evidence of pelvic or inguinal
lymphadenopathy.
REPRODUCTIVE ORGANS: The endometrial cavity is prominent and fluid filled.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Abdominal and pelvic wall edema is moderate. There is an
approximately 2.8 x 1.4 x 5 cm fusiform/bilobed area of fluid in the right
iliacus muscle (3:118 and 601:68) measuring approximately 24 ___, without
peripheral enhancement.
IMPRESSION:
1. No evidence of bowel ischemia. No rim-enhancing fluid collection.
2. Fluid in the right iliacus muscle may be due to evolving hematoma and/or
seroma. Infection is thought to be less likely.
3. Filiform origin of the celiac, but otherwise patent right CIA-SMA graft and
other mesenteric vessels as described above.
4. Distended, fluid-filled loops of small bowel without discrete transition
point.
5. Moderate bilateral nonhemorrhagic pleural effusions and associated moderate
atelectasis.
6. Mild to moderate abdominopelvic ascites.
7. Prominent, fluid-filled endometrial cavity.
RECOMMENDATION(S): Non-urgent pelvic ultrasound to evaluate the endometrium.
NOTIFICATION:
1. The finding of the fluid in the right iliacus muscle was communicated to
___, M.D. by ___, M.D. by telephone on ___ at
approximately 18:35.
2. Impression #2 above was discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 19:18.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ F p/w occluded R CIA-SMA graft with acute mesenteric ischemia
s/p lysis and PTA of the aortic SMA anastomosis// please rule out 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 color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ F p/w occluded R CIA-SMA graft with acute mesenteric ischemia
s/p lysis and PTA of the aortic SMA anastomosis// new onset tachypnea ? fluid
status new onset tachypnea ? fluid status
IMPRESSION:
Heart size and mediastinum are stable. Bilateral pleural effusions are
demonstrated, moderate. Bibasal consolidations are noted. No pneumothorax.
Biapical pleural calcifications.
Radiology Report
INDICATION: ___ year old woman with new picc// R picc 41cm Contact name:
sal, ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of a right PICC line projects over the distal SVC. There are small
bilateral pleural effusions, right greater than left, as well as bibasilar
consolidations. No pneumothorax. The size of the cardiac silhouette is
within normal limits.
IMPRESSION:
The tip of a new right PICC line projects over the distal SVC.
Radiology Report
INDICATION: ___ year old woman with occluded SMA graft// eval for effusions,
edema
COMPARISON: CT scan of the abdomen which includes the lung bases from ___
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. There is prominence of
the pulmonary interstitial markings which was not present on the prior
abdominal CT scan from ___. This may represent pulmonary edema; however, the
vascular pedicle is not widened. Follow up to resolution is recommended.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Unspecified abdominal pain
temperature: 97.4
heartrate: 91.0
resprate: 14.0
o2sat: 96.0
sbp: 186.0
dbp: 61.0
level of pain: 1
level of acuity: 2.0 | Ms. ___ presented to ___
on ___ with acute mesenteric ischemia due to occlusion of
her mesenteric bypass graft. The patient was taken to the
endovascular suite and underwent thrombolysis of her mesenteric
bypass graft on ___. 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 intensive care unit for
monitoring. She was then taken back to the endovascular suite on
___ and ___ for lysis checks without complication.
.
Post-lysis, the patient was started on a heparin drip for
anticoagulation. She was kept NPO on IVF given concern for bowel
ischemia. She remained hemodynamically stable and was
transferred to the vascular surgery step down unit on ___. The
remainder of her hospital course is described by system below:
.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV pain
medications and then transitioned to oral pain medications once
tolerating a diet. During her hospital stay, the patient
developed progressive right lower extremity pain and weakness. A
right iliacus hematoma was identified incidentally on a prior
CTA scan, and this was presumed to be the etiology of her pain.
Neurology was consulted to evaluate the patient and they agreed
with our assessment. She was started on low dose gabapentin for
her right lower extremity pain with some improvement. She is
scheduled to follow up in ___ clinic for further
evaluation.
.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. She received IV Lasix for
diuresis as needed throughout her hospital course with
improvement in her pulmonary status. She was breathing
comfortably on room air at the time of discharge.
.
GI/GU/FEN: The patient was initially kept NPO on IVF given
concern for bowel ischemia. She developed guiaic positive
diarrhea during her hospital stay. Gastroenterology was
consulted and she was started on a PPI. She ultimately underwent
upper and lower endoscopy which was negative for any sign of
acute or chronic bleeding. Her diet was advanced sequentially to
a Regular diet, which was well tolerated. She continued to have
diarrhea and was eventually started on loperamide PRN with
improved symptoms. Patient's intake and output were closely
monitored.
.
ID: The patient's fever curves were closely watched for signs of
infection. She remained afebrile, however she had a persistent
leukocytosis which peaked at 31 during her admission. Blood,
urine, and stool cultures were negative. C difficile testing was
negative on 2 occasions. She was continued on antibiotics
throughout her admission, and they were discontinued at the time
of discharge. Her WBC count was 16 at this time.
.
HEME: The patient was anticoagulated on a heparin drip for most
of her admission. Her blood counts were closely monitored for
signs of bleeding. Her hematocrit slowed trended downward and
she received a total of 2 units of pRBCs during her admission.
She ultimately underwent evaluation for GI bleed, which was
negative (as described above). Her hematocrit stabilized. She
was transitioned from heparin to xarelto in preparation for
discharge.
.
Prophylaxis: The patient received systemic anticoagulation
during this stay. She was encouraged to get up and ambulate as
early as possible. She worked with physical therapy on multiple
occasions during her hospital stay.
.
On ___, the patient 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 to rehab, and was given the
appropriate discharge and follow-up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
HPI: Ms. ___ is a ___ yo F who was brought into the ER by
family for acute onset left sided weakness, L facial droop and
dysarthia. Per patient's family she was eating soup this evening
when her daughter noted her left hand to be clumbsy. Patient was
also coughing on soup. When daughter came back into room she
noted patient was slumping towards the left and had difficulty
speaking. She was brought ___ ER about 30 mins after onset of
symptoms. Family report patient is very independent at baseline.
She lives at an assisted living but performs all of her ADLs and
IADLs independently. Upon eval patient reports headache.
Past Medical History:
PMH/PSH: (per daughter at bedside)
BASAL CELL CARCINOMA
HYPERLIPIDEMIA
HYPERTENSION (medication was discontinued as became orthostatic)
LEFT ROTATOR CUFF TENDONITIS
LOW BACK PAIN
OSTEOARTHRITIS
OSTEOPOROSIS
PERIPHERAL VASCULAR DISEASE
S/P OOPHORECTOMY
S/P PARTIAL THYROIDECTOMY
CATARACT
LOWER EXTREMITY EDEMA
Social History:
___
Family History:
Relative Status Age Problem
Mother ___ ___ MYOCARDIAL
INFARCTION
Father ___ ___ CONGESTIVE HEART
FAILURE
Physical Exam:
PHYSICAL EXAMINATION
Vitals:
98.1
64
160/74
16
Gen: WD/WN, comfortable, NAD. Elderly female lying on stretcher
HEENT: Pupils: PERRL, Right gaze preference
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: speech thick, slow and dysarthric, some word finding
difficulty
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to2
mm bilaterally. Right gaze preference. .
V, VII: Left facial droop
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Motor: Decreased bulk and normal tone.
Delt Bic Tri G IP Quad Ham TA ___
L 3 ___ 4 5 4 4 5 5
R 5 ___ 4 5 5 5 5 5
Sensation: Intact to light touch bilaterally.
DISCHARGE PHYSICAL EXAM
Vitals:
Tcurrent 98.8, Tmax 98.9, HR: 68-76, BP: ___
General: NAD
HEENT: NCAT, dry oral mucosa, hearing aids in place, bony growth
on r skull which is chronic
___: RRR
Pulmonary: CTAB
Abdomen: Soft
Extremities: Warm, 2+ bilateral lower extremity edema
Neurologic Examination:
Mental Status: Opens eyes to voice. Regards examiner but prefers
to keep eyes closed. Attention to examiner maintained.
Dysarthria is largely improved. Intact repetition, and intact
verbal comprehension. No paraphasias. Normal prosody. Able to
follow midline and appendicular commands.
Cranial Nerves: Pupils minimally reactive at 2.5mm
post-surgical. Can cross midline with EOMI but prefers to look
to right. V1-V3 without deficits to light touch bilaterally. LT
lower facial droop. Hearing intact with hearing aids in place
otherwise grossly impaired. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
Motor: Decreased bulk and normal tone. No tremor or asterixis.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 4 ___ 3 3 4 4 4 4 4 4
R 4+ ___ 5 5 4 5 5 5 5 5
Sensory: No deficits to light touch, pin, or proprioception
bilaterally. LT extinction to DSS.
DTRs:
Bi Tri ___ Pat Ach
L 3 2 3 2 1
R 3 2 3 2 1
Plantar response withdrawal bilaterally.
Coordination: No dysmetria with finger to nose testing on the
RT.
Gait: Deferred
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt
Ct
___ 5.1 2.82* 8.8* 26.4* 94 31.2 33.3 13.2
45.1 181 Import Result
___ 6.4 3.03* 8.9* 27.7* 91 29.4 32.1 13.1
43.8 219 Import Result
___ 8.0 3.35* 10.0* 30.3* 90 29.9 33.0 12.8
41.8 238 Import Result
___ 7.5 3.61* 11.2 33.4* 93 31.0 33.5 12.7
43.0 245 Import Result
BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___
___ 181 Import Result
___ 10.9 24.6* 1.0 Import Result
___ 219 Import Result
___ 9.8 25.7 0.9 Import Result
___ 238 Import Result
___ 9.7 25.1 0.9 Import Result
___ 245 Import Result
___ 9.4 23.9* 0.9 Import Result
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 118* 33* 1.3* 144 3.9 110* 24 14 Import
Result
___ 100 40* 1.4* 142 3.7 ___ Import
Result
___ 101* 45* 1.4* 139 4.0 ___ Import
Result
___ 2.0* Import Result
___ 52* Import Result
ESTIMATED GFR (MDRD CALCULATION) estGFR
___ Using this Import Result
___ Using this Import Result
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 18 23 207 140 49 0.2 Import Result
CPK ISOENZYMES CK-MB cTropnT
___ 3 0.04* Import Result
___ 3 0.04* Import Result
___ 0.05* Import Result
___ 5 0.02* Import Result
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
___ 8.3* 3.5 2.2 Import Result
___ 8.9 3.9 2.3 Import Result
___ 3.4* 8.9 3.6 2.2 156 Import
Result
DIABETES MONITORING %HbA1c eAG
___ 5.1 100 Import Result
LIPID/CHOLESTEROL Triglyc HDL CHOL/HD LDLcalc
___ 128 52 3.0 78 Import Result
PITUITARY TSH
___ 2.2 Import Result
LAB USE ONLY
___ Import Result
___ Import Result
___ Import Result
___ Import Result
___ Import Result
___ Import Result
___ Import Result
Blood Gas
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Na K Cl calHCO3
___ 111* 139 4.6 103 24 Import Result
IMAGING:
CTA H and N:
1. Intraparenchymal hemorrhage within the right basal ganglia
and inferior
right frontal lobe with surrounding edema, without midline
shift. No evidence
of infarction.
2. Atherosclerotic vascular calcification without stenosis,
occlusion, or
aneurysm formation.
3. Mild emphysematous changes.
NOTIFICATION: The findings were discussed with ___, M.D.
by ___
___, M.D. on the telephone on ___ at 10:32 ___, 2
minutes after
discovery of the findings.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. irbesartan 75 mg oral BID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. mupirocin calcium 2 % topical apply to left ankle wound once
a day
5. raloxifene 60 mg oral DAILY
6. Aspirin 81 mg PO ___
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. irbesartan 75 mg oral BID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. mupirocin calcium 2 % topical apply to left ankle wound once
a day
6. raloxifene 60 mg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Basal ganglia hemorrhage
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: Left-sided weakness. Evaluate for intracranial hemorrhage and
vascular patency.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
3) Spiral Acquisition 5.0 s, 39.6 cm; CTDIvol = 32.1 mGy (Head) DLP =
1,271.4 mGy-cm.
Total DLP (Head) = 2,190 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is intraparenchymal hemorrhage centered within the right basal ganglia
and inferior right frontal lobe, measuring 4 x 2 cm (03:18), with surrounding
edema, without midline shift. There is no infarction. There is prominence of
the ventricles, sulci, and cisterns, which are age-appropriate. There are
nonspecific periventricular and subcortical white matter hypodensities, which
may be a sequela of chronic small vessel microangiopathy. There is mild
mucosal opacification of bilateral ethmoid sinuses and maxillary sinuses. The
remaining paranasal sinuses and bilateral mastoid air cells appear clear.
CTA HEAD:
There are atherosclerotic vascular calcifications of the cavernous and clinoid
segments of bilateral internal carotid arteries. Otherwise, the circle of
___ and the principal intracranial vasculature are patent without stenosis,
occlusion, or aneurysm greater than 3 mm. The dural venous sinuses are
patent.
CTA NECK:
There are atherosclerotic vascular calcifications at the carotid bulbs
bilaterally. There is mild narrowing at right ICA without significant
stenosis or occlusion per NASCET criteria. The bilateral vertebral arteries
are widely patent with mild vascular calcifications. There is a 3 vessel
aortic arch with moderate atherosclerotic vascular calcifications of the great
vessels without significant stenosis. Irregularity of bilateral distal ICA
indicate fibromuscular dysplasia.
OTHER:
There is no lymphadenopathy per size criteria. The thyroid gland is not well
visualized. There are mild centrilobular emphysematous changes.
IMPRESSION:
1. Intraparenchymal hemorrhage within the right basal ganglia and inferior
right frontal lobe with surrounding edema, without midline shift. No evidence
of infarction.
2. Atherosclerotic vascular calcification without stenosis, occlusion, or
aneurysm formation.
3. Mild emphysematous changes.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:32 ___, 2 minutes after
discovery of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Weakness
Diagnosed with Nontraumatic intcrbl hemorrhage in hemisphere, cortical
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | Dr. ___ is a ___ yo woman with medical history of HT, HLD, and
lower extremity edema presenting with acute onset LT facial
droop RT gaze preference and LT upper extremity weakness
concerning for acute stroke.Found on CT scan to have hemorrhage
in the R basal ganglia likely hypertensive in etiology given her
BP in the 170's and history and location of bleed.
The following was done for the patient to manage her acute
hemorrhage on the stroke team.
# Neuro:
-Dr. ___ pressure was elevated, she was given IV
hydralazine PRN. Once she passed her swallow evaluation, she was
started on irbesartan (home medication). She was noted to have
persistent hypertension above 140 to about the 150 range so
amlodipine was started at 2.5mg. Patient has a history of
becoming orthostatic on bp meds so we were cautious with
medication, however due to her hypertensive hemorrhage bp below
at least 150 and more favorably 140 is desirable. On her last
day of admission, amlodipine was increased to 5mg. This may take
a few days to take effect.
-Patient's aspirin will be held indefinitely given her bleed and
no coronary artery disease for which she would need to take
aspirin. SQ heparin was started on the third day post bleed.
# Cardiopulmonary:
-Patient had an elevated troponin on admission, this was trended
which was stabilized and likely due to cardio renal syndrome
from ___ and ___ disease. Patient had no cardiac symptoms.
She was monitored on telemetry. No other acute issues.
#Renal:
-___, creatnine initially elevated to 2.0 likely contrast
induced with some ___. Patient was hydrated lightly and
creatinine improved from 2.0 to 1.4 to 1.3.
# ID/Tox/Metabolic:
- Patient did not have any infections while inpatient. She does
have a venous ulcer that is chronic on her left shin. This was
dressed and changed every day, did not seem infected. wound care
nurse also evaluated this.
# Endocrine
- TSH, A1c were checked and stable.
#Heme:
-Patient developed anemia likely due to bruising and phlebotomy.
As labs stabilized, blood draws were reduced. Patient was
asymptomatic and HD stable. No frank bleeding. Continue to
monitor.
# FEN:
-Patient initially passed speech and swallow evaluation but was
put on a puree and nectar thick diet which she tolerated well. A
day after this, she did develop one episode of emesis and
vasovagal episode, however this was transient and patient
recovered well.
-Patient's diet was held and she was re-evaluated by speech and
swallow. It was determined that patient needs to eat very slowly
and not speak while eating, then she can tolerate this modified
diet. Please continue to evaluate her and see if diet can be
advanced.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
Transitions of care:
1. Patient to follow up with stroke neurologist on scheduled
date
2. stop taking aspirin indefinitely
3. Have blood pressure checked dialy, goal less than 140.
Uptitrate PO meds as needed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ancef / Penicillins
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old man with prior DVT/PE and ___ who
presents from an assisted living facility with productive cough,
SOB, and mild ab pain for 2 weeks. Pt. reports that this has
been accopmanied by subjective fevers, decreased PO intake, sore
throat, and rhinnorrhea. HE describes the cough as productive of
yellow/white, jelly-like sputum. Wth respect to the abdominal
pain, he reports it is ___ dull, intermittent pain that does
not radiate. He reports he has not had a BM in 1 week. ROS also
positive for some dizziness that is new, though pt. unable to
further characterize. Pt. denies CP, palpitations, orthopnea,
and increased ___ edema.
In the ED, initial vitals: 97.6 86 135/88 22 94% 6L. Labs
notable for d-dimer of >1000, and CXR with question of
atelectasis and stable L hilar mass. He was given 500mg IV
levaquin for HCAP.
ROS: per HPI, denies chills, night sweats, headache, vision
changes, chest pain, nausea, vomiting, diarrhea, BRBPR, melena,
hematochezia, dysuria, hematuria, rashes.
Past Medical History:
- Diastolic Congestive heart failure - Echo in ___ LVEF >55%.
- Moderate pulmonary artery systolic hypertension on echo ___.
- Venous thromboembolism - bilateral DVT and PE in ___
unilateral DVT ___ s/p IVC filter, not a candidate for
longterm anticoagulation because of massive, recurrent GI bleed
from reflux esophagitis
- Severe peripheral vascular disease.
- Bilateral carotid endarterectomy.
- Chronic microvascular disease in the brain
- Chronic leg edema.
- Hypertension.
- Slowing growing lung mass in left hilum with no other
symptoms (negative bronchoscopy in ___, negative PET scan
___, and followed by annual CT scan
- Spinal stenosis.
- Osteoarthritis.
- Chronic lower back pain.
- Hx multiple falls.
- BPH status post TURP.
- S/p b/l knee surgery, right knee replacement in early
___ and left knee fracture repair prior to ___.
Social History:
___
Family History:
DM, Cancer (mother died in ___ of unknown cancer), MI (father
died in ___ of MI)
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1, 74, 118/56, 97 on 4L
General: pleasant, comfortable gentleam supine in bed in NAD
HEENT: head atraumatic; no head/neck lymphadenopathy; scleral
anicteric; no conjunctival injection or pallor; MM dry
Neck: supple; unable to assess JVP given body habitus
CV: distant ___ sounds; RRR; no murmurs appreciated
Lungs: anterior lung fields clear with occasional rhonchi
Abdomen: soft, diffusely mildly tender, nondistended,
normoactive bowel sounds, no rebound or gaurding
GU: no foley
Ext: WWP; 1+ pitting edema in b/l feet; no assymmetric edema; no
palpable cords
Neuro: A and O x3
DISCHARGE PHYSICAL EXAM:
VS: Tm 98.8, 79-88, 124-153.49-71, ___ on 4L
General: elderly gentleman sleeping comfortably and easily
arousable in NAD
HEENT: MMM
Neck: non-elevated JVD
CV: distant ___ sounds; RRR; no murmurs appreciated
Lungs: anterior lung fields clear with occasional rhonchi
Abdomen: soft, nontender, nondistended, normoactive bowel
sounds, no rebound or gaurding
GU: no foley
Ext: WWP; 1+ pitting edema in b/l feet; no assymmetric edema; no
palpable cords
Neuro: A and O x3
Pertinent Results:
=============================================
LABS ON ADMISSION:
=============================================
___ 12:35PM BLOOD WBC-7.5 RBC-4.63 Hgb-13.5* Hct-44.5
MCV-96 MCH-29.2 MCHC-30.4* RDW-13.9 Plt ___
___ 12:35PM BLOOD Neuts-67.6 ___ Monos-6.3 Eos-3.7
Baso-1.2
___ 12:35PM BLOOD ___ PTT-34.4 ___
___ 12:35PM BLOOD Glucose-136* UreaN-19 Creat-0.7 Na-141
K-4.2 Cl-94* HCO3-36* AnGap-15
___ 12:35PM BLOOD Albumin-4.0 Calcium-8.4 Mg-2.2
___ 12:39PM BLOOD Lactate-1.1
___ 12:35PM BLOOD proBNP-2382*
___ 02:18PM BLOOD D-Dimer-1078*
___ 12:35PM BLOOD cTropnT-<0.01
=============================================
LABS ON DISCHARGE:
=============================================
___ 05:20AM BLOOD WBC-5.6 RBC-4.21* Hgb-12.2* Hct-39.9*
MCV-95 MCH-29.1 MCHC-30.7* RDW-14.2 Plt ___
___ 05:20AM BLOOD Glucose-75 UreaN-17 Creat-0.8 Na-138
K-4.0 Cl-90* HCO3-39*
=============================================
OTHER RESULTS:
=============================================
___ BCX - no growth
___ CTA - IMPRESSION:
1. Stable appearing 2 x 2.5 cm left hilar mass with punctate
calcification. Borderline mediastinal lymph nodes are stable
and and large right hilar lymph has increased slightly over the
interval.
2. No evidence of pulmonary embolism.
3. Bibasilar atelectasis, left worse than right, with bilateral
air
bronchograms.
4. Cholelithiasis.
___ CXR - There are very low lung volumes which limits
evaluation. The left perihilar mass seen previously is not well
seen on this study. There is blunting of both CP angles, which
may represent pleural fluid. The heart size is difficult to
assess due to the overlying gas within the fundus of the stomach
and the low lung volumes. There are no pneumothoraces.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO DAILY
2. Furosemide 80 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Calcium Carbonate 500 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. K-DUR 20 mEq oral daily
9. Acetaminophen 650 mg PO Q8H:PRN pain
10. Metoprolol Tartrate 6.25 mg PO BID
11. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily
Disp #*30 Unit Refills:*0
3. Guaifenesin ER 600 mg PO Q12H
RX *guaifenesin 600 mg 1 tablet extended release(s) by mouth
twice a day Disp #*14 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q8H:PRN pain
5. Aspirin 325 mg PO DAILY
6. Calcium Carbonate 500 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. K-DUR 20 mEq oral daily
9. Metoprolol Tartrate 6.25 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Simvastatin 20 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*30 Capsule Refills:*3
15. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice daily
Disp #*30 Capsule Refills:*3
16. Sodium Chloride Nasal ___ SPRY NU BID
RX *sodium chloride [Nasal Spray (sodium chloride)] 0.65 % ___
spray intranasal twice daily Disp #*1 Bottle Refills:*2
17. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
Use if nebulizer not available.
RX *albuterol ___ puffs IH every 6 hours Disp #*1 Inhaler
Refills:*2
18. Furosemide 80 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Community acquired pnuemonia
Secondary Diagnosis:
Diastolic heart failure
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath.
TECHNIQUE: AP upright and lateral views of the chest.
COMPARISON: Chest CTA ___ and chest radiograph ___.
FINDINGS:
Lung volumes are low. This causes crowding of the bronchovascular structures.
Mediastinal contour is unchanged and a left-sided intrathoracic stomach is
again demonstrated. Heart size is difficult to assess given the presence of
the intrathoracic stomach. 2.8-cm left hilar mass containing calcifications
is re- demonstrated, similar in size compared to the previous study . Patchy
opacities in the lung bases may reflect atelectasis though infection is not
excluded. Additionally, a trace right pleural effusion may be present. There
is no overt pulmonary edema. No pneumothorax is seen. Multilevel
degenerative changes are noted in the thoracic spine.
IMPRESSION:
1. Low lung volumes with bibasilar opacities likely atelectasis, though
infection is not excluded. A trace right pleural effusion may also be
present.
2. No interval change in appearance of the left hilar mass.
Radiology Report
INDICATION: ___ male with right upper quadrant pain on palpation and
altered mental status.
COMPARISON: CTA chest from ___
RIGHT UPPER QUADRANT ULTRASOUND: Examination is limited secondary to
significant overlying midline bowel gas and patient body habitus. Limited
views of the liver are normal. The main portal vein is patent with
hepatopetal flow. No intra- or extra-hepatic biliary ductal dilatation is
identified. The common bile duct measures 3 mm.
The gallbladder is contracted and has a large 2.5 cm dependent stone within
it. This correlates with findings from prior CT examination from ___. No pericholecystic fluid is identified. There is a negative
sonographic ___ sign. Limited views of both kidneys demonstrate no
hydronephrosis. The spleen measures 9 cm.
IMPRESSION:
Contracted gallbladder with large dependent stone. No sonographic evidence of
acute cholecystitis.
Radiology Report
HISTORY: ___ male with history of DVT and PE, now with dyspnea,
cough, hypoxia. Evaluate for pulmonary embolism.
TECHNIQUE: Multi detector CT images were acquired through the chest and upper
abdomen before and after the uneventful intravenous administration of
Omnipaque contrast material. CTA chest protocol was performed. Coronal and
sagittal reformats were provided.
DLP: 535 mGy-cm
COMPARISON: CT of the chest dated ___.
FINDINGS:
The exam is severely limited by patient motion. Allowing for this limitation,
there is no significant axillary adenopathy. There are multiple subcentimeter
mediastinal nodes, the largest measuring 9 mm in the subcarinal location,
which is stable from prior (series 5, image 43). There are additionally
bilateral large supraclavicular lymph nodes measuring up to 12 mm (series 5,
image 7 and 23). There are subcentimeter prevascular, right snd left
paratracheal lymph nodes as well. There is a stable appearing 2 x 2.5 cm left
perihilar mass which demonstrations a central punctate calcification.
Additionally there is a large right hilar lymph node measuring 14 mm in short
axis, which has increased slightly from prior (series 5, image 44). There is
a stable appearing 4 mm left upper lobe pulmonary nodule (series 5, image 31).
There are no new pulmonary nodules identified. There is again seen bibasilar
atelectasis, left greater than right, with bilateral air bronchograms. There
are no pleural effusions. There is no pericardial effusion. Incidental note
is made of an intrathoracic stomach.
There is good opacification of the pulmonary vessels. No pulmonary embolus is
identified within the main, lobar, segmental, or subsegmental pulmonary
arteries.
The visualized portion of the liver is normal in appearance. There is again
seen a large calcified gallstone within the gallbladder. There is a calcified
epiphrenic lymph node measuring 4 mm (series 6, image 207), which is stable.
The remaining intra-abdominal organs are grossly unremarkable.
OSSEOUS STRUCTURES: There is diffuse osteopenia of the visualized osseous
structures. There are multilevel degenerative changes seen throughout the
thoracic spine.
IMPRESSION:
1. Stable appearing 2 x 2.5 cm left hilar mass with punctate calcification.
Borderline mediastinal lymph nodes are stable and and large right hilar lymph
has increased slightly over the interval.
2. No evidence of pulmonary embolism.
3. Bibasilar atelectasis, left worse than right, with bilateral air
bronchograms.
4. Cholelithiasis.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ male with worsening tachypnea. Evaluate for
pneumonia or volume overload.
FINDINGS: Comparison is made to previous study from ___.
There are very low lung volumes which limits evaluation. The left perihilar
mass seen previously is not well seen on this study. There is blunting of
both CP angles, which may represent pleural fluid. The heart size is
difficult to assess due to the overlying gas within the fundus of the stomach
and the low lung volumes. There are no pneumothoraces.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SOB
Diagnosed with HYPOXEMIA
temperature: 97.6
heartrate: 86.0
resprate: 22.0
o2sat: 94.0
sbp: 135.0
dbp: 88.0
level of pain: 2
level of acuity: 2.0 | Mr. ___ is an ___ year old gentleman with a history of prior
DVT/PE, diastolic CHF, severe peripheral vascular disease,
hypertension, and slow-growing lung mass who presents with
shortness of breath and sputum production.
# SOB/COUGH: On presentation, differential diagnosis included
pulmonary embolism (given history DVT/PE and not on
anticoagulation) vs community acquired pnuemonia vs diastolic
congestive heart failure exacerbation. CTA showed no evidence
of PE. Given age, CHF, assisted living, and small effusion, pt.
was started on levofloxacin for treatment of community acquired
pneumonia. He was initially volume depleted on exam and his
diuretics were held. He became more hypoxic the following day,
requiring 4L of O2 instead 3L. CXR showed evidence of mild
fluid overload. He was restarted on his diuretics and his
oxygenation improved. He was discharged to complete a 5 day
course of levofloxacin. Throughout this admission, he remained
afebrile and hemodynamically stable. He reported feeling
significantly better on the day of discharge.
# CONSTIPATION: Pt. reported mild diffuse abdominal pain on
admission. He had not had a bowel movement in 1 week. With
laxatives, he had a bowel movement and his pain improved. He was
doscahregd with a bowel regimen to prevent further constipation.
# HYPERCHOLESTEROLEMIA:
Pt. was continued on his home statin
# HX GI BLEED:
Pt. was continued on his home proton pump inhibitor.
# LUNG MASS: Unclear etiology. Left suprahilar soft tissue mass,
first found in ___, it began slowly growing at: 2.5 x 2.2 cm on
CT in ___ (at ___). Bronchoscopic
biopsy in ___ was negative for malignant cells, AFP was
negative, PET scan ___ was unremarkable, but the mass is
noted to continue to grow on CT this admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left arm pain, left hand tingling/weakness
Major Surgical or Invasive Procedure:
Lumbar puncture by ___ (___)
History of Present Illness:
The pt is a ___ year old right-handed man with a history of a
reactive lesion in his left frontal lobe (initially presenting
with slurred speech and left arm numbness in ___,
biopsied in ___ which showed reactive gliosis and felt to
be either tumefactive demyelination versus clinically isolated
syndrome), who presents with acute onset right upper arm pain
and
right hand tingling with weakness, now mostly resolved.
He had a "bad head cold" 2 weeks ago, and recently came back
from
a trip where he was carrying some medium heavy bags on his right
shoulder. 2 days ago he started having pain around the right
triceps area. It was sharp and throbbing and nothing relieved
it. Later that day he had numbness of all 5 fingertips on the
right hand, not involving the palm or his left hand, no
radiation
up the arm. During this time he noted he had a weak grip on the
right hand as well. 1 day ago he went to work at ___ and
had the right triceps pain but was able to work as usual and was
lifting medium heavy boxes. This morning the pain persisted so
he
came to the ER, but while being evaluated here the pain has
since
resolved. Neurology in consulted due to his prior history of a
left frontal lobe lesion in the setting of right arm symptoms.
On neuro ROS, the pt endorses chronic daily headaches for which
he takes Tylenol. He otherwise denies loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills in the past few days. 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:
Asthma
Chronic daily headaches - resolve with Tylenol
Social History:
___
Family History:
There is no history of seizures, developmental, migraine
headaches, strokes less than 50, neuromuscular disorders, MS,
dementia or movement disorders.
Physical Exam:
Physical Exam:
Vitals: T: 98 P: 81 R: 18 BP: 137/76 SaO2: 99% 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.
Full range of motion.
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.
Neurological examination:
- Mental Status:
ORIENTATION - Alert, oriented x 3. The pt. had good knowledge of
current events.
SPEECH Able to relate history without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was not dysarthric.
NAMING Pt. was able to name both high and low frequency objects.
COMPREHENSION
Able to follow both midline and appendicular commands. There was
no evidence of apraxia or neglect.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation. Blinks to
threat bilaterally. Funduscopic exam reveals normal appearing
optic discs.
III, IV, VI: EOMI without nystagmus. Normal pursuits and
saccades.
V: Facial sensation intact to light touch. Good power in muscles
of mastication.
VII: No facial weakness, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal velocity movements.
- Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
SAb SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD ___
L 5 5 ___ ___ 5 ___ ___
R 5 5 ___ ___ 5 ___ ___
- Sensory: No deficits to light touch, cold sensation, vibratory
sense, proprioception throughout in UE and ___. No extinction to
DSS.
- DTRs:
BJ SJ TJ KJ AJ
L ___ 2 1
R ___ 2 1
There was no evidence of clonus. Plantar response was flexor
bilaterally.
- Coordination: No intention tremor, normal finger tapping. No
dysdiadochokinesia noted. 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.
Discharge exam:
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.
Full range of motion.
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.
Neurological examination:
- Mental Status:
ORIENTATION - Alert, oriented x 3.
SPEECH no dysarthria
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was not dysarthric.
NAMING Pt. was able to name both high and low frequency objects.
COMPREHENSION
Able to follow both midline and appendicular commands. There was
no evidence of apraxia or neglect.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. Full peripheral vision
III, IV, VI: EOMI without nystagmus. Normal pursuits and
saccades.
V: Facial sensation intact to light touch. Good power in muscles
of mastication.
VII: No facial weakness, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal velocity movements.
- Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
SAb SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD ___
L 5 5 ___ ___ 5 ___ ___
R 5 5 ___ ___ 5 ___ ___
- Sensory: No deficits to light touch, cold sensation, vibratory
sense, proprioception throughout in UE and ___. No extinction to
DSS.
- DTRs:
BJ SJ TJ KJ AJ
L ___ 2 1
R ___ 2 1
There was no evidence of clonus. Plantar response was flexor
bilaterally.
- Coordination: No intention tremor, normal finger tapping. No
dysdiadochokinesia noted. 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:
Laboratory Data:
Bloods:
Chemistry
144 104 9
------------< 107
4.4 31 1.0
Ca: 10.1 Mg: 1.8 P: 3.1 ___
CBC: 7.9 14.8 211
43.8
N:68.5 L:23.0 M:5.8 E:2.2 Bas:0.5
___: 13.6 PTT: 30.2 INR: 1.3
Urinalysis
Color Yellow, Appear Clear, SpecGr 1.019, pH 8.0, Urobil Neg,
Bili Neg, Leuk Neg, Bld Neg, Nitr Neg, Prot Tr, Glu Neg,
Ket
Neg, RBC 1, WBC <1, Bact None, Yeast None, Epi <1, Mucous:
Rare
CSF: wbc 1, rbc 1, protein 31.
Radiology:
Last MRI head ___:
"IMPRESSION: Interval increase in size of left frontal lesion
with rim enhancement, newly developed extensive surrounding
edema
and the suggestion of a thin rim of peripheral diffusion
restriction. The location of the lesion and surrounding edema
likely accounts for the patient's facial symptoms. A tumefactive
demyelinating process remains most likely, neoplastic
etiologies,
including lymphoma (though the lack of CT hyperdensity and
central diffusion restriction makes this less likely), not
entirely excluded."
CT ___ WET READ: "No acute intracranial hemorrhage or
evidence of infarction. No herniation or midline shift.
Hypodensity in left frontal lobe at site of prior biopsy.
Resolved pneumocephalus."
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q6H:PRN headaches
2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
3. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN headaches
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
Discharge Disposition:
Home
Discharge Diagnosis:
Demyelinating Lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with left frontal lesion previously biopsied
(reactive glioma) presenting with right arm pain and numbness. Evaluation for
new intracranial lesion or bleed.
COMPARISON: Comparison is made to prior CT of the head from ___ as
well as prior CT of the head from ___.
TECHNIQUE: MDCT images were obtained through the brain without the
administration of intravenous contrast. Reformatted coronal, sagittal and
thin-slice bone images were reviewed.
FINDINGS: There is no evidence of intracranial hemorrhage, shift of normally
midline structures, or acute vascular territorial infarction. The ventricles
and sulci are normal in size and configuration.
A known lesion in the subcortical white matter of the left frontal lobe (2:18)
is poorly visualized on this noncontrast exam. Small area of adjacent
hypodensity may represent encephalomalacia or edema. Subtle interval changes
in size of the lesion are not well assessed on this study. The basal cisterns
appear patent and there is preservation of the gray-white matter
differentiation. There is a left frontal burr hole, which is unchanged. No
fractures are identified. The visualized paranasal sinuses, mastoid air cells
and middle ear cavities are clear. The globes are intact bilaterally. There
are no facial or cranial soft tissue abnormalities.
IMPRESSION: Poor visualization of known lesion in the left frontal lobe.
Consider MRI to further assess for interval change. Small focus of
encephalomalacia or edema abutting this lesion.
Radiology Report
TECHNIQUE: MRI of the brain without and with gad.
HISTORY: Followup known left frontal lesion. Presents with new neurological
symptoms.
COMPARISON: Multiple prior studies including ___
and ___.
FINDINGS: The previously noted left frontal enhancing lesion has markedly
decreased in size and no longer demonstrates enhancement or mass effect.
However, there has been interval development of a new lesion in the left
parietal lobe abutting the trigone of the left lateral ventricle without
enhancement.
Intracranial flow voids are maintained.
There is no evidence for acute ischemia or hydrocephalus.
Flow voids are maintained.
IMPRESSION: Interval decrease in size of previously seen left frontal lesion.
New non-enhancing lesion in the left periatrial area. Findings favor
demyelinating etiology.
Radiology Report
TECHNIQUE: MRI of the cervical spine without and with gad.
HISTORY: Left frontal lobe lesion with new neurological symptoms.
COMPARISON: ___ and ___.
FINDINGS: On the sagittal images, there is no malalignment or loss of
vertebral body height. No suspect marrow lesions are seen. The
craniovertebral junction is unremarkable. Mild prominence of the nasopharynx
lymphoid tissue is likely physiologic.
No pathologic enhancement is seen.
IMPRESSION: No cord lesion or significant compromise of the canal is seen.
Radiology Report
HISTORY: ___ man with multiple cortical demyelinating lesions.
History of difficulty LPs in the past. Patient refusing anything but fluoro
guided procedures. CSF pressure for diagnosis. Question inflammatory process
in CNS or MS.
___: Dr. ___, Fellow. Dr. ___, attending.
COMPARISON: Lumbar puncture procedure with fluoroscopy ___.
PROCEDURE/FINDINGS:
Informed consent was obtained after explaining the risks, indications and
alternatives management. The patient was brought to the fluoroscopic room and
placed on the fluoroscopic table in prone position. A preprocedure time out
was performed, confirming the patient's identity and procedure to be
performed.
Access to the lumbar subarachnoid space was obtained at the L3-L4 level, with
a 22-gauge spinal needle, under local anesthesia, and using 1% lidocaine with
aseptic precautions. Approximately 22 cc of CSF was collected into 4 sterile
tubes. The CSF was clear. The patient tolerated the procedure well without
any immediate complications or need for conscious sedation. The patient was
sent to the floor with postprocedure orders.
Fluoro Time: 0.1 minutes
IMPRESSION:
1. Successful fluoroscopically guided lumbar puncture at L3-L4 level. Samples
were sent for laboratory analysis.
2. Dr. ___ was present during the examination.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: RT ARM PAIN
Diagnosed with OTHER CONDITIONS OF BRAIN, SKIN SENSATION DISTURB, PAIN IN LIMB
temperature: 98.0
heartrate: 81.0
resprate: 18.0
o2sat: 99.0
sbp: 137.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | The pt is a ___ year-old right-handed male with a history of a
demyelinating lesion of the left frontal lobe felt to be either
tumefactive MS or clinically isolated syndrome who presents with
intermittent pain in the right triceps area with transient
tingling of the right fingertips and right grip weakness which
has since resolved. Neurological examination since admission
had been unremarkable. CT shows no hemorrhage or infarction. MRI
of the head showed interval decrease in size of previously seen
left frontal lesion and a new non-enhancing lesion in the left
periatrial area. Findings favor demyelinating etiology but it
is difficult to correlate the location of the lesions to the
current and previous presenting symptoms. The etiology of the
presenting syndrome is concerning for a progression of his left
frontal lesions. The differential diagnosis includes multiple
sclerosis versus tumor vs other demyelinating disorder (although
ADEM unlikely given normal
mental status). Alternatively his symptoms might be explained
by an unusual injury to the c-spine or brachial plexus, but
given no specific trauma elicited on history and the symptoms
are so intermittent, this is less likely. A lumbar puncture was
performed under fluro guidance as patient was unable to tolerate
bedside lumbar puncture. The CSF cell count and protein are
within normal limits and suggests against any CNA infection or
inflammatory processes. Other workup include ACE-I, ANCA, ___,
rheumatoid factor, LFTs, CBC, Chem 10 all returned normal.
Patient's CSF is also sent for MS profile which is pending at
the time of this report. At the time of discharge, patient's
exam is normal and he is symptom free. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ with a history of EtOH cirrhosis complicated by varices and
ascites, prior GIB, presenting with hematemesis and profound
metabolic acidosis.
History is unclear as collateral unable to be obtained
overnight.
Per OSH records, patient presented to ___ yesterday AM
with
multiple episodes of large-volume hematemesis. They found him to
be anemic with Hgb 5.3. He received 1U pRBC, octreotide,
protonix, and was transferred to ___ for continuity with Dr.
___. Of note, last EGD in ___ during admission for similar
presentation showed numerous ___ tears noted at the GE
junction, varices at the lower third of the esophagus, mild
portal hypertensive gastropathy.
In the ED, initial vitals were T 97.4 HR 120 BP 99/58 RR 20 O2
sat 98% RA. Patient was actively having hemoptysis and was soon
intubated for airway protection. Exam was notable for jaundice,
blood in oropharynx, abdominal distension, tachycardia,
unremarkable neuro exam. Labs: Hgb 5.5, pH 7.11, lactate 12.6,
bicarb 6, Cr 1.7. CXR showed no acute process. Patient received
ketamine and rocuronium for intubation, fent and midaz, CTX,
octreotide, pantoprazole, 10 mg Vitamin K, and
insulin/dextrose/calcium gluconate.
Past Medical History:
- Hypertension
- EtOH use disorder
- EtOH cirrhosis
- Iron deficiency anemia
Social History:
___
Family History:
Mother had breast cancer. Father died of old age.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: Reviewed in metavision
GEN: Inutbated, sedated, appears jaundiced
HEENT: Sclera icteric. Oropharynx with dried blood, OG tube
with dark maroon output
NECK: Bounding carotid pulse noted
CV: Normal S1S2, RRR, no murmurs
RESP: Clear anteriorly to auscultation,
GI: Abdomen distended, soft
MSK: Warm, well-perfused, no lower extremity edema
SKIN: Jaundiced
NEURO: Sedated. PERRL.
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 1125)
Temp: 98.4 (Tm 98.5), BP: 133/84 (116-146/71-86), HR: 64
(60-71), RR: 18 (___), O2 sat: 99% (96-99), O2 delivery: Ra,
Wt: 196.9 lb/89.31 kg
General: alert and oriented x3
Neuro: +asterixis, A&Ox3
HEENT: poor dentition, sublingual and scleral icterus
Neck: JVP non-elevated, no adenopathy
Lung: no increased work of breathing or use of accessory
muscles,
CTAB w/ no wheezes, rhonci
Card: normal s1/s2, no mrg
Abd: distended, +fluid wave, non-tense, non-tender to palpation,
+umbilical hernia (reducible)
Ext: no lower extremity edema, + palmar erythema
Pertinent Results:
ADMISSION LABS
___ 11:50PM BLOOD WBC-15.0* RBC-2.19* Hgb-5.5* Hct-19.8*
MCV-90 MCH-25.1* MCHC-27.8* RDW-20.4* RDWSD-65.9* Plt ___
___ 11:50PM BLOOD Neuts-82.7* Lymphs-9.3* Monos-6.2
Eos-0.0* Baso-0.3 Im ___ AbsNeut-12.44* AbsLymp-1.40
AbsMono-0.93* AbsEos-0.00* AbsBaso-0.04
___ 12:12AM BLOOD ___ PTT-42.6* ___
___ 02:40AM BLOOD Fibrino-78*
___ 11:50PM BLOOD Glucose-102* UreaN-27* Creat-1.7* Na-135
K-6.2* Cl-106 HCO3-6* AnGap-23*
___ 02:40AM BLOOD ALT-11 AST-49* LD(LDH)-200 AlkPhos-138*
TotBili-4.6*
___ 11:50PM BLOOD Calcium-7.9* Phos-5.2* Mg-1.7
___ 05:51AM BLOOD Hapto-<10*
___ 02:40AM BLOOD ASA-NEG Ethanol-45* Acetmnp-NEG
Tricycl-NEG
___ 12:00AM BLOOD ___ pO2-146* pCO2-22* pH-7.16*
calTCO2-8* Base XS--19
___ 12:00AM BLOOD Lactate-12.6*
MICROBIOLOGY
___ 12:12 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 1:55 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 10:00 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary):
IMAGING/PROCEDURES
EGD ___: Varices in distal esophagus, ligated. Grade C
esophagitis in distal esophagus. Portal hypertensive
gastropathy.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Multivitamins 1 TAB PO DAILY
2. HydrOXYzine 10 mg PO TID:PRN Itching
3. TraZODone 100 mg PO QHS:PRN Insomnia
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO DAILY
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth once a day
Disp #*2 Tablet Refills:*0
2. Lactulose 30 mL PO TID HE with asterixis
RX *lactulose 10 gram/15 mL 15 ml by mouth three times a day
Refills:*2
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*2
4. rifAXIMin 550 mg PO BID hepatic encephalopathy
5. Sucralfate 1 gm PO QID Duration: 10 Days
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*40 Tablet Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) [Vitamin B-1] 100 mg 1 tablet(s)
by mouth once a day Disp #*30 Tablet Refills:*2
7. Multivitamins 1 TAB PO DAILY
8. HELD- HydrOXYzine 10 mg PO TID:PRN Itching This medication
was held. Do not restart HydrOXYzine until you see your PCP
9. HELD- TraZODone 100 mg PO QHS:PRN Insomnia This medication
was held. Do not restart TraZODone until you see your PCP
10.Outpatient Lab Work
ICD-10: N___ Acute kidney failure, unspecified
Please draw CBC/chem-10/LFTs/coags on ___ to be followed by PCP
___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
HEMORRHAGIC SHOCK
VARICEAL HEMORRHAGE
___
ASCITES
HEPATIC ENCEPHALOPATHY
ALCOHOL USE DISORDER
SECONDARY PROPHYLAXIS
=====================
ALCOHOLIC CIRRHOSIS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with post intubation// Post intubation
TECHNIQUE: Portable AP chest
COMPARISON: Multiple prior chest radiographs, most recently ___.
FINDINGS:
Endotracheal tube terminates 3.8 cm above the carina. Enteric tube is seen
with the side port projecting in the expected location of the stomach. Lung
volumes are low. No focal consolidation is seen. No pleural effusion or
pneumothorax. The cardiomediastinal silhouette is within normal limits.
IMPRESSION:
1. ET tube terminates 3.8 cm above the carina.
2. No acute cardiopulmonary process.
Radiology Report
EXAMINATION: Ultrasound-guided paracentesis
INDICATION: ___ year old man with cirrhosis, GIB, ascites// diagnostic
paracentesis
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: Ultrasound guided diagnostic paracentesis
Location: left lower quadrant
Fluid: 30 cc of cloudy, yellow fluid
Samples: Fluid samples were submitted to the laboratory the requested analysis
(chemistry, hematology, microbiology).
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest
fluid pocket.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components
of the procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic paracentesis.
2. 30 cc of fluid were removed and sent for requested analysis.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: Rule out portal vein thrombus or other cause of cirrhosis
decompensation. Also evaluate for hydronephrosis/obstruction.
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON:
Abdominal ultrasound performed ___. CT abdomen/pelvis ___.
FINDINGS:
Liver: The hepatic parenchyma is coarsened and nodular.. No focal liver
lesions are identified. There is large volume ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation.
CHD: 7 mm
Gallbladder: There is tumefactive sludge, without findings of acute
cholecystitis.
Pancreas: The imaged portion of the pancreas appears within normal limits,
with portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen remains enlarged. There remains a 4.4 x 4.5 x 3.9 cm (4.6
x 3.7 by 4.5 cm on CT and ___ echogenic, partially calcified mass in the
spleen, no internal vascularity on Doppler interrogation, previously
characterized as a probable hemangioma, unchanged.
Spleen length: 18.0 cm
Kidneys: No stones, masses, or hydronephrosis are identified in either kidney.
Right kidney: 11.1 cm
Left kidney: 11.8 cm
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 40 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. Cirrhotic liver morphology, with large volume ascites and splenomegaly
likely due to portal hypertension. No liver lesions are identified.
3. Tumefactive sludge within the gall bladder, without findings of acute
cholecystitis.
4. Echogenic splenic mass, unchanged compared to ___, previously
characterized as a hemangioma.
5. No hydronephrosis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Upper GI bleed, Transfer
Diagnosed with Gastrointestinal hemorrhage, unspecified, Alcoholic cirrhosis of liver without ascites, Secondary esophageal varices with bleeding, Hypokalemia
temperature: 97.4
heartrate: 120.0
resprate: 20.0
o2sat: 98.0
sbp: 99.0
dbp: 58.0
level of pain: Critical
level of acuity: 2.0 | ___ y/o male w/active alcohol use and history of ETOH cirrhosis
(MELD 29) c/b varices, ascites, prior GIB, presenting in
hemorrhagic shock s/p intubation with hematemesis and lactic
acidosis secondary to variceal bleeding, now s/p EGD and banding
x2. H/H stabilized following banding and he did require several
units of blood/FFP/cryo prior to banding (6U of pRBC). Hospital
course was complicated by ___ likely ___ hemorrhagic shock
though patient decided to leave AMA despite rising Cr at time of
discharge. He expressed understanding of risks of leaving
including death given life-threatening bleeding that prompted
this current admission.
TRANSITIONAL ISSUES
===================
[ ] ***F/u paracentesis cell counts and culture to evaluate for
SBP. Pending at time of discharge.
[ ] Will need repeat EGD in 4 weeks given EV banding on ___
[ ] Needs CBC/chem-10/LFTs/coags checked on ___. If worsening
Cr (discharge Cr 1.9) or any concerning labs, please refer to ED
for further evaluation
[ ] Would benefit from initiation of Nadolol as an outpatient
once ___ has resolved given grade II varices
[ ] Will finish Ciprofloxacin for SBP ppx in the setting of GIB
(7 day course) on ___ (received CTX day ___
[ ] Prior auth on Rifaximin submitted prior to AMA departure,
please follow-up on status of it. The patient refused lactulose
doses.
[ ] Continue to emphasize the importance of abstaining from ETOH
and enroll in relapse prevention programs
[ ] Vitamin D level 8, would benefit from Vitamin D repletion
#UGIB
#Variceal hemorrhage. Presented as OSH transfer requiring
several transfusions of RBCs and FFP and one unit of
cryoprecipitate. Initial Hgb 5.5 with Hgb stabilizing in 8s
following EGD with banding x 2. Patient was intubated given
profound hematemesis and received octreotide gtt, IV PPI, and
CTX for SBP ppx. EGD showed Grade C esophagitis in distal
esophagus, 2 cords of grade II varices (one of which was oozing
at the GEJ) s/p 2 bands, PHG in the stomach with a single varix
2 cm in the fundus that was not bleeding. He was started on
Sucralfate and Nadolol after EGD but Nadolol was discontinued
prior to AMA discharge due to rising Cr at discharge. He was
given a Rx for Ciprofloxacin to complete 7 day course of
antibiotics for SBP ppx in the setting of GIB. He was also
discharged on PPI given esophagitis.
___. Recent Cr baseline 1.1 with peak of 2.1. Had initially
downtrended to 1.5 following multiple blood transfusions and two
day albumin challenge, though had risen to 1.9 on day of AMA
departure. ___ likely pre-renal vs ATN in the setting of
hemorrhagic shock as above. Imaging without signs of
hydronephrosis and urine culture negative for infection.
Discussed concerning nature of rise in Cr on day of departure
but patient expressed understanding of risks of leaving
including worsening renal failure and death and opted to leave
AMA. He will need repeat labs on follow-up with his PCP ___ ___
as we have advised.
#ETOH use disorder. Serum tox on arrival notable for ETOH level
to 0.045. Monitored on CIWA but did not require treatment for
ETOH withdrawal.
#Alcoholic cirrhosis (MELD 31, Childs Class C10). Decompensated
by varices, ascites, hepatic encephalopathy, and ___. Imaging
negative for PVT.
- Ascites: Underwent LVP with 3L removed on ___ did receive
albumin in the setting of ___. Diuretics held given ___ on
discharge. Outpatient fill history shows that he had previously
been on Lasix 40 and Spironolactone 150 daily though it is
unclear if he was taking this regimen recently.
- SBP: Paracentesis negative for SBP on admission. Paracentesis
at discharge removed 3L with diagnostics pending at time of
discharge. He was prescribed Ciprofloxacin on discharge to
complete total 7 day course of abx for SBP ppx in the setting of
GIB. Blood/urine culture without growth.
- Varices: 2 cords grade II varices s/p banding x2, with single
varix in stomach. Held nadolol on discharge given ___. Will need
repeat EGD in 4 weeks. PPI and sucralfate were prescribed
- Encephalopathy: HE likely precipitated by GIB, improved by
time of discharge. Will continue lactulose/rifaximin on
discharge
- Screening: He will need q6 month HCC screening and repeat EGD
in 4 weeks
- Nutrition: Seen by nutrition while hospitalized and given high
dose thiamine, MVI, and folate. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Banana / Horse/Equine Product Derivatives / lisinopril
Attending: ___.
Chief Complaint:
Left knee pain, hematoma, blister s/p fall on ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of CAD s/p CABG, AFib, on ASA
and Coumadin with hx of bilateral total knee arthroplasty (left
___, Right ___ s/p fall with left knee hematoma &
blistering.
Past Medical History:
OA, A-fib, h/o stroke, HTN, CAD (MI) s/p CABG, h/o CHF, asthma,
hypothyroid, s/p L TKR
Social History:
___
Family History:
Non-contributory
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Wound with dry blisters
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 07:47AM BLOOD WBC-5.6 RBC-2.74* Hgb-8.2* Hct-25.2*
MCV-92 MCH-29.9 MCHC-32.5 RDW-13.2 RDWSD-43.8 Plt ___
___ 07:05AM BLOOD WBC-5.5 RBC-2.84* Hgb-8.4* Hct-25.9*
MCV-91 MCH-29.6 MCHC-32.4 RDW-13.1 RDWSD-43.4 Plt ___
___ 07:46AM BLOOD WBC-7.4 RBC-2.82* Hgb-8.5* Hct-26.1*
MCV-93 MCH-30.1 MCHC-32.6 RDW-13.2 RDWSD-44.5 Plt ___
___ 06:35PM BLOOD WBC-8.4 RBC-2.88* Hgb-8.7* Hct-26.3*
MCV-91 MCH-30.2 MCHC-33.1 RDW-13.2 RDWSD-43.8 Plt ___
___ 08:10AM BLOOD WBC-7.6 RBC-2.89* Hgb-8.8* Hct-27.2*
MCV-94 MCH-30.4 MCHC-32.4 RDW-13.6 RDWSD-46.6* Plt ___
___ 08:00AM BLOOD WBC-7.5 RBC-2.80* Hgb-8.4* Hct-26.3*
MCV-94 MCH-30.0 MCHC-31.9* RDW-13.5 RDWSD-46.4* Plt ___
___ 07:30PM BLOOD WBC-6.6 RBC-2.87* Hgb-8.8* Hct-27.3*
MCV-95 MCH-30.7 MCHC-32.2 RDW-13.5 RDWSD-47.3* Plt ___
___ 05:48AM BLOOD WBC-6.6 RBC-2.99* Hgb-9.1* Hct-27.6*
MCV-92 MCH-30.4 MCHC-33.0 RDW-13.6 RDWSD-45.9 Plt ___
___ 10:45PM BLOOD WBC-6.3 RBC-2.76* Hgb-8.5* Hct-25.4*
MCV-92 MCH-30.8 MCHC-33.5 RDW-13.8 RDWSD-46.5* Plt ___
___ 04:55PM BLOOD WBC-6.6 RBC-3.05*# Hgb-9.2*# Hct-28.7*#
MCV-94 MCH-30.2 MCHC-32.1 RDW-13.9 RDWSD-47.8* Plt ___
___ 06:35PM BLOOD Neuts-71.3* Lymphs-16.7* Monos-9.5
Eos-1.9 Baso-0.2 Im ___ AbsNeut-6.01# AbsLymp-1.41
AbsMono-0.80 AbsEos-0.16 AbsBaso-0.02
___ 10:45PM BLOOD Neuts-56.7 ___ Monos-12.1 Eos-3.0
Baso-0.5 Im ___ AbsNeut-3.56 AbsLymp-1.72 AbsMono-0.76
AbsEos-0.19 AbsBaso-0.03
___ 04:55PM BLOOD Neuts-65.5 ___ Monos-10.6 Eos-2.0
Baso-0.3 Im ___ AbsNeut-4.35 AbsLymp-1.42 AbsMono-0.70
AbsEos-0.13 AbsBaso-0.02
___ 07:47AM BLOOD ___
___ 07:05AM BLOOD ___
___ 07:46AM BLOOD ___
___ 08:10AM BLOOD ___
___ 08:00AM BLOOD ___
___ 07:30PM BLOOD ___
___ 04:55PM BLOOD ___ PTT-38.9* ___
___ 07:46AM BLOOD Glucose-99 UreaN-13 Creat-0.6 Na-138
K-4.3 Cl-102 HCO3-29 AnGap-11
___ 08:10AM BLOOD Glucose-105* UreaN-13 Creat-0.6 Na-135
K-4.3 Cl-102 HCO3-29 AnGap-8
___ 08:00AM BLOOD Glucose-100 UreaN-17 Creat-0.6 Na-138
K-4.3 Cl-104 HCO3-29 AnGap-9
___ 07:30PM BLOOD Glucose-120* UreaN-23* Creat-0.7 Na-139
K-4.4 Cl-103 HCO3-28 AnGap-12
___ 04:55PM BLOOD Glucose-109* UreaN-15 Creat-0.7 Na-138
K-4.7 Cl-103 HCO3-27 AnGap-13
___ 07:46AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.1
___ 08:10AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0
___ 08:00AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0
___ 07:30PM BLOOD Calcium-8.6 Phos-2.4* Mg-1.9
___ 10:45PM WBC-6.3 RBC-2.76* HGB-8.5* HCT-25.4* MCV-92
MCH-30.8 MCHC-33.5 RDW-13.8 RDWSD-46.5*
___ 10:45PM NEUTS-56.7 ___ MONOS-12.1 EOS-3.0
BASOS-0.5 IM ___ AbsNeut-3.56 AbsLymp-1.72 AbsMono-0.76
AbsEos-0.19 AbsBaso-0.03
___ 10:45PM PLT COUNT-161
___ 05:03PM ___ COMMENTS-GREEN TOP
___ 05:03PM LACTATE-1.4
___ 04:55PM GLUCOSE-109* UREA N-15 CREAT-0.7 SODIUM-138
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
___ 04:55PM estGFR-Using this
___ 04:55PM WBC-6.6 RBC-3.05*# HGB-9.2*# HCT-28.7*#
MCV-94 MCH-30.2 MCHC-32.1 RDW-13.9 RDWSD-47.8*
___ 04:55PM NEUTS-65.5 ___ MONOS-10.6 EOS-2.0
BASOS-0.3 IM ___ AbsNeut-4.35 AbsLymp-1.42 AbsMono-0.70
AbsEos-0.13 AbsBaso-0.02
___ 04:55PM PLT COUNT-170
___ 04:55PM ___ PTT-38.9* ___
Medications on Admission:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Acetaminophen 1000 mg PO Q8H
9. Docusate Sodium 100 mg PO BID
10. Senna 8.6 mg PO BID
11. Vitamin D 1000 UNIT PO DAILY
12. Warfarin 3 mg PO DAYS (___)
13. EpiPen (EPINEPHrine) 0.3 (1:1,000) INJECTION PRN allergy
14. Warfarin 2 mg PO DAYS (MO,FR)
15. Cephalexin ___ mg PO ONCE
16. fluticasone 88 mcg inhalation BID
17. Losartan Potassium 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. EpiPen (EPINEPHrine) 0.3 (1:1,000) INJECTION PRN allergy
6. Furosemide 20 mg PO DAILY
7. Levothyroxine Sodium 112 mcg PO DAILY
8. Losartan Potassium 12.5 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Warfarin 3 mg PO DAILY
11. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN pain
12. Amoxicillin 500 mg PO Q8H Duration: 2 Doses
13. Docusate Sodium 100 mg PO BID
14. fluticasone 88 mcg inhalation BID
15. Metoprolol Succinate XL 25 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Senna 8.6 mg PO BID
18. Cephalexin ___ mg PO ONCE prior to dental procedures/
cleanings Duration: 1 Dose
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left knee hematoma, blistering
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ status post mechanical fall onto left knee on ___,
on coumadin with elevated INR 2.7, now with increased swelling
TECHNIQUE: Left knee, four views
COMPARISON: ___
FINDINGS:
Patient is status post left total knee arthroplasty. No hardware
complications are present. Alignment is unchanged. There is a small
suprapatellar joint effusion. No acute fracture or dislocation is present.
Soft tissue swelling is noted diffusely about the knee. Subcutaneous nodules
also seen anteriorly within the infrapatellar region.
IMPRESSION:
No acute fracture, dislocation, or evidence of hardware complications.
Diffuse soft tissue swelling.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with fever // fever
TECHNIQUE: Portable chest
COMPARISON: ___.
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change. No new infiltrate
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: s/p Fall, L Knee swelling
Diagnosed with CONTUSION OF KNEE, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING
temperature: 98.1
heartrate: 88.0
resprate: 16.0
o2sat: 97.0
sbp: 110.0
dbp: 57.0
level of pain: 8
level of acuity: 3.0 | The patient was admitted to the orthopedic surgery service for
left knee hematoma & blistering after sustaining a fall.
Her left knee wound was dressed with xeroform & bacitracin,
followed by ABD & ACE wrap. We continued her Amoxicillin for
tooth abscess. We initially held her Coumadin for INR of 2.3
given her hematoma and restarted Coumadin at low dose on
___. On ___, her INR was 1.3- she was restarted on her
home dose of Coumadin (3mg).
On ___, she had two noted temperatures. An infectious
work-up was done including CBC, urinalysis, urine culture, and
blood cultures. The urine culture was negative. Blood cultures
were pending at time of discharge.
On ___ overnight, she triggered for a low blood pressure
(systolics in ___. Blood pressure medications (Lasix & Toprol
XL) were held. Her blood pressure continued to trend low, but
the patient remained asymptomatic. Instructed the patient to
follow-up with her PCP after discharge to see if any changes
need to be made to her blood pressure medications.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient was seen daily by physical
therapy. Labs were checked throughout the hospital course and
repleted accordingly. At the time of discharge the patient was
tolerating a regular diet and feeling well. The patient was
afebrile with stable vital signs. The patient's hematocrit was
acceptable and pain was adequately controlled on an oral
regimen.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity.
Ms. ___ is discharged to home with services in stable
condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Reglan / Quinine Sulfate / Codeine / Augmentin /
Clindamycin / Dilaudid (PF) / Iodine
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with multiple medical
problems including multiple sclerosis with chronic paraplegia
due to spinal cord compression, IDDM, HTN, multiple DVTs (most
recently R left DVT on ___, now therapeutic on coumadin), CAD
(s/p RCA stents ___, seizures and sarcoidosis, who is
presenting with chest pain. The pain started at 5:45pm while she
was at home and trying to get into her wheelchair, which was too
small and causing her to be very frustrated. She describes it as
pressure, starting in her jaw and then radiating to the middle
of her chest, a/w shortness of breath and nausea. Overall the
pain was similar to her prior presentation when the RCA stent
was placed. She took a SL NTG at home which did not help, and
shortly after that she vomited. She called her ambulance company
who brought her to the ED. En route they gave her NTG spray x3,
however she was still in pain when she arrived to the ED. Pain
resolved shortly thereafter. The entire episode lasted about 30
minutes she thinks.
.
In the ED initial VS were hr 94 bp 107/58 rr 14 sat 95/ra. An
EKG showed sinus tach with no significant change from prior. Pt
was not given ASA as she states she is allergic. A chest x-ray
was ordered which showed bibasilar atelectasis with no definite
focal consolidation. A BNP was 114. INR therapeutic at 2.7.
.
On arrival to the floor she appeared comfortable and was denying
any chest pain or shortness of breath. This morning, vitals are
stable and she denies any symptoms.
.
She has a history of multiple DVTs with her most recent
diagnosed two months ago. She has been anticoagulated for each
one for 6 months but has not been placed on lifelong
anticoagulation due to GI bleeds while anticoagulated. At
present she is back on coumadin for her most recent DVT. Her
coumadin is currently at 7.5mg and her last dose of lovenox was
on ___. Followed by HCA ACMS. She had some bleeding from her
earlobe on ___ which mostly resolved with holding pressure
however she called the ___ clinic yesterday saying
she did not want to continue on blood thinners.
.
On review of systems, pt denies any recent cough, shortness of
breath (except during episode of chest pain), fevers. Patient
has chronic lower extremity edema and tenderness associated with
the DVT which has not changed in the last several weeks.
Past Medical History:
-Type II IDDM
-HLD
-HTN
-CAD s/p BMS to mid-RCA in ___ (repeat cath ___ showed <30%
in-stent restenosis)
-PVD s/p left BKA
-Multiple DVTs, previously off Coumadin ___ GI bleeding, back on
Coumadin as of ___ for recurrent R leg DVT
-Stroke in ___, p/w speech difficulty and L-sided weakness and
no residual deficit
-COPD
-Asthma
-OSA
-Obesity
-?Cardiac arrest?
-MS diagnosed in ___, MRI in ___ with innumerable T2 ___
lesions
-spinal cord compression s/p C3-7 and T7-11 laminectomies and
fusion with residual paraparesis and absent sensation in legs
-seizures disorder
-uterine CA s/p radical hysterectomy
-GI bleed while on coumadin
-recurrent UTIs, with indwelling foley catheter
-sarcoidosis
Social History:
___
Family History:
Per OMR: Multiple individuals w/ DM and CAD. Mother died of
brain tumor at ___ and father died of MI at ___. Brother lived to
___ and had a CABG.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1 136/70 97 16 94% RA. FSBS 341.
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Hirsutism on face.
NECK: Unable to assess JVP due to habitus
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2, distant heart sounds, ___ SEM, no rubs
or gallops, unable to appreciate any S3 or S4.
LUNGS: Poor inspiratory effort, diminished breath sounds
throughout, no wheeze appreciated, scattered sparse crackles, no
accessory muscle use.
ABDOMEN: Obese, soft, NTND. No HSM or tenderness.
EXTREMITIES: No significant edema, Left BKA. +Right calf
tenderness (chronic since recurrent DVT ___.
SKIN: Covered wound on RLE.
PULSES:
Right: Carotid 2+ Femoral 1+ DP 1+ ___ 1+
Left: Carotid 2+ Femoral 1+
.
DISCHARGE PHYSICAL EXAM: unchanged
Pertinent Results:
ADMISSION LABS:
___ 07:25PM BLOOD WBC-11.5* RBC-4.31 Hgb-13.3 Hct-36.6
MCV-85 MCH-30.9 MCHC-36.4* RDW-14.2 Plt ___
___ 07:25PM BLOOD Neuts-77.7* Lymphs-14.0* Monos-3.9
Eos-2.8 Baso-1.7
___ 07:25PM BLOOD ___ PTT-48.3* ___
___ 07:25PM BLOOD Glucose-333* UreaN-31* Creat-1.0 Na-137
K-4.4 Cl-98 HCO3-30 AnGap-13
___ 07:25PM BLOOD proBNP-114
___ 07:25PM BLOOD cTropnT-0.02*
___ 03:29AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.0
.
CARDIAC ENZYMES:
___ 07:25PM BLOOD cTropnT-0.02*
___ 03:29AM BLOOD CK-MB-3 cTropnT-0.01
.
CHEST X-RAY (___): Frontal and lateral views of the chest
were obtained. Mild bibasilar atelectasis is seen. No focal
consolidation is seen. There is no large pleural effusion or
pneumothorax. Cardiac and mediastinal silhouettes are stable.
Multilevel degenerative changes along the spine. IMPRESSION:
Bibasilar atelectasis. No definite focal consolidation.
.
2D-ECHOCARDIOGRAM:
___: The left atrium is normal in size. 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. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). 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 appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is an anterior
space which most likely represents a prominent fat pad. Compared
with the prior study (images reviewed) of ___, the
findings are similar.
.
CARDIAC CATH:
Cath ___: Selective coronary angiography of this right
dominant system revealed no significant obstructive coronary
disease. The ___-LAD had a separate ostium from the LCX and was
not cannulated. However, the LAD was noted to be normal in a
prior study on ___. The LCX was normal. The mid-RCA had
mild <30% in-stent restenosis.
2. Resting hemodynamics demonstrated mild systolic arterial
hypertension with BP of 148/80.
Medications on Admission:
-Coumadin 7.5mg (recently lowered, last dose of Lovenox was
___
-Clopidogrel 75mg PO daily
-Atorvastatin 80mg PO QHS
-Lasix 40mg PO daily
-Isosorbide mononitrate 120mg ER PO daily
-Metoprolol tartrate 75mg PO BID
-Carbamazepine 200mg PO QID
-Hydrocodone-acetaminophen ___ mg PO QID prn
-Albuterol sulfate 90 mcg/Actuation HFA q6H prn
-Famotidine 40 mg PO daily
-Fluticasone 110 mcg/Actuation Aerosol 2 puffs BID
-Baclofen 10 mg tab 1 PO TID
-Prochlorperazine maleate 10 mg tab PO q8h prn
-NPH insulin SQ 90 units in AM and 35 units qPM
-Humalog 6 units SQ qAM, no sliding scale
Discharge Medications:
1. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day.
Tablet(s)
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
7. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO four times
a day.
8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
9. famotidine 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
11. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
12. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea.
13. NPH insulin human recomb 100 unit/mL Suspension Sig: Ninety
(90) units Subcutaneous QAM.
14. NPH insulin human recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous at bedtime.
15. Humalog 100 unit/mL Solution Sig: Six (6) units Subcutaneous
QAM.
16. hydrocodone-acetaminophen ___ mg Tablet Sig: One (1)
Tablet PO four times a day as needed for pain.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Chest pain
Secondary:
Multiple sclerosis
DVTs
CAD
IDDM
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
EXAM: Chest, frontal and lateral views.
CLINICAL INFORMATION: ___ female with history of chest pain.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. Mild
bibasilar atelectasis is seen. No focal consolidation is seen. There is no
large pleural effusion or pneumothorax. Cardiac and mediastinal silhouettes
are stable. Multilevel degenerative changes along the spine.
IMPRESSION: Bibasilar atelectasis. No definite focal consolidation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT, MULTIPLE SCLEROSIS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 5
level of acuity: 1.0 | ___ year old woman with multiple medical problems, including MS,
pulmonary sarcoid, paraplegia, chronic indwelling catheter, DM,
CAD, s/p RCA stenting in ___ for unstable angina who presents
with chest pain concerning for ACS in the setting of emotional
stimulus.
.
#.CHEST PAIN: Initially concerning for ACS given description,
setting, resolution with nitro, and similarity to her prior ACS
presentation. Allergic to aspirin so did not receive any in ED.
Troponins negative x2, CK/MB negative. Given h/o DVT, considered
PE, but unlikely bc patient is therapeutic on Coumadin; no e/o
right heart strain on EKG or exam. Considered pneumonia, but
unlikely because no evidence on exam. BNP 114 and no e/o pulm
edema on CXR made CHF unlikely. Considered dobutamine echo (pt
states cannot lie flat for stress test), but determined
unnecessary as chest pain most likely noncardiac. Pt continued
on home statin, plavix and lisinopril.
.
# HTN: BP slightly elevated on admission; had not been on
lisinopril recently. currently slightly elevated. Will plan to
continue her home regimen for now and monitor closely. Of note
she says that she is no longer on lisinopril. Restarted
lisinopril 5mg on hospitalization; discharged on home meds.
.
# COPD: controlled on home regimen, no wheeze on exam. Continued
home fluticasone and albuterol.
.
# IDDM: type II, controlled with complications. Gave ISS and ___
home NPH. Discharged on home meds.
.
# Seizure Disorder: Per pt ___ MS. ___ to have ___
seizures per week (sometimes fewer) while on carbemazapine. Last
seizure was last ___. Continued home carbamazepine; seizure
precautions.
.
# Right Leg DVT: therapeutic on coumadin.
.
# Bleeding from Ear: HD stable. HCT stable. Anticoagulated. No
issues. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L groin pain
Major Surgical or Invasive Procedure:
Foley placement (d/c'd prior to discharge)
History of Present Illness:
Mr. ___ is a ___ male with no significant PMH
presenting
with L-sided groin pain x 6 hours.
Interview conducted with aid of phone ___ interpreter.
Mr. ___ reports that he was in his usual state of health until
___, when he developed acute onset L-sided lower abdominal pain
radiating to his groin around 4pm. He described the pain as
sharp
and "cramping" in nature. It improved somewhat with Aleve but
returned at 7pm, at which time he called EMS and was brought to
the ___ ED. He denies F/C, CP, dysuria, hematuria, back pain,
or decreased urination over the last few days. He had no N/V at
home, but after arrival to the ED he was intermittently
nauseated
and had 3 episodes of NBNB emesis. He denies
diarrhea/constipation or melena/hematochezia, with last bowel
movement ___. He has no history of kidney stones and no prior,
similar episodes. No recent weight loss. He does report taking
vit C daily for mouth sores, which he purchased from ___.
ED
VS T97.6, HR 90, BP 160/102, RR 18, 100% on RA --> HR 107, BP
111/58, RR 17, 100% 4L NC (reportedly with brief desaturations
to
the ___ on RA)
Exam: abd soft, NT, no flank or CVA tenderness
Labs: CBC WNL, Cr 1.2, K 3.4, HCO3 16, AG 22, Phos 0.7, LFTs
WNL,
lipase WNL, VBG ___ (unreliable per ED, added to old labs)
--> 7.42/31, lactate 4.4 -> 2.4, Stox neg, UA/UCx/BCx pending
Imaging: CTU with mild L-sided hydroureteronephrosis with distal
ureteral stone 2mm in size, CXR without consolidation or
pulmonary edema
Consults: Urology by phone thought presentation c/w stone and
dehydration
Interventions: morphine 4mg then 2mg, toradol, Zofran 4mg x 2,
Ativan 1mg, CTX 1g (06:20), NS 2L, LR 3L, bladder scanned
multiple times for 70cc so Foley eventually placed with 70cc UOP
(UA/UCx sent)
On arrival to the floor, Mr. ___ reports complete resolution of
his groin pain. He denies F/C, SOB, cough/hemoptysis, flank
pain,
N/V, dysuria, diarrhea/constipation, melena/hematochezia,
dizziness/lightheadedness, headaches, new rashes.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
No known ___
Social History:
___
Family History:
Parents are alive and healthy. No known history of renal disease
or renal stones.
Physical Exam:
ADMISSION:
==========
T98.2, BP 123/72, HR 96, RR 14, 100% RA
Lying 121/78, HR 92
Sitting 125/81, HR 100
Standing 119/74, HR 105
UOP: 399 cc since ___ AM
GENERAL: NAD, lying comfortably in bed
EYES: PERRL, anicteric sclerae
ENT: OP clear
CV: RRR, nl S1, S2, no M/R/G, no JVD
RESP: CTAB, no crackles, wheezes, or rhonchi
GI: + BS, soft, NT, ND, no rebound/guarding, no HSM
GU: No suprapubic fullness or tenderness to palpation; Foley in
place draining yellow urine; no CVA tenderness b/l
SKIN: No rashes or ulcerations noted
MSK: Lower extremities warm without edema
NEURO: AOx3, CN II-XII intact, ___ strength in all extremities,
sensation grossly intact throughout, gait testing deferred
PSYCH: pleasant, appropriate affect
DISCHARGE:
==========
24 HR Data (last updated ___ @ 746)
Temp: 98.5 (Tm 99.8), BP: 100/63 (100-133/63-81), HR: 83
(74-85),
RR: 16, O2 sat: 98% (98-100), O2 delivery: RA
___: 950cc UOP since MN
___: 4.2L UOP
GENERAL: NAD, lying comfortably in bed
EYES: PERRL, anicteric sclerae
ENT: OP clear
CV: RRR, nl S1, S2, no M/R/G, no JVD
RESP: CTAB, no crackles, wheezes, or rhonchi
GI: + BS, soft, NT, ND, no rebound/guarding, no HSM
GU: No suprapubic fullness or tenderness to palpation, no CVA
tenderness, no Foley
SKIN: No rashes or ulcerations noted
MSK: Lower extremities warm without edema
NEURO: AOx3, CN II-XII intact, ___ strength in all extremities,
sensation grossly intact throughout, gait testing deferred
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION:
==========
___ 10:30PM BLOOD WBC-7.8 RBC-5.06 Hgb-15.2 Hct-43.8 MCV-87
MCH-30.0 MCHC-34.7 RDW-12.5 RDWSD-39.0 Plt ___
___ 10:30PM BLOOD Neuts-60.2 ___ Monos-3.8* Eos-1.8
Baso-0.6 Im ___ AbsNeut-4.70 AbsLymp-2.59 AbsMono-0.30
AbsEos-0.14 AbsBaso-0.05
___ 10:30PM BLOOD Plt ___
___ 10:30PM BLOOD Glucose-131* UreaN-12 Creat-1.2 Na-141
K-3.4* Cl-103 HCO3-16* AnGap-22*
___ 02:50AM BLOOD ALT-12 AST-14 AlkPhos-46 TotBili-0.7
___ 02:50AM BLOOD Lipase-26
___ 10:30PM BLOOD Calcium-9.9 Phos-0.7* Mg-2.1
___ 12:57AM BLOOD pO2-58* pCO2-19* pH-7.56* calTCO2-18*
Base XS--1 Comment-GREEN TOP
___ 01:08AM BLOOD pO2-40* pCO2-31* pH-7.42 calTCO2-21 Base
XS--2 Intubat-NOT INTUBA
___ 03:18AM BLOOD Lactate-4.4*
DISCHARGE:
==========
___ 12:53PM BLOOD WBC-8.2 RBC-4.19* Hgb-12.5* Hct-37.1*
MCV-89 MCH-29.8 MCHC-33.7 RDW-12.3 RDWSD-39.8 Plt ___
___ 06:15AM BLOOD Neuts-76.0* Lymphs-13.8* Monos-9.2
Eos-0.5* Baso-0.2 Im ___ AbsNeut-6.97* AbsLymp-1.27
AbsMono-0.85* AbsEos-0.05 AbsBaso-0.02
___ 06:15AM BLOOD Glucose-100 UreaN-6 Creat-1.2 Na-142
K-3.7 Cl-104 HCO3-27 AnGap-11
___ 06:15AM BLOOD ALT-8 AST-14 AlkPhos-39* TotBili-1.1
___ 06:15AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9
___ 07:10AM BLOOD Lactate-1.6
UA (___): pH 7.0, lg blood, sm ___, 10 ket, 3 RBCs, 2 WBC, few
bact, 0 epis
UA ___ s/p Foley): pH 6.5, lg blood, 100 prot, 40 ket, neg
nit,
neg ___, > 182 RBCs, 4 WBCs, few bact, <1 epi
Ulytes (___):
UNa 100, UCr 373 (FeNa 0.2%)
UCx (___): negative
UCx (___): 1000 cfu Alpha hemolytic colonies consistent with
alpha streptococcus or Lactobacillus sp.
BCx (___): pending x2
IMAGING:
=========
EKG (___): ST at 105 bpm, nl axis, PR 158, QRS 90, QTC 462,
incomplete RBBB, TWI V2 (no prior for comparison)
CT urogram (___):
Mild hydroureteronephrosis on the left with distal ureteral
stone
measuring 2 mm in size. Additional 2-mm right renal stone is
seen
in the lower pole of the right kidney without right-sided
hydroureteronephrosis.
KUB (___):
No small bowel obstruction. Multiple densities consistent with
renal and ureteral calculi are better characterized on
concurrent
CT urogram.
CXR (___):
No focal consolidation. No suggestion of fluid overload.
Renal U/S (___):
1. Mild left-sided hydronephrosis, unchanged compared to recent
CT. No evidence of perinephric abscess.
2. No right-sided hydronephrosis.
3. Bladder is moderately distended with fluid despite presence
of
the Foley catheter which is not inferior definitively within the
bladder, concerning for malpositioning.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth nightly Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Nephrolithiasis with mild L-sided hydroureteronephrosis
Secondary:
Oliguric ___
Normocytic anemia
Microscopic hematuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT urogram without contrast.
INDICATION: ___ with left flank pain// Evaluate for kidney stone
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 5.9 s, 46.1 cm; CTDIvol = 4.1 mGy (Body) DLP = 190.2
mGy-cm.
Total DLP (Body) = 190 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas 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. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
mild hydroureteronephrosis on the left with distal ureteral stone measuring 2
mm in size. An additional 2-mm right renal stone is seen in the lower pole
without right-sided hydroureteronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Mild hydroureteronephrosis on the left with distal ureteral stone measuring 2
mm in size. Additional 2-mm right renal stone is seen in the lower pole of
the right kidney without right-sided hydroureteronephrosis.
Radiology Report
INDICATION: History: ___ with kidney stone// Evaluate position as per urology
protocol
TECHNIQUE: AP supine radiograph of the abdomen.
COMPARISON: Concurrent CT abdomen and pelvis
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
Millimetric density projecting over the region the right kidney is consistent
with interpolar right stone seen on concurrent CTU. Multiple densities are
seen in the pelvis, most superior of which likely represents ureteral
vesicular stone seen on recent CT.
IMPRESSION:
No small bowel obstruction. Multiple densities consistent with renal and
ureteral calculi are better characterized on concurrent CT urogram.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with kidney stone, desaturation// volume status
TECHNIQUE: AP upright portable view of the chest
COMPARISON: No relevant comparison identified.
FINDINGS:
Lungs are clear. Pleural spaces are normal. Cardiomediastinal silhouette is
normal.
IMPRESSION:
No focal consolidation. No suggestion of fluid overload.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with L CVA tenderness and nephrolithiasis with L
hydroureteronephrosis.// Please evaluate for hydro bilaterally and e/o
perinephric abscess on L.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
The right kidney measures 10.4 cm. The left kidney measures 10.5 cm there is
mild left-sided hydronephrosis. No stones or masses seen bilaterally. Normal
cortical echogenicity and corticomedullary differentiation are seen
bilaterally.
Bladder contains a small amount of fluid. Foley catheter does not appear
definitively within bladder.
IMPRESSION:
1. Mild left-sided hydronephrosis, unchanged compared to recent CT. No
evidence of perinephric abscess.
2. No right-sided hydronephrosis.
3. Bladder is moderately distended with fluid despite presence of the Foley
catheter which is not inferior definitively within the bladder, concerning for
malpositioning.
Gender: M
Race: ASIAN
Arrive by WALK IN
Chief complaint: L Flank pain
Diagnosed with Unspecified renal colic, Acidosis
temperature: 97.6
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 160.0
dbp: 102.0
level of pain: 10
level of acuity: 3.0 | ___ ___ man with no significant PMH
presenting with acute onset L-sided groin pain x 6 hours, likely
secondary to L-sided ureteral stone and mild L
hydroureteronephrosis, with course c/b oliguric ___, now
resolved.
# L-sided inguinal pain:
# Nausea/emesis:
# L-sided mild hydroureteronephrosis with distal 2mm ureteral
calculus:
# Oliguric ___:
# Elevated lactate:
Mr. ___ presented with ___ L inguinal pain and was
found
to have a 2mm distal ureteral stone with mild L
hydroureteronephrosis, as well as a 2mm R ureteral stone without
R-sided hydronephrosis. Stones likely calcium in composition,
possibly in setting of excessive vit C consumption. His pain and
nausea were controlled with morphine and Zofran in the ED.
Initial labs were suggestive of profound dehydration in setting
of emesis and poor PO intake, with lactate elevated to 4.4 and
Cr
to 1.3-1.4 (b/l unclear). He received 5L IVFs in the ED with
persistent poor UOP despite Foley catheter placement. He was
admitted to the hospital and received an additional 2L IVFs with
resolution of his oliguria and elevated lactate and improvement
in his Cr to 1.2 at discharge. UA was negative x 2. Initial UCx
grew ~1000 cfu GPCs (alpha hemolytic colonies) with repeat UCx
negative. Renal U/S on ___ showed mild, stable L hydronephrosis
without evidence of ___ abscess. He received
ceftriaxone
1g in the ED, not continued on admission in absence of evidence
for a UTI. ___ was discontinued on ___ and patient voided
spontaneously. Urology was consulted and recommended initiation
of tamsulosin 0.4mg QHS as medical expulsion therapy pending
outpatient urology ___. He will ___ with urology on ___ (Dr.
___ for repeat renal U/S to ensure stone passage. He was
advised to strain his urine and bring stone fragments to his
urology appointment. In addition, he was advised to discontinue
vitamin C supplementation. Of note, patient is scheduled to
travel to ___ to visit family on ___ I advised him to
postpone this trip given the need for repeat labwork this week
and the possibility of recurrent symptoms prior to confirming
stone passage at ___ clinic on ___. Should he decide to
travel, he confirmed that he will have ready access to medical
care.
# Normocytic anemia:
# Microscopic hematuria:
Hgb downtrended from 15.2 on admission to 11.7 on ___, improved
on recheck without intervention to 12.5 prior to discharge.
Initial UA ___ immediately after Foley placement showed >182
RBCs, likely secondary to nephrolithiasis vs traumatic Foley
placement, with repeat UA ___ showing only 3 RBCs with no
evidence of gross hematuria. He should have a repeat CBC drawn
at
a PCP ___ on ___ (will be seen at ___) to ensure stability. Further ___ of microscopic
hematuria
deferred to outpatient urology.
# Hypoxia:
Per ED, patient reportedly has transient desaturations to the
___
on RA, which resolved spontaneously. CXR without evidence of PNA
or edema, and no clinical evidence of volume overload. On
admission and discharge he was breathing comfortably and
saturating well on RA.
** TRANSITIONAL **
[ ] ___ with urology ___ for repeat renal U/S to ensure stone
passage and to ___ microscopic hematuria
[ ] repeat CBC and BMP on ___ to ensure stability of anemia and
improvement in ___
[ ] ___ BCx, pending at discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Desipramine / Lisinopril / Erythromycin Base /
Tetracycline / Oxycodone / Tramadol / Propoxyphene / Zocor /
Hydrocodone / Phenothiazines / Hydroxychloroquine /
ciprofloxacin / morphine
Attending: ___
Chief Complaint:
Headache and Fever
Major Surgical or Invasive Procedure:
LP
History of Present Illness:
Ms. ___ is a ___ year old woman with a PMHx of GN s/p living
donor Tx in ___ who presents with febrile neutropenia. Ms.
___ has been neutropenic for approximately 1 month possibly
secondary to valcyte vs. MMF (both have been d/c'd). She
presents today with headache and fever (she measured 100.4 at
home with oral thermometer). Both began at approximately 7pm.
She noted simultaneously a frontal headache without
nausea/vomiting, neck pain, or neck stiffness. She has 1 sick
contact in the form of her ___ year old grand-daughter who came to
visit today around noon for a birthday party and had "the
sniffles".
.
In the ED initial VS were 99.6 85 162/65 15 99% RA. Labs
significant for leukopenia to 1.7 with 35% PMNs, LP was
performed and results are pending. CXR WNL. UA WNL. Given
Vancomycin 1gm, Cefepime 2gm, Acyclovir 600mg, and 2mg dilaudid
as well as 25mg of benadyrl. VS prior to transfer were 98.3 °F
(36.8 °C), Pulse: 86, RR: 18, BP: 134/64, O2Sat: 98.
Past Medical History:
- Renal Failure, attributed to glomerulonephritis, no renal
biopsy. Hematuria in early ___ with progressive renal failure
and hypertension. Baseline creatinine, per patient is ___. Also
recalls two renal cysts.
- s/p ERCP for gallstones resulting in severe hoarseness
requiring ENT consultation
S/p CCY/appendectomy in her ___
- Connective tissue disease undifferentiated - ___
Fluctuating complicated course with potential diagnoses of
Crohn's, MS proteinuria, hematuria, rheum thought that the
unifying diagnosis is collagen vascular disease with
fibromyalgia.
- Multiple Sclerosis Diagnosed formally in ___ when patient
had classic findings on brain MRI. First event with left-sided
weakness and some sensory changes in legs. Four to five flares
in total. Last in ___ during hospital stay with sepsis. Unclear
if steroid treatments used. Some spacticity treated with
baclofen.
Remaining deficits include dysequilibrium, numbness, weakness of
left side.
-Psoriasis: skin psoriasis with plaquenil which resolved with
d/c
of plaquenil.
-Restless Legs Syndrome
Unclear if PLMD. Treated for several years with Mirapex.
-Migraine
-From young adulthood until menopause. Unilateral (but of either
side), photophobia and phonophobia present. Occasional aura.
Very
different than present complaint. Throbbing character.
- Fibromyalgia, affecting upper back, spine
- Back Pain
- Arthritis/DJD of spine
- Pancreatitis,
- ___ esophagus
- Sinus disease, years standing with deviated septum repair in
___. Post-nasal drip continues. No recent obvious sinus-like
pain (typical frontal and maxillary).
Social History:
___
Family History:
Father with DM. He died suddenly in his ___ of unclear causes.
Her mother died of dementia in her ___. Her brother committed
suicide.
Physical Exam:
ADMISSION:
VITALS: 99.2, 139/70, 78, 18, 100% RA, 54kg
GENERAL: well appearing woman, talkative and conversant, minor
distress ___ headache
HEENT: PERRL, EOMI, dry MM
NECK: no carotid bruits, no JVD, supple
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3, strength intact diffusely, no
kernigs/brudzinski's,
D/C:
O -
PHYSICAL EXAMINATION:
VITALS: 98.2/99.3, 137/69(104-140/50-70), 68-78, 18, 100% RA
GENERAL: Thin, pale, well appearing woman. Answers all questions
appropriate. AAOx3. No pain
HEENT: EOMI, moist MM, violaceous coloring around eyes
NECK: No nuchal rigidity, able to touch chin to chest,
left&right without pain. Brudzinsky and Kernig negative.
LUNGS: CTA b/l, unlabored. speaking in full sentences.
HEART: RRR, no MRG
ABDOMEN: Thin, Soft, NT, NABS
EXTREMITIES: No edema, warm, 2+ pulses
NEUROLOGIC: No tremor or asterixis
Pertinent Results:
ADMISSION:
___ 11:15PM BLOOD WBC-1.7*# RBC-2.99* Hgb-9.5* Hct-28.5*
MCV-95 MCH-31.9 MCHC-33.5 RDW-13.2 Plt ___
___ 11:15PM BLOOD Neuts-35* Bands-4 ___ Monos-18*
Eos-1 Baso-1 Atyps-2* Metas-1* Myelos-2*
___ 11:15PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-1+ Polychr-1+ Ovalocy-1+ Target-1+
D/C:
___ 05:55AM BLOOD WBC-1.4* RBC-2.81* Hgb-8.6* Hct-26.7*
MCV-95 MCH-30.8 MCHC-32.4 RDW-12.8 Plt ___
___ 05:55AM BLOOD Neuts-35* Bands-0 ___ Monos-17*
Eos-6* Baso-0 Atyps-3* ___ Myelos-0
___ 05:55AM BLOOD Glucose-100 UreaN-16 Creat-0.8 Na-141
K-4.5 Cl-105 HCO3-28 AnGap-13
STUDIES:
CSF: Cx = No Growth
___ 02:10AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-0
___ ___ 02:10AM CEREBROSPINAL FLUID (CSF) TotProt-38 Glucose-65
CXR - FRONTAL AND LATERAL CHEST RADIOGRAPHS: The heart size is
normal. The hilar
and mediastinal contours are within normal limits. There is no
pneumothorax,
focal consolidation, or pleural effusion.
IMPRESSION: No acute intrathoracic process.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Allopurinol ___ mg PO DAILY
3. Colchicine 0.6 mg PO DAILY:PRN gout
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
6. Atenolol 25 mg PO DAILY
hold for sbp < 90, hr < 55
7. Amlodipine 5 mg PO DAILY
hold sbp < 90
8. Baclofen 5 mg PO BID:PRN spacicity
9. Tacrolimus 3 mg PO Q12H
10. multivitamin *NF* 1 tab Oral daily
11. pramipexole *NF* 0.125-0.25 mg Oral qhs
12. Metoclopramide 10 mg PO Q8H:PRN headache or nausea
13. esomeprazole magnesium *NF* 20 mg Oral BID
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
15. biotin *NF* 1 mg Oral daily
16. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Amlodipine 5 mg PO DAILY
hold sbp < 90
3. Atenolol 25 mg PO DAILY
hold for sbp < 90, hr < 55
4. Baclofen 5 mg PO BID:PRN spacicity
5. biotin *NF* 1 mg Oral daily
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Metoclopramide 10 mg PO Q8H:PRN headache or nausea
8. pramipexole *NF* 0.125-0.25 mg Oral qhs
9. Tacrolimus 3 mg PO Q12H
10. Vitamin D 1000 UNIT PO DAILY
11. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
12. Esomeprazole Magnesium *NF* 20 mg ORAL BID
13. multivitamin *NF* 1 tab Oral daily
14. Hydrocortisone Cream 2.5% 1 Appl TP DAILY Duration: 1 Weeks
apply to lower eye lids
RX *hydrocortisone 2.5 % apply thin layer to affected areas
under the eyes once a day Disp #*1 Tube Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Neutropenic fever
Secondary:
Dermatitis
Glomerulonephritis status post renal transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Fever.
COMPARISON: Radiograph available from ___.
FRONTAL AND LATERAL CHEST RADIOGRAPHS: The heart size is normal. The hilar
and mediastinal contours are within normal limits. There is no pneumothorax,
focal consolidation, or pleural effusion.
IMPRESSION: No acute intrathoracic process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVERS POST TRANSPLANT
Diagnosed with FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE, NEUTROPENIA, UNSPECIFIED , HEADACHE
temperature: 99.6
heartrate: 85.0
resprate: 15.0
o2sat: 99.0
sbp: 162.0
dbp: 65.0
level of pain: 2
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with a renal allograft in
___ who presents with febrile neutropenia (at home measured
100.4) and HA concerning for potential meningitis.
# Febrile with Headache in background of Neutropenia: The
patient noted a resolution of her headache on day 2 of her
admission. Her temperature remained afebrile since admission and
through out her stay. In the ED the patient had a spinal LP to
evaluate for potential meningitis. The results of the CSF were
benign and the patient was subsequently taken off all
antibiotics. Her urine cx, and blood cx did were negative. Her
CSF cx was also negative. Her CXR was not concerning. We sent
labs for Adenovirus which is pending. She is unlikely to be
infected with CMV as her serology from couple days PTA was
negative. She was watched for 24 hours after stopping all
antibiotics. On day of discharge the patient was afebrile X 72
hours. She was without headache, no nuchal rigidity, and
without any other sources of pain. She was tolerating full PO,
able to urinate and move bowels without problems.
.
# Neutropenia: The neutropenia was first observed about one
month ago in the outpatient setting. Since then her Valcyte and
MMF were stopped as an outpatient. In the hospital we also
stopped Bactrim, and Allopurinol as those could also contribute
to the problem. Her ___ Ct remained stable between 450 and
500. On day of discharge her ___ Ct was 490. We also sent
virology for BK virus. The patient was instructed to have her
CBC checked bi-weekly. She was instructed to not use the Bactrim
as an outpatient until seen by Renal Transplant clinic.
.
Renal Transplant in ___: We continued her tacrolimus and
followed her daily tacro levels, which were wnl. As above,
Bactrim for PCP ppx was held until next appt with renal
transplant.
..
# Eye rash - patient was seen and consulted by Dermatology. They
are working up a potential connective tissue disease such as
Dermatomyositis. We sent of titers for ___, AntiJo1, Anti-Mi,
Aldolase, and CK. They made an appointment for her on ___ to
follow up as an outpatient.
.
For her HTN we continued atenolol and amlodipine
.
For her RLS we continue pramipexole
.
For her GERD we continued: esomeprazole
.
On day of discharge the patient did not complain of a headache.
She was afebrile > 72 hours. Her neutropenia remained unchanged
from prior to admission and this will be followed closely as an
outpatient by renal transplant |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old female with PMHx significant for
COPD and Colon polyps who was ambulating in her kitchen today
when her right knee buckled and she fell striking her head. She
reports remembers falling but does not recall after the fall.
She
reportedly had definite LOC per her daughter who was able to
easily arouse her. She went to an OSH where imaging revealed a
small right temporal SDH. She was transferred to ___ for
further management and care. She endorses mild pain at the site
of her head strike. She denies nausea, vomiting, dizziness,
changes in vision, speech, or hearing, changes in bowel or
bladder function.
Past Medical History:
COPD, Colon Polyps, constipation, right patellar
dislocation
Social History:
___
Family History:
NC
Physical Exam:
Upon Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERLL EOMs: intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
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, 4mm to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to modality of light touch bilaterally.
Reports
occasional sensory changes in Right knee region which are
chronic
Toes downgoing bilaterally
Upon Discharge:
alert and oriented x 3. PERRL bilaterally. EOMs intact. Tongue
midline. Face symmetric. No pronator drift. MAE ___ strength.
Pertinent Results:
___ NCHCT
No interval change in size of small right subdural hematoma
overlying the
Preliminary Reportfronto-temporal convexity.
Medications on Admission:
doxycycline, aricept, wellbutrin sr, amitiza, miralax, advair
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
2. Bisacodyl 10 mg PO/PR DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*12 Tablet Refills:*0
5. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6 hours PRN Disp
#*45 Tablet Refills:*0
Please continue your home medications
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subdural Hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Subdural hematoma, sternal tenderness, evaluate for sternal
injury.
COMPARISON: None available.
FINDINGS: AP and lateral views of the chest. There is mild cardiomegaly.
There is bibasilar atelectasis. No pleural effusion or pneumothorax. No
sternal abnormalities identified on the lateral film. There is kyphosis of
the thoracic spine. The mediastinal and hilar contours are normal. Mild
bibasilar atelectasis.
IMPRESSION: Mild cardiomegaly and bibasilar atelectasis. No gross sternal
fracture.
Radiology Report
HISTORY: Small right subdural hematoma. Evaluate for interval change.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Coronal and sagittal as well as
bone algorithm reconstructed images were obtained.
DLP: 891.93 mGy-cm.
CTDIvol: 53 mGy.
COMPARISON: Reference CT of the head from ___.
FINDINGS:
Compared to the study from 1 day prior, there is no change in the small right
subdural hematoma overlying the frontotemporal convexity, with millimetric
shift of the midline structures towards the left. There is no evidence of new
hemorrhage, edema, mass effect, or infarct. Prominence of the ventricles and
sulci is consistent with global atrophy. Tiny periventricular hypodensities
are consistent with chronic small vessel ischemia.
No fractures identified. Mucous retention cysts are seen in the maxillary
sinuses bilaterally. Minimal mucosal thickening of the right posterior ethmoid
air cell. Otherwise, the paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. Vascular calcifications are noted in the carotid siphons
bilaterally. The globes are unremarkable.
IMPRESSION:
No interval change in size of small right subdural hematoma overlying the
fronto-temporal convexity.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: SDH
Diagnosed with SUBDURAL HEM-BRIEF COMA, OTHER FALL
temperature: 98.5
heartrate: 89.0
resprate: 20.0
o2sat: 93.0
sbp: 136.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | ___ who had an unwitnessed fall striking herhead with brief LOC.
She was easily aroused and was intact immediately following the
fall. She was admitted to the neurosurgical service for Q4 hour
neuro checks and vital signs. She was started on Keppra 500 mg
BID.
On ___ the patient remained neurologically stable. A repeat
NCHCT was completed which revealed a stable SDH. It was noted by
nursing that the patient was unstable on her feet so a ___
consult was obtained. ___ recommended the patient use a walker
for stability and her for to be discharged home with home ___.
The patient was discharged home in stable condition with
instructions for follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Claritin / Feldene / ciprofloxacin
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo ___ man with history of borderline HTN and BPH who presents
with an episode of nonfluent aphasia.
He was in ___ for the winter and drove himself back,
arriving
in ___ last ___. He reports that he was driving up to 8
hours per day, but did take time to sight see and other things.
Denies pain or swelling in legs. Since he has been home, he has
had some URI/flu like symptoms, with temps to 101, stuffy nose,
sore throat and cough. Today was the first day he felt better,
so
he decided to call up his friends to go to lunch. He did feel a
little bit lightheaded, so he was trying to drink more fluid and
get some soda to get some sugar into his system.
He was telling a story when all of sudden, he had difficulty
telling the story and could not speak. His friend was speaking
to
him and he could understand things that were said to him, but he
just could not speak back. It lasted about ___ minutes and
resolved. He called his PCP to ask about the episode and was
instructed to come to the ED.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
PMHx:
- BPH
- Allergic Rhinitis
- History of hematuria, ___ -> simple renal cyst; pending
repeat
cystoscopy in next couple of weeks
- actinic keratosis/SCC
(Per OMR, pt does not report)
Borderline HLD/HTN
Vasovagal syncope with blood draws
Social History:
___
Family History:
Family Hx:
Mother passed away at age ___ from ___, had dementia
Father passed away at age ___ from kidney failure
Sister healthy
Physical ___:
Vitals:
General: Awake, cooperative, NAD. Little bit anxious.
HEENT: NC/AT
Neck: Supple. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, warm to palpation
Skin: no rashes or lesions noted.
Neurologic:
- Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of neglect. There was no evidence of left-right
confusion as the patient was able to accurately follow the
instruction to touch left ear with right hand.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: 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 IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation
throughout. Slightly diminished vibration at the big toes
bilaterally. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1+ 1+ 1+ 2 1
R 1+ 1+ 1+ 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
Pertinent Results:
___ 01:30PM ___ PTT-30.5 ___
___ 01:30PM PLT COUNT-149*
___ 01:30PM NEUTS-45.4* ___ MONOS-11.9* EOS-3.0
BASOS-3.1*
___ 01:30PM WBC-3.8*# RBC-5.56 HGB-16.1 HCT-49.9 MCV-90
MCH-29.0 MCHC-32.4 RDW-12.3
___ 01:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:30PM ALBUMIN-4.3 CALCIUM-8.9 PHOSPHATE-3.0
MAGNESIUM-2.1
___ 01:30PM cTropnT-<0.01
___ 01:30PM ALT(SGPT)-20 AST(SGOT)-26 ALK PHOS-56 TOT
BILI-0.5
___ 01:30PM estGFR-Using this
___ 01:30PM GLUCOSE-106* UREA N-14 CREAT-1.0 SODIUM-137
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-27 ANION GAP-15
___ 01:40PM GLUCOSE-106* NA+-143 K+-4.2 CL--95* TCO2-30
___ 01:44PM estGFR-Using this
___ 01:44PM CREAT-0.9
___ 02:00PM URINE RBC-0 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
___ 02:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 02:00PM URINE GR HOLD-HOLD
___ 02:00PM URINE HOURS-RANDOM
___ 02:00PM URINE HOURS-RANDOM
___ 09:10PM CK-MB-2 cTropnT-<0.01
___ 09:10PM CK(CPK)-66
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Avodart (dutasteride) 0.5 mg oral DAILY
Discharge Medications:
1. Avodart (dutasteride) 0.5 mg oral DAILY
2. Aspirin 325 mg PO DAILY
3. Finasteride 5 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
TIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Transient confusion.
COMPARISON: None.
FINDINGS: Frontal and lateral views of the chest were obtained. No focal
consolidation, pleural effusion or evidence of pneumothorax is seen. There is
slight prominence of the hila and underlying lymphadenopathy is not excluded.
The cardiac and mediastinal silhouettes are unremarkable.
IMPRESSION: Slight prominence of the hila, underlying lymphadenopathy not
excluded, although no definite evidence of such on the lateral view.
Radiology Report
TECHNIQUE: CT of the head and neck with contrast.
HISTORY: Code stroke.
COMPARISON: ___.
FINDINGS: On the unenhanced scan, no evidence for acute ischemia,
hydrocephalus, hemorrhage or mass is seen.
CTA of the circle of ___ demonstrates no aneurysm or high-grade stenosis.
CTA of the neck demonstrates mild calcification of the right carotid bulb. No
high-grade stenosis.
There are prominent scattered lymph nodes in the neck, which are not enlarged
by size criteria. Clinical correlation is advised.
There is mild mucosal thickening in the bilateral maxillary sinus. Scattered
bilateral ethmoid opacification seen.
IMPRESSION: No vascular abnormality detected.
Prominent lymph nodes in the neck, clinically correlate.
Mild mucosal thickening in bilateral maxillary and ethmoid sinuses.
Radiology Report
HISTORY: Recent long drive, now presenting with nonfluent aphasia concerning
for clot. Evaluate for DVT.
TECHNIQUE: Grayscale and color Doppler evaluation of the bilateral lower
extremities was performed.
COMPARISON: None available.
FINDINGS:
There is normal respiratory variation in the common femoral veins bilaterally.
Normal compressibility, flow, and augmentation of the bilateral common,
proximal, mid, and distal femoral and popliteal veins is seen. Normal color
flow is demonstrated in the posterior tibial and peroneal veins bilaterally.
IMPRESSION:
No evidence of deep vein thrombosis in the right or left lower extremity.
Radiology Report
TECHNIQUE: MRI of the brain without gad.
HISTORY: Transient nonfluent aphasia, evaluate for infarction.
COMPARISON: CTA head from ___.
FINDINGS: There is no evidence for acute infarction, mass, or midline shift.
Intracranial flow voids are present. Ventricles and sulci are age
appropriate. Scattered ethmoid opacification is noted.
IMPRESSION: No evidence for acute ischemia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: EPISODE APHASIA
Diagnosed with TRANS CEREB ISCHEMIA NOS
temperature: nan
heartrate: 80.0
resprate: 20.0
o2sat: 99.0
sbp: 150.0
dbp: 76.0
level of pain: 0
level of acuity: 1.0 | # Neuro
On initial assessment in the ED he was back to his normal state
of health
without deficits. NCHCT and CTA head/neck were within normal
limits, he was admitted and overnight his exam remained stable.
He underwent MRI of his brain in the morning which did not
reveal any evidence for ischemia. He was diagnosed with a
transient ischemic attack. The differential diagnosis includes a
complex partial seizure.
He did not have arrhythmias on telemetry in the hospital.
He underwent dopplers of his lower extremities which did not
show evidence of thrombosis.
The remainder of his workup including Echo and EEG were deferred
to the outpatient setting given the patient's stable condition
and lack of findings. He was started on aspirin 325mg daily and
will follow up with Dr. ___ in the outpatient clinic. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Daypro / Tramadol / Hydrocodone / bee venom
protein (honey bee) / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug)
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Right heart catheterization ___
Left heart catheterization ___
History of Present Illness:
Ms. ___ is a ___ female with medical history
notable
for RA, ILD (UIP), pulmonary artery hypertension who presents to
the ED with dyspnea.
Per patient, her shortness of breath has been worsening over the
past x1 month, described as dyspnea with exertion, difficulty
catching her breath after exertion. She used to be able to play
with her grandson in the yard w/o difficulty. A month ago she
could walk 20+ steps w/o issue, now she walks 5 steps and is
significantly dyspneic with lightheadedness. She has a chronic
cough that started ___ ago for which her Albuterol and
Symbicort
help. She saw her outpatient Pulmonologist on ___ who
recommended RHC in the setting of increased lightheadedness and
evidence of volume overload. Today, she reported that her
shortness of breath got acutely worse.
In the ED initial vitals were: 98.2 110 147/70 17 85% RA
She was placed on BiPAP due to hypoxia.
EKG: TWIs in V2-V6
Labs/studies notable for: proBNP: 5261, Lactate 3.3->1.9,
Trop<0.01, WBC 7.3, FluA/B neg, CXR with concern for worsening
interstitial lung disease and question of pneumonia
Patient was given: lasix 40mg IV x1, nitroglycerin sl x1, Foley
inserted
Vitals on transfer: 98.1 98 143/96 22 95% 4L NC
On the floor...
She reports significant dyspnea with exertion but not much SOB
at
rest (currently on 4LNC). She feels better than she did this
morning. Denies CP, fever, chills, cervical LAD, rhinorrhea,
nasal congestion, sore throat, or cough.
REVIEW OF SYSTEMS:
Positive per HPI, otherwise 10pt ROS obtained and negative
Past Medical History:
-Rheumatoid arthritis
-Bilateral knee osteoarthritis
-Interstitial lung disease (UIP)
-HTN
-Iron deficiency anemia
-Depression
-Diet controlled borderline diabetes
-Right total knee replacement
-Left total knee replacement
-Cyst removed from left wrist (age ___
-Cholecystitis ___
Social History:
___
Family History:
Mother with rheumatoid arthritis, CHF, and a pacemaker
Oldest brother had CHF
Father with OA
No history of ischemic heart disease or stroke
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
============================
VS: T 97.5 BP 139/88 HR 106 RR 22 O2SAT 92% 4LNC
GENERAL: Well developed, well nourished elderly woman, NAD,
tachypneic
NEURO: A&Ox3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
Dry mucosa.
NECK: Supple. JVP of 12cm. Positive hepatojugular reflex.
CARDIAC: Tachycardia with regular 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 but tachypneic. Dry
crackles throughout, rales cannot be excluded, no wheezes and
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
GU: Foley draining clear, yellow urine
EXTREMITIES: Warm, well perfused. No clubbing or cyanosis. 1+
pitting edema in b/l ___ up to mid leg.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAMINATION:
============================
VS: 24 HR Data (last updated ___ @ 507)
Temp: 97.9 (Tm 98.1), BP: 106/70 (79-132/47-88), HR: 91
(77-100), RR: 18 (___), O2 sat: 92% (85-98), O2 delivery: 4L
(4L-8L ambulating)
GENERAL: Well developed, well nourished elderly woman, NAD,
tachypneic
NEURO: A&Ox3. Mood, affect appropriate.
NECK: Supple. JVP of 5cm.
CARDIAC: Tachycardia with regular 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 but tachypneic. Dry
crackles throughout
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing or cyanosis. trace
edema in b/l ___.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
=============
___ 11:47AM BLOOD WBC-7.3 RBC-4.83 Hgb-11.6 Hct-37.2
MCV-77* MCH-24.0* MCHC-31.2* RDW-17.5* RDWSD-47.8* Plt ___
___ 11:47AM BLOOD Neuts-68.8 Lymphs-17.7* Monos-9.4 Eos-2.6
Baso-1.1* Im ___ AbsNeut-5.04 AbsLymp-1.30 AbsMono-0.69
AbsEos-0.19 AbsBaso-0.08
___ 11:47AM BLOOD Glucose-129* UreaN-16 Creat-1.0 Na-139
K-4.8 Cl-107 HCO3-20* AnGap-12
___ 11:47AM BLOOD proBNP-5261*
___ 05:43PM BLOOD cTropnT-<0.01
___ 11:53PM BLOOD CK-MB-3 cTropnT-<0.01
___ 12:03PM BLOOD ___ pO2-46* pCO2-38 pH-7.38
calTCO2-23 Base XS--1
___ 12:00PM BLOOD Lactate-3.3*
___ 12:03PM BLOOD O2 Sat-73
___ 06:30PM URINE Color-Straw Appear-Clear Sp ___
___ 06:30PM URINE Blood-TR* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:30PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 06:30PM URINE CastHy-3*
___ 06:30PM URINE Mucous-RARE*
PERTINENT/DISCHARGE LABS:
=======================
___ 06:20AM BLOOD Ret Aut-2.1* Abs Ret-0.09
___ 11:47AM BLOOD proBNP-5261*
___ 05:43PM BLOOD cTropnT-<0.01
___ 11:53PM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:20AM BLOOD CK-MB-3 cTropnT-<0.01
___ 04:45PM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:20AM BLOOD Triglyc-45 HDL-31* CHOL/HD-2.7 LDLcalc-44
___ 06:20AM BLOOD calTIBC-373 Ferritn-43 TRF-287
___ 12:00PM BLOOD Lactate-3.3*
___ 05:49PM BLOOD Lactate-1.9
___ 04:52PM BLOOD Lactate-1.6
___ 12:03PM BLOOD ___ pO2-46* pCO2-38 pH-7.38
calTCO2-23 Base XS--1
___ 05:49PM BLOOD ___ pO2-70* pCO2-43 pH-7.39
calTCO2-27 Base XS-0
___ 04:52PM BLOOD ___ pO2-77* pCO2-56* pH-7.35
calTCO2-32* Base XS-3 Comment-GREEN TOP
___ 03:17PM BLOOD Type-ART pO2-66* pCO2-50* pH-7.41
calTCO2-33* Base XS-5
___ 08:15AM BLOOD WBC-6.9 RBC-4.31 Hgb-10.5* Hct-33.9*
MCV-79* MCH-24.4* MCHC-31.0* RDW-18.1* RDWSD-49.5* Plt ___
___ 08:15AM BLOOD Glucose-74 UreaN-16 Creat-0.8 Na-140
K-4.5 Cl-103 HCO3-29 AnGap-8*
___ 08:15AM BLOOD Calcium-8.6 Phos-2.0* Mg-1.7
MICROBIOLGY:
===========
Influenza A by PCRNEGATIVENEG W
Influenza B by PCRNEGATIVENEG W
___ 6:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 11:47 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/STUDIES:
==============
CXR ___:
Increased opacification in bilateral lower lobes may represent
worsening of
the patient's known interstitial lung disease and/or
superimposed pneumonia.
TTE ___:
CONCLUSION:
The left atrial volume index is normal. The right atrium is
mildly enlarged. There is no evidence for an
atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg. There is
normal left ventricular wall thickness with a normal cavity
size. There is mild regional left ventricular
systolic dysfunction with hypokinesis of the mid-distal inferior
walls and basal-mid inferoseptal walls
(see schematic). Global left ventricular systolic function is
mildly depressed. The visually estimated left
ventricular ejection fraction is 45%. There is no resting left
ventricular outflow tract gradient. Normal
right ventricular cavity size with moderate global free wall
hypokinesis. There is abnormal
interventricular septal motion c/w right ventricular volume
overload. The aortic sinus diameter is normal
with normal ascending aorta diameter. The aortic arch diameter
is normal. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. There
is no aortic regurgitation. The mitral
leaflets are mildly thickened with no mitral valve prolapse.
There is trivial mitral regurgitation. The
tricuspid valve leaflets appear structurally normal. There is
moderate to severe [3+] tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is no pericardial
effusion.
IMPRESSION: Adequate image quality. Mildly depressed left
ventricular systolic dysfunction
consistent with coronary artery disease. Moderately depressed
right ventricular systolic function in the
setting of moderate to severe tricuspid regurgitation and
moderate pulmonary hypertension.
Cardiac Catheterization (RHC/LHC) ___:
FINDINGS:
Hemodynamics:
State: Baseline
Pressures
Site Systolic Diastolic EDP A Wave V Wave Mean HR
AO 99 62
51 97
RV 49 10
97
PA 50 21
32 96
PCW 11 10
9 97
RA 14 9
8 96
Oximetry
Site Oxygen Content Saturation Hemoglobin
PA 7.31 48 11.2
RA 7.77 51 11.2
AO 12.34 81 11.2
PA 7.31 48 11.2
RA 7.77 51 11.2
AO 12.34 81 11.2
Cardiac Output
Fick
Cardiac Output L/min 4.95
Cardiac Index L/min/m² 2.49
Resistances (dynes/sec/cm-5)
PV (___) SV (___) PV (dsc-5)
SV (dsc-5)
Resistance 4.7 8.7 372
695.2
State: O2 Therapy
Pressures
Site Systolic Diastolic EDP A Wave V Wave Mean HR
PA 48 21
33 75
PCW 12 12
10 91
Oximetry
Site Oxygen Content Saturation Hemoglobin
AO 14.78 97 11.2
PA 11.27 74 11.2
AO 14.78 97 11.2
PA 11.27 74 11.2
Cardiac Output
Fick
Cardiac Output L/min 7.1
Cardiac Index L/min/m² 3.57
Resistances (dynes/sec/cm-5)
PV (___) SV (___) PV (dsc-5)
SV (dsc-5)
Resistance 3.2 259.2
State: Nitric Oxide
Pressures
Site Systolic Diastolic EDP A Wave V Wave Mean HR
PA 46 21
32 87
PCW 12 13
11 88
Oximetry
Site Oxygen Content Saturation Hemoglobin
AO 15.08 99 11.2
PA 10.36 68 11.2
AO 15.08 99 11.2
PA 10.36 68 11.2
Cardiac Output
Fick
Cardiac Output L/min 5.27
Cardiac Index L/min/m² 2.65
Resistances (dynes/sec/cm-5)
PV (___) SV (___) PV
(dsc-5) SV (dsc-5)
Resistance 4.0
319.2
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is normal.
* Left Anterior Descending
The LAD is normal.
* Circumflex
The Circumflex is normal.
* Right Coronary Artery
The RCA has minimal luminal irregularities
Impressions:
Minimal non-obstructive CAD.
Moderate pulmonary hypertension without significant improvement
following inhaled NO or 100% oxygen.
CT Chest w/o Contrast ___:
1. Interval progression of the known interstitial lung disease
(UIP) as noted
by progression of fibrosis and traction bronchiectasis
associated with diffuse
honeycombing.
2. Stable enlargement of the main pulmonary artery, this can be
seen in the
setting of pulmonary arterial hypertension.
3. Few patchy opacities in the lower lobes may represent
superimposed
consolidation versus atelectasis.
4. Incidental 3 mm nonobstructive left renal calculus.
V/Q Lung Scan ___:
There are diffuse, heterogenous, nonsegmental areas of matched
perfusion and ventilation defects consistent with low likelihood
ratio for acute
pulmonary embolism.
CXR ___:
Compared to chest radiographs ___ through ___.
Severe fibrosing chronic infiltrative lung disease has worsened
substantially
since ___. Heart is mildly enlarged. No focal pulmonary
abnormality. No
vascular engorgement or pleural effusion to suggest any
component of pulmonary
edema.
TTE w/Bubble Study ___:
CONCLUSION:
There is a small patent foramen ovale. Moderately dilated right
ventricular cavity. The aortic valve is not
well seen. There is no aortic valve stenosis. The mitral
leaflets are mildly thickened. There is trivial
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. There is moderate [2+]
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is borderline elevated.
IMPRESSION: Adequate image quality. There is crossing of IV
saline contrast into the LA/LV early
suggesting presence of a PFO. The burden of saline bubbles is
small consistent with limited interatrial
shunting volume.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4-6H:PRN chest tightness/SOB
2. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
3. Citalopram 30 mg PO DAILY
4. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
5. Gabapentin 100 mg PO TID
6. Hydroxychloroquine Sulfate 200 mg PO BID
7. Lisinopril 20 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Furosemide 10 mg PO DAILY
10. BuPROPion XL (Once Daily) 450 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
2. Senna 8.6 mg PO BID
RX *sennosides [Senokot] 8.6 mg 1 tablet by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Torsemide 5 mg PO EVERY OTHER DAY
RX *torsemide 5 mg 1 tablet(s) by mouth every other day Disp
#*15 Tablet Refills:*3
4. Albuterol Inhaler 2 PUFF IH Q4-6H:PRN chest tightness/SOB
5. Aspirin 81 mg PO DAILY
6. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
7. BuPROPion XL (Once Daily) 450 mg PO DAILY
8. Citalopram 30 mg PO DAILY
9. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
10. Gabapentin 100 mg PO TID
11. Hydroxychloroquine Sulfate 200 mg PO BID
12. Vitamin D 1000 UNIT PO DAILY
13. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until instructed by your doctor to
restart it again.
14.Rolling Walker
DX: Congestive Heart Failure
ICD-10: I50.9
PX: Good
Length of need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
========
Interstitial lung disease
Acute decompensated heart failure
SECONDARY:
==========
Iron deficiency anemia
Rheumatoid arthritis
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with rales bilaterally with crackles- concern for CHF>//
eval for evidence of pulmonary edema
TECHNIQUE: Chest PA and lateral
COMPARISON: CT from ___
FINDINGS:
Diffuse interstitial abnormalities are noted, consistent with the patient's
known history of interstitial lung disease. Increased opacification in
bilateral lower lobes may represent worsening of the patient's interstitial
lung disease or superimposed pneumonia. The heart is moderately enlarged.
There is prominence of the pulmonary arteries consistent with pulmonary artery
hypertension. There is no pleural effusion or pneumothorax.
IMPRESSION:
Increased opacification in bilateral lower lobes may represent worsening of
the patient's known interstitial lung disease and/or superimposed pneumonia.
Radiology Report
EXAMINATION: CT CHEST
INDICATION: ___ year old woman with known ILD with acute increase in O2 req.//
Evaluate extent of ILD vs PNA
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: Prior from ___.
FINDINGS:
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
HEART AND VASCULATURE: Calcific atherosclerotic changes involving the thoracic
aorta as well as the coronary vessels. Stable enlargement of the main
pulmonary artery measuring up to 3.5 cm, this can be seen in the setting of
pulmonary arterial hypertension. There is mild cardiomegaly. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: Few prominent mediastinal lymph nodes, not
significantly changed compared to the prior CT. No significantly enlarged
axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal
mass.
AIRWAY: The airways are patent to the level of the segmental bronchi
bilaterally.
LUNGS: There is been interval progression of the honeycombing involving the
peripheral aspect of both lungs with an apical basilar gradient. Progression
of fibrotic changes involving the lung parenchyma and traction bronchiectasis.
Areas of mosaic attenuation are seen in the uninvolved lung parenchyma. Few
patchy opacities are seen in the superior segments of both lower lobes as well
as the posterior basal segments (for example series 302, image 129-130), which
may represent superimposed consolidation versus atelectasis.
PLEURAL SPACES: No pleural effusion or pneumothorax.
ABDOMEN: Included portion of the upper abdomen is shows evidence of prior
cholecystectomy. Small hiatus hernia. A nonobstructive tiny 3 mm calculus
seen in the upper pole of the left kidney. No evidence of hydronephrosis.
BONES/SOFT TISSUES: No suspicious osseous abnormality is seen.? Stable
sclerotic density in the anterolateral sixth rib on the left. Multilevel
degenerative changes involving the thoracic spine. No soft tissue abnormality
seen.
IMPRESSION:
1. Interval progression of the known interstitial lung disease (UIP) as noted
by progression of fibrosis and traction bronchiectasis associated with diffuse
honeycombing.
2. Stable enlargement of the main pulmonary artery, this can be seen in the
setting of pulmonary arterial hypertension.
3. Few patchy opacities in the lower lobes may represent superimposed
consolidation versus atelectasis.
4. Incidental 3 mm nonobstructive left renal calculus.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ILD.// Evaluate interval change.
Evaluate interval change.
IMPRESSION:
Compared to chest radiographs ___ through ___.
Severe fibrosing chronic infiltrative lung disease has worsened substantially
since ___. Heart is mildly enlarged. No focal pulmonary abnormality. No
vascular engorgement or pleural effusion to suggest any component of pulmonary
edema.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified
temperature: 98.2
heartrate: 110.0
resprate: 17.0
o2sat: 85.0
sbp: 147.0
dbp: 70.0
level of pain: 5
level of acuity: 2.0 | ___ female with medical history notable for RA, ILD, pulmonary
artery hypertension who presented with dyspnea found to have
volume overload from acute exacerbation of heart failure,
progression of ILD on Chest CT, and significantly elevated
pulmonary artery pressure on right heart catheterization.
ACTIVE ISSUES:
===============
#Acute hypoxic respiratory failure
#Interstitial lung disease:
Patient presented with subacute, progressive DOE. Patient with
known ILD (UIP) in the setting of rheumatoid arthritis with
progression noted on CT Chest this admission. She initially had
evidence of volume overload on the background of low pulmonary
reserve due to progressive ILD. TTE showed mildly depressed LV
function c/w CAD, moderately depressed RV sys function,
mod-severe TR, and moderate pulmonary HTN. LHC/RHC ___ was
significant for moderate mPAP (32; severe >=35) without
improvement with oxygen; no significant CAD. V/Q low probability
for PE (CTEPH). Finally, a TTE bubble study revealed no
intracardiac or intrapulmonary shunt. Therefore, her dyspnea was
attributed primarily to her worsening pulmonary disease. She was
diuresed to euvolemia during this admission (details below) but
her O2 requirement remained ~4LNC O2 at rest and ___ O2 with
ambulation. Her SBP could not tolerate a trial of low dose 10mg
Sildenafil tid. She was started on Torsemide 5mg qod and home O2
was setup. She was discharged with home O2 and ___ services to
manage initial O2. Discussed the need for home oxygen therapy
that I am prescribing for patient ___ to treat their
diagnosis of congestive heart failure and interstitial lung
disease. Patient fully understands the benefits and agrees to
the Home Oxygen therapy. Patient's current SpO2 at rest on room
air is 85%.
#Acute on chronic diastolic heart failure exacerbation:
Patient had initial evidence of volume overload with elevated
JVD, ___ edema, wet on dry crackles, and elevated pro-BNP all on
a poor pulmonary reserve background. The trigger for this
exacerbation was likely in the setting of worsening pulmonary
artery hypertension and
progressive ILD. While CXR was suggestive of PNA she remained
afebrile, without a cough, and normal WBC. and less likely
infection, ACS. TTE showed mildly depressed LV function c/w CAD,
mod-severe TR, and moderate PA HTN. LHC/RHC ___ significant for
moderate mPAP (32) without improvement with oxygen; no
significant CAD. Interval progression of ILD on CT Chest. She
received Lasix IV (40-60mg BID)during this admission. Her
admission weight was 97.7kg and discharge weight 94.4kg
(-3.3kg). A RHC performed after diuresis to dry weight on ___
showed a PCWP of 10. Therefore, her dry weight ~94.3kg. Her
heart failure management includes:
- Preload: Torsemide 5mg daily
- Afterload: Lisinopril 20mg daily HOLD due to hypotension
#?Concern for ACS
Initial concern for chest pain with exertion with associated
diaphoresis concerning for ACS, however, pt denied this once
admitted. ECG with new TWI in lateral leads and Q wave in III,
Trop x 3 < 0.01. TTE shows mildly depressed LV function c/w CAD.
No significant CAD on LHC ___. She was maintained on ASA 81mg
daily.
#Lightheadedness with ambulation:
She experienced lightheadedness during ambulation and
orthostatic vital signs were indicative of hypovolemia that
responded to gentle fluid boluses therefore, assessed as
overduresis and poor po intake. On day of discharge, she did not
have orthostatic vital signs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
The patient is a healthy ___ year old male with a 7 month history
of chronic NSAID use -advil 400 mg daily and naproxex ___ mg bid
for knee and back pain. Two days ago he awoke with severe mid
abdominal pain along with coffee ground emesis. He did not seek
immediate evaluation because he also had developed severe tooth
pain and sought dental care. The next day he vomited again and
this time the emesis had a small amount of blood. Pain worse
after eating a banana. He went to his PCP where he was found to
be tachycardic and had guiac positive stool. He was then
referred to the ED for admission. He was started on amoxicillin
for his dental abscess since his tooth was too swollen to be
extracted.
All other review of systems negative except as above.
Past Medical History:
DJD of spine
Lichen planus
chronic knee pain
Social History:
___
Family History:
Hi MGM has HTN. His parents are both alive and in good health.
Physical Exam:
PE at discharge:
Afeb, VSS
Cons: NAD, lying in bed
Eyes: EOMI, no scleral icterus
ENT: MMM
Cardiovasc: rrr, no murmur, no edema
Resp: CTA B
GI: +bs,soft, nt, nd
MSK: no significant kyphosis
Skin: no rashes +tattoos
Neuro: no facial droop
Psych: full range of affect, a little anxious
Pertinent Results:
___ 09:10PM LIPASE-189*
___ 03:17PM LACTATE-1.9
___ 03:15PM GLUCOSE-109* UREA N-11 CREAT-0.8 SODIUM-136
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-27 ANION GAP-16
___ 03:15PM estGFR-Using this
___ 03:15PM ALT(SGPT)-26 AST(SGOT)-31 ALK PHOS-87 TOT
BILI-0.6
___ 03:15PM LIPASE-108*
___ 03:15PM ALBUMIN-4.8 CALCIUM-10.1 PHOSPHATE-3.5
MAGNESIUM-2.1
___ 03:15PM WBC-9.0 RBC-4.25* HGB-14.6 HCT-42.9 MCV-101*
MCH-34.2* MCHC-33.9 RDW-12.6
___ 03:15PM NEUTS-73.5* ___ MONOS-6.1 EOS-1.5
BASOS-0.7
___ 03:15PM PLT COUNT-364
___ 03:15PM ___ PTT-38.3* ___
================
CXR: no PNA.
EGD:
Esophagus:
Mucosa: There was some mild erythema of distal ___ of the
esophagus consistent with esophagitis.
Stomach:
Mucosa: There was significant antral erythema consistent with
gastritis.
Excavated Lesions There were 4 large cratered, clean based
ulcers arranged in a circumferential pattern in the antrum. One
ulcer had a small red spot. There was no active bleeding.
Duodenum:
Mucosa: There was significant erythema and friability of the
mucosa in the duodenal bulb consistent with duodenitis.
Impression: Abnormal mucosa in the esophagus
Abnormal mucosa in the stomach
Gastric ulcer
Abnormal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: -The patient can return to floor when recovered
from sedation
-Please start 40mg protonix twice daily
-Please send H. pylori serology and treat with triple therapy if
positive
-Avoid all ibuprofen and naprosyn, avoid alcohol
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Naproxen 500 mg PO Q12H
2. Ibuprofen 400 mg PO DAILY
3. Amoxicillin 500 mg PO Q8H dental abscess
Discharge Medications:
1. Amoxicillin 500 mg PO Q8H dental abscess
2. TraMADOL (Ultram) 50 mg PO Q6H:PRN knee pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*60
Tablet Refills:*0
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth twice a day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
stomach ulcer
Discharge Condition:
alert, interactive
Followup Instructions:
___
Radiology Report
HISTORY: Epigastric pain.
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: None.
FINDINGS:
No focal consolidation, pleural effusion, or evidence of pneumothorax is seen.
The cardiac and mediastinal silhouettes are unremarkable. No evidence of free
air is seen beneath the diaphragms.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: Vomiting
Diagnosed with VOMITING
temperature: 98.4
heartrate: 102.0
resprate: 16.0
o2sat: 100.0
sbp: 137.0
dbp: 101.0
level of pain: 0
level of acuity: 3.0 | ___ y.O. M who presnts with abdominal pain/nausea, vomiting,
hematemesis with recent high level of nsaid use.
The pt had no bleeding while hospitalized. The GI was
consulted. Pt underwent EGD which revealed esophagitis,
gastritis, duodenitis, and a few shallow ulcers in the antrum,
c/w ulceration from NSAID use.
Post procedure the pt felt well and was able to take good PO. He
was discharged to home with a prescription for BID PPI and for
tramadol which he will try for his knee pain.
H.pylori has been sent, but the result is currently pending. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cramping in both posterior thighs after an ___
Major Surgical or Invasive Procedure:
1. L1 laminectomy, bilateral medial facetectomy and
foraminotomies.
2. Open reduction and treatment, fracture-dislocation, L1.
3. Posterior instrumentation, T11-L3.
4. Posterior spinal fusion, T11-L3.
5. Application of local autograft and allograft.
History of Present Illness:
___ year old male riding a motor cycle when he was hit by a truck
on the right side at approx ___ MPH. Was found to have a L1 body
fracture with retropulsion. Denies umbness, weakness, but has
cramping in both posterior thighs.
Past Medical History:
Pelvic fractures
Social History:
smokes 1 ppd, rare etoh, no drug use
Physical Exam:
Per Ortho Note dated ___
PHYSICAL EXAMINATION:
In general, the patient is a well appearing male in moderate
distress
Spine exam:
Vascular
Radial: L2+, R2+
___: L2+, R2+
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory:
Sensory UE
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
T2-L2 Trunk R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R nl, L nl
L5 (Grt Toe): R nl, L nl
S1 (Sm toe): R nl, L nl
S2 (Post Thigh): R nl, L nl
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was extensor bilaterally.
Babinski: downgoing
Clonus: none
Perianal sensation: intact
Rectal tone: intact
Physical Exam ___-
General-Well appearing sitting up in chair in NAD,comfortable
Heart-RRR
Lungs-CTAB
Abd-soft,nt,nd,+bs's
Extremities-WWP,2+rad/2+dp pulses,good capillary refill
___ throughout ___
+SILT bilaterally and equal
Pertinent Results:
___ 10:55AM BLOOD WBC-11.1* RBC-3.64* Hgb-11.4* Hct-32.2*
MCV-88 MCH-31.3 MCHC-35.5* RDW-12.2 Plt ___
___ 10:55AM BLOOD Plt ___
___ 07:35AM BLOOD Glucose-103* UreaN-10 Creat-0.9 Na-139
K-4.0 Cl-105 HCO3-27 AnGap-11
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
may take over the counter
2. Diazepam 5 mg PO Q6H:PRN pain, spasm
please do not operate heavy machinery, drink alcohol or drive
RX *diazepam 5 mg 1 tablet by mouth every six (6) hours Disp
#*75 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
please take while on pain medication
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
please do not operate heavy machinery, drink alcohol or drive
RX *oxycodone 10 mg ___ tablet(s) by mouth every four (4) hours
Disp #*100 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. L1 burst fracture.
2. Lumbar stenosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI OF THE LUMBAR SPINE
INDICATION: History: ___ with L1fx with retropulsion // Crd compression at
site of l1 fx?
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the
thoracic and lumbar spine were obtained.
COMPARISON: No prior similar examinations for comparison.
FINDINGS:
There is an acute burst fracture of L1 vertebra with retropulsion. There is
narrowing of the spinal canal at this level which is approximately 50%
compared to the level and below. The spinal canal measures approximately 7 mm
at this level. There is compression of the thecal sac. There is increased
signal within the ligamentum following at L1 level indicative of injury. There
also is likely disruption of the anterior and posterior longitudinal
ligaments. There is mild paraspinal soft tissue prominence at this level
indicative of paraspinal soft tissue injury. No intraspinal hematoma is seen.
In the thoracic region and I will compression fractures seen. Multilevel
degenerative changes identified. The small disc protrusion is seen at T7-T8
level.
From L2-3 through L5-S1 level disk degenerative changes are identified.
There appears to be increased signal within the partially visualized S3
segment of the sacrum. Clinical correlation is recommended to exclude
fracture
Note is distended urinary bladder.
IMPRESSION:
Less fracture of L1 with retropulsion and 50% narrowing of the spinal canal
and compression of the thecal sac. Other findings as described above.
Radiology Report
OR FILMS ON ___
FINDINGS: Eight films from the OR demonstrate hardware posterior to the L1
burst fracture. At the end of the procedure, posterior fixation device spans
from T11 to L3. The burst fracture is slightly less compressed, but there is
still posterior displacement of a portion of the vertebral body.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MCC BASIC TRAUMA
Diagnosed with FX LUMBAR VERTEBRA-CLOSE, MV COLLIS NOS-MOTORCYCL
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
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:
Allopurinol And Derivatives / Iodine / Tetracycline / Minocin /
Lipitor / Augmentin
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with past history of splenic lymphoma s/p rituxan and
splenectomy in ___ (in remission), HLD, HTN, and strong family
HX of CAD who presents with intermittent chest pain x1 ___. She
called into clinic today due to left sided chest pain and was
referred to the ED. The chest pain was squeezing/sharp on the
left side and radiates into the left shoulder blade and arm pit.
+ pleuritic with deep breaths, not exertional or reproducible.
No SOB. No leg swelling, no fevers, chills, cough. Was able to
play tennis a few days ago without any pain. She did recently
travel to ___ and ___ (returned ___, but otherwise no
history of immobility. No past DVT but did have an arterial
thrombus in hand. Has had chest pains a few times in the past
couple of years but thought they were more related to stress,
would usually be relieved with ativan. 4 days ago had similar
pain (but not as severe) in ___ with neg trop and normal ECG
and was sent home. Was due to see cardiology in ___ for
evaluation and ?stress test. Believes she had a stress test ___
year ago that was normal, however can only find one from ___
(also normal) which was also done for atypical chest pain.
In the ED, initial VS were 98.7, 78, 160/85, 16, 98%. Given
morphine 2mg x2 for chest pain with good results. Labs were
notable for negative troponin but mildly positive d-dimer at
562. CXR within normal limits. Unable to perform CTA chest to
r/o PE given contrast allergy, so started empirically on heparin
gtt and admitted for further work up and V/Q scan.
On the floor, the patient is comfortable and chest pain free.
Denies any shortness of breath, pleuritic pain, dizziness,
diaphoresis or palpitations. SHe does endorse a mild headache
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
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:
#. History of splenic marginal zone lymphoma
- s/p splenectomy
- s/p Rituximab ___
- patient has indolent disease, not in remission, ongoing
surveillance with her primary Oncologist Dr. ___ at
___.
#. History of ulnar artery thrombosis
- underwent arterial lysis and sympathetic of the right index
and middle fingers
#. History of prior Hepatitis A
#. Hypertension
#. Hyperlipidemia
#. History of Kidney Stones
Social History:
___
Family History:
Dad had 4V-CABG at age ___, mom with CAD, ___ Gma with "heart
problems" and brothew with cardiac tamponade.
Multiple malignancies on the paternal side. Grandmother suffered
from uterine cancer. Her uncle suffered from a non-Hodgkin's
lymphoma and 1 aunt suffered from lung cancer and another CLL on
the maternal side. There is mesothelioma and twin aunt suffered
from a renal cell cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.8 BP: 128/80 P: 66 R: 18 O2: 100% RA
General: Alert, oriented, lying in bed in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
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. Negative ___ sign, calves non-tender to palpation
with no palpable cords
Skin: warm, dry
Neuro: A&Ox3, grossly non-focal
DISCHARGE PHYSICAL EXAM:
Vitals: Tm: 97.8 T: 97.7 BP: 122/80 P: 76 (60-80s) R: 18 O2: 98%
RA
Walking pulse ox 94-100% without symptoms of SOB.
General: Alert, oriented, lying in bed in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
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. Negative ___ sign, calves non-tender to palpation
with no palpable cords
Skin: warm, dry
Neuro: Speech coherent, cognition intact, CNII-XII intact,
A&Ox3, grossly non-focal, moving all extremities.
Telemetry: NSR @ 67 with range 60-80s, no acute events
Pertinent Results:
ADMISSION LABS:
___ 08:50PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
___ 08:50PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1 RENAL EPI-<1
___ 08:40PM ___ PTT-42.3* ___
___ 08:30PM GLUCOSE-113* UREA N-19 CREAT-0.8 SODIUM-141
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-28 ANION GAP-16
___ 08:30PM estGFR-Using this
___ 08:30PM cTropnT-<0.01
___ 08:30PM proBNP-38
___ 08:30PM CALCIUM-9.5 PHOSPHATE-4.5 MAGNESIUM-2.1
___ 08:30PM D-DIMER-562*
___ 08:30PM WBC-10.6 RBC-4.62 HGB-13.1 HCT-39.0 MCV-85
MCH-28.4 MCHC-33.6 RDW-14.6
___ 08:30PM NEUTS-58.2 ___ MONOS-7.4 EOS-2.6
BASOS-1.1
___ 08:30PM PLT COUNT-384
DISCHARGE LABS:
___ 04:24AM BLOOD WBC-10.1 RBC-4.36 Hgb-12.6 Hct-37.2
MCV-85 MCH-28.9 MCHC-33.9 RDW-14.3 Plt ___
___ 04:24AM BLOOD ___ PTT-150* ___
___ 04:24AM BLOOD Plt ___
___ 04:24AM BLOOD Glucose-129* UreaN-17 Creat-0.7 Na-142
K-3.8 Cl-103 HCO3-27 AnGap-16
___ 04:24AM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:24AM BLOOD Calcium-9.1 Phos-4.6* Mg-2.1
IMAGING:
CXR PA/Lateral ___:
FINDINGS:
Cardiac, mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. The lungs are clear. No
pleural effusion or pneumothorax is seen. There are no acute
osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process
LUNG SCAN ___:
Following ventilation images, perfusion images were obtained in
the same
projections with Tc-99m labeled MAA.
INTERPRETATION: Ventilation images demonstrate normal
ventilation.
Perfusion images demonstrate normal perfusion.
Chest x-ray shows no acute process.
IMPRESSION: Normal ventilation-perfusion scan. Normal scan rules
out recent pulmonary embolism.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. ClonazePAM 0.5 mg PO BID:PRN anxiety
3. Rosuvastatin Calcium 40 mg PO HS
4. calcium carbonate *NF* 600 mg (1,500 mg) Oral daily
5. Aspirin 81 mg PO DAILY
6. Venlafaxine XR 37.5 mg PO DAILY
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. nitrofurantoin macrocrystal *NF* 50 mg Oral daily PRN UTI
9. Vitamin D 1000 UNIT PO DAILY
10. coenzyme Q10 *NF* unknown Oral daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. ClonazePAM 0.5 mg PO BID:PRN anxiety
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Rosuvastatin Calcium 40 mg PO HS
6. Venlafaxine XR 37.5 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Calcium Carbonate *NF* 600 mg (1,500 mg) ORAL DAILY
9. coenzyme Q10 *NF* 200 mg ORAL DAILY
Per home medications
10. nitrofurantoin macrocrystal *NF* 50 mg Oral daily PRN UTI
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain secondary to Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Chest pain radiating into the back and and left armpit.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac, mediastinal and hilar contours are normal. The pulmonary vasculature
is normal. The lungs are clear. No pleural effusion or pneumothorax is seen.
There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS
temperature: 98.7
heartrate: 78.0
resprate: 16.0
o2sat: 98.0
sbp: 160.0
dbp: 85.0
level of pain: 8
level of acuity: 2.0 | ___ with past history of splenic lymphoma s/p rituxan and
splenectomy in ___ (in remission), HLD, HTN, and strong family
HX of CAD who presents with intermittent chest pain x1 ___.
# Chest pain secondary to Anxiety: Patient presented with
atypical chest pain, recent travel, intermediate Wells score,
and mildly positive D-dimer (562) intially concerning for PE vs
cardiac etiology vs anxiety. Intially started on heparin drip.
Troponins negative x2. Patient active tennis player without
angina, and previous stress tests negative. EKG unchanged.
Telemetry unremarkable. CXR and V/Q scan normal. Patient noted
significant psychosocial stressors recently, and given her
history of chest pain with anxiety, this is the likely cause.
Would recommend continued management with clonazepam and
possible CBT.
# Hypertension: well-controlled on current home regimen. Patient
was continued on home lisinopril, HCTZ
# Hyperlipidemia: patient was continued on home rosuvastatin
# CODE: full
# CONTACT: husband ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Percocet / acetaminophen / Cipro / Augmentin
Attending: ___.
Chief Complaint:
Left distal femur periprosthetic fracture
Major Surgical or Invasive Procedure:
ORIF left distal femur fracture ___, ___
History of Present Illness:
___ is a ___ male with hx of A. fib on Coumadin,
stroke
___ years ago with residual left-sided deficits, and mitral valve
repair surgery who presents today with left leg pain after
sustaining a ground-level fall earlier today. He tripped while
walking up stairs onto his left side with immediate left hip
pain
and inability to bear weight. He denies head strike or loss of
consciousness. He initially presented to an outside hospital
were preliminary CT head and neck were negative. X-ray of the
left leg demonstrates a left distal femur fracture. Of note he
does have bilateral total hip replacements performed by Dr.
___ in ___. He denies any pain in his left total hip
arthroplasty site. This appears to be an isolated injury.
Past Medical History:
MVP/MVR s/p annuloplasty in ___ c/b possible endocarditis
___
Paroxysmal Atrial fibrillation s/p three PVI's and multiple
cardioversions.
Multifocal embolic ischemic strokes (right anterior frontal and
left cerebellar)s/p suboccipital craniotomy ___ and
hyperosmolar therapy for herniation and obliteration of the
fourth ventricle and the aqueduct.
Group A Streptococcus septic arthritis c/b bacteremia s/p
Hyperlipidemia
Arthritis
Gout
S/p bilateral total hip replacements
S/p right shoulder replacement
___ right femur pinning
___: left leg skin grafting d/t a burn
Left sided pancreatic mass, followed by Dr. ___ at ___
Social History:
___
Family History:
Brother with MI, died at age ___. Father died from accident. No
other significant family history.
Physical Exam:
LLE:
Incision c/d/I
Sensation intact to light touch in Saph/Sural/SP/DP/T nerve
distributions
Motor intact for ___, FHL, TA, ___
Dorsalis pedis & posterior tibial pulses palpable, toes warm &
well perfused
Pertinent Results:
___ 09:02AM BLOOD WBC-9.3 RBC-3.04* Hgb-9.3* Hct-28.8*
MCV-95 MCH-30.6 MCHC-32.3 RDW-14.6 RDWSD-49.9* Plt ___
___ 09:02AM BLOOD ___
___ 09:02AM BLOOD Glucose-118* UreaN-21* Creat-0.7 Na-142
K-4.0 Cl-105 HCO3-25 AnGap-12
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 150 mg PO QHS
2. Warfarin 7.5 mg PO DAILY16
3. Multivitamins 1 TAB PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Digoxin 0.125 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 40 mg SC Nightly Disp #*10 Syringe
Refills:*0
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*45 Tablet Refills:*0
5. Senna 17.2 mg PO BID
6. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. Digoxin 0.125 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Furosemide 20 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Sertraline 150 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left periprosthetic distal femur 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: CT left lower extremity
INDICATION: ___ man with leg pain. Evaluate distal femur fracture
anatomy.
TECHNIQUE: Helical CT axial images of the left knee were obtained in soft
tissue and bone algorithm. Coronal and sagittal reformats were provided.
DOSE: Acquisition sequence:
1) Spiral Acquisition 11.5 s, 24.5 cm; CTDIvol = 20.3 mGy (Body) DLP =
496.1 mGy-cm.
Total DLP (Body) = 496 mGy-cm.
COMPARISON: No prior relevant imaging is available on PACS at the time of
this dictation.
FINDINGS:
The bones are diffusely demineralized. There is a comminuted, impacted
fracture of the distal left femur. The distal fracture fragment is displaced
anteriorly by 1.1 cm relative to the proximal fracture fragment. There is
approximately 1.5 cm impaction. Fracture lines do not extend to the
articulation of the femoral condyles with the tibial plateaux. The patella is
relatively superior position with a not sign along the anterior aspect of the
distal femur consistent with chronic remodeling. The patellar tendon appears
to be intact.. There is trace fluid in the knee joint. There is associated
moderate soft tissue fat stranding. No evidence of hematoma.
Background multilevel degenerative changes are moderate and most pronounced in
the medial and patellofemoral compartments.
Atherosclerosis noted in the lower extremity arteries. Dystrophic
calcification seen in the distal quadriceps.
IMPRESSION:
1. Comminuted impacted left distal femur fracture.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) RIGHT
INDICATION: ___ year old man with prior R femur hardware// Hardware
Hardware
IMPRESSION:
No comparison. Two views of the right hip and two views of the right femur
are provided. The hip replacement hardware and the femoral fixation hardware
are in correct position. No dislocation or fracture.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) IN O.R. LEFT IN O.R.
INDICATION: ORIF LEFT FEMUR
IMPRESSION:
Fluoroscopic documentation of femoral repair. No radiologist was present.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Femur fracture, Transfer
Diagnosed with Oth fracture of lower end of left femur, init for clos fx, Fall (on) (from) other stairs and steps, initial encounter
temperature: 99.0
heartrate: 93.0
resprate: 18.0
o2sat: 96.0
sbp: 109.0
dbp: 66.0
level of pain: 8
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left distal femur periprosthetic fracture and
supratherapeutic INR and was admitted to the orthopedic surgery
service. Due to his supratherapeutic INR, surgery was delayed
for reversal with 10 IV vitamin K. The patient was taken to the
operating room on ___ for ORIF L distal femur, 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. Coumadin 5 mg
was restarted on POD0 with a lovenox 40 mg nightly bridge. On
discharge, his INR was 1.3, so he will continue the bridge at
rehab until therapeutic at ___. 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
touch down weight bearing in the left lower extremity, and will
be discharged on Coumadin/lovenox bridge 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: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy for small bowel
obstruction, with small-bowel resection and primary
anastomosis x1.
History of Present Illness:
Per Admission Note:
___. w distant hx/o hysterectomy and recent hx/o afib on Coum
p/w abdominal pain, N, V x1 day.
She report that she started having left upper quadrant abdominal
sharp pain around 8pm yesterday, which soon became bandlike
across the abdomen. She also reports nausea and vomiting several
times mainly undigested food. She had small bowel movement since
the pain started but does not remember passing flatus. She also
reports sweating a lot with pain. The pain progressively got
worse overnight which made her come to the ER this morning.
Past Medical History:
- HTN
- HLD
- afib
- mural thrombus, on coumadin
- DM2
- CAD
Social History:
___
Family History:
Mother: DM, HTN, MI; Brother: migraines
Physical ___:
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, non-tender. Incision C/D/I
Ext: No ___ edema, ___ warm and well perfused
Radiology Report
INDICATION: ___ with sudden onset epigastric pain, N/VNO_PO contrast //
Acute abdominal process
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus
technique.Coronal and sagittal reformations were performed.
DOSE: DLP: 505 mGy-cm
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
On linear left basilar opacity and dependent ground-glass right greater than
left likely atelectasis. There is moderate cardiomegaly. In addition there is
a rounded outpouching at the left ventricular apex suggesting ventricular
aneurysm. Previously seen intraluminal thrombus is no longer visualized based
on this non cardiac gated study. The aortic root calcifications are
visualized.
The liver, gallbladder, spleen, adrenal glands, kidneys, and pancreas are
unremarkable.
The stomach is relatively decompressed as is the proximal small bowel. There
is significant mid small bowel dilation leading to an acute transition point
in the upper abdomen (601b:15). This is in association with the region of
tethering adjacent to the left lateral aspect of the liver and gastric antrum
(02:35). Bowel distal to this region this also significantly dilated, with
air-fluid levels leading up to the second acute transition point adjacent to
the first (601b: 14 and 15). There is complete distal small bowel
decompression. The colon is also near completely decompressed. A few scattered
diverticula are noted without diverticulitis. The appendix is normal.
Uterus is not seen. Head and neck is are unremarkable. Small amount of fluid
seen within the pelvis and adjacent to the liver.
Atherosclerotic calcifications are noted in the abdominal aorta which is
normal in caliber.
There is a fat containing supraumbilical hernia and diastases of the rectus
abdominus in the region of the umbilicus.
No focal suspicious osseous lesion. Degenerative changes are noted in the
spine.
IMPRESSION:
1. High-grade small bowel obstruction. Dilated loops of small bowel leading up
to an acute transition point in the mid upper abdomen with adjacent tethering
in the region of the gastric antrum and liver. Small bowel distal to this
transition point is also dilated with a second acute transition point adjacent
to the first raising concern for closed loop obstruction. Stranding in the
mesentery without pneumatosis or apparent altered perfusion of the bowel wall.
2. Left ventricular aneurysm as seen on prior CT with decreased burden of
intraluminal thrombus.
NOTIFICATION: Findings discussed with Dr. ___ with Dr. ___ at 09:10 on
___ at the time of discovery.
Radiology Report
INDICATION: ___ with SBO now s/p NGT // eval NGT placement
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___.
FINDINGS:
Lower lung volumes seen on the current exam with secondary crowding of the
bronchovascular markings. Linear left basilar opacity is likely atelectasis.
Cardiac silhouette is enlarged but unchanged given differences in technique.
Enteric tube passes below the diaphragm, side-port past the GE junction. No
acute osseous abnormalities identified.
IMPRESSION:
Enteric tube seen with the tip in the stomach, side-port past the GE junction.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 97.4
heartrate: 74.0
resprate: 18.0
o2sat: 97.0
sbp: 176.0
dbp: 92.0
level of pain: 10
level of acuity: 3.0 | The patient presented to Emergency Department on ___. Upon
arrival to ED, CT Abdomen was suggestive of high small bowel
obstruction. Given findings, the patient was taken to the
operating room for Exploratory laparotomy for small bowel
obstruction, with small-bowel resection and primary anastomosis
x1. There were no adverse events in the operating room; please
see the operative note for details. Pt was extubated, taken to
the PACU until stable, then transferred to the ward for
observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV pain
medications and then transitioned to oral pain medications once
tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Initially
patient required a brief stay in the SICU given persistent
hypotension requiring pressors. However, this soon resolved and
cardiac workup at the time including EKG and cardiac enzymes was
negative. She also had a brief period of afib with RVR. A
cardiology consult was requested which recommended restart
heparin bridge to coumadin if INR <2
-Please restart home BP meds (metoprolol and losartan) when
hemodynamically stable
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On ___, the
NGT was removed. therefore, the diet was advanced sequentially
to a Regular diet, which was well tolerated. Patient's intake
and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating with assistance (a Physical therapy consult
recommeded a short stay in rehabilitation given patient's stairs
at home), voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ woman with depression who presents
with abdominal pain since 1pm ___. According to the
patient, she developed acute onset of intermittent low abdominal
pain that came in waves. She cannot think of any precipitating
factors and she denies eating anything unusual. Says there's
been
a "stomach bug" going around school (attends college at ___)
but denies any specific recent sick contacts. The pain is
similar
to pain she's had with ovarian cysts in the past. She went to
___ yesterday afternoon where they did a
pelvic ultrasound, which per patient report showed that her
ovaries looked normal. She eventually felt better and she was
discharged home. However, the pain recurred around 11pm and
became unbearable so she decided to come to the ___ ED for
further evaluation.
Her last BM was around 1 hour prior to the start of her symptoms
and it was reportedly normal. She cannot recall if she has been
passing gas since then. She did have 1 episode of vomiting upon
arriving in our ED. THe emesis consisted of previously-ingested
food (NBNB). No recent fevers/chills. Her last period was 1.5
weeks ago.
Past Medical History:
depression, ovarian cysts, neck abscess s/p I&D and 1 week
hospitalization at ___ about ___ year ago
Social History:
___
Family History:
non-contributory
Physical Exam:
EXAM: upon admission: ___
VS - 97.6 62 114/74 18 100% RA
GEN - awake/alert, NAD, cooperative
HEENT - NCAT, EOMI, MMM, no scleral icterus
___ - RRR, no M/R/G
PULM - CTAB, no W/R/R, breathing non-labored
ABD - soft, nondistended, moderately TTP in the B/L lower
quadrants (L>R) but without rebound/guarding (patient medicated
with IV morphine ~2 hrs prior to my exam)
EXTREM - warm, well-perfused, no peripheral edema
Physical examination upon discharge: ___:
vital signs: 98.3,hr=70,, bp=98/50, 98% room air
___: NAD
CV: ns1, s2, -s3, -s4
LUNGS: clear
ABDOMEN: soft, flat, mild ___ tenderness, no
rebount, no hepatomegaly, no splenomegaly
EXT: no calf tenderness bil., no pedal edema bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 07:00AM BLOOD WBC-5.1 RBC-3.98* Hgb-12.4 Hct-35.7*
MCV-90 MCH-31.1 MCHC-34.7 RDW-13.6 Plt ___
___ 12:20PM BLOOD WBC-8.2 RBC-4.04* Hgb-12.6 Hct-35.3*
MCV-88 MCH-31.3 MCHC-35.7* RDW-13.5 Plt ___
___ 01:10AM BLOOD WBC-12.3* RBC-4.53 Hgb-13.6 Hct-39.8
MCV-88 MCH-30.0 MCHC-34.2 RDW-13.8 Plt ___
___ 01:10AM BLOOD Neuts-84.4* Lymphs-10.5* Monos-4.0
Eos-0.5 Baso-0.5
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-81 UreaN-9 Creat-0.7 Na-139 K-4.4
Cl-104 HCO3-27 AnGap-12
___ 01:10AM BLOOD ALT-18 AST-33 AlkPhos-80 TotBili-0.5
___: cat scan of abdomen and pelvis:
Findings suggest small bowel obstruction with two suspected
transitions fairly nearby in space raising concern for possible
closed loop obstruction.
Medications on Admission:
fluoxetine 10'
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever
2. Docusate Sodium 100 mg PO BID
3. Senna 8.6 mg PO BID:PRN constipation
4. Fluoxetine 10 mg PO DAILY
5. Milk of Magnesia 30 mL PO ONCE Duration: 1 Dose
Discharge Disposition:
Home
Discharge Diagnosis:
partial small bowel obstruction
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 severe diffuse lower abdominal pain. Evaluate for
appendicitis.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after administration of 100cc intravenous contrast. Axial images
were interpreted in conjunction with coronal and sagittal reformats.
DLP: 336 mGy-cm
CTDIvol: 6 mGy
COMPARISON: None
FINDINGS:
CHEST: The visualized lung bases are clear. A 4-5 mm nodule is seen at the
left lung base, doubtful in significance, especially in this age group. There
is no pleural or pericardial effusion.
ABDOMEN:
The liver and gallbladder are normal. The pancreas is spleen are unremarkable.
The adrenal glands are normal bilaterally. The kidneys enhance and excrete
contrast normally. There is no hydronephrosis.
The majority of the oral contrast remains in the stomach. The proximal small
bowel is not dilated. This is followed by an abrupt transition to dilated
bowel measuring up to 3.3 cm in diameter. After a long segment, there is a
second transition located in space about 3.5 cm from the more proximal
suspected transition. There is trace ascites along the left paracolic gutter.
There is no bowel wall thickening or mesenteric free fluid. Maximum diameter
of the dilated loops is approximately 3.3 cm. The more distal small bowel is
mostly collapsed. Parts of the colon are nearly empty.
The appendix is normal in caliber. The large bowel is nondilated with no
evidence of colitis. There is no mesenteric or retroperitoneal
lymphadenopathy.
PELVIS: The uterus is normal. No adnexal masses are seen. The urinary bladder
is well distended and normal.
There is trace ascites along the left paracolic gutter.
VESSELS: The aorta is normal in caliber and its major branches are patent.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy.
IMPRESSION:
Findings suggest small bowel obstruction with two suspected transitions fairly
nearby in space raising concern for possible closed loop obstruction.
Final report discussed with Dr. ___ at 10:45 am on ___ by
telephone.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Nausea
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 97.6
heartrate: 62.0
resprate: 18.0
o2sat: 100.0
sbp: 114.0
dbp: 74.0
level of pain: 10
level of acuity: 3.0 | The patient was admitted to the hospital with abdominal pain and
nausea. She was also noted to have a mild elevation in her white
blood cell count. Upon admission, she was made NPO, and given
intravenous fluids. She underwent a cat scan of the abdomen
with findings suggestive of a partial small bowel obstruction.
She was placed on bowel rest. On HD #2, she began passing flatus
and resumed a regular diet. Her abdominal pain had resolved.
Her vital signs were stable and she was afebrile. She was
discharged home on HD #1. An appointment for follow-up was
offerred at Health ___ associates, but the patient plans to
seek own primary ___ provider. Recommendation for follow-up
with her primary ___ provider ___ 2 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
thrombectomy ___ at 10;38 AM
History of Present Illness:
Time/Date the patient was last known well: ___ at 05:30
Pre-stroke mRS ___ social history for description): 0
t-PA Administration
[] Yes - Time given:
[x] No - Reason t-PA was not administered: outside window on
arrival to ___ (not administered at OSH due to PLT < 100k)
Endovascular intervention:
[x]Yes - Time: 10:38
[]No - Reason EVT was not performed:
I was present during CT scanning and reviewed the images within
20 minutes of their completion.
___ Stroke Scale - Total [8]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. Best Gaze - 1
3. Visual Fields - 1
4. Facial Palsy - 2
5a. Motor arm, left - 2
5b. Motor arm, right - 0
6a. Motor leg, left - 1
6b. Motor leg, right - 0
7. Limb Ataxia - 0
8. Sensory - 0
9. Language - 0
10. Dysarthria - 0
11. Extinction and Neglect - 1
NIHSS was performed within 6 hours of patient presentation or
neurology consult at 09:50.
HPI:
Mr. ___ is a ___ man with history notable for
CAD c/b MI s/p CABG, PE (not on anticoagulation), HTN, and
recent
suspected diagnosis of Lyme disease (with serologies pending)
presenting with acute-onset left-sided weakness.
While walking on his lawn at approximately 05:30 this morning,
Mr. ___ suddenly fell to his left side as he attempted to
move a sprinkler. He felt that he was still able to move his
left
arm and leg, but was unable to push himself up to stand. He
denies loss of consciousness, headache, lightheadedness, sensory
disturbance, or abnormal movements with this episode. His wife
noticed him on the ground, and attempted to help him to his
feet,
but was unable to do so. EMS was activated and Mr. ___ was
brought to ___, where CT/CTA demonstrated a proximal
right M2 occlusion. Mr. ___ was then transferred to ___
for
consideration of thrombectomy.
On review of systems, noted recent fevers, chills, night sweats,
and right groin rash over the past few days; was recently
started
on doxycycline for empiric treatment of Lyme, but with
outpatient
serologies pending. ROS otherwise negative.
Past Medical History:
CAD c/b MI s/p CABG
PE (not on anticoagulation)
HTN
Suspected Lyme disease
Social History:
___
Family History:
mom dad- CAD; brother- MI at ___
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
General: NAD
HEENT: NCAT, neck supple
___: warm, well-perfused
Pulmonary: no tachypnea or increased WOB
Abdomen: soft, ND
Extremities: warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to month and place. Able
to relate history without difficulty. Speech is fluent with
intact naming, reading, and comprehension. No dysarthria. No
visual hemineglect. Able to follow both midline and appendicular
commands.
- Cranial Nerves: PERRL (3 to 2 mm ___. Subtle, peripheral
inferior right quadrantanopsia. Right gaze preference, overcomes
midline but unable to bury sclerae on left. V1-V3 without
deficits to light touch bilaterally. Left lower facial weakness.
Hearing intact to conversation. Palate elevation symmetric.
Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Proximal antigravity effort in LUE, drifts to bed; LLE
also drifts to bed. Full power on right.
- Reflexes: Deferred.
- Sensory: No deficits to light touch or pinprick bilaterally,
but with left-sided extinction to DSS.
- Coordination: No dysmetria with finger-to-nose testing on
right, no dysmetria on HKS bilaterally.
- Gait: Deferred.
__________________________________________________
AT DISCHARGE:
VITALS: reviewed in metavision
General: NAD, pleasant
HEENT: neck supple, abrasions to bridge of nose and scalp
___: warm, well-perfused
Pulmonary: no tachypnea or increased WOB
Abdomen: soft, ND
Extremities: warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to month and place. Able
to relate history without difficulty. Speech is fluent with
intact naming, reading, and comprehension. No dysarthria. No
visual hemineglect. Able to follow both midline and appendicular
commands.
- Cranial Nerves: PERRL (4 to 2 mm ___. Resolution of
peripheral
inferior right quadrantanopsia seen on admission. No gaze
preference, EOMI. V1-V3 without deficits to light touch
bilaterally. L NLFF. Left lower face slow to activate. Hearing
intact to conversation. Palate elevation symmetric. Trapezius
strength ___ bilaterally. Tongue midline.
- Motor: Pronation of left arm. Finger tapping full. Normal bulk
and tone throughout. No adventitious movements, such as tremor
or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
- Reflexes: Deferred.
- Sensory: No deficits to light touch or pinprick bilaterally,
- Coordination: No dysmetria with finger-to-nose testing on
right, no dysmetria on HKS bilaterally. Romberg negative
- Gait: Able to stand and walk on his own without difficulty
Pertinent Results:
LABS:
IMAGING:
___ 10:10 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC &
RECONS; CT BRAIN PERFUSION
CT HEAD WITHOUT CONTRAST:
There is loss of gray-white matter differentiation in the right
frontal operculum compatible with acute infarct. There is no
evidence of acute hemorrhage. Mild prominence of the ventricles
and sulci suggest involutional changes.
Partial opacification of the right sphenoid sinus. The remaining
visualized portion of the paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
CTA HEAD:
There is abrupt cutoff of the right M2 segment (4:293)
compatible
with occlusion. The remaining vessels of the circle of ___
and
their principal intracranial branches appear normal without
stenosis, occlusion, or aneurysm formation. The dural venous
sinuses are patent.
CTA NECK:
The 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.
CT PERFUSION:
Cerebral blood flow < 30% volume: 35 mL
T-max > 6.0 seconds volume: 89 mL
Mismatch volume: 54 mL
Mismatched ratio: 2.5
OTHER:
The visualized portion of the lungs are clear. The visualized
portion of the
thyroid gland is within normal limits. a 1.1 cm subcarinal lymph
node (4:4)
noted.
Echocardiogram:
Normal left ventricular cavity size with mild regional systolic
dysfunction most consistent with
single vessel coronary artery disease (distal RCA). MIldly
dilated thoracic aorta. No valvular pathology or
pathologic flow identified. No definite cardiac source of
embolism seen.
Liver ultrasound:
1. Echogenic liver consistent with steatosis. Other forms of
liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded
on the basis of this examination.
2. 2.1 x 1.5 x 1.0 cm echogenic hepatic lesion is possibly a
hemangioma,
however not fully characterized by ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Doxycycline Hyclate 100 mg PO Q12H
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Niacin SR 1000 mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO QPM
Discharge Medications:
1. FLUoxetine 20 mg PO DAILY
RX *fluoxetine 20 mg 1 capsule(s) by mouth DAILY Disp #*90
Capsule Refills:*3
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Doxycycline Hyclate 100 mg PO Q12H
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Niacin SR 1000 mg PO DAILY
8. Rosuvastatin Calcium 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Ischemic Infarct
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
INDICATION: Suspected stroke with acute neurological deficit.*** WARNING ***
Multiple patients with same last name!// Please exclude ICH, signs of early
ischemic stroke, large vessel occlusion, or other vascular abnormality.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 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:
Total DLP (Head) = 4,832 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is loss of gray-white matter differentiation in the right frontal
operculum and insula compatible with acute infarct. There is no evidence of
acute hemorrhage. Mild prominence of the ventricles and sulci suggest
involutional changes.
Partial opacification of the right sphenoid sinus. The remaining visualized
portion of the paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. Allowing for bilateral optic drusen, the visualized portion of the
orbits are unremarkable.
CTA HEAD:
There is abrupt cutoff of at the proximal right superior M2 division (4:293)
compatible with occlusion. There is paucity of distal vessels along the M3/M4
divisions relative to the left. The remaining vessels of the circle of ___
and their principal intracranial branches appear normal without stenosis,
occlusion, or aneurysm formation. The dural venous sinuses are patent.
CTA NECK:
Allowing for mild atherosclerotic disease, 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.
CT PERFUSION:
Cerebral blood flow < 30% volume: 35 mL
T-max > 6.0 seconds volume: 89 mL
Mismatch volume: 54 mL
Mismatched ratio: 2.5
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. a 1.1 cm subcarinal lymph node (4:4)
noted. There is no cervical lymphadenopathy by size criteria. Aerosolized
debris at the level of the carina (series 4, image 29) is identified. The
major salivary glands are unremarkable. Median sternotomy wires and post CABG
clips are identified. No suspicious osseous lesions.
IMPRESSION:
1. Acute infarct of the right frontal operculum secondary to a occlusion of a
right M2 superior segment. There is paucity of distal vessels along the right
M3/M4 segments relative to the left.
2. Unremarkable CTA of the neck allowing for minimal atherosclerotic disease.
No cervical internal carotid artery stenosis by NASCET criteria.
3. RAPID CT perfusion suggests a ischemic penumbra of approximately 54 mL,
with infarct core measuring approximately 35 mL.
4. Additional findings as described above.
Radiology Report
EXAMINATION: Diagnostic cerebral angiography with mechanical thrombectomy
The following vessels were catheterized:
Right common femoral artery
Right internal carotid artery
Right internal carotid artery after first pass
INDICATION: Patient is a ___ male who presents as a transfer from an
outside hospital with a right MCA syndrome in a ___ stroke scale of 8. CTA
demonstrated large vessel occlusion of the right M2 branch. CT perfusion
demonstrated a good area of penumbra. Risk and benefits of mechanical
thrombectomy were discussed with the patient plans were made to proceed.
ANESTHESIA: The anesthesia provider monitored the patient's hemodynamic and
respiratory parameters. Please refer to anesthesia record for details.
TECHNIQUE: Dr. ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
component to the procedure and has reviewed and agrees with the trainee's
findings.
COMPARISON: CTA performed ___
PROCEDURE: The patient was identified and brought to the neuro radiology
suite directly from the emergency department. He was transferred to the
fluoroscopic table supine. Bilateral groins were prepped and draped in the
standard sterile fashion. An emergent time-out was performed to confirm the
correct patient and procedure. The right common femoral artery was identified
using anatomic data and palpation of the pulse. The right common femoral
artery was accessed using standard micropuncture technique after infiltration
of local anesthetic. A long 8 ___ sheath was introduced connected to
continuous heparinized saline flush and secured with silk suture.
Next a stiff ___ 2 diagnostic catheter was introduced. It was connected
to continuous heparinized saline flush. There is advanced over an 038
glidewire through the aorta into the aortic arch. The wire was used to select
the right common carotid artery. The catheter was positioned over the wire
into the right common carotid artery. The wire was removed. Vessel patency
was confirmed via hand injection. A roadmap of the right common carotid
artery and its branches was performed. The 038 wire was reintroduced into the
diagnostic catheter and used to select the right internal carotid artery. The
catheter was positioned over the wire into the right internal carotid artery.
Standard AP and lateral views were obtained.
Following confirmation of a large vessel occlusion plans were then made for
mechanical thrombectomy. A roadmap was performed in preparation for an
exchange. An exchange length 038 wire was inserted into the diagnostic
catheter in into the right internal carotid artery. The diagnostic catheter
was removed over the wire. A Cook shuttle was then inserted over the wire
into the right internal carotid artery. The exchange length wire and internal
dilator was removed. The catheter was double flushed. The catheter was then
connected to continuous heparinized saline flush. Vessel patency was
confirmed. A fresh roadmap was performed. The ___ aspiration catheter was
connected to continuous saline flush then introduced into the Cook shuttle.
Within the ___ aspiration catheter was a microcatheter and a synchro micro
wire. The combination of the ___ the microcatheter and the synchro wire
were advanced through the Cook shuttle into the right internal carotid artery
and into the middle cerebral artery. The micro wire was used to select the
occluded vessel. The microcatheter was then advanced over the micro wire into
the occluded vessel. The microcatheter was connected to connect continuous
saline flush. The ___ aspiration catheter was then advanced over the
microcatheter to the level of the thrombus in the middle cerebral artery.
This was performed under roadmap guidance. The micro wire was then removed
and the trevo retriever 4 x 30 was introduced into the microcatheter and
advanced into the middle cerebral artery specifically the occluded M2 branch.
The stent retriever was then unsheathed within the occluded artery by pulling
back the microcatheter. Aspiration was applied to the ___ aspiration
catheter. The microcatheter was removed. The ___ in the stent retriever
were then removed as a unit under constant aspiration. Thrombus was
identified in the stent tree for. A follow-up angiogram was performed through
the guide catheter that demonstrated a TICI 3 recanalization of the affected
vessel. The guide catheter was then removed.
Right common femoral angiogram was performed via hand injection through the
sheath. The sheath was removed and the arteriotomy site closed using a 6
___ Perclose device. The patient was removed from the fluoroscopy table
and remained at his neurologic baseline without any evidence of complication.
Equipment:
___ ___ Rotating Valve
Cook ___ Connecting Tubing
Baxter ___ 3-way Stopcock
Terumo ___ .___" 150cm Angled Glidewire
___ ___ x 150cm ___ Wire
___ ___-___ ___ Micropuncture Set
Terumo RS___ ___ x 25cm Terumo Sheath Set
Cordis ___-___ ___ Berenstein II 100cm Cath.
Cardinal ___ 0 Silk Suture
___ ___ Injector tubing 72"
Cook ___ ___ x 90cm Shuttle Sheath Set
___ ___ .___ Angled Glidewire Exchange
___ 2641 Synchro2 Standard 14 200cm Wire
mivi tubing
Penumbra Inc. PAPS2 Canister Kit
Microvention ___ ___ PLUS Distal Access Catheter
___ ___ Trevo Retriever 4 x 30 ___ ___
___ 2641 Synchro2 Standard 14 200cm Wire $505.___
___ ___ Perclose ___ ___ ___
FINDINGS:
Right internal carotid artery: Hand injection demonstrates opacification of
the right internal carotid artery the anterior cerebral and middle cerebral
arteries. There is a cutoff of the superior m 2 branch of the middle cerebral
artery consistent with a large vessel occlusion. No other vessel cutoff
aneurysm or vascular malformation are noted.
Right internal carotid after first pass: Follow-up run after mechanical
thrombectomy demonstrates normal filling of the affected M2 branch consistent
with a TICI 3 recanalization. There remainder of the branches of the internal
carotid artery including the anterior cerebral and middle cerebral arteries
appear normal without signs of thrombus or vessel fall out.
Right common femoral artery. Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection. Vascular caliber is
appropriate for closure device.
IMPRESSION:
TICI 3 recanalization of occluded M 2 branch of the middle cerebral artery
achieved with 1 pass of the stenttreiver for in conjunction with aspiration.
RECOMMENDATION(S):
1. Admission to stroke unit.
2. Plan per neurology.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with R MCA cutoff s/p thrombectomy// Assess for
infarct
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CTA of the head and neck dated ___
FINDINGS:
A large focus of slow diffusion is seen in the right frontal operculum
extending superiorly to the high right frontal lobe and medially to the
insular cortex cortex, consistent with a subacute infarct, as seen on the
prior CTA of the head. There are scattered areas of hemorrhage within the
optic cortex
The ventricles and sulci are mildly prominent, consistent with mild global
cerebral volume loss. There is mild mucosal thickening of the right sphenoid
sinus. The intraorbital contents are normal. The mastoid air cells are
clear.
IMPRESSION:
1. Large right anterior MCA territorial subacute infarct with internal
hemorrhagic foci.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with elevated lfts// eval for liver pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
Anechoic region in the right lobe of the liver measures 5 mm and is consistent
with simple cyst. There is a 2.1 x 1.5 x 1.0 cm echogenic focus at the dome
of the liver, incompletely characterized, possibly a hemangioma. The main
portal vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. Common bile duct
measures 6 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 9.6 cm.
KIDNEYS: Limited views of the right kidney show no evidence of hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
2. 2.1 x 1.5 x 1.0 cm echogenic hepatic lesion is possibly a hemangioma,
however not fully characterized by ultrasound.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: CVA, Transfer
Diagnosed with Cereb infrc d/t unsp occls or stenos of left mid cereb art
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: prehosp
level of acuity: 1.0 | Mr. ___ is a ___ man with a history of CAD
c/b MI s/p CABG, PE (not on anticoagulation), HTN, and recent
suspected diagnosis of Lyme disease presenting with acute-onset
left-sided weakness. He was found to have an acute M2 cutoff and
was taken for thrombectomy. He had a successful reperfusion TICI
3 after one pass. He was subsequently admitted to the stroke
service for further work-up and monitoring.
#Acute R MCA infarct s/p Thrombectomy:
Etiology unknown but presumed possibly cardioembolic given his
history of coronary artery disease
Risk factors: A1c: 5.8 , TSH: 79, LDL: 79
- Patient underwent a TTE which was negative for any source of
thromboembolism of ASD
-He was continued on ASA, clopidogrel
-MRI brain revealed acute infarct in the R MCA territory
involving the inferior division. He also had evidence of small
hemorrhages in the stroke bed due to reperfusion injury.
He was counseled that because of temporal lobe is involved this
is an epileptogenic area and may result in seizures further on.
He did not show any evidence of seizures during his
hospitalization.
-Patient was started on fluoxetine 20mg daily to promote
mood/motor recovery
-Patient was started on atorvastatin 40mg daily
-Antiphospholipid antibodies and d-dimer were also sent
-Regarding his etiology , he likely has paroxysmal afib. We
discussed with the patient for him to be started on
eliquis/apixaban in ___ days after a repeat ct scan is done to
ensure the hemorrhages from the stroke are not worse. If CT
stable he will start 5mg BID of eliquis and STOP the aspirin and
Plavix
-We have also ordered the patient for ___ of hearts monitor
to look for pAF. We would like his pcp/cardiologist to consider
linq or ziopatch to further monitor for paroxysmal afib more
long-term
-His cardiologist is to also order a Factor V-Leiden to complete
a hypercoaguable stroke work up
#Lyme Disease + thrombocytopenia:
-Patient's lyme titers were obtained from ___ and he had
a positive igM lyme. His doxycycline was continued.
Thrombocytopenia in setting of lyme disease. Remained stable
#Elevated LFTs:
LFTs elevated but downtrending, most likely sequelae of Lyme
- RUQUS was done and showed steatohepatitis
-PCP to ___ LFTs. Recommend re-checking in about 1-week
_______________________________
TRANSITIONAL ISSUES
1. An order for CT scan has been placed to be done on ___ .
Please call ___ if you have not heard about time for CT
scan (outpatient)
2. Outpatient speech therapy prescription provided
3. PCP/Cardiologist:
- Monitor patient and ensure he takes 5mg BID of eliquis after
CT scan is done and bleed is stable . Aspirin and Plavix to be
discontinued when patient started on eliquis
- Monitor LFTs
- ___ of hearts monitor followed by further cardiac monitor
with zio patch or linq (Discretion of cardiologist )
- Please send Factor V ___ in outpatient setting to complete
hypercoaguable stroke work up
4. Lyme disease: continue doxycycline for appropriate length of
time (PCP to follow)
_______________________________
AHA/ASA Core Measures for Ischemic Stroke and Transient
Ischemic Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed â () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (X) Yes - () No
4. LDL documented? () Yes (LDL = ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if
LDL if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL]
6. Smoking cessation counseling given? (X) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (X) Yes [Type: ()
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (X) Yes - () No - () N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Captopril / Catapres / ACE Inhibitors / codeine / vancomycin /
Enalapril / lisinopril / Vasotec / Zosyn
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ Crohn's, ESRD (s/p 3 renal transplants FSGS), pAF (no AC
___ GIB), HTN, HLD presents as a transfer w/ LLQ pain.
Mr. ___ reports that around 2 weeks ago he was in ___
with a terrible cough, weakness and fatigue from the flu. He
started having abdominal pain at that time, but attributed to
muscle strain from coughing so much. Since that time, he
started having loose bowel movements, which transition to
constipation, and then back to loose again. He has had no blood
or mucus in his stools, and has had ___ bowel movements daily.
He has been able to eat and drink okay, and has not had any
nausea or vomiting.
Given his complex medical history and "just not feeling right,"
and his continual nagging abdominal pain, he called in to GI
clinic. Given his history of diverticulitis, they told him to
present to the ED at ___. There he underwent an
abdominal CT scan, that was read as perforated diverticulum. His
WBC was 9.7, and he received 3.375 Zosyn and 1L LR.
He was transferred to ___ due to history of renal transplant.
In the ED, initial vitals: T 97.8 HR 74 BP 149/74 RR 16 97% RA
-Exam notable for: NAD, CTAB, no edema, mild LLQ discomfort
-Labs notable for: wbc 6.6, hgb 13.1, plt 219, Cr 1.2, INR 1
-Imaging notable for: Renal US unremarkable (restrictive index
on higher end of normal)
-Colorectal surgery was c/s and recommended GI evaluation, IV
ABx, serial exams.
-Pt given: 1 L LR, zosyn 4.5 g, IV benadryl 50 mg
-Vitals prior to transfer: T 98.1 HR 73 BP 157/81 RR 19 96% RA
Upon arrival to the floor, the patient reports that he is
feeling OK. He denies fever, chills, chest pain, shortness of
breath, nausea, vomiting, change in bladder function, change in
vision or hearing, bruising, adenopathy, new rash or lesion. He
has been eating and drinking OK, and has had no changes in his
fistula from his Crohn's.
Of note, the patient and his wife noticed hives when he received
Zosyn, which improved with benedryl.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
-Atrial fibrillation - paroxysmal sine ___ PVI ___ no AC
as
patient with recurrent GI bleeds I/s/o CD
-FSGS with kidney transplants x 3; diagnosed with FSGS in ___
with first renal transplant at age ___, most recent transplant in
___. Has right brachial fistula. On cyclosporine
-ESBL sepsis
-Hypertension
-Hyperlipidemia
-Hyperparathyroidism, secondary s/p parathyroidectomy x2
-Crohn Disease, on low dose prednisone
-Cerebral aneurysm ("very small")
-Aortic regurgitation (mild)
-Ascending aorta dilation - mild (3.8 cm).
-Adrenal insufficiency, likely ___ chronic prednisone use
-Glaucoma
-H/o PE ___ years ago, unclear etiology/nature; treated with 8
month duration of warfarin
-Metastatic pulmonary calcifications (being worked up, but per
outpatient pulmonologist likely due to underlying
hyperparathyroidism and renal failure)
Social History:
___
Family History:
His father is deceased (___, cerebral aneurysm). His mother is
living (___; hypertension, arthritis, diverticulosis,
hyperlipidemia). He has 6 siblings (2 with cerebral aneurysms
clips; ___ (___), ___ (___), ___ (___), ___ (___), ___
(___).
He has no children. Niece with celiac disease. Nephew with UC.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: ___ 0715 Temp: 97.8 PO BP: 173/79 L Lying HR: 78
RR:
20 O2 sat: 95% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score:
___
General: Older man resting comfortably in bed, alert, oriented,
no acute distress, pleasant and cooperative with exam
HEENT: Sclerae anicteric, right eye with subconjunctival
hemorrhage in medial aspect, MMM, oropharynx with one healed
ulceration left posterior oral cavity, poor dentition, 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: Well- healed surgical scar midline. Soft, slightly
tender to palpation left lower quadrant, non-distended, bowel
sounds present, no organomegaly, no rebound or guarding,
palpable
mass left lower pelvis overlying kidney transplant.
GU: No foley. 0.5 cm fistula right gluteal fold, no drainage, no
redness.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Slight edema left ankle, chronic per patient
Skin: Red/brown chronic dry/sun damage changes on arms, face,
chest, Warm, dry.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
DISCHARGE PHYSICAL EXAM
=======================
VITALS: 24 HR Data (last updated ___ @ 1132)
Temp: 97.8 (Tm 98.1), BP: 160/86 (130-160/81-87), HR: 81
(73-81), RR: 18 (___), O2 sat: 94% (94-97), O2 delivery: Ra
General: Older man resting comfortably in bed, alert, oriented,
no acute distress, pleasant and cooperative with exam
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, nontender, bowel sounds present,
no
organomegaly, no rebound or guarding, palpable mass left lower
pelvis overlying kidney transplant.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Skin: Red/brown chronic dry/sun damage changes on arms, face,
chest, Warm, dry.
Neuro: CNII-XII intact, moves all four.
Pertinent Results:
ADMISSION LABS
===============
___ 12:20AM BLOOD WBC-6.6 RBC-4.63 Hgb-13.1* Hct-43.3
MCV-94 MCH-28.3 MCHC-30.3* RDW-14.4 RDWSD-49.8* Plt ___
___ 12:20AM BLOOD Neuts-75.3* Lymphs-14.7* Monos-8.6
Eos-0.3* Baso-0.6 Im ___ AbsNeut-4.98 AbsLymp-0.97*
AbsMono-0.57 AbsEos-0.02* AbsBaso-0.04
___ 12:20AM BLOOD ___ PTT-28.8 ___
___ 12:20AM BLOOD Glucose-75 UreaN-21* Creat-1.2 Na-140
K-4.6 Cl-107 HCO3-22 AnGap-11
___ 12:20AM BLOOD ALT-10 AST-13 LD(LDH)-132 AlkPhos-113
TotBili-1.1
___ 12:20AM BLOOD Albumin-3.5 Calcium-11.0* Phos-1.9*
Mg-1.9
___ 12:20AM BLOOD CRP-31.7*
INTERVAL LABS
===============
___ 06:06AM BLOOD 25VitD-14*
___ 12:22PM BLOOD PTH-243*
DISCHARGE LABS
================
___ 06:28AM BLOOD WBC-7.6 RBC-4.95 Hgb-14.1 Hct-46.7 MCV-94
MCH-28.5 MCHC-30.2* RDW-14.6 RDWSD-50.9* Plt ___
___ 06:28AM BLOOD ___ PTT-31.8 ___
___ 06:28AM BLOOD Glucose-89 UreaN-17 Creat-1.6* Na-143
K-4.7 Cl-105 HCO3-21* AnGap-17
___ 06:28AM BLOOD Calcium-11.1* Phos-2.3* Mg-1.7
MICROBIOLOGY
===============
__________________________________________________________
___ 1:48 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING/STUDIES
================
___ RENAL ULTRASOUND
1. Normal renal transplant morphology. No perinephric fluid
collections or hydronephrosis.
2. The resistive index of intrarenal arteries ranges from 0.71
to 0.82, slightly above the normal range concerning for
rejection, recommend close clinical observation.
___ CT A/P second read:
FINDINGS:
LOWER CHEST: Unchanged high-density material in the right lung
base suggests
prior aspiration of barium with adjacent bronchiectasis and
bronchial wall
thickening. No current pneumonia. Mild stable cardiomegaly. No
pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
Right hepatic lobe notch sign and widening of the periportal
space can be an
early sign of chronic liver disease. There is no evidence of
focal lesions.
There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The
gallbladder is distended and contains layering stones without
wall thickening
or pericholecystic inflammatory changes to suggest acute
cholecystitis.
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. Small accessory spleen measures 1
cm.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: Post bilateral nephrectomy with surgical clips but no
soft tissue in
the resection beds. Left pelvic transplant kidney with mild
fullness of the
collecting system, likely due to reflux. Normal nephrogram. no
perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Of
note, the
terminal ileum is normal in appearance.
There is evidence of fistulizing Crohn's disease with left
ischioanal fossa
abscess measuring 2.2 x 1.7 x 4.9 cm and lengthy fistulous tract
extending
anteriorly and cranially with 4 distinct contact points with the
rectum and
sigmoid colon (2:101 through 02:33) where it terminates in a 5.4
x 6.0 x 4.1
cm extraluminal collection in the mid abdomen predominantly
filled with air,
without drainable fluid or rim enhancement (2:92). A branch of
the inferior
mesenteric artery courses through the collection. There is an
additional
separate right sided fistulous tract from the collection to the
adjacent
sigmoid colon (___). Surrounding fat stranding and
thickening of the
sigmoid colon compatible with mild ongoing inflammation.
Additionally, a perianal fistula is present with external
opening in the right
gluteal cleft and internal opening not well visualized on CT,
with path and
local inflammatory change suggesting it is transsphincteric at 7
o'clock, new
since prior MRI in ___ (2:151 through 02:47). No abscess in
this region.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: Calcifications in the prostate gland.
LYMPH NODES: No abdominopelvic lymphadenopathy by CT size
criteria.
VASCULAR: There is no abdominal aortic aneurysm. Extensive
atherosclerotic
disease is noted. Patent visualized abdominopelvic vessels
including the
portal vein.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
Right total hip arthroplasty with associated streak artifact
which limits
assessment of the adjacent structures.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Contained perforation adjacent to the sigmoid colon
containing
predominantly air without drainable fluid and smaller left
ischioanal fossa
abscess with evidence of fistulizing Crohn's disease and
multiple tracts
connecting these collections to the recto-sigmoid colon. Please
see details
above.
2. Branch of the ___ traverses the contained perforation.
3. Multifocal mild inflammation of the sigmoid colon
4. Perianal fistula possibly transsphincteric, which could be
better evaluated
with MRI if clinically indicated.
5. Distended gallbladder with layering stones. No evidence of
acute
cholecystitis.
6. Post bilateral nephrectomy with left pelvic renal transplant.
7. Extensive atherosclerotic disease.
8. Hepatic morphology may suggest chronic liver disease.
RECOMMENDATION(S): Perianal MRI may be obtained for better
evaluation of the
perianal fistula, if clinically relevant.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO 5X/WEEK (___)
2. Aspirin 81 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
4. PredniSONE 8 mg PO DAILY
5. Verapamil SR 120 mg PO QHS
6. Gengraf (cycloSPORINE modified) 50 mg oral BID
7. fish oil-dha-epa (om-3-dha-epa-fish oil-vit
D3;<br>omega-3s-dha-epa-fish oil-D3) ___ mg oral DAILY
8. Calcitriol 0.25 mcg PO 4X/WEEK (___)
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 21 Doses
Please take next dose on ___ evening (around 10PM)
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth Twice daily
Disp #*21 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H Duration: 30 Doses
Please take next dose at midnight (12:01) at ___.
RX *metronidazole 500 mg 1 tablet(s) by mouth Every 8 hours Disp
#*30 Tablet Refills:*0
3. Amiodarone 200 mg PO 5X/WEEK (___)
4. Aspirin 81 mg PO DAILY
5. Calcitriol 0.25 mcg PO 4X/WEEK (___)
6. fish oil-dha-epa (om-3-dha-epa-fish oil-vit
D3;<br>omega-3s-dha-epa-fish oil-D3) ___ mg oral DAILY
7. Gengraf (cycloSPORINE modified) 50 mg oral BID
8. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
9. PredniSONE 8 mg PO DAILY
10. Verapamil SR 120 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
===============
Fistulizing Crohn's disease w/contained perforation
Secondary Diagnoses
==================
End stage renal disease with renal transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: History: ___ with hx of transplant and abdominal pain// Please
assess transplant function
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Reference CT abdomen pelvis ___
FINDINGS:
The left lower quadrant transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.71 to 0.82, slightly
above the normal range. The main renal artery shows a normal waveform, with
prompt systolic upstroke and continuous antegrade diastolic flow, with peak
systolic velocity of 145 cm/second. Vascularity is symmetric throughout
transplant. The transplant renal vein is patent and shows normal waveform.
IMPRESSION:
1. Normal renal transplant morphology. No perinephric fluid collections or
hydronephrosis.
2. The resistive index of intrarenal arteries ranges from 0.71 to 0.82,
slightly above the normal range concerning for rejection, recommend close
clinical observation.
Radiology Report
EXAMINATION: SECOND OPINION CT ABD/PELVIS
INDICATION: ___ year old man with Crohn's disease, now with abdominal pain and
concern for diverticulitis vs. Crohn's flare with fistula.// On CT ___
___, evidence of diverticulitis vs fistulizing Crohn's
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous contrast administration at an outside institution. Oral
contrast was administered. Coronal and sagittal reformations were reviewed on
PACS.
Images were satisfactory for interpretation.
DOSE: Total DLP: 597 mGy-cm
COMPARISON: CT enterography from ___.
CT of the abdomen and pelvis without contrast from ___.
FINDINGS:
LOWER CHEST: Unchanged high-density material in the right lung base suggests
prior aspiration of barium with adjacent bronchiectasis and bronchial wall
thickening. No current pneumonia. Mild stable cardiomegaly. No pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Right hepatic lobe notch sign and widening of the periportal space can be an
early sign of chronic liver disease. There is no evidence of focal lesions.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is distended and contains layering stones without wall thickening
or pericholecystic inflammatory changes to suggest acute cholecystitis.
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. Small accessory spleen measures 1 cm.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Post bilateral nephrectomy with surgical clips but no soft tissue in
the resection beds. Left pelvic transplant kidney with mild fullness of the
collecting system, likely due to reflux. Normal nephrogram. no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Of note, the
terminal ileum is normal in appearance.
There is evidence of fistulizing Crohn's disease with left ischioanal fossa
abscess measuring 2.2 x 1.7 x 4.9 cm and lengthy fistulous tract extending
anteriorly and cranially with 4 distinct contact points with the rectum and
sigmoid colon (2:101 through 02:33) where it terminates in a 5.4 x 6.0 x 4.1
cm extraluminal collection in the mid abdomen predominantly filled with air,
without drainable fluid or rim enhancement (2:92). A branch of the inferior
mesenteric artery courses through the collection. There is an additional
separate right sided fistulous tract from the collection to the adjacent
sigmoid colon (___). Surrounding fat stranding and thickening of the
sigmoid colon compatible with mild ongoing inflammation.
Additionally, a perianal fistula is present with external opening in the right
gluteal cleft and internal opening not well visualized on CT, with path and
local inflammatory change suggesting it is transsphincteric at 7 o'clock, new
since prior MRI in ___ (2:151 through 02:47). No abscess in this region.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: Calcifications in the prostate gland.
LYMPH NODES: No abdominopelvic lymphadenopathy by CT size criteria.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted. Patent visualized abdominopelvic vessels including the
portal vein.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Right total hip arthroplasty with associated streak artifact which limits
assessment of the adjacent structures.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Contained perforation adjacent to the sigmoid colon containing
predominantly air without drainable fluid and smaller left ischioanal fossa
abscess with evidence of fistulizing Crohn's disease and multiple tracts
connecting these collections to the recto-sigmoid colon. Please see details
above.
2. Branch of the ___ traverses the contained perforation.
3. Multifocal mild inflammation of the sigmoid colon
4. Perianal fistula possibly transsphincteric, which could be better evaluated
with MRI if clinically indicated.
5. Distended gallbladder with layering stones. No evidence of acute
cholecystitis.
6. Post bilateral nephrectomy with left pelvic renal transplant.
7. Extensive atherosclerotic disease.
8. Hepatic morphology may suggest chronic liver disease.
RECOMMENDATION(S): Perianal MRI may be obtained for better evaluation of the
perianal fistula, if clinically relevant.
NOTIFICATION: Findings discussed with Dr. ___ by Dr. ___ on the phone at
___ on ___, 20 min after discovery of the findings
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LLQ abdominal pain, Transfer
Diagnosed with Crohn's disease, unspecified, without complications, Dvtrcli of intest, part unsp, w perf and abscess w/o bleed, Left lower quadrant pain
temperature: 97.8
heartrate: 74.0
resprate: 16.0
o2sat: 97.0
sbp: 149.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | PATIENT SUMMARY
=================
___ w/ Crohn's, ESRD (s/p 3 renal transplants FSGS), pAF (no AC
___ GIB), HTN, HLD presents as a transfer w/ LLQ pain due to
perforation diverticulum vs fistulizing Crohn's.
ACUTE ISSUES
===============
# Diverticulitis complicated by perforated diverticulum:
CTAP w/ contained perforation without fluid containing abscess.
No clear e/o crohn's flare. Follows GI here at ___ and last
visit on ___ w/o any concerns for flare. CRP elevated at
31.7. He initially received zosyn in the ED, however developed
urticaria which improved with diphenhydramine. He was then was
transitioned to ciprofloxacin and flagyl to complete a 10 day
course of antibiotics (___). Colorectal surgery was
consulted and recommended non-emergent surgical resection with
diversion. Gastrotenterology was also consulted and was
concerned about Crohn's progression although imaging was
consistent with diverticulitis.
# Crohn's disease
Diagnosed in ___, complicated by anal fistulas, on prednisone
and cyclosporine (renal transplant). Previous ___
hospitalizations for diverticulitis vs sigmoid thickening
concerning for peroforating Crohn's. Last colonoscopy ___,
with normal colon except for diverticulosis and a 10 mm polyp
which was removed. His baseline is ___ bowel movements daily.
Followed by Dr. ___ seen in clinic on ___. He was
continued on his home prednisone 8 mg daily, modified
cyclosporine 50 mg PO BID and he took home medication without
issue. Patient has follow up with Dr. ___ in ___ and no
sooner appointment was needed.
# Urticaria
Patient and wife reported that he had hives after receiving
Zosyn in the ED, which improved with diphenhydramine and Zosyn
added to patient allergy list.
# Hyperparathyroidism, secondary s/p parathyroidectomy x2:
# Hypercalcemia
Continued calcitriol 4x/week. PTH was checked and 243. Calcium
elevated ~11. Vitamin D 14. Consider a DEXA scan as an
outpatient due to risk of osteoporosis. Hypercalcemia follow-up
with outpatient Nephrology Dr. ___.
CHRONIC ISSUES
==================
# Renal transplant:
# ESRD:
Baseline creatinine 1.3-1.6, currently at baseline. Transplant
US w/ high-normal resistance indexes, but otherwise no
abnormalities. Transplant service made aware of his admission.
He was continued on cyclosporine 50 mg BID and prednisone 8 mg
qd. Discharge creatinine 1.6. Unfortunately patient missed his
previously scheduled appointment with Dr. ___ due to still
being inpatient.
#pAF:
Not on AC due to Crohn's disease. He was in sinus rhythm on
admission, and was continued on amiodarone 200 mg 5x week.
#HTN:
#HLD
#Primary prevention
Continued verapamil ER 120 mg qd and aspirin 81 mg qd. Pt had
labile BP 130-180s/70-80s, no medication changes were made.
#Glaucoma: continued home latanoprost
TRANSITIONAL ISSUES:
==================
[] New Meds:
Ciprofloxacin 500mg PO Daily until ___
Metronidazole 500mg PO Q8H until ___
[] Stopped/Held Meds: None
[] Changed Meds: None
[] Please ensure that follow up with GI, CRS, and renal
transplant are scheduled. A visit with CRS was scheduled with a
colleague of Dr. ___ (Dr. ___.
[] Please continue to monitor HTN, as inpt BP was somewhat
labile from 130-180s/70-80s, no medication changes were made
[] Discharge creatinine 1.6
[] Please ensure that renal transplant addresses
hyperparathryoid with hypercalcemia and low vitamin D; consider
DEXA scan due to risk of osteoporosis.
[] Pt started on QTc prolonging medications QTc 450
[] AT TIME OF SURGERY: Consider stress dose steroids
perioperatively, patient has a
history of adrenal insufficiency
#CODE: Full code (presumed)
#CONTACT: ___ (wife) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left lower quadrant pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old gentleman with a history of atrial fibrillation,
hypertension and known renal cancer who presents for evaluation
of chronic left lower quadrant pain.
.
The patient first developed LLQ pain last ___. He had a CT scan
of his abdomen at an OSH which demonstrated diverticulitis and
he was treated w/ pain relief and antibiotics. Since that time,
he has maintained himself on a no seed, popcorn diet but the LLQ
pain has persisted. The pain often responds to tylenol or
oxycodone if needed for breakthrough pain. He spends half the
year in ___ and has had two CT scans in ___ since ___
which have been unchanged from prior showing his renal cancer
and more recently showing no evidence of diverticulosis per his
report. For the past two months he has had a 30lbs unintentional
weight loss associated w/ loss of appetite. His primary care
physician in ___ urged him to have a w/u when he returned to
___. His PCP here, Dr. ___ has recently stopped
his practice and the patient has an appointment w/ a new PCP
this ___. This morning he awoke and felt fatigued w/
complete loss of appetite. A friend visited and recommended
referral to ED for swifter formal w/u of his LLQ pain. On ROS he
reports an episode of low back pain that resolved w/ tylenol. He
denies fevers, night sweats, constipation or diarrhea, black
stool, cough, weakness or parasthesias, abnormal skin
rashes/changes/lesions. He urinates 2 times per night. His ROS
is otherwise completely negative. His last colonscopy is > ___
years ago. He is a non-smoker since ___ although his wife died
of tobacco related causes ___ years ago. He worked in the
___ and endorses little asbestos exposure.
.
With regards to his kidney cancer. This was apparantly diagnosed
over ___ years ago and is followed w/ serial imaging studies. He
has never had a biopsy or seen an oncologist for evaluation.
.
In the ED, initial VS were: 97.8 120 123/67 18. Labs were
significant for a relatively unremarkable chem7, ALT 71, AST 49,
AP 119, tbili 0.5, albumin 3.4. A CBC demonstrated WBC 9.7, hct
33.1, plts 376 and lactate 2.4 and INR 1.8. An EKG demonstrated
afib at 144, LAD, RBBB, TWI V1-V3. The patient was given IV
metoprolol x 4, metoprolol 50mg PO and was ultimately started on
a diltiazem gtt and given IV dilt of 10mg. A CT abdomen and
pelvis revealed a 4x6 cm heterogeneous left renal lesion
concerning for neaoplsm. There was evidence of extensive
slerotic bone metastases and bone lesions. An initial request
was made for the ICU however, as the patient was hemodynamically
stable he was triaged to ___ for continuation of a diltiazem
gtt. He received 2L NS prior to transfer: Vitals on transfer:
99.6 °F (37.6 °C), 103, 16, 128/74, Rhythm: Atrial Fibrillation,
O2Sat: 98.
.
Currently, 98.0 117/72 104 22 96RA. He denies active LLQ pain.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Atrial Fibrillation
Hypertension
Hyperlipidemia
Renal Cancer: Never had a biospy or seen an oncologist
Internal Bleed: ___ supratherapeutic INR on coumadin
Social History:
___
Family History:
Non contributory
Physical Exam:
Admission Physical Exam:
VS - 98.0 117/72 104 22 96RA.
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
BREAST EXAM: limited exam, no axillary lymphadenopathy, or
masses noted on exam, small lipoma noted on left axilla
HEART - PMI non-displaced, irregRR, nl S1-S2, no MRG
LUNGS - CTAB, small lipoma on left axilla
ABDOMEN - NABS, soft/ND, mild tenderness to deep palpation of
LLQ w/ pressure applied medially. No inguinal lymphadenomathy.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Discharge Physical Exam:
VS - Tm 99.5 Tc 99.1 BP 106/60 HR 80 RR 18 O2 97% RA
HEART - Regular rate, irregularly irregular rhythm, nl S1-S2, no
MRG
ABD- +BS, mild tenderness in left lower quadrant
Exam otherwise unchanged
Pertinent Results:
Admission labs:
WBC-9.7 RBC-3.70* HGB-9.8* HCT-33.1* MCV-90 MCH-26.4* MCHC-29.5*
RDW-16.0*
NEUTS-79.9* LYMPHS-13.1* MONOS-6.2 EOS-0.3 BASOS-0.4
PLT COUNT-376
.
GLUCOSE-124* UREA N-17 CREAT-1.0 SODIUM-136 POTASSIUM-4.8
CHLORIDE-98 TOTAL CO2-24 ANION GAP-19
ALT(SGPT)-71* AST(SGOT)-49* ALK PHOS-119 TOT BILI-0.5
ALBUMIN-3.4*
LACTATE-2.4* K+-4.5
.
Urinalysis- negative
Pertinent labs:
Discharge hct 25.2
PSA 4.4
TSH 0.66
Iron 17 TIBC 190* Ferritin 910* Transferrin 146*
SPEP- no specific abnormalities seen
UPEP- negative
LABS PENDING AT TIME OF DISCHARGE:
Free kappa/lambda chains
CA ___
CEA
Blood culture ___- pending, NGTD x 2
Imaging:
CT chest ___. No CT evidence of a dominant lung nodule or mass to suggest a
primary lung cancer. However, there are numerous less than or
equal to 5-mm diameter lower lung predominant nodules which
could potentially represent metastatic foci.
2. Known heterogeneous lower pole left kidney mass is only
partially imaged but remains concerning for renal neoplasm.
Please see separately dictated CT abdomen study on clip ___
for more complete evaluation of this and other abdominal
findings.
3. Mixed lytic and sclerotic skeletal lesions are concerning for
metastatic disease.
4. Diffuse calcified pleural plaques, consistent with previous
asbestos exposure.
5. Coronary artery calcifications.
CT abd/pelvis ___. No evidence of diverticulitis or colitis. Limited evaluation
for
mesenteric ischemia, but no secondary signs of bowel infarction.
2. Large heterogeneous lesion in the lower pole of the left
kidney concerning for a renal neoplasm. The central
hypo-attenuation suggests the possibility of an onchocytoma,
however the lesion cannot be reliably distinguished from RCC.
3. Extensive sclerotic bone metastases. The appearance of the
bone lesions is more consistent with a lung or prostate primary,
rather than the renal neoplasm, which may be an incidental
finding. Suggest correlation with PSA and chest radiography.
4. Lytic 11th rib lesions.
5. Pulmonary pleural plaques signify prior asbestos exposure and
provide a risk factor for pulmonary neoplasia.
6. Milk of calcium in the gallbladder
7. A nodule in anterior mid-gland of prostate is most typical of
avenous plexus
Medications on Admission:
Verapamil 120mg- 0.5tab po daily
Metoprolol 50mg- 0.5tab po daily
Losartan 50mg po daily
Lovastatin 20mg po qHS
Dabigatran 150mg po BID
Vitamin D 400IU po daily
Discharge Medications:
1. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
2. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours: you make take an additional tablet as need for
pain: DO NOT exceed 3000 mg in 24 hours.
5. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
twice a day: DO NOT take until ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
# Metastatic cancer, unknown primary
# Atrial fibrillation with rapid ventricular response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with atrial fibrillation, presenting with left
lower quadrant pain, unintentional weight loss, night sweats. Left lower
quadrant pain for two weeks.
COMPARISON: ___, an exam from another institution.
TECHNIQUE: MDCT data were acquired through the abdomen and pelvis after the
administration of intravenous contrast. Images were displayed in multiple
planes. DLP: 978 mGy-cm.
FINDINGS: There is minimal bibasilar scarring in the visualized lung bases.
There is a 7 mm left lower lobe nodule (2b:99) and 1.2 cm right lower lobe
nodule (2b:103). Bilateral calcified plaques are present. No consolidation or
effusion is visualized.
CT ABDOMEN: The liver has homogeneous appearance other than some focal fat
along the falciform ligament. The portal veins are patent. There is no
intra- or extra-hepatic biliary dilatation. There is high-density material
filling the gallbladder. The pancreas and spleen are unremarkable. The
adrenal glands are normal.
Several hypodense lesions are identified in the right kidney, the largest
lesion in the upper pole has cystic attenuation. Remainder of the smaller
lesions are too small to characterize. There is an ill-defined heterogeneous
and minimally enhancing mass in the lower pole of the left kidney, which
measures grossly 4 x 6 cm (2A:26) similar to CT from another institution ___. This lesion has both hypo- and hyper-dense components.
The stomach, small and large bowel are of normal caliber. The remainder of
the bowel is of normal caliber. There is diverticulosis throughout the
sigmoid colon without any evidence of diverticulitis. The appendix is not
visualized. There are no secondary signs of appendicitis in the right lower
quadrant.
CT PELVIS: A nodular focus along the periphery of the anterior mid-gland of
the prostate suggests a hyperplastic nodule or prominent venous plexus, but
the prostate is not well assessed with CT imaging. There is no free pelvic
fluid. The bladder is normal. There is no inguinal or pelvic adenopathy.
There are scattered atherosclerotic changes of the ectatic abdominal aorta and
iliacs with near occlusion of the right posterior iliac. There is no ascites.
No abdominal or retroperitoneal adenopathy is present.
BONE WINDOWS:
There are multilevel degenerative changes in the thoracolumbar spine. There
is heterogeneous sclerosis in T11 and L1 as well as a focal sclerotic lesion
in L4. There are lytic rib lesions of the bilateral 11th ribs (2a:28).
IMPRESSION:
1. No evidence of diverticulitis or colitis. Limited evaluation for
mesenteric ischemia, but findings suggestive of bowel abnormality.
2. Large heterogeneous lesion in the lower pole of the left kidney concerning
for a renal neoplasm.
3. Findings consistent with sclerotic bone metastases. The appearance of the
bone lesions is more frequently seen with non-renal malignancies, especially
lung or prostate primary malignancy. Suggest correlation with PSA and chest
radiography.
4. Pulmonary pleural plaques suggest prior asbestos exposure.
5. Milk of calcium in the gallbladder versus sludge or small stones.
6. A nodule in anterior mid-gland of prostate is most typical of a venous
plexus or hyperplastic nodule, but the prostate is not well evaluated with CT.
Radiology Report
AP CHEST, 10:36 P.M., ___
HISTORY: New diagnosis of spinal metastases, question lung nodules.
IMPRESSION: AP chest read in conjunction with imaging of the lower thorax on
recent abdominal CT scans, ___ and ___:
Heart size top normal. No evidence of central lymph node enlargement. Lungs
are well expanded. Pleural thickening and many focal pleural calcifications
due to asbestos exposure project over both lungs. A good candidate for a
noncalcified lung nodule is a 10 mm wide round opacity projecting over the
left third anterior interspace. Thoracic aorta is heavily calcified, but not
focally dilated.
Radiology Report
CT CHEST WITHOUT CONTRAST DATED ___
COMPARISON: CT abdomen study of ___.
TECHNIQUE: Multidetector CT volumetric acquisition of the chest was performed
without intravenous or oral contrast administration. Images are presented for
display in the axial plane at 5-mm and 1.25-mm collimation. A series of
multiplanar reformation images are also submitted for review.
FINDINGS: There is no evidence of a dominant, spiculated lung nodule or mass
to suggest the presence of primary lung malignancy. However, multiple less
than or equal to 5-mm diameter well-circumscribed round and/or oval nodules
are present in both lower lobes, located in the left lower lobe on images 149,
151, 192, and 215, and within the right lower lobe on images 181 and 173 and
209 and 214, all on series 4. Extensive bilateral calcified pleural plaques
are present, consistent with prior asbestos exposure, and note is also made of
nonspecific scarring in the lung apices and either scar or atelectasis in the
lung bases. A nonspecific area of dependent ground-glass and reticular
opacity is also present in the right upper lobe posteriorly (25, 2) and may
reflect dependent atelectasis or subclinical aspiration.
No enlarged mediastinal or hilar lymph nodes are evident. Cardiac silhouette
is mildly enlarged with particular prominence of the left atrium. Coronary
artery calcifications are present diffusely. There is no pericardial or
pleural effusion.
Exam was not specifically tailored to evaluate the subdiaphragmatic region,
and a known mass involving the lower pole portion of the left kidney is only
partially imaged on this study. High attenuation within the gallbladder is
demonstrated as shown on the prior abdominal CT as well, and note is also made
of extensive vascular calcifications involving the abdominal aorta and its
branches. Skeletal structures demonstrate extensive areas of mixed sclerosis
and lucency throughout the spine and sternum and to a lesser extent within the
ribs, best visualized on the multiplanar reformation images.
IMPRESSION:
1. No CT evidence of a dominant lung nodule or mass to suggest a primary lung
cancer. However, there are numerous less than or equal to 5-mm diameter lower
lung predominant nodules which could potentially represent metastatic foci.
2. Known heterogeneous lower pole left kidney mass is only partially imaged
but remains concerning for renal neoplasm. Please see separately dictated CT
abdomen study on clip ___ for more complete evaluation of this and other
abdominal findings.
3. Mixed lytic and sclerotic skeletal lesions are concerning for metastatic
disease.
4. Diffuse calcified pleural plaques, consistent with previous asbestos
exposure.
5. Coronary artery calcifications.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: LAP
Diagnosed with RENAL & URETERAL DIS NOS, SECONDARY MALIG NEO BONE, ATRIAL FIBRILLATION
temperature: 97.8
heartrate: 120.0
resprate: 18.0
o2sat: nan
sbp: 123.0
dbp: 67.0
level of pain: 5
level of acuity: 2.0 | ___ yo M with h/o atrial fibrillation, hypertension and ?renal
cell carcinoma presenting with weight loss, LLQ pain and new
sclerotic bony lesions concerning for metastatic cancer with
unknown primary, as well as atrial fibrillation with RVR.
# Diffuse metastatic lesions- Patient presented to ___ with
complaints of LLQ pain which was longstanding and 30lb weight
loss in the past 3 months. On CT scan, there was evidence of
multiple small pulmonary nodules, sclerotic and lytic lesions
throughout the spine as well as in the sternum and ribs,
suggesting diffuse metastatic cancer with unknown primary.
Further imaging showed no primary masses in the chest, abdomen
or pelvis, other than the known left kidney mass. Kidney mass
was most concerning for renal cell carcinoma, which could very
well cause the above metastatic lesions. PSA was 4.4 without
nodules noted on CT scan. Patient had not had a colonoscopy in
___ years. SPEP and UPEP were negative, with free light chains
pending at time of discharge.
Patient was seen by oncology while in-patient. It was
decided that a tissue diagnosis should be made via a bony
metastatic lesion, as the kidney mass would be too vascular and
at risk for seeding peritoneum. As patient was on dabigatran,
biopsy was deferred until dabigatran was completely washed out,
waiting ___ days.
Therefore, patient was discharged, with plan to see new PCP
on ___, then precede with biopsy as outpatient on
___. PCP was agreeable to following-up pathology,
and will help patient find appropriate oncologist once tissue
diagnosis is confirmed.
Throughout hospitalization, patient and family reiterated
wishes for the least invasive interventions, but were interested
in continuing to hear all possible options.
# Atrial fibrillation with RVR- On admission, patient was in
rapid ventricular response. He has known atrial fibrillation
and was on verapamil and metoprolol for rate control. Patient
denied symptoms of lightheadedness, chest palpitations, chest
pain or shortness of breath, however family noted increased
lethargy. Patient's rates were well controlled in the ___ on
diltiazem 60mg QID. Patient was discharged on this medication,
holding home verapamil and metoprolol. Patient can likely be
transitioned to long acting diltiazem if dosing continues to
control rate.
As above, dabigatran was held starting in the evening of
___. Patient was instructed to hold dabigatran until ___
___, 3 days following bone biopsy.
# Abdominal pain- As above, patient presented with intermittent
LLQ pain which had been present for several months. Patient had
several CT scans, one of which noted diverticulitis, and so
patient was treated with antibiotics. On CT scan on admission
to ___, there was no evidence of diverticulitis. Patient's
left kidney mass appeared to be in the region of described pain.
Patient reported that as outpatient, tylenol was controlling
discomfort as needed, and he took 500mg ___ tabs, totaling ___
tabs per week. Patient was started on standing tylenol ___
three times a day, and encouraged to continue to do so as
outpatient. He was instructed that he could take an extra tab
as needed for pain, but should not exceed a total of 3000mg in
24 hours.
# Anemia- Hematocrit dropped from 33 to 25. This was attributed
to hemoconcentration on admission, and 25 was thought to
represent patient's true baseline. He denied BRBPR or melena.
Iron studies were consistent with anemia of chronic disease.
Patient was asymptomatic and was therefore not transfused.
# Hypertension- As above, metoprolol and verapamil were held on
admission, while titrating up on diltiazem. Losartan was also
held. All three medications were held at time of discharge, and
blood pressure was well controlled on diltiazem alone.
# Hyperlipidemia- Therapeutic interchange for atorvastatin 10
while in house. Restarted lovastatin 20 at the time of
discharge
# Transitional issues-
- Please recheck hematocrit (25.2 on day of discharge)
- Biopsy scheduled for 930am on ___ please follow biopsy
results.
- Oncology fellow ___ saw patient inpatient, and will
also follow-up results
- Oncologist can be found via doctor-to-doctor line once tissue
diagnosis is made
- Diltiazem 60mg QID controlled rapid ventricular response while
inpatient
- Metoprolol, verapamil and losartan were held at time of
discharge
- Patient should restart dabigatran on ___ if there are no
complications following biopsy |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Levofloxacin
Attending: ___.
Chief Complaint:
shortness of breath, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo ___ speaking female with a
long history of severe bronchiectasis with known MRSA, last
admitted ___ ___ with GNR pna treated with cefepime and
vancomycin, who presents with a 7 day history of difficulty
breathing, cough productive of sputum and occassional blood,
fever (though pt did not take her temperature at home),
diaphoresis and myalgias. Prior to this, she had been on
clarithromycin followed by Bactrim and ___ fact has been on
various combinations of antibiotics chronically for the past
couple of years - she finished prolonged course of IV vancomycin
last ___. Her symptoms began on ___, when she
started feeling fatigued, difficulty breathing, pleuritic chest
pain and developed a cough productive of sputum. She was started
on Bactrim on ___, ___, whcih she took for the next five
days, but her symptoms grew progressively worse. Her symptoms
are consistent with her usual bronchiectasis flares. According
to her daughter, no interventions other than IV antibiotics have
been helpful.
She did not have any headache, dizziness, vomiting, diarrhea,
constipation, dysuria, palpitations, abdominal pain. However,
she has had poor PO intake for the past week due to decreased
appetite and nausea.
Past Medical History:
Recurrent lung infections, bronchiectasis of the right mid/lower
lobes
Social History:
___
Family History:
Daughter has bronchiectasis
Physical Exam:
On admission:
VS: 98.5, 112/64, 79, 18, 99% RA
GENERAL: frail and fatigued ___ mild respiratory distress but
clearly uncomfortable, lying ___ bed
HEENT: Mild-moderate erythema across torso and to the back of
her neck. Sclera anicteric. No cervical lymphadenopathy.
Oropharynx clear. Tongue not enlarged. possible swelling of
lower lip
CARDIAC: Poor heart sounds. Unable to distinguish clear s1, s2,
especially given pt's distress and rhonchi. Radial pulse mildly
weak and rapid. Did not hear any murmurs, rubs or gallops
LUNGS: moderate bronchial sounds ___ the apecies. Moderate to
severe coarse crackles and rhonchi ___ bases bilaterally. No
wheezes detected.
ABDOMEN: Normal bowel sounds. soft, nontender, nondistended.
EXTREMITIES: warm and well perfused. No edema.
Upon discharge:
Vitals continue to be stable: T 98.1, BP 104-128/54-70 (past 24
hr), HR 58-80, RR 18, O2sat 96-100% on RA. Patient appeared much
more comfortable, sitting upright ___ her chair. No respiratotry
distress. However, still appeared slightly weak. She no longer
has erythema across her torso or swelling of the lower lip.
Pulmonary exam markedly improved. Left lung sounds mostly clear.
Mild crackles at bases. Right lung continues to have moderate
crackles along bases, but much less than upon presentation. No
bronchial sounds, rhonchi or rales. Rest of exam was stable.
Pertinent Results:
Labs on admission:
___ 11:45AM BLOOD WBC-8.6 RBC-4.37 Hgb-12.7 Hct-36.2 MCV-83
MCH-29.0 MCHC-35.0 RDW-13.4 Plt ___
___ 11:45AM BLOOD Glucose-82 UreaN-8 Creat-0.5 Na-139 K-3.7
Cl-103 HCO3-27 AnGap-13
___ 12:19PM BLOOD Lactate-1.2
Labs on Discharge:
___ 08:10AM BLOOD WBC-5.2 RBC-3.72* Hgb-10.5* Hct-31.2*
MCV-84 MCH-28.2 MCHC-33.7 RDW-13.3 Plt ___
___ 08:10AM BLOOD Glucose-95 UreaN-5* Creat-0.4 Na-142
K-3.8 Cl-104 HCO3-35* AnGap-7*
___ 08:10AM BLOOD ALT-11 AST-19 LD(LDH)-154 AlkPhos-69
TotBili-0.2
___ 08:10AM BLOOD Albumin-3.1* Calcium-8.6 Phos-3.0 Mg-1.7
___ 08:10AM BLOOD Vanco-14.6
UA:
___ 01:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
Micro:
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. RARE
GROWTH.
IDENTIFICATION AND SENSITIVITIES PER DE.
___ PAGER
___ ___.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S
VANCOMYCIN------------ 1 S
Imaging:
Chest x-ray (___)
FINDINGS: Since the prior radiograph from ___, there
has been
removal of the right arm PIC line. Again seen is severe
bronchiectasis
affecting the right middle and lower lobes as well as the left
lower lobe.
There maybe slight worsening of bronchiectasis ___ left lower
lobe. ___ the
right upper lobe, just above the minor fissure, an ill-defined
patchy opacity
persists which may represent infectious process. There is no
pleural effusion
or pneumothorax. Lungs remain hyperexpanded. Cardiomediastinal
silhouette is
unchanged. Osseous structures are intact. A right PICC line
has been
removed.
IMPRESSION:
1. No significant change ___ severe bronchiectasis ___ the right
middle and
right lower lobes. Possible interval worsening ___ left lower
lobe
bronchiectasis.
2. Stable ill-defined opacity ___ the right upper lobe may
represent
continuing infectious process. No new focal consolidation.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen ___ *NF* (diphenhydramine-acetaminophen) unknown
Oral qHS cold symptoms
2. Benzonatate 100 mg PO TID:PRN cough
3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
4. Ibuprofen 200 mg PO Q8H:PRN pain
take with food
5. Loratadine *NF* 10 mg Oral BID itching
6. albuterol sulfate *NF* 90 mcg/actuation Inhalation 2 puffs
qid sob, wheeze
7. Sulfameth/Trimethoprim DS 1 TAB PO BID
for two weeks of every month, alternate with cefpodixime
8. Cefpodoxime Proxetil 200 mg PO Q12H
start after bactrim and take 2 weeks of every month/alternate
with bactrim
Discharge Medications:
1. Vancomycin 1250 mg IV Q 12H
Please infuse over 2 hours. Continue until ___ or told
otherwise by your physicians.
RX *vancomycin 500 mg Infuse 1250mg IV every 12 hours Disp #*0
Not Specified Refills:*0
2. Benzonatate 100 mg PO TID:PRN cough
3. Ibuprofen 200 mg PO Q8H:PRN pain
take with food
4. Loratadine *NF* 10 mg Oral BID itching
5. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
6. albuterol sulfate *NF* 90 mcg/actuation Inhalation 2 puffs
qid sob, wheeze
7. Acetaminophen ___ *NF* (diphenhydramine-acetaminophen) 0 350
ORAL HS:PRN cold symptoms
8. Clarithromycin 500 mg PO Q12H
Last day ___
RX *clarithromycin 500 mg 1 tablet(s) by mouth twice a day Disp
#*18 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Bronchiectasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with dyspnea and cough, rule out pneumonia.
COMPARISONS: Multiple prior studies including most recent chest radiograph
from ___ and CT chest without contrast from ___.
TECHNIQUE: PA and lateral chest radiographs were provided.
FINDINGS: Since the prior radiograph from ___, there has been
removal of the right arm PIC line. Again seen is severe bronchiectasis
affecting the right middle and lower lobes as well as the left lower lobe.
There maybe slight worsening of bronchiectasis in left lower lobe. In the
right upper lobe, just above the minor fissure, an ill-defined patchy opacity
persists which may represent infectious process. There is no pleural effusion
or pneumothorax. Lungs remain hyperexpanded. Cardiomediastinal silhouette is
unchanged. Osseous structures are intact. A right PICC line has been
removed.
IMPRESSION:
1. No significant change in severe bronchiectasis in the right middle and
right lower lobes. Possible interval worsening in left lower lobe
bronchiectasis.
2. Stable ill-defined opacity in the right upper lobe may represent
continuing infectious process. No new focal consolidation.
Radiology Report
STUDY: Portable AP chest radiograph.
COMPARISON EXAM: PA and lateral chest radiograph ___.
INDICATION: ___ woman with new PICC line.
FINDINGS: There is interval placement of a right PICC line with tip heading
cephalad. There is no pneumothorax. Patchy bibasilar atelectasis is again
present on this study and appears slightly worsened at the right
hemidiaphragm. However, this appearance is likely due to difference in study
technique. The remainder of the exam is stable.
IMPRESSION:
1. New PICC line with tip heading cephalad. PICC nurse ___ was alerted to
this finding by Dr. ___ telephone on ___ at 11:35, the time of
discovery.
Radiology Report
INDICATION: Bronchiectasis with need for long-term antibiotics. Please
replace PICC.
RADIOLOGISTS: Dr. ___, Dr. ___.
PROCEDURE/FINDINGS: The patient was brought to the angiography suite and
placed supine on the table. The right upper extremity was prepped and draped
in the usual sterile fashion. Fluoroscopic imaging demonstrated the
indwelling right PICC to be terminating within the right internal jugular
vein. After removal of the stylet, 1 cc of sterile saline was injected fast
into the PICC, under fluoroscopic guidance, following which the tip flipped
into the SVC, with its tip in the low SVC. Demonstration of the PICC position
was confirmed with a fluoroscopic spot image. The PICC was secured to the
skin with a StatLock device and sterile dressing. The patient tolerated the
procedure well, with no immediate post-procedural complications.
IMPRESSION: Successful repositioning of right upper extremity PICC, status
post power flushing, with catheter tip in the low SVC. The line is ready to
use.
The total fluoroscopy time was 1.2 minutes and the radiation dose was 1 mGy.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: DYSPNEA/FEVER
Diagnosed with FEVER, UNSPECIFIED, COUGH, BRONCHIECTASIS WITHOUT ACUTE EXACERBATION
temperature: 98.6
heartrate: 81.0
resprate: 16.0
o2sat: 96.0
sbp: 116.0
dbp: 65.0
level of pain: 7
level of acuity: 3.0 | Assessment & Plan:
___ yo woman with history of recurrent bronchiectasis who
presents with fever, SOB, pleuritic pain and cough productive of
blood-tinged sputum consistent with her prior episodes of
bronchiectasis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Groin Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old male with PMH of morbid obesity,
CKD, anemia, hyperlipidemia, HTN, h/o MRSA abscesses, poorly
controlled DM II with last A1c of 14.7 on ___ s/p bilateral
BKAs secondary to progressive ___ ulcers and infections. He
presented ___ with groin pain and found to have a groin
cellulitis initially concerning for Fournier's gangrene.
Admitted to surgery.
.
Seen by urology on admission who recommended broad spectrum abx
converage with vancomycin, Unasyn, and Flagyl. He has not had
any pain or fevers since starting antibiotics. UA with lge leuks
and moderate bacteria. Urine and blood cultures pending. CT
showed scrotal thickening c/w clinical cellulitis. No fluid
collection. Scrotal ultrasound showed no fluid collection or
abscess.
.
Given findings on imaging and evolving clinical presentation, it
is unlikely that the patient is developing Fournier's gangrene.
Transferred to medicine for continued management of cellulitis.
.
ROS: (+) as per HPI.
Past Medical History:
DM Type 2
charcot foot
hypercholesterolemia
Hypertension
h/o MRSA
L BKA
Social History:
___
Family History:
DM-parents, grandparents; MI-father
Physical ___:
ON ADMISSION:
Vitals - Tm 99.1 Tc 98.0 136/78 102 20 98%RA
General - Obese white male. Lying in bed in NAD
HEENT - PERRLA, EOMI, anicteric, MMM, OP clear. Eczemetous rash
on face.
Cards - RRR, S1 and S2, no m/r/g
Lung - CTAB, no w/r/r
Abdomen - Soft, NT/ND, shiny erethyma over inferior portion of
panus.
Skin - Erythema extending from inferior portion of panus of
groin and gluteals. Now with flaking skin. Less erethemetous
than prior. Areas of draining pus, especially on perineum.
Non-blanching. Non-tender.
Ext - BKA b/l.
Neuro - Awake, alert and oriented. Moving all extremeties.
ON DISCHARGE:
General - Obese white male. Lying in bed in NAD
Cards - RRR, S1 and S2, no m/r/g
Lung - CTAB, no w/r/r
Abdomen - Soft, NT/ND, shiny erethyma over inferior portion of
panus.
Skin - Erythema extending from inferior portion of panus of
groin and gluteals. Continues to improve and be less
erethemetous than prior. Areas of draining pus, especially on
perineum although most pus expressed by urology this AM.
Non-tender.
Ext - BKA b/l.
Neuro - Awake, alert and oriented. Moving all extremeties.
Pertinent Results:
On Admission:
___ 02:43PM BLOOD WBC-14.4*# RBC-3.49* Hgb-9.9* Hct-30.5*
MCV-87 MCH-28.4 MCHC-32.5 RDW-13.0 Plt ___
___ 02:43PM BLOOD Neuts-85.4* Lymphs-10.1* Monos-3.0
Eos-1.4 Baso-0.1
___ 02:43PM BLOOD Glucose-274* UreaN-36* Creat-2.5* Na-135
K-4.0 Cl-101 HCO3-24 AnGap-14
___ 05:20AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.9
___ 08:00AM BLOOD calTIBC-211* Ferritn-607* TRF-162*
___ 05:20AM BLOOD %HbA1c-14.8* eAG-378*
On Discharge:
___ 07:20AM BLOOD WBC-11.0 RBC-3.16* Hgb-9.1* Hct-28.7*
MCV-91 MCH-28.9 MCHC-31.8 RDW-13.4 Plt ___
___ 07:20AM BLOOD Glucose-104* UreaN-24* Creat-2.5* Na-139
K-4.0 Cl-105 HCO3-24 AnGap-14
___ 07:20AM BLOOD Calcium-8.3* Phos-4.4 Mg-1.9
Studies:
.
Scrotal US ___ - IMPRESSION: Marked scrotal wall
thickening concerning for cellulitis.
.
CT Pelvis ___ - IMPRESSION:
1. Marked scrotal thickening compatible with cellulitis. No
evidence of
fluid collection or Fournier's gangrene. 2. Thickened bladder
which is consistent with cystitis. Bladder mass cannot be
excluded. Bladder ultrasound with a distended bladder should be
performed after resolution of acute symptoms. 3. Fat and soft
tissue density in left medial buttock of unknown significance -
may represent the healed sequelae of prior decubitous ulcer.
Correlate with physical exam and clinical history.
Medications on Admission:
Lantus 25' QAM & 85' QPM
Novolog SSI
Simvastatin 40',
Metoprolol 25
Loratadine 5'
Discharge Medications:
1. Zosyn 4.5 gram Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 7 days: Please continue until ___ to
complete a 10-day course.
Disp:*22 Doses* Refills:*0*
2. insulin glargine 100 unit/mL Cartridge Sig: ___ (25)
Units Subcutaneous In the morning.
Disp:*1 Cartridge* Refills:*2*
3. insulin glargine 100 unit/mL Cartridge Sig: ___ (85)
Units Subcutaneous In the evening.
Disp:*1 Cartridge* Refills:*2*
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. loratadine 10 mg Tablet Sig: 0.5 Tablet PO daily ().
8. insulin lispro 100 unit/mL Cartridge Sig: As Directed
Subcutaneous With Meals: Please refer to home insulin sliding
scale for dosing.
9. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days: Please continue for 7
additional days to complete a 10 day course on ___.
Disp:*14 Tablet(s)* Refills:*0*
10. One Touch Delica Lancets Misc Sig: As Needed
Miscellaneous With meals.
Disp:*60 Lancets* Refills:*2*
11. One Touch Ultra Test Strip Sig: As needed Miscellaneous
With meals.
Disp:*60 Strips* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Cellulitis
Secondary: Diabetes Mellitus II
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: Scrotal swelling.
FINDINGS: The right testis measures 3.3 x 2.8 x 3.5 cm. The left testis
measures 3.0 x 2.3 x 3.4 cm. Both testes have homogeneous echotexture and
vascularity. There is marked diffuse hypervascular scrotal thickening. No
evidence of gas in the scrotal wall. Both epididymi are normal with normal
vascularity. There is a small left hydrocele and small left scrotal pearl
identified. Normal arterial and venous waveforms are interrogated.
Focal ultrasound of both groins demonstrate normal vascularity and lymph
nodes. No fluid collections are identified.
IMPRESSION: Marked scrotal wall thickening concerning for cellulitis.
Findings were discussed in person with Dr. ___ at 1500 on ___.
Radiology Report
INDICATION: ___ man with scrotal pain and swelling. Evaluate for
collection.
TECHNIQUE: MDCT data were acquired through the pelvis without intravenous
contrast. Images were displayed in multiple planes.
FINDINGS: Extensive scrotal wall edema is present. There is no fluid
collection or subcutaneous gas. The bladder is collapsed around a Foley
catheter. The bladder is collapsed though the wall appears thickened. The
visualized bowel including the appendix are of normal caliber and appearance.
There is no free pelvic fluid. There is no pelvic or inguinal adenopathy.
BONE WINDOWS: There are no lytic or sclerotic lesions. An abnormal fat
density lesion with a soft tissue rind is seen in the left medial buttock just
lateral to the gluteal fold (2:31, 300B:81).
IMPRESSION:
1. Marked scrotal thickening compatible with cellulitis. No evidence of
fluid collection or Fournier's gangrene.
2. Thickened bladder which is consistent with cystitis. Bladder mass cannot
be excluded. Bladder ultrasound with a distended bladder should be performed
after resolution of acute symptoms.
3. Fat and soft tissue density in left medial buttock of unknown significance
- may represent the healed sequelae of prior decubitous ulcer. Correlate with
physical exam and clinical history.
D/W Dr ___ in person.
Radiology Report
PICC LINE PLACEMENT
INDICATION: IV access needed for IV antibiotics.
The procedure was explained to the patient. A timeout was performed.
OPERATORS: ___ (resident), ___ (fellow), and Dr. ___
(___). The attending was present throughout the procedure.
TECHNIQUE: Using sterile technique and local anesthesia, bilateral basilic
veins were accessed under direct ultrasound guidance using micropuncture sets
in attempts to place a central PIC. Hard copies of ultrasound images were
obtained before and immediately after establishing intravenous access.
Bilateral high grade stenosis of veins, however, prevented passage of the
catheter into central vessels. Final access was via the left basilic vein,
through which a peel-away sheath was then placed over a guidewire and a 4
___ single lumen PICC line measuring was then placed through the peel-away
sheath with its tip positioned in the left axillary vein under fluoroscopic
guidance. Position of the catheter was confirmed by a fluoroscopic spot film
of the chest. The catheter was not able to be further advanced due to
high-grade stenosis of the extrathoracic left subclavian vein as it traverses
the first rib, as documented with contrast images. 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
post-procedural complications.
IMPRESSION:
1. Ultrasound and fluoroscopically guided placement of left 4 ___
single-lumen midline catheter in left axillary vein via the left basilic vein.
2. The midline catheter is ready to be used.
3. If a PICC is clinically necessary, angioplasty must first be performed
given high-grade stenosis of extrathoracic left subclavian vein.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: GROIN ABSCESS
Diagnosed with IDDM W SPEC MANIFESTATION, CELLULITIS OF LEG
temperature: 99.0
heartrate: 110.0
resprate: 16.0
o2sat: 99.0
sbp: 164.0
dbp: 67.0
level of pain: 3
level of acuity: 3.0 | Mr. ___ is a ___ y/o M with morbid obesity, CKD, anemia,
hyperlipidemia, HTN, h/o MRSA abscesses, poorly controlled DM II
with last A1c of 14.7 on ___ s/p bilateral BKAs secondary to
progressive ___ ulcers and infections who presented with groin
cellulitis.
.
#. Cellulitis - The patient presented at the urging of his wife.
In the ___ the patient underwent scrotal ultrasound which showed
no fluid collection or abscess. A CT scan showed scrotal
thickening c/w clinical cellulitis. No fluid collection.
In the ___, he was seen by urology who recommended broad spectrum
abx converage with vancomycin, Unasyn, and Flagyl and admission
to surgery given concern for developing Fournier's gangrene. On
the surgical floor the patient was stable and given results of
imaging the diagnosis of cellulitis was made. The patient was
transferred to the medical service where antibiotics were
adjusted to vancomycin/zosyn to cover pseudomonas and MRSA which
the patient has grown from cultures of foot abscesses in the
past. On the medical floor, the paitent's wound began to drain
in the area of the perineum and a large amount of pus was
expressed and sent for wound culture. The wound culture grew
group B strep. All other cultures negative. The patient's rash
improved on antibiotic therapy and a midline picc ___ could not
get central) line was placed for continued ___. Discharged
on Bactrim and Zosyn to complete a 10 day course.
.
#. Chronic Kidney Disease - Laboratory data from the patient's
prior admission ___ years ago shows a Cr baseline of 1.8-2.0. On
admission here the Cr was 2.5. Urine lytes and BUN:Cr ratio were
not consistent with a pre-renal etiology. A UA was (+) although
urine culture negative and the patient was without UTI Sx. The
Cr remainede levated over the remainder of the patient's stay.
Most likely this is a new baseline for this patient due to
progression of diabetic kidney injury. PTH WNL and Vit D level
pending. Urine micro-alb elevated to 430.
.
#. DM II - The patient has very poorly controlled DMII with a
HgA1c on admission here of >14. Patient brought in home
glucometer and it was apparent that the patient was not getting
accurate readings at home. Placed on home standing insulin and
agressive sliding scale here with good control of ___. ___
consulted and the patient will follow-up with nephrology at
___ for continued management.
.
#. Anemia - Patient has a h/o anemia with baseline hct ~25. Iron
studies from ___ year ago are c/w ACD. Hct on admission is at
baseline. Patient asymptomatic. No active signs of hemolysis or
bleeding.
.
#. HL - continued home simvastatin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Vancomycin / Sudafed / IVIG
Attending: ___.
Chief Complaint:
Fever and cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ with metastatic breast cancer to bone/brain
on herceptin/lapatinib, h/o SVC thrombus on enoxaparin,
pan-hypogammaglobulinemia, h/o recurrent aspiration pneumonia;
who presents with fever to 102.6 F. She reports her fever
started yesterday ___ at ~3pm. She is not sure if she had an
aspiration event, but recalls eating some ___ and lying
down. Upon awakening, she started having a productive cough of
yellow sputum and had subsequently shaking chills in the
afternoon. She called ___ clinic and was recommended to come
to the ED for admission. She also reports feeling sleepy
throughout the day ever since starting Tykerb. She endorses
nausea, head congestion and her usual fatigue and left knee/hip
pain when ambulating. She denies drinking more than ___
alcoholic drinks/month. She denies vomitting, hemoptasis,
abdoninal pain, diarrhea, dysuria, neck pain, vision changes,
photophobia.
Of note, she has Herceptin q3 weeks and takes PO meds at home.
Her last Herceptin treatment was one week ago.
In ER:
VS: 99.7 96 145/100 18 94%, ___ pain
PX: AA&Ox3 ___ speaking; portacath
Studies: WBC 6.5, HCT 39.5, PLT 58, Lactate:2.3;
CXR: worsenining consolidation on lateral compared to prior,
spoke with rads, likely LL base
Fluids given: NS first liter
Meds given: HAP coverage anaerobes: cefepime 2g IV, flagyl 500
mg IV (has vanc allergy), and oxycodone 5 mg po x1
Consults called: None
VS prior to transfer to the floor: 100.3 94 14 112/66 100%2l nc,
94% ra
Review of Systems:
(+) Per HPI
(-) Denies night sweats, recent weight gain. Denies visual
changes, headache, dizziness, sinus tenderness, neck stiffness,
rhinorrhea, sore throat or dysphagia. Denies chest pain,
palpitations, orthopnea, dyspnea on exertion. Denies shortness
of breath or wheezes. Denies vomiting, heartburn, diarrhea,
constipation, BRBPR, melena, or abdominal pain. No dysuria,
urinary frequency. Denies arthralgias or myalgias. Denies
rashes. No increasing lower extremity swelling. No
numbness/tingling or muscle weakness in extremities. No feelings
of depression or anxiety. All other review of systems negative.
Past Medical History:
Past Oncologic History:
Metastatic breast cancer:
- ___: diagnosed at stage IV with mets to lymph nodes and
liver; initially treated with doxorubicin, a bone marrow
transplant,
and a partial mastectomy
- ___: had recurrence with multiple liver lesions seen in her
liver; treated with trastuzumab and paclitaxel
- remained in remission on trastuzumab and paclitaxel for ___
years, until ___ when she had mets to her left hip and
underwent a partial hip replacement
- ___: noted to have brain mets, and she underwent surgical
resection and Cyberknife therapy
- ___: noted to have cancer in her femur and underwent more
surgery; received additional therapy (which she could not
recall) in the meantime, and she has continued to be on
trastuzumab
- ___: underwent XRT for metastatic disease in her spine
- ___: had L2 progressive metastases, underwent surgery and
then gamma knife radiation treatment in ___ developed
thrombocytopenia after radiation
- combination of lapatinib and trastuzumab were tried, but
patient developed significant diarrhea as well as pneumonia;
lapatinib was discontinued
- ___: started zolendronate again
- ___: re-staging showed no new systemic metastases; she has
old cerebellar met, which had been radiated.
- continued on fulvestrant every month and trastuzumab every
three weeks; zolendronate being held due to recent tooth pull
___ Revision PSF T9-L4 related to increased pain.
--___ PET scan showed two foci in the
left lateral thigh. ? mets vs post-surgical The area from
T11-L4 lights up, ? mets vs post surgical. right acetabulum
unchanged. CEA increasing. Switched to CPT-11 and herceptin
continued.
.
Other Past Medical History:
- HTN
- Dyslipidemia
- GERD
- RLS
- Depression
- Insomnia
- Chronic pain
- Hypercoagulability/SVC thrombus: possible borderline
protein C/S deficiency; on enoxaparin
- Hypogammaglobulinemia: previous reaction to IVIG, now on Doxy
ppx since ___
Social History:
___
Family History:
Her daughter had breast cancer at ___, and had a recurrence. Her
neice also had breast cancer. Her brother had lung cancer. She
denies any other family history of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 99.1 104/66 89 20 96% 2L NC; ___ pain while resting in bed
GEN: No apparent distress
HEENT: no trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: regular rate and rhythm, no murmurs/gallops/rubs
PULM: Decreased breath sounds L>R, no rales/crackles/rhonchi
GI: soft, non-tender, non-distended; no guarding/rebound
EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV
present
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, ___ motor function globally
DERM: Porta-cath in place on right chest: c/d/i. Verticle scar
on left knee.
DISCHARGE PHYSICAL EXAM
VS: Tc 98.3, Tm 98.4, BP 131/78 (106-131/60-80), HR 61 (61-76),
R 20, O2 98% 2L
GEN: No apparent distress
HEENT: PERRL, EOMI, MMM, oropharynx clear
CV: regular rate and rhythm, no murmurs/gallops/rubs
PULM: Mild rhonchi at RLL, no rales/crackles/rhonchi
GI: soft, non-tender, non-distended +BS
EXT: no clubbing/cyanosis/edema; 2+ distal pulses, L knee
swollen (baseline)
DERM: Porta-cath in place on right chest: c/d/i. Verticle scar
on left knee.
Pertinent Results:
ADMISSION LABS
___ 11:33PM BLOOD WBC-6.5 RBC-4.59 Hgb-12.3 Hct-39.9 MCV-87
MCH-26.9* MCHC-31.0 RDW-17.7* Plt Ct-58*
___ 11:33PM BLOOD Neuts-95.3* Lymphs-2.4* Monos-1.6*
Eos-0.5 Baso-0.1
___ 05:16AM BLOOD ___ PTT-50.1* ___
___ 11:33PM BLOOD Glucose-149* UreaN-12 Creat-0.6 Na-140
K-3.4 Cl-103 HCO3-23 AnGap-17
___ 05:16AM BLOOD ALT-11 AST-16 LD(LDH)-163 AlkPhos-79
TotBili-0.4
___ 05:16AM BLOOD Albumin-3.3* Calcium-8.1* Phos-3.0 Mg-1.6
___ 11:34PM BLOOD Lactate-2.3*
DISCHARGE LABS
___ 06:00AM BLOOD WBC-3.2*# RBC-3.92* Hgb-10.9* Hct-33.9*
MCV-86 MCH-27.7 MCHC-32.1 RDW-18.3* Plt Ct-56*
___ 06:00AM BLOOD Neuts-78.3* Lymphs-11.5* Monos-6.2
Eos-3.6 Baso-0.5
___ 06:00AM BLOOD ___ PTT-49.7* ___
___ 06:00AM BLOOD Glucose-96 UreaN-10 Creat-0.6 Na-145
K-4.3 Cl-110* HCO3-27 AnGap-12
___ 06:00AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.9
MICROBIOLOGY
___ Blood Culture, Routine (Pending):
___ URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
___ Blood Culture, Routine (Pending):
IMAGING
___ ECG: Sinus rhythm at the upper limits of normal rate. T
wave abnormalities. Since the previous tracing of ___ the
rate is faster. T wave abnormalities are more prominent.
___ CHEST (PA & LAT): Heterogeneous left lung base opacity
may represent atelectasis or infection in the appropriate
clinical setting. Kerly B line in the right lung base are new,
could be inflammatory or new
lympangitic spread of tumor in this patient with history of
malignancy.
Pulmonary edema is unlikely.
___ CT CHEST W/O CONTRAST: Mild and diffuse peribronchial
ground-glass opacities in both lower lobes and lingula could be
due to chronic aspiration or resolving pneumonia, but could be
active atypical pneumonia, caused by virus or pneumocystis.
Minimal bilateral lower lobe, middle and lingular bronchiectasis
could be sequel of chronic aspiration. Eccentric calcification
in lower SVC is most likely chronic calcified
thrombus, unchanged since ___ CT which convincingly showed
this to be
non-stenotic.
Medications on Admission:
(Home medication list reconciled on this admission)
Lovenox 80 mg/0.8 mL Sub-Q Syringe Inject 80MG SC TWICE A DAY
Mirapex 0.25 mg ___ Tablet(s) by mouth at bedtime
Herceptin 440 mg IV Solution Q3 weeks
Tykerb 250 mg 3 Tablet(s) by mouth daily
Vitamin D 1,000 unit 2 Tablet(s) by mouth daily
doxycycline hyclate 100 mg 1 Capsule by mouth twice a day
diazepam 5 mg 1 Tablet by mouth up to 2 tablets daily prn spasm
(wean as able)
omeprazole 20 mg D.R. 1 Capsule by mouth twice daily
prochlorperazine maleate 10 mg 1 Tablet by mouth q6h prn nausea
Lomotil 2.5 mg-0.025 mg 2 Tablets by mouth four times a day prn
diarrhea
Sertraline 100 mg 2 Tablets by mouth once a day
OxyContin 40 mg 12 hr 1 Tablet by mouth twice a day
oxycodone 15 mg 1 Tablet by mouth every ___ hours prn pain (up
to 4 a day)
Gabapentin 300 mg 2 Capsules by mouth three times daily
Budeprion SR 100 mg 1 Tablet by mouth daily for additional
benefit with zoloft
ranitidine 150 mg 2 Tablets by mouth at bedtime
Discharge Medications:
1. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous BID (2 times a day).
2. Mirapex 0.25 mg Tablet Sig: ___ Tablets PO at bedtime.
3. Herceptin 440 mg Recon Soln Sig: Four Hundred Forty (440) mg
Intravenous q3weeks.
4. Tykerb 250 mg Tablet Sig: Three (3) Tablet PO once a day.
5. Vitamin D3 1,000 unit Tablet Sig: Two (2) Tablet PO once a
day.
6. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
twice a day: Please do not take this antibiotic until ___
(After you finish levaquin and flagyl on ___.
7. diazepam 5 mg Tablet Sig: ___ Tablets PO once a day as needed
for muscle spasm.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
10. Lomotil 2.5-0.025 mg Tablet Sig: Two (2) Tablet PO four
times a day as needed for diarrhea.
11. sertraline 100 mg Tablet Sig: Two (2) Tablet PO once a day.
12. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO at
bedtime.
13. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
14. OxyContin 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO every twelve (12) hours.
15. oxycodone 5 mg Tablet Sig: Three (3) Tablet PO every ___
hours as needed for pain.
16. Budeprion SR 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day.
17. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
18. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please take through ___.
Disp:*5 Tablet(s)* Refills:*0*
19. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours): Please continue taking through ___.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Aspiration pneumonitis
Secondary Diagnosis
Chronic aspiration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST CT
INDICATION: Metastatic breast cancer as well as a pneumonia of possibly other
process.
TECHNIQUE: Unenhanced MDCT of thorax was performed using a standard
department protocol. Contiguous axial images at 5 mm and 1.25 mm slice
thickness were reviewed concurrently with coronal and sagittal reformats.
Study was reviewed in conjunction with prior CT dated ___ and a CT
component of FDG PET-CT from ___.
FINDINGS:
AIRWAYS AND LUNGS: Airways are patent to subsegment bronchi. Mild and
diffuse peribronchial ground-glass opacities in both lower lobes and lingula
are most likely new. Bronchiectasis in both lower lobes, lingula and middle
lobe is mild. There is no lung consolidation or pleural abnormality.
MEDIASTINUM: Thyroid gland is normal. Right subclavian port line extends till
low SVC. Eccentric calcification in lower SVC, just before the cavoatrial
junction is most likely chronic calcified thrombus, and has been present since
___. Prior chest CT in ___ was done with contrast and did not
reveal stenosis/obstruction of SVC. Coronary arteries calcification is
moderate-to-severe. Heart is normal size. Minimal pericardial fluid is
likely reactive.
ABDOMEN: This study is not designed for assessment of subdiaphragmatic
pathology, and moreover, extensive artifacts from a spinal fixation device
further reduces detection and visibility of soft tissue lesions. Withing
limitations, imaged upper abdomen is unremarkable.
BONES: Posterior spinal fixation device extends from D9-D11 vertebrae. Wedge
compression deformity of D9, D12 and L1 is similar since ___.
IMPRESSION:
1. Mild and diffuse peribronchial ground-glass opacities in both lower lobes
and lingula could be due to chronic aspiration or resolving pneumonia, but
could be active atypical pneumonia, caused by virus or pneumocystis.
2. Minimal bilateral lower lobe, middle and lingular bronchiectasis could be
sequel of chronic aspiration.
3. Eccentric calcification in lower SVC is most likely chronic calcified
thrombus, unchanged since ___ CT which convincingly showed this to be
non-stenotic.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, FEVER, UNSPECIFIED
temperature: 99.7
heartrate: 96.0
resprate: 18.0
o2sat: 94.0
sbp: 145.0
dbp: 100.0
level of pain: 8
level of acuity: 2.0 | ___ w/ PMHx of metastatic breast cancer to bone/brain on
herceptin/lapatinib, h/o SVC thrombus on enoxaparin,
pan-hypogammaglobulinemia on chronic doxycycline, h/o recurrent
aspiration pneumonia; who presents with fever to 102.7 F,
productive cough and found to have CXR concerning for LLL
pneumonia.
# Aspiration pneumonitis: Has had recurrent admissions for
aspiration pna/pneumonitis. She had fever to 102.6 at home, on
admission was 100.3 with a 2L O2 requirement. She was put on IV
cefepime and flagyl, subsequently changed to levaquin and
flagyl, and has been afebrile since. She had a GI workup
including EGD / swallowing study in ___ for a similar
event, and no abnormality was found. CXR concerning for LLL
pneumonia, and CT chest showed findings consistent with possible
chronic aspiration. Unclear etiology of her seemingly chronic
aspiration. Given her fever upon admission, she was continued on
levaquin and flagyl for 7 day course for CAP and aspiration
coverage.
# Metastatic breast cancer: Last Herceptin treatment was one
week ago. Tykerb was held while she was inpatient and continued
upon discharge.
# Thrombocytopenia: Chronic. Likely ___ chemotherapy. Her PLT
counts have ranged 49-98 over this year and currently remain
stable.
# Hypogammaglobulinemia: Pt is on doxycycline as she had a bad
reaction to IVIG in the past. Doxycyline was held while pt is on
levoquin and flagyl, with instruction to re-start doxycycline
after she finishes her 7-day course of levoquin and flagyl.
# GERD: She was continue on her home pantoprazole.
# SVC thrombus: She was continued on her home enoxaparin.
# Depression: She was continued on her home sertraline and
bupropion.
# Chronic pain: She was continued on her home oxycontin and
oxycodone.
TRANSITIONAL ISSUES
# Recommend f/u pending blood culture
# Recommend sleep study to assess for OSA given her chronic
fatigue, as this may be contributing to her chronic aspiration
(though she reports feeling fatigued every since she started
Tykerb) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tylenol
Attending: ___.
Chief Complaint:
left flank pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ h/o ?IgA nephropathy, recurrent UTI/nephrolithiasis presents
with severe L flank pain in setting of recent removal of
ureteral stent 2 days prior to presentation. Patient was
diagnosed with L sided kidney stone at ___ ~1 week
prior to admission, stone was removed via ureteroscopy and stent
placed. Was having significant cramping L flank pain after stent
placement, which steadily improved until day stent was removed.
Developed severe L flank pain after stent removal, +associated
nausea and poor PO intake. Also having difficulty urinating as
well, +scant hematuria. Pain not well controlled with codeine
prescribed. No f/c however.
Past Medical History:
?IgA nephropathy--> seen by ___ nephrologist, presumptive
diagnosis for pt's chronic "kidney pain" and intermittent
hematuria
Episode of pyelonephritis in ___.
Nephrolithiasis.
Status post vaginal surgery.
Status post Mirena IUD insertion.
History of UTIs, most recently prior to this episode in
___.
Frequent infections (Patient notes "crappy immune system.")
Possible history of nephritis several years ago.
Social History:
___
Family History:
As per HPI. Notable for three brothers with PMD dysmyelinating
disease; family history of kidney stones in mother and sister;
maternal grandmother has chronic kidney infections; at least one
of her brothers also has chronic kidney infections.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 97.9 53 108/63 20 99% RA
GEN Alert, oriented, no acute distress, appears fatigued
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft, nondistended, +min ttp in b/l lower abd quadrants L>R.
+CVAT on L
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
LABS: reviewed, see below
DISCHARGE PHYSICAL EXAM:
VS 98.0 98.0 55 110/65 99%RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft, nondistended, +min ttp in b/l lower abd quadrants L>R.
+mild CVAT on L
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
LABS: reviewed, see below
Pertinent Results:
___ 07:45AM BLOOD ALT-12 AST-23 AlkPhos-59 TotBili-0.5
___ 07:45AM BLOOD Glucose-95 UreaN-12 Creat-0.6 Na-138
K-4.8 Cl-102 HCO3-27 AnGap-14
___ 07:00AM BLOOD Glucose-91 UreaN-10 Creat-0.6 Na-141
K-4.3 Cl-106 HCO3-30 AnGap-9
___ 07:45AM BLOOD WBC-6.3 RBC-5.13 Hgb-15.3 Hct-45.1 MCV-88
MCH-29.7 MCHC-33.8 RDW-11.9 Plt ___
___ 07:00AM BLOOD WBC-5.0 RBC-4.28 Hgb-12.5 Hct-38.0 MCV-89
MCH-29.2 MCHC-32.9 RDW-12.0 Plt ___
CT abdomen/pelvis ___:
IMPRESSION:
1. No evidence of nephrolithiasis or pyelonephritis. Minimal
fullness of the
collecting system on the left. No hydronephrosis.
2. Focal hepatic hypodensities, too small to characterize,
likely cysts or
hamartomas.
The study and the report were reviewed by the staff radiologist.
Renal ultrasound ___:
FINDINGS: The right kidney measures 9.1 cm and the left kidney
measures 9.4
cm. There is mild left hydronephrosis with no stones or masses
identified.
There is no hydronephrosis, stones, or masses of the right
kidney. Renal
echogenicity and corticomedullary architecture is within normal
limits. The
bladder is moderately well seen and normal in appearance with
ureteral jets
seen bilaterally.
IMPRESSION: Mild left hydronephrosis with no visualized stones.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Clonazepam Dose is Unknown PO TID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 (One) tablet(s) by mouth twice a day
Disp #*12 Tablet Refills:*0
2. Senna 2 TAB PO HS
RX *sennosides [senna] 8.6 mg 2 (Two) tablet by mouth at bedtime
Disp #*6 Tablet Refills:*0
3. Clonazepam 0.5 mg PO ONCE MR1 Duration: 1 Doses
4. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every four (4)
hours Disp #*18 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 (One) capsule(s) by mouth
twice a day Disp #*6 Capsule Refills:*0
7. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine 100 mg 1 (One) tablet(s) by mouth three
times a day Disp #*9 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
left flank pain likely from recent removal of ureteral stent
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Left-sided flank pain after stent removal, question
hydronephrosis.
COMPARISON: Renal ultrasound from ___.
TECHNIQUE: Grayscale and Doppler ultrasound images of the kidneys were
obtained.
FINDINGS: The right kidney measures 9.1 cm and the left kidney measures 9.4
cm. There is mild left hydronephrosis with no stones or masses identified.
There is no hydronephrosis, stones, or masses of the right kidney. Renal
echogenicity and corticomedullary architecture is within normal limits. The
bladder is moderately well seen and normal in appearance with ureteral jets
seen bilaterally.
IMPRESSION: Mild left hydronephrosis with no visualized stones.
Radiology Report
ABDOMEN, TWO VIEWS: ___.
HISTORY: ___ female with left-sided flank pain. History of stones.
FINDINGS: Upright and supine views of the abdomen are compared to previous
exam from ___ and renal ultrasound from earlier the same day.
Nonspecific, nonobstructive bowel gas pattern is seen with moderate amount of
stool seen particularly in the ascending colon. No abnormal air-fluid levels
are identified. No free air below the diaphragm. Intrauterine device
projects over the pelvis. Given overlying gas and stool, evaluation for
subtle calcification is limited. There is no definite new calcification seen.
Osseous structures are unremarkable.
IMPRESSION: No definite calcification to suggest renal or ureteral calculus
noting limited visualization.
Radiology Report
INDICATION: Patient with recent left-sided stent removal with persistent and
worsening left flank pain. Assess for ureteral stone.
COMPARISONS: Renal ultrasound exam of the same date.
TECHNIQUE: MDCT-acquired contiguous images through the abdomen and pelvis
were obtained with and without intravenous contrast at 5-mm slice thickness in
prone position. Coronal and sagittal reformatted images are provided.
FINDINGS:
CT OF THE ABDOMEN: Imaged lung bases are clear. No pleural effusion is seen.
Heart is normal in size without pericardial effusion.
There is no evidence of nephrolithiasis on pre-contrast images. No ureteral
stone is identified. There is mild prominence of the left collecting system.
The kidneys enhance and excrete contrast symmetrically. The ureters are
normal in appearance throughout their course. Bilateral urinary jets are
identified.
The liver enhances homogeneously. Focal hepatic hypodensities in segment VII
(4:13) are too small to characterize and likely represent cysts or hamartomas.
No suspicious hepatic lesions identified. There is no evidence of
intrahepatic biliary ductal dilatation. The portal vein is patent. The
gallbladder is incompletely distended. There is no gallbladder wall edema or
pericholecystic fluid collection to suggest acute inflammation. The spleen is
unremarkable. A 12-mm splenule is incidentally noted. The pancreas enhances
homogeneously without ductal dilatation or peripancreatic fluid collection.
The adrenal glands are normal. The imaged small and large bowel loops are
unremarkable without evidence of bowel wall thickening or obstruction. The
appendix is visualized and appears normal. No pathologically enlarged
mesenteric or retroperitoneal lymph nodes are seen. There is no free air or
free fluid within the abdomen.
CT OF THE PELVIS: The bladder, distal ureters, rectum and sigmoid colon are
unremarkable. An IUD is positioned within the endometrial cavity. The
ovaries are unremarkable. There is no pelvic lymphadenopathy. There is no
free air within the pelvis.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is seen.
IMPRESSION:
1. No evidence of nephrolithiasis or pyelonephritis. Minimal fullness of the
collecting system on the left. No hydronephrosis.
2. Focal hepatic hypodensities, too small to characterize, likely cysts or
hamartomas.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LLQ ABD/LEFT FLANK PAIN
Diagnosed with URIN TRACT INFECTION NOS
temperature: 98.8
heartrate: 95.0
resprate: 20.0
o2sat: 99.0
sbp: 144.0
dbp: 84.0
level of pain: 10
level of acuity: 3.0 | ___ h/o ?IgA nephropathy, recurrent UTI/nephrolithiasis presents
with severe L flank pain in setting of recent removal of
ureteral stent 2 days prior to presentation.
#left flank pain/recent L nephrolithiasis s/p ureteral stent
placement and removal: flank pain most likely residual pain
from ureteral stent removal. There was initial concern for
infected stone given UA findings of hematuria and pyuria,
however was nitrite negative, remained afebrile without
leukocytosis throughout hospitalization. Also, no stones were
seen on CTU or KUB. Mild left sided hydronephrosis seen, most
likely from recent obstructing stone on the left. Patient did
endorse significant dysuria and difficulty urinating, which she
said is characteristic of UTIs she has had in the past so
patient was started empirically on PO ciprofloxacin, for which
she will take for a total of 7 days given recent
instrumentation. Her pain was well controlled with IV morphine
and toradol, to which she was transitioned to oxycodone by the
day of discharge. She was taking good PO throughout her
hospitalization. She was also discharged home on Pyridium for
her dysuria.
#chronic flank pain/likely diagnosis of IgA nephropathy: the
patient was previously being worked up for chronic flank pain
and hematuria by Dr. ___ nephrology. She has been given
a presumptive diagnosis of IgA nephropathy at this time. She
does report flank pain that follows any URI-type symptoms she
may have, so this could support this diagnosis. Her kidney
function appears at baseline this hospitalization with her
creatinine ~0.6. She will need to follow up with Dr. ___
___ further ___.
#recurrent nephrolothiasis: patient also being followed for this
by Dr. ___. Patient will need to follow up the analysis of
the stone obtained at ___. She also needs to follow
up with Dr. ___ 24-hr urine collection studies which
she had previously been instructed to do however she never
follow up on.
Transitional Issues:
1. The patient needs to follow up on the analysis of the kidney
stone collected at ___. She also needs to follow up
with her urologists there who placed and subsequently pulled the
left ureteral stent.
2. The patient also needs to re-establish follow up with Dr.
___ her previous diagnosis of IgA nephropathy and
___ of her recurrent nephrolithiasis. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
painful left thumb
Major Surgical or Invasive Procedure:
___ I and D of left thumb pustule
History of Present Illness:
Pt is a ___ year old female with stage IA left breast cancer who
began adjuvant chemotherapy with Taxotere and Cytoxan on ___
who presents with painful left thumb. The patient reports that
she scraped her thumb on a thorn yesterday while clearing away
___ flowers. It did not bleed at the time. She woke
this morning with a painful left thumb and it was difficult to
move. She felt achy all over, and took her temperature which
was 99.5. She was directed to come to the ER. In the ER, she
received Cefepime 2g, Clindamycin 300mg and had blood cultures
drawn. On arrival to the floor, she states that she generally
feels well but still has slight discomfort in her thumb. The
area of redness has not increased since this morning.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies arthralgias or myalgias. Denies
rashes or skin breakdown. No numbness/tingling in extremities.
All other systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
- ___ the patient palpated a nodule in the left breast. A
diagnostic mammogram documented a new asymmetry in the area, and
a targeted US confirmed a solid lobulated mass measuring 12 x 11
x 7 mm at the 10 o'clock position, 1-cm from the nipple. She
underwent US guided core biopsy which showed papillary
carcinoma,
at least in situ.
- ___: left breast lumpectomy and right breast biopsy.
The
pathology examination showed ductal hyperplasia and apocrine
metaplasia in the right breast. In the left breast showed
adenoid
cystic carcinoma, measuring 0.9 cm, G1, ER/PR negative, HER2 not
amplified, with positive margins. DCIS of intermediate nuclear
grade and LCIS of pleomorphic type were present.
- ___: left mastectomy. The final pathology examination
showed carcinoma with basaloid features, grade 2, 4 lymphnodes
examined were negative.
- ___ started adjuvant chemotherapy with Taxotere and Cytoxan
for stage IA left breast cancer (adenoid cystic carcinoma with
basaloid features, pT1, pN0, G2, ER-, PR-, HER2 negative);
cycles q 3 weeks
GYNECOLOGIC HISTORY: G3P3, menarche at 12. Pre-menopausal. Her
periods have been irregular for the past few years. LMP
___. Used oral contraceptives x ___ year.
PMH/PSH: tonsillectomy and adenoidectomy in ___.
Social History:
___
Family History:
mother alive and well, in her ___. Father has hx
of aortic aneurysm. Two sisters of her grandmother died of lung
cancer in their ___. No other cancer history in her family. She
had a brother who died of drug overdose at age ___, no other
siblings.
Physical Exam:
VS: 99.8 bp 138/72 HR 90 RR 18 SaO2 97 RA
GEN: NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple, no JVD
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, NT, ND, no HSM, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c/e, 2+ ___ bilaterally; left DIP joint of thumb is
erythematous, warm, with circular area approximately 2cm in
largest diameter. No tracking in tendons or soft tissue,
slightly tender, range of motion of thumb intact except for
flexion which is only slightly limited by edema; slight white
lesion on top is unclear whether pustule or calous
SKIN: warm skin
NEURO: oriented x 3, normal attention, CN no focal deficits,
intact sensation to light touch
PSYCH: appropriate
Pertinent Results:
___ 06:24PM LACTATE-1.3
___ 06:05PM GLUCOSE-104* UREA N-9 CREAT-0.6 SODIUM-140
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-32 ANION GAP-13
___ 06:05PM WBC-1.1* RBC-4.21 HGB-11.5* HCT-34.8* MCV-83
MCH-27.3 MCHC-33.0 RDW-13.0
___ 06:05PM NEUTS-3* BANDS-0 LYMPHS-67* MONOS-17* EOS-2
BASOS-0 ATYPS-11* ___ MYELOS-0 NUC RBCS-1*
___ 06:05PM PLT SMR-NORMAL PLT COUNT-226
Attempted I&D ___
The patient's left thumb was cleaned with chlorhexadine and
allowed to dry. A #10 blade was used to make a 1mm incision on
top of the erythematous lesion. No pus could be expressed.
Only a small amount of serosanguinous drainaige (< 1cc) could be
expressed. This was sent for culture. Direct pressure for 15
seconds stopped bleeding, dressed with bandaid.
Medications on Admission:
DEXAMETHASONE - 4 mg Tablet - 1 Tablet(s) by mouth twice a day
for three days starting the day prior to chemotherapy
HAIR PROSTHESIS - - as needed
LORAZEPAM - 0.5 mg Tablet - ___ Tablet(s) by mouth q6-8h as
needed for anxiety, nausea/vomiting
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth as directed
Take twice daily for the 2 days after chemotherapy, then take
every 8 hours as needed.
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
every 8 hours as needed for nausea
Discharge Medications:
1. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 14 days.
Disp:*56 Capsule(s)* Refills:*0*
2. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO every ___ hours
as needed for anxiety, nausea, insomnia.
3. Zofran 8 mg Tablet Sig: One (1) Tablet PO twice daily for the
two days after chemotherapy then every 8 hours as needed.
4. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice daily
for three days starting the day before chemotherapy. Tablet(s)
5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for nausea.
Discharge Disposition:
Home
Discharge Diagnosis:
Neutropenia
Cellulitis
Anemia
Nausea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with neutropenic fever.
COMPARISON: None available.
PA AND LATERAL CHEST RADIOGRAPHS: The cardiomediastinal and hilar contours
are normal. The lungs are well expanded and clear, without focal
consolidation, pleural effusion or pneumothorax. No acute osseous abnormality
is evident. Status post left mastectomy with a left breast tissue expander in
place.
IMPRESSION: No acute intrathoracic pathology.
Radiology Report
INDICATION: Left thumb cellulitis with DIP tenderness, evaluate for
osteomyelitis.
COMPARISON: None.
LEFT THUMB RADIOGRAPHS: There is no acute fracture or dislocation. Joint
spaces are preserved. There is normal mineralization. There is no periosteal
reaction or osteolysis.
IMPRESSION: No radiographic evidence of osteomyelitis. If there is continued
clinical concern, MRI can be performed.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with CELLULITIS, FINGER NOS, NEUTROPENIA, UNSPECIFIED , MALIGN NEOPL BREAST NOS, DIABETES UNCOMPL ADULT
temperature: 98.6
heartrate: 101.0
resprate: 20.0
o2sat: 100.0
sbp: 159.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | Assessment/Plan:Patient is a ___ year old female with stage IA
left breast cancer who began adjuvant chemotherapy with Taxotere
and Cytoxan on ___ who presents neutropenic with a cellulitis
of the left thumb.
.
#Thumb cellulitis - The patient was treated empirically with
vancomycin and unasyn initially after receiving a single dose of
Cefepime and Clindamycin x 1 in the ER. Her wound culture from
incision and drainage of a small pustule at the ___ her
cullulitis at the time of admission grew Methacillin sensitive
staph aureus. The patient's cellulitis improved daily, though
she had minimal tenderness at her thumb DIP. After reviewing her
case informally with infectious disease and primary oncologist,
the patient was switched to Keflex ___ mg Q6H for 14 days,
despite an ANC < 500. It was reinforced that if her cullulitis
recrudesced that she would need immediate medical attention
because her WBC was still low. A plain film was obtained of her
thumb as a baseline for comparison should the tenderness in her
DIP fail to resolve and the possibility of osteomyelitis need to
be considered. In addition as ESR and CRP were obtained for
baseline values. She will follow up with her primary oncologist
in 10 days as scheduled or sooner if needed.
.
.
#Stage 1A adenoid cystic carcinoma of the left breast with
basaloid features. She will contintue adjuvant chemotherapy with
Taxotere and Cytoxan as an outpatient following recovery of her
counts.
.
#Neutropenia - The patient was placed on neutropenic precautions
and diet. Her counts recovered slowly, though her cellulitis
improved steadily. SHe was discharged on oral antibiotics with
close follow up while her ANC was still < 500. She was advised
to continue to avoid crowds and sick contacts; and to avoid
fresh fruit and vegetables for 3 more days after discharge. She
was told to seek immediate attention if she feels sick.
.
#Anemia - secondary to chemotherapy. No role for tranfusion
.
#Nausea - Zofran, Ativan, Compazine as needed
.
#FULL CODE |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ y/o woman with little past medical history who
is in the ___ week of pregnancy after IVF. She lives on a barn
(that she purchased in ___ with her husband where she has a
horse. She was in her barn on ___ and developed acute onset of
shortness of breath. She then became dizzy and felt very weak
and had to sit down for about 15 minutes. She does periodically
get short of breath and fatigued when she is in her barn, but
her symptoms improve after sitting for just ___ minutes. On
this occasion, her symptoms were much worse than normal. She
proceeded to go to work (at ___) and noted
that her heart rate was well above 100 (she is normally at 80)
and she still felt difficult to take a deep breath so she came
to ___ ED after discussion with her Atrius OB/GYN providers.
At ___ ED, she was noted to have desaturations to 89% with
ambulation and to have HR as high as 120 with ambulation. She
had a CT PE that was negative for PE or any other acute process
so she was admitted to the medical floor.
She does endorse a lot of dysuria; she had it previously and had
an outpatient Ucx that was negative, but her dysuria has since
gotten worse. No fevers/n/v/ha/rash/arthralgias. No cough. No
history of allergy symptoms. She has a very remote history of
exercise induced asthma and last used an inhaler ___ years ago.
All other ROS negative.
Past Medical History:
PCOS
Exercise Induced Asthma
Osteoarthritis
Social History:
___
Family History:
Diabetes Mellitus - Father and Mother
___ - Grandfather
"various cancers"
Physical Exam:
AF Pox 98-100% at rest and ambulation (checked by me) HR
initially as high as 115 with ambulation, but by end of day, HR
mostly 100-108 with ambulation.
Gen: WD/WN female, very knowledgeable about her medical care,
speaking rapidly with no evidence of respiratory distress or
discomfort
Lung: Somewhat decreased bs on exhalation
CV: RRR, no murmur
Abd: Nabs, soft, nt
Ext: trace edema bilaterally
Neuro: cn ___ grossly intact
Left breast exam: No masses
Psych: normal affect
Lymph: NO cervical ___
___ Results:
___ 11:53PM BLOOD WBC-11.0* RBC-3.48* Hgb-10.9* Hct-33.0*
MCV-95 MCH-31.3 MCHC-33.0 RDW-11.9 RDWSD-40.9 Plt ___
___ 11:53PM BLOOD Glucose-88 UreaN-7 Creat-0.6 Na-136 K-3.8
Cl-103 HCO3-21* AnGap-16
___ 11:53PM BLOOD proBNP-30
___ 02:25AM BLOOD D-Dimer-446
Ucx: Greater than 100,000 GNR
INDICATION: History: ___ with acute shortness of breath
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) = 101 mGy-cm.
COMPARISON: None
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: There is prominent triangular
soft tissue
within the anterior mediastinum that likely represents
hyperplastic thymic
tissue in a patient of this age. No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Please note the extreme lung apices and bases
are not included on this examination as part of the protocol.
There is mild dependent atelectasis bilaterally. Otherwise, the
lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the
segmental bronchi bilaterally.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES AND SOFT TISSUES: No suspicious osseous abnormality is
seen.? There is no acute fracture. Within the left breast,
there is a 11 x 15 mm rounded focus of soft tissue density with
punctate calcifications, (series 2, image 45), which should be
followed up with a breast ultrasound.
IMPRESSION:
1. Please note that the extreme lung apices and bases are not
included on this examination as part of the protocol.
2. No evidence of pulmonary embolism or aortic abnormality.
3. 11 x 15 mm rounded focus of soft tissue density with punctate
calcifications within the left breast, which should be
correlated with
physical examination and follow up with a breast ultrasound is
suggested on a nonemergent basis.
RECOMMENDATION(S): Left breast ultrasound is recommended on a
nonemergent
basis.
Medications on Admission:
None
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q8H
RX *albuterol sulfate [Ventolin HFA] 90 mcg 2 inhalations po
three times a day Disp #*1 Inhaler Refills:*0
2. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1
capsule(s) by mouth twice a day Disp #*12 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Shortness of breath - nearly resolved, ? due to asthma
2. Lightheadedness, resolved, ? due to UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with acute shortness of breath
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) = 101 mGy-cm.
COMPARISON: None
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: There is prominent triangular soft tissue
within the anterior mediastinum that likely represents hyperplastic thymic
tissue in a patient of this age. No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Please note the extreme lung apices and bases are not included
on this examination as part of the protocol. There is mild dependent
atelectasis bilaterally. Otherwise, the lungs are clear without masses or
areas of parenchymal opacification. The airways are patent to the level of
the segmental bronchi bilaterally.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES AND SOFT TISSUES: No suspicious osseous abnormality is seen.? There is
no acute fracture. Within the left breast, there is a 11 x 15 mm rounded
focus of soft tissue density with punctate calcifications, (series 2, image
45), which should be followed up with a breast ultrasound.
IMPRESSION:
1. Please note that the extreme lung apices and bases are not included on this
examination as part of the protocol.
2. No evidence of pulmonary embolism or aortic abnormality.
3. 11 x 15 mm rounded focus of soft tissue density with punctate
calcifications within the left breast, which should be correlated with
physical examination and follow up with a breast ultrasound is suggested on a
nonemergent basis.
RECOMMENDATION(S): Left breast ultrasound is recommended on a nonemergent
basis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Chest pain
Diagnosed with Dyspnea, unspecified
temperature: 98.3
heartrate: 99.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 85.0
level of pain: 0
level of acuity: 3.0 | Patient is a ___ y/o woman 9 weeks pregnant, who is admitted with
acute onset of shortness of breath accompanied by dizziness and
fatigue when working in her barn. She was noted to have
desaturations with ambulation in the ED as well as to mildly
tachycardic.
On the floor, her dyspnea rapidly improved without treatment and
she had no desaturations with ambulation. Her tachycardia with
ambulation also improved.
It is possible that with exposure to various allergens in the
barn that she had some transient bronchospasm that was not
appreciated and resolved. I gave her an albuterol inhaler for
use tid for 3 days and then as needed. CT negative for PE, and
a cardiac defect such as a shunt (PFO) would not cause such
transient hypoxia.
In regards to fatigue and lightheadedness, her Ucx is positive
for GNR. She was treated with macrobid and given a prescription
to take home for the next seven days. I will follow up on the
final culture result. It is possible that this infection,
coupled with her pregnancy and work in the barn led to her
fatigue and lightheadedness, both of which had resolved by her
arrival to the medical floor. She is eating and drinking well
and had no documented hypotension.
I called the patient on ___ - she was feeling better at home,
and realized that she had sprayed her barn with pesticides to
combat insects, and she is wondering if that triggered her
shortness of breath, ? bronchospasam. She remains on the
macrobid.
Patient was told she needs a non urgent left breast ultrasound
given the calcifications and ? of small soft tissue mass. Her
breast exam was normal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
1. Open left distal radius and ulna fracture.
2. Left elbow dislocation.
Major Surgical or Invasive Procedure:
___. Washout and debridement, open fracture down to bone.
2. Open reduction and internal fixation, left intra-
articular distal radius fracture, 3 or more fragments.
3. Pinning of distal radioulnar joint dislocation.
4. Closed treatment, left elbow dislocation, with
manipulation and anesthesia.
___
Left elbow dislocation with external fixator
History of Present Illness:
___ with significant PMH to include blindness had mechanical
fall down approx 7 stairs. No LOC. Immediate left arm pain and
deformity. Patient speaks ___ - much of history obtained
from family. Patient given tetanus and clinda at OSH.
Past Medical History:
AFIB, blind, CHF, DM, Asthma, Pulm Htn, HTN
Social History:
___
Family History:
nc
Physical Exam:
Vital Signs: 99.1 119/60 82 16 97% RA
NAD, well appearing
LUE: splint/external fixator in place to 90 degrees elbow
flexion. gross motor and SILT m/r/u in fingers exposed out of
splint.
Pertinent Results:
___ 05:30AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.0
___ 05:50AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.0
___ 09:45AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0
___ 06:10AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.4
___ 04:54AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.2
___ 07:10AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.1
___:20AM BLOOD Glucose-165* UreaN-23* Creat-1.2* Na-147*
K-3.6 Cl-109* HCO3-31 AnGap-11
___ 05:30AM BLOOD Glucose-136* UreaN-19 Creat-0.8 Na-145
K-4.2 Cl-109* HCO3-28 AnGap-12
___ 05:50AM BLOOD Glucose-101* UreaN-19 Creat-0.9 Na-142
K-3.9 Cl-107 HCO3-30 AnGap-9
___ 09:45AM BLOOD Glucose-163* UreaN-19 Creat-0.9 Na-140
K-3.8 Cl-104 HCO3-28 AnGap-12
___ 06:10AM BLOOD Glucose-89 UreaN-18 Creat-0.9 Na-142
K-4.0 Cl-108 HCO3-29 AnGap-9
STUDY: LEFT ELBOW, ___.
CLINICAL HISTORY: Patient with left elbow dislocation with
external fixation.
FINDINGS: Multiple images of the left elbow from the operating
room
demonstrates interval placement of external fixation hardware in
the distal
humerus and the ulna. Fracture plate within the distal radius
is also seen.
On the last views, there is persistent subluxation of the
olecranon from the
trochlea and of the radial head from the capitellum. There are
small bony
fragments adjacent to the radial head fracture. The total
intraoperative time
was 183.3 seconds. Please refer to the operative note for
additional details.
___. ___
___: FRI ___ 11:30 ___
___ 04:54AM BLOOD Glucose-84 UreaN-18 Creat-0.8 Na-146*
K-3.8 Cl-109* HCO3-30 AnGap-11
___ 09:28AM BLOOD Glucose-109* UreaN-16 Creat-0.9 Na-146*
K-4.0 Cl-107 HCO3-31 AnGap-12
___ 07:10AM BLOOD Glucose-101* UreaN-16 Creat-0.6 Na-140
K-4.2 Cl-106 HCO3-27 AnGap-11
___ 12:20AM BLOOD Neuts-84.9* Lymphs-10.0* Monos-4.3
Eos-0.5 Baso-0.2
___ 12:20AM BLOOD WBC-15.0* RBC-3.31* Hgb-10.0* Hct-32.3*
MCV-98 MCH-30.2 MCHC-31.0 RDW-12.9 Plt ___
___ 05:30AM BLOOD WBC-10.5 RBC-2.96* Hgb-8.9* Hct-29.1*
MCV-98 MCH-30.2 MCHC-30.7* RDW-13.0 Plt ___
___ 05:50AM BLOOD WBC-9.7 RBC-2.71* Hgb-8.2* Hct-26.6*
MCV-98 MCH-30.2 MCHC-30.8* RDW-12.9 Plt ___
___ 09:45AM BLOOD WBC-11.4* RBC-3.01* Hgb-9.2* Hct-29.7*
MCV-99* MCH-30.5 MCHC-30.9* RDW-12.9 Plt ___
___ 11:20AM BLOOD WBC-7.5 RBC-2.33* Hgb-7.3* Hct-23.1*
MCV-99* MCH-31.2 MCHC-31.4 RDW-13.0 Plt ___
___ 06:10AM BLOOD WBC-7.9 RBC-2.41* Hgb-7.6* Hct-23.5*
MCV-98 MCH-31.4 MCHC-32.3 RDW-13.5 Plt ___
___ 04:54AM BLOOD WBC-7.6 RBC-2.96* Hgb-9.2* Hct-28.5*
MCV-96 MCH-30.9 MCHC-32.2 RDW-13.7 Plt ___
___ 09:28AM BLOOD WBC-7.6 RBC-3.26* Hgb-10.1* Hct-31.5*
MCV-97 MCH-31.0 MCHC-32.1 RDW-13.8 Plt ___
___ 07:10AM BLOOD WBC-7.2 RBC-3.14* Hgb-9.6* Hct-30.5*
MCV-97 MCH-30.6 MCHC-31.5 RDW-13.8 Plt ___
Medications on Admission:
Prednisone 5mg daily (held)
Cetirizine 10mg daily (held)
Hydroxychloroquine 400mg daily
Lansoprazole 30mg delayed release TID
Nitrofurantoin 100mg TID (held)
Simvastatin 40mg daily (held)
Zolpidem 10mg QHS (held)
Lisinopril 20mg daily
Donepizil 10mg daily
Alprazolam 0.5mg BID
Lasix 20mg daily
Ipratropium Bromide 1puff q4-6H PRN
Combigan 0.2%-0.5% eye drops, 1gtt BID right eye (non-form)
Verapamil ER 240mg daily
Citalopram 20mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
standing dose
2. ALPRAZolam 0.5 mg PO BID
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Citalopram 20 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
8. Lisinopril 20 mg PO DAILY
9. Lansoprazole Oral Disintegrating Tab 30 mg PO TID
10. PredniSONE 5 mg PO DAILY
11. Hydroxychloroquine Sulfate 400 mg PO DAILY
12. Furosemide 20 mg PO DAILY
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Donepezil 10 mg PO HS
15. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
16. Verapamil SR 120 mg PO Q 12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Open left distal radius and ulna fracture.
2. Left elbow dislocation.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with left elbow dislocation and left forearm
fracture.
TECHNIQUE: Four views of the left wrist, forearm and elbow were obtained.
COMPARISON: Forearm radiographs from earlier today.
FINDINGS:
In the interval, fractures were reduced and a cast has been placed. The
articulation at the elbow joint has improved and there is near anatomic
alignment. There is significant volar displacement of the distal radius and
ulna by about 10 mm, foreshortening by about 30 mm and radial displacement by
about 8 mm.
Radiology Report
STUDY: 12 intraoperative fluoroscopic images of the left wrist and elbow,
___.
COMPARISON: Radiographs earlier the same day.
INDICATION: Left wrist and elbow fractures, ORIF.
FINDINGS AND IMPRESSION: Multiple views of the left wrist and elbow. Status
post left distal radius ORIF with volar plate and screws. The hardware
appears intact. Improved alignment of the fracture. Status post elbow
reduction. No hardware is noted on these radiographs. Again seen is the
displaced radial head fracture. Total intraoperative fluoroscopic imaging
time is 80.3 seconds. Please see operative report for further details.
Radiology Report
HISTORY: ___ woman who is status post open reduction, internal
fixation of a left forearm fracture and close reduction of a left elbow
fracture dislocation. Confirm reduction.
TECHNIQUE: Five views of the left elbow.
COMPARISON: Fluoroscopic images of the left elbow performed on ___ at 10:30 hours.
FINDINGS:
Proximal radius and ulna are medially subluxed relative to the distal ulna.
Comminuted radial head fracture is again present. 0.8 cm fracture fragment is
present anterior to the distal humerus. Splint material projects over the
posterior aspect of the left elbow. Surgical plate within the mid-to-distal
left radius is partially imaged.
IMPRESSION:
1. Proximal radius and ulna are medially subluxed relative to the distal
humerus.
2. Comminuted fracture of the radial head.
3. 0.8 cm fracture fragment is again present anterior to the distal left
humerus.
CT examination of the left elbow would provide further imaging evaluation if
clinically warranted.
Radiology Report
STUDY: LEFT ELBOW, ___.
CLINICAL HISTORY: Patient with left elbow dislocation with external fixation.
FINDINGS: Multiple images of the left elbow from the operating room
demonstrates interval placement of external fixation hardware in the distal
humerus and the ulna. Fracture plate within the distal radius is also seen.
On the last views, there is persistent subluxation of the olecranon from the
trochlea and of the radial head from the capitellum. There are small bony
fragments adjacent to the radial head fracture. The total intraoperative time
was 183.3 seconds. Please refer to the operative note for additional details.
Radiology Report
INDICATION: ___ woman with fall.
TECHNIQUE: Contiguous MDCT images through the chest, abdomen, and pelvis was
performed after the administration of intravenous contrast. Axial, coronal,
and sagittal reformats were acquired.
COMPARISON: CT of the chest from ___.
FINDINGS:
CT OF THE CHEST:
There is no mediastinal hemorrhage, pericardial or pleural effusion. The
aorta is normal. There is no pneumothorax. Mild bibasilar atelectatic
changes. Incidental note is made of a tracheal diverticulum (series 2, image
7) changed from ___.
CT OF THE ABDOMEN:
The liver, gallbladder, pancreas, spleen, and both adrenal glands are normal.
Multiple hypoattenuating small cortical renal lesions, likely representing
simple cysts. There is no free fluid and no free air. There is diverticulosis
of the sigmoid and descending colon without evidence of diverticulitis.
There is no free air and no free fluid. There is no large pelvic or
retroperitoneal hematoma.
CT OF THE PELVIS:
The urinary bladder and uterus demonstrate no acute pathology. There is a
hypoattenuating simple about 3.6-cm right ovarian cyst (301B, image 26 and
series 300B, image 26). There are no pelvic fractures.
BONES: There are old left-sided rib fractures. The compression fractures of
the spine are seen.
IMPRESSION:
1. No acute process of the chest, abdomen, and pelvis.
2. Chronic left-sided rib fractures.
3. Descending and sigmoid colon diverticulosis, but no diverticulitis.
Hypoattenuating renal lesions, likely simple cysts.
4. Right ovarian cyst. Further workup with ultrasound is recommended.
Gender: F
Race: HISPANIC OR LATINO
Arrive by AMBULANCE
Chief complaint: OPEN FOREARM FX
Diagnosed with FX LOW RADIUS W ULNA-OPN, POST DISLOC ELBOW-CLOSED, FALL ON STAIR/STEP NEC, DIABETES UNCOMPL ADULT
temperature: 96.2
heartrate: 60.0
resprate: 20.0
o2sat: 99.0
sbp: 154.0
dbp: 72.0
level of pain: 7
level of acuity: 2.0 | The patient was admitted to the Orthopaedic Trauma Service for
repair of a left both bone forearm fracture and elbow
dislocation. The patient was taken to the OR and underwent an
ORIF both bone forearm fracture and placement of external
fixator for the elbow dislocation. The patient tolerated the
procedures without complications and was transferred to the PACU
in stable condition. Please see operative reports for details.
Post operatively pain was controlled with a PCA with a
transition to PO pain meds once tolerating POs. The patient
tolerated diet advancement without difficulty and made steady
progress with ___.
Weight bearing status: nonweight bearing left upper extremity.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision/splint was clean, dry,
and intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. All questions were answered prior to discharge
and the patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
celecoxib
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
Intramedullary nail placement (short trochanteric fixation
nail), left hip ___
History of Present Illness:
___ yo F with a past medical history of dementia, osteoporosis,
history of multiple hip fractures who presents after fall with
left hip fracture now ___ s/p ORIF (___). Patient made
limited contributions to the history given baseline dementia.
She was noted to have left hip pain on transfer at nursing
facility. Plain films were performed which showed a left
intertrochanteric fracture. She was transferred to ___ for
further management. At ___, further imaging confirmed left hip
fracture. Patient went to the OR on ___ ORIF on ___. Post-op
course was complicated by hypoactive delirium, UTI (treated with
ceftriaxone and then cipro), acute blood loss anemia s/p 2U pRBC
(___), and hypoxia attributed to hypervolemia. A CXR was
performed on ___ and showed evidence of pulmonary edema. She
received IV Lasix 20 mg. At the time of transfer patient was
afebrile and hemodynamically stable.
Past Medical History:
Chronic constipation
Progressive cognitive decline
Hypertension
Hyperlipidemia
Hypothyroidism
Severe osteoporosis with multiple spine and pelvic fractures
Scoliosis
Spinal stenosis
Chronic LBP
L amblyopia
Psychosis on chronic risperidone
Social History:
___
Family History:
- Hypertension
- Hyperlipidemia
- Hypothyroidism
- Dementia
- Psychosis, h/o treatment with risperidone
- Osteoporosis s/p bisphosphonate therapy in the past
- h/o tallus fracture
- h/o right pubic ramus fracture ___ h/o left
inferior/superior
ramus hip fracture ___
- h/o compression fracture s/p vertebroplasty
- Scolioisis
- Spinal stenosis
Physical Exam:
TRANSFER PHYSICAL EXAM
VS: T 98.2, BP 136/77, HR 91, RR 16, 97% 3L NC.
GEN: Lying in bed, awake and arousable, minimally conversant,
oriented to person and place, and pale
HEENT: Moist mucous membranes, anicteric sclerae, positive
conjunctival pallor, extraocular movements were intact, pupils
were equal round and reactive to light
PULM: Moderately increased work of breathing with some
paratracheal retractions. Examination was limited by effort but
clear in the apices bilaterally
COR: regular rate and rhythm with ___ crescendo-decrescendo
murmur heard throughout the precordium which radiated to the
carotids
ABD: Normal bowel sounds were present, soft, non-tender,
non-distended
EXTREM: Left lower extremity 2+ edema up to the thigh. Left
upper thigh notably warm when compared to the right extremity
DISCHARGE PHYSICAL EXAM
Vitals: 98.1 | 122/71 | 88 | 18 | 96% on 2L NC
Weight: 48.5kg
I/O: Total in: 330 Total Out: 1645 Net: -188
General: Lying in bed, awake and arousable, minimally
conversant, oriented to person, and pale
HEENT: sclera anicteric, pupils equal round and reactive to
light, conjunctival pallor, mildly dry MM, oropharynx clear
Neck: unable to assess JVP
Lungs: examination limited by patient effort, comfortable work
of breathing without evidence of use of accessory muscles
CV: regular rate and rhythm with ___ crescendo-decrescendo
murmur heard throughout the precordium which radiated to the
carotids
ABD: Normal bowel sounds were present, soft, non-tender,
non-distended
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: foley present
Ext: Left lower extremity 2+ edema up to the thigh. Left upper
thigh notably warm when compared to the right extremity
Pertinent Results:
CHEMISTRIES
===========
___ 05:35AM BLOOD Glucose-100 UreaN-13 Creat-0.5 Na-142
K-4.9 Cl-103 HCO3-31 AnGap-13
___ 04:56AM BLOOD Glucose-93 UreaN-9 Creat-0.3* Na-140
K-3.5 Cl-102 HCO3-32 AnGap-10
___ 05:38AM BLOOD Glucose-89 UreaN-9 Creat-0.2* Na-142
K-2.7* Cl-105 HCO3-29 AnGap-11
___ 01:25PM BLOOD Glucose-149* UreaN-12 Creat-0.3* Na-145
K-3.9 Cl-111* HCO3-24 AnGap-14
___ 01:30AM BLOOD Glucose-92 UreaN-12 Creat-0.3* Na-143
K-3.9 Cl-110* HCO3-25 AnGap-12
___ 09:40AM BLOOD Glucose-96 UreaN-13 Creat-0.2* Na-142
K-3.1* Cl-110* HCO3-25 AnGap-10
___ 05:41AM BLOOD Glucose-107* UreaN-17 Creat-0.4 Na-140
K-3.5 Cl-103 HCO3-28 AnGap-13
___ 03:17PM BLOOD Glucose-146* UreaN-27* Creat-0.7 Na-141
K-3.8 Cl-100 HCO3-30 AnGap-15
___ 03:17PM BLOOD Glucose-146* UreaN-27* Creat-0.7 Na-141
K-3.8 Cl-100 HCO3-30 AnGap-15
___ 05:35AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.9
___ 04:56AM BLOOD Albumin-2.8* Calcium-8.3* Phos-1.8*
Mg-2.4
___ 05:38AM BLOOD Calcium-8.3* Phos-2.0* Mg-1.4*
___ 01:30AM BLOOD Calcium-8.0* Phos-1.7* Mg-1.8
___ 09:40AM BLOOD Calcium-8.1* Phos-1.9*# Mg-1.8
___ 03:17PM BLOOD Calcium-9.5 Phos-3.8 Mg-2.1
HEMATOLOGY
==========
___ 05:35AM BLOOD WBC-11.5* RBC-4.11 Hgb-11.2 Hct-36.0
MCV-88 MCH-27.3 MCHC-31.1* RDW-16.3* RDWSD-50.4* Plt ___
___ 04:56AM BLOOD WBC-10.1* RBC-3.79* Hgb-10.3* Hct-32.4*
MCV-86 MCH-27.2 MCHC-31.8* RDW-15.8* RDWSD-47.7* Plt ___
___ 01:25PM BLOOD WBC-9.0 RBC-3.54* Hgb-9.7* Hct-30.7*
MCV-87 MCH-27.4 MCHC-31.6* RDW-14.9 RDWSD-47.0* Plt ___
___ 01:30AM BLOOD WBC-9.1 RBC-3.32*# Hgb-9.1*# Hct-28.3*#
MCV-85 MCH-27.4 MCHC-32.2 RDW-14.5 RDWSD-44.7 Plt ___
___ 09:40AM BLOOD WBC-12.1* RBC-2.43* Hgb-6.3* Hct-20.9*
MCV-86 MCH-25.9* MCHC-30.1* RDW-15.0 RDWSD-46.9* Plt ___
___ 05:28AM BLOOD WBC-11.9* RBC-2.85* Hgb-7.3* Hct-25.0*
MCV-88 MCH-25.6* MCHC-29.2* RDW-15.1 RDWSD-49.2* Plt Ct-95*
___ 05:41AM BLOOD WBC-13.4* RBC-3.30* Hgb-8.5* Hct-27.1*
MCV-82 MCH-25.8* MCHC-31.4* RDW-15.5 RDWSD-46.2 Plt ___
___ 03:17PM BLOOD WBC-15.7* RBC-3.79* Hgb-9.8* Hct-31.2*
MCV-82 MCH-25.9* MCHC-31.4* RDW-15.5 RDWSD-45.8 Plt ___
DIFFERENTIAL
============
___ 04:56AM BLOOD Neuts-64.4 ___ Monos-7.5 Eos-3.1
Baso-0.2 Im ___ AbsNeut-6.49* AbsLymp-2.41 AbsMono-0.76
AbsEos-0.31 AbsBaso-0.02
___ 09:40AM BLOOD Neuts-68.1 ___ Monos-9.3 Eos-1.4
Baso-0.2 Im ___ AbsNeut-8.22* AbsLymp-2.48 AbsMono-1.12*
AbsEos-0.17 AbsBaso-0.02
___ 03:17PM BLOOD Neuts-70.3 Lymphs-18.2* Monos-10.9
Eos-0.1* Baso-0.1 Im ___ AbsNeut-11.04* AbsLymp-2.85
AbsMono-1.71* AbsEos-0.01* AbsBaso-0.02
___ 03:17PM PLT COUNT-181
___ 03:17PM ___ PTT-27.2 ___
Urine Studies
=============
___ 08:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 08:30PM URINE BLOOD-NEG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
___ 08:30PM URINE RBC-12* WBC-44* BACTERIA-MANY YEAST-NONE
EPI-5
___ 08:30PM URINE HYALINE-28*
___ 08:30PM URINE MUCOUS-FEW
___ 03:40PM URINE HOURS-RANDOM
___ 03:40PM URINE UHOLD-HOLD
___ 03:40PM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 03:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0 LEUK-SM
___ 03:40PM URINE RBC-4* WBC-49* BACTERIA-FEW YEAST-NONE
EPI-109
___ 03:40PM URINE HYALINE-30*
___ 03:40PM URINE MUCOUS-MANY
proBNP
======
___ 05:35AM BLOOD proBNP-671*
___ 05:38AM BLOOD proBNP-___*
Troponin
========
___ 03:17PM BLOOD cTropnT-<0.01
Thyroid Studies
===============
___ 01:25PM BLOOD TSH-6.1*
___ 04:56AM BLOOD T4-6.5
CXR
===
___ Imaging CHEST (PORTABLE AP)
In comparison to the prior radiograph of 1 day earlier, the
patient is
markedly rotated towards right, limiting assessment of
cardiomediastinal
contours and obscuring a portion of the right lung. With this
limitation in mind, there has not been a gross interval change
since the recent study, but repeat radiograph with improved
positioning would be helpful for more accurate assessment when
the patient's condition permits.
___ Imaging CHEST (PORTABLE AP)
Comparison to ___. Decrease lung volumes. Increased
distension of the vascularity with new blunting of the right
costophrenic sinus, as well as increased diameter of the cardiac
silhouette. Overall, the changes are highly suggestive of new
moderate pulmonary edema, with accompanying right pleural
effusion.
___ Imaging DX PELVIS & HIP UNILATE
Postoperative radiograph of the bilateral femoral fracture.
Documentation of correct. Stabilizing nail placement. Expected
postoperative appearance of the soft tissues and of the bones.
The contour abnormalities at the level of the left superior and
inferior pubic ramus are of unchanged appearance
___ Imaging KNEE (AP, LAT & OBLIQUE)
Extensive vascular calcifications. No other soft tissue
abnormalities. Moderate narrowing of the joint space,
particularly at the
medial aspect of the joint. Mild subcortical sclerosis at the
level of the tibia. Mild to moderate narrowing of the
retropatellar space. No cortical disruptions suggestive of
fracture.
ECHOCARDIOGRAM ___
==============
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). The ascending aorta is
mildly dilated. The aortic valve leaflets are mildly thickened
(?#). There is a minimally increased gradient consistent with
minimal aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Minimal aortic valve
stenosis. Mild symmetric left ventricular hypertrophy with
normal cavity size and systolic function. Mildly dilated
ascending aorta
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PNEUMOcoccal 23-valent polysaccharide vaccine 0.5 ml IM
Start: ___, First Dose: Next Routine Administration Time
2. Acetaminophen 650 mg PO Q6H:PRN pain/fever
3. Docusate Sodium 100 mg PO BID constipation
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Fleet Enema ___AILY:PRN constipation
6. Levothyroxine Sodium 37.5 mcg PO DAILY hypothyroidism
7. Potassium Chloride 10 mEq IP QAM
8. Senna 17.2 mg PO QHS constipation
9. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice daily
Disp #*28 Capsule Refills:*0
2. Enoxaparin Sodium 40 mg SC QPM
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 MG SC Every evening Disp #*28
Syringe Refills:*0
3. Polyethylene Glycol 17 g PO DAILY Constipation
4. Sertraline 50 mg PO DAILY
5. Levothyroxine Sodium 37.5 mcg PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN pain/fever
7. Bisacodyl 10 mg PO DAILY:PRN constipation
8. Fleet Enema ___AILY:PRN constipation
9. Potassium Chloride 10 mEq IP QAM
10. Senna 17.2 mg PO QHS constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Left intertrochanteric hip fracture
Pulmonary edema
Urinary tract infection
Encephalopathy
SECONDARY
Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT
INDICATION: History: ___ with s/p fall and reported L intertrioch fx // eval
traumatic injury
TECHNIQUE: AP view of the pelvis and AP and lateral views of the right hip.
COMPARISON: CT pelvis from ___ abdominal radiograph from ___
FINDINGS:
Patient is status post ORIF of the proximal right femur. Hardware is in
anatomic alignment without evidence of complication. There is fracture
deformity at the left pubic bone involving the superior and inferior pubic
rami of indeterminate age, but new since the prior study. Left
intratrochanteric fracture is seen. There is varus angulation of the left
femoral head and foreshortening of the femoral shaft. The pubic symphysis is
not widened.
IMPRESSION:
Left intratrochanteric fracture with varus angulation of the left femoral head
and foreshortening of the left femoral shaft. Deformities of the left
superior and inferior pubic rami are of indeterminate age, but new since ___.
Radiology Report
INDICATION: History: ___ with s/p fall and reported L intertrioch fx // eval
traumatic injury
TECHNIQUE: AP and lateral views of the left femur
COMPARISON: None.
FINDINGS:
Comminuted, mildly displaced left intertrochanteric fracture is seen,
including involvement of the lesser trochanter, with varus angulation of the
femoral head and mild foreshortening of the left femoral shaft. There is no
acute fracture of the more distal left femur. No suprapatellar joint effusion
is seen. There is no dislocation. Vascular calcifications are seen.
IMPRESSION:
Left intratrochanteric fracture, as above. No fracture of the more distal
femur, however, there is external artifact projecting over the medial distal
femoral metaphysis, partially obscuring the view.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: History: ___ with s/p fall and reported L intertrioch fx // eval
traumatic injury
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Patient is rotated somewhat to the left. There are low lung volumes. Cardiac
and mediastinal silhouettes are grossly stable given differences in patient
position and inspiration. Chronic right mid lung atelectasis/scarring is
seen. Alternately, there may be some fluid in the minor fissure.
Indistinctness of the hila and perihilar markings suggest mild interstitial
edema.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ woman. Status post fall.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.7 cm; CTDIvol = 48.2 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass effect. The
ventricles and sulci are prominent consistent with age-related atrophy.
Confluent periventricular and subcortical white matter hypodensities likely
represent the sequela of chronic small vessel ischemic disease.
There is no evidence of fracture. The frontal sinus is clear. There are
minimal aerosolized secretions in the ethmoid air cells and sphenoid sinuses.
The maxillary sinuses are clear. There is cerumen in the external auditory
canals.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ woman status post fall.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.4 s, 21.1 cm; CTDIvol = 36.9 mGy (Body) DLP = 778.3
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) = 838 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a dextro scoliosis of the cervical spine. Retrolisthesis of C4 on C5
appears chronic. There is no acute fracture. The bones are demineralized.
There is no prevertebral soft tissue swelling.There is fluid layering in the
sphenoid sinus. Respiratory motion limits evaluation of the lung apices which
demonstrate apical scarring.
IMPRESSION:
Diffuse osteopenia limits evaluation for subtle fractures. Within this
limitation, no acute fracture or traumatic malalignment.
Radiology Report
INDICATION: ___ with fall and reported left hip 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 7.9 s, 61.6 cm; CTDIvol = 7.2 mGy (Body) DLP = 441.0
mGy-cm.
Total DLP (Body) = 441 mGy-cm.
COMPARISON: CT pelvis ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury based on an unenhanced scan. The heart and great
vessels are within normal limits. Coronary artery calcifications are noted.
There is a small pericardial effusion.
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 is bibasilar atelectasis. There is no areas of
concerning consolidation or nodules. 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: 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, 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 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: A Foley catheter ends in the vagina.
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 a comminuted intertrochanteric fracture of the left femur
with an adjacent hematoma extending into the medical compartment muscles. Old
sternal, left superior pubic ramus and inferior pubic ramus fractures are
noted.
An intramedullary rod and screw transfix a healed right intertrochanteric
femur fracture. Multiple mid to lower thoracic and lumbar compression
deformities appear chronic. A left sacral insufficiency fracture is most
likely not acute. No focal suspicious osseous abnormality.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Limited study due to osteopenia and suboptimal patient positioning.
1. The Foley catheter is in the vagina. Recommend repositioning so it is in
the urinary bladder.
2. A comminuted intertrochanteric fracture of the left femur is identified
with an adjacent hematoma extending into the medical compartment muscles.
3. Left inferior and superior pubic rami fractures are chronic.
4. Multiple mid to lower thoracic and lumbar compression deformities appear
chronic, but are indeterminate in age in the absence of priors. Consider MRI
if there is concern for an acute spinal injury.
5. Healed sternal fractures.
6. Left sacral insufficiency fracture, most likely not acute.
7. Trace simple pericardial effusion.
Radiology Report
INDICATION: Intertrochanteric fracture of the left proximal femur.
COMPARISON: ___
IMPRESSION:
Several fluoroscopic images from the operating room demonstrates placement of
a short intramedullary rod with gamma nail and distal interlocking screw.
Please refer to the operative note for additional details. Total intraservice
fluoroscopic time was 97.1 seconds.
Radiology Report
EXAMINATION: DX PELVIS AND HIP UNILATERAL
INDICATION: ___ year old woman s/p fall. // r/o r/o
r/o
IMPRESSION:
Postoperative radiograph of the bilateral femoral fracture. Documentation of
correct. Stabilizing nail placement. Expected postoperative appearance of
the soft tissues and of the bones. The contour abnormalities at the level of
the left superior and inferior pubic ramus are of unchanged appearance.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ___ year old woman s/p fall. // r/o r/o
IMPRESSION:
No comparison. Extensive vascular calcifications. No other soft tissue
abnormalities. Moderate narrowing of the joint space, particularly at the
medial aspect of the joint. Mild subcortical sclerosis at the level of the
tibia. Mild to moderate narrowing of the retropatellar space. No cortical
disruptions suggestive of fracture.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with increasing O2 requirement, +wheeze //
?pulmonary congestion ?pulmonary congestion
IMPRESSION:
Comparison to ___. Decrease lung volumes. Increased distension of the
vascularity with new blunting of the right costophrenic sinus, as well as
increased diameter of the cardiac silhouette. Overall, the changes are highly
suggestive of new moderate pulmonary edema, with accompanying right pleural
effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new pulmonary edema, unclear I/Os,
persistent O2 requirement // Interval change in edema
IMPRESSION:
In comparison to the prior radiograph of 1 day earlier, the patient is
markedly rotated towards right, limiting assessment of cardiomediastinal
contours and obscuring a portion of the right lung. With this limitation in
mind, there has not been a gross interval change since the recent study, but
repeat radiograph with improved positioning would be helpful for more accurate
assessment when the patient's condition permits.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Femur fracture
Diagnosed with Displaced intertrochanteric fracture of left femur, init, Fall on same level, unspecified, initial encounter
temperature: 98.7
heartrate: 74.0
resprate: 14.0
o2sat: 97.0
sbp: 139.0
dbp: 87.0
level of pain: unable
level of acuity: 2.0 | Orthopedics Hospital Course;
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left intertrochanteric fracture with varus angulation
of the left femoral head and foreshortening of the left femoral
shaft. and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for operative
fixation of left intertrochanteric hip fracture with
intramedullary nail 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. On POD 4, the patient developed
hypoxia down to 93% on 4L NC, this improved somewhat to 2L NC on
POD5. A chest xray showed mild fluid overload so she was given
20 mg IV furosemide. Her urinalysis was consistent with a
urinary tract infection and she was given 3 doses of IV
Ceftriaxone which was converted to PO Cipro of which she will
complete a 7 day course. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfur-8
Attending: ___.
Chief Complaint:
Polytrauma s/p MVC
Major Surgical or Invasive Procedure:
___: Intubated for airway protection (outside hospital)
___: Extubated
History of Present Illness:
___ female with history of Factor 5 Leiden deficiency
presented with a transfer from an outside hospital for surgical
evaluation. Patient was restrained passenger of a vehicle
traveling approximately ___ miles per hour there was a single
car accident against a tree. Prolonged extrication. At the
outside hospital she was intubated for airway protection. She
had evidence of a subcapsular splenic hematoma with positive
trace fluid in the pelvis. She had a right frontoparietal
subdural hematoma. She had rib fractures and clavicular
fracture. There is evidence of small apical pneumothorax on the
right. She also had evidence of a transverse process fracture at
L1. She was transferred here for further evaluation. She
received 380 mg of Dilantin. She was started on propofol with
difficulty with sedation.
Past Medical History:
HTN/ factor V deficency
Social History:
___
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAMINATION
HR: 131 BP: 142/74 Resp: 18 O(2)Sat: 100 Normal
Constitutional: Intubated, awake and responding to commands
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
In C-collar, no midline C-spine tenderness
Chest: Intubated, chest wall tender to palpation, equal
breathsounds
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Rectal: no gross blood
Extr/Back: No cyanosis, clubbing or edema, abrasion to R
knee, no midline spine tenderenss tenderness
Skin: abrasion to R knee
Neuro: Intubated, but awake and following commands, moving
all extremites
AT discharge:
99.5/99.5 95 147/90 18 99%RA
General: AAOx3, NAD
Cardiac: RRR
Resp: CTA b/l
Abdomen: soft, non tended, non distended
Extr/Back: No cyanosis, clubbing or edema, abrasion to R
knee, no midline spine tenderenss tenderness
Skin: abrasion to R knee
Pertinent Results:
___ 06:52AM BLOOD WBC-8.9 RBC-3.70* Hgb-11.1* Hct-32.7*
MCV-89 MCH-30.1 MCHC-34.0 RDW-13.1 Plt ___
___ 02:13AM BLOOD WBC-8.9 RBC-3.68* Hgb-11.1* Hct-32.3*
MCV-88 MCH-30.3 MCHC-34.5 RDW-13.4 Plt ___
___ 09:42PM BLOOD WBC-9.4 RBC-3.91* Hgb-11.8* Hct-34.5*
MCV-88 MCH-30.2 MCHC-34.3 RDW-13.4 Plt ___
___ 11:06AM BLOOD WBC-10.6 RBC-4.15* Hgb-12.4 Hct-36.9
MCV-89 MCH-29.9 MCHC-33.5 RDW-13.1 Plt ___
___ 07:25AM BLOOD WBC-14.8* RBC-4.21 Hgb-12.8 Hct-37.3
MCV-89 MCH-30.5 MCHC-34.4 RDW-13.6 Plt ___
___ 02:13AM BLOOD Glucose-107* UreaN-5* Creat-0.4 Na-137
K-3.7 Cl-106 HCO3-22 AnGap-13
___ 11:06AM BLOOD Glucose-98 UreaN-5* Creat-0.5 Na-140
K-4.2 Cl-109* HCO3-18* AnGap-17
___ 07:25AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
___ CXR
1. Left minimally displaced midclavicular fracture.
2. Low lung volumes. Patchy opacity projecting over the mid and
lower right lung zones, possibly reflective of aspiration.
___. Tiny right cerebral subdural hematoma without significant
mass effect. No fracture.
2. Fracture of the right first rib and left distal clavicular
shaft
3. Asymmetric widening of the right C5-6 facet joint, may be
positional
though clinical correlation for focal pain at this site advised.
No
malalignment or definite cervical vertebral body fracture.
___. Small splenic laceration (lower pole) with trace adjacent
free fluid.
2. Fractures involving right first rib, left second, third ribs,
left
clavicle, right L1 transverse process.
3. Right adrenal nodule measuring 2.0 x 3.1 cm. Question nodule
versus
hematoma.
4. Lower lobe consolidations concerning for
aspiration/atelectasis.
5. Endotracheal tube tip 1.4 cm above the carina. Retraction by
1 cm advised.
___ HEAD CT
No significant interval change in the 3-mm right frontal
anterior subdural hematoma without significant mass effect.
___ CXR
The ET tube and NG tube have been removed. The left clavicular
fracture is again visualized. There is also widening of the
left AC joint suggesting ligamentous injury in this region as
well. There is volume loss at the left base. There is a tiny
left pneumothorax. There is no focal infiltrate.
___ C-SPINE MRI
Normal the cervical spine MR. ___ with cervical spine CT
is
recommended.
___ ANKLE XRAY
There is normal alignment without fracture or dislocation.
There is mild soft tissue swelling laterally
___ KNEE XRAY
Cortices are intact. Mineralization is normal. Point surfaces
are smooth.
Joint spaces are maintained. Soft tissues are unremarkable.
___ CLAVICLE STUDY
Displaced mid clavicle fracture.
Left second rib fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth Q6 hours Disp #*40
Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Ibuprofen 400 mg PO Q8H:PRN pain
4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q3 hours Disp #*50
Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*40 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Polytrauma s/p MVC
Injuries:
Right frontal anterior subdural hematoma
L1 nondisplaced transverse process fracture
Right rib ___ fracture
Left rib fracture ___
Displaced left distal shaft clavicle fracture
Tiny right apical pneumothorax
Small splenic laceration (lower pole)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female status post trauma.
COMPARISON: None available.
FINDINGS:
Single AP portable radiograph of the chest demonstrates low lung volumes.
Several overlying lines and a trauma board is noted. Endotracheal tube
terminates 3.2 cm above the level of the carina in appropriate position.
Enteric tube is identified its tip projecting over the left upper quadrant.
There is no pneumothorax. There is a mid left clavicular fracture. Heart size
is exaggerated by low lung volumes. No large pleural effusion is seen. Patchy
opacity projecting over the right mid and lower lung zone may reflect
aspiration.
IMPRESSION:
1. Left minimally displaced midclavicular fracture.
2. Low lung volumes. Patchy opacity projecting over the mid and lower right
lung zones, possibly reflective of aspiration.
NOTIFICATION: Findings discussed with Dr. ___ by ___ via
telephone at 7:34 on ___ at the time study was reviewed.
Radiology Report
EXAMINATION: CT head and CT C-spine second opinion interpretation
INDICATION: ___ s/p restrained passenger MVC vs tree, ?LOC, w/chest pain
intubated prior to transfer to ___ // CT head second read
TECHNIQUE: Outside hospital CT head and cervical spine were performed without
contrast with multiplanar reformations.
DOSE: Unknown, performed at outside hospital
COMPARISON: None
FINDINGS:
CT head: There is a tiny right cerebral subdural hematoma without significant
mass effect or shift of normally midline structures. This collection measures
up to 3 mm in maximal thickness. No parenchymal hemorrhage. No edema. No signs
of acute major vascular territorial infarction. Ventricles and sulci are
normal in size and configuration. Basilar cisterns are widely patent. Patient
is intubated. No fracture.
CT C-spine: An acute fracture involving the right first rib is noted. Cervical
spine aligns normally. There is no definite fracture involving the cervical
spine. However, on the right at the C5-6 facet joint, there is mild apparent
widening of the joint space which could be positional though clinical
correlation for pain at this site is advised. Prominence of prevertebral soft
tissues likely due to intubation and fluid pooling in the hypopharynx. A
displaced fracture of the left distal clavicular shaft is noted. Small locules
of gas are noted in the soft tissues of the chin which may reflect the
laceration. Imaged thyroid gland appears normal. Areas of atelectasis of the
apices noted with mild paraseptal emphysema simulating a tiny pneumothorax.
IMPRESSION:
1. Tiny right cerebral subdural hematoma without significant mass effect. No
fracture.
2. Fracture of the right first rib and left distal clavicular shaft
3. Asymmetric widening of the right C5-6 facet joint, may be positional
though clinical correlation for focal pain at this site advised. No
malalignment or definite cervical vertebral body fracture.
Radiology Report
EXAMINATION: CT CHEST, ABDOMEN, AND PELVIS - second opinion interpretation
INDICATION: Trauma.
TECHNIQUE: Multidetector CT through the chest, abdomen, and pelvis was
performed at an outside hospital following IV contrast administration with
multiplanar reformations provided. Please note, evaluation limited given
absence of sagittal reformations through the chest and lack of coronal
reformations through the abdomen pelvis. DOSE: Unknown
COMPARISON: None
FINDINGS:
CHEST: Thoracic aorta appears patent. No mediastinal hematoma. No
lymphadenopathy or pneumomediastinum. The endotracheal tube is seen within the
lower trachea with its tip located 1.4 cm above the carina. Heart is normal in
size and shape. No pericardial effusion. Lower lobe opacities likely reflect
aspiration and atelectasis. No evidence of contusion. No pneumothorax. No
hemothorax.
ABDOMEN: The liver appears intact without focal concerning lesion. No
perihepatic fluid. Main portal vein is patent. The gallbladder and pancreas
appear intact. There is subtle hypodensity within the lower pole of the spleen
best seen on series 3 image 34, possibly representing a contusion. Minimal
fluid adjacent to the spleen could represent minimal hemoperitoneum. Right
adrenal nodule measures 2.0 x 3.1 cm. Above this may represent a
nodule/adenoma, given trauma, right adrenal hematoma is difficult to exclude.
Kidneys enhance symmetrically without focal lesion or signs of injury. The
abdominal aorta is normal in course and caliber with widely patent major
branches.
PELVIS: There is no evidence of bowel or mesenteric injury. The appendix is
normal. No free air or free fluid. Uterus and adnexal structures appear
normal. The urinary bladder is decompressed around a Foley catheter.
BONES: Acute fracture involving the right L1 transverse process is noted. A
right first rib fracture is noted anteriorly though better assessed on
concurrent CT cervical spine. A displaced left distal shaft clavicle fracture
noted. Fractures involving the left second third posterior ribs appear
nondisplaced.
IMPRESSION:
1. Small splenic laceration (lower pole) with trace adjacent free fluid.
2. Fractures involving right first rib, left second, third ribs, left
clavicle, right L1 transverse process.
3. Right adrenal nodule measuring 2.0 x 3.1 cm. Question nodule versus
hematoma.
4. Lower lobe consolidations concerning for aspiration/atelectasis.
5. Endotracheal tube tip 1.4 cm above the carina. Retraction by 1 cm advised.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with tiny right SDH; evaluate for interval
change.
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: DLP: 785 mGy-cm
CTDI: 51 mGy
COMPARISON: Head CT from earlier on the same day, dated ___ at
02:19h.
FINDINGS:
At the right frontal convexity there is a tiny subdural hematoma, overall
unchanged, still measuring up to 3 mm in thickness. There is no significant
mass effect or shift of normally midline structures. The ventricles and sulci
are normal in size and configuration, unchanged. The cisterns are patent.
There is no acute territorial infarct. There is no intraparenchymal
hemorrhage.
No osseous abnormalities are seen. There is mucosal thickening of the right
frontal, posterior ethmoidal air cells, and maxillary sinus. Otherwise, the
remaining partially visualized paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable. The patient is
intubated as seen on scout view.
IMPRESSION:
No significant interval change in the 3-mm right frontal anterior subdural
hematoma without significant mass effect.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with b/l rib fractures after ___ apical R
PTX on CT // interval change?
TECHNIQUE: Portable chest
___
FINDINGS:
The ET tube and NG tube have been removed. The left clavicular fracture is
again visualized. There is also widening of the left AC joint suggesting
ligamentous injury in this region as well. There is volume loss at the left
base. There is a tiny left pneumothorax. There is no focal infiltrate.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST
INDICATION: ___ restrained passenger in MVC vs tree incl tiny R SDH, multiple
rib ___, L clavicle ___ R apical PTX, complaining of head and neck pain, C
collar in place // please eval for C spine fractures, ligamentous injury,
please protocol accordingly
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial gradient echo and T2 weighted imaging was performed.
COMPARISON: No prior spine imaging studies are available for comparison
FINDINGS:
Alignment is normal. Vertebral body and intervertebral disc signal intensity
appear normal. The spinal cord appears normal in caliber and configuration.
There is no evidence of spinal canal or neural foraminal narrowing. There is
no evidence of infection or neoplasm.
Impression 2. 1000 no cervical spine CT is available. Evaluation of the
cervical spine after trauma begins with a CT. Many significant abnormalities
may be missed with MR alone.
IMPRESSION:
Normal the cervical spine MR. ___ with cervical spine CT is
recommended.
RECOMMENDATION(S): Correlate with cervical spine CT
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) BILATERAL
CLINICAL HISTORY ___ s/p restrained passenger MVC vs tree, ?LOC, w/chest
pain. injuries: small R 3 mm SDH, sm splenic lac, R 1st rib, L ___ rib, L
3rd rib, and R L1 TP fracture // Fracture Fracture
COMPARISON: None
FINDINGS:
Cortices are intact. Mineralization is normal. Point surfaces are smooth.
Joint spaces are maintained. Soft tissues are unremarkable.
IMPRESSION:
Unremarkable study.
Radiology Report
EXAMINATION:
ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION:
___ s/p restrained passenger MVC vs tree, ?LOC, w/chest pain. injuries: small
R 3 mm SDH, sm splenic lac, R 1st rib, L ___ rib, L 3rd rib, and R L1 TP
fracture w/ R lateral ankle tenderness // fracture
TECHNIQUE: Three views of the right ankle
COMPARISON: None.
IMPRESSION:
There is normal alignment without fracture or dislocation. There is mild soft
tissue swelling laterally
Radiology Report
EXAMINATION: CLAVICLE LEFT
INDICATION: ___ year old woman s/p MVC with L clavicular fracture // please
assess fracture
TECHNIQUE: Two views, 3 radiographs
COMPARISON: Chest x-ray ___
FINDINGS:
There is a fracture through the mid clavicle, with superior displacement of
the proximal component by more than 1 shaft width, 19 mm. No obvious bridging
callus. Mild acromioclavicular degenerative change is demonstrated. The
acromioclavicular interval is at the upper limits of normal, 3 mm.
Coracoclavicular interval is unremarkable. Amorphous increased density
superimposed on the lower neck on the left on the initial AP view is
presumably related to material outside the patient.
Left second rib fracture is also noted.
IMPRESSION:
Displaced mid clavicle fracture.
Left second rib fracture.
Gender: F
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with FRACTURE ONE RIB-CLOSED, MV COLLISION NOS-PASNGR
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | This is a ___ year old female polytrauma s/p MVC with prolonged
extrication, intubated at OSH for airway protection, transferred
to ___ and admitted to the Trauma Service. Injuries identified
include small right 3 mm SDH, small splenic laceration, right
1st rib fracture, left ___ rib fracture, left clavicle
displaced fracture, and right L1 TP fracture.
The patient was admitted to the TICU and was extubated without
difficulty. On tertiary exam, her cervical spine was tender so
the collar remained in place. C-Spine MRI was ontained on HD2,
which came back negative for any fracture or ligamentous injury.
Neurosurgery was consulted for the ___; they recommended a
repeat Head CT in 6 hours which came back negative for any
progression of hemorrhage. No seizure prophylaxis was indicated.
The patient was monitored closely with q4 hour neurological
exams and OT was consulted for cognitive evaluation. They
recommended neurosurgery follow-up in 4 weeks for a repeat head
CT.
Orthopedics was consulted for the clavicle fracture, who
recommended sling for comfort, physical therapy, and follow-up
in clinic in 2 weeks.
The patient was called out of the TICU and transferred to the
floor in hemodynamically stable condition on HD2. Serial
hematocrits and neuro exams were stable. The patient was
encouraged to cough and deep breath and use incentive spirometer
and got nebulisers as needed. Pain was well controlled. Diet was
progressively advanced as tolerated to a regular diet with good
tolerability. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
rasburicase / methylene blue
Attending: ___.
Chief Complaint:
tachypnea, hypoxia, and cough
Major Surgical or Invasive Procedure:
___ Intubation/Extubation
___ PARS PLANA VITRECTOMY 27 GAUGE, MEMBRANE PEEL,
INTRAOCULAR ANTIBIOTICS LEFT EYE
___ FLEXIBLE BRONCHOSCOPY,LINEAR ENDOBRONCHIAL
ULTRASOUND,TRANSBRONCHIAL NEEDLE ASPIRATION,BRONCHOALVEOLAR
LAVAGE,ASPIRATION OF SECRETIONS.
History of Present Illness:
Mr. ___ is a ___ year-old male with a history of HTN,
dyslipidemia, COPD, PAD, spinal stenosis, OSA, and CLL (ZAP70
positive and IGVH unmutated, Dx. ___ who presented to
the emergency department from his outpatient ___
clinic with tachypnea, hypoxia, and cough. He has had a cough
productive of yellow mucus for the last ___ days days. He does
not report any fever, chest pain, unilateral leg swelling,
nausea, vomiting, or diarrhea. He does not report any medication
changes.
In the ED,
- Initial Vitals: T ___ HR 121 BP 124/71 RR 28 on 96% NRB
- Exam:
Const: Tachypneic, with audible wheezing
Eyes: No conjunctival injection
HENT: NCAT, Neck supple without meningismus
CV: RRR, Warm, well-perfused extremities
RESP: Diffuse wheeze, tachypneic, increased respiratory effort
GI: soft, non-tender, non-distended
MSK: No gross deformities appreciated tender to palpation left
calf. No swelling, erythema, or asymmetry noted
Skin: Warm, dry. No rashes
Neuro: Alert, Speech fluent. No facial droop.
Psych: Appropriate mood and affect.
- Labs:
-WBC 13.1, 96% lymphocytes, ANC 0.39
-Hgb 9.8 HCT 31.2 PLT 108
-BUN 31, Cr 2.4, HCO3 24, Gap 16
-Tbili 2.8, AST 66:ALT 26, LDH 292, UricA 12.8, Hapto 229
-VBG: 7.38/49, Lactate 1.8
-Blood cultures: PND
- Imaging:
-LENIs: No evidence of DVT in bilateral lower extremity veins.
-CXR: Lungs are fully expanded and clear. Cardiomediastinal
and
hilar silhouettes and pleural surfaces are normal. No
pneumothorax.No pleural effusion. IMPRESSION: No acute
intrathoracic abnormality.
- Consults:
- Interventions:
-Started on IV Vancomycin and Cefepime
-Given 1L LR
-Tylenol and Nebs
Upon arrival to ICU, he recounts the above history and reports
feeling symptomatically improved.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
-AIHA
-Chronic lymphocytic leukemia
-Hepatitis B core antibody positive
-Memory impairment, seen by cognitive neurology in ___
-COPD
-OSA on cpap (reportedly not using)
-Hypertension
-NSVT
-Enteritis (admitted ___
-Left common iliac artery aneurysm with eccentric mural
thrombus and possible chronic dissection, conservative
management
with vascular surgery
-Erectile dysfunction s/p penile implant
-Urinary retention/incontinence
-s/p excision of eyelid lesion
Social History:
___
Family History:
-Mother: Died at the age of ___ from an injection of medicine?
-Father: Passed in his sleep of unknown causes
-Son: ___ cell trait?
-Sister: ___ cancer (diagnosed over age ___
-Several siblings with asthma
-Brother: ___ cancer (passed away from this)
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: T 98.3F HR 106 BP 128/77 O2: 97& on 15L Oximizer
GENERAL: Alert and interactive. Tachypneic, increased WOB
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Tachycariic, Regular rhythm, Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Tachypneic, some accessory muscle use and mild belly
breathing. Lungs with overall poor airflow. Diffuse mild
expiratory wheezing. Rhonchorous breath sounds noted posteriorly
in scattered fields. Upper airway rhonchorous.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: Mild bilateral lower extremity edema to the mid
shin. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3.
DISCHARGE PHYSICAL EXAM
========================
General: Elderly gentleman seated in chair, comfortable
HEENT: Left eye with minor conjunctival hemorrhage,
swelling/erythema of eyelids much improved. EOMI.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Rhonchorous lung sounds in all fields, stable. minimal
expiratory
wheezes.
Abdomen: No masses. Mildly distended.
Ext: Warm, well perfused, 2+ pulses, no clubbing, edema in R arm
improving
Neuro: Alert and responsive. Moving all limbs spontaneously. No
focal neurologic deficits.
Pertinent Results:
ADMISSION LABS
=========================
___ 07:06PM TYPE-ART PO2-70* PCO2-44 PH-7.38 TOTAL CO2-27
BASE XS-0
___ 07:06PM LACTATE-1.2
___ 07:06PM freeCa-1.11*
___ 06:13PM ___ PO2-19* PCO2-58* PH-7.32* TOTAL
CO2-31* BASE XS-0
___ 05:38PM GLUCOSE-118* UREA N-37* CREAT-3.1* SODIUM-140
POTASSIUM-5.7* CHLORIDE-98 TOTAL CO2-23 ANION GAP-19*
___ 05:38PM cTropnT-0.03* proBNP-2971*
___ 05:38PM CALCIUM-8.7 PHOSPHATE-4.4 MAGNESIUM-2.0
___ 05:38PM ___ PTT-28.7 ___
___ 05:37PM URINE HOURS-RANDOM UREA N-373 CREAT-167
SODIUM-22
___ 05:37PM URINE OSMOLAL-321
___ 05:37PM URINE COLOR-Yellow APPEAR-Cloudy* SP
___
___ 05:37PM URINE COLOR-Yellow APPEAR-Cloudy* SP
___
___ 05:37PM URINE BLOOD-LG* NITRITE-NEG PROTEIN-100*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
___ 05:37PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-300*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
___ 05:37PM URINE RBC-4* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 05:37PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 05:37PM URINE GRANULAR-1*
___ 05:37PM URINE GRANULAR-4*
___ 05:37PM URINE AMORPH-OCC*
___ 05:31PM OTHER BODY FLUID VoidSpec-IMPROPER S
___ 12:22PM ___ PO2-23* PCO2-49* PH-7.38 TOTAL
CO2-30 BASE XS-1
___ 12:22PM LACTATE-1.8
___ 12:22PM O2 SAT-30
___ 12:07PM GLUCOSE-141* UREA N-32* CREAT-2.6* SODIUM-141
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-26 ANION GAP-18
___ 12:07PM estGFR-Using this
___ 12:07PM WBC-13.1* RBC-2.92* HGB-10.0* HCT-32.4*
MCV-111* MCH-34.2* MCHC-30.9* RDW-14.7 RDWSD-60.3*
___ 12:07PM NEUTS-3* LYMPHS-96* MONOS-1* EOS-0* BASOS-0
AbsNeut-0.39* AbsLymp-12.58* AbsMono-0.13* AbsEos-0.00*
AbsBaso-0.00*
___ 12:07PM ANISOCYT-1+* MACROCYT-1+* RBCM-SLIDE REVI
___ 12:07PM PLT SMR-LOW* PLT COUNT-114*
___ 11:35AM UREA N-31* CREAT-2.4*# SODIUM-139
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-24 ANION GAP-16
___ 11:35AM ALT(SGPT)-26 AST(SGOT)-66* LD(LDH)-292* ALK
PHOS-73 TOT BILI-2.8* DIR BILI-0.8* INDIR BIL-2.0
___ 11:35AM TOT PROT-7.6 ALBUMIN-4.1 GLOBULIN-3.5
CALCIUM-9.4 PHOSPHATE-3.2 MAGNESIUM-1.9 URIC ACID-12.8*
___ 11:35AM HAPTOGLOB-229*
___ 11:35AM NEUTS-4* LYMPHS-94* MONOS-2* EOS-0* BASOS-0
AbsNeut-0.53* AbsLymp-12.41* AbsMono-0.26 AbsEos-0.00*
AbsBaso-0.00*
___ 11:35AM ANISOCYT-1+* MACROCYT-1+* RBCM-SLIDE REVI
___ 11:35AM PLT SMR-LOW* PLT COUNT-108*
___ 11:35AM PLT SMR-LOW* PLT COUNT-108*
DISCHARGE LABS
=========================
___ 12:00AM BLOOD WBC-16.1* RBC-2.44* Hgb-7.4* Hct-24.3*
MCV-100* MCH-30.3 MCHC-30.5* RDW-17.6* RDWSD-63.7* Plt ___
___ 12:00AM BLOOD Neuts-17* Lymphs-79* Monos-3* Eos-0*
Baso-1 AbsNeut-2.79 AbsLymp-12.96* AbsMono-0.49 AbsEos-0.00*
AbsBaso-0.16*
___ 12:00AM BLOOD ___
___ 12:00AM BLOOD Glucose-97 UreaN-14 Creat-3.7*# Na-133*
K-4.3 Cl-92* HCO3-26 AnGap-15
___ 12:00AM BLOOD ALT-9 AST-13 AlkPhos-114 TotBili-0.4
___ 12:00AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.7
IMAGING
=============
MRI Brain and orbits ___
1. Possible punctate acute to subacute infarct in the right
caudate head.
2. 14 x 7 x 15 mm T1 hypointense, T2 hyperintense collection in
the left
lateral globe without increased diffusion signal, felt to be
most likely
secondary to choroidal detachment. Sub choroidal abscess is
considered
unlikely given lack of increased diffusion-weighted signal as is
metastasis
although evaluation is limited due to the absence of intravenous
contrast.
3. Edema of the left globe and the adjacent left preseptal soft
tissues
without a focal fluid collection, could possibly represent
scleritis.
4. Suggestion of trace edema the left lateral rectus muscle
could be reactive,
however this may be artifactual in nature. Clinical correlation
is
recommended.
5. Extensive paranasal sinus disease, including aerosolized
secretions is
overall similar compared to ___, with the exception
of increased opacification of the right sphenoid sinus. The
presence of aerosolized secretions could suggest acute
sinusitis.
EGD ___
- Normal esophagus
- Hematin was noted in the stomach
- Food in the stomach
- Erythema in the stomach body
- Erythema in the second part of the duodenum
- Polyp (4mm) in the second part of the duodenum
- Focal irregularity in the third part of the duodenum
Venous US ___
1. Eccentric, nonocclusive thrombus in the right internal
jugular vein.
2. Decreased respiratory variation in the right subclavian,
internal jugular
and axillary veins may suggest presence of thrombus proximally.
___ UNILAT UP EXT VEINS US RIGHT
1. Partially occlusive deep venous thrombosis within the right
internal
jugular vein appears grossly unchanged from the prior exam.
Abnormal
respiratory variation is suggestive of DVT within the right
subclavian vein,
also grossly unchanged.
2. Near occlusive DVT within the right axillary vein, appears
propagated when
compared to the prior exam from ___.
___ CARDIAC PERFUSION TEST
1. Medium sized, moderate severity resting perfusion defect
involving the RCA territory.
2. Normal left ventricular cavity size. Moderate systolic
dysfunction with global hypokinesis and akinesis of the entire
inferior wall.
___ CT CHEST W/O CONTRAST
___ CT ABD/PELVIS W/O CONTRAST
1. 6 mm spiculated right upper lobe pulmonary nodule and left
hilar
consolidation/mass severely narrowing the left lower lobe
bronchus, new since
___. Findings are suspicious for malignancy.
2. Redemonstrated are numerous prominent lymph nodes in the
chest and abdomen,
some which have increased in size since the prior study.
3. Severe narrowing of the left lower lobe bronchus results in
partial
atelectasis of the left lower lobe.
4. Dilated ascending aorta measuring up to 4.2 cm, unchanged
from ___.
5. Infrarenal abdominal aortic aneurysm measuring up to 3.1 cm,
unchanged
since ___.
___ FINE NEEDLE ASPIRATION (BRONCHOSCOPY) x3, Bronchial
Lavage
Pending x4
___ EBUS TISSUE IMMUNOPHENOTYPING
Immunophenotypic findings consistent with involvement by the
patient's known chronic lymphocytic leukemia/small lymphocytic
lymphoma (CLL/SLL). Correlation with clinical, morphologic (see
separate cytology reports ___-___ through ___-7114), and
other ancillary findings is recommended. Flow cytometry
immunophenotyping may not detect all abnormal populations due to
topography, sampling or artifacts of sample preparation.
___ CT HEAD W/O CONTRAST
1. No acute intracranial process.
2. Mild paranasal sinus disease.
___ CT ORBITS, SELLA & IAC
1. Persistent minimal left periorbital thickening. The left
scleral edema
seen on the MRI from ___ is not adequately reassessed
on this CT.
2. Hyperdense or enhancing material along the previously seen
prosthetic left
lens, new compared to the noncontrast head CT from ___, and not
clearly seen on the prior MRI from ___. This may
represent
infectious debris versus sequela of the interim intervention..
3. The collection in the lateral aspect of the posterior left
globe seen on
the MRI from ___, which was felt to represent
choroidal detachment,
is not seen on the present CT, which may be secondary to
differences in
modalities.
4. No evidence for retrobulbar collection.
5. Fluid in the left sphenoid sinus. Complete left and trace
right mastoid
air cell opacification. These findings may be secondary to
prolonged supine
positioning in the inpatient setting. However, please correlate
with any
associated infectious symptoms.
MICROBIOLOGY
=================
___ 12:11AM OTHER BODY FLUID FluAPCR-POS* FluBPCR-NEG
___ Universal PCR For Bacteria, and Fungi
Negative for Bacterial or Fungal DNA
___ TISSUE (EYE BIOPSY)
No gram stain findings. No growth.
___ BRONCHOALVEOLAR LAVAGE
No gram stain findings. No growth.
___ VITREOUS FLUID SAMPLE
No gram stain findings. No growth.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atovaquone Suspension 1500 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Entecavir 0.5 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. FoLIC Acid 4 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
12. Rosuvastatin Calcium 40 mg PO QPM
13. Simethicone 80 mg PO QID:PRN gas
14. Vitamin D 400 UNIT PO DAILY
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
16. Metoprolol Succinate XL 50 mg PO DAILY
17. Tamsulosin 0.4 mg PO QHS
18. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Ciprofloxacin 0.3% Ophth Soln 1 DROP LEFT EYE Q4H
RX *ciprofloxacin HCl 0.3 % 1 drop to left eye every four (4)
hours Refills:*0
3. Cyclopentolate 1% 1 DROP LEFT EYE BID
RX *cyclopentolate 1 % 1 drop to left eye twice a day Refills:*0
4. Fluconazole 400 mg PO DAILY
Give daily and after hemodialysis on hemodialysis days.
RX *fluconazole 200 mg 2 tablets by mouth once a day Disp #*60
Tablet Refills:*0
5. Metoprolol Tartrate 75 mg PO BID
RX *metoprolol tartrate 75 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
6. Midodrine 5 mg PO 3X/WEEK (___)
For DIALYSIS sessions.
RX *midodrine 5 mg 1 tablet(s) by mouth three times a week Disp
#*30 Tablet Refills:*0
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
RX *prednisolone acetate 1 % 1 drop to left eye four times a day
Refills:*0
8. Tobramycin-Dexamethasone Ophth Oint 1 Appl LEFT EYE
DAILY:PRN Eye irritation (foreign body sensation, discomfort)
RX *tobramycin-dexamethasone [TobraDex] 0.3 %-0.1 % 1 drop to
left eye once a day Disp #*3.5 Gram Gram Refills:*0
9. Warfarin 2.5 mg PO DAILY16
Dosing as instructed by ___ clinic.
RX *warfarin 2.5 mg 1 tablet by mouth once a day Disp #*30
Tablet Refills:*0
10. Entecavir 0.5 mg PO 1X/WEEK (___)
RX *entecavir 0.5 mg 1 tablet(s) by mouth once a week Disp #*12
Tablet Refills:*0
11. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
12. Docusate Sodium 100 mg PO BID
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
14. FoLIC Acid 4 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
18. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
19. Simethicone 80 mg PO QID:PRN gas
20. Vitamin D 400 UNIT PO DAILY
21. HELD- Allopurinol ___ mg PO DAILY This medication was held.
Do not restart Allopurinol until you see your doctor.
22. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you see your cardiologist/PCP
23. HELD- Atovaquone Suspension 1500 mg PO DAILY This
medication was held. Do not restart Atovaquone Suspension until
you see your oncologist.
24. HELD- Tamsulosin 0.4 mg PO QHS This medication was held. Do
not restart Tamsulosin until you see your PCP.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
==============================
#LEFT ENDOPHTHALMITIS
#Spiculated RUL pulmonary nodule
#Left hilar consolidation/mass
#URICEMIA
#RHABDOMYOLSIS
#ACUTE TUBULAR NECROSIS ON HEMODIALYSIS
#Right IJ THROMBUS
#RCA Distribution Hypokinesis
#Mildly depressed EF (45-50%)
#Sinus Tachycardia
#CMV Viremia
#Influenza A infection
#COPD GOLD II
#Underlying OSA
#Acute Hypoxic Respiratory Failure, improved
#Hemolysis, likely secondary to rasburicase and G6PD
#Autoimmune hemolytic anemia: Steroid-responsive
#Methemoglobinemia
#Hemoptysis
#Acute blood loss anemia
#Intubation/mechanical ventilation for airway protection
SECONDARY DIAGNOSES
==============================
#CLL
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with sob, cough. Question of pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: CT scan dated ___
FINDINGS:
Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes
and pleural surfaces are normal. No pneumothorax. No pleural effusion.
IMPRESSION:
No acute intrathoracic abnormality.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ with LLE tenderness, hypoxia, cancer. Eval DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with URI// r/o infection
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
There is subsegmental atelectasis in the left lung base. Cardiomediastinal
silhouette is stable. There is no pleural effusion. No pneumothorax is seen.
Parenchymal opacity in the left lower lobe has improved. No evidence of
pneumonia. Mild pulmonary vascular congestion is again noted
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure// r/o infiltrate
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Ill-defined left lower lobe opacities are noted. There is no pleural effusion
or pneumothorax identified. The size of the cardiomediastinal silhouette is
enlarged but not significantly changed since prior. There is mild interval
prominence of the vascular pedicle suggesting elevated venous pressures.
IMPRESSION:
Mildly increased prominence of the vascular pedicles bilaterally may reflect
increasing venous pressures.
Ill-defined left lower lobe opacities are present and could reflect
aspiration/pneumonia in the proper clinical context.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with progressive renal failure// ? obstructive
uropathy
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Re-demonstrated is a 4.2 x 3.5 x 3.0 cm anechoic cyst in the right mid kidney
as well as a 0.9 x 0.9 x 1.0 cm anechoic cyst in the left lower pole.
Right kidney: 11.2 cm
Left kidney: 11.1 cm
The bladder is moderately well distended and normal in appearance. Partially
visualized is a penile prosthesis reservoir.
IMPRESSION:
Normal renal ultrasound.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with acute renal failure and hypercarbic
respiratory failure on BiPAP // pulm edema? interval change?
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are clear. Heart size is normal. There is no pleural effusion. No
pneumothorax is seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with influenza A, COPD, respiratory failure //
PNA?
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. There is subsegmental
atelectasis within the lingula. Cardiomediastinal silhouette is stable.
There is no pleural effusion. No pneumothorax is seen
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright view.
INDICATION: PICC line placement.
COMPARISON: Prior study from ___, earlier on the same day.
FINDINGS:
PICC line terminates at the cavoatrial junction. Cardiac, mediastinal and
hilar contours appear stable. Retrocardiac opacity suggesting atelectasis is
unchanged in addition to minor suspected lingular atelectasis. There is no
pleural effusion or pneumothorax.
IMPRESSION:
PICC line terminates at the cavoatrial junction; no other definite short-term
change.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old man intubated // ET tube placement
TECHNIQUE: Chest PA and lateral
COMPARISON: Prior chest radiograph done ___
FINDINGS:
Right-sided PICC line terminates in the distal SVC. ETT in situ with the tip
terminating just below the level of the medial clavicles. Enteric tube in
situ which courses out of site inferiorly. Left retrocardiac opacity most
likely representing atelectasis similar compared to prior. Bilateral
parahilar vascular congestion slightly increased compared to prior. Mild
interstitial edema is also slightly increased. No pneumothorax.
IMPRESSION:
ET tube in situ with the tip projecting just below the level of the medial
clavicles. Bilateral perihilar vascular congestion and mild interstitial
edema is slightly increased compared to prior. Left lower lobe atelectasis is
unchanged.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with CLL, ___, hypotension, with new dialysis
requirement s/p dialysis catheter insertion. // Confirm no pneumothorax or
other procedural complication; confirm line placement Contact name: ___
___: ___
TECHNIQUE: Semi-erect AP portable radiograph of the chest, single projection.
COMPARISON: Most recent radiograph of the chest performed ___
05:47. Additional radiographs of the chest dating back to ___.
CT chest ___.
FINDINGS:
A right-sided PICC line is in-situ. Tip is seen at the level of the right
atrium, approximately 5 cm beyond the cavoatrial junction.
Patient remains intubated. The tip of the endotracheal tube is located
approximately 2.5 cm above the carina. There is a new right sided central
venous catheter, with the tip in the mid SVC. Finally, there is a feeding
tube, coursing normally throughout the mediastinum, and incompletely
visualized in the left hemiabdomen.
Stable cardiomediastinal silhouette.
Stable volume loss in the left hemithorax, with mild shift of the mediastinal
structures into the left hemithorax.
Stable appearance of left retrocardiac opacity, with more linear areas of
atelectasis in the left basal lung. Stable right basilar atelectasis. No new
consolidation in either lung.
No definite pleural fluid is identified. No pneumothorax.
Stable mild bilateral perihilar vascular congestion.
IMPRESSION:
Tip of the PICC line is identified within the right atrium. There is
additionally a new right-sided central venous catheter, with the tip
terminating within the mid SVC. Additional support lines unchanged.
No pneumothorax. No hemothorax.
Stable parenchymal findings, as above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with COPD and influenza recently extubated //
Evaluate for consolidation Evaluate for consolidation
IMPRESSION:
The patient was extubated in the meantime interval. Right PICC line tip right
atrium and should be pulled back 3 cm to secure it position at the cavoatrial
junction or above. Right internal jugular line tip is at the level of
superior SVC.
Heart size and mediastinum are stable. Vascular congestion has resolved in
the interim. Left retrocardiac consolidation is unchanged. Lungs are
otherwise clear. There is no new consolidation demonstrated.
Radiology Report
INDICATION: ___ gentleman with a medical history of hypertension,
COPD, OSA on CPAP, CLL and autoimmune hemolytic anemia on chronic steroids who
presents with acute hypoxic respiratory failure with increased work of
breathing in the setting of influenza A infection. Now on iHD and anuric. //
please place tunneled dialysis line
COMPARISON: Chest x-ray from ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ , Dr.
___ fellow and Radiology resident, Dr. ___
___ the procedure. The attending(s) personally supervised the trainee
during any key components of the procedure where applicable and reviewed and
agrees with the findings as reported below.
ANESTHESIA: Intravenous analgesia was provided using divided doses of
fentanyl. The patient's hemodynamic parameters were continuously monitored by
an independent trained radiology nurse. 1% lidocaine was injected in the skin
and subcutaneous tissues overlying the access site.
MEDICATIONS:
CONTRAST: 0 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 1 minute, 3 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right upper chest was prepped and draped in
the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short Amplatz wire
was advanced to make appropriate measurements for catheter length. The Amplatz
wire was then passed distally into the IVC.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine mixed with epinephrine, a small skin incision was made at the
tunnel entry site. A 23cm tip-to-cuff length catheter was selected. The
catheter was tunneled from the entry site towards the venotomy site from where
it was brought out using a tunneling device. The venotomy tract was dilated
using the introducer of the peel-away sheath supplied. Following this, the
peel-away sheath was placed over the Amplatz wire through which the catheter
was threaded into the right side of the heart with the tip in the right
atrium. The sheath was then peeled away. The catheter was sutured in place
with 0 silk sutures. Steri-strips were also used to close the venotomy
incision site. Final spot fluoroscopic image demonstrating good alignment of
the catheter and no kinking. The tip is in the right atrium. The catheter was
flushed and both lumens were capped. Sterile dressings were applied. The
patient tolerated the procedure well.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing 23 cm
tip to cuff tunneled HD catheter with tip terminating in the right atrium.
Immediately post procedure, the patient did have tachycardia but remained
asymptomatic. The patient's tachycardia resolved spontaneously after
approximately 20 minutes postprocedure. The primary team was notified. The
patient was transferred back to the floor in stable condition.
IMPRESSION:
Successful placement of a 23cm tip-to-cuff length tunneled dialysis line.
The tip of the catheter terminates in the right atrium. The catheter is ready
for use.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with altered mental status along with new onset
bilateral upper extremity tremor-like activity. Appears lethargic but
arousable. Answers questions but slowly. Gross movement intact upper and
lower extremities bilaterally.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 15.1 cm; CTDIvol = 45.3 mGy (Head) DLP =
684.4 mGy-cm.
2) Stationary Acquisition 2.0 s, 7.7 cm; CTDIvol = 44.4 mGy (Head) DLP =
342.2 mGy-cm.
Total DLP (Head) = 1,027 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
Mild motion artifact and significant leftward tilt of the patient's head
limits evaluation. As visualized, there is no evidence of acute intracranial
hemorrhage, edema, mass effect, or acute major vascular territorial
infarction. Mild periventricular white-matter hypodensities are nonspecific
but likely sequela of chronic small vessel ischemic disease in this age group.
Mild global parenchymal volume loss is again seen with prominent ventricles
and sulci, likely age related.
There is fluid in the left maxillary sinus, aerosolized secretions within
bilateral posterior ethmoid air cells and left sphenoid sinus, as well as
complete left and partial right mastoid air cell opacification, which may be
secondary to prolonged supine positioning in the inpatient setting. There is
also opacification of left sphenoid sinus, and opacification of multiple right
anterior/middle ethmoid air cells, new compared to ___, but
otherwise of unknown chronicity. S/p left cataract surgery.
IMPRESSION:
1. Motion limited exam without evidence for acute abnormalities.
2. Fluid and aerosolized secretions in the paranasal sinuses, as well as left
greater than right mastoid air cell opacification, could be secondary to
prolonged supine positioning in the inpatient setting. However, please
correlate clinically with any infectious symptoms.
3. Complete opacification of multiple right middle ethmoid air cells on the
left seen at sinus is new compared to the ___, but otherwise of
unknown chronicity.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with rhonchi on auscultation; requiring O2
supplementation 2L // r/o acute pathology
TECHNIQUE: Portable AP view of the chest.
COMPARISON: Multiple prior chest radiographs, most recently ___
FINDINGS:
There has been interval placement of a tunneled right internal jugular
dialysis line, with the tip terminating in the right atrium. There is a
right-sided PICC whose tip is obscured by the overlying dialysis line,
however, the tip probably overlies the SVC.
The lungs are well expanded. Left retrocardiac opacity is improved. The
right lung is clear. Cardiomediastinal silhouette is stable. Hilar contours
and pleural surfaces are normal.
IMPRESSION:
1. Improved retrocardiac opacity, suggesting interval decrease in right lung
base atelectasis.
2. Interval placement of a tunneled right internal jugular dialysis line, with
the tip terminating in the right atrium. No pneumothorax.
3. The tip of the right-sided PICC is obscured by the overlying dialysis,
however, probably overlies the SVC.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: Mr. ___ is a ___ year-old male with a history of
HTN,dyslipidemia, COPD, PAD, spinal stenosis, OSA, and CLL (ZAP70positive and
IGVH unmutated, Dx. ___ who presented with tachypnea, hypoxia, and
cough, found to have influenza A withcourse complicated by progressive renal
failure ___ ATN,methemoglobinemia, and hemolysis (new diagnosis of G6PD
deficiency) requiring initiation of CRRT. Now on iHD, of O2. has PICC line and
tunneled HD line on right side, has RUE swelling > Left // ?right upper
extremity DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the left subclavian vein.
There is decreased respiratory variation in the right subclavian, right IJ and
right axillary veins.
There is eccentric, nonocclusive thrombus in the right internal jugular vein.
The right axillary and brachial veins are patent, show normal color flow, and
compressibility. The visualized portions of the right basilic, and cephalic
veins are patent, compressible and show normal color flow.
Catheters are present within the left subclavian and right basilic veins.
IMPRESSION:
1. Eccentric, nonocclusive thrombus in the right internal jugular vein.
2. Decreased respiratory variation in the right subclavian, internal jugular
and axillary veins may suggest presence of thrombus proximally.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 6:38 pm, 2 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hemoptysis // evaluate lung fields
evaluate lung fields
IMPRESSION:
Comparison to ___. Improved ventilation of the left lung bases.
Borderline size of the cardiac silhouette. No pneumonia, no pulmonary edema,
no pleural effusions. The right PICC line and the hemodialysis catheter are
in stable correct position.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with COPD, CLL, previously intubated for acute
hypercarbic respiratory failure, now with hematemesis and intubated for
bronchoscopy // 1) ET tube placement 2)any evidence of pulmonary hemorrhage
or aspiration
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the endotracheal tube projects over the midthoracic trachea. The
tip of a right PICC projects over the cavoatrial junction and that of a right
hemodialysis catheter projects over the right atrium.
Increased retrocardiac opacities may reflect atelectasis and or consolidation.
A small left pleural effusion is also noted. No pneumothorax. No
consolidation or pleural effusion is seen on the right. Size of the cardiac
silhouette is mildly enlarged but unchanged.
IMPRESSION:
Increased bibasal opacities likely reflect atelectasis however superimposed
aspiration/pneumonia would be hard to exclude in the proper clinical context.
Radiology Report
INDICATION: ___ year old man with hemoptysis, intubated for airway protection
// distended abdomen; obstruction?
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Comparisons made to prior CT scans of the abdomen, most recently
from ___.
FINDINGS:
There are multiple dilated loops of large and small bowel throughout the
abdomen. There is gas within the rectum.
There is no gross free intraperitoneal air, however this study is limited
secondary to the supine and semi upright positioning of the patient..
There are multilevel degenerative changes of the lumbar spine with large
osteophytes.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies. There are multiple pelvic phleboliths.
IMPRESSION:
Multiple dilated loops of large and small bowel throughout the abdomen with a
nonobstructive bowel gas pattern.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CLL, hemoptysis now intubated for airway
protection // NG tube placement NG tube placement
IMPRESSION:
ET tube tip is relatively low, 2 cm above the carina. NG tube tip is in the
stomach. Hemodialysis catheter tip is in the right atrium. Right PICC line
tip is not clearly seen, most likely terminating in the cavoatrial junction.
Heart size and mediastinum are stable. Right basal opacity, left retrocardiac
opacity and right upper lobe opacity are unchanged compared to ___
radiograph. Small amount of left pleural effusion is present.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man intubated for airway protection in setting of
hemoptysis // preparation for extubation preparation for extubation
IMPRESSION:
Comparison to ___. Stable correct position of the monitoring and
support devices. Mild left pleural effusion. Mild retrocardiac atelectasis.
No pulmonary edema. No pneumonia.
Radiology Report
EXAMINATION: MRI BRAIN AND ORBITS PT4 MR ___
INDICATION: ___ year old man with endophthalmitis // evaluate for infection
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal orbit images
acquired at 3 mm slice thickness. Precontrast sequences included axial and
coronal T1, coronal STIR.
COMPARISON: Head CT dated ___.
FINDINGS:
MRI BRAIN: There is a punctate focus of increased diffusion weighted signal in
the right caudate head, which corresponds to FLAIR and T2 hyperintensity,
possibly reflecting a punctate subacute infarct-likely microvascular (302:16,
6:12). No additional acute infarct is seen.
No evidence of edema, mass, mass effect or hemorrhage. Periventricular and
subcortical T2 and FLAIR hyperintensities are noted which may represent small
vessel ischemic changes. Prominence of the ventricles and sulci are
suggestive of involutional changes.
Left greater than right mastoid effusions are redemonstrated. Left greater
than right maxillary sinus and aerosolized secretions, are similar to the
prior CT. Aerosolized secretions in the right sphenoid sinus are increased.
Opacification of the left sphenoid sinus is similar. Mild mucosal thickening
is present in the frontal sinuses.
MRI ORBITS:
Evaluation of the orbits is suboptimal due to the absence of intravenous
contrast.
There is a T1 hypointense, T2 hyperintense collection in the left lateral
globe measuring 14 x 7 x 15 mm (AP by TRV by CC). No increased DWI signal.
Mildly increased STIR hyperintense signal of the sclera of the globe is noted.
The increased STIR signal may extend into the adjacent extraconal soft tissue
with trace edema in the left lateral rectus muscle (6:8, 10:12), although the
involvement of the left lateral rectus may be artifactual in nature. No soft
tissue fluid collection. Intraconal fat appears otherwise preserved.
The patient appears to be status post left lens replacement.
The bony orbits are unremarkable. The optic nerves and complex are normal,
without edema. Retrobulbar soft tissues are normal.
The right orbit and globe are unremarkable.
IMPRESSION:
1. Possible punctate acute to subacute infarct in the right caudate head.
2. 14 x 7 x 15 mm T1 hypointense, T2 hyperintense collection in the left
lateral globe without increased diffusion signal, felt to be most likely
secondary to choroidal detachment. Sub choroidal abscess is considered
unlikely given lack of increased diffusion-weighted signal as is metastasis
although evaluation is limited due to the absence of intravenous contrast.
3. Edema of the left globe and the adjacent left preseptal soft tissues
without a focal fluid collection, could possibly represent scleritis.
4. Suggestion of trace edema the left lateral rectus muscle could be reactive,
however this may be artifactual in nature. Clinical correlation is
recommended.
5. Extensive paranasal sinus disease, including aerosolized secretions is
overall similar compared to ___, with the exception of increased
opacification of the right sphenoid sinus. The presence of aerosolized
secretions could suggest acute sinusitis.
NOTIFICATION: The findings were discussed with ___, m.D. by ___
___, M.D. on the telephone on ___ at 11:16 am, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with COPD, CLL, presenting for flu, with
shortness of breath, found to be wheezy // ?shortness of breath
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Right-sided 8 minutes catheter is unchanged. NG tube has been removed. Small
left pleural effusion with left basilar atelectasis is also unchanged.
Cardiomediastinal silhouette is stable. No pneumothorax.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ with chronic lymphocytic leukemia, RIJ thrombus not on
anticoagulation due to hemoptysis. // ?Right Internal Jugular thrombus
extension? Sorry could not find exam
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: Right upper extremity venous Doppler dated ___
FINDINGS:
There is normal flow with respiratory variation in the left subclavian vein.
There is suggestion of intraluminal, eccentric echogenicity within the right
subclavian vein with abnormal respiratory variation suggestive of a partially
occlusive thrombus.
There is eccentric, intraluminal echogenicity and partial compressibility of
the right internal jugular vein consistent with partially occlusive thrombus,
grossly unchanged from the prior exam.
The right axillary vein demonstrates a large thrombus, noncompressibility, and
minimal flow consistent with a near occlusive thrombus that appears more
conspicuous from the prior exam.
The right basilic and cephalic veins are patent, compressible and show normal
color flow. PICC line is noted within the right basilic vein.
Incidentally noted is a lymph node along the right IJ vein measuring 0.7 cm in
the short axis, likely reactive.
IMPRESSION:
1. Partially occlusive deep venous thrombosis within the right internal
jugular vein appears grossly unchanged from the prior exam. Abnormal
respiratory variation is suggestive of DVT within the right subclavian vein,
also grossly unchanged.
2. Near occlusive DVT within the right axillary vein, appears propagated when
compared to the prior exam from ___.
NOTIFICATION: Findings were communicated with ___, MD on ___ at 11:13 AM via telephone.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST; CT CHEST W/O CONTRAST
INDICATION: ___ year old man with endophthalmitis that by eye exam appears
fungal, but without clear source // ?fungal or bacterial source that may have
seeded his eye and caused endophthalmitis
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE:
Total DLP (Body) = 649 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: CT abdomen and pelvis ___
Chest CT ___
FINDINGS:
HEART AND VASCULATURE: The ascending aorta is dilated measuring 4.2 cm. The
aortic valve is heavily calcified. There is extensive coronary artery
calcification. There is trace pericardial effusion.
AXILLA, HILA, AND MEDIASTINUM: Multiple bilateral subcentimeter axillary and
subpectoral lymph nodes are noted, increased since the prior study. Multiple
subcentimeter bilateral supraclavicular lymph nodes are noted. Multiple
mediastinal lymph nodes are noted with the largest nodal conglomerate in the
precarinal region measuring 1.1 x 2.2 cm (3:108), previously measuring 1.7 x
1.0 cm in ___.
PLEURAL SPACES: There is mild thickening of the left posterior pleura at the
lung base. No significant pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is a left hilar consolidation with severe narrowing of
the left inferior lobar bronchus resulting in partial atelectasis of the left
lower lobe (3: 125, 3:179), new since the prior study from ___. There
is a 6 mm pulmonary nodule in the right upper lobe (3:64), new since the prior
study from ___. Respiratory motion limits evaluation of the remaining
lung parenchyma.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the unenhanced upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas 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. Again seen is a 3.1 cm
cyst in the right kidney. There is no suspicious renal lesions within the
limitations of an unenhanced scan. There is no hydronephrosis. There is no
nephrolithiasis. There is no perinephric abnormality.
GASTROINTESTINAL: Enteric contrast is noted within the stomach and small bowel
loops. Small bowel loops demonstrate normal caliber and wall thickness
throughout. Diverticulosis of the colon is noted, without evidence of wall
thickening or fat stranding.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Penile prosthesis is again noted with a left inguinal
reservoir intact.
LYMPH NODES: Prominent mesenteric and retroperitoneal lymph nodes are again
noted, some which are slightly increased in size since ___. There is
no pelvic or inguinal lymphadenopathy.
VASCULAR: An infrarenal abdominal aortic aneurysm is noted measuring up to 3.1
cm, unchanged since ___. Extensive atherosclerotic disease is noted.
BONES: Mild retrolisthesis of L3 on L4 is chronic. There is no evidence of
worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. 6 mm spiculated right upper lobe pulmonary nodule and left hilar
consolidation/mass severely narrowing the left lower lobe bronchus, new since
___. Findings are suspicious for malignancy.
2. Redemonstrated are numerous prominent lymph nodes in the chest and abdomen,
some which have increased in size since the prior study.
3. Severe narrowing of the left lower lobe bronchus results in partial
atelectasis of the left lower lobe.
4. Dilated ascending aorta measuring up to 4.2 cm, unchanged from ___.
5. Infrarenal abdominal aortic aneurysm measuring up to 3.1 cm, unchanged
since ___.
NOTIFICATION: The findings and recommendations were communicated to ___
___, MD via phone at 8:04 pm on ___.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with left endophthalmitis s/p vitreous removal with
persistent eye pain requiring opiates with varying relief, also would like to
evaluate for intracranial hemorrhage (less likely). Evaluate orbits abscess,
hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP =
855.5 mGy-cm.
Total DLP (Head) = 856 mGy-cm.
COMPARISON: MRI brain and orbits dated ___.
CT head dated ___.
FINDINGS:
No evidence for acute intracranial hemorrhage, edema, mass effect, or loss of
gray/white matter differentiation. Grossly unchanged mild periventricular and
subcortical white matter hypodensities, nonspecific but likely sequela of
chronic small vessel ischemic disease in this age group. Stable prominence of
the ventricles and sulci, in keeping with age-related global parenchymal
volume loss.
No evidence for suspicious bone lesions.
There is fluid within the left sphenoid sinus and mild mucosal thickening in
the right sphenoid sinus and the bilateral ethmoid air cells. There is mild
mucosal thickening in the partially imaged left maxillary sinus. There is
complete left and trace right mastoid air cell opacification. These findings
are better assessed on the concurrent CT of the orbits, which is reported
separately.
IMPRESSION:
1. No acute intracranial process.
2. Mild paranasal sinus disease.
3. Please refer to separate report of CT orbits performed on the same day for
description of the orbital findings.
Radiology Report
EXAMINATION: CT ORBITS, SELLA AND IAC W/ CONTRAST Q1215 CT HEADSUB
INDICATION: ___ with CLL, complicated hospital course, most recent left
endophthalmitis s/p vitreous removal with persistent eye pain requiring
opiates with varying relief. Evaluate orbital abscess.
TECHNIQUE: Helically-acquired multidetector CT axial images were obtained
through the orbits after uneventful intravenous administration of 70 cc
Visipaque. Axial images reconstructed with soft tissue and bone algorithm to
display images with 1.0 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, 12.7 cm; CTDIvol = 27.2 mGy (Head) DLP = 328.2
mGy-cm.
Total DLP (Head) = 328 mGy-cm.
COMPARISON: MR ___ dated ___.
Head CT from ___.
FINDINGS:
Minimal left periorbital soft tissue thickening persists, with left scleral
edema better seen on the prior MRI. The globes demonstrate normal contours.
The collection in the lateral aspect of the posterior left globe seen on the ___ MRI, which was felt to be secondary to choroidal detachment, is
not clearly seen on the present CT, which may be secondary for differences in
modalities. There is hyperdense or enhancing material along the previously
seen prosthetic left lens, new compared to the noncontrast head CT from ___, and not clearly seen on the prior MRI from ___
(4:37, 10:47).
Optic nerve complexes and extraocular movement muscles appear symmetric.
Edema of the left lateral rectus muscle was suspected on the ___
MRI, but is not clearly visible on the present CT, which may be secondary to
differences in modalities. No evidence for intraorbital fat stranding,
collection, or mass.
This exam is not technically optimized for evaluation of the included
intracranial structures. No pathologic contrast enhancement is seen on
limited evaluation. Carotid siphon and vertebral artery calcifications are
noted. Concurrent noncontrast head CT is reported separately.
There is mild mucosal thickening in the anterior and posterior ethmoid air
cells and in the partially imaged, left greater than right maxillary sinuses.
There is a small mucous retention cyst in the partially imaged left maxillary
sinus. There is fluid in the left sphenoid sinus along with mild mucosal
thickening. There is mild mucosal thickening and mucous retention cysts in the
right sphenoid sinus. Partially imaged nasal septum is mildly deviated to the
left.
There is complete left mastoid air cell opacification. Trace opacification of
the dependent right mastoid air cells is not included in the field of view but
is seen on the concurrent head CT. Bilateral middle ear cavities appear
clear.
IMPRESSION:
1. Persistent minimal left periorbital thickening. The left scleral edema
seen on the MRI from ___ is not adequately reassessed on this CT.
2. Hyperdense or enhancing material along the previously seen prosthetic left
lens, new compared to the noncontrast head CT from ___, and not
clearly seen on the prior MRI from ___. This may represent
infectious debris versus sequela of the interim intervention..
3. The collection in the lateral aspect of the posterior left globe seen on
the MRI from ___, which was felt to represent choroidal detachment,
is not seen on the present CT, which may be secondary to differences in
modalities.
4. No evidence for retrobulbar collection.
5. Fluid in the left sphenoid sinus. Complete left and trace right mastoid
air cell opacification. These findings may be secondary to prolonged supine
positioning in the inpatient setting. However, please correlate with any
associated infectious symptoms.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by UNKNOWN
Chief complaint: Hypoxia
Diagnosed with Sepsis, unspecified organism, Acute kidney failure, unspecified, Other neutropenia, Fever presenting with conditions classified elsewhere, Other pneumonia, unspecified organism, Dyspnea, unspecified
temperature: 102.0
heartrate: 121.0
resprate: 28.0
o2sat: 96.0
sbp: 124.0
dbp: 71.0
level of pain: 5
level of acuity: 2.0 | ========================
TRANSITIONAL ISSUES
========================
- continue fluconazole (400mg PO daily, on HD days give after HD
session) (___)
- f/u pending infectious studies (notably vitreous fluid
Universal PCR send-out for bacteria and fungi and viral PCR)
- f/u Ophthalmology clinic ___
- f/u Dialysis ___
- f/u ___ ___ ___
- f/u Cardiology clinic ___
- f/u Infectious Disease clinic ___
- recommend ___ month repeat imaging for Right spiculated nodule
- f/u pending bronchoscopy BAL and Biopsy cytology, pathology
from ___
- initiated hemodialysis schedule ___
- re-assess indication for home allopurinol (stopped on
discharge)
- warfarin to be managed in ___ clinic;
discharge dose 2.5mg daily
- advise against future heparin boluses
- given limited course of warfarin and history of hemoptysis,
aspirin was held on discharge; reassess restart when appropriate
- given hemodialysis and relatively low BP's, lisinopril not
started inpatient; reassess indication when tolerated
- given sinus tach and metoprolol adjustments made iso acute
illness, reassess metoprolol dosing as tolerated
- monitor CMV VL and consider therapy
#CODE STATUS: Full Code
#CONTACT: ___ (daughter) ___
========================
BRIEF HOSPITAL COURSE
========================
___ with a history of HTN, dyslipidemia, OSA, PAD, COPD, spinal
stenosis, and CLL (ZAP70 positive and IGVH unmutated, Dx. ___ who presented with tachypnea, hypoxia, and cough, found to
have influenza A c/b renal failure ___ viral rhabdomyolysis/ATN
s/p CRRT (ICU care ___ and started on hemodialysis,
methemoglobinemia/hemolysis (new diagnosis of G6PD deficiency),
RIJ thrombus on warfarin (c/b large hemoptysis and hypoxia with
ICU intubation ___, as well as Left eye endophthalmitis
of unclear source (likely fungal) s/p vanc/ceftaz and discharged
on fluconazole.
He presented from his outpatient ___ clinic with tachypnea,
hypoxia, and cough, found to have influenza A and COPD
exacerbation with course c/b respiratory failure requiring
intubation, progressive renal failure requiring dialysis and
methemoglobinemia and hemolysis ___ rasburicase and G6PD
deficiency requiring ICU care from ___. He was
subsequently treated on the floor until ___ AM, when he had an
episode of possible hemoptysis with dyspnea, with O2 sats down
to low-mid ___ on RA requiring 5L of NC. Code blue was called
given concern for acute hypoxic respiratory failure iso large
volume hemoptysis/hematemesis. Heparin gtt was stopped and
patient was given protamine 15mg IV and transferred to the FICU.
He had an EGD that did not show any UGIB. Bronchoscopy was
likewise inconclusive for pulmonary source of bleed although did
reveal multiple blood clots. His ICU course was complicated by
worsening left visual deficits requiring ophthalmology consult
and local and systemic antibiotics. He was extubated on ___ and
transferred back to the floor on ___ with stable O2 sats. On
broad antibiotics (vanc/ceftaz/fluconazole) his persistent
visual deficits and eye pain warranted OR vitreous removal with
ophthalmology on ___ with some symptomatic relief but was
ultimately not revealing in definitive microbiologic source
(ophthalmology exam was however persistently consistent with
fungal infection); he completed a course of vanc/ceftaz and
discharged on fluconazole. His Right IJ (line-associated)
thrombus was treated with heparin gtt and transitioned to
warfarin by discharge.
ACTIVE ISSUES
#LEFT ENDOPHTHALMITIS
Reported blurry vision in the Left eye first on ___ in which
daughter said he has had cataract surgery. Found in ICU with
conjucntival injection and lid swelling with blurry vision;
ophthalmology consult recommended starting vanc/ceftaz and
performed vitreous biopsy and injected vanc/ceftaz alongside
ointments. MRI Brain and Orbit ___ hyperintensity with unlikely
sub-choroidal abscess. Further ophtho evaluation was consistent
with fungal etiology for which he was started on fluconazole
(___) and he was serially given intravitreal injections
(voriconazole, vanc/ceftaz) alongside evaluations with ultimate
therapeutic and diagnostic vitreous OR removal by Ophthalmology
on ___, biopsy microbiology studies sent out. CT Torso
obtained for infectious source remarkable for spiculated RUL
pulmonary nodule and Left hilar consolidation/mass as detailed.
Of note, patients B-glucan was elevated over assay and
decreased, but remained above normal limits, following
fluconazole treatment; clinical correlate was obfuscated iso
hemodialysis. Infectious studies otherwise unrevealing for a
clear and consistent source, yield especially mitigated by
prolonged systemic antibiotic therapy. Bronchoscopy infectious
studies of Bronchoalveolar Lavage and Tissue biopsy were
negative; notably universal PCR for bacteria and fungi still
pending for vitreous eye sample. Underwent CT Head/Orbit for
persistent eye pain reflective of post-surgical changes.
Completed Vancomycin/Ceftazidime (HD dosing) ___.
Fluconazole planned (___) for 400mg PO daily and to
be taken after HD on HD days.
- continue fluconazole (400mg PO daily, on HD days give after HD
session) (___)
- f/u pending infectious studies (notably vitreous fluid
Universal PCR send-out for bacteria and fungi and viral PCR)
- f/u Infectious Disease clinic ___
- f/u Ophthalmology clinic ___
#Spiculated RUL pulmonary nodule
#Left hilar consolidation/mass
CT Torso obtained ___ with pursuit of elucidating infectious
source of endophthalmitis revealing for spiculated RUL pulmonary
nodule and Left hilar consolidation/mass. In the setting of CLL,
consideration granted to secondary malignancy or Richter
transformation; in the setting of both left endophthalmitis (of
unclear origin) and consolidation, an infectious etiology
warranted evaluation. Underwent Bronchoscopy with IP on ___,
with BAL for microbiology/cytology and bilateral lymph node
biopsies by EBUS. Infectious studies unrevealing as above.
Cytology and pathology pending.
- recommend ___ month repeat imaging for Right spiculated nodule
- f/u pending bronchoscopy BAL and Biopsy cytology, pathology
from ___
#URICEMIA
#RHABDOMYOLSIS
#ACUTE TUBULAR NECROSIS ON HEMODIALYSIS
At presentation his SCr was 4.7 (baseline ___ with mild CK
elevation and uric acid 12 which was thought to be d/t viral
myositis leading to rhabdomyolysis and hyperuricemia causing
acute kidney injury w/ urine microscopy ___/ ___ casts c/w
ATN. Given his CLL, there was concern for TLS and he received
rasburicase on ___. His acute renal failure continued to
progress with worsening SCr, metabolic acidosis and hyperkalemia
and he was started on CRRT on ___ and transitioned to HD on
___. His BP was supported with PRN midodrine on HD days.
Nephrology followed during his hospital admission.
- initiated hemodialysis schedule ___
- re-assess indication for home allopurinol (stopped on
discharge)
#Right IJ THROMBUS
Thrombus discovered ___ iso tunneled HD access line which was
not removed. Started on heparin gtt for anticoagulation but c/b
massive hemoptysis and hypoxia requiring FICU transfer and brief
intubation, with bronch and EGD in ICU suggesting more pulmonary
source than GI. With CT Torso findings, his pulmonary
nodule/consolidation may be postulated as the source of the
bleed iso mild thrombocytopenia, aspirin use, and heparin bolus.
Anticoagulation was subsequently held but with repeat ultrasound
on ___ concerning for extending thrombus, heparin gtt was
restarted with ultimate transition to warfarin. Discharged on
warfarin 2.5mg (half of 5mg tablets because ?allergic to blue
2.5mg tablets) and initiated with ___ clinic.
- Discharge warfarin dose 2.5mg daily
- warfarin to be managed in ___ clinic
- advise against future heparin boluses
#RCA Distribution Hypokinesis
#Mildly depressed EF (45-50%)
#Sinus Tachycardia
TTE pursued for vegetation assessment on ___ revealing
for RCA-distribution hypokinesis with focal RV apical systolic
dysfunction. Patient without observed acute chest pain or
shortness of breath non-relieved from nebulizer treatment.
Nuclear stress test in ___ had normal myocardial perfusion
and normal LV systolic function. No signs of heart failure iso
new mildly depressed EF (45-50%). Pursued nuclear pharmacologic
stress test which was not completed due to tachycardia, but in
part suggestive of fixed infarct at rest. Also observed with
sinus tachycardia intermittently increasing to HR 130's,
although not iso distress or sepsis. Cardiology consulted
without malignant origin of sinus tachycardia, recommending
outpatient cardiology follow-up in 1 month, with metoprolol
increased from 50mg XL to 75mg BID and lisinopril to be
initiated as tolerated.
- given limited course of warfarin and history of hemoptysis,
aspirin was held on discharge; reassess restart when appropriate
- given hemodialysis and relatively low BP's, lisinopril not
started inpatient; reassess indication when tolerated
- given sinus tach and metoprolol adjustments made iso acute
illness, reassess metoprolol dosing as tolerated
#CMV Viremia
CMV viral load negative in ___, positive on ___.
Without evidence of active end-organ involvement (e.g.,
endophthalmitis not likely due to CMV), ID informal
recommendations deferred inpatient treatment for repeat
surveillance.
- monitor CMV VL and consider therapy
CHRONIC/RESOLVED ISSUES
#Influenza A infection
#COPD GOLD II
#Underlying OSA
#Acute Hypoxic Respiratory Failure, improved
He developed respiratory failure requiring intubation from ___
to ___. Respiratory failure likely ___ influenza infection in
the setting of COPD as well as acute renal failure requiring
dialysis on ___ and inability to compensate metabolically.
Antibiotics (cefepime ___, ceftazidime ___, vancomycin ___
were discontinued early as low suspicion for bacterial
pneumonia. For flu, he completed a 5 day course of oseltamivir
(___) and for COPD exacerbation he was treated with
methylprednisolone 60 mg IV q6h ___ and rapidly tapered
after that to prednisone.
#Hemolysis, likely secondary to rasburicase and G6PD
#Autoimmune hemolytic anemia: Steroid-responsive
#Methemoglobinemia
He had a positive IgG direct Coombs test from ___ and a
warm autoimmune hemolytic anemia ___ his underlying CLL. He was
being treated with steroid taper and has been stable on 5 mg
prednisone. He developed acute hemolysis requiring multiple RBC
transfusions ___ rasburicase on ___ and underlying G6PD
deficiency.
In regards to methemoglobinemia, his O2 sat was persistently
84-86% with a methemoglobin of 17 after receiving rasburicase on
___, which is a rare complication observed in pts with G6PD
deficiency. Since he has G6PD deficiency he cannot receive
methylene blue and he was given vitamin C 1g IV q6h from
___. His methemoglobinemia gradually resolved with levels
<5 on ___.
#Hemoptysis
#Acute blood loss anemia
#Intubation/mechanical ventilation for airway protection
Patient with 500cc witness hematemesis vs hemoptysis on
___. Heparin gtt had been started ___ for RIJ clot. No
prior episodes of hematemesis. Intubated on ___ for airway
protection. His anticoagulation was stopped. Underwent EGD with
GI on ___ that was unremarkable. Underwent bronchoscopy that
revealed blood clots in trachea and mainstem bronchi bilaterally
with oozing from behind clots. He was extubated on ___ with
some continued bloody secretions. He was able to maintain his
oxygen saturations on NC and was transitioned back to the floor
on ___.
#CLL:
Followed by Dr. ___ and his CLL is stable and he is
not on active treatment and he had surveillance CT imaging
demonstrating stable lymph node involvement. Hepatitis B core
positive, VL last negative ___, and continued on entecavir
prophylaxis with HD dosing. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Allopurinol And Derivatives / Iodine / Sulfur /
Ibuprofen / Metoprolol / Diltiazem / Metronidazole /
Fexofenadine / Antihistamines / Levaquin / Protonix /
Penicillins / Cleocin / Ambien / Lisinopril / Diazepam / Ultram
/ Cipro Cystitis / Labaetolol / Lantus
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
___ 10:46PM CK(CPK)-171
___ 10:46PM CK-MB-6 cTropnT-0.27*
___ 04:59PM AST(SGOT)-98* LD(LDH)-324* CK(CPK)-157 ALK
PHOS-107* TOT BILI-0.2
___ 04:59PM CK-MB-6
___ 04:59PM cTropnT-0.27*
___ 04:59PM ALBUMIN-3.4*
___ 12:46PM GLUCOSE-181* UREA N-52* CREAT-2.4* SODIUM-142
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-22 ANION GAP-14
___ 12:46PM CK(CPK)-95
___ 12:46PM ALT(SGPT)-87* AST(SGOT)-106* ALK PHOS-106*
TOT BILI-0.4
___ 12:46PM LIPASE-29
___ 12:46PM CK-MB-4 cTropnT-0.05*
___ 12:46PM ALBUMIN-3.5
___ 12:46PM WBC-11.7* RBC-3.68* HGB-11.4 HCT-35.9 MCV-98
MCH-31.0 MCHC-31.8* RDW-13.2 RDWSD-47.5*
___ 12:46PM NEUTS-72.4* LYMPHS-15.0* MONOS-9.1 EOS-2.0
BASOS-0.6 IM ___ AbsNeut-8.48* AbsLymp-1.76 AbsMono-1.06*
AbsEos-0.23 AbsBaso-0.07
___ 12:46PM PLT COUNT-222
___ 12:46PM ___ PTT-28.5 ___
___ 08:26AM GLUCOSE-132* UREA N-49* CREAT-2.0* SODIUM-146
POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-24 ANION GAP-13
___ 08:26AM estGFR-Using this
___ 08:26AM CALCIUM-9.1 PHOSPHATE-4.4 MAGNESIUM-2.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. DULoxetine ___ 20 mg PO QAFTERNOON
3. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
4. Gabapentin 200 mg PO QHS
5. Senna 17.2 mg PO QHS
6. Sucralfate 1 gm PO QID
7. Verapamil SR 360 mg PO Q24H
8. Ascorbic Acid ___ mg PO DAILY
9. Cetirizine 10 mg PO DAILY
10. melatonin 3 mg oral QHS
11. diclofenac sodium 1 % topical TID:PRN pain
12. NovoLIN 70/30 U-100 Insulin (insulin NPH and regular human)
100 unit/mL (70-30) subcutaneous DAILY
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN SOB/wheeze
14. Ranitidine 150 mg PO BID
15. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
Discharge Medications:
1. Lidocaine 5% Patch 2 PTCH TD QAM apply to chest for rib pain
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
3. Verapamil SR 120 mg PO Q24H
Hold for SBP<110, HR<60
4. Citalopram 20 mg PO DAILY
5. NovoLIN 70/30 U-100 Insulin (insulin NPH and regular human)
100 unit/mL (70-30) subcutaneous DAILY
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN SOB/wheeze
7. Senna 17.2 mg PO QHS
8. Sucralfate 1 gm PO QID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES
================
ATRIAL FIBRILLATION
1ST DEGREE AV BLOCK
RIB FRACTURES
ACUTE ON CHRONIC KIDNEY INJURY
SECONDARY DIAGNOSES:
===================
DEMENTIA
IRON DEFICIENCY ANEMIA
DIABETES
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with rib pain after cpr // eval rib fx
COMPARISON: Prior from ___
FINDINGS:
AP portable semi upright view of the chest. Overlying EKG leads are present.
The lungs are clear bilaterally.
There is no focal consolidation, effusion, or pneumothorax. Heart size is
stable. Mediastinal contour is stable. Imaged osseous structures are intact.
No displaced rib fracture is seen.
IMPRESSION:
1. No acute intrathoracic process
2. Please note, evaluation for anterior rib fractures is limited on chest
radiograph.
Radiology Report
INDICATION: ___ with epi, CPR, large hematoma just inferior to right knee //
Evaluate for fracture dislocation
COMPARISON: Prior exam from ___
FINDINGS:
AP, lateral, oblique views of the right knee and AP and lateral views of the
right tibia and fibula were provided. There is mild loss of medial
tibiofemoral joint space. Mild marginal spurring is seen. There is no joint
effusion at the right knee. Mild dorsal patellar spurring is seen. Vascular
calcifications are noted in the right distal thigh. The right tibia and
fibula appear intact. Mild soft tissue swelling is seen anteriorly along the
upper calf region. Limited views of the right ankle demonstrate no acute
fracture or mortise asymmetry. There is a retrocalcaneal enthesophytes.
IMPRESSION:
No acute fracture. Small anterior contusion along the upper calf without
underlying bony abnormality.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with syncopal episode // Evaluate for fracture, bleed, mass
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT dated ___
FINDINGS:
Motion artifact limits evaluation. There is no evidence of fracture, acute
major infarction,hemorrhage,edema,or discrete mass. There is prominence of
the ventricles and sulci suggestive of involutional changes. There is
moderate to severe hypodensity of the periventricular white matter most likely
representing chronic microvascular ischemic disease.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The native lenses are removed bilaterally.
IMPRESSION:
1. No acute intracranial abnormalities within limitation of motion artifact.
2. Involutional changes and moderate to severe chronic microvascular ischemic
disease.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ with syncope, CPR for 10 to 15 minutes // Evaluate for rib
and sternal fractures
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: CT chest ___
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. The
pulmonary arteries are normal in caliber. There is moderate atherosclerotic
calcification of the coronary vessels, aortic arch, and origins of the great
vessels. There is mild cardiomegaly. Otherwise, the heart, pericardium, and
great vessels are within normal limits based on an unenhanced scan. No
pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: No evidence of traumatic lung injury. No focal consolidation.
There is an incidentally noted 2 mm pulmonary nodule in the right upper lobe
(03:56) as well as a 3 mm subpleural pulmonary nodule in the left lower lobe
(03:67). There is a calcified granuloma in the left upper lobe (03:45). 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: The patient is status post cholecystectomy. Nonobstructive renal
calculi are noted in the right renal pelvis as well as bilateral hypodense
lesions which are incompletely characterized but may represent renal cysts.
Scattered colonic diverticular noted. There is fatty replacement of the
pancreas. There is a small hiatal hernia.
BONES: No suspicious osseous abnormality is seen.? there are acute
nondisplaced fractures of the anterior left fourth and fifth ribs as well as
the right anterolateral fifth and sixth ribs. There are moderate multilevel
degenerative changes of the thoracic spine most pronounced at T4-T7, which are
only minimally progressed compared to prior with no acute fracture or
subluxation.
IMPRESSION:
1. Acute nondisplaced fractures of the anterior left fourth and fifth ribs as
well as the anterolateral right fifth and sixth ribs.
2. No additional acute intrathoracic findings.
3. 2 incidentally noted pulmonary nodules measuring up to 3 mm. See below for
recommendations.
4. Small nonobstructive right renal calculi.
5. Colonic diverticulosis.
6. Small hiatal hernia.
RECOMMENDATION(S):
For incidentally detected multiple solid pulmonary nodules smaller than 6mm,
no CT follow-up is recommended in a low-risk patient, and an optional CT
follow-up in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with syncopal episode // Evaluate for fracture, bleed, mass
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Total DLP (Body) = 530 mGy-cm.
COMPARISON: CT cervical spine dated ___
FINDINGS:
There is straightening of the cervical lordosis. There is minimal
anterolisthesis of C3 on C4, unchanged. No acute fractures are
identified.There is moderate to severe multilevel degenerative disease of the
cervical spine noting endplate sclerosis, disc space narrowing and facet
arthropathy resulting in mild spinal canal narrowing, worst at C3-C4 and
moderate to severe neural foraminal narrowing, worst at C3-C4 and C4-C5.There
is no prevertebral edema.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
1. No evidence of acute cervical spine fracture or malalignment.
2. Multilevel cervical spondylosis as described above.
Radiology Report
INDICATION: ___ year old woman s/p cardiac arrest with hypoxia/hypotension //
? pneumothorax ? effusion
TECHNIQUE: Single AP view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Lungs are well inflated and clear. There is no consolidation, effusion, or
edema. No visualized pneumothorax. Cardiomediastinal silhouette is stable.
No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: S/P CPR, Syncope
Diagnosed with Syncope and collapse
temperature: 96.8
heartrate: 74.0
resprate: 17.0
o2sat: 100.0
sbp: 120.0
dbp: 80.0
level of pain: 8
level of acuity: 2.0 | TRANSITIONAL ISSUES:
==================
[ ] GOC- patient is full code with MOLST form, confirmed by HCP.
Given age and dementia, could re-address with HCP ___,
especially in light of rib fractures and pain from chest
compressions.
[ ] polypharmacy- we removed several as patient was on many
non-essential medications
[ ]patient to go home with ___ have cardiology
follow-up
[ ]patient developed ___ that appeared pre-renal due to fluid
responsiveness, recommend checking Cr 1 week after discharge.
Discharge Cr 1.9, at apparent baseline
[ ] we stopped and then reintroduced verapamil at a lower dose
than patient's home dose (360mg daily). She will be discharged
with 120mg verapamil daily
[ ] Given that patient was hypotensive on presentation and
presented with possible cardiac arrest, our goal BP for her is
SBP 110-160. If she has sustained SBPs above 170, would
recommend increasing verapamil to 240mg, but would avoid placing
patient on 360mg verapamil
Ms. ___ is a ___ yo F with PMH of afib (not on AC), IDDM, CKD
III (baseline Crt 1.8-2.3), HTN, h/o diverticular bleeding, and
cognitive impairment who presented after being found
unresponsive
the morning of presentation in her nursing home. Unclear whether
pulseless. S/p 10 minutes of CPR with spontaneous recovery of
consciousness.
ACUTE ISSUES:
=============
#?Syncope
Patient was found unresponsive at rehab with concern for cardiac
arrest s/p 10 min of CPR with immediate return of mental status.
Unclear whether patient was pulseless at this point. Found to
have multiple bilateral rib fractures on CXR, likely from CPR.
In the ED, she was briefly hypotensive after getting home
verapamil, and was given fluids and started on levophed, though
levophed was stopped after one hour. Transferred to the CCU, but
downgraded to floor when she remained hemodynamically stable.
Had elevated troponins, though they plateaued, and were likely
elevated in the setting of ten minutes of CPR with chest
compressions. After getting fluids, negative orthostatic
hypotension. Was monitored on telemetry, and remained in sinus
rhythm throughout her hospital course. Patient had TTE here,
without evidence of LV outflow tract obstruction or significant
aortic stenosis which could explain syncopal episode. Some
concern for tachy-brady syndrome, though she was in sinus rhythm
with HR ___ throughout her hospital course, without
arrythmia events. Initially, her home verapamil 360mg daily was
held, then re-introduced at 120mg daily. She was discharged with
___.
# Hypotension
Patient found to have BPs 70/40s in ED, which developed soon
after receiving verapamil. Received 1L LR and started on
levophed drip briefly for 1 hour. Unclear whether hypotension
was secondary to dehydration, as patient improved rapidly with
fluid resuscitation or verapamil toxicity. She was initially
started on broad spectrum antibiotics in the ED, though these
were stopped after patient's blood pressure improved with fluid
resuscitation, and she had no infectious symptoms or positive
cultures or UA. After patient was normotensive, we restarted
verapamil at a reduced dose of 120mg daily. She has since become
hypertensive, but given that she presented with hypotension and
syncope, our goal BP for her was SBP 110 to 160.
#Rib fractures
Secondary to resuscitation efforts at the nursing home. Was
given standing tylenol, lidocaine patches and frequent low-dose
oxycodone 2.5mg q3h for pain control. Oxycodone was spaced out
and eventually stopped as patient's pain control improved to
avoid worsening delirium. She will be discharged on lidocaine
patches and Tylenol for pain control.
___ on CKD
Patient developed ___ after being hypotensive, likely
pre-renal, responded to fluid resuscitation. Peak creatinine was
3.2, Cr at discharge is 1.9, at baseline.
# Atrial fibrillation:
Patient is not on anticoagulation because of her frequent falls.
At home was on verapamil 360mg, but as she developed hypotension
following verapamil administration while in the ED, this was
held. While it was held, HRs were in the ___. We re-introduced
verapamil at a reduced dose of 120mg daily, and her HRs remained
in the ___. Throughout her hospital stay, she was in sinus
rhythm with first degree AV block.
#Transmaminitis
Had transaminitis with peak AST/ALT 106/87. Given that
transaminitis improved with correction of hypotension, likely
from brief ischemia. LFTs are within normal limits at discharge.
CHRONIC ISSUES:
===============
# Depression:
Citalopram held with concern for QTc prolonging effect,
re-introduced while patient was on telemetry. QTc at discharge
is 468
# Neuropathic pain:
Held gabapentin 200 mg QHS because of concern for sedation. Held
duloxetine given QTc prolonging effect. Will not be discharged
on these medications.
# DMII:
Tradjenta was held, as this is non formulary at ___, and
patient was placed on sliding scale insulin. Re-started home
meds on discharge.
# GERD:
Stopped ranitidine
# ___:
To avoid polypharmacy in a ___ y/o woman, we have stopped her
iron tablets and vitamin C
CORE MEASURES:
# CODE STATUS: FULL CODE per MOLST
# CONTACT/HCP: ___
Relationship: niece
Phone number: ___
Cell phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hyperkalemia
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ is a ___ with a history of T2DM, CKD (baseline Cr
2.5), recent admission at ___ for toxic megacolon secondary to C
diff requiring colectomy and colostomy who is transferred from
his Neurology appointment with hyperkalemia.
He was at a neurology appointment for headache when labs were
done showing K of 7.9 and a Cr of 7.94. An ECG was done which
was reportedly concerning for ischemia so he was given 325 mg of
aspirin. He was transferred via EMS to ___ ED.
In ED initial VS: 97.8 94 ___ 95% RA
-Patient was given:
___ 20:00 IV Insulin Regular 10 units
___ 20:00 IV Dextrose 50% 25 gm
___ 20:00 IH Albuterol 0.083% Neb Soln 1 NEB
___ 20:00 IH Ipratropium Bromide Neb 1 NEB
___ 20:00 IV Metoclopramide 10 mg
___ 20:39 IV Sodium Bicarbonate 50 mEq
___ 21:48 IV Calcium Gluconate (1 gm ordered) Started
Stop
___ 21:48 IV Insulin Regular 0 units
___ 21:48 IV Sodium Bicarbonate 50 mEq
___ 22:31 IV Vancomycin (1000 mg ordered)
___ 23:14 IVF NS 500 mL
-Imaging notable for:
CXR (___): Subtle consolidation in the right midlung is
concerning for pneumonia. Recommend follow-up to resolution.
ECG: peaked T waves, widening QRS
-Consults: Renal: agreed with insulin/glucose/calcium, rec 500
cc NS STAT, place Foley and monitor UOP, renal US to r/o
obstruction, urine lytes and osms, check q2h whole blood
potassiums, kayexelate
VS prior to transfer: 0 99.4 106 110/51 16 95% RA
On arrival to the MICU, he reports feeling well. He has a
chronic cough which may be slightly worse although he is not
sure. No dyspnea, no CP, no palpitations, no abd pain, no n/v/d,
no fevers, no dysuria, no decreased urine output. He has been
feeling at baseline
Past Medical History:
Hypertension
Hypercholesterolemia
Stroke with residual R spastic hemiparesis (___)
C diff infection c/b toxic megacolon requiring total colectomy
s/p colostomy (___ ___
Disc displacement, thoracic
COPD
CKD stage 3
Carpal tunnel syndrome
OA
Obesity
IDDM, type 2
Diabetic peripheral neuropathy
Ventral hernia
History of rheumatic fever
HyperPTH
Social History:
___
Family History:
CAD/PVD in his maternal grandmother; Cancer, T2DM in his father;
emphysema in his mother.
Physical Exam:
ADMISSION:
VITALS: 97.7 144 136/72 28 92% RA
GENERAL: Alert,no acute distress
HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear
NECK: supple, JVP not elevated
LUNGS: Decreased breath sounds bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, regular, no murmurs, rubs, gallops
ABD: soft, non-tender, +erythema/irritation around colosotomy
EXT: no edema, dopplerable pulses
NEURO: alert and oriented x4, able to say ___ backwards, no
asterixis
DISCHARGE:
VS: 97.6 155/76 82 18 91 RA
GENERAL: Elderly male, seated in the chair in NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: No LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Decreased bibasilar breath sounds, otherwise clear
ABDOMEN: Nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Ileostomy present,
stoma
appears well vascularized.
EXTREMITIES: No cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. A&Ox3, answering questions
appropriately. R spastic hemiparesis at baseline.
SKIN: Warm and well perfused, venous stasis related
hyperpigmentation of shins b/l.
Pertinent Results:
ADMISSION:
___ 07:53PM BLOOD WBC-9.4 RBC-4.41* Hgb-12.1* Hct-37.0*
MCV-84 MCH-27.4 MCHC-32.7 RDW-17.2* RDWSD-52.4* Plt ___
___ 07:53PM BLOOD Glucose-242* UreaN-166* Creat-8.5*
Na-129* K-8.1* Cl-89* HCO3-16* AnGap-32*
___ 07:53PM BLOOD CK-MB-4 proBNP-438*
___ 07:53PM BLOOD Calcium-10.1 Phos-11.5* Mg-2.2
___ 05:22AM BLOOD Vanco-23.5*
___ 02:11AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:49PM BLOOD ___ Temp-37.4 FiO2-20 pO2-54*
pCO2-37 pH-7.31* calTCO2-20* Base XS--6 Intubat-NOT INTUBA
___ 07:57PM BLOOD Lactate-1.8 K-7.8*
___ 10:45PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
___ 05:44AM URINE Hours-RANDOM Creat-78 Na-24
___ 01:35AM URINE Hours-RANDOM Creat-207 Na-<20
PERTINENT:
___ 03:58AM BLOOD WBC-12.9* RBC-3.88* Hgb-10.5* Hct-32.0*
MCV-83 MCH-27.1 MCHC-32.8 RDW-17.0* RDWSD-50.8* Plt ___
___ 02:40PM BLOOD WBC-12.9* RBC-3.71* Hgb-10.3* Hct-31.5*
MCV-85 MCH-27.8 MCHC-32.7 RDW-17.6* RDWSD-54.3* Plt ___
___ 06:20AM BLOOD WBC-15.9* RBC-3.71* Hgb-10.3* Hct-32.2*
MCV-87 MCH-27.8 MCHC-32.0 RDW-17.8* RDWSD-56.9* Plt ___
___ 04:25AM BLOOD WBC-12.3* RBC-4.01* Hgb-10.9* Hct-35.3*
MCV-88 MCH-27.2 MCHC-30.9* RDW-17.6* RDWSD-57.1* Plt ___
___ 06:25AM BLOOD WBC-12.0* RBC-3.87* Hgb-10.6* Hct-33.8*
MCV-87 MCH-27.4 MCHC-31.4* RDW-17.6* RDWSD-56.0* Plt ___
___ 07:53PM BLOOD Neuts-80.6* Lymphs-11.2* Monos-6.0
Eos-1.5 Baso-0.4 Im ___ AbsNeut-7.59* AbsLymp-1.06*
AbsMono-0.57 AbsEos-0.14 AbsBaso-0.04
___ 07:53PM BLOOD Glucose-242* UreaN-166* Creat-8.5*
Na-129* K-8.1* Cl-89* HCO3-16* AnGap-32*
___ 12:06AM BLOOD Glucose-182* UreaN-156* Creat-8.2*
Na-129* K-7.2* Cl-91* HCO3-16* AnGap-29*
___ 08:00AM BLOOD Glucose-200* UreaN-146* Creat-7.0* Na-134
K-5.3* Cl-93* HCO3-19* AnGap-27*
___ 04:20PM BLOOD Glucose-220* UreaN-147* Creat-6.3* Na-134
K-5.0 Cl-92* HCO3-19* AnGap-28*
___ 02:40PM BLOOD Glucose-204* UreaN-131* Creat-4.6* Na-138
K-4.1 Cl-97 HCO3-20* AnGap-25*
___ 02:41PM BLOOD Glucose-241* UreaN-119* Creat-3.9* Na-141
K-4.6 Cl-98 HCO3-22 AnGap-26*
___ 04:25AM BLOOD Glucose-200* UreaN-112* Creat-3.6* Na-142
K-4.1 Cl-100 HCO3-23 AnGap-23*
___ 06:25AM BLOOD Glucose-181* UreaN-107* Creat-3.5* Na-140
K-4.0 Cl-100 HCO3-21* AnGap-23*
___ 07:53PM BLOOD CK-MB-4 proBNP-438*
___ 07:53PM BLOOD cTropnT-0.08*
___ 02:40PM BLOOD CK-MB-2 cTropnT-0.06*
DISCHARGE:
___ 06:25AM BLOOD WBC-12.0* RBC-3.87* Hgb-10.6* Hct-33.8*
MCV-87 MCH-27.4 MCHC-31.4* RDW-17.6* RDWSD-56.0* Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-181* UreaN-107* Creat-3.5* Na-140
K-4.0 Cl-100 HCO3-21* AnGap-23*
___ 06:25AM BLOOD Calcium-9.7 Phos-4.2 Mg-1.9
MICRO:
___ 7:53 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL
MORPHOLOGIES.
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 ___. ___ ON ___
AT 0005.
GRAM POSITIVE COCCI IN CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
___ 7:53 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 10:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 12:54 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___ 2:40 pm BLOOD CULTURE Source: Venipuncture Random.
Blood Culture, Routine (Pending):
___ 6:20 am BLOOD CULTURE X 1.
Blood Culture, Routine (Pending):
___ 4:25 am BLOOD CULTURE Source: Venipuncture Random.
Blood Culture, Routine (Pending):
STUDIES/IMAGING:
CXR ___
FINDINGS:
AP portable upright view of the chest.
Subtle opacities noted in the right mid lung concerning for
pneumonia. Left
lung is clear. No large effusion or pneumothorax.
Cardiomediastinal
silhouette appears normal. Bony structures are intact peer
IMPRESSION:
Subtle consolidation in the right midlung is concerning for
pneumonia.
Recommend follow-up to resolution.
RENAL US ___
FINDINGS:
The right kidney measures 11.4 cm. The left kidney measures 2.5
cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal
cortical
echogenicity and corticomedullary differentiation are seen
bilaterally.
The urinary bladder is not visualized, patient catheterized.
IMPRESSION:
Normal appearing kidneys.
CXR ___
FINDINGS:
Opacities in the right midlung are again noted and appear
slightly increased
since prior. Similarly there are new right medial basal
opacities. There is
no focal consolidation seen within the left lung. Streaky
linear opacities
may reflect atelectasis. No pleural effusion or pneumothorax is
identified
with the caveat that the right costophrenic angle was not
included on these
radiographs. The size of the cardiomediastinal silhouette is
within normal
limits.
IMPRESSION:
Increased right midlung and new right basilar opacities are
concerning for
multifocal pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 5 mg PO DAILY
2. Losartan Potassium 12.5 mg PO DAILY
3. Labetalol 200 mg PO TID
4. mometasone 50 mcg/actuation nasal DAILY
5. Multivitamins 1 TAB PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
7. CloNIDine 0.2 mg PO QAM
8. CloNIDine 0.4 mg PO QPM
9. Gabapentin 300 mg PO TID
10. Rosuvastatin Calcium 20 mg PO QPM
11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
12. Vitamin D 1000 UNIT PO DAILY
13. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation
DAILY
14. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth twice a day Disp
#*30 Capsule Refills:*0
2. Cefpodoxime Proxetil 400 mg PO Q24H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
3. GuaiFENesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL 15 mL by mouth every six (6) hours
Refills:*0
4. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
three times a day Disp #*60 Tablet Refills:*0
5. Vancomycin Oral Liquid ___ mg PO/NG Q6H
RX *vancomycin 125 mg/2.5 mL 1 syringe(s) by mouth every six (6)
hours Disp #*72 Syringe Refills:*0
6. Gabapentin 100 mg PO BID
RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
7. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
10. CloNIDine 0.2 mg PO QAM
11. CloNIDine 0.4 mg PO QPM
12. Labetalol 200 mg PO TID
13. mometasone 50 mcg/actuation nasal DAILY
14. Multivitamins 1 TAB PO DAILY
15. Rosuvastatin Calcium 20 mg PO QPM
16. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation
DAILY
17. Vitamin D 1000 UNIT PO DAILY
18. HELD- Losartan Potassium 12.5 mg PO DAILY This medication
was held. Do not restart Losartan Potassium until ___ are told
to do so by your doctor
19. HELD- Torsemide 5 mg PO DAILY This medication was held. Do
not restart Torsemide until ___ are told to do so by your doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
==============
Acute kidney injury on chronic kidney disease
Pneumonia
Hyperkalemia
Chronic obstructive pulmonary disease
Secondary Diagnoses
================
Supraventricular tachycardia
Hypertension
History of Clostridium difficile infection requiring colectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with EKG changes// eval for pulmonary edema
COMPARISON: None
FINDINGS:
AP portable upright view of the chest.
Subtle opacities noted in the right mid lung concerning for pneumonia. Left
lung is clear. No large effusion or pneumothorax. Cardiomediastinal
silhouette appears normal. Bony structures are intact peer
IMPRESSION:
Subtle consolidation in the right midlung is concerning for pneumonia.
Recommend follow-up to resolution.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with CKD with acute rise in Cr and hyperkalemia.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 11.4 cm. The left kidney measures 2.5 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The urinary bladder is not visualized, patient catheterized.
IMPRESSION:
Normal appearing kidneys.
Radiology Report
INDICATION: ___ year old man with productive cough, bacteremia// pneumonia?
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Opacities in the right midlung are again noted and appear slightly increased
since prior. Similarly there are new right medial basal opacities. There is
no focal consolidation seen within the left lung. Streaky linear opacities
may reflect atelectasis. No pleural effusion or pneumothorax is identified
with the caveat that the right costophrenic angle was not included on these
radiographs. The size of the cardiomediastinal silhouette is within normal
limits.
IMPRESSION:
Increased right midlung and new right basilar opacities are concerning for
multifocal pneumonia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal EKG, Abnormal labs
Diagnosed with Acute kidney failure, unspecified
temperature: 97.8
heartrate: 94.0
resprate: 17.0
o2sat: 95.0
sbp: 105.0
dbp: 72.0
level of pain: 0
level of acuity: 1.0 | ___ w/ ___ R spastic hemiparesis ___ stroke, CKD (Cr 2.5),
hypertension, type 2 diabetes, previously admitted admitted to
___ ___ w/ c diff c/b toxic megacolon s/p total colectomy w/
ileostomy on abx through ___, who initially presented to his
outpatient neurologist ___ with headache, found to have
generalized weakness, labs notable for ___ on CKD (Cr 8, K 7.9).
Patient was subsequently told to present to the ED.
# ___ on CKD
After arrival to the ED, ECG was concerning for widening QRS
complex iso hyperkalemia ~8. He was given insulin/dextrose and
IV calcium, sent to the ICU for close monitoring. Of note, foley
was also placed with 400cc of urine in bag initially. In the
ICU, patient received 2L isotonic bicarbonate, insulin/dextrose,
kayexalate and multiple dosesIV lasix 80-120mg. His Cr began to
quickly downtrend and his hyperkalemia imrproved, 4.2 and 4.0
respectively upon call out to the floor. No dialysis was
required. Renal was consulted and felt that acute renal failure
was most likely multifactorial iso acute infection (pneumonia,
see below), ongoing use of antiHTNs including ___, and ongoing
ileostomy losses. Renal ultrasound was unremarkable, no concern
for obstruction.
- Cr at time of discharge: 3.5
# Hypoxemia
# Multifocal pneumonia
Patient had also been complaining of cough and had new O2
requirement ___ NC, CXR revealed R sided opacities concerning
for pneumonia. Leukocytosis to maximum 15.9k with neutrophilic
predominance. He was initially started on azithromycin ___ in
the ICU given history of known COPD, ceftriaxone was added the
following day (___). Sputum culture was unremarkable. Patient
subsequently remained afebrile and O2 requirement was no longer
present on ___ with continued abx. Patient was transitioned to
cefpodoxime ___. He will continue azithromycin through ___,
cefpodoxime through ___.
# History of C. difficile
Given patient's history of C. difficile colitis c/b colectomy
and ileostomy, patient was started on prophylactic PO vancomycin
with initiation of antibiotics during this admission. There was
no voluminous ostom output, C diff was not sent. He will
continue PO vancomycin through ___ (2-weeks after completion of
antibiotics for pneumonia).
# GPC bacteremia - One set of blood culture bottles from ___
returned showing GPCs. Patient was started on IV vancomycin
given concern for possible pneumonia and bactermia. He remained,
however, HD stable and cultures eventually showed two
morphologies of coagulase negative Staph, felt most likely to be
contaminant. IV vancomycin was discontinued and patient remained
HD stable, afebrile. Subsequent blood cultures show NGTD, remain
pending at time of discharge.
# Supraventricular tachycardia - Patient had an asymptomatic
30-beat run of SVT while in the ICU. Trops .09->.06 ___KMB during this admission iso acute renal injury. Arrhythmia
did not recur for the remainder of this admission.
# Type 2 Diabetes Mellitus - Home regimen is Lantus 50U qPM.
FSBGs remained <200 with Lantus 30U qPM and ISS. Should continue
to uptitrate as outpatient as patient is eating more with
resolution of acute infection.
CHRONIC ISSUES:
==============
# HTN
- Continued home labetalol, clonidine
- Held home torsemide and losartan given ___, to be restarted as
an outpatient
# COPD
- Nebulizers PRN
- Home meclidinium-vilanterol was held (not formulary)
# HLD
- Continued home crestor
# Pain
- Continued gabapentin with renal dosing 100mg BID (decreased)
TRANSITIONAL ISSUES
=================
- Discharge Cr: 3.5
- Patient will continue cefopoxime through ___
- Patient will continue oral vancomycin through ___
- Patient with persistent leukocytosis of 12.0 on day of
discharge, he should have repeat CBC drawn at his next PCP visit
to ensure continued downtrend with resolution of pneumonia
- Please follow-up pending blood cultures, coag neg staph from
___ most likely contaminant
- Lantus was decreased 50U qPM -> 30UqPM, please uptitrate as
blood sugars allow
- Gabapentin was decreased to 100mg BID based on renal function,
can uptitrate as outpatient if Cr improves
- Hb downtrended 12.1 -> 10.6 (normocytic) throughout admission,
likely component of CKD, should continue to monitor as
outpatient
- CT scan ordered by patient's outpatient neurologist ___
showed persistent subtotal opacification of the maxillary
sinuses with high and low attenuation material suggesting
allergic fungal sinusitis; given that patient improved with
antibiotics, no fungal work-up was initiated (ie serum markers,
sinus biopsy); should consider ID/ENT involvement should patient
develop worsening symptoms
- ___ consider outpatient holter/cardiac ischemia work-up given
run of SVT and troponinemia during this admission
- Started on sevelmer for hyperphosphatemia and CKD.
- PCP can arrange outpatient neurology followup as he did not
complete his appointment prior to admission.
======================================
#CODE STATUS: DNR/DNI (confirmed by MICU team)
#CONTACT: ___ (Sister, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Seroquel / Milk of Magnesia
Attending: ___.
Chief Complaint:
L arm and R leg pain
Major Surgical or Invasive Procedure:
___ - ORIF of the R patella
History of Present Illness:
This is a ___ year-old-woman with multiple medical problems
presenting with left upper arm pain and right knee pain after a
fall today. The patient was in her bedroom and tripped on
clothes on the floor. She struck her right knee and subsequently
her left upper arm on the side of her bed. No head strike or
LOC. Films in ED notable for displaced left midshaft humerus
fracture and a displaced right patellar fracture. CT head and C
spine negative.
Past Medical History:
--Schizophrenia
--Depresion
--Anxiety
--GERD
--Psychogenic polydipsia
--Left shoulder replacement
--Asthma
--Hypothyroidism
--Osteoporosis
--Hyperlipidemia
--Insomnia
--S/p ASD repair ___
--S/p L hip replacement ___
--S/p multiple R leg fractures ___
Social History:
___
Family History:
Patient's mother is in her ___ and still bowls.
Maternal: Grandmother died of lung cancer and mother is survivor
of lung cancer.
Siblings: She has two brothers and one sister, all of whom are
deceased.
Physical Exam:
ADMISSION PHYSIAL EXAM
======================
In general, the patient is A&Ox3
Vitals: AF 90 138/70 18 100%
Right upper extremity:
Skin intact
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
+Radial pulse
Left upper extremity:
Skin intact
significant gross swelling and obvious deformity to mid arm
Full, painless AROM/PROM of wrist and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Right lower extremity:
Skin intact
Soft, non-tender thigh and leg
gross swelling and ecchymosis overlying anterior patella,
palpable defect in mid portion of patella, patient is able to
extend knee fully
Full, painless AROM/PROM of hip and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Left lower extremity:
Skin intact
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 99.7 131/54 89 18 95%3L
I/O: 1050(PO)+1130(IVF)/1300
General: Older than stated age, lip-smacking, pleasant, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Ronchi diffusely in bilateral lung fields with expiratory
wheeze appreciated in R lung field (unable examine patient's
posterior lung fields due to pain).
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: RLE in brace with bandage c/d/i. WWP, 2+ pulses, no
clubbing, cyanosis or edema
Skin: No concerning lesions
Neuro: Movement limited back RLE brace and LUE sling and
significant pain
Pertinent Results:
ADMISSION LABS
==============
___ 10:25AM ___ PTT-32.6 ___
___ 10:25AM PLT COUNT-203
___ 10:25AM NEUTS-78.4* LYMPHS-12.8* MONOS-7.8 EOS-0.7
BASOS-0.3
___ 10:25AM WBC-6.5 RBC-3.84* HGB-11.6* HCT-35.4* MCV-92
MCH-30.1 MCHC-32.7 RDW-13.4
___ 10:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:25AM CALCIUM-8.4 PHOSPHATE-2.6* MAGNESIUM-1.6
___ 10:25AM estGFR-Using this
___ 10:25AM GLUCOSE-117* UREA N-15 CREAT-0.9 SODIUM-125*
POTASSIUM-4.5 CHLORIDE-90* TOTAL CO2-25 ANION GAP-15
___ 10:37AM LACTATE-1.2
DISCHARGE LABS
==============
___ 01:30PM BLOOD WBC-4.9 RBC-2.75* Hgb-8.2* Hct-25.6*
MCV-93 MCH-29.8 MCHC-32.0 RDW-13.4 Plt ___
___ 01:30PM BLOOD Glucose-108* UreaN-8 Creat-0.5 Na-130*
K-4.5 Cl-96 HCO3-26 AnGap-13
___ 05:08AM BLOOD ALT-145* AST-76* AlkPhos-167* TotBili-0.2
___ 05:08AM BLOOD Calcium-8.1* Phos-2.2* Mg-1.8
REPORTS
=======
___ CXR: As compared to the previous radiograph, no relevant
change is seen. The lung volumes have decreased but no new focal
parenchymal opacities have occurred. The known fibrotic changes
in the right lung are constant in appearance. The left lung is
also unchanged. Unchanged borderline size of the cardiac
silhouette without evidence of pulmonary edema.
___ XRay L humerus: comminuted, displaced fracture of the
mid-shaft humerus with varus angulation of the distal fracture
fragment, periprosthetic.
___ XRay R knee: Displaced transverse patellar fracture
___ CT head, c-spine and torso: negative for acute injury
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
3. Aspirin 81 mg PO DAILY
4. Bisacodyl ___AILY:PRN constipation
5. Divalproex (DELayed Release) ___ mg PO QHS
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 800 mg PO TID
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Metoprolol Succinate XL 25 mg PO HS
10. Montelukast Sodium 10 mg PO QAM
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO BID
13. Risperidone 13 mg PO HS
14. Sertraline 200 mg PO QAM
15. Simvastatin 40 mg PO DAILY
16. traZODONE 300 mg PO HS insomnia
17. azelastine 137 mcg nasal BID
18. butalbital-acetaminophen 50-325 mg oral DAILY:PRN headache
19. Fluticasone Propionate 110mcg 1 PUFF IH BID
20. Lactulose 60 mL PO HS:PRN constipation
21. Lidocaine 5% Patch 1 PTCH TD QAM left shoulder
22. Lorazepam ___ mg PO DAILY:PRN anxiety
23. mometasone 50 mcg/actuation nasal BID
24. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
25. Ibuprofen 800 mg PO TID:PRN pain
26. Clindamycin 1 Appl TP TID face
27. calcium carbonate-vit D3-min 1,200 mgcalcium -1,000 unit
oral daily
28. Guaifenesin-CODEINE Phosphate ___ mL PO TID:PRN cough
29. Loratadine 10 mg PO DAILY
30. Ketoconazole 2% 1 Appl TP BID breast folds
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. azelastine 137 mcg nasal BID
4. Bisacodyl ___AILY:PRN constipation
5. Divalproex (DELayed Release) ___ mg PO QHS
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate 110mcg 1 PUFF IH BID
8. Gabapentin 800 mg PO TID
9. Lactulose 60 mL PO HS:PRN constipation
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Loratadine 10 mg PO DAILY
12. Montelukast Sodium 10 mg PO QAM
13. Omeprazole 20 mg PO BID
14. Sertraline 200 mg PO QAM
15. butalbital-acetaminophen 50-325 mg oral DAILY:PRN headache
16. calcium carbonate-vit D3-min 1,200 mgcalcium -1,000 unit
oral daily
17. Clindamycin 1 Appl TP TID face
18. Multivitamins 1 TAB PO DAILY
19. mometasone 50 mcg/actuation nasal BID
20. Metoprolol Succinate XL 25 mg PO HS
21. Lidocaine 5% Patch 1 PTCH TD QAM left shoulder
22. Ketoconazole 2% 1 Appl TP BID breast folds
23. Guaifenesin ___ mL PO Q6H:PRN cough
24. Risperidone 17 mg PO HS
25. Simvastatin 40 mg PO DAILY
26. TraZODone 300 mg PO HS insomnia
27. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours as
needed for breakthrough pain Disp #*30 Tablet Refills:*0
28. OxycoDONE (Immediate Release) 2.5 mg PO Q8H
RX *oxycodone 5 mg 0.5 (Half) tablet(s) by mouth Every 8 hours
Disp #*7 Tablet Refills:*0
29. Enoxaparin Sodium 40 mg SC DAILY Duration: 12 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
30. Lorazepam 1 mg PO Q6H:PRN anxiety
31. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L periprosthetic humerus fracture
R patellar fracture
Discharge Condition:
At the time of discharge, Ms. ___ was ambulating with assist,
tolerating a regular diet, A&Ox3, and pain was controlled
without nausea
Followup Instructions:
___
Radiology Report
CHEST AND PELVIS FILMS, ___
INDICATION: ___ female with fever and hypotension. Fall out of bed.
COMPARISON: Chest x-ray from ___, and pelvis films from ___.
FINDINGS: Single portable view of the chest. Rightward mediastinal shift is
again seen with fibrotic changes at the periphery of the right lung, unchanged
from prior. There is no visualized pneumothorax or new consolidation. Left
shoulder arthroplasty changes are seen. Chronic deformities identified at the
posterior aspect of the right third and fourth ribs.
Single frontal view of the pelvis. Left hip total arthroplasty changes are
identified. Pubic symphysis and SI joints are preserved. Degenerative
changes are noted in the lower lumbar spine. Heterotopic ossification again
seen adjacent to the left femoroacetabular joint. There is no evidence of
hardware complication.
IMPRESSION:
1. Rightward mediastinal shift, likely due to volume loss in the right,
unchanged from prior.
2. Left total hip arthroplasty changes without acute fracture.
Radiology Report
HISTORY: Fall with head trauma.
COMPARISON: Head CT on ___
TECHNIQUE: CT images of the brain were acquired without IV contrast.
Sagittal and coronal reformatted images were subsequently reviewed.
FINDINGS:
There is no evidence of hemorrhage, edema, mass or acute territorial
infarction. The ventricles and sulci are prominent in size and configuration
consistent with age related volume loss. The basal cisterns appear patent
and there is preservation of gray-white matter differentiation.
No fractures are identified. There is mucosal thickening of the bilateral
maxillary sinuses and mucosal thickening of the ethmoid air cells. The
mastoid air cells and middle ear cavities are clear. The globes and orbits
are unremarkable.
IMPRESSION:
No evidence of hemorrhage or acute territorial infarction.
Radiology Report
HISTORY: Fall and hypotension.
COMPARISON: C-spine. CT on ___
TECHNIQUE: CT images of the spine were acquired without IV contrast.
Sagittal and coronal reformatted images were subsequently reviewed.
DLP: 1152
FINDINGS:
There is no prevertebral soft tissue abnormality identified. There is no
evidence of fracture or abnormal alignment. There is some straightening of the
cervical lordosis. Multilevel intervertebral degenerative changes are seen in
the cervical spine with mild to moderate disc space narrowing at C7-T1. An
anterior osteophytes seen at C5-6, not significantly changed from the prior
exam. There is multilevel uncovertebral and facet joint hypertrophy.
No lymphadenopathy is present by CT size criteria. Note made of an azygous
fissure.
IMPRESSION:
No evidence of fracture or malalignment.
Radiology Report
LEFT HUMERUS FILMS WITH ADDITIONAL VIEW OF THE LEFT HAND, ___
HISTORY: ___ female with right knee effusion and trauma. Arm pain.
COMPARISON: Left shoulder radiographs from ___.
FINDINGS: Postoperative changes of left shoulder arthroplasty are again seen.
There is an acute comminuted fracture through the mid diaphysis of the left
humerus. It is seen to involve the region of the tip of the humeral
prosthesis. There is medial angulation and lateral displacement of the distal
fracture fragment in the region of the cement. Single view of the left hand
demonstrates a well-circumscribed calcific density medial to the triquetrum
and pisiform, which does not appear acute in nature. No definite fracture
identified on this single view.
IMPRESSION: Acute comminuted angulated mid left humeral diaphyseal fracture.
Radiology Report
RIGHT FEMUR AND TIBIA/FIBULA FILMS: ___
INDICATION: ___ female with right knee effusion, status post trauma.
COMPARISON: None.
FINDINGS: Frontal and lateral views of the proximal and distal right femur
and of the right tibia and fibula.
There is an acute transversely oriented fracture through the mid portion of
the patella with approximately 1.4 mm displacement of the fracture fragments.
Significant associated soft tissue swelling and a moderate suprapatellar joint
effusion. Elsewhere, there is no visualized fracture.
There are orthopedic screws seen at the medial malleolus without evidence of
hardware complication or fracture. Deformity of the distal right fibula
suggestive of prior healed fracture with and prior orthopedic hardware. There
is no acute fracture seen distally.
IMPRESSION: Acute transversely oriented fracture through the patella with 1.4
cm of displacement.
Radiology Report
HISTORY: Fall and hypotension, concerning for acute traumatic injury.
TECHNIQUE: MDCT imaging of the chest, abdomen, and pelvis with intravenous
contrast was performed. Multiplanar reformats were prepared and reviewed.
COMPARISON: Comparison is made with CT trachea from ___ and CT
abdomen and pelvis from ___.
FINDINGS:
CHEST: Evaluation of the chest is somewhat limited due to breathing motion
artifact. There is volume loss in the right lung with associated mild
rightward shift of the mediastinum. Linear opacities are seen in the right
lung, especially the upper lobe, likely representing atelectasis or scarring.
The previously seen pulmonary nodules are not visualized on this exam, likely
due to technical differences. Lungs are otherwise clear. The airways are
patent to the subsegmental levels bilaterally.
Prominent but non pathologically enlarged lymph nodes are again noted in the
mediastinum, similar prior exam. No pathologically enlarged axillary,
mediastinal, or hilar lymph nodes are identified. There is no pleural
effusion or pericardial effusion. Mitral annular calcifications are noted.
The heart, pericardium, and great vessels are within normal limits. The
thyroid gland is unremarkable. Debris is seen in the esophagus, possibly
representing refluxed stomach contents.
ABDOMEN: The liver is homogeneous in texture with no focal lesions. There is
no biliary ductal dilatation. The patient is status post cholecystectomy.
The spleen, pancreas, and adrenal glands are normal. The kidneys are
unremarkable besides a tiny hypodensity in the right kidney which is too small
to characterize. The stomach, duodenum, and intra-abdominal loops of bowel
are normal in caliber and unremarkable. Duodenal diverticulum is noted.
There is no retroperitoneal or mesenteric lymphadenopathy. The
intra-abdominal aorta is normal in appearance.
PELVIS: Detailed evaluation somewhat limited by left hip arthroplasty. The
sigmoid colon and rectum are normal in appearance. The distal ureters and
bladder are grossly normal, Foley catheter is in place. There is no pelvic or
inguinal lymphadenopathy. There is trace free fluid in the pelvis.
BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for
infection or malignancy is seen. Multiple bilateral old healed rib fractures
are seen. A left total hip replacement is noted. No acute fracture or
dislocation is seen. A left mid-shaft humeral fracture is seen on scout
image. Right adductor intramuscular lipoma is noted.
IMPRESSION:
1. A left mid-shaft humeral fracture is again noted on scout image. No other
acute fracture or dislocation.
2. Trace free fluid in the pelvis without underlying cause identified.
3. Otherwise no acute findings in the chest, abdomen or pelvis.
Radiology Report
EXAMINATION: KNEE (2 VIEWS) RIGHT IN O.R.
INDICATION: Fracture
TECHNIQUE: 2 fluoroscopic spot images of the right knee.
COMPARISON: None
FINDINGS:
2 fluoroscopic spot images of the right knee are used for localization
purposes without the radiologist present and demonstrate a K-wire and cerclage
wire fixation of the patellar fracture. This is reported to be the right
patella. The total fluoroscopic time is 61.3 seconds. For further details
please see the intraoperative report.
IMPRESSION:
Intra-operative radiographs demonstrates patellar fracture fixation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with rhonchi, fever 103 // question aspiration
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen. The lung
volumes have decreased but no new focal parenchymal opacities have occurred.
The known fibrotic changes in the right lung are constant in appearance. The
left lung is also unchanged. Unchanged borderline size of the cardiac
silhouette without evidence of pulmonary edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with FX HUMERUS SHAFT-CLOSED, FRACTURE PATELLA-CLOSED, JOINT REPLACEMENT-SHOULDER, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT
temperature: 97.2
heartrate: nan
resprate: nan
o2sat: 89.0
sbp: 74.0
dbp: 30.0
level of pain: 13
level of acuity: 1.0 | ___ year-old woman with schizophrenia and trachobronchomalicia
complicated by recurrent bronchitis who was admited on ___
for left midshalf humerus fracture and displaced R patellar
fracture after a mechanical fall.
# Right transverse patellar fracture/Left Humerus Fracture: The
patient presented to the emergency department and was evaluated
by the orthopedic surgery team. The patient was found to have a
left peiprosthetic humerus fracture and right patellar fracture
and was admitted to the orthopedic surgery service. The left
humerus was placed in a coaptation splint and later ___
brace and will be treated nonoperatively. The patient was taken
to the operating room on ___ for ORIF of the right patella,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after 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 perioperative antibiotics and anticoagulation
per routine. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable. At the time of discharge,
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 to the left
upper extremity and weight bearing as tolerates in the right
lower extremity and was discharged on a 2 week course of lovenox
for DVT prophylaxis. The patient will follow up in two weeks
per routine.
# Trachobronchomalacia complicated by post-operative cough and
fever: The patient has a known history of trachobronchomalacia
status post thoracic tracheoplasty/broncoplasty with mesh of
right right mainstem bronchus and bronchus intermedius, and
right mainstem bronchus bronchoplasty in ___. Post-operative
from orthopedics procedure on ___, she developed
fever to Tmax 103 on ___ at 1AM with increased cough and
supplemental oxygen requirement. History of recent sedation for
surgery and coughing after food suggested aspiration event The
patient was administered 1 dose of levofloxacin on ___,
which was discontinue becase aspiration pneumonitis was more
likely than pneumonia given lack of significant worsening on
chest X-ray and quick improvement with supportive oxycodone
therapy. At the time of discharge, patient had been afebrile
for over 36 hours and was breathing comfortably on ___ NC.
# Asthma: Cough and fever manged per above. In that setting,
patient was found to have expiratory wheeze on exam, but without
increased work of breathing or E:I ratio to suggest asthma
exacerbation. The patient was continued on home regimen of
montelukast, loratidine, and fluticasone with albuterol inhaler
switched to PRN nebulizer treatments.
# Osteoporosis: Patient with longstanding osteoporosis followed
by outpatient Endocrinology. Given recurrent fractures (see
above), recommend further outpatient follow-up with
Endocrinology. Patient was continued on her home vitamin D and
calcium supplementation during this admission.
# Schizophrenia/Depression/Anxiety: Patient mood and mental
status remained stable during this admission. She was continued
on her home sertraline, risperadone, and divalproex with home
lorazepam dose decreased to prevent oversedation in the setting
of narcotic pain regimen. Anticipated rehab stay less than 30
days.
# Hyponatremia: The patient was found to hyponatremic to Na
125-129 during this admission. Etiology likely secondary to
known psychogenic polydipsia and IV fluids in perioperative
period. Sodium normalized with fluid restriction and was 130 at
the time of discharge.
# Gastroesophageal Reflux DIsease: Remained stable. Patient was
continued on home omeprazole 20mg BID.
# Coronary artery disease: Remained stable. Patient was
continued on home metoprolol dose converted to tartrate 6.25
QID. She was placed back on home metoprolol succinate 25mg at
the time of discharge.
# Hyperlipidemia: Remained stable. Patient was continued on home
simvastatin.
# Insomnia: Remained stable. Patient was continued on her home
trazadone and monitored carefully for oversedation in the
setting of narcotic pain regimen.
# Hypothyroidism: Remained stable. Patient was continued on home
levothyroxine.
================================
TRANSITIONAL ISSUES
================================
- Pain regimen: Tylenol ___ Q6H, oxycodone 2.5mg Q8H, oxycodone
2.5-5mg Q4H:PRN pain
- Please DECREASE narcotic doses as pain from fractures improve
- STARTED on Lovenox for DVT prophylaxis, to complete 2 weeks
(last day ___
- CONSIDER course of Levofloxacin if patient spikes for possible
PNA
- Anticipated rehab stay less than 30 days |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right weakness, VDRF
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
Ms. ___ ___ year old female with history of hypertension off
all medications who presents from ___
intubated for right sided weakness, decreased responsiveness,
and respiratory distress. Per the report of the patient's
children, Ms. ___ had been in her usual state of health
with no deficits through this morning (___) at 0600hrs at
which time she went to the bathroom and was heard by her husband
to be grunting. He observed the patient slumped to the right
with her left hand in the air waving and grunting for air.
Despite his attempts, he was unable to have her rise from the
toilet at which time he contacted his son, who in turn contacted
EMS. On their arrival, the patient was intubated for what was
described as agonal breathing and transported to ___
___. They arrived approximately at 0730hrs, and per report
the ___ was 22 although her specific deficits and scoring were
not recorded in the transfer documentation. A CT Head performed
at ___ revealed a dense left MCA sign without any associated
hemorrhage. tPA was not administered and the patient was
transported to ___ for further intervention.
Code stroke was called at 1131hrs upon the arrival of the
patient, and she was seen by neurology at 1135, intubated and
sedated s/p Fentanyl administration. Of note, in the transport,
the patient received Ativan gtt for sedation; however a pump
failure required the patient to receive gtt via gravity, thus it
was not clear the total amount of sedation administered. No
review of systems was able to be performed due to intuation.
Past Medical History:
- Hypertension (off medications)
- Cataract surgery in right eye
- Appendectomy in ___
- Patient sees physicians quite infrequently per report
Social History:
___
Family History:
- ___ cousin has history of stroke, no other neurologic history
- No cardiovascular history in family per patient's children
Physical Exam:
Vitals:
BP 127/61-136/61, HR 63, RR 14, SpO2 96% on 5 PEEP 40% FiO2
___: Sedated / Intubated
HEENT: Endotracheal tube placed, right pupil is ovoid and
non-reactive (prior cataract surgery)
Neck: Supple, no nuchal rigidity
Pulmonary: Referred ETT/Mechanical Respiration in all fields
Cardiac: RRR
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Sedated and intubated with no response to verbal
stimuli. Grimaces to sternal rub.
-Cranial Nerves:
I: Olfaction not tested.
II: left pupil reactive 1.5 to 1mm, right pupil post-surgical
ovoid, non-reactive.
III, IV, VI: Unable to assess ___ to compliance with request /
intubated sedated.
V: Unable to assess ___ to compliance with request / intubated
sedated.
VII: No facial droop, confounded by ETT placement and sedation.
VIII: No response to command
IX, X: Assessment confounded by ETT placement and sedation.
XI: Unable to assess ___ to compliance with request / intubated
sedated.
XII: Assessment confounded by ETT placement and sedation.
-Motor: Normal bulk, increased tone in lower extremities
bilaterally, flaccid tone in RUE. Unable to assess pronator
drift/asterixis. No adventitious movements, such as tremor,
noted. Withdraws with triple flexion in RLE, no movement in RUE;
in left w/d to pain in ___. No cooperation with commands.
-DTRs:
Bi Tri ___ Pat Ach
L 2 1 2 3 1
R 1 1 1 3 1
- Plantar response was mute bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: w/d to painful stimuli in right lower extremity and in
left hemibody
-Coordination and Gait: Did not assess ___ intubation/sedation
DISCHARGE EXAMINATION:
Pertinent Results:
___ CTA Head/Neck IMPRESSION:
Evolving left anterior cerebral and middle cerebral artery
infarctions with complete occlusion of the internal carotid,
middle cerebral, and anterior cerebral arteries on the left.
There is no evidence of hemorrhage. Hypodensity suggesting
chronic lacunar infarctions in the left pons and right putamen.
___ CT Head IMPRESSION: Infarct of virtually the entire
left MCA and ACA territories, new since yesterday, with
hyperdense left MCA. Edema causes shift of the midline
structures by approximately 7 mm, new since the prior study.
Medications on Admission:
- No medications (was on Atenolol and Lisinopril for HTN around
the time of cataract surgery last year, but self d/c'ed after
procedure)
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
- Left ACA/MCA Occlusion
- Ischemic Stroke
Secondary:
- Hypertension
- Hyperlipidemia
Discharge Condition:
Patient Expired
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman with right-sided weakness.
Contiguous axial images were obtained through the brain before administration
of intravenous contrast. Subsequently, CT perfusion and CT angiography were
performed implying a total of 110 cc of Omnipaque intravenous contrast. Images
were formatted on a separate workstation.
COMPARISON: Noncontrast head CT of ___ at 8:36.
FINDINGS:
Again seen is hypodensity throughout the left anterior and middle cerebral
artery distributions. This has progressed since the prior study and there is
greater swelling with effacement of sulci. Again seen is hyperdensity in the
left internal carotid artery in its distal cavernous and supraclinoid
segments. This hyperdensity extends into the left middle cerebral artery.
There is no evidence of hemorrhage. Overall, these findings indicate left
internal carotid artery occlusion with left anterior cerebral and middle
cerebral artery distribution infarction. There is hypodensity in the left
pons, poorly seen due to overlying artifact, but this appears to represent an
old infarction. Hypodensity in the right putamen suggests a chronic lacune.
There is dense calcification of the cavernous carotid arteries bilaterally.
The CT perfusion examination demonstrates markedly elevated mean transit time
in the left anterior cerebral and middle cerebral artery distributions. This
is associated with markedly low apparent blood volume and blood flow. These
findings, along with the hypodensity and swelling seen on the noncontrast
portion of the examination, indicate completed infarction.
The CTA examination demonstrates complete occlusion of the left internal
carotid artery at its origin. This extends to occlusion of the anterior
cerebral and middle cerebral artery branches. There is faint opacification in
several distal MCA and even fainter and several distal ACA branches. The
right posterior cerebral artery appears somewhat narrowed and irregular.
However, there is no evidence of ischemia in this distribution.
The right distal internal carotid artery and its major intracranial branches
appear normal. The vertebral arteries and their major intracranial branches
also appear normal.
IMPRESSION:
Evolving left anterior cerebral and middle cerebral artery infarctions with
complete occlusion of the internal carotid, middle cerebral, and anterior
cerebral arteries on the left. There is no evidence of hemorrhage.
Hypodensity suggesting chronic lacunar infarctions in the left pons and right
putamen.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with left MCA stroke.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The ET tube tip is 5 cm above the carina. Heart size and mediastinum are
unchanged. Cardiomegaly is moderate to severe. Lung volumes are preserved.
Bilateral pleural effusions are noted, moderate. Basal consolidations, right
more than left are present and potentially right upper lobe opacity that might
reflect infectious process. No pneumothorax is seen.
Radiology Report
HISTORY: Right IJ placement.
FINDINGS: In comparison with the earlier study of this date, there has been
placement of a right IJ catheter that extends into the upper portion of the
right atrium. Suggestion of some increasing opacification at the right base
that could represent an area of consolidation.
Other monitoring and support devices remain in place.
Radiology Report
HISTORY: ET tube placement.
FINDINGS: In comparison with study of ___, there is no change. Endotracheal
tube tip lies just above the clavicular level, approximately 5 cm above the
carina. Right IJ catheter again extends well into the right atrium.
Radiology Report
HISTORY: ___ woman with left MCA stroke, evaluate for progression of
infarct.
COMPARISON: CTA of the head from ___.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There continuing evolution of the left MCA and ACA territory
infarctions. There is a hyperdense left MCA. Mass effect by the edema has
increased since the prior CT and causes approximately 7 mm shift of the
normally midline structures. There is effacement of the left lateral
ventricle as well from the edema.
IMPRESSION: Infarct of virtually the entire left MCA and ACA territories, new
since yesterday, with hyperdense left MCA. Edema causes shift of the midline
structures by approximately 7 mm, new since the prior study.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: INTUBATED
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ female with extensive left ICA/MCA clot and hemispheric
hypodensity suggestive of extensive stroke. Based on the
patient's time of presentation to BI at approximately 5.5 hours
status post onset of symptoms as well as the extensive clot seen
in CTA/P studies, no intervention is indicated. There is
concern that the patient will potentially swell, and per
discussions with the patient's family, no craniectomy or heroic
interventions should be undertaken. She was made DNR status and
repeat NCHCT in AM (24hrs s/p study) will determine whether
patient will be
ongoing management or comfort measures.
# INFARCT ___ L ICA OCCLUSION:
Repeat imaging 24 hours from original NCHCT demonstrated
significant injury involving the ACA/MCA territory on the right
which was consistent with the patients right paresis. Patient
extensor in the LUE with pain to the right body.
# CODE STATUS:
Per discussion with the family on repeat imaging, they wished to
have their family come to pay their respects prior to making the
patient CMO, which occurred on ___. The patient was
extubated, and given morphine PRN any respiratory distress. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Cymbalta / hydrochlorothiazide / Prozac
Attending: ___.
Chief Complaint:
Thumb pain
Major Surgical or Invasive Procedure:
___ Arthrocentesis
History of Present Illness:
___ year old female PMH HTN, HLD, DM2, MDD, dementia, hx of GNR
septic arthritis of knee, presenting with chief complaint of R
thumb pain.
She reports with R thumb pain for the past several days. She
notes having a cut on her hand/thumb. Cannot recall how that cut
happened or when. Reports pain, swelling and difficulty with
movement. No fevers, chills, recent infections. Reports chronic
joint pain in both shoulders. But not other significant joint
involvement.
Pain has been persistent, with significant swelling. Patient
presented to clinic where she was noted to have pain localized
to the joint and reproducible with palpation and active and
passive range of motion. Thumb notably swollen, warm, and
erythematous.
Notably Patient has a history of GNR septic arthritis of the R
knee, s/p surgical washout last year. She was referred to the ED
for further work up.
In the ED, initial vitals were: 98.7 74 141/72 16 100% RA
Labs notable for H/H of ___, WBC of 4.5. Normal coags. CRP
11.4
Blood cx, joint fluid cx pending.
Imaging notable for: No acute fracture. No radiographic
findings to suggest acute osteomyelitis. If clinical concern
remains high, MRI is more sensitive.
Patient was given: ___ 20:03 IV Ampicillin-Sulbactam 3 g
Hand surgery was consulted and performed arthrocentesis s/p
median and radial nerve block, <1cc. Joint fluid- no cyrstals.
Recommended "Admit to medicine for IV abx. Unasyn until medicine
decides what antibiotics they want."
Prior to transfer: 98.9 79 152/57 18 96% RA
On the floor, patient appears to be doing well. States pain is
present but has improved since coming to the hospital. Denies
fevers chill. Chronic shoulder pain is not bothering her
currently.
Past Medical History:
PAST MEDICAL HISTORY
Hyperlipidemia
Hypertension
Osteoarthritis (R knee)
Anxiety
Back pain
Cataract
Colonic adenoma
Constipation
Dementia (cant remember daily activities)
Depression
Diabetes mellitus (insulin)
Diverticulosis
Glaucoma
Fibroids
PAST SURGICAL HISTORY
Discectomy
Hysterectomy d/t fibroids
Shoulder surgery
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 98.1 163/57 75 18 98%RA Blood sugar 335
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, no cervical LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
Ext: Warm, well perfused, right wrist and thumb in plaster
cast, wrapped in gauze. Fingers are warm and mobile. Mild TTP
over tip of thumb. Unable to asses joint for ROM, erythema or
swelling. Forearm and elbow are normal.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation. Normal sensation in right fingers.
DISCHARGE PHYSICAL EXAM:
VS - 98 68 152/61 16 98% ra
General: well-appearing elderly woman, nontoxic, NAD
HEENT: no scleral icterus
Neck: supple
CV: rrr, no m/r/g
Lungs: nl wob on ra, LCAB
Abdomen: soft, NT/ND, +bs
GU: no foley
Ext: R hand with soft brace on. Thumb is non-erythematous, no
swelling. Pain with deep palpation over snuff box. No pain with
passive movement.
Neuro: moving all 4 extremities, no gross deficits
Skin: no rashes or excoriations
Pertinent Results:
ADMISSION LABS:
====================
___ 02:00PM BLOOD WBC-4.5 RBC-3.57* Hgb-10.6* Hct-32.9*
MCV-92 MCH-29.7 MCHC-32.2 RDW-14.2 RDWSD-48.0* Plt ___
___ 02:00PM BLOOD Neuts-39.2 ___ Monos-12.1 Eos-1.3
Baso-0.7 Im ___ AbsNeut-1.75 AbsLymp-2.08 AbsMono-0.54
AbsEos-0.06 AbsBaso-0.03
___ 02:00PM BLOOD ___ PTT-33.3 ___
___ 02:00PM BLOOD Glucose-257* UreaN-12 Creat-0.9 Na-137
K-4.2 Cl-101 HCO3-27 AnGap-13
___ 07:21AM BLOOD Calcium-9.9 Phos-4.3 Mg-1.9
___ 02:00PM BLOOD CRP-11.4*
MICRO:
====================
___ blood cultures: pending
___ wound cultures from hand: no microorganisms on gram stain,
culture pending
IMAGING/STUDIES:
====================
___ WRIST PLAIN FILM:
No acute fracture. No radiographic findings to suggest acute
osteomyelitis. If clinical concern remains high, MRI is more
sensitive.
___ PLAIN FILM FINGERS:
No acute fracture. No radiographic findings to suggest acute
osteomyelitis. If clinical concern remains high, MRI is more
sensitive.
DISCHARGE LABS:
====================
___ 08:20AM BLOOD WBC-4.3 RBC-3.51* Hgb-10.1* Hct-32.2*
MCV-92 MCH-28.8 MCHC-31.4* RDW-14.4 RDWSD-48.7* Plt ___
___ 08:20AM BLOOD Plt ___
___ 08:20AM BLOOD Glucose-242* UreaN-10 Creat-0.6 Na-139
K-3.1* Cl-108 HCO3-20* AnGap-14
___ 08:20AM BLOOD Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Gabapentin 200 mg PO TID
3. Losartan Potassium 100 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Citalopram 30 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Aspirin 81 mg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. NIFEdipine CR 30 mg PO DAILY
11. Acetaminophen 325 mg PO Q6H:PRN pain
12. Glargine 24 Units Breakfast
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Citalopram 30 mg PO DAILY
5. Gabapentin 200 mg PO BID
RX *gabapentin 100 mg 2 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
6. Glargine 24 Units Breakfast
7. Losartan Potassium 100 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. NIFEdipine CR 30 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Ibuprofen 600 mg PO TID W/MEALS Duration: 5 Days
Take until ___ with meals then stop.
RX *ibuprofen 600 mg 1 tablet(s) by mouth q8 hours Disp #*50
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Right thumb pain secondary to tendonitis
SECONDARY DIAGNOSES
- Hypertension
- Osteoarthritis
- Depression
- Type 2 diabetes mellitus
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: History: ___ with R thumb pain // osteomyelitis? fx?
TECHNIQUE: Four views of the right wrist and three views of the right thumb
COMPARISON: None.
FINDINGS:
Right wrist: No acute fracture is seen. No cortical destruction is seen to
suggest acute osteomyelitis. Slight ulnar minus variance is noted. The
pisiform bone may be atypical in position, although this does not correlate
with reported site of concern. Mild degenerative change is seen at the first
carpometacarpal joint.
Right thumb: No acute fracture or dislocation is seen. No concerning
osteoblastic or lytic lesion is seen. No osseous destruction is seen to
suggest acute osteomyelitis radiographically.
IMPRESSION:
No acute fracture. No radiographic findings to suggest acute osteomyelitis.
If clinical concern remains high, MRI is more sensitive.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: R Thumb pain
Diagnosed with Other synovitis and tenosynovitis, right hand
temperature: 98.7
heartrate: 74.0
resprate: 16.0
o2sat: 100.0
sbp: 141.0
dbp: 72.0
level of pain: 10
level of acuity: 4.0 | BRIEF SUMMARY STATEMENT:
==============================
Ms ___ is a ___ woman with dementia, prior GNR septic
arthritis of the knee, HTN, and T2DM who presented with right
thumb pain, received arthrocentesis by hand team in the ED, and
was admitted due to concern for possible septic joint. She was
treated initially with Vancomycin & Ceftriaxone, and Hand
Surgery was consulted due to concern for septic arthritis.
However, cultures were negative, and joint was not inflamed or
erythematous, so septic arthritis was thought to be unlikely.
Pain thought to be secondary to tendonitis, so patient was
started on NSAIDS. Antibiotics were discontinued after her dose
on ___. She was evaluated by OT, who fitted her for a splint
and recommended outpatient OT & 24-hour care at home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
post-operative worsening abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo G1P0 who is 8 days (___) s/p lsc LSO at ___
with Dr ___, MD for torsion presents today with
increasing abdominal pain. Pain suboptimally controlled since
surgery due to patient's history of IVDU, receives monthly
naltrexone so really only taking motrin & tylenol. However,
pain increasing daily and now ___. Feeling warm/flushed at
home with chills but has not taken temp. Initially had some
vaginal bleeding that has resolved, no abnormal/prurulent
discharge. No significant N/V and is moving bowels normally.
Does endorse sensation of incomplete emptying of bladder but no
dysuria. Saw Dr ___ for f/u who gave Rx for ceftriaxone
and recommended presentation to ED.
Op note obtained and to summarize:
post op dx: left adnexa with mass, edema, no viable tissue with
pelvic adhesions
procedure: lsc LOA and LSO
findings: nl right adnexa, nl uterus, left adnexa with sig
adhesions to pelvic sidewall, uterus and colon. left tube and
ovary (once freed) very edematous, no viable tissue, appeared
necrotic. floseal used.
Past Medical History:
Ob/gyn hx: TAB x1 with D&C. LMP 2 weeks ago, regular q28 days
without sig pain, no dyspareunia. Not using contraception,
sexually active with one male partner. ___ hx STDs or abnl
Pap.
PMHx: IVDU (heroin, last use 2mo ago then went to detox),
depression, aniety, PTSD, migraines
PSHx: D&C, lsc LOA/LSO as above
Social History:
___
Family History:
non-contributory
Physical Exam:
On admission:
VS: 98.4 93 123/64 18 100%
NAD but flushed and appears to be in pain
RRR
CTAB
abd soft, ND, incisions well-healed, very TTP in RLQ, no R/G
no appreciable masses
no edema
---
On the day of discharge:
Afebrile, vital signs within normal limits
Gen: no acute distress, well appearing
CV: RRR
Pulm: CTAB
Abd; soft, non-tender to palpation, non-distended, no rebound or
guarding
Ext: no calf tenderness, no edema
Pertinent Results:
___ 07:10PM BLOOD WBC-11.3* RBC-4.62 Hgb-13.7 Hct-42.2
MCV-91 MCH-29.8 MCHC-32.6 RDW-13.6 Plt ___
___ 07:10PM BLOOD Neuts-74.8* Lymphs-17.5* Monos-4.3
Eos-2.7 Baso-0.6
___ 06:57AM BLOOD WBC-7.9 RBC-3.78* Hgb-11.3* Hct-35.1*
MCV-93 MCH-30.0 MCHC-32.3 RDW-13.4 Plt ___
___ 06:57AM BLOOD Neuts-71.5* ___ Monos-4.8 Eos-3.1
Baso-0.5
___ 10:45AM BLOOD WBC-8.3 RBC-3.77* Hgb-11.5* Hct-34.8*
MCV-92 MCH-30.6 MCHC-33.2 RDW-13.5 Plt ___
___ 07:00AM BLOOD WBC-7.8 RBC-3.83* Hgb-11.5* Hct-34.9*
MCV-91 MCH-30.2 MCHC-33.1 RDW-13.7 Plt ___
___ 06:57AM BLOOD ___ PTT-31.2 ___
___ 07:10PM BLOOD Glucose-81 UreaN-13 Creat-0.7 Na-136
K-4.3 Cl-101 HCO3-26 AnGap-13
___ 06:57AM BLOOD Glucose-92 UreaN-11 Creat-0.7 Na-139
K-4.1 Cl-107 HCO3-25 AnGap-11
___ 07:10PM BLOOD ALT-50* AST-44* AlkPhos-87 TotBili-0.1
___ 06:57AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.8
___ 07:00AM BLOOD HIV Ab-NEGATIVE
___ 06:57AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
___ 06:57AM BLOOD HCV Ab-NEGATIVE
___ 07:26PM BLOOD Lactate-1.3
---
CT A&P WITH CONTRAST ___
INDICATION: ___ female with recent left-sided
oophorectomy for ovarian torsion, now with worsening pelvic
pain. Evaluate for abdominal and pelvic pathology.
COMPARISON: None available.
TECHNIQUE: Axial helical MDCT images were obtained from the
lung bases to the pubic symphysis after administration of IV and
oral contrast. Coronal and sagittal reformations were
generated.
DLP: 443.32 mGy-cm.
FINDINGS: The imaged lung bases are clear and the visualized
heart and pericardium are unremarkable.
CT ABDOMEN: The liver enhances homogeneously, without focal
lesions or intrahepatic biliary duct dilatation. The
gallbladder is unremarkable and the portal vein is patent. The
pancreas, spleen, and adrenal glands are within normal limits.
The kidneys demonstrate symmetric nephrograms and excretion of
contrast. There are no focal renal lesions bilaterally. The
small and large bowel are normal without wall thickening or
dilatation to suggest obstruction. The appendix is visualized
and does not appear inflamed. There is no mesenteric or
retroperitoneal lymphadenopathy. The aorta is no aneurysmal.
The main intra-abdominal vessels are grossly patent. There is
no abdominal free air or abdominal wall hernia.
CT PELVIS: There is a moderate amount of mildly complex free
fluid in the pelvis, mostly accumulating in the right lower
pelvis with associated significant peritoneal enhancement and
stranding in the anterior aspect of the lower hemipelvis
(significant image 2:73) suggestive of inflammatory process.
Withing the fluid there is a 2-cm right ovarian cyst with
enhancing walls, likely a corpus luteal cyst. There is no pelvic
wall or inguinal
lymphadenopathy. No organized fluid collection is present.
OSSEOUS STRUCTURES: There are no lytic or blastic lesions
concerning for malignancy.
IMPRESSION: Moderate amount of mildly complex fluid in the
pelvis with peritoneal enhancement but no organized collection
mostly localized to the the right lower hemipelvis with
associated stranding in the anterior lower pelvis may reflect
post surgical changes with inflammation, but infection cannot be
excluded.
---
PELVIC ULTRASOUND ___
HISTORY: ___ woman postop day 10 status post
laparoscopy for left salpingo-oophorectomy for ovarian torsion.
Persistent abdominal pain right lower quadrant with small fluid
collection in the right hemipelvis. Assess for any drainable
collections.
COMPARISON: Recent CT abdomen from ___.
FINDINGS:
Both transabdominal and endovaginal ultrasound scanning was
performed.
Partially distended urinary bladder is unremarkable. The
anteflexed uterus measures 8.7 x 3.5 x 5.2 cm. The endometrium
measures 0.9 cm, likely related to patient's menstrual cycle.
The right ovary measures 3.8 x 2.2 x 2.8 cm demonstrating a few
follicles and follicular cysts. There is a ill-defined 4.2 x
2.6 x 7.2 cm heterogenous attenuation material in the cul-de-sac
extending from the left adnexa, most in keeping with blood
products. No
vascularity is identified in the color Doppler evaluation.
Small amount of free fluid is identified in the left adnexa
however no drainable loculated collections are seen.
IMPRESSION:
Heterogenous avascular material in the cul-de-sac extending from
the left adnexa, consistent with clotted hemorrhage, related to
recent surgery. No loculated drainable pelvic collections
identified.
Medications on Admission:
1. Naltrexone monthly (got shot 2 weeks ago)
2. Gabapentin 400mg TID
3. Celexa 20mg daily
4. Vistaril 50mg daily prn
5. Clonidine 0.1 daily
6. Seroquel 50mg qhs
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
Do not take >4000mg acetaminophen in 24 hrs.
RX *acetaminophen 500 mg ___ tablet(s) by mouth four times daily
Disp #*50 Tablet Refills:*1
2. Citalopram 20 mg PO DAILY
3. CloniDINE 0.1 mg PO DAILY
4. Gabapentin 600 mg PO TID
The dose is now ___ three times daily.
RX *gabapentin 600 mg 1 tablet(s) by mouth three times daily
Disp #*45 Capsule Refills:*1
5. HydrOXYzine 50 mg PO HS
6. Ibuprofen 600 mg PO Q6H:PRN pain
Take with food to avoid GI upset.
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*50 Tablet Refills:*1
7. Levofloxacin 500 mg PO Q24H
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth daily
Disp #*10 Tablet Refills:*0
8. Lorazepam 1 mg PO Q6H:PRN pain
RX *lorazepam 0.5 mg 1 tablet by mouth up to four times daily
Disp #*10 Tablet Refills:*0
9. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times daily Disp #*15 Tablet Refills:*0
10. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every 8
hours Disp #*10 Tablet Refills:*0
11. QUEtiapine Fumarate 50 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Infected pelvic hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman postop day 10 status post laparoscopy for left
salpingo-oophorectomy for ovarian torsion. Persistent abdominal pain right
lower quadrant with small fluid collection in the right hemipelvis. Assess
for any drainable collections.
COMPARISON: Recent CT abdomen from ___.
FINDINGS:
Both transabdominal and endovaginal ultrasound scanning was performed.
Partially distended urinary bladder is unremarkable. The anteflexed uterus
measures 8.7 x 3.5 x 5.2 cm. The endometrium measures 0.9 cm, likely related
to patient's menstrual cycle. The right ovary measures 3.8 x 2.2 x 2.8 cm
demonstrating a few follicles and follicular cysts. There is a ill-defined
4.2 x 2.6 x 7.2 cm heterogenous attenuation material in the cul-de-sac
extending from the left adnexa, most in keeping with blood products. No
vascularity is identified in the color Doppler evaluation. Small amount of
free fluid is identified in the left adnexa however no drainable loculated
collections are seen.
IMPRESSION:
Heterogenous avascular material in the cul-de-sac extending from the left
adnexa, consistent with clotted hemorrhage, related to recent surgery. No
loculated drainable pelvic collections identified.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, OTHER POST-OP INFECTION, ABN REACT-SURG PROC NEC
temperature: 98.4
heartrate: 93.0
resprate: 18.0
o2sat: 100.0
sbp: 123.0
dbp: 64.0
level of pain: 8
level of acuity: 3.0 | On ___, Ms. ___ presented to the emergency department,
complaining of worsening abdominal pain, in the setting of
having undergone emergent surgery (laparoscopic left
salpingo-oophorectomy and lysis of adhesion) for a left ovarian
torsion 8 days prior at an outside hospital.
Her labs demonstrated a mild leukocytosis. Her exam was notable
for significant right lower quadrant tenderness to palpation. A
CT scan demonstrated mildly complex fluid in the pelvis with
peritoneal enhancement but no organized collection mostly in the
right lower hemipelvis with extension into the left with
associated stranding. All together, her clinical presentation
was concerning for an early post-operative infection, so the
decision was made to admit her to the gynecology service for
further evaluation and treatment.
She was started on IV antibiotics (levaquin and flagyl).
Radiology was consulted for consideration of drainage of the
pelvic fluid visualized on CT, however, given her stable vital
signs and unclear picture, the decision was made to proceed with
non-interventional management and to monitor her clinically on
IV antibiotics. Over the course of hospital day ___, her pain
slightly improved. She remained afebrile with normal vital signs
and a non-acute abdomen. On hospital day 2, she underwent a
pelvic ultrasound that demonstrated heterogenous avascular
material in the cul-de-sac extending from the left adnexa,
consistent with clotted hemorrhage, related to recent surgery,
with no loculated drainable pelvic collections identified.
For her pain control, she was started on standing tylenol and
toradol, ativan 1mg q4h prn, increased on her home medication of
gabapentin to 600mg TID, and continued on her home meds of
hydroxyzine, clonidine, seroquel, with moderate improvement in
her pain.
On hospital day 2, she was transitioned to oral antibiotics
(levaquin, flagyl). She was discontinued of all IV pain
medications and transitioned to standing ibuprofen instead of
toradol. Her ativan dosing frequency was decreased to q6h. She
continued to experience improvement in her abdominal pain and
reported significant improvement by hospital day 3.
She was discharged home on hospital day 3 in improved condition,
with a presumed diagnosis of post-operative pelvic hematoma
concerning for infection, improved on antibiotics. She was
discharged home on a 10 day course of antibiotics, with the
above pain regimen, in overall stable condition. Close follow-up
with gynecology and her home psychiatrist was arranged. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ M w a PMHx of L parietooccipital
hemorrhage secondary to left transverse and sigmoid sinus
thrombosis who was admitted to the stroke service on ___ -
___ after presenting with garbled speech and several
generalized seizures. He was discharged home with good
improvements and was actually seen by Dr. ___ in clinic on
___. Mr. ___ presents this evening after an episode
of right arm shaking and worsening confusion.
Mr. ___ is severely aphasic and the majority of the
history is provided by his wife. She states that this evening
around 6PM, her husband went upstairs to the bathroom. He began
to complain of feeling "not right" and "weak". He was unable to
take off his clothes and was having difficulty communicating and
understanding her. She then noticed that he was holding his
right arm slightly away from his body, with the elbow bent and
then right hand "clawed." She states that he then had ___
minutes of low amplitude, high frequency shaking of the right
hand. She called EMS and Mr. ___ was transported to
___. EMS note that at the time of their arrival, Mr.
___ was following simple commands, but had significantly
slowed speech. Upon arrival to ___, his speech was noted
to be slurred and he had severe word-finding difficulties with
nonsensical speech. At 9:30PM, he had another episode of right
arm shaking. His wife states that this time the shaking was
higher amplitude, involved the proximal arm, and was painful to
her husband. He was given 1mg ativan IV with resolution of the
event. At that point, his wife asked for transfer to ___ ED -
as this is where Mr. ___ receives much of his care.
Upon arrival to ___, Mr. ___ has no more shaking of the
RUE but is significantly aphasic with decreased speech output
and poor comprehension. His wife states that this is far from
his baseline, and that his aphasia had been steadily improving
since his discharge in ___. Dr. ___ note from
___ states: "He is receiving outpatient speech therapy.
Overall, he has noted significant improvement in his speech and
is now able to carry out short conversations."
Past Medical History:
- left transverse and sigmoid sinus thrombosis ___ - ___
-- c/b L parietooccipital hemorrhage
-- and p/w garbled speech and several generalized seizures
- HTN
- s/p bilateral hip replacement
- inguinal hernia repair
- s/p R wrist surgery for carpal tunnel
- s/p prostate surgery for BPH
- elevated anticardiolipin IgM at 24.2
-- negative ACA IgG, negative beta-2 glycoprotein IgG
Social History:
___
Family History:
- father: multiple small strokes, prostate cancer, colon cancer
- brother: + lupus anticoagulant
- mother: liver cancer in mother, prostate
Physical ___:
ADMISSION EXAM:
T97.5 HR70 BP147/71 RR16 Sat98%RA
GEN - elderly M, lying covered in bed, appears comfortable
HEENT - NC/AT, MMM
NECK - full ROM, no meningismus
CV - RRR, no M/R/G appreciated
RESP - normal WOB, CTAB
ABD - soft, non-tender, non-distended
EXTR - cool, but good capillary refill
Neurological Examination
MS - eyes open spontaneously, attends to examiner, smiles, but
is unable to participate fully in examination; oriented to name,
___ "second week" "14", not oriented to place, unable to
follow simple commands without visual and physical cueing; when
asked a question will respond with a non-sequitor: "I feel some
problem with the... the...". Decreased naming with high
frequency objects ("finger" for thumb). Response time latency is
increase. Speech production is sparse and slow. Voice is quiet.
Apraxia when asked to "brush your teeth" and "salute", even with
miming.
CN - unable to appreciate previously noted right superior
quadrantanopsia, though testing is severely limited due to
aphasia and comprehension; PERRL, EOMI with R>L end gaze
nystagmus, speech is quiet but not dysarthric or slurred, face
is symmetric at rest and with activation, tongue is midline and
with full movements, palate elevates symmetrically
MOTOR - increased tone vs paratonia in RUE; unable to appreciate
deficits on confrontational strength testing but he does subtly
orbit around the RUE
SENSORY - reacts to light touch in all extremities, more
detailed exam is complicated by aphasia
REFLEXES - 2+ in B/L UEs, 2 at patellars, 0 at ankles, toes are
down bilaterally
COORD - no evidence of gross ataxia, but again, formal
coordination testing is limited by aphasia and apraxia
GAIT - deferred
DISCHARGE EXAM:
Neurologic:
Mental status:
Alert, attentive but perseverative. Speech is fluent in
___. Anomia of low and high frequency objects.
Comprehension is intact to midline and appendicular commands but
not cross-body commands. He is quite apraxic when performing
coordination examination maneuvers.
Otherwise unchanged.
Pertinent Results:
ADMISSION LABS (___):
7.1 > 15.2 / 44.2 < 140
Neuts-69.1 ___ Monos-7.1 Eos-2.6 Baso-0.4
___ PTT-38.4* ___
138 | 99 | 20
-----------------< 98
4.3 | 27 | 1.0
cTropnT-<0.01
Valproate-68
Serum and Urine tox screens negative
UA: bland
UCx: <10,000 organisms/ml.
IMAGING:
MR ___ head (___): Report
IMPRESSION:
1. New region of slow diffusion within the left occipital and
left temporal lobe with corresponding T2/FLAIR signal
hyperintensity consistent with late acute/ early subacute
infarction. Chronic blood products in the region are better
appreciated. Intrinsic cortical T1 signal hyperintensity within
this region likely reflects micro hemorrhage versus laminar
necrosis.
2. Persistent thrombosis of the left transverse sinus, left
sigmoid sinus, and left jugular bulb/proximal left internal
jugular vein. Collateral venous channels are identified.
ANTICOAGULATION:
___ 11:15PM BLOOD ___ PTT-38.4* ___
___ 01:15PM BLOOD ___ PTT-36.0 ___
___ 04:54AM BLOOD ___ PTT-38.4* ___
___ 04:56AM BLOOD ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Valproic Acid ___ mg PO Q8H
4. Warfarin 8 mg PO DAILY16
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Warfarin 8 mg PO DAILY16
4. Enoxaparin Sodium 80 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 80 mg SC twice a day Disp #*14
Syringe Refills:*3
5. LeVETiracetam 750 mg PO BID
RX *levetiracetam 250 mg 3 tablet(s) by mouth twice a day Disp
#*180 Tablet Refills:*3
6. Outpatient Speech/Swallowing Therapy
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
cerebral venous sinus thrombosis
Seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN
INDICATION: Known history of venous thrombosis.
TECHNIQUE: MRI of the head was performed without contrast appear MRV of the
brain was performed without contrast.
COMPARISON: Prior MRI dated ___ P.
FINDINGS:
MRI head: New from prior study, there is extensive restricted diffusion in the
left occipital and left temporal lobe. There is extensive corresponding
increased T2/FLAIR signal within both the cortex and white matter of this
region. There is intrinsic T1 signal hyperintensity in also noted within the
left temporal lobe and left occipital lobe cortex within this same region
likely reflecting micro hemorrhage or laminar necrosis. Ventricles and sulci
are within normal limits for age. There is nonspecific T2/FLAIR signal
hyperintensity again noted in the periventricular white matter. There is
susceptibility artifact again noted on gradient echo images in the left
occipital and left temporal lobes which appears similar to prior study
consistent with previously noted hemorrhage within this region. There is no
evidence of mass effect or shift of midline. There is no extra-axial fluid
collection. Vascular flow voids are unremarkable. The orbits are unremarkable.
There is opacification of anterior ethmoid air cells. The remaining paranasal
sinuses and mastoid air cells are clear appear.
MRV: There is thrombosis of the left transverse sinus, left sigmoid sinus, and
left jugular bulb/ left proximal internal jugular vein similar to prior study.
Extensive venous collaterals are again noted in the left parietal, occipital,
and temporal regions. Normal flow signal is demonstrated within the superior
sagittal sinus, straight sinus, right transverse sinus, right sigmoid sinus,
and right internal jugular vein. Evaluation of the deep venous systems reveals
normal flow signal in the thalamostriate veins and internal cerebral veins.
The vein ___ is also unremarkable.
IMPRESSION:
1. New region of slow diffusion within the left occipital and left temporal
lobe with corresponding T2/FLAIR signal hyperintensity consistent with late
acute/ early subacute infarction. Chronic blood products in the region are
better appreciated. Intrinsic cortical T1 signal hyperintensity within this
region likely reflects micro hemorrhage versus laminar necrosis.
2. Persistent thrombosis of the left transverse sinus, left sigmoid sinus,
and left jugular bulb/proximal left internal jugular vein. Collateral venous
channels are identified.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with seizure // r/o infection r/o infection
COMPARISON: Chest radiographs ___.
IMPRESSION:
Low lungs are fully expanded and clear. Extrapleural fat deposition projects
posterior to the sternum. Cardiomediastinal and hilar silhouettes are normal
and there is no pleural effusion.
Radiology Report
EXAMINATION: MR HEAD W/ CONTRAST
INDICATION: ___ year old man with venous sinus thrombosis here with seizure //
please obtain MRI of the brain with contrast
TECHNIQUE: A MRI of the brain was performed with intravenous contrast only.
COMPARISON: Prior MRI dated ___.
FINDINGS:
The ventricles and sulci are normal in caliber and configuration. There is
increased signal noted within the cortex of the left occipital and left
temporal lobe in the region of known infarction. However, intrinsic T1 signal
hyperintensity was seen within this region on recent noncontrast MRI and
therefore this is felt more likely to reflect micro hemorrhage or laminar
necrosis rather than enhancement. No definite enhancing lesions are
identified. The bilateral hippocampi appear symmetric in size and signal.
There is no evidence of mass effect or shift of midline. There is no
extra-axial fluid collection. Thrombosis of the left transverse sinus, left
sigmoid sinus, and left jugular bulb is again noted. Remaining vascular flow
voids are unremarkable. The orbits are unremarkable. Opacification of anterior
ethmoid air cells is again noted. The remaining paranasal sinuses and mastoid
air cells appear clear.
IMPRESSION:
1. Increased cortical signal in the left temporal and left occipital lobe.
Intrinsic T1 signal was seen in this region on recent prior noncontrast MRI of
the head and therefore this is felt more likely to reflect laminar necrosis or
micro hemorrhage rather than enhancement. No enhancing lesions are seen.
2. Unchanged thrombosis of the left transverse sinus, left sigmoid sinus, and
left jugular bulb.
Gender: M
Race: PORTUGUESE
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with MUSCSKEL SYMPT LIMB NEC, OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY
temperature: 97.5
heartrate: 70.0
resprate: 16.0
o2sat: 98.0
sbp: 147.0
dbp: 71.0
level of pain: 0
level of acuity: 1.0 | ___ was admitted to the Stroke Neurology service for
evaluation of his breakthrough seizures. MRI/MRV of the head
demonstrated that his left sagittal venous sinus thrombosis was
unchanged in extent, and he had a new L parieto-occipital area
of diffusion restriction which was attributed to his persistent
thrombus. There was no other evidence of seizure triggers; his
depakote level was therapeutic and he had no signs of infection.
Prior to admission, his INR had been stable on a dose of
Coumadin 8 mg daily. On admission he was mildly supratherapeutic
at 3.1 mg. He missed one dose and his INR dropped to 1.6. He was
started on a lovenox bridge. Given the evidence of labile INR,
his other medications were reviewed. Given the interaction
between depakote and coumadin, he was switched from depakote to
levetiracetam. He received a loading dose of levetiracetam and
was started on 750 mg BID. He had no further seizures. He was
discharged in stable condition with home OT and outpatient
speech therapy.
TRANSITIONS OF CARE
-------------------
- Continue lovenox bridge until INR therapeutic
- Follow INR; coumadin dose may need to be adjusted since
depakote was stopped.
- MRI/MRV in ___ weeks, then follow up with Dr. ___ in Stroke
___ Clinic. The need for anti-edema therapy or
substitution of warfarin with lovenox will be considered if MRI
continues to reveal progression. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L leg weakness and falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ old right-handed man with a past medical
history of HTN, IDDM, CAD s/p CABG, CKD, and NASH cirrhosis who
presents with left lower extremity weakness and frequent falls.
Beginning in ___, Mr. ___ noticed that when we would
walk, his left leg would give out from under him and he would
collapse to the ground. He started to use a cane to walk, never
having used an assistive device before. Unfortunately, the
weakness progressed and he began to fall more frequently,
currently falling ___ times per week. He denies head strike.
He was seen by his PCP ___ for this issue, who recommended ___
and obtained an x-ray of his knee and lower spine. Spine x-ray
was notable for degenerative changes of the L-sine. Knee x-ray
was notable for mild patellofemoral arthritis. He been
participating with ___ since ___ but has noticed progression of
symptoms despite this.
Of note, he was evaluated for right leg pain on ___ in the ED
characterized by " R leg pain for 3 weeks. It is right ankle
pain
that extends up to the thigh. He currently has right lateral
thigh pain. It is worse at night. It is worse when he is lying
in
bed. There is no chest pain or shortness of breath. There is no
lower extremity edema. There is no fever or chills. There is no
redness or rash. There is no weakness or back pain or neurologic
symptoms. No loss of bowel or bladder function." At that time he
had full strength in both legs. This was felt to be possible RLS
and he was given Tramadol and told to follow-up with his PCP.
Currently, he right leg pain is resolved, but reports new left
leg pain and thigh pain. There are two separate types of pain he
reports, the first begins in his left ankle, and is a sharp,
burning pain, which shoots up to his left knee. The pain lasts
about 5 minutes and then subsides. He will get this pain a few
times, per day, mostly with sitting or standing and the pain is
relieved by walking. He also has a throbbing pain in his left
lateral thigh, which also occurs with rest, lasts for 5 minutes
at a time and is relieved with walking, but he feels they occur
separately and are distinct pains. Both began in ___. He
reports
occasional low back pain, but none recently and no pain with
radiation into the leg. No bowel or bladder symptoms.
At baseline he has numbness in the toes without extension into
the foot, but this is a chronic issue.
He presented to the ED today another fall at home.
He has an initial visit with neurology scheduled for ___ with
Dr. ___ this issue.
Past Medical History:
CAD status post CABG in ___ for angina.
- Hypertension.
- Dyslipidemia ___ TC 115, ___ 128, LDL 54, HDL 36).
- Type 2 diabetes ___, A1c 6.3%).
- CKD stage IV.
- ___ complicated by cirrhosis
- Gout
- OSA
- Colonic polyps
Social History:
___
Family History:
No neurologic disease
Physical Exam:
ADMISSION:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple.No nuchal rigidity
Pulmonary: Nonlabored breathing
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: Mild ___ edema.
Skin: scattered bruises and abrasions over bilateral elbows and
knees
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects except
hammock which he said "you sleep in it." Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Pt was able to register 3
objects.
-Cranial Nerves:
II, III, IV, VI: PERRL 3mm, irregular and post-surgical. EOMI
without nystagmus. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to snap, but not finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Atrophy of bilateral lower extremities, L > R and
proximally more than distally. No pronator drift bilaterally.
Fasciculations in b/l quads.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___ ___
L 5 ___ ___ 1 4+ 5 5 5
R 5 ___ ___ 5 5 5 5 5
Everstion left 5
Inversion left 5
-Sensory: hyperestesia to pinprick in the L2 dermatome,
otherwise
normal. Proprioception intact.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 -- 1
R 2 2 2 -- 1
Difficulty assessing bilateral patellas due to abrasions over
knee, patient would not relax and would not allow me to test
there due to pain.
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF bilaterally.
-Gait: Stands with pressure on right leg. Able to take short,
small steps with the cane with multiple steps to turn. Narrow
based. Romberg positive.
DISCHARGE:
Discharge exam not significantly changed except noted areflexia
in patellar and Achilles reflexes
Pertinent Results:
___
There is no evidence of acute territorial infarction,
hemorrhage, edema, or
mass. There is mild prominence of the ventricles and sulci
suggestive of
involutional changes. Minimal periventricular white matter
hypodensities are
nonspecific but likely reflect the sequela of chronic
microvascular
infarction. Mild atherosclerotic calcifications are noted
involving the
cavernous carotid arteries.
There is no evidence of fracture. A well-circumscribed lucent
lesion in the
right frontal bone (03:28) is unchanged from ___ and appears
nonaggressive.
The visualized portion of the paranasal sinuses, mastoid air
cells, and middle
ear cavities are clear. The visualized portion of the orbits
are
unremarkable.
IMPRESSION:
No acute intracranial abnormality.
___ ___ contrast
1. Lumbar spondylosis, most pronounced at L3-L4 with moderate to
severe canal
narrowing as well as bilateral subarticular zone narrowing.
2. Foraminal narrowing most pronounced at L5-S1 level and
moderate-to-severe
left and moderate right foraminal narrowing is seen.
3. No acute fracture or traumatic subluxation.
___ Pelvis w/ and ___ contrast
No abnormality seen along the course of the sacral plexus nerve
roots.
Muscular edema possibly from strain or inflammation.
___ Thoracic Spine ___ contrast
. Focal anterior displacement of the cord at T6/T7 with mass
effect on the
dorsal aspect of the cord and widening of the dorsal CSF space,
may be
secondary to a dorsal thoracic arachnoid web versus tiny
arachnoid cyst.
2. No underlying cord signal abnormalities are identified.
Medications on Admission:
AMLODIPINE - amlodipine 10 mg tablet. 1 tablet(s) by mouth every
evening for blood pressure - (Prescribed by Other Provider)
ATORVASTATIN [LIPITOR] - Lipitor 40 mg tablet. 1 tablet(s) by
mouth once a day/pm
COLCHICINE [COLCRYS] - Colcrys 0.6 mg tablet. 1 tablet(s) by
mouth every day for gout ;Name ___ Only
___ [ULORIC] - Uloric 40 mg tablet. 1 Tablet(s) by mouth
daily to prevent gout flairs
HYDROCORTISONE - hydrocortisone 2.5 % topical ointment. use once
a day to itchy rash on left arm for next week, dont use on other
areas of body once a day
INSULIN GLARGINE [LANTUS] - Lantus 100 unit/mL subcutaneous
solution. ___t bedtime
INSULIN LISPRO [HUMALOG KWIKPEN] - Humalog KwikPen 100 unit/mL
subcutaneous. use as per sliding scale to treat blood sugars
before breakfast, lunch, bedtime
LIDOCAINE - lidocaine 5 % topical ointment. use for 12 hrs on
thigh and 12 hrs off prn pain
LISINOPRIL - lisinopril 20 mg tablet. 1 tablet(s) by mouth every
evening
LOSARTAN - losartan 100 mg tablet. 1 Tablet by mouth once a day
METOPROLOL SUCCINATE - metoprolol succinate ER 100 mg
tablet,extended release 24 hr. 1 tablet extended release 24
hr(s)
by mouth daily for blood pressure and heart THIS REPLACES THE
ATENOLOL PILLS
NITROGLYCERIN - nitroglycerin 0.4 mg sublingual tablet. 1
Tablet(s) sublingually every ___ minutes x 3 as needed for
chest
pain. If no relief after 3 call ___
RING RELIEF EAR DROPS - ring relief ear drops . to right ear
bid
or as directed as needed - (Prescribed by Other Provider)
ROLLATOR ___ - rollator ___ . use as directed ICD 10
(GAIT INSTABILITY) R 26.9 fax ___ tel# ___
ROLLATOR ___ OR TRANSPORT CHAIR - rollator ___ or
transport
chair . use as directed due to gait instability ICD10 code
R26.0
TEST STRIPS - test strips . use as directed to check blood
sugars 3 times a day *pt is insulin dependent diabetic*
Medications - OTC
ALCOHOL SWABS [ALCOHOL PADS] - Alcohol Pads. 7 times a day
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by
mouth daily - (Dose adjustment - no new Rx)
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - FreeStyle Lite
Strips. USE AS DIRECTED TO CHECK BLOOD SUGARS 3 TIMES A DAY
CALCIUM CARBONATE - calcium carbonate 200 mg calcium (500 mg)
chewable tablet. 1 Tablet(s) by mouth twice a day as needed for
indigestion - (On Hold from ___ to unknown for
hypercalcemia)
DOCOSANOL [ABREVA] - Abreva 10 % topical cream. 5 times a day
topically as directed as needed for cold sore
FISH OIL-DHA-EPA [FISH OIL] - Fish Oil 1,200 mg-144 mg-216 mg
capsule. 1 Capsule(s) by mouth once a day
INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE ULT-FINE II] -
BD Insulin Syringe Ult-Fine II 1 mL 31 gauge x ___. Use once
daily as directed with Lantus insulin. Name ___ Only
LANCETS ___ SOFTCLIX LANCETS] - ___ Softclix
Lancets. use to obtain blood sample to test your blood sugar
twice a day or as directed
LANCETS [FREESTYLE LANCETS] - FreeStyle Lancets 28 gauge. CHECK
BLOOD SUGAR 3 TIMES A DAY
MULTIVITAMIN - multivitamin tablet. 1 Tablet(s) by mouth once a
day
PEN NEEDLE, DIABETIC [BD INSULIN PEN NEEDLE UF SHORT] - BD
Insulin Pen Needle UF Short 31 gauge x ___. Use three times a
day with humalog kwikpen
VITAMIN E - vitamin E 400 unit capsule. 2 Capsule(s) by mouth
once a day
Discharge Medications:
1. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth Three times daily
Disp #*90 Capsule Refills:*2
2. TraMADol 25 mg PO Q12H:PRN Pain - Severe
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*2
3. ___ 1 unknown unit miscellaneous DAILY
RX ___ [Ultra-Light Rollator] Use daily for ambulation
Daily Disp #*1 Each Refills:*0
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Calcium Carbonate 500 mg PO BID
8. Colchicine 0.6 mg PO DAILY
9. ___ 40 mg PO DAILY
10. Glargine 60 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Lisinopril 20 mg PO DAILY
12. Losartan Potassium 100 mg PO DAILY
13. Metoprolol Tartrate 50 mg PO BID
14. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Lower Motor Neuron Disease in Left Leg
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ___
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST ___ MR SPINE
INDICATION: ___ year old man with LLE weakness and falls // eval for
radiculothy, spinal disease eval for radiculothy, spinal disease
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: L-spine radiographs from ___
FINDINGS:
There is no evidence of fracture, or traumatic subluxation. The bone marrow
signal is unremarkable. Mild diffuse disc desiccation is seen throughout the
lumbar spine. No cord signal abnormalities are identified. The conus
terminates at T12/L1.
L1-L2: Mild disc bulge is seen. There is no significant neural foraminal or
spinal canal narrowing.
L2-L3: There is no significant spinal canal or neural foraminal narrowing.
There is mild bilateral facet joint arthropathy and ligamentum flavum
hypertrophy.
L3-L4: Central disc bulge, facet joint osteophytes, and ligamentum flavum
arthropathy contribute to moderate to severe canal narrowing at this level as
well as bilateral subarticular zone narrowing. There is buckling of the nerve
roots cranial to this area of stenosis. Mild bilateral neural foraminal
narrowing is seen.
L4-L5: Ligamentum flavum hypertrophy and facet joint osteophytes contribute
to mild to moderate spinal canal narrowing at this level. Moderate neural
foraminal narrowing is seen bilaterally.
L5-S1: Central disc bulge, facet joint and ligamentum flavum arthropathy
results in mild spinal canal narrowing. There is moderate-to-severe left and
moderate right neural foraminal narrowing seen.
No paraspinal or paravertebral soft tissue abnormalities are identified.
IMPRESSION:
1. Lumbar spondylosis, most pronounced at L3-L4 with moderate to severe canal
narrowing as well as bilateral subarticular zone narrowing.
2. Foraminal narrowing most pronounced at L5-S1 level and moderate-to-severe
left and moderate right foraminal narrowing is seen.
3. No acute fracture or traumatic subluxation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with fall // eval for 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 16.0 s, 16.1 cm; CTDIvol = 49.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___, MR brain ___
FINDINGS:
There is no evidence of acute territorial infarction, hemorrhage, edema, or
mass. There is mild prominence of the ventricles and sulci suggestive of
involutional changes. Minimal periventricular white matter hypodensities are
nonspecific but likely reflect the sequela of chronic microvascular
infarction. Mild atherosclerotic calcifications are noted involving the
cavernous carotid arteries.
There is no evidence of fracture. A well-circumscribed lucent lesion in the
right frontal bone (03:28) is unchanged from ___ and appears nonaggressive.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: MR THORACIC SPINE W/O CONTRAST T9421 MR ___ SPINE
INDICATION: ___ year old man with worsening LLE weakness and pain. Please
evaluate.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: None.
FINDINGS:
Spinal labeling has been provided on series 4, image 9. Alignment is normal.
Vertebral body and intervertebral disc signal intensity appear normal aside
from mild diffuse disc desiccation. There is no evidence of neural foraminal
narrowing.
At C6/C7, there is a focal area of displacement of the spinal cord with slight
mass effect on the posterior cord and widening of the dorsal CSF space. No
underlying cord signal abnormalities are identified. No other paraspinal or
paravertebral soft tissue abnormalities are seen.
IMPRESSION:
1. Focal anterior displacement of the cord at T6/T7 with mass effect on the
dorsal aspect of the cord and widening of the dorsal CSF space, may be
secondary to a dorsal thoracic arachnoid web versus tiny arachnoid cyst.
2. No underlying cord signal abnormalities are identified.
Radiology Report
INDICATION: ___ year old man with atrophy of leg muscles, fasciculations //
Eval for Compressive lesions
TECHNIQUE: T1- and T2-weighted multiplanar images of the pelvis (sacral
plexus) were acquired in a 1.5 T magnet.
Intravenous contrast: 7 mL Gadavist.
COMPARISON: None.
FINDINGS:
Image quality somewhat degraded by motion.
No mass lesions along the course of the sacral plexus. Nerve roots making up
the sacral plexus demonstrate normal signal, caliber, and course.
Mildly increased signal on STIR images noted within the left adductor and
obturator muscles, left iliopsoas, and gluteus minimus and medius muscles
without associated enhancement, likely reflecting muscle strain or other
inflammation.
No bone marrow signal abnormality.
Incidental note made of prostomegaly and colonic diverticular disease.
IMPRESSION:
No abnormality seen along the course of the sacral plexus nerve roots.
Muscular edema possibly from strain or inflammation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: s/p Fall, L Knee injury
Diagnosed with Weakness
temperature: 97.7
heartrate: 71.0
resprate: 18.0
o2sat: 100.0
sbp: 155.0
dbp: 76.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ presented with weakness in proximal left lower
extremity as well as frequent falls and associated pain. Upon
admission, he was continued on his home medications and received
pain medication regimen for left leg pain including Gabapentin.
He underwent MRI of Thoracic and Lumbar spines as well as MRI
pelvis which showed some disc bulging with some nerve root
contact. Laboratory workup was seen to be negative for
infectious or autoimmune cause of symptoms. Due to appearing
stable, patient was deemed able to be discharged from the
hospital with close follow up and outpatient physical therapy. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Percocet /
Gantrisin
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with HLD, OA and anxiety who presents with pleuritic chest
pain and RUQ pain. Chest pain located right chest near the
costomargin, worse with deep breath and cough. Denies
association with food. Denies shortness of breath. Patient had
subjective fever and cough since ___. Cough nonproductive.
Denies nasuea, vomiting, tolerating PO intake.
In the ED, initial VS were: 98.2 92 112/67 18 95% RA. Labs
notable for a mildly elevated lipase to 72, otherwise nl.
Initial CXR showed a wedge-shaped opacity concerning for
pulmonary infarction. She subsequently underwent a CTA chest
which showed no PE but demonstrated a RUL/RML PNA. She was given
500mg Levofloxacin and one dose of Vicodin. RUQ US was
unremarkable.
On arrival to the floor, patient feels well and wants to know
when she can go home. Continues to have mild pleuritic chest
pain. Denies shortness of breath, palpitations.
REVIEW OF SYSTEMS:
(+) per HPI
(-) chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, shortness of breath, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
-Anxiety
-Osteoarthritis
-Chronic back pain
-Hyperlipidemia
-H/o melanoma
-S/p appendectomy
-Ovarian cyst
-Melenola s/p excision
-s/p Appy
Social History:
___
Family History:
non-contributory
Physical Exam:
VS - Temp 97.7F, BP 118/74, HR 78, R 18, O2-sat 99 % RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, steady gait
Pertinent Results:
___ 02:40AM BLOOD WBC-10.3 RBC-3.83* Hgb-12.3 Hct-36.4
MCV-95 MCH-32.3* MCHC-33.9 RDW-12.7 Plt ___
___ 02:40AM BLOOD Neuts-83.3* Lymphs-10.1* Monos-4.9
Eos-1.6 Baso-0.1
___ 02:40AM BLOOD ___ PTT-35.7 ___
___ 02:40AM BLOOD Glucose-107* UreaN-14 Creat-0.8 Na-136
K-4.9 Cl-103 HCO3-20* AnGap-18
___ 02:40AM BLOOD ALT-20 AST-41* AlkPhos-79 TotBili-0.3
___ 02:40AM BLOOD Lipase-72*
___ 02:40AM BLOOD Albumin-3.7
.
___ CXR
IMPRESSION: Right upper lobe peripheral wedge-shaped opacity
may represent pneumonia, but raises the possibility of pulmonary
infarction. If clinically indicated, CTA could be performed for
further evaluation.
.
___ RUQ U/S
IMPRESSION: Normal liver and gallbladder.
.
___ CTA Chest (Prelim read)
IMPRESSION:
1. No acute aortic pathology or pulmonary embolism.
2. Right upper lobe opacity extending into the right middle lobe
is compatible with pneumonia. Two small adjacent nodules are
likely infectious. Right hilar and mediasintal lymphadenopathy
are likely reactive.
3. Segmental bronchial wall thickening, likely due to
inflammatory process.
4. Coronary artery calcifications.
5. 1cm right thyroid nodule could be further evaluated with
nonurgent ultrasound, if clinically indicated.
.
___ BCx - pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q8H:PRN pain
2. Lorazepam 1 mg PO HS
3. Simvastatin 40 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250
mg-mcg-mcg Oral Daily
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Lorazepam 1 mg PO HS
3. Simvastatin 40 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Levofloxacin 500 mg PO DAILY
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
6. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250
mg-mcg-mcg Oral Daily
7. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q8H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chest pain.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. A peripheral
wedge-shaped opacity in the right upper lobe is new from ___. No other
opacity is seen. There is no pleural effusion or pneumothorax. Heart size is
normal. Mediastinal silhouette and hilar contours are normal. No displaced
rib fracture is identified.
IMPRESSION: Right upper lobe peripheral wedge-shaped opacity may represent
pneumonia, but raises the possibility of pulmonary infarction. If clinically
indicated, CTA could be performed for further evaluation.
Findings were entered into the ED dashboard at 4:05 a.m., ___ upon study
interpretation.
Radiology Report
INDICATION: Right upper quadrant pain and pleuritic chest pain.
COMPARISON: CT ___.
FINDINGS: The liver shows no focal or textural abnormality. Doppler
assessment of the main portal vein shows patency and normal hepatopetal flow.
There is no intra- or extra-hepatic bile duct dilation. The common duct is
normal for patient's age, measuring up to 8 mm. The gallbladder is normal
without stones. The imaged portions of the pancreatic head and body are
normal, although the tail is not well seen due to overlying bowel gas. The
imaged portions of the IVC are normal. There is no ascites in the upper
abdomen.
IMPRESSION: Normal liver and gallbladder.
Radiology Report
INDICATION: ___ woman with chest pain. Prior radiograph concern for
pulmonary infarction. Evaluate for pulmonary embolism.
COMPARISON: Chest radiograph ___, CT ___.
TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed
using Omnipaque intravenous contrast. Images are presented for display in the
axial plane at 2.5-mm and 1.25-mm collimation. A series of multiplanar
reformation images are submitted for review.
FINDINGS:
CTA CHEST: The thoracic aorta is normal in caliber without evidence of
dissection. The pulmonary artery is normal in caliber. The pulmonary arterial
vasculature is well visualized to the subsegmental level without filling
defect to suggest pulmonary embolism. No pathologically enlarged axillary
lymph nodes are identified. Prominent mediastinal lymph nodes measuring up to
8 mm in the right lower paratracheal station (2:26) and 9 mm in the right
lower paratracheal station (2:34) are noted. Right hilar lymph nodes are
enlarged measuring 1.4 x 1.7 cm (2:39) and 1.5 x 1.9 cm (2:47), likely
reactive. Left hilar lymph nodes are not enlarged. Aside from coronary
artery calcifications in the LAD, the heart, pericardium, and great vessels
are within normal limits. There is no pericardial effusion. There is a small
right pleural effusion. A 1-cm nodule is seen in the right thyroid lobe.
A wedge-shaped peripheral opacity in the right upper lobe extending into the
right middle lobe is compatible with pneumonia. This extends to the pleura.
Bronchial thickening in the segmental bronchioles of all lobes. A 3-mm nodule
in the right apex (3:37) and a 6-mm nodule in the right upper lobe (3:45) are
likely related to the infection. Linear scarring or atelectasis is noted in
the lingula and lung bases bilaterally. Airways are patent to the
subsegmental levels bilaterally.
The imaged portions of the upper abdomen including the imaged liver, spleen
and adjacent splenule, pancreas, and bilateral adrenal glands are normal.
There is an accessory left hepatic artery from the left gastric artery.
BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.
IMPRESSION:
1. No acute aortic pathology or pulmonary embolism.
2. Right upper lobe opacity extending into the right middle lobe is
compatible with pneumonia. Two small adjacent nodules are likely infectious.
Right hilar and mediasintal lymphadenopathy are likely reactive.
3. Segmental bronchial wall thickening, likely due to inflammatory process.
4. Coronary artery calcifications.
5. 1cm right thyroid nodule could be further evaluated with nonurgent
ultrasound, if clinically indicated.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PAIN (NONCARDIAC FEATURES)
Diagnosed with CHEST PAIN NOS, SHORTNESS OF BREATH, PNEUMONIA,ORGANISM UNSPECIFIED
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ with OA, HLD and anxiety who presented with pleuritic chest
pain and was found to have a PNA on CXR and CTA.
#Community-acquired PNA: CURB-65 score is 1 (age) with low 30
day mortality. Patient was ruled out for PE. RUQ U/S done for
pain in that region and was negative for hepatobiliary process.
Started Levofloxacin 500mg daily for 7 day course to be
completed on ___.
#Anxiety: Continue lorazepam qHS
#Hyperlipidemia: Continue simvastatin
TRANSITIONAL ISSUES:
- f/u final read of CT chest
- CT chest showed thyroid nodules, recommend outpatient
ultrasound
- f/u BCx from ___
- complete 7 day course of Levofloxacin on ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Chest pain, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of COPD, HTN, seizures, carotid stenosis s/p
stent presenting with 1 week of productive cough, left sided
chest pain and chest tightness that is worse with coughing.
Patient endorses shortness of breath with exertion and fevers.
He tried albuterol and flovent at home without relief. Cough is
productive of green sputum, no hemoptysis. Chest pain is dull on
the left side of his chest. He denies previous episodes of COPD
exacerbation, but reports he was hospitalized at ___ for
bilateral lower lobe pneumonia requiring intubation and
ventilation for several weeks in ___ with an additional short
hospitalization in ___. Patient reports that he never fully
recovered from his prior hospitalization. He denies, abdominal
pain, N/V, lower extremity edema. He also complains of neck pain
which is chronic. Denies recent travel or long car rides/trips.
He has no history of DVT or PE.
Chart review ___ showed patient was
found down in the field in unresponsive, but breathing with slow
respirations thought to be due to opioid use. Patient was
intubated in the field and later found to have bilateral lower
lobe pneumonia thought to be secondary to aspiration. Patient
required intubation and ventilation for several days before
being extubated. Patient received course of vanc/zosyn.
In the ED, initial vitals:
97.5 |76 |138/81 |20 |100% RA
Labs were significant for lactate 1.0, negative tropX1, BNP 307,
WBC 6.5 VBG: pH 7.37, pCO2 51, pO2 30, HCO3 31
Imaging showed
CXR: No acute cardiopulmonary abnormality.
In the ED, he had he received duonebs with no relief, patient
given azithromycin 500mg and prednisone 60mg
EKG: NSR, LAD, no ST elevations or depressions
Vitals prior to transfer: 98.0 | 81 | 145/88 | 18 | 98% RA
Currently, patient reports that he continues to feel short of
breath and has fits of coughing. He continues to endorse some
fatigue. He denies chest pain currently.
Past Medical History:
Carotid Stenosis s/p stenting L carotid
HTN
Hypercholesterolemia
h/o seizure
cervical stenosis s/p surgery
COPD
Retina pigmentosa
anxiety
Alcohol abuse
Social History:
___
Family History:
Family history of early MI in mother at age ___.
Physical Exam:
ADMISSION EXAM
==============
VS: 97.4 | 161/100 | 98 | 16 | 99% RA
GEN: Alert, sitting in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Expiratory wheezes, quiet breath sounds throughout, mildly
increased expiratory phase.
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal,
action tremor which is chronic from neck surgery in ___.
DISCHARGE EXAM
==============
VS: 97.4 | 153/91 | 78 | 19 | 99% RA
GEN: Alert, sitting in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Expiratory wheezes, quiet breath sounds throughout,
prolonged expiratory phase. Slightly improved compared to
yesterday.
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal,
action tremor which is chronic from neck surgery in 1990s.
Pertinent Results:
ADMISSION LABS
==============
___ 03:05PM PLT COUNT-243
___ 03:05PM NEUTS-61.9 ___ MONOS-9.2 EOS-4.0
BASOS-0.5 IM ___ AbsNeut-4.05 AbsLymp-1.56 AbsMono-0.60
AbsEos-0.26 AbsBaso-0.03
___ 03:05PM WBC-6.5 RBC-4.62 HGB-13.5* HCT-40.6 MCV-88
MCH-29.2 MCHC-33.3 RDW-13.6 RDWSD-43.4
___ 03:05PM cTropnT-<0.01 proBNP-307*
___ 03:05PM estGFR-Using this
___ 03:05PM GLUCOSE-95 UREA N-12 CREAT-0.8 SODIUM-137
POTASSIUM-6.9* CHLORIDE-101
___ 03:14PM LACTATE-1.0
___ 04:18PM ___ PO2-30* PCO2-51* PH-7.37 TOTAL
CO2-31* BASE XS-1
___ 05:15PM K+-4.1
PERTINENT LABS
==============
___ 12:45AM BLOOD cTropnT-<0.01
DISCHARGE LABS
==============
___ 06:20AM BLOOD WBC-8.5 RBC-4.36* Hgb-12.9* Hct-38.5*
MCV-88 MCH-29.6 MCHC-33.5 RDW-13.5 RDWSD-43.5 Plt ___
___ 06:20AM BLOOD ___ PTT-26.5 ___
___ 06:20AM BLOOD Glucose-102* UreaN-14 Creat-0.6 Na-139
K-3.9 Cl-104 HCO3-24 AnGap-15
___ 06:20AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.1
MICRO
=====
___ 3:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING
=======
CXR ___: No acute cardiopulmonary abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
2. ALPRAZolam 0.5 mg PO TID:PRN anxiety
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
6. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN wheezing
7. LevETIRAcetam 500 mg PO BID
8. Lisinopril 40 mg PO DAILY
9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
10. Propranolol LA 160 mg PO DAILY
11. Simvastatin 40 mg PO QPM
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. ALPRAZolam 0.5 mg PO TID:PRN anxiety
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. LevETIRAcetam 500 mg PO BID
5. Lisinopril 40 mg PO DAILY
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
7. Propranolol LA 160 mg PO DAILY
8. Simvastatin 40 mg PO QPM
9. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Please take one puff, twice each day no matter what.
13. PredniSONE 60 mg PO DAILY Duration: 4 Days
Please take the full course, even if you begin to feel better.
14. Levofloxacin 750 mg PO DAILY Duration: 4 Days
Please take the entire course of antibiotic, even if you are
feeling better.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
COPD exacerbation
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 cough
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac, mediastinal and hilar contours are normal. Pulmonary vasculature is
normal. No focal consolidation, pleural effusion or pneumothorax is seen.
There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea
Diagnosed with Chest pain, unspecified
temperature: 97.5
heartrate: 76.0
resprate: 20.0
o2sat: 100.0
sbp: 138.0
dbp: 81.0
level of pain: 3
level of acuity: 2.0 | ___ with history of COPD, HTN, carotid stenosis s/p stent
presenting with 1 week of productive cough, SOB, left sided
chest pain and chest tightness that is worse with coughing
thought to be COPD exacerbation. Patient had negative cardiac
work-up including EKG NSR, without ischemic changes, negative
trops x2. Patient received azithromycin in the ED, which was
changed to levofloxacin for a 5-day course given his recent
hospitalization. Patient was also started on a PO prednisone for
a 5-day burst. Patient was also given albuterol nebs. Patient's
flovent was stopped and the patient was started on advair.
Patient did not have oxygen requirement at any time during
hospitalization and he was without respiratory distress. He had
significant expiratory wheezes on exam, which showed some
improvement during his hospitalization. Patient would likely
benefit from outpatient pulmonology for optimization of his COPD
treatment and PFTs.
Patient was continued on his home blood pressure, seizure,
anxiety, and pain medications with the exception of
cyclobenzaprine which was held.
TRANSITIONAL
============
- Prednisone 60mg PO QDay x5 days (d1 = ___
- Levofloxacin 750mg PO QDay x 5days (d1 = ___
- STOP fluticasone inhaler
- START fluticasone-salmeterol inhaler
- Patient may benefit from pulmonary follow up and PFTs, given
recent complicated hospitalization at ___.
- ___ and home safety evaluation by 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:
Rib Pain
Major Surgical or Invasive Procedure:
Bronchoscopy with Biopsy ___
History of Present Illness:
___ hx HTN, COPD, ___ who was referred to the ED with
complaints of chest pain, dyspnea and cough.
Patient originally presented to his PCP ___ with complaints
of worsening back pain ___. He has a hx of LBP from trauma but
none recently that would explain his acute change. His back pain
was associated with tingling radiating down the legs to his
knees. He also had c/o right shoulder pain waking him up at
night. He was found to have a positive straight leg test on the
left and decreased ROM in the shoulder. X-rays of the shoulder &
back were unremarkable. ___ was ordered and he was started on
etodolac and methocarbamol. He continued to have pain, so was
started on oxycodone. He represented to his PCP ___ with
continued back pain and new b/l ___ edema thought to be ___ CHF.
A L-spine MRI and CT was ordered and patient was started on
furosemide. Patient obtained CT on day of admission as
outpatient, noted to have multiple rib lesions/deformities as
well as a spiculated LUL nodule with hilar adenopathy concerning
for multiple myeloma vs multifocal metastatic disease. Patient
was contacted by PCP and was feeling worse so was referred to
the ED by his PCP for pain management and expediated workup.
In the ED, initial vitals: T98.8 P85 BP151/88 RR18 O2 sat 98%
RA. Patient continued to endorse feeling dyspneic w/mild cough,
left chest wall pain. Labs were notable for Hgb 13.6, Cr 0.8,
lactate 1.0. Patient was given dilaudid and admitted to medicine
for further evaluation.
On arrival to the floor, patient sitting comfortably but
uncofrtable with ambulation. Afebrile 97.7; 151/77; HR88; RR 18
93% RA. Patient complains of "sciatica" which has grown
progressively worse over past 2 months. Notes radiating tingling
pain mainly down R leg. No asscoiated weakness. Has some mild
low back pain. Chronic for ___ years but acutely worsened in
last 2 months. Also with significant sharp pain in L upper rib
and at base of R rib cage. Keeps patient awake at night. Ongoing
for 2 months. Has slept poorly for ~2 months.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No palpitations. No
nausea or vomiting. No diarrhea or constipation. No dysuria or
hematuria. No hematochezia, no melena.
Past Medical History:
Hypertension
COPD
Diastolic CHF
Social History:
___
Family History:
Father deceased at ___ from cancer. Mother died with ___
at ___. Multiple brothers and sisters living in ___, oldest
is ___. All healthy. No known Cancer.
Physical Exam:
ADMISSION PE:
Vitals: 97.7; 151/77; HR88; RR 18 93% RA, significant rib/back
pain
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear (upper dentures),
EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: mild barrel chested. Purse-lipped breathing but no
asscessory muscle use for breathing, diffuse inspiratory wheezes
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 cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, ambulates with discomfort
DISCHARGE PE:
Vitals: 98.2; 138/75; HR85; RR 18 94% RA, back pain, rib pain,
tolerable
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear (upper dentures),
EOMI
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: mild barrel chested. Purse-lipped breathing but no
asscessory muscle use for breathing, mild exp wheeze diffusely
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, no edema
Neuro: ___ strength upper/lower extremities, grossly normal
sensation, ambulates with discomfort
Pertinent Results:
ADMISSION LABS:
___ 03:30PM BLOOD WBC-7.4 RBC-4.20* Hgb-13.6* Hct-39.5*
MCV-94 MCH-32.4* MCHC-34.3 RDW-13.2 Plt ___
___ 03:30PM BLOOD Neuts-66.4 ___ Monos-7.3 Eos-2.7
Baso-0.2
___ 09:19AM BLOOD UreaN-18 Creat-0.9 Na-134 K-4.1 Cl-95*
HCO3-27 AnGap-16
___ 03:30PM BLOOD Albumin-4.2
___ 03:35PM BLOOD Lactate-1.0
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-8.4 RBC-3.94* Hgb-12.5* Hct-37.6*
MCV-95 MCH-31.8 MCHC-33.3 RDW-13.3 Plt ___
___ 05:30AM BLOOD Glucose-103* UreaN-14 Creat-0.7 Na-134
K-4.1 Cl-98 HCO3-28 AnGap-12
___ 05:30AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.0
MICRO: None
STUDIES/IMAGING:
ENDOBRONCHIAL ULTRASOUND-GUIDED TRANSBRONCHIAL NEEDLE
ASPIRATION, LEFT
INTERLOBAR MASS:
POSITIVE FOR MALIGNANT CELLS.
Consistent with adenocarcinoma.
A few clusters of tumor cells are present on cell block
preparation and are positive on immunostain
for TTF-1.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob, wheezing
3. Tiotropium Bromide 1 CAP IH DAILY
4. Carvedilol 3.125 mg PO BID
5. etodolac 400 mg oral BID:PRN pain
6. Furosemide 20 mg PO DAILY:PRN swelling
7. Methocarbamol 250-500 mg PO BID:PRN muscle spasm
8. OxycoDONE (Immediate Release) 5 mg PO BID:PRN severe pain
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob, wheezing
2. Carvedilol 3.125 mg PO BID
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Tiotropium Bromide 1 CAP IH DAILY
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides 8.6 mg 1 tab by mouth twice a day Disp #*60
Tablet Refills:*0
7. TraZODone 25 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth qHS:PRN
Disp #*30 Tablet Refills:*0
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
hold for sedation, RR<12
9. Nicotine Patch 14 mg TD DAILY
Remove patch at night.
RX *nicotine 14 mg/24 hour 1 patch daily once a day Disp #*14
Patch Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Lung Mass with Rib lesions
Secondary Diagnosis:
-Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI OF THE LUMBAR SPINE
INDICATION: ___ year old man with severe low back pain x 2 months, radiating
symptoms // ? any abnormality
TECHNIQUE: This is a limited study. Scout images and sagittal T2 weighted
images were obtained. Patient was unable to continue due to pain.
COMPARISON: None
FINDINGS:
The sagittal T2 weighted images demonstrate degenerative changes in the discs
from L2-3 through L5-S1 level with bulging at L2-3 and L4-5 levels. No
evidence of high-grade spinal stenosis is seen.
IMPRESSION:
Limited study with only sagittal T2 weighted images obtained demonstrates disk
bulging at L2-3 and L4-5 levels without high-grade spinal stenosis. Consider
repeat examination with sedation if clinically indicated for further
assessment.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with extrapleural lesions found on chest xray,
also c/o back pain // ? multiple myeloma or multifocal metastatic disease
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.
DOSAGE: TOTAL DLP 235mGy-cm
COMPARISON: Chest radiograph from ___.
FINDINGS:
The observed abnormalities on recent chest radiograph correspond to an
expansile destructive lesion involving the right sixth rib laterally, and a
similar process involving the left third anterior rib. Additional smaller
permeative lytic lesions are seen in multiple additional sites including
multiple bilateral ribs, sternum and vertebral bodies. Mild compression
deformities are present in the mid thoracic spine, and are similar to an older
chest radiograph of ___.
Within the lungs, a spiculated, 13 mm x 8 mm left upper lobe nodule is present
(image 99, series 4), as well as to irregularly marginated right upper lobe
nodules measuring 6 mm (42, 4) and 7 mm (39, 4). 3 mm lingular nodule adjacent
to major fissure is also demonstrated (124, 4). Lungs are otherwise remarkable
for moderate to marked emphysema. Diffuse bronchial wall thickening may
reflect coexisting chronic bronchitis. Incidental calcified granuloma is
present in the right middle lobe, as well as nonspecific scarring in the right
middle lobe, lingula and both lung bases. Focal retained secretions are
present within the proximal trachea.
Examination of the soft tissue structures of the thorax demonstrates
subcentimeter mediastinal lymph nodes which do not meet strict size criteria
for abnormal enlargement. Left hilar lymphadenopathy is present but difficult
to measure in the absence of intravenous contrast. Enlarged left hilar nodes
encase and narrow the left upper lobe bronchus approximately 1 cm beyond its
origin and also result in significant narrowing and irregularity of the
lingular bronchus with distal patency.
Heart size is normal, and focal coronary artery calcifications are present.
Exam was not tailored to evaluate the subdiaphragmatic region, but note is
made of diffuse vascular calcifications. 2 hypodensities measuring less than 1
cm within the liver (images 62 and 54, 2) are too small to accurately
characterize by CT. Fullness of both adrenal glands is present without a
definitive mass.
IMPRESSION:
1. Dominant lytic rib lesions account for the observed chest wall
abnormalities on recent chest radiography, and there accompanied by widespread
permeative bone lesions. These findings likely represent diffuse metastatic
disease considering the presence of coexisting left upper lobe and left hilar
abnormalities, but multiple myeloma could present with a similar imaging
appearance.
2. Spiculated 13 mm left upper lobe lung nodule is consistent with primary
lung malignancy and is associated with bulky left hilar lymph node enlargement
with narrowing and irregularity of left upper lobe and lingular bronchi.
Consider PET CT for more complete assessment.
3. Subcentimeter right upper lobe nodules are nonspecific but could
potentially represent synchronous primary neoplasms or inflammatory lesions.
NOTIFICATION: The impression above was entered by Dr. ___ on
___ at 09:55 into the Department of Radiology critical communications
system for direct communication to the referring provider.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea, Productive cough
Diagnosed with BONE & CARTILAGE DIS NOS, CHEST SWELLING/MASS/LUMP, HYPERTENSION NOS
temperature: 98.8
heartrate: 85.0
resprate: 18.0
o2sat: 98.0
sbp: 151.0
dbp: 88.0
level of pain: 6
level of acuity: 2.0 | ___ hx HTN, COPD, ___ who was referred to the ED with
complaints of chest pain, dyspnea and cough after completing
outpatient CT notable for LUL lesions and lytic bone lesions
concerning for metastatic disease.
# Chest pain/cough: felt to be ___ recently discovered lung
lesions, hilar adenopathy as well as rib lesions/deformities
noted on CT. Concern for metastatic cancer with lung primary.
Patient seen by interventional pulmonology. Underwent
bronchoscopy with biopsies. Results pending at time of
discharge. Controlled pain with PO dilauded this admission,
however patient often appeared hesitant to admit to pain and had
a low narcotic requirement. Discharged with 5mg Oxycodone
q4H:PRN, however he should continue to work on adequate pain
control with his PCP. Patient will also need to follow up with
the interventional pulmonology for final biopsy results as well
as to determine what type of oncologist he should see.
#Insomnia - patient reports poor sleep over the past several
months. Started on trazodone PRN for sleep this admission which
patient reports was helpful. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
simvastatin
Attending: ___.
Chief Complaint:
BRBPR, diarrhea, abd pain
Major Surgical or Invasive Procedure:
sigmoidoscopy by GI on ___
History of Present Illness:
Mr. ___ is a ___ M with HTN, HLD, myelodysplastic syndrome and
colonic adenoma in ___ who presents with 1 day of abdominal
pain, BRBPR, and diarrhea. He states that his symptoms started
yesterday morning when he woke up with abdominal pain that felt
like gas pains, sometimes sharp. Pt went to the bathroom to have
a BM to help relieve the gas and had BRBPR mixed with stool. He
thought it was perhaps due to hemorrhoids which he does not have
a history of, however then pt kept having BMs which were mostly
blood or blood and stool mix. Abd pain is located in RLQ
radiating to the suprapubic area. The patient had ___
___ two days ago (the day before his abd pain started). No
one else in the family ate the same food.
Pt notes that every time he took any PO intake including water
he felt the need to have a BM which was sometimes gas but
usually blood and stool mix. His abdominal pain improved with
BMs, and pt currently only has mild discomfort with palpation.
He denies any nausea, vomiting, fevers, chills, recent illness,
sick contacts, or travel. No pain with bowel movements, no
anorectal pain or discomfort. No history of similar episodes.
Patient does endorse decreased PO intake because he was afraid
to have more bloody BMs, as well as slight nasal congestion.
Takes a daily aspirin, not on any blood thinners. Patient's wife
mentions that her husband drinks a moderate amount on the
weekends. He says that he had a few brandy's 2 days ago.
In the ED, initial vs were: 98.7 ___ 18 100%.
Labs were remarkable for normal lactate, normal CBC, normal chem
with BUN of 9. CT abdomen pelvis was performed which showed
colitis in the distal colon. Guaiac was positive in the ED,
however there was no bright red blood on rectal exam. ACS was
consulted in the ED given the possibility of it being ischemic
in origin, however they felt no acute surgical issue was
present. Patient received 2L NS and was admitted to medicine.
Vitals on Transfer: 98.2 65 165/91 16 98% RA
On the floor, vs were: 98.3 140/90 64 18 100% on RA. He reports
LRQ/suprapubic discomfort. He says that he was very "gasy"
yesterday with multiple watery BM's that were bloody. He
describes the blood as bright red. He says that the abd pain was
crampy and "gasy" in nature and were relieved with BM's. He was
hungry but was afraid to eat d/t frequent BM's. The patient says
that he has ___ brandy's on the weekends and smokes ___ pack of
cigarettes daily. He does not take ibuprofen on a regular basis.
Past Medical History:
1. Remote history of melanoma
2. Recent pneumonia
Social History:
___
Family History:
Mother - Alive, no medical problems
Father - died in his sleep of unknown causes
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
============================
Vitals: T98.3 140/90 64 18 100% on RA
General: Alert, oriented, no acute distress, pleasant, grimaces
with movement involving lower abd quadrants
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, LRQ/suprapubic tenderness to palpation,
non-distended, bowel sounds hyperactive, no rebound tenderness
or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
Neuro: nonfocal
PHYSICAL EXAM ON DISCHARGE:
===========================
Vitals: 98.8 144/90 67 18 100% on RA
General: Alert, oriented, no acute distress, pleasant, grimaces
with movement involving lower abd quadrants
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, LRQ/suprapubic tenderness to palpation,
non-distended, bowel sounds hyperactive, no rebound tenderness
or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
Neuro: nonfocal
Pertinent Results:
LABS ON ADMISSION:
==================
___ 10:22AM LACTATE-1.4
___ 10:18AM GLUCOSE-110* UREA N-9 CREAT-0.8 SODIUM-136
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-28 ANION GAP-13
___ 10:18AM CALCIUM-9.7 PHOSPHATE-2.8 MAGNESIUM-1.9
___ 10:18AM WBC-6.8 RBC-4.29* HGB-13.5* HCT-43.7 MCV-102*
MCH-31.5 MCHC-30.9* RDW-14.2
___ 10:18AM NEUTS-43.6* LYMPHS-49.3* MONOS-4.0 EOS-2.4
BASOS-0.6
___ 10:18AM PLT COUNT-155
LABS ON DISCHARGE:
====================
___ 07:15AM BLOOD WBC-5.9 RBC-4.63 Hgb-14.5 Hct-47.2
MCV-102* MCH-31.3 MCHC-30.8* RDW-14.0 Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-102* UreaN-6 Creat-0.8 Na-141
K-3.8 Cl-103 HCO3-28 AnGap-14
___ 07:15AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.1
MICROBIOLOGY:
=============
DIARRHEA RESOLVED AND STOOL STUDIES WERE NEVER SENT
STUDIES:
==========
CT A/P ___:
1. Bowel wall thickening and fat stranding involving the
descending colon to the sigmoid colon concerning for
inflammatory/infectious/ischemic process, although the
distribution favors an ischemic etiology.
2. Diverticulosis without diverticulitis.
Sigmoidoscopy ___:
Sigmoid erythema consistent with very mild colitis. (biopsy)
Stool in the colonOtherwise normal sigmoidoscopy to splenic
flexure
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Pravastatin 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Pravastatin 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
ACUTE DIAGNOSES:
1. Colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Patient with a history of abdominal pain and bright red blood per
rectum, evaluate for diverticulitis.
COMPARISON: CT abdomen pelvis from ___.
TECHNIQUE: Axial helical MDCT scan of the abdomen and pelvis were obtained
following the intravenous administration of 130 cc of Omnipaque in a split
bolus technique. Oral contrast was not given. Multiplanar reformatted images
in coronal and sagittal axes were generated.
DLP: 321 mGy-cm
FINDINGS:
LOWER CHEST: Lung bases demonstrate mild dependent atelectasis but is
otherwise clear. The visualized portions of the heart and pericardium
unremarkable.
LIVER: The liver enhances homogeneously, without focal lesions or intrahepatic
biliary duct dilatation. The gallbladder contains small stones but is
otherwise unremarkable. The portal vein is patent.
PANCREAS: The pancreas does not demonstrate focal lesions, peripancreatic
stranding or fluid collection.
SPLEEN: Calcifications are again noted along the cortex of the spleen, likely
related to prior trauma. Otherwise, the spleen is homogeneous and normal in
size.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: Small hypodense lesions as seen in bilateral kidneys, too small to
fully characterize. The kidneys demonstrate symmetric nephrograms and
excretion of contrast. No pelvicaliceal dilatation or perinephric
abnormalities are present.
GI TRACT: The stomach, duodenum and small bowel are within normal limits,
without evidence of wall thickening or obstruction. There is bowel wall
thickening and fat stranding involving the descending colon to the sigmoid
colon with abrupt transition from normal to abnormal bowel at both the
proximal and distal ends. Scattered colonic diverticula are noted without
evidence of diverticulitis. The appendix is normal.
VASCULAR: The aorta demonstrates moderate atherosclerotic calcifications but
is of normal caliber without aneurysmal dilatation. The IVC and major
abdominal vessels are patent.
RETROPERITONEUM AND ABDOMEN: There is no retroperitoneal or mesenteric lymph
node enlargement. No ascites, free air or abdominal wall hernias are noted.
PELVIC CT: The urinary bladder and terminal ureters are normal. No pelvic
wall or inguinal lymph node enlargement is seen. There is no pelvic free
fluid. Note is made of bilateral small fat containing inguinal hernias.
OSSEOUS STRUCTURES: No blastic or lytic lesion suspicious for malignancy is
present.
IMPRESSION:
1. Bowel wall thickening and fat stranding involving the descending colon to
the sigmoid colon concerning for inflammatory/infectious/ischemic process,
although the distribution favors an ischemic etiology.
2. Diverticulosis without diverticulitis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with NONINF GASTROENTERIT NEC
temperature: 98.7
heartrate: 102.0
resprate: 18.0
o2sat: 100.0
sbp: 163.0
dbp: 106.0
level of pain: 3
level of acuity: 3.0 | Mr. ___ is a ___ yo M with a history of MDS, HTN, HLD, ___
and EtOH use and a colonic adenoma in ___ who presents with
BRBPR and abdominal discomfort found to have distal colitis.
#) Descending colon and sigmoid colitis: Patient's symptoms were
prominent for painful BRBPR with diarrhea that lasted about
24hrs. Diarrhea and BRBPR resolved shortly after
hospitalization. Unclear etiology but DDx include: vascular
(ischemic colitis likely given painful BRBPR and watershed zone
location of colitis on CT), infectious (dysentery likely given
flatulence/abd pain relieved by BM and BRBPR; however, no fever
or leukocytosis), and inflammatory/malignancy/anatomical less
likely given the presentation and CT findings. Inflammatory less
likely given age and presentation but Crohn's does have a
bimodal presentation; however, symptoms resolved quickly. Pt
does have risk factors for mesenteric atherosclerosis including
HTN, smoking, and dyslipidemia. The patient was seen and
evaluated by GI who thought etiology most likely ischemic
colitis vs. infectious. A sigmoidoscopy was performed by GI and
was notable for erythema consistent with colitis with unclear
etiology. Stool studies for infectious causes were sent and are
pending at time of discharge. An outpatient follow up was
arranged with PCP and GI for further work up.
#) HTN: Chronic. Patient was hypertensive on presentation. We
held lisinopril and aspirin in the setting of acute GI bleed.
#) HLD: chronic.
- continue pravastatin
#) MDS: Hematocrit remained stable throughout hospitalization.
No indication for acute intervention. We recommend outpatient
follow up.
#) ___ abuse: The patient smokes ___ ppd. We offered
nicotine patch. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abnormal MRI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old right-handed woman with a PMHx of
SLE and antiphospholipid syndrome on Coumadin and aspirin,
hypertension, and migraines who presents as a transfer from
___ with an abnormal MRI brain that demonstrates
abnormal DWI, ADC, and FLAIR signal in the left parietal region
as well as abnormal FLAIR signal in bilateral white matter
diffusely.
The MRI brain was obtained by her neurologist/rheumatologist
(Dr. ___ in ___ as a screening
study two weeks ago; she obtained it on ___ at 2pm, and Dr.
___ and asked her to go to the ED. She did not report
any neurologic symptoms that instigated the study.
Today, she reports ___ days of headache with right temporal
non-radiating pulsating pain with associated photophobia. No
phonophobia or N/V. The pain is constant, and she has been
taking Tylenol. She notes that she does not typically get
headaches, but she was diagnosed with migraines by Dr. ___ in
___, at which time she reported associated blurriness of
vision. Today, she also reports intermittent blurry vision and
diplopia that has been gradual in onset over the last week. This
worse on the right side of her vision, doesn't go away with
closure with either eye, she's not sure if worse far away or up
close. She denies loss of vision. She also notes that she has
been having difficulty pronouncing words and difficulty getting
words out, but this has been improving; her concentration has
also been poor for the last ___ weeks. She denies dysarthria,
neologisms, paraphasic errors, or difficulty concentrating
others.
Of note, she was diagnosed with two prior strokes (once in ___
or ___ and once in ___. Both of these were found
incidentally with imaging; she denies that any neurologic
deficits prompted the imaging.
On neuro ROS, the pt denies loss of vision, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus, and hearing
difficulty. Denies difficulties comprehending speech. Denies
focal weakness, numbness, and parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation,
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash
Past Medical History:
SYSTEMIC LUPUS ERYTHEMATOSUS
ANTIPHOSPHOLIPID SYNDROME
STROKE
MIGRAINES
MENORRHAGIA
HYPERTENSION
IRON DEFICIENCY ANEMIA
VITAMIN D DEFICIENCY
Social History:
Lives with mother and sister. Unemployed. No smoking, occasional
EtOH, no drugs. Highest level of schooling was some college.
Pre-stroke mRS
- Modified ___ Scale:
[x] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
Relative Status Age Problem Comments
Mother HYPERTENSION
DIABETES MELLITUS
Physical Exam:
Admission exam:
Vitals: T: 98.2F P: 84 R: 15 BP: 119/80 SaO2: 100RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. No nuchal rigidity.
Pulmonary: no work of breathing
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Neurologic:
Please see top of note for NIHSS.
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and most low frequency objects
(named "hand" instead of "glove" and "pine needle" instead of
cactus on stroke card). Able to read without errors (but slow
pace). Speech was not dysarthric. Able to follow both midline
and appendicular commands. Pt was able to register 3 objects and
recall ___ at 5 minutes ___ with categorical prompting, ___
with MC prompts). There was no evidence of neglect. She was
unable to identify numbers drawn on either hand on graphesthesia
testing.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: left NLFF
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 and tone. No pronation, no drift. No
orbiting with arm roll. No adventitious movements, such as
tremor, noted. No asterixis noted.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS.
-DTRs: diffusely brisk, no clonus, no spread, toes equivocal
-Coordination: No intention tremor, no dysdiadochokinesia noted.
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.
Discharge exam:
Vitals: T97.7, BP 130's/80's, HR 70, RR 15, ___ 97
Neurologic:
-Mental Status: Alert, awake, oriented x3, able to follow
command
"touch left thumb to right ear," continues with difficulty
reporting history and remembering past events.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm.
III, IV, VI: EOMI without nystagmus
V: Facial sensation intact to light touch.
VII: Facial droop improved, 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 and tone. No drift.
[Delt] [Bic] [Tri] [ECR] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
-Sensory: intact to touch
-Reflexes: diffusely brisk
-Coordination: finger to nose without tremor
-Gait: normal gait without ataxia
Pertinent Results:
___ 06:50PM PTT-60.7*
___ 12:07PM ___ PTT-135.4* ___
___ 10:00AM GLUCOSE-115* UREA N-11 CREAT-0.8 SODIUM-137
POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-22 ANION GAP-16
___ 10:00AM ALT(SGPT)-25 AST(SGOT)-27 LD(LDH)-226
CK(CPK)-65 ALK PHOS-63 TOT BILI-0.5
___ 10:00AM GGT-28
___ 10:00AM CK-MB-<1 cTropnT-<0.01
___ 10:00AM TOT PROT-6.7 ALBUMIN-3.7 GLOBULIN-3.0
CHOLEST-184
___ 10:00AM %HbA1c-5.0 eAG-97
___ 10:00AM TRIGLYCER-56 HDL CHOL-64 CHOL/HDL-2.9
LDL(CALC)-109
___ 10:00AM TSH-1.7
___ 10:00AM HBs Ab-Negative
___ 10:00AM RHEU FACT-<10 CRP-2.3
___ 10:00AM C3-81* C4-8*
___ 10:00AM HCV Ab-Negative
___ 10:00AM WBC-2.3* RBC-3.89* HGB-12.2 HCT-35.6 MCV-92
MCH-31.4 MCHC-34.3 RDW-12.7 RDWSD-42.5
___ 10:00AM NEUTS-66.5 ___ MONOS-10.6 EOS-1.8
BASOS-0.4 IM ___ AbsNeut-1.51* AbsLymp-0.46* AbsMono-0.24
AbsEos-0.04 AbsBaso-0.01
___ 10:00AM PLT COUNT-132*
___ 10:00AM ___ PTT-116.4* ___
___ 11:35PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:35PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:35PM URINE MUCOUS-RARE
___ 10:30PM URINE HOURS-RANDOM
___ 10:30PM URINE HOURS-RANDOM
___ 10:30PM URINE HOURS-RANDOM
___ 10:30PM URINE UHOLD-HOLD
___ 10:30PM URINE GR HOLD-HOLD
___ 10:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 09:30PM GLUCOSE-82 UREA N-14 CREAT-0.8 SODIUM-139
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-23 ANION GAP-15
___ 09:30PM estGFR-Using this
___ 09:30PM ALT(SGPT)-20 AST(SGOT)-23 ALK PHOS-65 TOT
BILI-0.4
___ 09:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:30PM WBC-2.7* RBC-4.22 HGB-13.6 HCT-39.1 MCV-93
MCH-32.2* MCHC-34.8 RDW-12.7 RDWSD-42.7
___ 09:30PM NEUTS-71.1* LYMPHS-17.9* MONOS-8.8 EOS-1.8
BASOS-0.4 AbsNeut-1.94 AbsLymp-0.49* AbsMono-0.24 AbsEos-0.05
AbsBaso-0.01
___ 09:30PM PLT COUNT-146*
___ 09:30PM ___ PTT-44.7* ___
MR head
IMPRESSION:
1. Chronic symmetric watershed infarcts involving bilateral
ACA/MCA/PCA border
zones are of unclear etiology. Normal appearance of the
extracranial carotid
and vertebral arteries and the large vessels of the circle of
___ on
subsequent CTA raises the possibility of small vessel disease in
the setting
of lupus and antiphospholipid syndrome as the underlying cause.
2. Acute left posterior parietal cortical infarction is likely
related to the
same process.
CTA head and neck
IMPRESSION:
1. Chronic symmetric bilateral ACA/MCA/PCA watershed infarct.
Acute left
posterior parietal cortical infarction is better appreciated on
the recent
MRI.
2. No hemorrhage.
3. Normal head and neck CTA.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydroxychloroquine Sulfate 300 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
6. Warfarin 12.5 mg PO DAILY16
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Hydroxychloroquine Sulfate 300 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Warfarin 12.5 mg PO DAILY16
8.Outpatient Physical Therapy
ICD 434
Pt needs ___
Department: NEUROLOGY
With: ___ ___
Building: ___ ___ Floor
Discharge Disposition:
Home
Discharge Diagnosis:
Ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ woman with lupus, abnormal MRI (in PACS) and on
coumadin. ? vasculitis or stenoses
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.4 mGy (Head) DLP = 2.7
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.4 mGy (Head) DLP = 2.7
mGy-cm.
4) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
5) Spiral Acquisition 4.8 s, 37.7 cm; CTDIvol = 31.0 mGy (Head) DLP =
1,166.2 mGy-cm.
Total DLP (Head) = 2,096 mGy-cm.
COMPARISON: ___ outside brain MRI
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Symmetric hypodensity and volume loss involving the ACA/MCA/PCA border zones,
consistent with chronic watershed infarcts. Acute left posterior parietal
cortical infarction is better appreciated on the prior MRI. There is no
hemorrhage. There is no mass effect or shift of normally midline structures.
The paranasal sinuses, mastoid air cells, middle ear cavities are clear. The
orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
The 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. Chronic symmetric bilateral ACA/MCA/PCA watershed infarct. Acute left
posterior parietal cortical infarction is better appreciated on the recent
MRI.
2. No hemorrhage.
3. Normal head and neck CTA.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Headache, Transfer
Diagnosed with Headache
temperature: 98.2
heartrate: 84.0
resprate: 15.0
o2sat: 100.0
sbp: 119.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | Patient with a known history of SLE with antiphospholipid
antibodies on Coumadin (non complaint due to menorrhagia) who
presents with a new left posterior parietal infarct. Location
is suggestive of a small embolus to the left inferior division
MCA. The CTA of her head and neck is normal and there is no
evidence of venous sinus thrombosis. She in addition has
extensive bihemispheric leukoaraiosis mostly subcortical, though
there are a few chronic appearing cortical infarcts in both
frontal lobes. Etiology is thought to be due Coumadin non
compliance. She was restarted on coumadin with a heparin bridge.
Rheum evaluated the patient and did not think that she is in
active flare up. Per Dr. ___ Ob-Gyn patient recently
had Sylar IUD placed. If patient continues to have heavy period
despite this next options would ___ IUD (although higher
hormones dose), or uterine artery embolization or hysterectomy.
Pt has follow up with neurology, PCP, rheum and ob gyn.
Of note patient was noted to have LDL 109, but refused statin.
She was seen by ___ who recommended outpatient ___.
******************* |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Weakness and falls at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ yo ___ man with h/o a fib,
insulin dependent DM type II, CKD stage III, bilateral DVT on
enoxaparin, and metastatic HER2 negative, BRCA1 mutated
esophageal adenocarcinoma s/p esophageal stent, currently on
treatment with FOLFOX with palliative intent who presents from
home with severe fatigue and frequent falls.
Per patient's wife patient has been increasingly fatigued and
has
had multiple falls at home over the last 2 to 3 weeks. At
baseline he has excellent performance status. Fatigue and falls
seem to start prior to his recent admission from ___. At
that admission, was thought symptoms were multifactorial
including progressive malignancy and severe protein calorie
malnutrition. He was last seen in ___ clinic on ___, where
patient completed C1D15 of FOLFOX treatment. At that time
patient's functional status was thought to be improved from two
weeks prior but there was concern over falls at home.
Over the last two days since his treatment, he has been so weak
that he has been having difficulty with ambulation. On the night
prior to admission, patient could harldy move from room to room
in his house due to weakness and his wife asked their son to
stay
over to help with care. Otherwise patient feels well. He states
he has been eating and drinking as best he can with the soft
food
diet and states his appetite has been good. No fever, chills,
nausea/vomiting, diarrhea, abdominal pain, shortness of breath,
chest pain, or ___ edema. Wife called the on-call
oncologist who recommended that patient may need admission to
rule out acute issues and be skilled for SNF vs. Rehab given
incrfeasingly difficulty for family to care for him at home
On arrival to the ED, patient was in no acute distress. Initial
labs were significant for a mild hyponatremia, baseline
creatinine, contraction alkalosis, and anemia. Pertinent
negative
include normal UA. EKG shows a-fib with LAD but no ischemic
findings. CXR with known bilateral pleural effusions but no
infiltrate. CT head without intracranial bleeding.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
- Progressively worsening dysphagia to solid foods since ___. Seen by his outside hospital PCP who referred to ENT.
Their
initial evaluation was unremarkable.
- ___: Esophagogram at outside hospital showed a bulky
mucosal mass in the distal esophagus measuring about 10 cm in
length. Referred to ___
___: EGD with EUS at ___ showed a fungating, ulcerated and
infiltrative circumferential non-bleeding 10 cm mass of
malignant
appearance at the lower third of the esophagus and
gastroesophageal junction.
T staging by EUS was atleast T3 with involvement of mucosa,
submucosa and the muscularis propria. 3 lymph nodes were noted
in
the the ___ region and 2 were noted in the
para-esophageal region.
- ___: PET/CT showed multifocal FDG avid lymphadenopathy with
FDG avid right basilar pulmonary nodule, lower esophageal mass,
and left adrenal nodule.
- ___: MRI head showed no intracranial metastatic disease
- ___: Biopsy of RP lymph node confirmed metastatic
adenocarcinoma consistent with GI origin
Molecular & IHC analysis showed absence of HER2 mutation and 0%
PD-L1 expression. NGS showed BRCA1 Q1756fs*74 mutation, along
with tp53 loss (R273H), STK11 loss exons ___, ARID2 R1273*,
GATA6
amplification, MCL1 amplification(equivocal) and RUNX1 loss
exons
___. The tumor was microsatellite status MS-stable and the tumor
mutation burden was low ___ Muts/Mb).
- ___: Re-staging with PET/CT showed worsening disease with
multiple enlarging pulmonary nodules with increasing FDG uptake,
multiple new intensely FDG avid hepatic metastases, and both new
and enlarging FDG avid retroperitoneal lymph nodes. Also seen
were new left greater than right bilateral pleural effusions.
PAST MEDICAL HISTORY (per OMR):
- Atrial fibrillation on warfarin
- DM type 2 on insulin
- CKD stage III
- Hyperlipidemia
Social History:
___
Family History:
- Mother: ___ cancer (age ___ y), ? ovarian cancer
- Sister: ___ cancer (dx in her ___
- Maternal aunt: ___ cancer
- ___ uncle: ___ breast cancer
- Maternal first cousin: ___ cancer
- Father: ___ cancer
- Has 2 healthy sons, 4 grand sons and 1 daughter
Physical ___:
=======================
___ PHYSICAL EXAM
=======================
Vitals: ___ 1806 Temp: 97.9 PO BP: 115/73 HR: 81 RR: 18 O2
sat: 97%
GENERAL: Pleasant elderly man with no acute distress
HEENT: PERRL, EOMI, MMM
NECK: No JVD, Supple
LUNGS: Decreased breath sounds at bases bilaterally. Upper lung
sounds clear to auscultation
HEART: Irregular rhythm, normal rate. No murmurs, rubs, gallops
ABD: Normal BS, Soft, non-tender, non-distended
EXT: 1+ ___ edema bilaterally.
SKIN: Warm, no rashes
NEURO: Alert and oriented x3. ___ flexor strength, 4+/5
extensor
strength in upper extremities. ___ strength in lower
extremities.
Normal finger to nose, negative Romberg.
ACCESS: PIV
========================
DISCHARGE PHYSICAL EXAM
========================
GENERAL: Pleasant elderly man with no acute distress
HEENT: PERRL, EOMI, MMM, anicteric sclear
NECK: No JVD, Supple
LUNGS: Decreased breath sounds at bases bilaterally. Upper lung
sounds clear to auscultation
HEART: Irregular rhythm, normal rate. No murmurs, rubs, gallops
ABD: Normal BS, Soft, non-tender, non-distended
EXT: 2+ b/l ___ edema, wrapped in ACE wrap
SKIN: Warm, no rashes
NEURO: unchanged from admission w/r/t AO, gross strength and
cerebellar testing.
ACCESS: PIV
Pertinent Results:
==============
ADMISSION LABS
==============
___ 11:29AM BLOOD WBC-5.3 RBC-2.70* Hgb-8.3* Hct-25.6*
MCV-95 MCH-30.7 MCHC-32.4 RDW-17.1* RDWSD-54.6* Plt ___
___ 11:29AM BLOOD Neuts-73.2* Lymphs-13.3* Monos-9.3
Eos-3.2 Baso-0.2 Im ___ AbsNeut-3.87 AbsLymp-0.70*
AbsMono-0.49 AbsEos-0.17 AbsBaso-0.01
___ 11:29AM BLOOD Plt ___
___ 11:29AM BLOOD ___ PTT-38.3* ___
___ 11:29AM BLOOD Glucose-172* UreaN-40* Creat-1.6* Na-132*
K-4.7 Cl-90* HCO3-30 AnGap-12
___ 11:29AM BLOOD Calcium-10.1 Phos-2.9 Mg-2.1
___ 11:35AM BLOOD Lactate-1.9
===============
DISCHARGE LABS
===============
___:13AM BLOOD WBC-7.6 RBC-2.63* Hgb-8.1* Hct-25.0*
MCV-95 MCH-30.8 MCHC-32.4 RDW-16.8* RDWSD-54.1* Plt ___
___ 06:13AM BLOOD Plt ___
___ 06:13AM BLOOD ___ PTT-77.6* ___
___ 06:13AM BLOOD Glucose-137* UreaN-17 Creat-1.2 Na-135
K-4.4 Cl-95* HCO3-27 AnGap-13
___ 06:13AM BLOOD Calcium-9.6 Phos-2.6* Mg-2.2
================
INTERVAL LABS
================
___ 05:08AM BLOOD Ret Aut-2.3* Abs Ret-0.06
___ 07:00PM BLOOD LMWH-1.27
___ 10:09PM BLOOD CK-MB-2 cTropnT-0.05*
___ 06:00AM BLOOD CK-MB-2 cTropnT-0.05*
___ 05:08AM BLOOD calTIBC-281 Ferritn-1171* TRF-216
___ 07:15AM BLOOD Osmolal-277
==================
IMAGING/PROCEDURES
==================
___ CXR
1. Small bilateral pleural effusions with associated basilar
atelectasis,
decreased on the right and similar on the left compared to
prior.
2. Lung nodules corresponding to known metastatic disease.
___ CT Head w/o contrast
There is no evidence of acute major infarction, hemorrhage,
edema, or discrete
mass. Mild prominence of the ventricles and sulci is consistent
with age
related involutional changes. No osseous abnormalities seen. The
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The orbits are
unremarkable.
IMPRESSION:
No acute intracranial process.
___ CTA CHEST
IMPRESSION:
-Right upper and lower lobe segmental and subsegmental pulmonary
emboli
without evidence of right heart strain.
-Large bilateral pleural effusions.
-Extensive thoracic and abdominal metastatic disease.
___ TTE
The left atrium is moderately dilated. Color-flow imaging of the
interatrial septum raises the suspicion of an atrial septal
defect, but this could not be confirmed on the basis of this
study. The estimated right atrial pressure is ___ mmHg. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). There is
no left ventricular outflow obstruction at rest or with
Valsalva. Right ventricular chamber size and free wall motion
are normal. There are three aortic valve leaflets. The aortic
valve leaflets are moderately thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
(___) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Bilateral pleural effusions are present. No
pericardial effusion is present. Mild symmetric left ventricular
hypertrophy with normal cavity size, and regional/global
systolic function. Restrictive left ventricular filling pattern.
Mild to moderate mitral regurgitation. Mild to moderate
tricuspid regurgitation. Moderate pulmonary artery systolic
hypertension.
Compared with the prior study (images reviewed) of ___,
there are now bilateral pleural effusions and regurgitation
appear slightly worse.
___ Bilateral LENIs
1. RIGHT LEG: Re-demonstration of thrombus within one of the
duplicated
femoral veins. There is no evidence of occlusion within the
popliteal vein.
However, there is now evidence of occlusion in a posterior
tibial vein and
gastrocnemius vein.
2. LEFT LEG: Re-demonstrated is occlusion of the left
gastrocnemius vein.
There is evidence of occlusion in the greater saphenous vein and
a posterior
tibial vein, which in comparison to the prior study appears to
be a new
finding.
3. Bilateral ___ cysts.
NOTIFICATION: The impression and recommendation above was
entered by Dr.
___ on ___ at 17:21 into the Department of
Radiology
critical communications system for direct communication to the
referring
provider.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 60 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. Allopurinol ___ mg PO DAILY
5. Enoxaparin Sodium 90 mg SC Q12H
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Glargine 4 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Enoxaparin Sodium 100 mg SC Q12H
2. Furosemide 40 mg PO DAILY
3. Glargine 4 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
5. Allopurinol ___ mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
===================
PRIMARY DIAGNOSIS
===================
Pulmonary Embolism
====================
SECONDARY DIAGNOSIS
====================
Falls
Anemia
Hyponatremia
Diastolic Heart Failure (HFpEF >70%)
Metastatic HER2 negative, BRCA1 mutated esophageal
adenocarcinoma (involving lower ___ of esophagus and GEJ)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with fatigue, falls, weakness// r/o PNA
COMPARISON: Chest radiograph ___
FINDINGS:
PA and lateral views of the chest provided.
Right PICC line terminates at the level of the right cavoatrial junction.
Esophageal stent is noted.
Small bilateral pleural effusions appear similar on the left side and
decreased on the right side compared to prior exam. No pneumothorax. There
is associated bibasilar atelectasis, improved on the right. Nodular opacities
seen throughout the lungs correspond to known metastases. Widening of the
superior mediastinum likely consistent with known adenopathy. Mild
cardiomegaly stable.
IMPRESSION:
1. Small bilateral pleural effusions with associated basilar atelectasis,
decreased on the right and similar on the left compared to prior.
2. Lung nodules corresponding to known metastatic disease.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall on lovenox// r/o sdh
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: MR head ___
Noncontrast head CT ___
FINDINGS:
There is no evidence of acute major infarction, hemorrhage, edema, or discrete
mass. Mild prominence of the ventricles and sulci is consistent with age
related involutional changes. No osseous abnormalities seen. The paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are
unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old man with mestastatic esophageal cancer, syncope and
now w/exertional hypoxemia// PE, significant lymphangitic spread/or
interstitial process, eval ?pericardial effusion
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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8
mGy-cm.
2) Stationary Acquisition 2.9 s, 0.2 cm; CTDIvol = 48.3 mGy (Body) DLP =
9.7 mGy-cm.
3) Spiral Acquisition 5.4 s, 35.1 cm; CTDIvol = 5.5 mGy (Body) DLP = 189.6
mGy-cm.
Total DLP (Body) = 201 mGy-cm.
COMPARISON: PET-CT dated ___ chest radiograph dated ___,
___
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level there are
filling defects within the right upper lobe segmental arteries, extending to
the subsegmental level (5:53, 52). Right lower lobar segmental pulmonary
embolus is also noted (5:87), also extending to the subsegmental level. The
main and right pulmonary arteries are normal in caliber, and there is no
evidence of right heart strain.
There is a dominant prevascular nodal mass (05:30), which measures to 3.4 x
2.2 cm other, smaller mediastinal lymph nodes (for example 5:68) are again
noted, and compatible with metastatic disease, as seen on recent PET-CT. The
thyroid gland is slightly heterogeneous. A punctate calcification is noted in
the lower pole of the left lobe (05:26) also seen on the prior study. There
has been interval stenting of the mid and distal esophagus.
There is no evidence of pericardial effusion. There are large bilateral
pleural effusions.
Re-demonstrated are numerous pulmonary nodules, not significantly changed in
size since the recent PET-CT, and compatible with widespread pulmonary
metastases (5:31, 35, 41, 92, 94, 106). The airways are patent to the
subsegmental level.
Limited images of the upper abdomen demonstrates extensive retroperitoneal
lymphadenopathy and nodularity, compatible with extensive metastatic disease.
Known hepatic lesions, and other mesenteric lymphadenopathy is not as well
demonstrated on this noncontrast enhanced study.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
-Right upper and lower lobe segmental and subsegmental pulmonary emboli
without evidence of right heart strain.
-Large bilateral pleural effusions.
-Extensive thoracic and abdominal metastatic disease.
NOTIFICATION: The findings were discussed with Dr. ___, M.D. by
___, M.D. on the telephone on ___ at 3:19 pm, 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with bilateral DVTs on lovenox but with new PE.
Concern for progression of DVT on lovenox// ? progression of DVTs
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Reference is made to the prior bilateral lower extremity
ultrasound dated ___. and distal aspects.
FINDINGS:
RIGHT LEG: There is normal compressibility and flow the right common femoral
vein. There is duplication of the right femoral vein. As before, one of the
duplicated right femoral veins is occluded at the mid and distal segments.
There is no evidence of occlusion of the popliteal vein, which is also
duplicated. There is occlusion of the lesser saphenous vein. There is normal
color flow and compressibility in the right peroneal veins. One of the
posterior tibial veins is non-compressible compatible with occlusion. In
addition, there is absence of color flow within the right gastrocnemius vein
compatible with occlusion. Re-demonstrated is ___ cyst within the right
popliteal fossa measuring up to 4.2 cm in longitudinal diameter, similar to
prior.
LEFT LEG: There is normal compressibility and flow in the left common femoral,
femoral and popliteal veins. As before, there is occlusion of the left
gastrocnemius vein. In addition, there is non-compressibility of the greater
saphenous vein distal to its bifurcation at the common femoral vein compatible
with occlusion. There is non-compressibility and lack of flow in a posterior
tibial vein on the left compatible with occlusion. A heterogeneous hypoechoic
lesion within the left popliteal fossa is felt to demonstrate a ___ cyst.
IMPRESSION:
1. RIGHT LEG: Re-demonstration of thrombus within one of the duplicated
femoral veins. There is no evidence of occlusion within the popliteal vein.
However, there is now evidence of occlusion in a posterior tibial vein and
gastrocnemius vein.
2. LEFT LEG: Re-demonstrated is occlusion of the left gastrocnemius vein.
There is evidence of occlusion in the greater saphenous vein and a posterior
tibial vein, which in comparison to the prior study appears to be a new
finding.
3. Bilateral ___ cysts.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 17:21 into the Department of Radiology
critical communications system for direct communication to the referring
provider.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: s/p Fall, Weakness
Diagnosed with Adult failure to thrive
temperature: 98.1
heartrate: 84.0
resprate: 20.0
o2sat: 98.0
sbp: 99.0
dbp: 43.0
level of pain: 0
level of acuity: 2.0 | ========
SUMMARY
========
Mr. ___ is an ___ yo ___ Jewish man with h/o a fib,
insulin dependent DM type II, CKD stage III, bilateral DVT on
enoxaparin, and metastatic HER2 negative, BRCA1 mutated
esophageal adenocarcinoma s/p esophageal stent, currently on
treatment with FOLFOX with palliative intent who presents from
home with severe fatigue and frequent falls at home likely
multifactorial including newly discovered PEs, progression of
known DVTs and new DVTs, deconditioning, weakness, anemia.
========================
ACUTE MEDICAL ISSUES
========================
#Right upper and lower lobe segmental and subsegmental pulmonary
emboli
#Bilateral lower ext DVTs, progression on lovenox
#Hypoxia
On admission patient underwent ambulatory sat given his recent
fall with syncopal-like description and was found to be
hypoxemic on exertion to 81%. He subsequently underwent a CTA
which showed right upper and lower segmental and subsegmental
PEs. This occurred despite patient being on lovenox 80mg BID for
bilateral DVTs. Factor Xa level, checks prior to next dose, was
elevated indicating patient is supratherapeutic on lovenox
dosing. He was transitioned to a heparin drip and bilateral
lower extremity venous ultrasound was obtained to assess clot
burden. Lower extremity ultrasound showed both progression and
new lower extremity DVTs. Hematology was consulted for guidance
in further anticoagulation management given concern for lovenox
failure. Recommendations per heme included several options that
all inherent risks associated with them. One option was to
increase his dose of Lovenox by 25% (1.25mg/kg) which is the
___ guideline recommendation for lovenox failure
(___), however, patient was supratherapeutic on factor
Xa testing on current lovenox dose and increasing dose would
greatly increase bleeding risk. Another option was to place a
vena cava filter and continue on lovenox on current dose but
would likely clot off filter given prothrombotic state. After
discussion with the patient and his family it was decided that
he would be discharged home on a slightly increased Lovenox dose
of 100mg BID given his risk of falling/bleeding and his weight
of 88kg (but very volume overloaded with ___ 3+ pitting edema).
He will continue close monitoring and ongoing treatment of his
malignancy.
#Falls
#Weakness
Most falls appear to be orthostatic in nature. ED labs notable
for SBP ___ where outpatient blood pressures were typically 120s
systolic. His blood pressure improved with IV fluids. However,
given his anemia, deconditioning, ongoing malignancy, and the
findings of pulmonary embolism, etiology of weakness and falls
likely multifactorial. ___ saw patient and recommended home with
services. Patient lives with his wife who has expressed growing
concern with her ability to care for patient at home by herself
and expressed a need for either 24 hour home health aid vs.
transitioning care to a long term care facility. He was
ultimately discharged with maximal home services and we
discussed private payment for home health aides.
# Metastatic HER2 negative, BRCA1 mutated esophageal
adenocarcinoma (involving lower ___ of esophagus and GEJ)
He has confirmed metastatic disease which showed BRCA1 mutation
(suspected to be germline) and loss of p53. He has progressive
metastatic disease in lung, liver, mediastinal and
retroperitoneal lymph nodes, which has overall increased on the
latest PET scan in ___ compared to the one in ___.
Until recently, he had an excellent performance status.
Currently being treated with first line FOLFOX with palliative
intent, after extensive discussions about his goals of care.
Prior to the functional decline leading to this admission,
patient wanted to try 2 treatment cycles and then assess for
response/progression. Per patient request, palliative care was
consulted to explore goals of care again following this setback.
In discussions with the patient and his family he states that
quality of life is more important to him than quantity and that
he would like to be around his family and at home if possible
for the remainder of his treatment. Plan is to follow-up with
oncology for the remainder of his chemotherapy and reassessment
as well as ongoing goals of care discussions.
#Anemia
Likely due to CKD and malignancy with contribution of iron
restricted erythropoiesis. Given onset in ___ days after last
chemo (___) makes chemo effect less likely. More likely is poor
hematopoiesis from chemo with ongoing chronic slow blood loss
anemia from
esophageal cancer, although there was no bleeding noted on CT
during this admission. Likely contributing to weakness as above.
Transfused 1U PRBC ___ with appropriate bump in in hgb and
remained stable throughout the rest of his admission.
# CKD
# Metabolic alkalosis
Baseline CKD with baseline Cr 1.5-1.7. Patient with persistent
metabolic alkalosis with bicarb of 30. Less likely contraction
as patient appears clinically hypervolemic and renal function
improving with home Lasix dose.
# Hyponatremia
Initially responsive to fluids but fluctuating between 132-134.
Suspect hypervolemic hyponatremia from CHF. Urine electrolyte
free water clearance is positive and hyponatremia continued to
improve with Lasix.
# Diastolic Heart Failure (HFpEF >70%)
Patient with significant lower extremity swelling that is
thought to be due to combination of HFpEF, DVT, and
malnutrition. No rales on exam and JVP not elevated making
exacerbation unlikely. While would be preferable to lower home
Lasix dose further given falls and concern for orthostasis as
above, patient also reported ongoing pillow orthopnea with
increase from 2 to 3 pillows in last week. Last echo ___ w/o
significant valvulopathy and only trivial/physiologic effusion.
Decreased home dose back to 40mg po Lasix and checked
orthostatics which were negative. Also monitored I/O, lytes, and
daily weights which remained stable.
# Type 2 DM
Continued on insulin glargine and ISS at home and liberalized
dietary restrictions to increase caloric intake and for patient
comfort.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with a history of
autoimmune
hepatitis and primary biliary cholangitis with resultant
cirrhosis and portal hypertension, who presents from urgent care
after a fall, with ___ showing a subarachoid hemorrhage.
Patient states that this morning she woke up feeling in her
usual
state of health. She went to a scheduled doctor's visit. On
return home, she started to feel generally ill, associated with
fatigue, feelings of being alternately warm and cold, and thinks
she may have had a fever. She noted a little difficulty
breathing, though no cough. Also noticed that her nose was
dripping. She reports that in the setting she was about to go
get
lunch with her sons when she lost her balance and fell. She
fell
backwards onto her buttocks, and then hit the back of her head.
She remained conscious throughout this event. No headaches,
nausea, or vomiting. Denies any chest pain or palpitations
prior
to this event. Following this event, she went to urgent care
where she was found to have a fever to 100.2. A head CT
revealed
a subarachnoid hemorrhage, and a chest x-ray showed concern for
pulmonary edema. She was therefore referred to the emergency
department.
Regarding her shortness of breath, patient states that this is
new this afternoon. She denies any chest pain. She states that
she has a history of a rapid heart rate, and does follow with a
cardiologist after a previous hospitalization. However, this is
not been an issue lately, and her heart rate normally runs in
the
___ - she monitors this daily. She has not had any leg
swelling.
She sleeps lying flat with a single pillow.
On review of records, patient is followed in liver clinic for
her
autoimmune hepatitis and primary biliary cholangitis with
cirrhosis. Her cirrhosis has remained well-compensated cirrhosis
without signs of HE, ascites or GI bleeding. She has been on
propranolol for esophageal varices and ursodiol.
In the ED:
Initial vital signs were notable for: T 97.6, HR 70, BP 104/54,
RR 16, 95% 2L NC
Exam notable for: neuro intact, atraumatic skeletal survey
Labs were notable for:
- CBC: WBC 6.7 (59%n, 13%m), hgb 13.7, plt 68
- Lytes:
141 / 107 / 19 AGap=12
-------------- 135
3.7 \ 22 \ 0.7
- LFTs: AST: 33 ALT: 23 AP: 143 Tbili: 0.6 Alb: 3.2
- trop <0.01
- proBNP 2234
- Lactate:1.5
- flu negative
Studies performed include: CXR with diffuse interstitial
abnormality which could represent mild pulmonary edema,
fibrosis,
or atypical infection. No definite focal consolidation within
the
limitations of extensive interstitial abnormality.
Consults:
- Neurosurgery, who on repeat exams found that patient remained
neurologically intact. No Keppra, no activity restrictions, no
NSURG follow-up indicated.
- Trauma surgery, with no concern for additional traumatic
injuries. No additional imaging indicated.
Patient was given:
___ 07:24 IV CefTRIAXone 1 gm
___ 07:25 IV Azithromycin 500 mg
___ 08:35 PO/NG Propranolol 20 mg
___ 10:11 PO Ursodiol 500 mg
Vitals on transfer: T 97.5, HR 72, BP 119/69, RR 18, 96% 2L NC
Upon arrival to the floor, patient recounts history as above.
She
is relieved to hear that the bleed was very small and that she
will not need surgery.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative
Past Medical History:
- Autoimmune hepatitis
- Primary biliary cholangitis
- Cirrhosis with portal HTN c/b esophageal/rectal varices
- OA
- Bradycardia
- Palpitations
- hypertension
Social History:
___
Family History:
- father - MI in his ___, ?aortic dissection
- mother - died in her ___
- cousin with autoimmune disease in the muscles
Physical Exam:
VITALS: T 98.0, HR 75, BP 145/77, RR 20, 93% 2L NC
GENERAL: Alert and in no apparent distress, speaking in full
sentences
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. JVP at clavicle at
60 degrees
RESP: Lungs with soft crackles at bases bilaterally. Breathing
is non-labored
GI: Abdomen soft, mildly distended, non-tender to palpation.
Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
EXT: wwp. Varicose veins present. No pitting edema.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 01:35AM BLOOD WBC-6.7 RBC-4.31 Hgb-13.7 Hct-42.1 MCV-98
MCH-31.8 MCHC-32.5 RDW-13.0 RDWSD-46.5* Plt Ct-68*
___ 01:42AM BLOOD ___ PTT-29.3 ___
___ 01:35AM BLOOD ALT-23 AST-33 AlkPhos-143* TotBili-0.6
___ 01:35AM BLOOD proBNP-2234*
___ 01:35AM BLOOD cTropnT-<0.01
___ 06:25AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.8
CXR:
FINDINGS:
The lungs are well inflated. There is diffuse interstitial
abnormality which could represent edema, fibrosis, or atypical
infection. No definite focal consolidation. There is moderate
cardiomegaly. The aorta is tortuous, but the mediastinal and
hilar contours are otherwise unremarkable. Mild-to-moderate
compression deformity of a midthoracic vertebra is of
indeterminate chronicity.
IMPRESSION:
1. Diffuse interstitial abnormality which could represent mild
pulmonary
edema, fibrosis, or atypical infection. No definite focal
consolidation
within the limitations of extensive interstitial abnormality.
2. Age indeterminate compression deformity of a midthoracic
vertebra.
Correlation with tenderness recommended to assess acuity.
ECHO:
IMPRESSION: Suboptimal image quality. Probable mild regional
wall motion abnormality suggestive of CAD and mild LV systolic
dysfunction. RV not well seen, RV function appears mildly
depressed in some views. Mild to moderate tricuspid
regurgitation and mild to moderate pulmonary hypertension.
RECOMMEND: If clinically indicated, a TTE with an endocardial
border definition agent (e.g. Lumason) is suggested for further
evaluation of EF and wall motion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Propranolol 20 mg PO BID
2. Ursodiol 500 mg PO BID
3. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 4 Doses
through ___
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
2. Cefpodoxime Proxetil 200 mg PO BID
through ___
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*4
Tablet Refills:*0
3. Propranolol 20 mg PO BID
4. Ursodiol 500 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
6.Rolling Walker
dx: unsteady gait
prognosis: good
length of need: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
Fall
Orthostasis
Subarachnoid hemorrhage
Abnormal CXR, atypical PNA vs interstitial PNA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with fall// eval PNA, pulm edema
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
The lungs are well inflated. There is diffuse interstitial abnormality which
could represent edema, fibrosis, or atypical infection. No definite focal
consolidation. There is moderate cardiomegaly. The aorta is tortuous, but
the mediastinal and hilar contours are otherwise unremarkable.
Mild-to-moderate compression deformity of a midthoracic vertebra is of
indeterminate chronicity.
IMPRESSION:
1. Diffuse interstitial abnormality which could represent mild pulmonary
edema, fibrosis, or atypical infection. No definite focal consolidation
within the limitations of extensive interstitial abnormality.
2. Age indeterminate compression deformity of a midthoracic vertebra.
Correlation with tenderness recommended to assess acuity.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, s/p Fall, SDH
Diagnosed with Traum subrac hem w/o loss of consciousness, init, Other fall on same level, initial encounter
temperature: 97.6
heartrate: 70.0
resprate: 16.0
o2sat: 95.0
sbp: 104.0
dbp: 54.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ yo woman with autoimmune hepatitis and
primary biliary cholangitis with resultant cirrhosis and portal
hypertension, who presented after a fall with small stable SAH
and diffuse pulmonary abnormality.
# Subarachnoid hemorrhage
# Orthostasis
# Fall
Patient presented following a fall, with Noncon head CT showing
a subarachnoid hemorrhage. She had been evaluated by
neurosurgery, who felt that no intervention wasrequired,
including no follow-up imaging or neurosurgery follow-up. Also
evaluated by trauma surgery with no need for additional imaging
per their recommendation. The fall appeared likely mechanical,
possibly triggered by respiratory illness or orthostasis. She
was mildly orthostatic on ___ eval but was asymptomatic from this
and possibly related to her propranolol
- No need for neurosurgery or trauma surgery follow-up
- ___ consult -> recommends outpatient ___ after DC
# Fever
# Presumed atypical PNA
# Acute hypoxic Respiratory failure
Patient reported feeling alternating hot and cold spells, and
was found to have a fever to 102 at urgent care. Other symptoms
included nasal congestion and some shortness of breath though
she denied these symptoms after presentation. She was not
clearly hypoxic but had a "new 02 requirement." CXR findings
raised concern for atypical infection, edema, fibrosis. PE was
felt unlikely. She was not volume overloaded on exam. Her 02
sat remained stable and she was asymptomatic. She was
prescribed antibiotic course for 5 days to exclude/treat
infection. TTE was ordered though CHF was felt less likely.
Echo did show EF 45-50% but was poor quality. Hypokinesis
suggested CAD, there was mild pulm HTN as well. Given that she
was asymptomatic and an alternative diagnosis to her CXR
findings was felt more likely, the decision was made to treat
for infection but no aggressively with any diuresis
- She should have follow up CXR in ___ weeks to document
resolution. If findings still present she should have CT scan
and pulm referral.
- Cardiology referral/follow up is recommended given echo
findings for consideration for further evaluation.
# Thrombocytopenia:
Plt 68 on admission. Per patient long-standing issue, and on
review of records was in the ___ in ___. Thought to be from
cirrhosis.
- continued to monitor
# Autoimmune hepatitis
# Primary biliary cholangitis
# Cirrhosis with portal HTN c/b esophageal/rectal varices
- continued home propranolol
- continued home urosodiol |