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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Ambien / flu shot
Attending: ___.
Chief Complaint:
R leg weakness
Major Surgical or Invasive Procedure:
none this admission
History of Present Illness:
CC: low back pain, right leg pain, RLE weekness 1 week s/p L4-S1
ALIF and PSF.
HPI: ___ with a long history of lumbar spine problems who is 1
week s/p L4-S1 ALIF and PSF for back pain and bilateral leg
weakness and numbness, worse on the right. She was discharged
from ___ ___ after a benign post-op course. She was at home
on ___ when she had difficulty getting off the couch and some
increased back pain. On ___ she had worsening back pain and a
sharp shooting pain down the lateral aspect of her right leg.
Her leg numbess never resolved after surgery but had been
getting better, on ___ it worsened. She was seen at ___
___ today where an MRI was performed and reportedly showed no
abnormalities, at that time she was transfered here for further
evaluation.
She denies any fever, chills, bowel or bladder incontinence or
perianal numbness.
Past Medical History:
HTN
s/p L4/5 laminectomy (R sole numbness/intolerable pain;
difficulty ascending stairs at the time)
s/p b/l hip replacements
guillain ___ ___
Social History:
Retired and widowed. Quit smoking ___ ago. Rare etoh. No
illicits The patient's ethnicity is from ___.
MEDS:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID:PRN gi upset
4. Docusate Sodium 100 mg PO BID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Metoprolol Tartrate 50 mg PO Q6H tachycardia
9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN pain
ALL: Ambien and the flu shot
ROS: As per HPI otherwise negative
PHYSICAL EXAMINATION:
In general, the patient is a delightful middle aged woman in no
acute distress
Vitals: 98.8, 89, 132/61, 20, 974% on RA
Vascular
DP: L2+, R2+
Motor-
glut Quad Ham TA Gastroc
L 5 4+ 5 5 5
R 5 4+ 5 4- 5
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:
Pat Ach
L 0* 0*
R 0* 0*
*patient reports this is her baseline
Babinski: downgoing
Clonus: none
IMAGING:
CT Lumbar spine shows hardware is intact and within bone, no
notable change in alignment or failure of hardware. Radiologist
reports mild left hydronephrosis.
Radiology Report
HISTORY: Post L4-S1 anterior/posterior fusion, new right lower extremity
weakness. Question hardware displacement or periprosthetic fracture.
COMPARISON: Prior lumbar spine radiograph from ___.
FINDINGS: Cross table and lateral views of the lumbar spine demonstrate
anterior and posterior fusion of L4 through S1. There is anterolisthesis of
L5 on S1. There are no definite surgical hardware related complications.
However, please refer to lumbar CT spine performed on the same day for better
description of findings. Note is made of bilateral hip arthroplasties.
Radiology Report
INDICATION: L4-S1 anterior and posterior fusion, new right-sided weakness,
MRI at ___ negative. Evaluate for presence of hardware displacement or
periprosthetic fracture.
COMPARISON: Outside CT of the L-spine, ___. Outside MR of the L-spine,
___. Radiograph of the L-spine, ___.
TECHNIQUE: Contiguous helical MDCT images were obtained through the lumbar
spine without IV contrast. Multiplanar axial, coronal and sagittal images
were generated.
TOTAL BODY DLP: 958 mGy-cm.
FINDINGS: In general, evaluation is limited by streak artifact from fusion
hardware. The patient is status post anterior and posterior fusion from L5 to
S1. There are anterior disc spacers at L4-L5 and L5-S1 with associated
vertebral body screws. There are posterior pedicle screws bilaterally at L4,
on the left at L5, and bilaterally at S1. Hardware appears in expected
position without evidence of hardware fracture or loosening. There is
macerated bone graft along the posterior elements bilaterally.
There are apparent ___ fractures in L5 and S1 along both pedicle
screws (2:64-66, 69-71). It is unclear whether these relate with expected
postoperative changes, and correlation with the operative report is
recommended. Compared to the CT of the L-spine from ___, there
is significant improvement in anterolisthesis of L4 on L5, but persistent
grade 1 anterolisthesis of L5 on S1.
There is gas in the anterior abdominal wall which is likely postoperative.
Additionally, prevertebral hematoma and edema causes mass effect on the left
ureter resulting in mild hydronephrosis on the left (105B:13).
IMPRESSION:
1. Perihardware fractures in L5 and S1 along both pedicle screws may relate
to recent surgery, and correlation with the operative report is recommended.
No significantly displaced fracture fragment is detected.
2. Postoperative residual gas in the anterior body wall.
3. Prevertebral hematoma and edema causes mass effect on the left ureter
causing mild hydronephrosis.
Radiology Report
INDICATION: ___ year old woman s/p ANT/POST lumbar fusion with new onset leg
pain // BLE leg pain
TECHNIQUE: Grayscale, color, and spectral Doppler evaluation was performed of
the bilateral lower extremity veins.
COMPARISON: ___.
FINDINGS:
There is normal phasicity of the common femoral veins bilaterally. There is
normal compression and augmentation of the bilateral common femoral, proximal
femoral, mid femoral, distal femoral, popliteal, posterior tibial, and
peroneal veins.
IMPRESSION:
No evidence of DVT in either the right or the left lower extremity.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FUSION LEG WEAKNESS
Diagnosed with OTHER ACUTE POSTOPERATIVE PAIN
temperature: 98.8
heartrate: 89.0
resprate: 20.0
o2sat: 97.0
sbp: 132.0
dbp: 61.0
level of pain: 5
level of acuity: 2.0 | Patient was admitted to the ___ Spine Surgery Service. CT
scan and XR of lumbar spine were obtained, and MRI reviewed.
Scans were consistent with recent L4-S1 fusion, and no abnormal
fluid collection or any compressive neural lesions were
identified. DVT of lower extremities was neg for DVT.
The patient had some improvement during her stay in the pain in
her leg, although she remained weak in her tib ant, gastroc, and
___ on the R leg ___ grade). The patient's exam remained
stable, without progression of weakness or pain.
Physical therapy was consulted for mobilization OOB to ambulate,
and recommended the patient for a stay at rehab.
Hospital course was otherwise unremarkable. She was continued
on her macrobid for UTI to end ___. 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:
Ampicillin
Attending: ___.
Chief Complaint:
Mechanical Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old female with a history of DM2, HTN,
gait disorder (r/o NPH) and arthritis who presented after
falling on day of admission while trying to change her curtains.
She was using her walker and felt that her legs became weak. She
slid onto her bottom, denied LOC, denied hitting her head. She
did not experience chest pain, palpitations, or shortness of
breath. She did not experience any confusion after falling. She
could not get up and so she called EMS for help.
Of note, the patient had a similar fall 8 days prior to
admission (___) when she reports that she fell due to weakness.
She did not seek medical attention at that time; however, 3 days
after her fall (___) she presented to the ED with lower back
pain. She denied LOC, weakness, numbness or new incontinence of
bowel or bladder at that time. Xrays of her pelvis/hips showed
no acute abnormalities. She was discharged home on Percocet. Her
daughter noted that the patient seemed more confused during this
past week while on Percocet, where she had difficulty
remembering phone numbers and seemed slow. The pt had a similar
reaction to Percocet after her R TKR.
The patient complains of lower back pain that is not new. She
had one episode of vomiting week prior to admission that she
attributes to the Percocet. She also admits to poor PO intake,
although she has been drinking fluids. Denies dizziness,
lightheadedness, chest pain, palpitations, SOB, hematuria,
hematochezia, dysuria.
In the ED, initial VS were T 98.1 HR 92 HR 146/78 RR 16 SpO2
98%RA
Exam notable for right hip tenderness.
Physical therapy was consulted and due to the patient's
propensity for falls the decision was made to admit to medicine
for further management.
On arrival to the floor, patient reports right hip 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.
All other 10-system review negative in detail.
Past Medical History:
Abnormal pelvic ultrasound: saw Gyn: Candidate for repeat
biopsy.
___: Refusing D&C
Multinodular goiter (resected)
Gout
Asthma
No Known History of Seizures, Head Injuries
Diabetes Mellitus Type 2
Hypertension
Hypothyroidism
Anxiety
Dysphoria
Seen by Psychiatry at ___
Elevated BMI
Osteoarthritis
Emergency room ___:
--___:
-Chest pain
--___:
-Confusion, including regarding Rx, seen by Neurology, referred
for followup Neurology. Evidence of prior CVA on CT
___:
In followup Neurology ___
-Gait disorder
-Fall risk
-Rule out NPH. MRI ordered, patient not agreeing to imaging
___:
-Candidate for total knee replacement (done)
-Referred Cardiology ___ regarding preop clearance (done)
Stress MIBI ___: No anginal symptoms/ischemic EKG changes nml
perfusion study without defects
Hyperlipidemia
Seasonal Allergies
Elevated BMI
Osteoarthritis
Past Psychiatric History
saw Dr. ___ through ___, then
___
No history of hospitalizations or suicide attempts
PAST SURGICAL HISTORY:
- s/p R TKR
- s/p lipoma removal
- s/p D&C
- total thyroidectomy for recurrent multinodular goiter with
reimplanted right lower and left upper parathyroid glands into
right sternocleidomastoid muscle: Dr. ___: ___ ___
Social History:
___
Family History:
Mother with stroke in her ___ and DM2. Father had stroke in his
___. No family history of cancer, sudden cardiac death or MI.
Does report a family history of HTN.
Physical Exam:
ADMISSION EXAM:
VS T 98.2 BP 159/96 HR 94 RR 17 SpO2 100%RA Wt 98.7kg
General: Well-appearing, pleasant female in NAD
HEENT: NC/AT, nonicteric sclerae, PERRL, EOMi. MMM
Neck: Supple, No JVD
CV: RRR, S1+S2, no murmurs, rubs, or gallops
Lungs: CTAB, no wheezes, rales or rhonchi
Abdomen: Obese, soft, nontender, no organomegaly or masses. +BS
Ext: Moving all extremities spontaneously. Some tenderness to R
hip to palpation. No lower extremity edema. DP and radial pulses
2+ bilaterally.
Neuro: Patient is AAOx2 (knows place, not year). CN II-XII
intact. ___ strength in all muscle groups. ___ reflexes
throughout. Gait not assessed.
Skin: Warm and well-perfused, no rashes.
DISCHARGE EXAM:
VS : T 98.0 BP 150/80 HR 85 RR 19 SpO2 99% RA
I/O: episodes of urinary incontinence
General: Well-appearing, pleasant female in NAD
HEENT: NC/AT, nonicteric sclerae, PERRL, EOMi. MMM
Neck: Supple, No JVD
CV: RRR, S1+S2, no murmurs, rubs, or gallops
Lungs: CTAB, no wheezes, rales or rhonchi
Abdomen: Obese, soft, nontender, no organomegaly or masses. +BS
Ext: Moving all extremities spontaneously. No hip tenderness to
palpation bilaterally. No lower extremity edema. DP and radial
pulses 2+ bilaterally.
Neuro: Patient is AAOx2 (knows place, not year).
Skin: Warm and well-perfused, no rashes.
Pertinent Results:
ADMISSION LABS:
___ 04:45PM PLT COUNT-254
___ 04:45PM NEUTS-51.5 ___ MONOS-5.8 EOS-2.9
BASOS-0.8
___ 04:45PM WBC-10.5 RBC-3.70* HGB-12.0 HCT-35.9* MCV-97
MCH-32.5* MCHC-33.5 RDW-13.3
___ 04:45PM CALCIUM-9.1 PHOSPHATE-2.7 MAGNESIUM-1.7
___ 04:45PM cTropnT-<0.01
___ 04:45PM estGFR-Using this
___ 04:45PM GLUCOSE-158* UREA N-29* CREAT-1.0 SODIUM-140
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-29 ANION GAP-15
___ 09:24PM URINE MUCOUS-RARE
___ 09:24PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-6
___ 09:24PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
___ 04:45PM ___ PTT-28.5 ___
IMAGING:
PELVIS (AP ONLY) Study Date of ___
FINDINGS:
No acute fracture or dislocation is identified. The patient is
osteopenic. The pubic symphysis and sacroiliac joints are
intact. No focal sclerotic or lytic lesion is seen. There is a
rounded opacity in the overlying soft tissues adjacent to the
right femur, measuring 3 cm. A calcification in the mid-pelvis
may represent a calcified fibroid or mesenteric lymph node, less
likely an appendicolith.
IMPRESSION:
No acute fracture or dislocation identified. However, given the
patient's osteopenia, if symptoms persist, followup imaging or
MR should be considered.
HIP UNILAT MIN 2 VIEWS RIGHT Study Date of ___
FINDINGS:
No acute fracture or dislocation is identified. The patient is
osteopenic. The pubic symphysis and sacroiliac joints are
intact. No focal sclerotic or lytic lesion is seen. There is a
rounded opacity in the overlying soft tissues adjacent to the
right femur, measuring 3 cm. A calcification in the mid-pelvis
may represent a calcified fibroid or mesenteric lymph node, less
likely an appendicolith.
IMPRESSION:
No acute fracture or dislocation identified. However, given the
patient's osteopenia, if symptoms persist, followup imaging or
MR should be considered.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Metoprolol Tartrate 100 mg PO BID
5. Lisinopril 40 mg PO DAILY
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Citalopram 40 mg PO DAILY
8. FreeStyle Lancets (lancets) 28 gauge miscellaneous Daily
9. Acetaminophen 650 mg PO BID Pain
10. Vitamin D 1000 UNIT PO DAILY
11. GlipiZIDE 10 mg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. MetFORMIN (Glucophage) 500 mg PO DAILY
14. TraMADOL (Ultram) 50 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO BID Pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Citalopram 40 mg PO DAILY
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Metoprolol Tartrate 100 mg PO BID
9. TraMADOL (Ultram) 50 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. FreeStyle Lancets (lancets) 28 gauge miscellaneous Daily
12. GlipiZIDE 10 mg PO DAILY
13. Lisinopril 40 mg PO DAILY
14. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Mechanical fall
Secondary diagnoses:
Hypertension
Diabetes
Osteoarthritis
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: Status post fall. Evaluate for fracture.
COMPARISON: AP pelvis and right hip radiographs from ___.
FINDINGS:
No acute fracture or dislocation is identified. The patient is osteopenic.
The pubic symphysis and sacroiliac joints are intact. No focal sclerotic or
lytic lesion is seen. There is a rounded opacity in the overlying soft
tissues adjacent to the right femur, measuring 3 cm. A calcification in the
mid-pelvis may represent a calcified fibroid or mesenteric lymph node, less
likely an appendicolith.
IMPRESSION:
No acute fracture or dislocation identified. However, given the patient's
osteopenia, if symptoms persist, followup imaging or MR should be considered.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with BACKACHE NOS, OTHER FALL
temperature: 98.1
heartrate: 92.0
resprate: 16.0
o2sat: 98.0
sbp: 146.0
dbp: 78.0
level of pain: 8
level of acuity: 3.0 | The patient is a ___ with a history of HTN, DM2, arthritis,
gait instability who presented after a fall, who was admitted
for placement.
# Fall: The etiology of the patient's fall is likely a
combination of factors, including baseline gait instability as
well as chronic knee pain and opiate use. Syncope work-up was
largely negative including negative cardiac biomarkers and EKGs.
Hip and pelvis films were done to rule out trauma which were
negative. ___ evaluated patient and felt that she would benefit
from rehab.
# HTN: On admission patient's BP was 159/96 HR 94, but she had
not taken her antihypertensives that morning. ___ BP
128-143/50s-70s, and continued to be well controlled on ___.
She was continued on her home lisinopril, metoprolol,
amlodipine.
# DM: At home patient takes glipizide and metformin. Her blood
glucose levels were monitored throughout admission and were
well-controlled on insulin sliding scale (her home diabetic
medications were held during admission). On ___ her morning BG
130, on ___ BGs 130s-150s and remained well controlled by day
of discharge.
# H/o CVA: There were no acute neurological signs of stroke this
admission. The patient was continued on home aspirin.
# Hyperlipidemia: The patient was continued on her home statin.
# Hypothyroidism: The patient was continued on home
levothyroxine.
# TRANSITIONAL ISSUES
-While Xrays showed no acute abnormalities, given patient's
osteopenia, consider f/u MRI of pelvis if patient's symptoms
persist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Levaquin
Attending: ___.
Chief Complaint:
Transfer with pyelonephritis, ?pneumonia, respiratory failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman with COPD on home 2L, HTN, and
opioid use disorder on suboxone, who is being transferred from
___ with pyelonephritis and pneumonia.
The patient shares that for about four days she has been
experiencing frequent urination, with dysuria, but no gross
hematuria or vaginal discharge. She had a few episodes of
diarrhea on the day these symptoms began, but this did not
continue. Then over the day prior to presentation, she developed
subjective fevers, chills, and right sided abdominal and back
pain. This pain was so severe that she became nauseous and had a
few episodes of vomiting. She went to ___
because of the pain. She was afebrile and hemodynamically stable
upon presentation. Her labs were notable for WBC 4.2, Hb 13.5,
platelet 214, Na 139, Cr 0.7, AST 24, ALT 9, AP 128, lipase 11.
She had a CT abdomen that showed right sided hydronephrosis and
hydroureter, along with a UA with large blood, large LEs, WBC 8,
moderate bacteria, negative glucose, negative nitrites, negative
ketones. While in the ED at ___, she became more
dyspneic. ABG notable for pH 7.32, pCO2 47, pO2 47 and she was
wheezing on exam. CXR was concerning for pneumonia. She was
started on ceftriaxone to cover pyelo/pneumonia and azithromycin
for atypical coverage. BIPAP was initiated for her respiratory
status, and she was given solumedrol 125 mg IV once for
potential component of COPD exacerbation. She was transferred to
___ because lack of ICU beds.
In the ED, initial vitals notable for 97.2 110 112/60 20 95%
BIPAP. On exam she appeared uncomfortable, diaphoretic.
bilateral wheezing and coarse breath sounds, and had right flank
tenderness. Labs were notable for WBC 18.3, lactate 3.2, pH
7.36, pCO2 38. Urology was consulted and said they did not
believe she needed urgent intervention. She was given 1L of
fluid.
Upon arrival to the ICU, the patient continues to have right
sided flank pain, but says it is somewhat better. She is off
BIPAP and feels like her breathing is improving. She has a COPD
exacerbation every few months, and has not been hospitalized for
it in many months. She says she has never been intubated before.
REVIEW OF SYSTEMS:
As per HPI
Past Medical History:
COPD on home 2L O2 at night
T2DM controlled by diet
Opioid use disorder, on suboxone
HTN
HLD
Depression
Anxiety
Migraines
Social History:
___
Family History:
Mother and father died of "old age."
Physical Exam:
Discharge exam:
===============
VITALS: 98.4 PO 166 / 85 81 18 95 Ra
GENERAL: elderly appearing woman, no acute distress.
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: good air entry bilaterally, occasional wheeze
ABDOMEN: nondistended, soft, nontender, present BS
EXTREMITIES: no cyanosis, clubbing or edema
NEURO: awake, alert, oriented x 4, speech fluent, CN ___
intact, moving all extremities
Pertinent Results:
Admission labs:
===============
___ 08:20AM BLOOD ___
___ Plt ___
___ 08:20AM BLOOD ___
___
___
___ 10:20AM BLOOD ___ ___
___ 08:20AM BLOOD ___
___
___ 08:20AM BLOOD ___
___ 08:20AM BLOOD ___
___ 04:07AM BLOOD ___
___ 08:34AM BLOOD ___
___ Base XS--3
___ 07:46PM BLOOD ___
___
Microbiology:
=============
Imaging:
========
CTU ___:
1. No CT findings to suggest pyelonephritis.
2. Mild right hydroureteronephrosis has minimally improved since
the most
recent exam. Right ureter is dilated to the UVJ with
perinephric and
periureteral stranding, possibly reflecting a recently passed
stone.
3. ___ suspected enhancing soft tissue in the region of
the right UVJ may be secondary to incomplete distention of
urinary bladder, though a bladder lesion cannot be definitively
excluded. CT cystoscopy is recommended for further evaluation.
4. New bibasilar consolidations, consistent with pneumonia.
5. ___ indeterminate 3.7 x 1.8 cm left adrenal
lesion. This
should be further evaluated with adrenal protocol CT or MRI.
6. Hepatic steatosis.
CT Chest without contrast ___:
Severe atelectasis, includes bilateral lower lobe collapse and
segmental
atelectasis in both the middle lobe and lingula. Although there
may be mild aspiration in the left upper lobe, there is no
appreciable contribution of infection, and no appreciable
pleural effusion.
Dilatation of the main pulmonary artery may be a transient
feature of
increased pulmonary vascular resistance due to
Atherosclerosis severe in head neck and coronary arteries.
Severe
atelectasis.
CT Cystogram with contrast ___:
Focal tapering of the distal right ureter near the right UVJ.
This may
reflect slowed transit of contrast in the setting of
inflammation from a
recently passed stone or an obstructing lesion. It should be
noted that
contrast was present within the right ureter and bladder on the
scout images. Direct visualization, such as ureteroscopy, is
recommended for further evaluation.
CT Torso Second Opinion ___:
Mild right hydroureteronephrosis without suspicious renal mass
seen. The
entirety of the right ureter is dilated to the UVJ which could
be related to recently passed stone. No renal calculi are seen.
The bladder is
decompressed. Ill defined suspected enhancing soft tissue in
the region of the right UVJ may be due to nondistention of the
bladder. Correlate with cystoscopy.
Indeterminate 4.4 x 1.9 cm left adrenal lesion. In the absence
of known
malignancy, this is overwhelmingly favored to be benign. This
could be
further evaluated with dedicated adrenal protocol CT or MRI or
___ on ___ exams.
CXR ___:
IMPRESSION:
1. Low lung volumes with ___ of partial right
middle lobe collapse and left basilar atelectasis.
2. No definite pulmonary edema.
Discharge labs:
===============
___ 07:25AM BLOOD ___
___ Plt ___
___ 07:25AM BLOOD ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Anoro Ellipta ___ mcg/actuation
inhalation daily
2. Atorvastatin 10 mg PO QPM
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. budesonide 0.25 mg/2 mL inhalation BID
5. ___ 1 TAB SL BID
6. ___ 1 TAB SL DAILY
7. Centrum Silver
(___)
___ oral daily
8. Docusate Sodium 100 mg PO DAILY
9. DULoxetine 60 mg PO DAILY
10. Prochlorperazine 5 mg PO Q6H:PRN nausea
11. ___ Neb 1 NEB NEB Q6H
12. ___ TAB PO Q6H:PRN Pain -
Moderate
13. Losartan Potassium 100 mg PO DAILY
14. OLANZapine (Disintegrating Tablet) 10 mg PO QHS
15. Pantoprazole 20 mg PO Q24H
16. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
17. Topiramate (Topamax) 25 mg PO BID
18. TraZODone 100 mg PO QHS:PRN insomniA
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 1 Dose
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
2. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
3. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX ___ [Bactrim DS] 800 ___ mg 1
tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0
4. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
6. ___ TAB PO Q6H:PRN Pain -
Moderate
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Anoro Ellipta ___
mcg/actuation inhalation daily
9. Atorvastatin 10 mg PO QPM
10. Budesonide 0.25 mg/2 mL inhalation BID
11. ___ 1 TAB SL DAILY
12. ___ 1 TAB SL BID
13. Centrum Silver
(___)
___ oral daily
14. Centrum Silver
(___)
___ oral daily
15. Docusate Sodium 100 mg PO DAILY
16. DULoxetine 60 mg PO DAILY
17. ___ Neb 1 NEB NEB Q6H
18. Losartan Potassium 100 mg PO DAILY
19. OLANZapine (Disintegrating Tablet) 10 mg PO QHS
20. Pantoprazole 20 mg PO Q24H
22. Prochlorperazine 5 mg PO Q6H:PRN nausea
23. Topiramate (Topamax) 25 mg PO BID
24. TraZODone 100 mg PO QHS:PRN insomniA
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis
Pyelonephritis
Hydronephrosis/hydroureter
Possible bladder mass
Hypoxic/hypercarbic respiratory failure
Acute COPD exacerbation
Encephalopathy
Discharge Condition:
Condition: good
Mental status: intact at baseline
Ambulatory status: ambulates with walker
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with dyspnea, reported pneumonia, please eval for
pneumonia and pulmonary edema
TECHNIQUE: Chest PA and lateral
COMPARISON: CT torso ___ at 02:07, Chest radiograph ___
at 02:37
FINDINGS:
Lung volumes are low. Heart size is accentuated as result appearing mildly
enlarged. The aorta appears tortuous. Crowding of bronchovascular structures
is present without overt pulmonary edema. Right middle lobe partial collapse
is re-demonstrated along with left basilar atelectasis. No definite focal
consolidation, large pleural effusion or pneumothorax is identified. Surgical
anchor is noted in the right humeral head.
IMPRESSION:
1. Low lung volumes with re-demonstration of partial right middle lobe
collapse and left basilar atelectasis.
2. No definite pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with AECOPD// hypoxemia hypoxemia
IMPRESSION:
Heart size and mediastinum are unchanged including moderate cardiomegaly.
Large bilateral pleural effusions are present. Vascular congestion has
progressed no representing interstitial pulmonary edema.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ year old woman with pyelonephritis, urology c/f potential mass
leading to presentation// please evaluate for stones or mass
TECHNIQUE: The technique cannot be commented upon as this study was performed
at an outside institution and was uploaded into PACs for comparison purposes
only.
DOSE: Not available
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is linear bibasilar atelectasis. There is no pericardial
or pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver is diffusely low in attenuation compatible with
diffuse hepatic steatosis. There is no evidence of focal lesions. There is
no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: There is diffuse fatty atrophy of the pancreas. There is no
peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: In the medial limb of the right adrenal gland there is a 7 mm lesion
with macroscopic fat compatible with myelolipoma. Within the left adrenal
gland, there is a 4.4 x 1.9 cm hyperdense lesion which is incompletely
characterized on this single-phase exam.
URINARY: There is mild right hydroureteronephrosis with a delayed nephrogram
and perirenal and periureteral fat stranding. The ureter appears dilated
along its entire course. No renal, ureteral, or bladder calculi are seen.
The left kidney is normal in appearance without hydronephrosis. No suspicious
renal masses are seen. Subcentimeter hypodensity in the lower pole of the
left kidney is too small to characterize.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits.
PELVIS: The bladder is decompressed. Ill defined suspected enhancing soft
tissue in the region of the right UVJ may be due to nondistention of the
bladder. there is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. At least moderate
atherosclerotic disease is noted.
BONES: There are advanced degenerative changes in the lumbar spine. There is
evidence of prior kyphoplasty at L2 and L3. No suspicious lytic or blastic
osseous lesions are seen. Chronic appearing osseous changes at the L4-5 disc
space may represent the sequela of prior infection. There is focal kyphosis
of the lower thoracic ___ at T10-11 were there is complete loss of
the intervertebral disc space and there is bony ___ of the 2 vertebral
bodies. This is present to a lesser degree at the T9-T10 level.
SOFT TISSUES: There is a small fat containing umbilical hernia.
IMPRESSION:
Mild right hydroureteronephrosis without suspicious renal mass seen. The
entirety of the right ureter is dilated to the UVJ which could be related to
recently passed stone. No renal calculi are seen. The bladder is
decompressed. Ill defined suspected enhancing soft tissue in the region of
the right UVJ may be due to nondistention of the bladder. Correlate with
cystoscopy.
Indeterminate 4.4 x 1.9 cm left adrenal lesion. In the absence of known
malignancy, this is overwhelmingly favored to be benign. This could be
further evaluated with dedicated adrenal protocol CT or MRI or re-evaluated on
follow-up exams.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with pyelonephritis, hypoxemia// r/o PNA
TECHNIQUE: Multi-detector helical scanning of the chest, coordinated with
intravenous infusion of nonionic, iodinated contrast agent, following oral
administration of contrast agent for selected abdominal studies, and/or
followed by scanning of the neck, was reconstructed as contiguous 5 mm and 1.0
or 1.25 mm thick axial, 2.5 or 5 mm thick coronal and parasagittal, and 8 mm
MIP axial images. Concurrent scanning of the abdomen and pelvis and/or neck
will be reported separately. All images of the chest were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.5 s, 35.4 cm; CTDIvol = 11.2 mGy (Body) DLP = 389.4
mGy-cm.
Total DLP (Body) = 389 mGy-cm.
COMPARISON: There are no prior chest CT scans available for review.
FINDINGS:
Supraclavicular and axillary lymph nodes are not largely valuation, there are
no soft tissue abnormalities in the imaged chest wall suspicious for
malignancy. Findings below the diaphragm will be reported separately.
There are no thyroid abnormalities warranting further imaging evaluation.
Atherosclerotic calcification is moderate in head and neck vessels,, severe in
all coronary arteries.
Aorta is normal size. Main pulmonary artery is moderately enlarged, 36 mm.
Pericardial effusion is small. Pleural effusions are minimal if any.
Lymph nodes:
Thoracic lymph nodes are not enlarged.
Lungs:
Both lower lobes are collapsed and atelectasis in the right middle lobe and
lingula is at least segmental. Bronchial tree is patent.
Mild peribronchial ground-glass opacification in the left upper lobe could be
due to early pneumonia or aspiration.
Chest cage:
There are no bone lesions suspicious for malignancy or infection.
IMPRESSION:
Severe atelectasis, includes bilateral lower lobe collapse and segmental
atelectasis in both the middle lobe and lingula. Although there may be mild
aspiration in the left upper lobe, there is no appreciable contribution of
infection, and no appreciable pleural effusion.
Dilatation of the main pulmonary artery may be a transient feature of
increased pulmonary vascular resistance due to
Atherosclerosis severe in head neck and coronary arteries. Severe
atelectasis.
Radiology Report
EXAMINATION: CTU with and without contrast.
INDICATION: ___ year old woman with pyelonephritis// w/ hematuria protocol
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired
prior to and after intravenous contrast administration with the patient in
prone position. The non-contrast scan was done with low radiation dose
technique. The contrast scan was performed with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.8 s, 50.4 cm; CTDIvol = 4.0 mGy (Body) DLP = 197.3
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
3) Stationary Acquisition 22.9 s, 0.2 cm; CTDIvol = 389.7 mGy (Body) DLP =
77.9 mGy-cm.
4) Spiral Acquisition 7.8 s, 50.9 cm; CTDIvol = 16.6 mGy (Body) DLP = 836.4
mGy-cm.
Total DLP (Body) = 1,114 mGy-cm.
COMPARISON: Same-day second opinion CT torso.
FINDINGS:
LOWER CHEST: Bibasilar confluent airspace opacities containing air
bronchograms are new since prior CT and consistent with pneumonia.
ABDOMEN:
HEPATOBILIARY: Diffuse hypoattenuation of the liver is consistent with hepatic
steatosis. There is no evidence of focal lesions. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: 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: 7 mm lesion containing macroscopic fat within the medial limb of the
right adrenal gland is most consistent with a myelolipoma. 3.3 x 1.8 cm
hyperdense lesion within the left adrenal gland is incompletely characterized
on this single phase postcontrast exam. The right and left adrenal glands are
normal in size and shape.
URINARY: There is persistent mild right hydroureteronephrosis with mild
perinephric fat stranding, minimally improved since prior examination. The
right ureter demonstrates moderate dilatation throughout its entire course
with associated periureteral fat stranding. No definite calculi are seen
within the bilateral kidneys, ureters or bladder. The left kidney is
unremarkable without hydronephrosis. No concerning renal lesions are
identified. Subcentimeter hypodensity in the lower pole of left kidney, too
small to further characterize, is most consistent with a simple renal cyst.
A Foley catheter is present within a decompressed urinary bladder. Again seen
is an ill-defined area of early enhancing soft tissue adjacent to the right
UVJ, which may be secondary to incomplete distention of the urinary bladder.
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: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Severe multilevel degenerative changes of the visualized thoracolumbar
spine. Kyphoplasties at L2 and L3 are noted. No aggressive osseous lesion
identified. There is bony ___ of the T10-T11 vertebral bodies, with focal
kyphosis centered at this level, present to a lesser degree at the T9-T10
level.
SOFT TISSUES: Small fat-containing umbilical hernia. Otherwise, the abdominal
and pelvic wall is within normal limits.
IMPRESSION:
1. No CT findings to suggest pyelonephritis.
2. Mild right hydroureteronephrosis has minimally improved since the most
recent exam. Right ureter is dilated to the UVJ with perinephric and
periureteral stranding, possibly reflecting a recently passed stone.
3. Ill-defined suspected enhancing soft tissue in the region of the right UVJ
may be secondary to incomplete distention of urinary bladder, though a bladder
lesion cannot be definitively excluded. CT cystoscopy is recommended for
further evaluation.
4. New bibasilar consolidations, consistent with pneumonia.
5. Re-demonstrated indeterminate 3.7 x 1.8 cm left adrenal lesion. This
should be further evaluated with adrenal protocol CT or MRI.
6. Hepatic steatosis.
RECOMMENDATION(S): CT cystogram for further evaluation of the urinary
bladder.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:01 pm, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT cystogram.
INDICATION: ___ year old woman with pyelonephritis// ?bladder mass
TECHNIQUE: Multidetector CT images of the pelvis were acquired without
intravenous contrast. Non-contrast scan has several limitations in detecting
vascular and parenchymal organ abnormalities, including tumor detection. 25
mL of Omnipaque, diluted with 100 mL of saline, was administered through the
Foley catheter.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 30.9 cm; CTDIvol = 14.3 mGy (Body) DLP = 431.1
mGy-cm.
Total DLP (Body) = 431 mGy-cm.
COMPARISON: None provided.
FINDINGS:
PELVIS: On the scout images, contrast is noted within the right ureter and
urinary bladder. Following administration of intravesicular contrast, there
is focal tapering of the distal right ureter near the right UVJ (3:35-36),
which may reflect slowed transit of contrast due to inflammation from recently
passed stone or an obstructing lesion. There is no filling defect within the
urinary bladder. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
LYMPH NODES: There is no pelvic or inguinal lymphadenopathy.
VASCULAR: Moderate atherosclerotic disease is noted.
BONES: Multilevel, multifactorial degenerative changes of the lumbar spine.
Prior kyphoplasties at L2 and L3. Concerning osseous lesions identified.
Focal kyphosis centered at T10-T11 with complete loss of intervertebral disc
space and bony ___ of the T10-T11 vertebral bodies present to a lesser
degree at the T9-T10 level.
SOFT TISSUES: Small fat-containing umbilical hernia.
IMPRESSION:
Focal tapering of the distal right ureter near the right UVJ. This may
reflect slowed transit of contrast in the setting of inflammation from a
recently passed stone or an obstructing lesion. It should be noted that
contrast was present within the right ureter and bladder on the scout images.
Direct visualization, such as ureteroscopy, is recommended for further
evaluation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Acute pyelonephritis
temperature: 97.2
heartrate: 110.0
resprate: 20.0
o2sat: 95.0
sbp: 112.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with COPD on home 2L, HTN, and
opioid use disorder on suboxone, who is being transferred from
___ with sepsis secondary to pyelonephritis,
hydronephrosis/hydroureter with potential bladder mass,
pneumonia, and hypoxic/hypercarbic respiratory failure with COPD
exacerbation.
#Sepsis secondary to pyelonephritis:
#Hydronephrosis/hydroureter:
#Possible bladder mass: Patient with symptoms, lab and imaging
findings initially concerning for pyelonephritis given right
hydro and 2mm right UVJ stone. She was continued on ceftriaxone
(day 1 = ___ and given tamsulosin and toradol to
facilitate stone passage. Her lactate was initially elevated to
3.2 but normalized with fluids. Urine cultures from OSH returned
positive for proteus sensitive to ceftriaxone. ___ and Urology
were consulted due to concern for an obstructing stone and
possible bladder mass. She had a CT cystogram and CTU, which
showed resolution of the right hydronephrosis representing
likely stone passage, and also did not show pyelonephritis. All
invasive interventions were deferred in light of these findings.
Urology recommended ___ of antibiotics for clinical
pyelonephritis. Pt was discharged on Bactrim given culture
results and known allergy to quinolones.
Atypical urothelial cells noted on urine cytology. Urology
recommending further ___ of questionable bladder mass as an
outpatient. Urology will contact for ___ for office
cystoscopy.
#Hypercarbic/hypoxic respiratory failure:
#COPD exacerbation/COPD: She was taken off Bipap on arrival to
the ICU. There was initial concern for aspiration pneumonia but
CT Chest only showed bilateral severe atelectasis without
evidence of infection. She was treated for a COPD exacerbation
with prednisone 60 mg daily (day 1 = ___ for a planned
___ course and duonebs. She was started on azithromycin
(___) for atypical coverage for a planned ___ course.
Legionella was negative. She was weaned to room air prior to
discharge. Trending pulse ox confirmed no desats with
ambulation.
#Opioid use disorder: Home suboxone was continued. She
intermittently received oxycodone 5 mg ___ doses for flank
pain.
#HTN: Held home losartan while in the ICU. Resumed at time of
discharge.
#Depression/anxiety: Continued home Cymbalta, Olanzapine and
Trazodone
#Migraines: Continued home topamax BID and also received fiorcet
intermittently
#adrenal incidentaloma: On OSH CT Torso: "Indeterminate 4.4 x
1.9 cm left adrenal lesion. In the absence of known malignancy,
this is overwhelmingly favored to be benign. This could be
further evaluated with dedicated adrenal protocol CT or MRI or
___ on ___ exams." And again on our CT:
___ indeterminate 3.7 x 1.8 cm left adrenal lesion.
This should be further evaluated with adrenal protocol CT or
MRI." Defer to outpatient providers for further ___ if
deemed necessary.
CODE STATUS: DNR/DNI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine / Vicodin / Dilaudid / codeine
Attending: ___.
Chief Complaint:
s/p syncope, VT arrest
Major Surgical or Invasive Procedure:
R Internal Jugular Line (Placed ___, removed ___
History of Present Illness:
___ yo male with history of ___ with EF of 40-50%, CKD ___ IgA
nephropathy, afib on Coumadin, and HTN who presents as transfer
from ___ after having VT arrest. Patient was in his
usual state of health on ___ at 1400 when he suddenly and
without prodromic symptoms had a syncopal episode. No loss of
bowel or bladder. Denies head strike. Patient denies associated
chest pain, SOB or palpitations. Not sure how long he was down,
but guesses that it was only a few minutes. When he awoke, he
felt weak but was otherwise asymptomatic. Patient has had recent
falls including one with a headstrike in the last week, but
denies losing consciousness during those. He waited for his wife
to come home (about 3 hours) and then presented to the ___
___ for further evaluation.
Of note, patient was recently admitted to ___ on
___ where he was treated for massive volume overload with
anasarca. He was 50lbs above his dry weight and diuresed
aggressively while admitted. He was discharged on ___ weighing
114kg. He was discharged on a increased dose of torsemide (40mg
BID). He reports that in the days leading to his admission he
noticed that his legs continued to get slimmer and that he
constantly felt dehydrated and thirsty.
On presentation to ___, patient was found to have ___ on
CKD (Cr 3.95 from 2.3), hypnatremia to 127, and hypokalemia to
2.7. Decision was made to admit patient for above issues. While
awaiting bed patient had VT arrest, requiring cardioversion.
ROSC after single cardioversion. He was given 40meq of K in
1000mlNS, started on an amiodarone load, and transferred to
___ for further care.
In the ED, initial vitals were: HR117 139/85 18 99% Nasal
Cannula
He was noted to be alert and oriented and asymptomatic.
Labs: Notable for hyponatremia to 127, hypokalemia to 3.0. Cr
3.5. H/H 9.3/29.5 (stable from ___. INR 5.1. Troponin .03.
Imaging: CXR was performed. No official read, but shows pulm
vascular congestion.
Patient was continued on amiodarone and fluids from OSH.
Decision was made to admit to CCU for s/p VTach arrest
Vitals on transfer were: 115 128/84 14 100% Nasal Cannula
On the floor, patient without complaints. No CP or SOB. Denies
recent DOE, orthopnea or PND. No palpitations. No N/V/Abd pain.
Has bilateral pitting edema that is improved over past few
weeks.
Past Medical History:
Chronic systolic congestive heart failure w/ ejection fraction
of around 40%, with moderate to significant TR and MR.
___ on Coumadin
___ kidney disease secondary to IgA nephropathy, has had
nephrotic syndrome with recent sapphanous vein thrombosis
Chronic anemia on B12
Gastric bypass in ___ c/b by GIB w/marginal ulcer while
anticoagulated in ___
Hypertension
Hyperlipidemia
TIA
Coronary artery disease a status post MI moderate-sized area of
inferior ischemia on nuclear stress in ___ per cardiologist
note
Gout
Morbid obesity s/p bypass
PSH:
Status post gastric bypass in ___
Status post hernia repair
Status post total knee replacement
Status post squamous cells carcinoma removal of the scalp
Social History:
___
Family History:
His father died at the age of ___ due to heart attack, he was
heavy smoker. Mother died at the age of ___ as a complication of
bowel obstruction
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T= 97.9 BP= 130/85 HR= 120 in AF RR= 15 O2 sat=99% RA
GEN: Pleasant, calm, NAD
HEENT: Multiple dry ulcerations on scalp. No conjunctival
pallor. No icterus. PERRL, EOMI, MMM. OP clear.
NECK: Supple, No LAD. JVP to mandible. No thyromegaly.
CV: PMI in ___ intercostal space, lateral mid clavicular line.
irregularly irregular. ___ low pitched systolic murmur best
heard at apex with radiation to LLSB.
LUNGS: No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM.
EXT: WWP, Bilateral 3+ pitting edema in ___.
NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation
throughout. ___ strength throughout.
DISCHARGE PHYSICAL EXAMINATION:
VS: 97.4-98.2, BPs 99-109/50s-60s RR ___ HR 78-101 96-100% RA
I/O: ___ (24hr)1400/1500
Wt: 96kg
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: Several surgical lesions/biopsy sites/flaps present over
the head from treatment of invasive squamous cell carcinoma.
Sclera anicteric.
NECK: Supple with JVP <10 cm.
LUNGS: breathing comfortably on room air. CTAB.
EXTREMITIES: grossly edematous lower extremities with 2+ pitting
edema to the sacrum; warm
SKIN: Several ecchymoses over the arms; scalp findings as above.
Pertinent Results:
ADMISSION LABS:
===============
___ 11:10PM BLOOD WBC-5.7 RBC-2.97* Hgb-9.3* Hct-29.5*
MCV-99* MCH-31.3 MCHC-31.5* RDW-14.7 RDWSD-53.3* Plt ___
___ 11:10PM BLOOD Neuts-86.9* Lymphs-6.3* Monos-5.6
Eos-0.2* Baso-0.5 Im ___ AbsNeut-4.99 AbsLymp-0.36*
AbsMono-0.32 AbsEos-0.01* AbsBaso-0.03
___ 11:10PM BLOOD ___ PTT-125.7* ___
___ 11:10PM BLOOD Glucose-252* UreaN-129* Creat-3.5*
Na-127* K-3.0* Cl-80* HCO3-20* AnGap-30*
___ 11:10PM BLOOD ALT-12 AST-23 LD(LDH)-265* AlkPhos-102
TotBili-0.2
___ 11:10PM BLOOD cTropnT-0.03*
___ 11:10PM BLOOD Calcium-8.3* Phos-6.3* Mg-2.4
___ 06:51AM BLOOD Lactate-1.3
___ 11:35PM URINE Color-Straw Appear-Clear Sp ___
___ 11:35PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 11:35PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
OTHER PERTINENT/DISCHARGE LABS:
===============================
___ 05:40AM BLOOD TSH-3.9
___ 05:44AM BLOOD WBC-6.2 RBC-2.75* Hgb-8.6* Hct-26.4*
MCV-96 MCH-31.3 MCHC-32.6 RDW-15.4 RDWSD-53.6* Plt ___
___ 05:44AM BLOOD Plt ___
___ 05:44AM BLOOD ___ PTT-32.7 ___
___ 05:44AM BLOOD Glucose-84 UreaN-89* Creat-2.6* Na-132*
K-4.7 Cl-89* HCO3-28 AnGap-20
___ 04:40AM BLOOD ALT-16 AST-24 LD(LDH)-226 AlkPhos-79
TotBili-0.3
___ 05:40AM BLOOD CK-MB-3 cTropnT-0.05*
___ 05:44AM BLOOD Calcium-8.1* Phos-5.4* Mg-2.1
___ 06:14AM BLOOD Lactate-2.0
___ 11:43AM URINE Color-Straw Appear-Clear Sp ___
___ 11:43AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 11:43AM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-1
___ 11:43AM URINE Hours-RANDOM Creat-38 TotProt-40
Prot/Cr-1.1*
IMAGING/STUDIES:
================
___ CXR (AP Portable)
Pulmonary vascular congestion.
___ TTE (Portable)
The left atrium is mildly dilated. The right atrium is markedly
dilated. The estimated right atrial pressure is ___ mmHg. Left
ventricular wall thicknesses and cavity size are normal. Overall
left ventricular systolic function is moderately depressed
(Quantitative Biplane (LVEF= 39%) secondary to akinesis of the
basal inferior/inferoseptal walls and mild hypokinesis of the
remainin segments. There is considerable beat-to-beat
variability of the left ventricular ejection fraction due to an
irregular rhythm/premature beats. Doppler parameters are
indeterminate for left ventricular diastolic function. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The ascending aorta is mildly dilated. The number
of aortic valve leaflets cannot be determined. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild-moderate (___) mitral regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Moderate global systolic dysfunction with
regionality as described above. Mild-moderate mitral
regurgitation. Mild aortic regurgitation. Mild pulmonary artery
systolic hypertension.
**************
___ Renal U/S
IMPRESSION:
1. No hydronephrosis bilaterally. The bilateral renal cortex is
increased in echogenicity consistent with diffuse renal
parenchymal disease.
2. Bilateral Bosniak II renal cysts.
**************
___ CXR -- Central Line Placement
IMPRESSION:
In comparison with the study ___, there is an placement
of right IJ
catheter with its tip in the low SVC. No evidence of post
procedure
pneumothorax.
The patient has taken a slightly better inspiration and there is
no evidence of pulmonary vascular congestion at this time.
***************
___ CT Abdomen
IMPRESSION:
1. No CT findings correlating with reported history of a lower
extremity
edema. No concerning abdominopelvic mass or central venous
compression.
2. Small amount of oral contrast within the excluded stomach,
post bypass
surgery, suggests a gastrogastric fistula.
3. Bilateral adrenal adenomas, measuring up to 1.7 x 1.0 cm on
the right.
4. Multiple bilateral renal hypodensities, many of which
represent simple
cysts. A 3.2 x 3.1 cm intermediate density lesion in the left
lower pole may
represent a hemorrhagic or proteinaceous cyst. These were
recently
characterized on the ultrasound examination from ___.
5. Aortic valvular and diffuse coronary artery calcifications.
6. Diffuse body wall edema.
___
IMPRESSION:
-New left IJ approach pulmonary artery catheter tip terminates
at the level of
the distal right main pulmonary artery or the right interlobar
pulmonary
artery. No pneumothorax.
-Right IJ central venous catheter terminates in the low SVC.
-Low lung volumes cause bronchovascular crowding and bibasilar
atelectasis.
MICROBIOLOGY:
=============
None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Metoprolol Succinate XL 200 mg PO DAILY
3. Warfarin 2.5 mg PO 6X/WEEK (___)
4. Warfarin 0.5 mg PO 1X/WEEK (FR)
5. Calcitriol 0.25 mcg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Torsemide 40 mg PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
9. carisoprodol 350 mg oral Q6H
10. Ferrous Sulfate 325 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Cyanocobalamin 1000 mcg IM/SC EVERY 4 WEEKS (MO)
13. Amiodarone 300 mg PO DAILY
14. Metolazone 5 mg PO 2X/WEEK (___)
15. Vitamin D ___ UNIT PO 1X/WEEK (___)
16. Calcium Acetate 1334 mg PO TID W/MEALS
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Calcitriol 0.25 mcg PO DAILY
3. Metoprolol Succinate XL 200 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Torsemide 60 mg PO QAM
RX *torsemide 20 mg 3 tablet(s) by mouth every morning Disp #*90
Tablet Refills:*0
7. Torsemide 80 mg PO QPM
RX *torsemide 20 mg 4 tablet(s) by mouth every evening Disp
#*120 Tablet Refills:*0
8. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth once daily
Disp #*30 Tablet Refills:*0
9. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. HydrALAZINE 10 mg PO TID
RX *hydralazine 10 mg 1 tablet(s) by mouth three times per day
Disp #*90 Tablet Refills:*0
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
12. Calcium Acetate 1334 mg PO TID W/MEALS
13. Cyanocobalamin 1000 mcg IM/SC EVERY 4 WEEKS (MO)
14. Ferrous Sulfate 325 mg PO DAILY
15. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
16. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Polymorphic Ventricular Tachycardia
Cardiac Arrest
Systolic Heart Failure, acute on chronic
Acute on chronic renal failure
Atrial fibrillation
Coronary Artery Disease
Anemia
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 post arrest, evaluate for pulmonary edema or effusion.
TECHNIQUE: Single upright AP chest radiograph
COMPARISON: Outside hospital chest radiographs dated ___
FINDINGS:
Low lung volumes cause bronchovascular crowding. There is no focal
consolidation, pleural effusion, pulmonary edema, or pneumothorax. Minimal
linear bibasilar atelectasis is present, slightly improved from earlier
radiograph from the same date Heart is upper limits of normal in size and
accompanied by pulmonary vascular congestion.
IMPRESSION:
Pulmonary vascular congestion.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with CKF ___ IGA nephropathy with ___ on CKD //
?etiology ___ on CKD
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 12.1 cm. The left kidney measures 10.8 cm. There is
no hydronephrosis, stones, or masses bilaterally. The kidneys demonstrate
increased echogenicity bilaterally consistent with diffuse renal parenchymal
disease. Multiple bilateral Bosniak II cortical cysts are identified
measuring up to 1.5 cm in the right upper pole and 2.0 cm within the left
lower pole. The largest cyst is simple in appearance and is located in the
left interpolar region measuring 3.9 cm.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
1. No hydronephrosis bilaterally. The bilateral renal cortex is increased in
echogenicity consistent with diffuse renal parenchymal disease.
2. Bilateral Bosniak II renal cysts.
Radiology Report
EXAMINATION: CHEST PORT LINE/TUBE PLCT 1 EXAM
INDICATION: ___ year old man with central line // Central line placement
Contact name: CCU intern, ___: ___ Central line placement
IMPRESSION:
In comparison with the study ___, there is an placement of right IJ
catheter with its tip in the low SVC. No evidence of post procedure
pneumothorax.
The patient has taken a slightly better inspiration and there is no evidence
of pulmonary vascular congestion at this time.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ year old man with cardiogenic shock, placing PA catheter for
tailored therapy // Swan-Ganz placement Swan-Ganz placement
IMPRESSION:
Fluoroscopic image shows placement of a right Swan-Ganz catheter that extends
several cm beyond the mediastinal border. Further information can be gathered
from the procedure report.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with heart failure and PA catheter placement //
Placement of PA catheter? Contact name: ___: ___
TECHNIQUE: Portable chest
COMPARISON: ___.
FINDINGS:
There is crowding at the bases. The right IJ line is unchanged. There is a
new left IJ Swan-Ganz catheter with tip in the main pulmonary artery. The
heart continues to be moderately enlarged.
IMPRESSION:
-New left IJ approach pulmonary artery catheter tip terminates at the level of
the distal right main pulmonary artery or the right interlobar pulmonary
artery. No pneumothorax.
-Right IJ central venous catheter terminates in the low SVC.
-Low lung volumes cause bronchovascular crowding and bibasilar atelectasis.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ year old man with CHF, ___, IgA nephropathy with persistent ___
edema despite diuresis. R/O vascular obstruction // source ___ edema;
vascular obstruction?
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained
without intravenous contrast. Noncontrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection. Oral contrast was not administered.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 54.4 cm; CTDIvol = 16.5 mGy (Body) DLP = 897.9
mGy-cm.
Total DLP (Body) = 898 mGy-cm.
COMPARISON: Ultrasound from ___.
FINDINGS:
LOWER CHEST: Streaky bibasilar opacities likely represent atelectasis. No
pleural effusions. Heart is normal in size. Coronary artery calcifications
are diffuse. Aortic valvular calcifications are also noted. Trace
nonhemorrhagic pericardial effusion (2:7) is likely physiologic.
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 surgically 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: A 1.7 x 1.0 cm right adrenal nodule measures -2.9 ___ (02:24),
consistent with an adenoma. Nodularity along the left adrenal gland (2:22,
28), likely represent additional adenomas.
URINARY: The kidneys are of normal and symmetric size. There are multiple
bilateral renal cysts. The largest in the right upper pole measures 1.4 x 1.2
cm (601b:36). Innumerable hypodensities are also noted on the left, most of
which appear simple. An exophytic cyst in the left upper pole measuring 2.0 x
1.7 cm contains a single punctate wall calcification (601b:44). The largest
cyst in the left lower pole measures approximately in 3.2 x 3.0 cm and is
intermediate in density (30 ___, 02:31) ; this may represent a hemorrhagic or
proteinaceous cyst. Sub-cm hypodensities are too small to characterize.
There is no hydronephrosis. There is no nephrolithiasis. There is no
perinephric abnormality.
GASTROINTESTINAL: Patient is post gastric bypass surgery. A small amount of
ingested oral contrast is seen within the excluded stomach (02:25), raising
the possibility for a gastrogastric fistula. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. A single diverticulum is seen near the splenic flexure
(601b:36). Normal appendix. No ascites. No pneumoperitoneum.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate gland and seminal vesicles are unremarkable in
appearance.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Mild-to-moderate degenerative changes are noted throughout the thoracolumbar
spine.
SOFT TISSUES: Diffuse subcutaneous edema is noted.
IMPRESSION:
1. No CT findings correlating with reported history of a lower extremity
edema. No concerning abdominopelvic mass or central venous compression.
2. Small amount of oral contrast within the excluded stomach, post bypass
surgery, suggests a gastrogastric fistula.
3. Bilateral adrenal adenomas, measuring up to 1.7 x 1.0 cm on the right.
4. Multiple bilateral renal hypodensities, many of which represent simple
cysts. A 3.2 x 3.1 cm intermediate density lesion in the left lower pole may
represent a hemorrhagic or proteinaceous cyst. These were recently
characterized on the ultrasound examination from ___.
5. Aortic valvular and diffuse coronary artery calcifications.
6. Diffuse body wall edema.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Vtach, Transfer
Diagnosed with Syncope and collapse
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: uta
level of acuity: 1.0 | ___ with hx of sCHF (EF 40-45%), CKD ___ IgA nephropathy, and
Afib on anticoagulation who presented to an outside hospital
with nonprodromal syncope and had a polymorphic VT arrest.
Subsequently found have ___, hypokalemia (K 2.7), and severe
volume overload.
# Systolic heart failure (HFrEF) exacerbation: TTE ___ 39%
and hypokinesis of basal inferior/inferoseptal walls. Etiology
likely ischemic as pt reports he had two MIs on stress testing
done by his cardiologist. Pt presented in volume overloaded
state; reports weight gain causing progressive immobility over
the last 6mo. Initially admitted to CCU, placed on dobutamine
gtt at 2.5mcg. Lactate was 4 on ___ -> normalized with
dobutamine and auto-diuresis. Dobutamine d/ced ___. He
autodiuresed -6L over CCU stay, and was transferred to the
floor. Ont he floor his UOP was not adequate and he did not
tolerate dobutamine d/t tachycardia. He was transferred back to
the CCU for tailored diuresis with swan-ganz catheter (-8.4L).
CVP 7, PCW 14 suggested intravascularly dry state, though he had
persistent lower extremity edema likely due to his renal disease
with nephrotic syndrome. He returned to the floor ___, where he
was placed on an oral diuretic regimen and remained euvolemic.
He was discharged on Torsemide 60 PO QAM and 80mg PO QHS. He was
discharged on an afterload reduction regimen with hydralazine
10mg PO Q8H and isosorbide dinitrate 10mg TID. He was also
discharged with metoprolol succinate 200mL daily, which was his
home dose. He was started on ASA 81mg and this was continued at
discharge. His home atorvastatin 80mg was continued. A left
heart cath was deferred during this admission due to the
patient's reduced renal function. He will need an outpatient
viability study after discharge to assess for reversible
ischemia.
# Afib: On metoprolol, amiodarone and Coumadin prior to
admission. Amiodarone was held on admission and was held on
discharge as the patient had a polymorphic VT arrest in the
setting of hypokalemia and amiodarone. His INR was perisistently
subtherapeutic during this hospital stay and was 1.7 on
discharge. His dose of warfarin was increased on discharge to
5mg per day from 4mg per day. His INR should be followed as an
outpatient and his dose of warfarin should be adjusted
accordingly. He persistently had HRs that elevated into the
130s-140s on exertion, likely secondary to deconditioning. He
was started on his home dose of metoprolol succinate 200mg daily
and was discharged on this dose.
# s/p polymorophic VT arrest: probably provoked from hypokalemia
in setting of amiodarone. Etiology of hypokalemia unclear (renal
injury vs. medication-induced). He was seen by electrophysiology
and IC dwas deemed not indicated given VT was provoked.
Amiodarone was discontinued and his electrolytes were monitored
carefully with repletion to K>4 and Mg>2.
#CAD: moderate-sized area of inferior ischemia on nuclear stress
in ___ per cardiologist note. He will need a viability study as
an outpatient for reversible ischemic lesions. Cath was deferred
due to his CKD. He was continued on home atorvastatin 80mg. He
was started on ASA 81mg. He was discharged on both of these.
# ___ on CKD: Baseline Cr ~2.3 due to longstanding IgA
nephropathy. On presentation Cr was 3.95. Likely cardiorenal,
and improved to 2.6 on discharge after diuresis. Home calcitriol
was continued and he was discharged on this. He had a renal
ultrasound which showed diffuse parenchymal disease and a
multiple renal Bosniak cysts (see transitional issues).
# Anemia: Pt had a history of GIB with marginal ulcer in ___
s/p intervention. His Hb was 8.6 on discharge, which was
slightly decreased from an admission Hb of 9.3. He had no signs
or symptoms of bleeding during his hospital stay. He was
continued on his home pantoprazole 40mg BID. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Coccyx Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ end-stage liver cancer on hospice who presents 4 days after
a fall with coccyx pain.
She has been on hospice for 9 months for hepatocellular
carcinoma. She has had accelerated failure to thrive with weight
loss but is still taking PO intake.
She has had pain after mechanical fall about 4 days ago. She has
been trying to use PO dilaudid for pain without success. The
hospice nurse evaluated her this morning, but she has been
getting significant post-dose confusion. It was decided to take
her to the hospital for more intensive pain control.
She has slowly been getting more confused. She has a history of
hepatic encephalopathy and is on lactulose. The confusion has
been attributed to a combination of opiate pain medication and
encephalopathy.
In the ED, initial VS 11:34 0 99 71 105/62 18 94%
Patient presented to ER for pain management. After ER discussion
with both the hospice team and family they clearly only want her
pain to be controlled and do not wish to pursue alternative
reasons for her confusion including infection or electrolyte
abnormalities. Therefore no labs, urine testing or further
imaging were obtained.
Imaging was performed with bilateral hip film, T-spine, and
lumbo-sacral spine showing age-indeterminate L1 compression
fracture < 50 %.
She was given dilaudid 0.5 mg IV x 1 and ketorolac 15 mg IV x 1.
Patient will be admitted for GIP inpatient hospice service with
Dr. ___ to follow as her inpatient physican.
VS on transfer were: 99.___
Mental status is AAOx1-2 with some baseline confusion.
Currently, patient reports great improvement in lower back pain.
She is surrounded by family at bedside and comfortable.
ROS: 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:
- End-stage liver cancer on hospice
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission:
VS - No vital signs
GENERAL - non-toxic, chronically ill appearing female in NAD
HEENT - NC/AT, 2 mm on R, 4 mm on L, 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 - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - bruising, 2+ peripheral pulses (radials, DPs),
bilateral heel blisters, sacral wound (chronic)
NEURO - awake, A&Ox3
Discharge:
VS - No vital signs
GENERAL - non-toxic, chronically ill appearing female in NAD
HEENT - NC/AT, 2 mm on R, 4 mm on L, 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 - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - bruising, 2+ peripheral pulses (radials, DPs),
bilateral heel blisters, sacral wound (chronic)
NEURO - awake, A&Ox3
Pertinent Results:
___ BILAT HIPS (AP,LAT & AP PELVIS)
Final Report
INDICATION: ___ female with fall four days prior and
increasing pain, evaluate for fracture.
COMPARISONS: None.
TWO VIEWS OF THE HIPS: The bones are osteopenic. There is no
fracture or dislocation. Mild degenerative changes of the left
hip are marked by joint space loss and osteophyte formation.
Orthopedic hardware seen within the left femoral head appears to
be in satisfactory position without definite evidence of
loosening. Vascular calcifications are noted.
___
INDICATION: ___ female with fall, evaluate for
fracture.
TWO VIEWS OF THE LUMBAR SPINE: The bones are diffusely
osteopenic, decreasing the sensitivity for detection of subtle
fractures. There are five non-rib-bearing lumbar vertebrae.
There is an age-indeterminate wedge compression deformity of L1.
There is no spondylolisthesis. Moderate degenerative changes
of the lower lumbar spine are marked by disc space narrowing,
endplate sclerosis and facet arthropathy. Extensive vascular
calcifications are noted. A TIPS stent is noted. The hips are
better evaluated on concurrent dedicated radiographs.
TWO VIEWS OF THE THORACIC SPINE: The bones are diffusely
osteopenic,
decreasing the sensitivity for detection of subtle fractures.
Within this limitation, there is no obvious compression
deformity. Degenerative changes are marked by disc space loss.
The imaged portion of the heart and lungs are grossly
unremarkable.
IMPRESSION: Age-indeterminate wedge compression of L1.
Correlate clinically or to prior imaging if available.
___
INDICATION: ___ female with fall, evaluate for
fracture.
TWO VIEWS OF THE LUMBAR SPINE: The bones are diffusely
osteopenic, decreasing
the sensitivity for detection of subtle fractures. There are
five
non-rib-bearing lumbar vertebrae. There is an age-indeterminate
wedge
compression deformity of L1. There is no spondylolisthesis.
Moderate
degenerative changes of the lower lumbar spine are marked by
disc space
narrowing, endplate sclerosis and facet arthropathy. Extensive
vascular
calcifications are noted. A TIPS stent is noted. The hips are
better
evaluated on concurrent dedicated radiographs.
TWO VIEWS OF THE THORACIC SPINE: The bones are diffusely
osteopenic,
decreasing the sensitivity for detection of subtle fractures.
Within this
limitation, there is no obvious compression deformity.
Degenerative changes
are marked by disc space loss. The imaged portion of the heart
and lungs are
grossly unremarkable.
IMPRESSION: Age-indeterminate wedge compression of L1.
Correlate clinically
or to prior imaging if available.
Radiology Report
INDICATION: ___ female with fall four days prior and increasing pain,
evaluate for fracture.
COMPARISONS: None.
TWO VIEWS OF THE HIPS: The bones are osteopenic. There is no fracture or
dislocation. Mild degenerative changes of the left hip are marked by joint
space loss and osteophyte formation. Orthopedic hardware seen within the left
femoral head appears to be in satisfactory position without definite evidence
of loosening. Vascular calcifications are noted.
Radiology Report
INDICATION: ___ female with fall, evaluate for fracture.
TWO VIEWS OF THE LUMBAR SPINE: The bones are diffusely osteopenic, decreasing
the sensitivity for detection of subtle fractures. There are five
non-rib-bearing lumbar vertebrae. There is an age-indeterminate wedge
compression deformity of L1. There is no spondylolisthesis. Moderate
degenerative changes of the lower lumbar spine are marked by disc space
narrowing, endplate sclerosis and facet arthropathy. Extensive vascular
calcifications are noted. A TIPS stent is noted. The hips are better
evaluated on concurrent dedicated radiographs.
TWO VIEWS OF THE THORACIC SPINE: The bones are diffusely osteopenic,
decreasing the sensitivity for detection of subtle fractures. Within this
limitation, there is no obvious compression deformity. Degenerative changes
are marked by disc space loss. The imaged portion of the heart and lungs are
grossly unremarkable.
IMPRESSION: Age-indeterminate wedge compression of L1. Correlate clinically
or to prior imaging if available.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: COXXYX PAIN
Diagnosed with FX LUMBAR VERTEBRA-CLOSE, UNSPECIFIED FALL, LUMBAGO, MAL NEO LIVER, PRIMARY, HEPATIC ENCEPHALOPATHY
temperature: 99.0
heartrate: 71.0
resprate: 18.0
o2sat: 94.0
sbp: 105.0
dbp: 62.0
level of pain: 0
level of acuity: 3.0 | ___ end-stage liver cancer on hospice who presents 4 days after
a fall with coccyx pain admitted to hospital for pain control
with comfort as primary goal.
# Coccyx pain
Patient had mechanical fall and presented with tailbone pain.
Plain films show no acute fracture and indeterminate age
fracture at L1. Goal of admission was pain control given goals
of care. She was given IV dilaudid 0.5 mg IV x 2 in addition to
toradol with good relief.
She was transitioned to her home dilaudid ___ mg PO q 3 hr prn
pain, tylenol as needed, and naproxen as needed for pain.
Her mental status has been AAOx3 to sedated with narcotic
administration.
She will be transferred to a respite bed for further symptom
management.
# End-stage liver cancer
Patient has been on hospice for 9 months for liver cancer.
She continued on aldactone, lactulose, lasix, reglan, ritalin,
trazodone, ativan, compazine, zoloft for comfort.
# Impaired skin integrity
Bilateral heel ulcers and sacral wound noted on admission. She
should continue to have wound care for comfort.
# FEN: regular diet
# CODE: DNR/DNI/CMO
# CONTACTS:
- Dr. ___ (Hospice director) ___
- ___ hospice number ___
- ___ (son/HCP) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OTOLARYNGOLOGY
Allergies:
adhesive tape
Attending: ___.
Chief Complaint:
acute respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old female with long standing
historyof what appears to be idiopathic subglottic stenosis
first diagnosed in ___. She subsequently underwent an LTR
reconstruction with anterior cricoid split in ___ and has
required intermittent balloon dilations ~ every ___ months by
Dr. ___ that time. The most recent dilation was
performed on ___. She presents today after developing a sore
throat and cough over the last 24hrs. At around 2300 she awoke
with acute dyspnea and significant noisy breathing. Due to this
discomfort and known airway abnormality she presented to the
___ ED. She
was found to be stridulous upon arrival but maintaining her
saturations.
She received Decadron IV and racemic epi and had significant
improvement of her symptoms following the nebulizer.
Otolaryngology was consulted for evaluation of her airway. Pt
reports minimal URI symptoms with developing a productive cough
over the last 24hrs and slight odynophagia and minimal
rhinorrhea. No change in her voice. No inciting trauma or event.
No recent aspiration nor chest pain. No fevers or chills. She
had recent possible sick exposure to her grandchildren, one of
whom
had a cold.
Past Medical History:
Subglottic stenosis, HTN, polychondritis, breast cancer s/p
mastectomy and xrt
___ - Laryngotracheal recontruction with rib graft Nissen
fundoplication, numerous tracheal dilations. Right mastectomy
Social History:
___
Family History:
n/c
Physical Exam:
On admission:
Vitals: 97.6 - 114- 145/63 - 14 - 100% neb
General: NAD, A&Ox3
Eyes: extraocular movements intact, pupils equally round and
reactive to light, no lid or conjunctival inflammation or
drainage
AD: Auricle - no tenderness to palpation, no inflammation or
lesions; Canal - without inflammation or lesions; Tympanic
membrane - appears intact, mobile
AS: Auricle - no tenderness to palpation, no inflammation or
lesions; Canal - without inflammation or lesions; Tympanic
membrane - appears intact, mobile
Nose: By anterior rhinoscopy there is no pus or polyps, mucosa
is pink and moist, septum is minimally deviated to the left
OC: mucous membranes are moist and pink, floor of mouth and
tongue are soft and non-tender to palpation, no trismus, no
mucosal lesions, salivary secretions are clear
OP: mucous membranes moist and pink, no lesions.
Neck: no masses, adenopathy or tenderness
Cervicofacial skin: no gross lesions
TMJ: no tenderness
Respiratory Effort: unlabored without stridor or stertor, voice
normal
Neuro: Vision grossly intact, PERRL, EOMI, Sensation intact in
all distributions, facial motion symmetric and intact in all
distributions, strong shoulder shrug, tongue protrudes midline
On discharge:
NAD, A&Ox3
PERRL, mmm, OP clear
breathing comfortably on room air. Unlabored without stridor or
stertor, voice normal
RRR
ext: wwp
Pertinent Results:
___ 03:08AM BLOOD WBC-13.3* RBC-4.38 Hgb-9.9* Hct-33.3*
MCV-76* MCH-22.7* MCHC-29.9* RDW-19.3* Plt ___
___ 12:55AM BLOOD WBC-10.5 RBC-4.68 Hgb-10.7* Hct-35.3*
MCV-75*# MCH-22.9*# MCHC-30.4* RDW-19.2* Plt ___
___ 12:55AM BLOOD ___ PTT-33.7 ___
___ 01:00AM BLOOD Lactate-1.2
___ CXR:
IMPRESSION:
1. No acute cardiopulmonary process.
2. Cardiomegaly.
___: neck soft tissue: AP and lateral images of the neck. The
larynx an proximal trachea are poorly
visualized on lateral projection and proximal trachea is
narrowed on AP projection. Posterior to the epiglottis, there
may be soft tissue swelling to account for poorly assessed
structures. No acute fracture & visualized lung apices are
clear. ADDENDUM: Also visualized on this examination is
moderate disc narrowing and associated osteophytes at the C5-C6
level. I cannot entirely exclude soft tissue prominence in the
posterior nasopharynx. No prevertebral soft tissue swelling
anterior to the upper cervical spine.
Medications on Admission:
valsartan- HCTZ, mometasone inhaler, mometasone
nasal spray, astelin, ranitidine, nexium, mucinex, singulair,
vitamin D
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Astelin (azelastine) 137 mcg nasal 2 sprays in each nostril
BID
3. Docusate Sodium 100 mg PO BID
4. Asmanex Twisthaler (mometasone) 220 mcg (60 doses) inhalation
2 puffs daily
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Nasonex (mometasone) 50 mcg/actuation nasal 2 sprays each
nostril BID
7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
twice a day Disp #*10 Tablet Refills:*0
8. Methylprednisolone 4 mg PO DAILY
Please take as instructed on Medrol Dose Pack
Tapered dose - DOWN
RX *methylprednisolone [Medrol (Pak)] 4 mg as instructed
tablets(s) by mouth as instructed on Dose Pack Disp #*1 Dose
Pack Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Subglottic Stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Tracheal stenosis and shortness of breath, now requiring assessment
for pneumonia.
COMPARISON: Comparison is made with chest radiographs from ___
and ___.
FINDINGS:
PA and lateral images of the chest.
The lungs are well expanded. Atelectasis is seen in the right bilateral lung
bases. There is no pleural effusion or pneumothorax. The cardiomediastinal
silhouette is enlarged. Known tracheal stenosis is noted.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Cardiomegaly.
Radiology Report
HISTORY: Stridor. Apparent known upper tracheal stenosis
COMPARISON: Comparison is made with chest radiographs from ___
(___) and ___.
AP and lateral images of the neck. The larynx an proximal trachea are poorly
visualized on lateral projection and proximal trachea is narrowed on AP
projection. Posterior to the epiglottis, there may be soft tissue swelling to
account for poorly assessed structures. No acute fracture & visualized lung
apices are clear.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Respiratory distress
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 97.6
heartrate: 116.0
resprate: 16.0
o2sat: 98.0
sbp: 150.0
dbp: 84.0
level of pain: 0
level of acuity: 1.0 | The patient was admitted to the Otolaryngology-Head and Neck
Surgery Service on ___ after presenting to the ED in acute
respiratory distress in the setting of chronic subglottic
stenosis likely acutely exacerbated by URI. The patient was
given racemic epi in the ED. She was started on IV decadron and
emperic antibiotics with unasyn and was admitted to the ICU for
close observation on continuous pulse O2 monitoring. She was
monitored with repeat fiberoptic scope exams which demonstrated
an increased subglottic diameter from approximately 4mm to 6mm
over her hospitalization. Over the the course of her hospital
stay, her respiratory status greatly improved and she was weaned
off O2. The patient was started on on diet on HD1, which she
tolerated without issue. She was continued on her home
medications on admission. The patient was discharged home on
___ in stable conditions, with O2 saturations stable on room
air, pain controlled, tolerating a regular diet and voiding
without issue. She was discharged home in stable condition,
ambulating and voiding independently, and with adequate pain
control. The patient was given instructions to follow-up in
clinic with Dr. ___ PCP ___ ___ weeks. Pt was given
detailed discharge instructions outlining wound care, activity,
diet, follow-up and the appropriate medication scripts for a
medrol dose pack and 5 days of augmenting. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left flank pain secondary to severe left hydronephrosis
Major Surgical or Invasive Procedure:
Interventional radiology placed left 8 ___ nephrostomy tube.
History of Present Illness:
___ year old healthy male with 1 day of left flank pain found to
have severe left hydroureteronephrosis and severe cortical
thinning. No e/o infection or obstructive stone.
Past Medical History:
HEMORRHOIDS
No surgical history
Social History:
___
Family History:
Kidney cancer: no
Prostate cancer: no
Bladder cancer: no
He has a family history of nephrolithiasis, but no family
history of any GU malignancies.
Physical Exam:
GEN: NAD, resting comfortably, AAO
HEENT: NCAT, anicteric sclera
PULM: nonlabored breathing, normal chest rise
ABD: soft, moderately distended with prominent fullness in
the left abdomen and suprapubic region, nontender
EXT: WWP. wearing scds. no e/c/p/d.
Pertinent Results:
___ 07:50AM BLOOD WBC-6.5 RBC-4.02* Hgb-12.6* Hct-37.3*
MCV-93 MCH-31.3 MCHC-33.8 RDW-12.4 RDWSD-42.2 Plt ___
___ 10:56AM BLOOD WBC-8.5 RBC-4.20* Hgb-13.3* Hct-38.6*
MCV-92 MCH-31.7 MCHC-34.5 RDW-12.5 RDWSD-41.0 Plt ___
___ 07:50AM BLOOD Glucose-98 UreaN-13 Creat-1.1 Na-140
K-4.2 Cl-103 HCO3-24 AnGap-13
___ 10:56AM BLOOD Glucose-118* UreaN-14 Creat-1.1 Na-137
K-5.4 Cl-103 HCO3-21* AnGap-13
___ 10:56AM BLOOD ALT-20 AST-43* AlkPhos-68 TotBili-0.5
___ 10:56AM BLOOD Albumin-4.8
___ 11:00 am URINE **FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
NONE
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Disposition:
Home
Discharge Diagnosis:
flank pain, left
hydronephrosis, severe left
megaureter
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 LLQ, L flank pain. Eval for nephrolithiasis, other
intra abdominal process
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 8.5 s, 0.5 cm; CTDIvol = 40.9 mGy (Body) DLP =
20.5 mGy-cm.
2) Spiral Acquisition 6.9 s, 54.6 cm; CTDIvol = 10.0 mGy (Body) DLP = 546.0
mGy-cm.
Total DLP (Body) = 566 mGy-cm.
COMPARISON: None available.
FINDINGS:
LOWER CHEST: Bibasilar atelectasis. Otherwise, visualized lung fields are
within normal limits. There is no evidence of pleural or pericardial
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Subcentimeter hypodense lesion seen in the left lobe of the liver is too small
to further characterize. 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: Megaureter and massive hydronephrosis of the left kidney with
thinning of the cortex, a chronic finding. Multiple renal stones identified,
with the largest conglomerate measuring 1.7 cm in the lower pole of the left
kidney. The right kidney appears normal. Of note, the insertion of the left
ureter in the bladder is not clearly delineated, it is seen
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits.
PELVIS: The urinary bladder is unremarkable. The distal left ureter is
enlarged, measuring 6.1 cm. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: There is some distortion in the pelvis in the region of
prostate and seminal vesicles which is felt most likely to be secondary to the
dilated left ureter.
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. Left megaureter and massive hydronephrosis, a chronic finding. Multiple
nonobstructing renal stones identified with the largest conglomerate measuring
1.7 cm in the left lower pole.
2. Of note, the insertion of the left ureter into the bladder is not clearly
delineated on this exam and there is secondary distortion of the region of the
seminal vesicles. Consider pelvic MRI to further delineate for underlying
anomalous insertion.
3. Otherwise unremarkable exam without findings to explain symptoms. The
right kidney appears normal.
NOTIFICATION: Updated findings discussed with Dr. ___, by Dr.
___.
Radiology Report
INDICATION: ___ year old man with left flank pain ___ left hydronephrosis//
left PCN
COMPARISON: CT abdomen and pelvis ___
TECHNIQUE:
OPERATORS: Dr. ___ Interventional ___ and Dr. ___
___, Radiology resident performed the procedure. Dr. ___
supervised the trainee during any key components of the procedure where
applicable and reviewed and agrees with the findings as reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
70 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 30 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS:
CONTRAST: 20 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 5.9 minute, 55 mGy
PROCEDURE:
1. Left ultrasound guided renal collecting system access.
2. Left nephrostogram.
3. Left ___ percutaneous nephrostomy tube placement.
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 left flank was prepped and draped in the usual sterile fashion.
After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues,
the left renal collecting system was accessed through a posterior lower pole
calyx under ultrasound guidance using a 21 gauge Cook needle. Ultrasound
images of the access were stored on PACS. Prompt return of urine confirmed
appropriate positioning. Injection of a small amount of contrast outlined a
dilated renal collecting system. Under fluoroscopic guidance, a Nitinol wire
was advanced into the renal collecting system. After a skin ___, the needle
was exchanged for an Accustick sheath. Once the tip of the sheath was in the
collecting system; the sheath was advanced over the wire, inner dilator and
metallic stiffener. The wire and inner dilator were then removed and diluted
contrast was injected into the collecting system to confirm position. A
___ wire was advanced through the sheath and coiled in the collecting
system. The sheath was then removed and a 8 ___ nephrostomy tube was
advanced into the renal collecting system. The wire was then removed and the
pigtail was formed in the collecting system. Contrast injection confirmed
appropriate positioning. The catheter was then flushed, 0 silk stay sutures
applied and the catheter was secured with a Stat Lock device and sterile
dressings. The catheter was attached to a bag.
Patient tolerated the procedure without any immediate ___
complication.
FINDINGS:
Severe left sided hydronephrosis. Limited opacification of the ureter with
contrast given the substantial caliber.
IMPRESSION:
Successful placement of left 8 ___ nephrostomy tube.
Radiology Report
EXAMINATION: MR UROGRAM
INDICATION: ___ year old man with severe left hydronephrosis// rule out pelvic
sarcoma, rule out ectopic ureter insertion (MR ___
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen and pelvis
were acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
10 mg of furosemide were administered intravenously during the examination.
COMPARISON: CT ___
FINDINGS:
Kidneys, Ureters, and Bladder:
There is re-demonstrated left megaureter and severe hydronephrosis with marked
cortical thinning of the kidney. Debris and renal stones noted in the
dependent portion of the distally megaureter and the dependent portion of the
left kidney.
The distal most ureter at the UVJ (series 10, image 19) is decompressed with
normal location of ureteral insertion on the urinary bladder. The transition
to dilated ureter 1.5 cm proximal to the level of the UVJ (series 10, image
19) at the level of the seminal vesicles.
Prostate is within normal limits. Left seminal vesicles are mildly prominent,
but likely within normal limits.
The right kidney is unremarkable.
Liver: No suspicious hepatic lesions. Hepatic parenchyma is normal in signal
intensity.
Biliary: No intra or extrahepatic biliary ductal dilatation. Gallbladder is
unremarkable.
Pancreas: Pancreas is normal in size and signal intensity. No main pancreatic
ductal dilatation. No focal lesion.
Spleen: No splenomegaly.
Adrenal Glands: No focal adrenal lesion.
Gastrointestinal Tract: The stomach is nondistended and without mural
thickening. No small or large bowel dilatation or mural thickening. The
appendix is unremarkable.
Lymph Nodes: No lymphadenopathy.
Vasculature: No aortic aneurysm. The aorta its major branches are patent.
Osseous and Soft Tissue Structures: No fracture, dislocation or suspicious
osseous lesion. Skin thickening overlying the left flank likely secondary to
recent intervention. Otherwise, superficial soft tissues are within normal
limits.
IMPRESSION:
1. Redemonstration of severe left hydronephrosis and megaureter, extending to
the level of the left UVJ. The insertion of the left ureter is normal.
2. Multiple renal stones re-demonstrated.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, B Flank pain
Diagnosed with Unspecified abdominal pain
temperature: 97.4
heartrate: 73.0
resprate: 18.0
o2sat: 100.0
sbp: 138.0
dbp: 83.0
level of pain: 8
level of acuity: 3.0 | ___ y/o p/w severe left hydronephrosis and cortical thinning with
associated megaureter. His Cr on admission was 1.1 and there was
no evidence of infection. His left kidney appeared to be
chronically obstructed. He was admitted from the ED and our
colleagues in ___ were consulted for LEFT PCN placement and
decompression. He was taken to ___ and they placed the PCN.
Overnight and since placement of the PCN his symptoms improved
and on HD2 he was discharged to home with the PCN to gravity
drainage. He was given explicit instructions for follow up for
definitive management and visiting nurse services set up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
indomethacin
Attending: ___.
Chief Complaint:
Exposed pacemaker
Major Surgical or Invasive Procedure:
___: Pacemaker removal and lead extraction
___: Placement of new bi-v pacer
___: Pacer site hematoma evacuation, debridement, and closure
History of Present Illness:
Mr. ___ is an ___ gentleman with a history of CHF, CAD
(s/p CABG x 5 in ___, atrial flutter s/p ablation, a fib (on
warfarin), complete AV block s/p PPM (MED model ___.
BIV implanted ___ ___ model ___ s/p gen change
___, required washout in ___ for migration and PPM pocket
abscess) who represents with skin breakdown and appliance
migration through skin.
Patient reports appliance had and has been functioning
appropriately. He noticed some bleeding on his shirt over the
past 2 days and home health aide noticed metal coming through
skin this morning. No spreading redness, purulent drainage, or
warmth at site. He has not had any fevers, chills, nausea,
vomiting, chest pain, palpitations, or shortness of breath (more
than baseline), but has noticed his blood pressure higher than
baseline today at 160-170's systolic. Patient was seen at his
cardiologist's office and transferred to ___ and
later ___. Per EMS, he was tachy to the 110's en route.
Pt tachy to 110s en-route per EMS. Paced ___ in ED. EKG
paced w/ PVCs. Pt in NAD - has been hypertensive today to
160s-170s systolic.
In the ED, initial vitals were 98.2 86 173/105 16 97% RA. EKG
was paced with PVC's. CXR showed mild pulmonary vascular
congestion and pacemaker leads in unchanged location compared
with prior exam. Labs were notable for WBC of 11.2 and INR of
2.8 (on coumadin). Patient was admitted to the ___ service for
IV antibiotics, pacemaker repositioning vs. replacement, and
monitoring.
On arrival to the floor, patient is in no acute distress and
confirms the above history.
Past Medical History:
1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: yes (5V), MI, CHF
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: atrial flutter s/p ablation ___ complete
heart block s/p AICD replaced ___ to Biventricular pacer,
s/p generator change in ___, s/p pocket infection (treated
with antibiotics, avoided explant)
3. OTHER PAST MEDICAL HISTORY:
- left total hip and knee replacement
- osteoarthitis
- lymphocele repair with RLE cellulitis
- GERD
- s/p repair of quadriceps rupture
- chronic renal insufficiency
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM
97.8 83 18 169/84 95 RA
GENERAL: Pleasant, centrally obese older gentleman in NAD. A+O x
3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple, could not assess JVP due to habitus
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi. PPM edge is exposed laterally with mild
erythema but no warmth or purulent drainage. Non-tender to
palpation.
ABDOMEN: Soft, obese, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: Hyperpigmentation of b/l ankles, trace pedal edema,
distal pulses 1+ and symmetrical
NEURO: A+O x 3, moving all 4 (though notes difficulty w/ left
leg s/p femoral nerve injury during L hip replacement)
DISCHARGE EXAM:
Vitals: 98.2/98.3 64 102/54 18 99%RA
Weight: 113.3 kg -> 112.3 -> 110.9 -> 110.0 -> 109.3 -> 106.7 ->
107.9 -> 109.2 -> 109.2 -> 108.5 -> 109.2 -> 110.0 kg
(discharge weight)
GENERAL: Pleasant, centrally obese older gentleman in NAD. A+O x
3
HEENT: MMM. Sclera anicteric
NECK: Supple, JVD flat
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4. Large, firm, ___ round hematoma on L anterior chest
with compression dressing that has serosanguinous drainage. PPM
pocket R anterior chest with sutures intact.
LUNGS: Distant breath sounds. Wheezing, no rales
ABDOMEN: Obese, nontender
EXTREMITIES: Hyperpigmentation of b/l ankles, ___ peripheral
edema with trace edema to thigh, improving
Pertinent Results:
ADMISSION LABS
___ 03:00PM BLOOD WBC-11.2* RBC-5.45# Hgb-15.8# Hct-47.2#
MCV-87# MCH-28.9 MCHC-33.4 RDW-16.3* Plt ___
___ 03:00PM BLOOD ___ PTT-43.5* ___
___ 03:00PM BLOOD Glucose-95 UreaN-20 Creat-1.6* Na-141
K-4.1 Cl-102 HCO3-25 AnGap-18
___ 03:00PM BLOOD Calcium-9.7 Phos-2.7 Mg-1.7
DISCHARGE LABS
___ 07:15AM BLOOD WBC-8.3 RBC-3.57* Hgb-10.3* Hct-32.2*
MCV-90 MCH-28.9 MCHC-32.0 RDW-17.6* Plt ___
___ 07:15AM BLOOD ___
___ 07:15AM BLOOD UreaN-46* Creat-2.1* Na-138 K-4.8 Cl-95*
HCO3-30 AnGap-___ Wound Culture: PENDING
___ MRSA SCREEN-PENDING
___ SWAB GRAM STAIN-FINAL; WOUND CULTURE-PRELIMINARY;
ANAEROBIC CULTURE-FINAL INPATIENT
___ Blood Culture- PENDING
___ Blood Culture- PENDING
___ 12:19 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
STUDIES AND IMAGING
___ EKG
Biventricular paced rhythm with a single ventricular premature
beat which does not appear to be sensed by the pacemaker. Since
the previous tracing atrial activity is difficult to assess.
Suggest pacemaker interrogation.
Rate PR QRS QT/QTc P QRS T
74 0 ___ 0 176 37
___ CXR
1. Mild pulmonary vascular congestion.
2. Pacemaker leads in unchanged location compared with prior
exam.
___ ECHO
Limited transgastric views due to poor image quality 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 pericardial effusion.
The ejection fraction is ___.
___ EKG
Atrial fibrillation and ventricular paced rhythm with capture as
compared to the previous tracing of ___. Ventricular ectopy
is no longer recorded. Otherwise, no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
70 0 ___ 0 -58 126
___ CXR:
Evaluation of the lung parenchyma is somewhat limited due to
dense
overlying soft tissues. Within these limitations, there is dense
retrocardiac opacification, seen best on the lateral view, which
may be due to atelectasis related to stable moderate-to-severe
cardiomegaly. However, pneumonia is a consideration in the
appropriate clinical setting. Cardiomediastinal and hilar
contours are unchanged. No pleural effusion is identified.
IMPRESSION: Dense retrocardiac opacification could be
consistent with
pneumonia in the appropriate clinical setting, though
atelectasis related to stable cardiomegaly is also likely.
___ TTE:
The left atrium is mildly dilated. The right atrium is
moderately dilated. A mobile, echodense mass/thrombus measuring
1.3x0.6 cm associated with a catheter/pacing wire is seen in the
right atrium (clips ___. The estimated right atrial pressure
is ___ mmHg. 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. Doppler parameters are indeterminate
for left ventricular diastolic function. Right ventricular
chamber size and free wall motion are normal. The aortic arch is
mildly dilated. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Small mobile echodensity
associated with the wire in the right atrium. Normal global left
ventricular systolic function. Mild mitral regurgitation. Mildly
dilated aortic arch.
___ TEE:
The left atrium is dilated. Moderate to severe spontaneous echo
contrast is present in the left atrial appendage. A posssible
thrombus is seen at the mouth of the left atrial appendage on
the mitral valve side (best seen on clip 36). The right atrium
is dilated. Moderate to severe spontaneous echo contrast is seen
in the body of the right atrium. No mass or thrombus is seen in
the right atrium or right atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. LV systolic function
appears mildly depressed with possible hypokinesis of the
inferior and inferoseptal walls in the base and midventrical
(distal and apex not well seen). The right ventricular systolic
function is depressed mild global free wall hypokinesis. There
are simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta at ~40 and 37 cm. The aortic
valve leaflets (3) are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. If clinically indicated, a complete
transthoracic examination with Doppler is recommended to better
assess LV systolic wall motion.
IMPRESSION: Possible thrombus in the ___. Mildly depressed
biventricular systolic function. Moderate mitral regurgitation.
Complex atheroma of the descending aorta.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
Hold for HR<55 or SBP<90
4. Fish Oil (Omega 3) ___ mg PO DAILY: QAM
5. Fluticasone Propionate 110mcg 1 PUFF IH BID
6. Furosemide 40 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Nitroglycerin SL 0.4 mg SL PRN chest pain
9. Pantoprazole 40 mg PO Q24H
10. Tiotropium Bromide 1 CAP IH DAILY
11. Fish Oil (Omega 3) 1000 mg PO DAILY QPM
12. Tricor *NF* (fenofibrate nanocrystallized) 145 mg Oral daily
13. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN wheezing, SOB
14. Acetaminophen 650 mg PO Q6H:PRN pain
15. Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Fluticasone Propionate 110mcg 1 PUFF IH BID
5. Pantoprazole 40 mg PO Q24H
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN wheezing, SOB
8. Fish Oil (Omega 3) ___ mg PO DAILY: QAM
9. Fish Oil (Omega 3) 1000 mg PO DAILY QPM
10. Multivitamins 1 TAB PO DAILY
11. Nitroglycerin SL 0.4 mg SL PRN chest pain
12. Tiotropium Bromide 1 CAP IH DAILY
13. Tricor *NF* (fenofibrate nanocrystallized) 145 mg ORAL DAILY
14. Warfarin 2 mg PO DAILY16
15. Amiodarone 200 mg PO DAILY
16. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
17. Metoprolol Succinate XL 100 mg PO DAILY
18. Potassium Chloride 40 mEq PO DAILY
19. Tamsulosin 0.4 mg PO HS
20. Torsemide 80 mg PO QAM, Q3PM
21. Metolazone 5 mg PO ASDIR for weight gain of 3 lbs or more
Duration: 1 Doses
Please take if your weight increases by more than 3 lbs.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Exposed pacemaker
- Complete heart block
- Acute-on-Chronic Diastolic and Systolic Heart Failure
- Anterior Chest Hematoma
- ___
- Anemia
SECONDARY DIAGNOSES:
- Hypertension
- CKD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male pacemaker breakthrough through the skin.
Evaluate for lead migration.
COMPARISON: ___.
TECHNIQUE: AP and lateral chest radiograph.
FINDINGS: A pacemaker projecting over the left axilla is re-demonstrated.
Two right ventricular, one right atrial and one left coronary sinus leads are
unchanged in position compared with prior exam. Sternotomy wires are intact.
Surgical clips are noted within the mediastinum compatible with prior CABG.
Lung volumes are low, accounting for bronchovascular crowding. There is
prominence of interstitial markings, but no focal parenchymal opacities. The
heart size is moderately to severely enlarged. The aorta is tortuous. There
is no pleural effusion or pneumothorax.
IMPRESSION:
1. Mild pulmonary vascular congestion.
2. Pacemaker leads in unchanged location compared with prior exam.
Radiology Report
HISTORY: Pacemaker lead extraction and intubation.
FINDINGS: In comparison with the study of ___, the subclavian pacer leads
have been removed. Endotracheal tube is now in place with its tip
approximately 4 cm above the carina.
Continued enlargement of the cardiac silhouette with some retrocardiac
opacification suggesting atelectasis. No evidence of pulmonary vascular
congestion.
Radiology Report
INDICATION: Status post pacemaker placement. Evaluate for pneumothorax.
COMPARISON: Chest radiographs ___.
FINDINGS: A frontal supine view of the chest was obtained portably. There
has been interval placement of a right pacemaker with the leads projecting
over the expected locations of the right atrium and right ventricle. No focal
consolidation, pleural effusion or appreciable pneumothorax. Mediastinal
silhouette is slightly narrower. Heart size is unchanged.
IMPRESSION: No appreciable pneumothorax.
Radiology Report
HISTORY: PPM placement, subclavian access, right lead position.
CHEST, TWO VIEWS
Detail is limited due to overlying soft tissues and underpenetration,
accentuated by rotated positioning.
Allowing for this, a right-sided pacemaker is present, with lead tips over the
right atrium and right ventricle. Sternotomy wires, prominent
cardiomediastinal silhouette, and tortuous aorta appear grossly unchanged. No
CHF, frank consolidation or gross effusion is identified. The lungs are
hyperinflated and the diaphragms are flattened, consistent with COPD. The
extreme posterior costophrenic angles are excluded from the films. Allowing
for hyperlucency of the lungs secondary to COPD, no pneumothorax is detected.
Mild degenerative changes of the thoracic spine are noted.
IMPRESSION: Status post pacemaker, with lead tips over right atrium and right
ventricle. No gross change compared with ___.
Radiology Report
INDICATION: Increasing white blood cell count. Assess for pneumonia.
COMPARISON: Comparison is made to chest radiograph performed ___.
FINDINGS: Evaluation of the lung parenchyma is somewhat limited due to dense
overlying soft tissues.
Within these limitations, there is dense retrocardiac opacification, seen best
on the lateral view, which may be due to atelectasis related to stable
moderate-to-severe cardiomegaly. However, pneumonia is a consideration in the
appropriate clinical setting. Cardiomediastinal and hilar contours are
unchanged. No pleural effusion is identified.
IMPRESSION: Dense retrocardiac opacification could be consistent with
pneumonia in the appropriate clinical setting, though atelectasis related to
stable cardiomegaly is also likely.
Radiology Report
HISTORY: Pacemaker and chest tightness.
FINDINGS: In comparison with the study of ___, there is little change.
Enlargement of the cardiac silhouette without vascular congestion, pleural
effusion, or acute focal pneumonia. Stable pacemaker leads in the region of
the right atrium and apex of the right ventricle.
Radiology Report
HISTORY: Congestive failure, to assess for improvement.
FINDINGS: In comparison with the study of ___, there is little change.
Again there is enlargement of the cardiac silhouette with essentially normal
pulmonary vessels, raising the possibility of cardiomyopathy.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: PACEMAKER ISSUE
Diagnosed with DUE TO OTHER CARDIAC DEVICE,IMPLANT,GRAFT, ACCIDENT NOS
temperature: 98.2
heartrate: 86.0
resprate: 16.0
o2sat: 97.0
sbp: 173.0
dbp: 105.0
level of pain: 0
level of acuity: 2.0 | ___ with CHF, CAD, CHB s/p PPM with history of PPM pocket
infection presents with exposed device, now s/p lead extraction
with temp lead placement c/b cardiac arrest, pacer site hematoma
with substantial blood loss requiring resuscitation, and flash
pulmonary edema, now improving with diuresis.
ACTIVE ISSUES
# Pacemaker Pocket Erosion: Patient presented with an exposed
PPM. Although there was not overt erythema, warmth, or purulent
drainage, a pocket infection was a very likely contributor to
his pocket erosion, and he was started on vancomycin. On
___, patient underwent pacemaker lead extraction. He had 4
leads (LV lead by BiV, RA, and RV pacing leads, and ICD lead).
Lead extractions were difficult as leads were covered with
fibrous tissue and 1 was stuck in the subclavian vein which was
stuck to the clavicle. Two leads snapped, one was able to be
extracted, the other had to be taken out through surgery.
Patient is pacer dependent and had asystole due to the temp wire
being dislodged intraoperatively. He had approximately 1 minute
of CPR prior junctional escape and repositioning of the
temporary pacing wire (via left groin) with capture. He was
noted to have chronic erosions of pocket. Pocket did not look
acutely infected, swabs were sent, and he was continued on
vancomycin. The patient was left intubated overnight due to
complicated lead extraction and monitored in the CCU. He was
successfully extubated the following morning. Later in the day,
he acutely developed a large hematoma at the left pectoral wound
site where his pacer device was removed. Pressure was held, EP
came to evaluate, and pressure dressing applied. Patient
received new pacer device on ___ that was uncomplicated.
# Anterior Chest Wall Hematoma: Device extraction was
complicated by a large (approximately 10") anterior chest
hematoma. His HCT trended from an admission level of 47 to 26.
Thereafter, it remained stable in the mid 20___. He did not
require blood transfusion. He eventually had wound dehiscence
due to the size of the hematoma and required surgical evacuation
and placement of temporary sutures to allow for healing by
secondary intention. He initially completed a 2 week course of
vanc prior to dehiscence, and then after evacuation he was
started on a course of vanco x4d converted to clinda till ___
to complete a 7 day course. He did not have clinical signs of
infection but due to the type of wound and presentation, he was
empirically treated.
# Complete Heart Block: Upon admission, patient's PPM was
functioning normally. He was maintained on telemetry. He
received a new dual chamber PPM that is functioning properly and
is v-paced at 70 bpm. Intermittently had atrial capture of afib
and paced at ~120, asymptomatic, which was stopped when his mode
was switched.
# Acute on chronic renal failure: Patient developed ___ with a
creatinine of 2.3 from a baseline of 1.5-1.6 in the setting of a
significant HCT drop (47->26). Source of bleeding was anterior
chest hematoma. Patient's renal failure was most likely due to
prerenal physiology. His creatinine stablilized at 2.0-2.1 by
discharge with continued diuresis.
# Acute on Chronic Diastolic and Systolic CHF: Last documented
EF 45%. Patient's carvedilol and furosemide were held during his
CCU course due to low BP. He required additional diuresis upon
arrival back to floor. Diuresed over the course of 2 weeks with
lasix gtt eventually converted to torsemide 80 BID with
metolazone 5 mg PO twice weekly as needed to maintain weight of
around 110kg. He should maintain a ___ cc fluid restriction.
# Leukocytosis: Secondary to hematoma. Downtrended after
evacuation. No concern for infection during the hospital
course.
CHRONIC ISSUES
1. Cardiomyopathy: Patient was transitioned from furosmide to
torsemide as above.
2. Atrial Fibrillation: Patient's coumadin was held in
preparation for his pacemaker extraction. It was restarted
post-procedure and he was therapeutic on discharge. He was
loaded with amiodarone and cardioversion was planned, but TEE
revealed left atrial appendage hematoma, so this was aborted. He
was discharged with amiodarone 200 mg PO daily in case future
cardioversion is considered.
3. CAD: Patient was continued on ASA and atorvastatin. His
Tricor was held as it is non-formulary but was restarted upon
discharge.
4. Asthma vs. COPD: Patient was continued on
albuterol-ipratropium. His tiotropium was held given he was
already on ipratropium. He was continued on fluticasone.
5. GERD: Patient continued pantoprazole.
TRANSITIONAL ISSUES
- discharge weight: 110 kg
- physical therapy
- f/u with EP for evaluation of wound
- f/u with wound care after discharge from rehab
- maintain euvolemia, patient may require metolazone 5 mg twice
per week |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Biaxin / Cephalosporins / Codeine / Percocet /
Erythromycin Base / Morphine / Vicodin / Tegretol / phenytoin /
Flagyl / vancomycin / Cipro / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP, balloon dilation
History of Present Illness:
The patient is a ___ female w/PMHx sphincter of Oddi
dysfunction and diverticulitis now presenting with abdominal
pain. She was discharged from ___ about a month ago after an
admission for diverticulitis. Since that time she was doing ok.
Then yesterday, she had an attack of pain at 8:30am, it awoke
her from sleep. She had another at 11:30am and then today at
2:30am,
which has been unremitting. The pain is epigastric, slightly
radiating through to her back but not to the sides, "tight" and
comes in waves. It feels like her prior episodes of sphincter
of Oddi dysfunction. She gets attacks q4mths but they resolve
when she drinks a big glass of water. She has had no nausea
except with pain medication, and no vomiting, no diarrhea. She
passes stool about once a day now. She presented to ___
but was
transferred here since she has gotten care here before. She
denies fevers, chills, chest pain, shortness of breath or
dysuria or other urinary changes.
In the ED: her vitals were unremarkable, she was evaluated with
labs, and a RUQ U/S which showed no abnormalities other than a
"1.7 cm porta hepatic node" which was felt to be non-specific
and possibly due to underlying liver disease.
Seen in the hospital, she conveys the above history. She is very
uncomfortable when I first meet her -- crying, rocking in bed,
clutching a warm pack to her epigastric region. Her symptoms
seem to increase as I interview her, and then lessen slightly
once I leave the bedside -- it seems there may be a component of
anxiety in addition to her pain. The nurse medicates her again
with hydromorphone so I can resume the interview. She is
concerned that this episode might delay her diverticulitis
surgery (she says she's scheduled to see Dr. ___ in a few
days).
ROS: [x] As per above HPI, otherwise reviewed and negative in
all systems
Past Medical History:
Sphincter of Oddi dysfunction s/p ERCP and sphincterotomy in
___ with Dr. ___ -- ___ episode at age ___, ___ was in ___
Cystitis -- w/diverticulitis ___
Multiple drug allergies -- has not seen an allergy specialist
Epilepsy
Attention deficit disorder
Migraines -- ~5x/mth
GERD
Active smoking
s/p Cholecystectomy
s/p Right ankle surgery
s/p Tonsillectomy/adnoidectomy
s/p Left breast cosmetic surgery
Social History:
___
Family History:
Gallstone disease in grandmother. No family history of peptic
ulcer disease. No family history of seizure disorder.
Physical Exam:
Admission:
VS: T 98.6, HR 83, BP 113/66, RR 20, O2 sat 100% on RA
Lines/tubes: PIV
Gen: young woman seated in bed, crying, clutching her abdomen
and rocking and forth, somewhat anxious as well, alert
HEENT: anicteric, PERRL, MMM
Neck: supple
Chest: equal chest rise, CTAB posteriorly, no WOB or cough
Cardiovasc: RRR, no m/r/g, no peripheral edema
Abd: obese, NABS, soft, non-tender (including LLQ and
epigastrium) to deep palpation, non-distended, no organomegaly
Extr: WWP
Skin: no rashes noted on limited exam
Neuro: speaking easily, no facial droop, moving all 4 extr,
sensation to light touch intact
Psych: anxious, crying -- then after hydromorphone more calm
Discharge:
AVSS
No apparent distress, ambulating the halls
MMM
soft, nontender, mildly distended abdomen, positive bowel sounds
No distress
Pertinent Results:
___ 09:45AM BLOOD WBC-10.5 RBC-4.41 Hgb-13.6 Hct-40.3
MCV-91 MCH-30.7 MCHC-33.6 RDW-12.4 Plt ___
___ 09:45AM BLOOD Neuts-72.2* Lymphs-15.7* Monos-5.6
Eos-6.2* Baso-0.3
___ 06:15AM BLOOD ___ PTT-30.4 ___
___ 09:45AM BLOOD Glucose-109* UreaN-8 Creat-0.6 Na-137
K-3.7 Cl-104 HCO3-28 AnGap-9
___ 09:45AM BLOOD ALT-82* AST-138* AlkPhos-156* TotBili-1.2
___ 07:20AM BLOOD ALT-60* AST-35 AlkPhos-235* TotBili-0.5
___ 06:15AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.7
___ 09:45AM BLOOD Lipase-28
ERCP: The common bile duct, common hepatic duct, right and left
hepatic ducts, and biliary radicles were filled with contrast
and well visualized. The course and caliber of the structures
are normal with no evidence of extrinsic compression, no ductal
abnormalities, and no filling defects. The duct was swept using
the extraction balloon catheter with no stones or sludge noted
on extraction. Procedures: A 6 mm CRE balloon was used to dilate
the stenosed sphincterotomy site.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 1 tab oral DAILY
3. Multivitamins 1 TAB PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Adderall (dextroamphetamine-amphetamine) 20 mg oral BID
7. Ursodiol 500 mg PO TID:PRN pain
8. LaMOTrigine 100 mg PO BID
9. carisoprodol 350 mg oral DAILY:PRN sciatica
10. Ibuprofen 800 mg PO Q8H:PRN pain
11. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
12. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
Discharge Medications:
1. Adderall (dextroamphetamine-amphetamine) 20 mg oral BID
2. Calcium Carbonate 500 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. LaMOTrigine 100 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
7. carisoprodol 350 mg oral DAILY:PRN sciatica
8. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
9. Ibuprofen 800 mg PO Q8H:PRN pain
10. Multivitamins 1 TAB PO DAILY
11. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 1 tab oral DAILY
12. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
may make you drowsy
RX *hydromorphone 2 mg 1 tablet(s) by mouth every 4 hours Disp
#*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bile duct disorder
Abdominal pain
Constipation
Transaminitis
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: ___ woman with elevated liver enzymes
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
LIVER: The echogenicity of the liver is homogeneous. 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. There is a 1.7 cm lymph node in the
porta hepatis.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
There are no stones seen within the common bile duct.
GALLBLADDER: The gallbladder is surgically absent.
PANCREAS: Head, body and tail of the pancreas are within normal limits,
without masses or pancreatic ductal dilatation.
SPLEEN: Normal echogenicity, measuring 12.1 cm.
A limited view of the right kidney is unremarkable.
IMPRESSION:
1. Status post cholecystectomy. No evidence of intra or extrahepatic biliary
duct dilation. No stones seen within the common bile duct.
2. 1.7 lymph node in the porta hepatis is nonspecific and could relate to
underlying liver disease.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Epigastric pain
Diagnosed with ABDOMINAL PAIN EPIGASTRIC, ABDOMINAL PAIN RUQ
temperature: 98.6
heartrate: 96.0
resprate: 18.0
o2sat: 99.0
sbp: 94.0
dbp: 73.0
level of pain: 8
level of acuity: 3.0 | # Epigastric pain
Likely secondary to stenosis of prior sphincterotomy site. She
presented with elevated lfts which downtrended after the
procedure. In addition, her epigastric abdominal pain also
improved afer the procedure. She notes that she feels "a quiver"
at the site where she would get SOD pain. She was given a
limited prescription of dilaudid (she was warned against driving
as this could make her drowsy). She was tolerating a low fat
regular diet at the time of discharge. Of note, she had self
discontinued the urosdiol. This was not restarted at discharge.
# Constipation:
She had constipation on LLQ pain. She was initially concerned
that this was due to diverticulitis. However, she did not have
fevers, chills, leukocytosis or other worrisome symptoms. She
was treated with aggressive bowel regimen with improvement in
her symptoms. At the time of discharge she was moving her bowels
and was pain free in this area. She was encouraged to maintain
adequate hydration and limit narcotics as much as possible. In
regards to her prior diverticulitis, she is scheduled to follow
up with Dr. ___ on ___.
# Epilepsy
- continue lamotrigine
# ADD
- continue Adderall
# Active smoking
- nicotine patch while here |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Lithium /
oxcarbazepine / metformin / Victoza
Attending: ___.
Chief Complaint:
Chest pain, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx of CAD, CHF, DM2, CKD, COPD on home O2 at night
presenting to the ED with chest pain and dyspnea for the past 3
days.
The patient reports that last ___ he began experiencing
productive cough with thick sputum. This continued over the
weekend, with progressively worsening SOB. This morning, he woke
up with a worsened productive cough and significant dyspnea, so
called the ambulance.
He also endorses chest discomfort located across his chest on
both right and left sides. He says this pain does not feel like
cardiac chest pain; "I would know because I've had a heart
attack before".
The patient reports that he has had difficulty not retaining
fluid, and says that his legs have been progressively more heavy
and fluid filled over the past ___ weeks. He says he has been
gaining weight but is unclear how much. He is also unsure of his
baseline weight. He was seen by his cardiologist last week with
recommendation to be admitted for CHF control, however he waited
until today due to ___ Day.
The patient reports using oxygen at night and when he naps. He
says his baseline O2 sat is ~93% without oxygen.
In the ED, initial vitals were 97.8 66 120/64 18 100% Nasal
Cannula
EKG: NSR, no ST or T-wave abnormalities
Labs/studies notable for:
133 92 33 /
------------ 198 AGap=16
3.9 29 1.0 \
BNP 631
Trop <0.01
Patient was given:
___ 09:57 IH Albuterol 0.083% Neb Soln 1 NEB
___ 09:57 IH Ipratropium Bromide Neb 1 NEB
___ 11:16 PO PredniSONE 60 mg
Vitals on transfer:
98.0 64 114/57 18 100% NC
On the floor, the patient says that his symptoms have improved
significantly since coming to the ED. He is still requiring
oxygen and is still short of breath. He denies any current f/c,
rhinorrhea, congestion, sore throat, current CP, abd pain, N/V,
changes in bowel/bladder. He says his fingers and arms are weak
but he has significant neuropathy and this symptom is unchanged.
He also endorses a left medial foot ulcer.
All other systems negative in a 12-system ROS
Past Medical History:
- Heart failure, preserved EF (>55%, ___
- PVD
- Venous insufficiency, left leg reflex proximal SFV
- Venous stasis dermatitis
- CAD s/p RCA DES in ___, presented with chest discomfort
- Active tobacco use, 1 ½ ppd
- Morbid obesity
- CKD, stage II/III
- Mixed dyslipidemia
- Type 2 DM
- Hypertension
- COPD
- Bipolar disorder
- Choledocholithiasis
- hx of gallstone pancreatitis
Social History:
___
Family History:
Father died at ___ due to CAD. Mother died at ___ due to gastric
cancer. No early CAD or sudden cardiac death.
Physical Exam:
ADMISSION EXAM
==============
VS: 97.7 117/67 60 20 98% 3L NC
I/O: None recorded
Weight: 152.6kg. Wt on ___: 145.7kg. Goal weight per cards
note: 141 kg
GENERAL: Morbidly obese male, NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MM are dry. NC in
place. NECK: JVP obscured
CARDIAC: Distant heart sounds due to obesity, RRR, no m/r/g
LUNGS: Crackles from bases to mid-lung in the posterior fields.
Mild expiratory rhonchi, no wheezing.
EXTREMITIES: Significant venous stasis dermatitis bilaterally
from knees to tops of feet. 2 cm clean ulceration on medial left
foot, wrapped in gauze. 2+ pitting edema to knees bilaterally.
PULSES: 2+ radial pulses, unable to palpate distal pulses due to
edema
DISCHARGE EXAM
==============
VS: 98.3 57-63 108-135/58-67 18 95% 1L NC
I/O: ___ since midnight, ___ yesterday
Weight 138.6 today, ___ yesterday. Wt on ___: 145.7kg. Goal
weight per cards note: 141 kg
GENERAL: Morbidly obese male, NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MM are dry.
NECK: JVP obscured
CARDIAC: Distant heart sounds due to obesity, RRR, no m/r/g
LUNGS: trace bibasilar crackles and intermittent rhonchi, no
wheezing
EXTREMITIES: Significant venous stasis dermatitis bilaterally
from knees to tops of feet. No pitting edema.
Pertinent Results:
ADMISSION LABS
==============
___ 09:56AM BLOOD WBC-8.2 RBC-4.10* Hgb-13.0* Hct-39.3*
MCV-96 MCH-31.7 MCHC-33.1 RDW-14.9 RDWSD-51.7* Plt ___
___ 09:56AM BLOOD Neuts-76.6* Lymphs-11.8* Monos-7.7
Eos-2.1 Baso-0.5 Im ___ AbsNeut-6.26* AbsLymp-0.96*
AbsMono-0.63 AbsEos-0.17 AbsBaso-0.04
___ 09:56AM BLOOD Glucose-198* UreaN-33* Creat-1.0 Na-133
K-3.9 Cl-92* HCO3-29 AnGap-16
___ 09:56AM BLOOD ALT-119* AST-76* AlkPhos-103 TotBili-0.4
___ 09:56AM BLOOD proBNP-631*
___ 09:56AM BLOOD cTropnT-<0.01
___ 05:42PM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:56AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.9
___ 09:56AM BLOOD TSH-3.0
___ 07:59PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:59PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:59PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 07:59PM URINE CastHy-1*
PERTINENT LABS
==============
___ 09:56AM BLOOD proBNP-631*
___ 09:56AM BLOOD cTropnT-<0.01
___ 05:42PM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:25PM BLOOD CK-MB-1 cTropnT-<0.01
DISCHARGE LABS
==============
___ 06:55AM BLOOD WBC-10.0 RBC-4.81 Hgb-15.3 Hct-45.8
MCV-95 MCH-31.8 MCHC-33.4 RDW-14.5 RDWSD-49.8* Plt ___
___ 06:55AM BLOOD ___ PTT-33.5 ___
___ 06:55AM BLOOD Glucose-181* UreaN-33* Creat-1.3* Na-136
K-4.0 Cl-93* HCO3-31 AnGap-16
___ 06:55AM BLOOD Calcium-9.6 Phos-2.7 Mg-2.1
IMAGING
=======
CXR ___
IMPRESSION:
Cardiomegaly and mild interstitial edema.
MICROBIOLOGY
============
BCx ___ NGTD
UCx ___ MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Urinary legionella antigen ___ NEGATIVE
Sputum Cx ___ contaminated
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN COPD
3. ammonium lactate 12 % topical DAILY
4. Atorvastatin 80 mg PO QPM
5. Bumetanide 4 mg PO TID
6. BuPROPion (Sustained Release) 150 mg PO DAILY
7. BusPIRone 20 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Cyclobenzaprine 5 mg PO Q6H
10. Cyclobenzaprine 10 mg PO HS
11. Fluticasone Propionate 110mcg 1 PUFF IH BID
12. Gabapentin 1200 mg PO TID
13. Glargine 80 Units Breakfast
Glargine 80 Units Dinner
Humalog 60 Units Breakfast
Humalog 60 Units Lunch
Humalog 60 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
14. Metolazone 2.5 mg PO 1X/WEEK (SA)
15. Metoprolol Succinate XL 50 mg PO DAILY
16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
17. Potassium Chloride 50 mEq PO TID
18. Pregabalin 300 mg PO QAM
19. Pregabalin 150 mg PO QHS
20. sitaGLIPtin 25 mg oral DAILY
21. Spironolactone 50 mg PO DAILY
22. Tamsulosin 0.4 mg PO QHS
23. TraZODone 300 mg PO QHS
24. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP DAILY
25. Acetaminophen ___ mg PO Q8H:PRN headaches
26. Aspirin 81 mg PO DAILY
27. Cetirizine 10 mg PO DAILY
28. Vitamin D 1000 UNIT PO DAILY
29. Guaifenesin-Dextromethorphan 5 mL PO Q4H:PRN cough/cold
symptoms
30. lidocaine 4 % topical DAILY
31. Magnesium Oxide 400 mg PO BID
32. Nicotine Patch 21 mg TD DAILY
33. Aquaphor Ointment 1 Appl TP DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN headaches
2. Aquaphor Ointment 1 Appl TP DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Bumetanide 4 mg PO TID
6. BuPROPion (Sustained Release) 150 mg PO DAILY
7. BusPIRone 20 mg PO DAILY
8. Cetirizine 10 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Cyclobenzaprine 5 mg PO Q6H
11. Cyclobenzaprine 10 mg PO HS
12. Fluticasone Propionate 110mcg 1 PUFF IH BID
13. Gabapentin 1200 mg PO TID
14. Guaifenesin-Dextromethorphan 5 mL PO Q4H:PRN cough/cold
symptoms
15. Glargine 60 Units Breakfast
Glargine 60 Units Dinner
Humalog 30 Units Breakfast
Humalog 30 Units Lunch
Humalog 30 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 60 Units before
BKFT; 60 Units before DINR; Disp #*1 Vial Refills:*0
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
60 Units before BKFT; 60 Units before DINR; Disp #*5 Syringe
Refills:*0
16. Metoprolol Succinate XL 50 mg PO DAILY
17. Spironolactone 25 mg PO DAILY
RX *spironolactone [Aldactone] 25 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
18. Tamsulosin 0.4 mg PO QHS
19. TraZODone 300 mg PO QHS
20. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP DAILY
21. Vitamin D 1000 UNIT PO DAILY
22. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN COPD
23. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
24. ammonium lactate 12 % topical DAILY
25. Lidocaine 4 % TOPICAL DAILY
26. Magnesium Oxide 400 mg PO BID
27. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
28. Potassium Chloride 50 mEq PO TID
Hold for K > 4.5
29. sitaGLIPtin 25 mg oral DAILY
30. Nicotine Patch 21 mg TD DAILY
31. Pregabalin 150 mg PO QHS
32. Pregabalin 300 mg PO QAM
33. Outpatient Lab Work
The patient will need a Chem10. ICD-10 code I50.33, ICD-9 code
___.33
34. Walker
Patient needs a bariatric rolling walker with four wheels and
brakes. Quantity: 1. Duration 999. 0 refills.
Patient weight: 138 kg.
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
#acute-on-chronic chronic obstructive pulmonary disease
#acute-on-chronic diastolic heart failure
#Dyspnea
SECONDARY DIAGNOSES
===================
#Diabetes mellitus, type 2
#Venous stasis dermatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with cough, chest pressure. Evaluate for
pulmonary edema vs pneumonia.
TECHNIQUE: AP frontal and lateral chest radiographs were obtained.
COMPARISON: Chest radiograph from ___ II 1015, ___ and ___.
FINDINGS:
Lung volumes are low. Given AP technique, the heart is mildly enlarged.
There is mild interstitial edema. No focal consolidation or pneumothorax is
seen.
IMPRESSION:
Cardiomegaly and mild interstitial edema.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Heart failure, unspecified
temperature: 97.8
heartrate: 66.0
resprate: 18.0
o2sat: 100.0
sbp: 120.0
dbp: 64.0
level of pain: 7
level of acuity: 2.0 | BRIEF SUMMARY
=============
___ with PMHx of CAD, CHF, DM2, CKD, COPD on home O2 at who
presented to the ED with dyspnea, thick sputum, and chest
discomfort for 3 days PTA with associated weight gain and
worsening ___ edema for ___ weeks prior to admission. He was
diagnosed with a COPD exacerbation with superimposed dCHF
exacerbation and was treated with antibiotics, steroids, and
nebulizers for his COPD and was diuresed aggressively for his
CHF exacerbation. His shortness of breath resolved and his O2
normalized. He was set up to go to rehab, but at the last minute
our case management alerted us that his insurance would not
cover it since he had not seen ___ in two days. Despite
attempting to persuade the patient to stay, he opted to go home
against our advice with home ___ services and home ___.
ACUTE ISSUES
============
#acute-on-chronic dCHF: The patient noted an increase in weight
over a few weeks prior to his admission, as well as worsening
lower extremity edema. On admission, he had 2+ pitting edema and
significant crackles on lung exam. His BNP was only ~600,
however. He was evaluated for causes of CHF exacerbations but
none were found. He had a negative TSH, negative troponins and
unchanged EKG, negative UA, CXR with no e/o pneumonia, no
arrhythmias, and denied any medication non-adherence or dietary
indiscretions. He was diuresed with a lasix drip at 20mg/hr for
several days, then transitioned to his home bumetadine 4 mg TID
after achieving euvolemia. His home metoprolol and atorvastatin
were continued, but his spironolactone dose was reduced from 50
mg daily to 25 mg daily due to hypotension. His goal weight per
his cardiology NP is 310 lb (141kg). Discharge weight 138.6 kg.
#acute COPD exacerbation: The patient presented to the hospital
with 3 days of worsening cough productive for thick sputum. On
exam, he demonstrated bilateral wheezes and rhonchi. He was
treated with a 3 day course of azithromycin 500 mg daily, a
5-day course of prednisone 40 mg daily, and nebulizer
treatments. His SOB and wheezing subsequently resolved and his
cough greatly improved prior to discharge. No obvious trigger
for his COPD exacerbation was found. Flu swab negative.
#Chest discomfort: The patient presented with 3 days of chest
discomfort located across his chest and equal bilaterally. He
states that this pain did not feel like cardiac chest pain that
he has had in the past. His EKG had no evidence of ischemia, and
his troponins were negative x3.
CHRONIC ISSUES
# CAD s/p DES to RCA in ___:
- Continued atorvastatin 80 mg daily
- Continued aspirin 81 mg daily
- continued Metoprolol succinate 50 mg daily
- continued clopidogrel 75 mg daily
# CKD: Creatinine increased slightly during his course, likely
secondary to diuresis. Discharge creatinine 1.3.
# DM2: The patient's home insulin regimen is glargine 80u before
breakfast and dinner and lispro 60u TID with meals. His home
regimen was continued initially, however he experienced
hypoglycemia to the ___ so his regimen was reduced. He again
became hypoglycemic so his regimen was further reduced to Lantus
60 units BID with 30 units of Humalog TID before meals with
sliding scale. ___ need to uptitrate back to home regimen. Home
Jauniva held but restarted on discharge.
# HTN: Continued Metoprolol, spironolactone. Spironolactone dose
decreased to 25 mg daily. Can uptitrate PRN.
# HLD:
- continued atorvastatin
#BPH:
- Continued tamsulosin
#Neuropathy:
- Continued pregabalin qam and qpm
- Continued gabapentin
- continued cyclobenzaprine
#Tobacco abuse:
- Continued buproprion SR 150 daily
- Continued nicotine patch, 21 mg
#Anxiety:
- Continued buspirone
#Insomnia:
- continued trazodone
#Venous stasis dermatitis/PVD:
- Continued aquaphor
- Continued triamcinolone ointment
#Bipolar disorder:
- continued bupropion, buspirone
TRANSITIONAL ISSUES
===================
-Discharge weight: 138.6 kg
-The patient will need a chem10 on ___ to be reviewed by his
PCP. He is being discharged on his home regimen of Bumex 4 mg po
TID and potassium chloride 50 mEq daily.
-Please check weights daily. If changes by >3 pounds, contact
cardiology NP ___ @ ___
-Spironolactone decreased from 50 to 25 mg daily; Uptitrate PRN
-The patient had several episodes of hypoglycemia during his
hospitalization likely due to a significant decrease in his food
consumption. His insulin regimen was reduced from Lantus 80
units BID with 60 units of Humalog TID before meals with sliding
scale to Lantus 60 units BID with 30 units of Humalog TID before
meals with sliding scale. ___ need to uptitrate back to home
regimen.
-The patient was set up to go to rehab, but at the last minute
our case management alerted us that his insurance would not
cover it since he had not seen ___ in two days. Despite
attempting to persuade the patient to stay, he opted to go home
against our advice with home ___ services and home ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine / Penicillins / Ciprofloxacin Hcl / Warfarin / Cozaar /
Norvasc / Lisinopril / Rosuvastatin
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an ___ y/o man with PMHx restrictive lung disease,
chronic bronchitis, CAD s/p DES to LAD and ramus intermedius
(___), ischemic/non ischemic cardiomyopathy (LVEF 30%), HTN,
HLD and CKD (baseline Cr 1.6-2.0) who initially presented to ___.
___ with cough and SOB. At ___ he was
treated with Ceftriaxone, Azithromycin and Solumedrol 125mg for
presumed COPD exacerbation. He was noted to be covered in bed
bugs. He then requested transfer to ___ he receives
his care here.
.
He has had multiple recent admission to ___ for CHF and
presumed COPD exacerbations, most recently ___ and ___
repsectively. His dry weight is reportedly 162 lbs. He states
that for the past ___ days he has noted myalgias, rhinorrhea,
non productive cough and shortness of breath. He denies fever,
chills, rigors, worsening orthopnea, PND or pedal edema. He
states he has been taking all medications at home as prescribed.
He received a flu shot this year. Denies sick contact, nausea,
vomiting, chest pain. Labs at ___ notable for WBC 8.6
(75% PMNs), HCT 45, Plt 160, K 3.7 and Cr 1.6. Lytes were
otherwise WNL. Blood cultures not performed.
.
In the ED, initial VS were:
T 98.7 HR 100 BP 145/74 RR 20 O2 Sat 98% 2L
EKG was performed and was unchanged from baseline. No labs or
imaging were performed, as initial studies were performed at ___
___ and were sent over on transfer. He was given
Oseltamivir and admitted to medicine.
.
On arrival to the floor, initial VS were:
T 98 BP 152/100 HR 89 RR 26 O2 Sat 99% RA
.
REVIEW OF SYSTEMS:
(+)
(-) fever, chills, night sweats, headache, vision changes,
congestion, sore throat, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria
Past Medical History:
- Coronary artery disease: Catheterization ___ with 90% LAD,
90% ramus intermedius lesions, both stented with drug eluding
stents; OM1 with 50-60% lesion; repeat catheterizations ___ and
___ showed patent stents
- Combined ischemic/non-ischemic cardiomyopathy with systolic
congestive heart failure: LVEF ___ on TTE ___
- Hypertension
- Hyperlipidemia
- Chronic kidney disease: Baseline Cr 1.7- 2.0
- Chronic obstructive pulmonary disease
- Gastroesophageal reflux disease
- Cataracts: bilateral, not repaired
- Sleep apnea
- Lower back pain
- Osteoarthritis
- Hemorrhoid repair ___ years ago
- Hernia repair (epigastric, ___ inguinal ___
- Benign prostatic hypertrophy
- Restless leg syndrome
- Gout
Social History:
___
Family History:
Multiple siblings with heart disease. Sister with ESRD. His son
has CAD and diabetes; his daughter has diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
T 98.7 HR 100 BP 145/74 RR 20 O2 Sat 98% 2L
GENERAL - elderly man in NAD, paradoxical breathing, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVP 15cm above the RA, no carotid
bruits
LUNGS - Diffuse wheezes in all lung fields, rales at the
bilateral bases R>L, paradoxical breathing using abd muscles to
breathe, diffuse rhonchi
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, 2+ peripheral pulses (radials, DPs)
NEURO - A&Ox3, CNs II-XII grossly intact, non focal
DISCHARGE PHYSICAL EXAM:
T 97.3 136/88 90 97RA weight 162lbs
GENERAL - elderly man, breathing comfortably at rest on room
air, appropriate
HEENT - NC/AT, PERRLA, EOMI, MMM
NECK - supple, no thyromegaly, JVP not elevated
LUNGS - Upper airway breath sounds, but clear on pulmonary
auscultation. Good aeration.
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - Moderate distension, Tympanitic to percussion. Normal
BS. Soft, NT.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - A&Ox3, CNs II-XII grossly intact, non focal
Pertinent Results:
ADMISSION LABS:
___ 08:00AM BLOOD WBC-7.0 RBC-4.83 Hgb-14.8 Hct-45.7 MCV-95
MCH-30.6 MCHC-32.4 RDW-12.4 Plt ___
___ 08:00AM BLOOD Neuts-93.8* Lymphs-4.5* Monos-1.5*
Eos-0.1 Baso-0.1
___ 08:00AM BLOOD Glucose-224* UreaN-23* Creat-1.8* Na-141
K-4.4 Cl-102 HCO3-25 AnGap-18
___ 08:00AM BLOOD CK(CPK)-66
INTERIM LABS:
___ 08:00AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-4521*
___ 06:55PM BLOOD CK-MB-5 cTropnT-<0.01
DISCHARGE LABS:
___ 07:55AM BLOOD WBC-9.0 RBC-4.24* Hgb-12.7* Hct-40.5
MCV-96 MCH-30.1 MCHC-31.5 RDW-12.7 Plt ___
___ 07:55AM BLOOD Glucose-91 UreaN-40* Creat-1.7* Na-142
K-4.2 Cl-104 HCO3-29 AnGap-13
___ 07:55AM BLOOD ALT-15 AST-19 AlkPhos-55 TotBili-0.5
___ 07:55AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.2
_______________________________
MICROBIOLOGY:
___ 7:55 am BLOOD CULTURE: No growth in 48 hours.
___ 3:45 pm Influenza A/B by ___: Negative for Influenza A
and B.
SPUTUM CX: contamination with upper respiratory secretions.
_______________________________
ECG: ___ Marked baseline artifact marring interpretation
of rhythm but probabe sinus rhythm with frequent premature
ventricular complexes. Inferior myocardial infarction of
indeterminate age. Anteroseptal myocardial infarction of
indeterminate age. Non-specific ST segment changes. Low voltage
precordial leads. Compared to the previous tracing of ___ the
findings are similar.
ECG: ___ Sinus rhythm with premature ventricular complex.
Inferior myocardial infarction of indeterminate age.
Anteroseptal myocardial infarction of indeterminate age with
persistent ST segment elevations anteriorly consistent with
possible aneurysm. Clinical correlation is suggested.
Non-specific ST segment changes. Compared to tracing #1 the
ventricular rate is slower and fewer premature ventricular
complexes are seen.
_______________________________
CXR: PA & Lateral:: ___: There is a marked scoliosis of the
thoracic spine. Probable hiatal hernia is present. The heart
is not enlarged. No evidence of failure is present. No
pneumonia is seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN respiratory distress
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Calcitriol 0.25 mcg PO 1X/WEEK (___)
6. Clopidogrel 75 mg PO DAILY
7. Clotrimazole Cream 1 Appl TP BID
8. cycloSPORINE *NF* 0.05 % ___ BID
9. Docusate Sodium 100 mg PO BID constipation
10. Felodipine 5 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
12. FoLIC Acid 1 mg PO DAILY
13. Gabapentin 300 mg PO BID
14. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
15. Lorazepam 0.5 mg PO HS:PRN restless legs
16. Metoprolol Succinate XL 25 mg PO BID
17. Multivitamins 1 TAB PO DAILY
18. Simethicone 40-80 mg PO QID:PRN gas/bloating
19. Valsartan 320 mg PO DAILY
20. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN Pain
21. Furosemide 60 mg PO DAILY
22. Nitroglycerin SL 0.4 mg SL PRN chest pain
23. Potassium Chloride 8 mEq PO DAILY Duration: 24 Hours
Hold for K >
24. ZYRtec *NF* 10 mg Oral daily
25. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN respiratory distress
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Calcitriol 0.25 mcg PO 1X/WEEK (___)
6. Clopidogrel 75 mg PO DAILY
7. Clotrimazole Cream 1 Appl TP BID
8. Docusate Sodium 100 mg PO BID constipation
9. Felodipine 5 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
11. FoLIC Acid 1 mg PO DAILY
12. Furosemide 60 mg PO DAILY
13. Gabapentin 300 mg PO BID
14. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
15. Lorazepam 0.5 mg PO HS:PRN restless legs
16. Metoprolol Succinate XL 25 mg PO BID
17. Multivitamins 1 TAB PO DAILY
18. Nitroglycerin SL 0.4 mg SL PRN chest pain
19. Simethicone 40-80 mg PO QID:PRN gas/bloating
20. Valsartan 320 mg PO DAILY
21. ZYRtec *NF* 10 mg Oral daily
22. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN Pain
23. cycloSPORINE *NF* 0.05 % ___ BID
24. Potassium Chloride 8 mEq PO DAILY Duration: 24 Hours
Hold for K >
25. PredniSONE 5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute bronchitis
Reactive airway disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: cough and dyspnea, history of COPD and CHF.
CHEST, PA AND LATERAL
COMPARISON: Outside film ___.
There is a marked scoliosis of the thoracic spine. Probable hiatal hernia is
present. The heart is not enlarged. No evidence of failure is present. No
pneumonia is seen.
IMPRESSION: No failure, no pneumonia.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: COUGH/CONGESTION
Diagnosed with INFLUENZA WITH PNEUMONIA, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, HYPERTENSION NOS
temperature: 98.7
heartrate: 100.0
resprate: 20.0
o2sat: 98.0
sbp: 145.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ y/o man with PMHx restrictive lung disease, chronic
bronchitis, ischemic/non ischemic cardiomyopathy (LVEF 30%), CKD
who was transfered from ___ ED with cough and SOB.
ACTIVE ISSUES:
# Acute on chronic bronchitis/bronchiolar hypersensitivity :
His clinical presentation of coughing and shortness of breath
was initally concerning for CHF exacerabation vs PNA vs
bronchitis vs influenza. Ultimately after trial of diuresis,
CXR without infiltrate, and flu swab negative (received tamiflu
until he ruled out), he manifested as likely bronchitis with
superimposed reactive airway component. He was treated with
duonebs, prednisone (initially got high dose IV solumedrol at
___. ___), and azithromycin. His prednisone dose was decreased
to 40mg from 60mg and his Azithromycin was discontinued after 4
days to avoid further GI upset.
# Acute on chronic systolic CHF: He has a history of mixed
ischemic/non ischemic cardiomyopathy with LVEF 30%. There was
initial concern of volume overload, but after Lasix 60mg IV
diuresis x1, he was clearly euvolemic. Dry weight 162lbs. He
continued Imdur, metoprolol, and po lasix.
#GI Upset: On day 3 of admission, he had nausea and vomiting
that was chocolate in color, but non-bloody. Gastroccult
positive, however both hematocrit and hemodynamics were stable.
Initially treated cautiously with bowel rest and IV PPI, however
he did not have further episodes of emesis. This stomach upset
was likely result of high dose prednisone and azithromycin.
Prednisone was decreased to 40mg to complete 5day course.
Azithromycin was discontinued entirely. He resumed regular diet
without further episodes of emesis.
#Urinary Retention/BPH: He has a history of known BPH. He was
found to be retaining urine which was relieved after foley
insertion. He passed void trial successfully. Transitional
issue to PCP to start ___ on outpatient basis.
CHRONIC ISSUES:
# CAD: He did not present with ACS (no CP, EKG unchanged from
baseline, and trops negative). He continued his home meds (ASA,
Plavix, Imdur).
# CKD: ___ longstanding HTN. His creatinine was at baseline (Cr
1.6-2.0)
# HTN: stable, he continued home meds: Imdur, Metoprolol,
Felodipine, Valsartan
# HLD: stable, he continued home Atorvastatin.
# Gout: no evidence of acute gout flare. He continued
allopurinol. He received additional prednisone for COPD
exacerbation on top of his normal 5mg daily home dose. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
adhesive tape / aspirin
Attending: ___.
Chief Complaint:
drainage from left groin wound
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F s/p L CFA thrombectomy patch angioplasty of L CFA and
SFA ___ presents for increased wound drainage. She reports
her wound began draining a week or so after she was discharged.
Per OMR she was seen in clinic on ___ where her wound did have
some slight dehiscence at the proximal incision and the staples
in this region were removed. The wound probed 1cm deep and
this
was packed with Nu-Gauze. The patient reports that she has not
seen the wound, but her ___ felt there was some increased
redness
and possible purulent drainage - though minimal. She was
evaluated ~3 days ago at an OSH ___) where she was
started on Keflex and discharged home. The ___ felt the wound
was not improving and the patient was instructed to present to
___ ED for further evaluation. She has had no fevers, chills,
nausea, emesis or diarrhea.
Past Medical History:
Acute LLE ischemia ___, CAD s/p MI previous cath and RCA
stent,h/o Mitral valve disease, Obesity, Hyperlipidemia, HTN,
Musculoskeletal disorder, RA
PSH: ___ L CFA thrombectomy patch angioplasty of LCFA and
SFA, left hip surgery, mitral valve replacement (tissue)
Social History:
___
Family History:
non contributory
Physical Exam:
Gen: Obese elderly female in NAD
CV: Irreg rhythm
Lungs: CTA bilat
Abd: Soft, no m/t/o
Extremities: Warm, well perfused with dopplerable ___ signals
bilat
Wound: L groin with proximal wound dehicense. No surrounding
erythema or drainage. Packed wet to dry with wick. Wound staples
have been removed.
Pertinent Results:
___:40AM BLOOD WBC-5.9 RBC-4.13* Hgb-10.3* Hct-35.4*
MCV-86 MCH-24.8* MCHC-29.0* RDW-18.9* Plt ___
___ 08:00AM BLOOD Glucose-110* UreaN-20 Creat-0.8 Na-138
K-4.1 Cl-102 HCO3-27 AnGap-13
___ 08:00AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0
___ 06:40AM BLOOD ___
___ 08:00AM BLOOD ___ PTT-44.2* ___
___ 10:00PM BLOOD ___ PTT-44.9* ___
___ 08:47PM BLOOD ___ PTT-46.5* ___
___ 9:56 am SWAB Source: groin wound.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Medications on Admission:
bumex 1mg;, acetaminophen 325 prn, ASA 81', atenolol
50', atorvastatin 10', bisacodyl ___ mg prn, colace prn,
famotidine 20'', lorazepam 0.5 mg q6h prn, MTX 15 mg ___,
miconazole 2 % Powder bid prn, polyethylene glycol daily prn,
polyvinyl alcohol-povidon(PF) ___ eye drops daily prn, tramadol
50-100 mg Q4H prn mg prn pain, valsartan 80', warfarin 2' (goal
INR ___
Discharge Medications:
1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once): have
your INR checked on weds ___.
4. methotrexate sodium 15 mg Tablet Sig: One (1) Tablet PO once
a week.
5. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
9. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): take this while taking pain meds.
12. bumetanide 1 mg Tablet Sig: One (1) Tablet PO once a day.
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
14. Outpatient Lab Work
please have your ___ checked on ___
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Drainage from Left thigh wound
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Patient with recent left common femoral thrombectomy, now wound
with purulent drainage. Please evaluate for pseudoaneurysm or abscess
involvement in arterial repair site.
COMPARISON: Comparison is made to ultrasound performed on ___.
TECHNIQUE: Contrast-enhanced axial images in arterial phase were acquired
from the pelvic brim to the mid thigh. Coronal and sagittal reformations were
provided.
FINDINGS: Exam is severely limited by artifact from the left total hip
replacement.
Calcifications are evident throughout the bilateral common, internal and
external iliac arteries without evidence of critical stenosis. The common
femoral as well as superficial and deep femoral arteries are well opacified
and patent. Visualized aspects of vessels demonstrate no pseudoaneurysm.
Evaluation of soft tissue is again severely limited though no large abscess
identified within region of surgical staples.
The rectum, bladder and visualized large bowel are unremarkable.
Bone-on-bone degenerative change identified within the right hip with
subchondral cyst formation. No fracture is identified. Significant
lumbosacral degenerative change evident. No free air or fluid within the
abdomen.
IMPRESSION:
1. Exam is limited by left total hip replacement. Recommend review of prior
ultrasound for evaluation of soft tissues at the surgical site. No large
abscess identified. No pseudoaneurysm evident on limited view.
2. Severe bone-on-bone degenerative change in the right hip.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: WOUND EVAL
Diagnosed with OTHER SPEC COMPL S/P SURGERY, ABN REACT-SURG PROC NEC
temperature: 98.2
heartrate: 63.0
resprate: 18.0
o2sat: 100.0
sbp: 149.0
dbp: 64.0
level of pain: 2
level of acuity: 3.0 | Ms. ___ was admitted on ___ with concern for a left groin
wound infection. A wound culture was taken and she was started
on iv vancomycin, cipro and flagyl for broad coverage. She was
afebrile throughout her course, tolerated a regular diet and
ambulated independently. There was not frank pus from the wound,
and no real concern for infection, however, given that she had a
patch angioplasty, she was kept on antibiotics for prophylaxis.
On ___ her wound culture showed gram negative rods and she was
transitioned to oral augmentin. She was deemed stable for
discharge home with 10 days of augmentin and daily wound packing
by ___. The remaineder of her staples were removed without
difficulty. She will follow up in the ___ clinic in 1 week.
She will have her INR checked on ___ by her
PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, encephalopathy
Major Surgical or Invasive Procedure:
Diagnostic Paracentesis (___)
Diagnostic and Therapeutic Paracentesis (___)
Diagnostic and Therapeutic Paracentesis (___)
History of Present Illness:
Ms. ___ is a ___ female with a history of PSC
cirrhosis (Child C) historically decompensated by ascites/SBP,
hepatic encephalopathy, esophageal varices, and malnutrition as
well as ulcerative colitis, recurrent C. diff colitis on
suppressive vancomycin, insulin-dependent type II diabetes ___
recent admission for hyperglycemic emergency, presenting with
4-day history of diarrhea unable to keep up with her fluid
intake. ALl history from ___ as patient somnolent on arrival
to floor. Patient reports nausea and tender belly at this time.
Patient denies any fever, chills, shortness of breath, chest
pain, dysuria at this time. She had 4.3 L para on ___.
Past Medical History:
- Primary sclerosing cholangitis with decompensated cirrhosis
(Child C c/b varices, ascites, encephalopathy, malnutrition)
-Ulcerative colitis on 5-ASA
-Recurrent cholangitis
-C diff on PO vancomycin
-TAH in ___ for fibroids
-IDDM Type 2
Social History:
___
Family History:
Father - DM, alive (___).
Mother - DM, alive (___).
Two sons with HTN.
Daughter healthy.
No family history of liver disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
T 97.1 HR 62 BP 106/58 RR 18 SaO2 99% RA
GA: Comfortable
HEENT: + scleral icterus
Cardiovascular: Normal S1, S2, regular rate and rhythm, no
murmurs/rubs/gallops, 2+ peripheral pulses bilaterally
Pulmonary: Clear to auscultation bilaterally
Abdominal: Soft, nontender, distended, no masses
Extremities: No lower leg edema
Integumentary: No rashes noted
DISCHARGE PHYSICAL EXAM
========================
T 98.7 HR 74 BP 106 / 63 RR 16 SaO2 98% Ra
GENERAL: Adult woman laying in bed
HEENT: icteric sclera, MMM
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi
GI: abdomen soft, non-tender, mildly distended, normoactive BS
EXTREMITIES: warm, no edema
NEURO: A&Ox3, CN grossly intact, spontaneously moving all
extremities, (-) asterixis
Pertinent Results:
ADMISSION LABS
=======================
___ 10:55PM BLOOD WBC-3.1* RBC-2.91* Hgb-8.7* Hct-25.4*
MCV-87 MCH-29.9 MCHC-34.3 RDW-25.8* RDWSD-76.2* Plt ___
___ 10:55PM BLOOD Neuts-65.9 ___ Monos-7.4 Eos-3.2
Baso-0.6 NRBC-0.9* Im ___ AbsNeut-2.04 AbsLymp-0.70*
AbsMono-0.23 AbsEos-0.10 AbsBaso-0.02
___ 10:55PM BLOOD ___ PTT-26.7 ___
___ 10:55PM BLOOD Plt ___
___ 10:55PM BLOOD Glucose-353* UreaN-24* Creat-0.9 Na-134*
K-6.2* Cl-101 HCO3-20* AnGap-13
___ 10:55PM BLOOD ALT-57* AST-244* AlkPhos-1072*
TotBili-12.6*
___ 10:55PM BLOOD Albumin-2.8*
___ 10:59PM BLOOD Lactate-2.2* K-4.5
___ 10:55PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 10:55PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-100* Ketone-TR* Bilirub-MOD* Urobiln-2* pH-6.5 Leuks-NEG
___ 10:55PM URINE RBC-1 WBC-4 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 10:55PM URINE CastHy-4*
___ 10:55PM URINE Mucous-RARE*
DISCHARGE LABS
========================
___ 04:47AM BLOOD WBC-1.4* RBC-2.56* Hgb-7.7* Hct-23.0*
MCV-90 MCH-30.1 MCHC-33.5 RDW-22.7* RDWSD-72.3* Plt Ct-73*
___ 04:47AM BLOOD Plt Ct-73*
___ 04:47AM BLOOD ___ PTT-35.8 ___
___ 04:47AM BLOOD Glucose-158* UreaN-14 Creat-0.7 Na-133*
K-4.7 Cl-102 HCO3-20* AnGap-11
___ 04:47AM BLOOD ALT-23 AST-71* AlkPhos-634* TotBili-8.2*
___ 04:47AM BLOOD Albumin-2.8* Calcium-7.7* Phos-1.5*
Mg-2.2
PERTINENT LABS
========================
___ 03:35PM ASCITES TNC-91* RBC-4693* Polys-2* Lymphs-5*
Monos-1* Mesothe-2* Macroph-90*
___ 09:14AM ASCITES TNC-41* RBC-6814* Polys-2* Lymphs-15*
Monos-78* Mesothe-5* Other-0
___ 03:35PM ASCITES TotPro-1.1
___ 09:14AM ASCITES TotPro-0.9 Glucose-320 LD(LDH)-37
Albumin-0.3
___ 01:50AM BLOOD WBC-5.2 RBC-2.49* Hgb-7.2* Hct-23.0*
MCV-92 MCH-28.9 MCHC-31.3* RDW-26.2* RDWSD-88.7* Plt ___
___ 08:55AM BLOOD WBC-3.5* RBC-2.83* Hgb-8.4* Hct-25.7*
MCV-91 MCH-29.7 MCHC-32.7 RDW-25.1* RDWSD-80.4* Plt Ct-94*
___ 04:38AM BLOOD WBC-1.5* RBC-2.35* Hgb-6.9* Hct-21.4*
MCV-91 MCH-29.4 MCHC-32.2 RDW-24.1* RDWSD-77.8* Plt Ct-76*
___ 05:01AM BLOOD WBC-1.7* RBC-3.00* Hgb-8.8* Hct-26.8*
MCV-89 MCH-29.3 MCHC-32.8 RDW-23.0* RDWSD-73.0* Plt Ct-84*
MICROBIOLOGY/PATHOLOGY
-=======================
___ 6:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 1:27 pm PERITONEAL FLUID 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): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
___ 12:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 3:35 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
___ 3:35 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
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 (Final ___: NO GROWTH.
___ 4:25 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
Reported to and read back by ___ ___ 12:01PM.
POSITIVE. (Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of
C. difficile and Therefore, positive C. diff PCR tests
trigger
reflex C. difficile toxin testing, which is highly
specific for
CDI.
C. difficile Toxin antigen assay (Final ___:
NEGATIVE. (Reference Range-Negative).
PERFORMED BY EIA.
This result indicates a low likelihood of C. difficile
infection
(CDI).
___ 9:14 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
___ 9:14 am PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 10:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 10:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
RADIOLOGY
=========================
EGD (___)
Normal mucosa in the whole esophagus. Congestion, petechiae, and
mosaic mucosal pattern in the stomach fundus and stomach body
compatible with portal hypertensive gastropathy. Small
inflammatory polyp noted in stomach body. An NJ tube was placed
past the third portion of the duodenum. The tube was moved from
the mouth into the nose and bridled at 110cm. The tube flushed
without difficulty. Normal mucosa in the whole examined
duodenum.
CHEST X RAY (___)
IMPRESSION:
Left basilar opacity likely atelectasis though infection is not
excluded.
CT ABDOMEN (___)
IMPRESSION:
1. Diffuse wall thickening of the colon, likely reflecting
portal colopathy.
Collapse of the colon (from the mid transverse colon distally),
diffuse
mesenteric stranding and large volume ascites limits evaluation
for infectious
process.
2. Cirrhotic liver with large volume ascites, splenomegaly, and
upper
abdominal varices.
3. Pancreatic cystic lesions are better characterized on prior
MRCP.
LIVER/GALLBLADDER US (___)
IMPRESSION:
1. Cirrhotic liver, with splenomegaly and large volume ascites.
2. Patent main portal vein with slow flow.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO TID:PRN cough
2. Calcium Carbonate 1000 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Furosemide 60 mg PO DAILY
5. Lactulose 30 mL PO TID
6. Rifaximin 550 mg PO BID
7. Sertraline 75 mg PO DAILY
8. Simvastatin 40 mg PO QPM
9. Spironolactone 100 mg PO DAILY
10. Thiamine 100 mg PO DAILY
11. Ursodiol 300 mg PO BID
12. Vancomycin Oral Liquid ___ mg PO BID C,diff prophylaxis
13. Midodrine 10 mg PO TID
14. Multivitamins 1 TAB PO DAILY
15. Cholestyramine 4 gm PO DAILY:PRN itching
16. Ciprofloxacin HCl 500 mg PO Q24H
17. Ferrous Sulfate 325 mg PO DAILY
18. Pantoprazole 40 mg PO Q24H
19. Zinc Sulfate 220 mg PO DAILY
20. Vitamin A ___ UNIT PO DAILY
21. Mesalamine ___ 2400 mg PO BID
22. Glargine 16 Units Breakfast
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Discharge Medications:
1. NovoLOG Mix ___ U-100 (insulin asp prt-insulin
aspart) 100 unit/mL (70-30) subcutaneous BID
16 units with breakfast AS DIR
16 units at bedtime AS DIR
RX *insulin asp prt-insulin aspart [Novolog Mix ___
U-100] 100 unit/mL (70-30) AS DIR at breakfast, at bedtime Disp
#*10 Syringe Refills:*0
2. 70/30 16 Units Breakfast
70/30 16 Units Bedtime
Glargine 20 Units Breakfast
3. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*70 Capsule Refills:*0
4. Benzonatate 100 mg PO TID:PRN cough
5. Calcium Carbonate 1000 mg PO DAILY
6. Cholestyramine 4 gm PO DAILY:PRN itching
7. Ciprofloxacin HCl 500 mg PO Q24H
8. Ferrous Sulfate 325 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Lactulose 30 mL PO TID
11. Mesalamine ___ 2400 mg PO BID
12. Midodrine 10 mg PO TID
13. Multivitamins 1 TAB PO DAILY
14. Pantoprazole 40 mg PO Q24H
15. Rifaximin 550 mg PO BID
16. Sertraline 75 mg PO DAILY
17. Simvastatin 40 mg PO QPM
18. Thiamine 100 mg PO DAILY
19. Ursodiol 300 mg PO BID
20. Vitamin A ___ UNIT PO DAILY
21. Zinc Sulfate 220 mg PO DAILY
22. HELD- Furosemide 60 mg PO DAILY This medication was held.
Do not restart Furosemide until cleared by your liver doctors.
23. HELD- Spironolactone 100 mg PO DAILY This medication was
held. Do not restart Spironolactone until cleared by your liver
doctors.
24.Tube Feeds
Glucerna 1.2
@ 65 mL/hr over 24 hours (1872 kcal, 94 g pro, ~1260 mL H20)
Flush with 30 mL q6 hours
Dispense 1 month supply with 2 refills
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
================
Hepatic Encephalopathy
Abdominal Pain, Diarrhea
Rectal Variceal Bleeding
Decompensated Cirrhosis Secondary to Primary Sclerosing
Cholangitis
Severe Malnutrition
Hyperglycemia
Secondary Diagnoses
================
Ulcerative Colitis
C. Difficile Colonization
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 cirrhosis, diarrhea, abd pain// ?intrabdominal
infection ?cirrhotic liver eval, colitis, cdiff changes
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ultrasound from ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There is no focal liver mass. The
main portal vein is patent with slow 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 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 12.2 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis. The right
kidney measures 11 cm. The left kidney measures 10 cm. A simple cyst in the
interpolar region of the left kidney measures 3.9 x 3.9 x 4.4 cm.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver, with splenomegaly and large volume ascites.
2. Patent main portal vein with slow flow.
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast
INDICATION: History: ___ with cirrhosis, diarrhea, abd painNO_PO contrast//
?intrabdominal infection ?cirrhotic liver eval, colitis, cdiff changes
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) = 557 mGy-cm.
COMPARISON: CT abdomen pelvis from ___ and MRCP from ___
FINDINGS:
LOWER CHEST: There is bibasilar atelectasis, left greater than right. A 5 mm
right middle lobe nodule is unchanged. There is no pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver is cirrhotic in morphology with a prominent caudate
lobe and heterogeneous attenuation throughout, unchanged from prior. An
intermediate density lesion measuring 7 mm in the right hepatic lobe (02:29)
does not have a clear correlate on prior MRCP from ___, and may
represent a regenerative nodule.
There is no evidence of intrahepatic or extrahepatic biliary dilatation.
Mural edema of the gallbladder likely reflects third spacing of fluids. No
radiopaque stones are seen.
Portal vasculature is patent. There are upper abdominal varices. There is
large volume abdominal ascites.
PANCREAS: The pancreas has normal attenuation throughout. There is no main
ductal dilatation. Pancreatic cystic lesions, measuring up to 1.6 cm in the
pancreatic tail, are better characterized on MRCP from ___.
SPLEEN: The spleen is enlarged measuring up to 16 cm. There is no 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.
Left renal cysts are again seen measuring up to 4.2 cm. There is no evidence
of hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: Small hiatal hernia is re-demonstrated. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. There
is diffuse wall thickening of the colon, likely reflecting portal colopathy.
Collapse of the colon (from the mid transverse colon distally), diffuse
mesenteric stranding and large volume ascites limits evaluation for infectious
process. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: The uterus is not visualized.
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. Diffuse wall thickening of the colon, likely reflecting portal colopathy.
Collapse of the colon (from the mid transverse colon distally), diffuse
mesenteric stranding and large volume ascites limits evaluation for infectious
process.
2. Cirrhotic liver with large volume ascites, splenomegaly, and upper
abdominal varices.
3. Pancreatic cystic lesions are better characterized on prior MRCP.
Radiology Report
INDICATION: ___ year old woman with cirrhosis, hepatic encephalopathy// PNA
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
There is new retrocardiac somewhat linear opacity. Elsewhere, the lungs are
clear. Cardiac silhouette is moderately enlarged. No acute osseous
abnormalities.
IMPRESSION:
Left basilar opacity likely atelectasis though infection is not excluded.
Radiology Report
INDICATION: ___ year old woman with PSC cirrhosis// therapeutic para
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: Right upper quadrant ultrasound dated ___.
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.
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 6 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:
-Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
-6 L of fluid were removed.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Weakness
temperature: 97.1
heartrate: 62.0
resprate: 18.0
o2sat: 99.0
sbp: 106.0
dbp: 58.0
level of pain: 8
level of acuity: 3.0 | PATIENT SUMMARY
================
Ms. ___ is a ___ female with a history of PSC
cirrhosis historically decompensated by ascites/SBP, hepatic
encephalopathy, esophageal varices, and malnutrition as well as
ulcerative colitis, recurrent C. diff colitis on suppressive
vancomycin, insulin-dependent type II diabetes with recent
admission for hyperglycemic emergency. She presented with a
4-day history of diarrhea and abdominal pain, and was managed
inpatient for hepatic encephalopathy and ascites.
ACUTE MEDICAL ISSUES
==================
# Hepatic Encephalopathy.
Ms. ___ initially presented with significant somnolence and
received naloxone and lactulose, with improvement of her mental
status. Following several days of treatment with lactulose and
rifaximin, her encephalopathy had resolved and she had returned
to her baseline mental status without any overt impairment.
# Abdominal Pain, Diarrhea
Ms. ___ presented with significant right upper quadrant
abdominal pain and worsening alkaline phosphatase and bilirubin.
She remained afebrile, but demonstrated marked tenderness to
palpation on abdominal exam. C. difficile antigen was negative,
while stool PCR was positive, consistent with colonization but
not active infection. Diagnostic paracentesis was performed to
evaluate for spontaneous bacterial peritonitis, revealing
___ fluid with a SAAG of 2.5 suggesting
portal hypertension likely due to PSC cirrhosis, but with WBC of
41, less suggestive of recurrent SBP. However, given the acuity
of decompensation and severity of abdominal tenderness, Ms.
___ was treated empirically with ceftriaxone for SBP. Blood
and ascites cultures subsequently demonstrated no growth to
date, and SBP suppressive therapy with ciprofloxacin was
resumed. Given negative work-up, abdominal pain was likely
secondary only to distension caused by worsened ascites.
Symptoms subsequently improved following diuresis and
therapeutic paracentesis on ___. The patient subsequently
reaccumulated ascites in the setting of fluid administration,
transfusion, and holding diuretics for multiple days iso GI
bleeding and creatinine elevation. Given hyponatremia in setting
of diuresis and plan for regular outpatient paracenteses, home
furosemide and spironolactone were held on discharge.
# Rectal Variceal Bleeding
The patient developed bright red blood per rectum overnight on
___ likely secondary to known rectal varices noted on ___
colonoscopy. Lower suspicion for esophageal variceal bleeding
given character of blood, hemodynamic stability, and absence of
symptoms. Patient was started on octreotide for rectal variceal
bleeding (discontinued ___, IV pantoprazole. IV ceftriaxone,
and made NPO. Pantoprazole was subsequently switched to PO given
low suspicion for variceal bleeding, and diet was advanced.
Patient received additional blood transfusion morning of ___
for Hgb 6.9. The patient subsequently had no further gross
bleeding, with normal, non-bloody or melenic stools for more
than two days prior to discharge. She completed a 5 day course
of ceftriaxone.
# Decompensated Cirrhosis Secondary to Primary Sclerosing
Cholangitis
Patient with history of primary sclerosis cholangitis cirrhosis,
decompensated this admission by hepatic encephalopathy, ascites,
and rectal variceal bleeding and treated as discussed above.
Home lactulose and rifaximin were continued as above for
encephalopathy. Home diuretics were discontinued in the setting
of elevated creatinine and hyponatremia as above. Severe
malnutrition in the setting of cirrhosis was treated with
placement of a feeding tube and initiation of tube feeds for
nutritional support. Bleeding from rectal varices was treated as
above.
# Severe Malnutrition
Patient underwent nutritional evaluation and was started on tube
feeds as discussed above.
#Hyperglycemia, Insulin-dependent type II diabetes. Ms. ___
presented with persistent hyperglycemia ranging to >400 despite
continuation of her home insulin regimen. ___ was consulted
and she required uptitration of her home insulin while here. Due
to initiation of tube feeds, the patient's insulin regimen was
changed to 20U lantus in the morning, with 16U 70/30 Novolog mix
with breakfast and 16U 70/30 with dinner.
CHRONIC ISSUES
==================
# Ulcerative Colitis
Patient continued home mesalamine 2400 mg BID.
# C. Difficile Infection
Patient continued PO vancomycin. Dose initially increased to
empirically cover for possible C. difficile infection to QID in
setting of antibiotics for 7 days after last antibiotic dose
until ___, will reduce to BID after. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Demerol
Attending: ___.
Chief Complaint:
Crohn's flare
Major Surgical or Invasive Procedure:
1. Angiojet thrombectomy of left common iliac artery, iliac
lysis catheter to left ___ (___)
2. Lysis catheter check and advanced further in left ___
(___)
3. Lysis catheter check and removal of catheter (___)
4. Transesophageal echocardiogram (___)
History of Present Illness:
Mr. ___ is a ___ with Crohn's disease who was
admitted from ___ with Crohn's flare re-presenting with
abdominal pain.
Prior to recent admission he was on mesalamine for his Crohn's.
He presented with abdominal pain, elevated CRP, and OSH imaging
showing ileal inflammation c/w Crohn's flare. GI was consulted
and he was treated with cipro/flagyl and started on budesonide
on
___ with symptomatic improvement. GI was planning to start
Humira, but due to delay obtaining insurance authorization, he
was discharged on budesonide with plan to initiate Humira as an
outpatient.
Two days after discharge his abdominal pain recurred. He
developed central throbbing, cramping abdominal pain, abdominal
distention, nausea without vomiting, hiccups, and diarrhea
without melena or hematochezia.
He called his outpatient GI who recommended Tylenol and bowel
rest overnight, but, when this did not improve his pain,
recommended he present for readmission.
Currently, most bothersome is his hiccups and nausea. He does
not
currently have any abdominal pain or distention. He has had
alternating chills/sweats and measured a fever of 100.3 at home.
No chest pain or shortness of breath. No dizziness or
lightheadedness.
ED Course
Vitals: T 97.6, HR 125 --> 84, BP 138/92, SpO2 100% on RA
Data: Lactate 2.5 --> 1.5, Cr 1.4, Crp 46.5, KUB without SBO
Interventions: LR 1L, solumedrol 20mg IV, Zofran, Haldol,
Ativan,
Tylenol
Course: GI consult recommended CRP and KUB. Recommended starting
steroids (done in the ED) with plan to decide about timing of
starting Humira once admitted.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Crohn's disease
*Hx of being on infliximab (Remicade) many years ago
*Prior to flare in early ___, was maintained on
mesalamine
- Hematuria - s/p cystoscopy with no concerning findings per
patient
- Hypertension
- GERD / acid reflux
Social History:
___
Family History:
kidney stones on his father's side
Physical ___:
Admission exam:
===============
VITALS: ___ 1654 Temp: 98.1 PO BP: 148/92 HR: 85 RR: 18 O2
sat: 98% O2 delivery: RA
GENERAL: NAD, appears uncomfortable, hiccupping frequently
EYES: Anicteric, PERRL
ENT: MMM. No OP lesion, erythema or exudate. Ears and nose
without visible erythema, masses, or trauma.
CV: Heart regular, no m/g.
RESP: Lungs CTAB no w/r/r. Breathing comfortably
GI: Abdomen soft, non-distended, non-tender to palpation,
normoactive bowel sounds.
GU: No suprapubic ttp or fullness
MSK: Extremities warm without edema. Moves all extremities
SKIN: No rashes or ulcerations noted on examined skin
NEURO: Alert, oriented, face symmetric, speech fluent sensation
to light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
.
.
Discharge exam
==============
General: resting comfortably in NAD
Heart: no apparent distress,
Lung: breathing comfortably on room air,
Abdomen: soft, non distended, non tender, no rebound, no
guarding
Neuro: alert and oriented x3
Extremities: RLE: catheter in place, no bleeding, no hematoma,
no redness, LLE: warm foot,
dopplerable ___, no motor or sensory deficits
Pertinent Results:
Admission labs:
==============
___ 09:27AM BLOOD WBC-9.7 RBC-6.60* Hgb-12.8* Hct-44.4
MCV-67* MCH-19.4* MCHC-28.8* RDW-22.5* RDWSD-41.3 Plt ___
___ 09:27AM BLOOD Neuts-80.5* Lymphs-9.9* Monos-8.2
Eos-0.4* Baso-0.4 Im ___ AbsNeut-7.80* AbsLymp-0.96*
AbsMono-0.80 AbsEos-0.04 AbsBaso-0.04
___ 06:50AM BLOOD Anisocy-2+* Poiklo-1+* Polychr-1+*
Ovalocy-1+* Schisto-1+* RBC Mor-SLIDE REVI
___ 09:27AM BLOOD Glucose-136* UreaN-17 Creat-1.4* Na-138
K-4.6 Cl-97 HCO3-24 AnGap-17
___ 09:27AM BLOOD Lipase-32
___ 09:27AM BLOOD Albumin-4.0 Calcium-9.7 Phos-6.3* Mg-2.2
___ 09:27AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
.
.
Notable labs since admission:
=============
-___ CRP: 46.7
-___ CRP: 18.7
Notable labs from recent hospitalization:
=============
-___ Quant gold: NEGATIVE
-___ HCV Ab: NEGATIVE
-___ Hep B Ab panel: all negative (needs immunization)
-___ Vit D: 21 (low)
-___ Ferritin: 14 (low)
Micro:
=======
-___ UCx: no growth (final)
-___ Stool C. diff PCR: negative
-___ Stool Cx:
FECAL CULTURE (Final ___:
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Final ___:
NO CAMPYLOBACTER FOUND.
Imaging: per OMR
=========
___ KUB:
Nonspecific bowel gas pattern with a paucity of air within the
bowel and a single air-fluid level seen in the right mid
quadrant, likely within the duodenum.
___ Unilateral (left) upper extremity venous u/s:
FINDINGS: Grayscale and Doppler sonograms of the left internal
jugular, subclavian, axillary, basilic and paired brachial veins
demonstrate nonocclusive thrombus in the basilic vein, but the
other veins appear clear without thrombosis. At the level of
the
mid forearm a small superficial vein also shows nonocclusive
thrombus.
IMPRESSION: Superficial thrombophlebitis, but no evidence of
deep venous thrombosis.
___ Left lower extremity Doppler ultrasound
IMPRESSION: No evidence of deep venous thrombosis in the left
lower extremity veins.
Discharge labs:
==============
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mesalamine (Rectal) ___ID
2. Mesalamine ___ 1600 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Budesonide 9 mg PO DAILY
5. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. Apixaban 10 mg PO BID
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*13 Tablet Refills:*0
2. Apixaban 5 mg PO BID
Start ___
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*3
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
4. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*3
5. PredniSONE 40 mg PO DAILY
Refer to gastroenterology for duration
Tapered dose - DOWN
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
6. Budesonide 9 mg PO DAILY
7. Mesalamine (Rectal) ___ID
8. Mesalamine ___ 1600 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Home
Discharge Diagnosis:
Crohn's flare
Arterial emboli with left iliac artery and right lower lobe
pulmonary arteries
Acute left limb ischemia
Superficial thrombophlebitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with persistent vomiting and nausea iso Crohn's disease.
Eval for air fluid levels
TECHNIQUE: Upright and supine views of the abdomen.
COMPARISON: CT abdomen pelvis performed ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel. There is a
paucity of air within the bowel. A single air-fluid level seen in the right
mid quadrant likely within the duodenum.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Nonspecific bowel gas pattern with a paucity of air within the bowel and a
single air-fluid level seen in the right mid quadrant, likely within the
duodenum.
Radiology Report
EXAMINATION: Left upper extremity venous ultrasound.
INDICATION: Erythema and swelling of the left forearm at site of recent
intravenous catheter placed.
TECHNIQUE: Grayscale and Doppler sonograms of the left internal jugular,
subclavian, axillary, basilic and paired brachial veins were performed
including color and spectral Doppler imaging studies.
COMPARISON: None.
FINDINGS:
Grayscale and Doppler sonograms of the left internal jugular, subclavian,
axillary, basilic and paired brachial veins demonstrate nonocclusive thrombus
in the basilic vein, but the other veins appear clear without thrombosis. At
the level of the mid forearm a small superficial vein also shows nonocclusive
thrombus.
IMPRESSION:
Superficial thrombophlebitis, but no evidence of deep venous thrombosis.
Radiology Report
EXAMINATION: NON-INVASIVE PERIPHERAL ARTERIAL STUDY
INDICATION: ___ year old man with crohns disease with pain to foot, can be
done in AM// ?any evidence of arterial obstruction
TECHNIQUE: Doppler ultrasound and pulse volume recordings were obtained at
multiple levels in both lower extremities
FINDINGS:
On the right side, triphasic Doppler waveforms are seen in the femoral,
superficial femoral, popliteal, posterior tibial and dorsalis pedis arteries.
No monophasicwaveforms are seen.
On the left side, triphasic Doppler waveforms are seen in the femoral,
superficial femoral and popliteal arteries. Absentwaveforms are seenposterior
tibialis and dorsalis pedis.
The right ABI is 1.1 and the left ABI could not be calculated. Pulse volume
recordings demonstrate gross asymmetry a the metatarsal and digital levels..
IMPRESSION:
1. Absence of detectable arterial flow at the level of the ankle (PTA/DPA).
An ABI could not be calculated.
2. Normal study in the right lower extremity without evidence of arterial
insufficiency.
NOTIFICATION: Dr. ___ was notified at 19:34, ___ of the
above results.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old man with crohns disease with pain to foot, can be
done in AM// ?DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the left
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old man with Crohn's disease, found to have left
superficial thrombophlebitis, now with some c/f extension on exam, please
assess for clot propagation// propagation of left upper extremity
thrombophlebitis?
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: US from ___.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The left internal jugular, axillary, and brachial veins are patent, show
normal color flow, spectral doppler, and compressibility. Persistent thrombus
is again seen in the Left basilic vein, spanning over several cm.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
Persistent thrombus is seen in the left basilic vein, spanning over several
cm. With the available imaging, it is difficult to compare degree of
propagation from prior exam
Radiology Report
EXAMINATION: DUPLEX US of the left lower extremity.
INDICATION: ___ year old man with Crohn's, has had intermittent episodes of
left foot numbness, tingling, mild pain over last few days. Found to have
decreased flow in ___ and DP arteries on ABI. Please assess for plaque
build-up or clot vs vasospasm as cause of symptoms// Arterial anatomy, plaque
build-up, clot?
TECHNIQUE: Grayscale ultrasound, color Doppler, and spectral Doppler
waveforms of the left lower extremity were obtained.
COMPARISON: Noninvasive vascular ultrasound dated to ___
FINDINGS:
There is minimal heterogeneous plaque left common femoral artery to the mid
posterior tibial artery.
Peak systolic velocities are as follows:
Common femoral artery waveform is triphasic. Peak systolic velocity is 61
cm/sec.
Proximal superficial femoral artery waveform is triphasic. Peak systolic
velocity is 61 cm/sec
Mid superficial femoral artery waveform is triphasic with mild delayed
upstroke. Peak systolic velocity is 56 cm/sec
Distal superficial femoral artery waveform is triphasic with mild delayed
upstroke. Peak systolic velocity is 34 cm/sec
Popliteal artery waveform is triphasic with mild delayed obstruct. Peak
systolic velocity is 34 cm/sec
Posterior tibial artery waveform is triphasic with mild delayed upstrokes.
Peak systolic velocity is 21 cm/sec. The PTA at the level of the malleolus
demonstrates no evidence of flow and appears to be occluded. The occlusion of
was just distal to the take-off of an unnamed branch. Note is made of
improvement of waveforms upon changing position from recumbent to sitting up
over the site of the bed without restoration of distal flow.
Peroneal artery waveform is triphasic with mild delayed upstrokes. Peak
systolic velocity is 38 cm/sec.
Anterior tibial artery waveform is triphasic with mild delayed upstroke. Peak
systolic velocity is 51 centimeters/second.
Dorsalis pedis artery demonstrates no appreciable flow.
IMPRESSION:
1. Left distal posterior tibial artery occlusion below the level of the ankle.
2. Left dorsalis pedis artery occlusion.
NOTIFICATION: Findings discussed with Dr. ___ at 15:59 ___.
Radiology Report
EXAMINATION: CTA TORSO
INDICATION: ___ year old man with Crohn's disease here with Crohn's flare
found to have LLE distal occlusion on arterial duplex.// CTA torso with runoff
to lower extremities to eval for vascular abnormalities/aneurysm that would
predispose to LLE thrombus/thromboembolism
TECHNIQUE: Thoracic, abdomen and pelvis CTA: Non-contrast and multiphasic
post-contrast images were acquired through the thorax, 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 24.1 s, 156.9 cm; CTDIvol = 3.4 mGy (Body) DLP =
531.1 mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8
mGy-cm.
3) Stationary Acquisition 6.1 s, 0.2 cm; CTDIvol = 52.9 mGy (Body) DLP =
10.6 mGy-cm.
4) Spiral Acquisition 24.1 s, 156.7 cm; CTDIvol = 3.4 mGy (Body) DLP =
526.1 mGy-cm.
5) Spiral Acquisition 10.6 s, 69.1 cm; CTDIvol = 7.2 mGy (Body) DLP = 493.0
mGy-cm.
Total DLP (Body) = 1,563 mGy-cm.
COMPARISON: CT ___.
FINDINGS:
VASCULAR:
There is no thoracic or abdominal aortic aneurysm or dissection. There is no
calcium burden in the abdominal aorta and great abdominal arteries.
The thoracic aorta is unremarkable. The abdominal aorta is unremarkable.
There is a clot measuring 8.5 mm x 17 mm in length involving the junction of
the left common inguinal artery, and the external and internal iliac arteries.
There is no other significant finding proximally to the popliteal artery. The
popliteal artery demonstrates no flow at its middle third both on the right
and on the left, likely due to perfusional abnormality.
CHEST:
HEART AND VASCULATURE: Even though the examination is performed to adequately
assess the aorta, the pulmonary vasculature is still well opacified to the
subsegmental level, with evidence of pulmonary emboli involving segmental
arteries of the right basal lower lobe segments. 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: 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: The base of the neck was not imaged.
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: 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 or hydronephrosis. There is a 1.7 cm
hypodensity in the middle third of the left kidney with nonspecific
attenuation values. There are no urothelial lesions in the kidneys or
ureters. There is no perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Colon and rectum are within normal limits. There
is no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
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: The visualized reproductive organs are unremarkable.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Presence of emboli with left iliac artery, and right lower lobe pulmonary
arteries for which the main diagnostic consideration includes an embolic
source, possibly secondary to a patent foramen ovale. An echocardiogram is
recommended.
2. Nonspecific left renal lesion, likely a cyst which should be characterized
with ultrasound.
RECOMMENDATION(S): Echocardiography and renal ultrasound.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, n/v/d
Diagnosed with Crohn's disease, unspecified, without complications
temperature: 97.6
heartrate: 125.0
resprate: 17.0
o2sat: 100.0
sbp: 138.0
dbp: 92.0
level of pain: 7
level of acuity: 2.0 | ___ y/o M w/ Crohn's disease who was very recently discharged
after treatment for flare of Crohn's of small intestine.
Essentially failed treatment with budesonide, presenting this
admission w/ obstructive symptoms. GI was consulted. He was
started on IV steroids and placed on bowel rest w/ mIVF. His
symptoms and CRP levels improved. Diet was advanced gradually
and he was tolerating a regular, low-residue diet at the time of
discharge. During this admission, he was initiated on adalimumab
(Humira), with the first dose of 160 mg given on ___. He
will continue to follow up with his ___ GI specialists as an
outpatient.
While hospitalized, he was found to have a superficial
thrombophlebitis of the left forearm. There was no evidence of
suppurative thrombophlebitis. It was treated with conservative
measures (elevation, hot/cold packs).
While hospitalized, he also suffered from intermittent episodes
of left foot numbness, tingling, color change (turned white)
with skin noticeably cooler to touch in left foot. These
episodes were intermittent and transient. A left lower
extremity Doppler ultrasound was negative for DVT. A lower
extremity ABI, which was obtained while the patient was
symptomatic, showed decreased flow in the DP and ___ arteries of
the foot. Arterial duplex demonstrating excellent flow from
femoral through tibialis with absent flow distal to the ankle.
CT angiogram of the torso (___) revealed emboli within
the left iliac artery and right lower lobe pulmonary arteries.
It also revealed an incidental left renal lesion with
recommendation for outpatient ultrasound.
Based on these findings he was started on a heparin drip and was
transferred urgently to the OR where he had an angioget
thrombectomy of the left common iliac and placement of a lysis
catheter terminating in the left posterior tibial artery (on
___. Refer to the operative report for further details.
The lysis catheter was left in place and he returned to the OR
on ___ for advancement. The catheter was removed after a third
trip to the OR on ___. He tolerated all the above procedures
well with no issues. He was stable on post operative check. An
transesophageal echocardiogram was performed on ___ which did
not reveal a patent foramen ovale and a normal EF with no
intraventricular or atrial thrombus. Following these procedures
the patient remained on a heparin drip and was therapeutic with
goal PTT between 60 to 80. Per the recommendation of vascular
medicine, we transitioned him to a DOAC on ___. He will follow
up with vascular medicine as an outpatient and will monitor him
on that medication. Insurance approval was obtained.
He will need his primary care physician to arrange outpatient
iron infusions for ongoing treatment of his anemia with severe
iron-deficiency.
At the time of discharge the patient was tolerating a regular
diet with no issues. His pain in his foot had resolved and he
had palpable pulses. He received a loading dose of apixaban
(10mg) and he was discharged home in stable conditions. All
questions were answered to his satisfaction and appropriate
follow up was arranged. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old woman who presents to the ED with
complaint of headache and transient right-sided weakness.
She has had migraines since she was a child. Until ___ years ago,
she would get them 2 times a year. ___ years ago, she started
getting the migraines 2 times a week when she started metformin.
She stopped it and they went away. She has been getting them ___
times a year since then. Typical migraines are characterized by
a
bilateral throbbing with photophobia, and occasionally nausea.
On ___ she got one of her typical migraines. Ever since, she has
been bothered by essentially daily headaches which are quite
different. She describes these as a bifrontal aching, also
associated sometimes with photophobia and nausea. She also
describes occasional blurring of her vision and "seeing stars",
but denies any particular trigger for these. There is no
positional nature to the headache. They are not worse with
cough,
bending, straining, or Valsalva. They do not wake her from
sleep.
There is no pulsatile tinnitus or transient visual obscurations.
On ___, she went to urgent care. They ordered an MRI for ___.
She went back to ___ on ___ and was told MRI was normal. They
gave her zofran which helped with the nausea and sumatriptan.
She
was seen by her Neurologist, Dr. ___, on ___. Exam at that
time, including fundoscopy was normal. She was started on
Gabapentin 600mg night. Amitriptyline or Topamax were also
considered.
On ___ of last week, she had an episode at work in the
afternoon. She tried to use her right arm to move her computer
mouse, but realized she was completely unable to do so. She
tried
to speak but could not. She feels that she knows what she wanted
to say, but was unable to get it out. She did not try to walk
and
did not look in a mirror. After 5 minutes, these symptoms
resolved completely and she was instantly back to normal.
The next day, she had identical episode while in the car with
her
husband. This again came on with no warming or prodrome. When
her
husband asked her a question, she found she was unable to speak.
She could understand what he was saying. Again she was unable to
move her entire right arm. Her husband did not notice any facial
droop. Again, within 5 minutes she was back to normal.
On ___, while walking to her car with her husband, she
tried
speaking him to but could not. She tried to point to the car but
could not move the arm. This time, he noticed drooping of the
right side of her face. Initially, she was able to walk, but a
few moments later she apparently collapsed to the ground. Her
husband had to help her into the car. At the same time, she was
incontinent of urine. Again, within 5 minutes she was back to
normal.
Today at work, she was in a meeting when her boss noticed
drooping of the right side of the face. When she tried to speak,
she was unable to do so. She could not move her right arm.
Again,
within 5 minutes she was back to normal. After this, she decided
to present to the ED.
During all of these episodes, there has been no vision loss or
change, loss of consciousness, imbalance, sensory changes or
loss. She denies any preceding ___, abnormal tastes or
smells, or epigastric rising sensation.
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:
Depressive disorder
Overweight
Rhinitis, allergic
PCOS (polycystic ovarian syndrome)
Hypertension
Type 2 diabetes mellitus
Migraines
Mild intermittent asthma without complication
Gastroesophageal reflux disease
Social History:
___
Family History:
No family history of neurologic disease, including migraine.
Physical Exam:
ADMISSION:
Vitals: 98.4 74 143/96 16 99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: No nuchal rigidity
Pulmonary: Breathing comfortably on room air.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented. Able to relate history without
difficulty. Attentive to interview and exam. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. Fundoscopic exam is somewhat limited by
frequent refixation, but within this there does not appear to be
any papilledema.
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 Gastroc
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was 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. Able to walk in tandem without difficulty. Romberg
absent.
DISCHARGE:
Tmax: 37 °C (98.6 °F)
T current: 37 °C (98.6 °F)
HR: 76 (68 - 88) bpm
BP: 160/91(110) {___} mmHg
RR: 22 (8 - 26) insp/min
SPO2: 98%
Heart rhythm: SR (Sinus Rhythm)
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented, attentive. Language is fluent
with intact comprehension. Normal prosody. There
were no paraphasic errors. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
CN
I: not tested
II,III: PERRL (more photosensitive on right)
III,IV,VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical, symm forehead wrinkling
VIII: intact to conversation
IX,X: palate elevates symmetrically, uvula midline
XI: SCM/trapezeii ___ bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone, no rigidity; no asterixis or
myoclonus. No pronator drift or orbiting abnormality.
Delt Bi Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 ___ 5 5 5
R 5 ___ 5 5 5
IP Quad Hamst DF PF
L2 L3 L4-S1 L4 S1/S2
L 5 5 5 5 5
R 5 5 5 5 5
-Sensory: No deficits to light touch throughout.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF bilaterally.
-Gait: deferred as HOB flat to increase cerebral perfusion.
Pertinent Results:
___ 12:35PM BLOOD WBC-8.1 RBC-4.47 Hgb-12.6 Hct-38.2 MCV-86
MCH-28.2 MCHC-33.0 RDW-13.3 RDWSD-41.7 Plt ___
___ 12:35PM BLOOD Neuts-56.3 ___ Monos-5.5 Eos-2.1
Baso-0.6 Im ___ AbsNeut-4.53 AbsLymp-2.84 AbsMono-0.44
AbsEos-0.17 AbsBaso-0.05
___ 06:10AM BLOOD ___ PTT-28.0 ___
___ 12:35PM BLOOD Glucose-144* UreaN-10 Creat-0.6 Na-141
K-4.2 Cl-104 HCO3-21* AnGap-16
___ 06:10AM BLOOD ALT-23 AST-36 LD(LDH)-130 AlkPhos-54
TotBili-0.5
___ 12:35PM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:10AM BLOOD Albumin-3.9 Calcium-9.0 Phos-4.9* Mg-1.8
Cholest-145
___ 06:10AM BLOOD %HbA1c-8.5* eAG-197*
___ 06:10AM BLOOD Triglyc-549* HDL-19* CHOL/HD-7.6
LDLmeas-60
___ 06:10AM BLOOD TSH-4.4*
___ 12:35PM BLOOD ANCA-NEGATIVE B
___ 12:35PM BLOOD ___ CRP-17.2*
___ 12:35PM BLOOD VZV IgG-POS* Trep Ab-NEG
___ 12:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 12:42PM BLOOD SED RATE-29 H
___ 04:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:00PM URINE RBC-3* WBC-2 Bacteri-FEW* Yeast-NONE
Epi-2 TransE-<1
___ 04:00PM URINE CastHy-2*
___ 04:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 4:00 pm URINE **FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ CTA head/neck
IMPRESSION:
1. No acute intracranial abnormality.
2. There is moderate to severe stenosis involving the M1 and
proximal M2
branches of the left MCA. Otherwise, unremarkable intracranial
vasculature.
3. Possible small right sided carotid web.
4. Patent bilateral cervical carotid and vertebral arteries
without evidence of stenosis, occlusion, or dissection.
5. No dural venous sinus thrombosis.
___ MRI/MRA brain w/ & w/o contrast
IMPRESSION:
1. Punctate foci of diffusion abnormality in the left frontal
lobe with subtle enhancement indicative of subacute infarct.
2. Focal likely high-grade stenosis at the distal M1 segment of
the left
middle cerebral artery unchanged from the CT examination of ___.
___ Renal U/S w/ doppler
IMPRESSION:
Normal renal ultrasound. No evidence of renal artery stenosis.
___ CXR
IMPRESSION:
No acute cardiopulmonary abnormality.
___ TTE
IMPRESSION: No structural cardiac source of embolism (e.g.patent
foramen ovale/atrial septal defect, intracardiac thrombus, or
vegetation) seen. Mild symmetric left ventricular hypertrophy
with normal biventricular cavity sizes, and regional/global
biventricular systolic function. Mild tricuspid regurgitation.
Normal estimated pulmonary artery systolic pressure.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cetirizine 10 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. GlipiZIDE XL 15 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) Dose is Unknown PO Frequency is
Unknown
5. Basaglar KwikPen U-100 Insulin (insulin glargine) 100 unit/mL
(3 mL) subcutaneous unknown
6. butalbital-acetaminophen-caff 50-325-40 mg/15 mL oral BID:PRN
headache
7. Norethindrone-Estradiol 1 TAB PO DAILY
8. Propranolol LA 120 mg PO DAILY
9. Gabapentin 300 mg PO BID
10. Sumatriptan Succinate 50 mg PO DAILY:PRN migraine
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth once daily Disp
#*30 Capsule Refills:*0
3. Verapamil SR 240 mg PO Q24H
RX *verapamil 240 mg 1 tablet(s) by mouth once a day Disp #*30
Capsule Refills:*0
4. MetFORMIN XR (Glucophage XR) 500 mg PO TID
Do Not Crush
5. Basaglar KwikPen U-100 Insulin (insulin glargine) 100
unit/mL (3 mL) subcutaneous unknown
6. butalbital-acetaminophen-caff 50-325-40 mg/15 mL oral
BID:PRN headache
7. Cetirizine 10 mg PO DAILY
8. Gabapentin 300 mg PO BID
9. GlipiZIDE XL 15 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
subacute left frontal ischemic infarcts
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 WANDW/O CONTRAST
INDICATION: ___ year old woman with intermittent R sided weakness ? of M1/2
stenosis// eval vessel occlusion/stenosis/stroke
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of cc of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations. 3D time-of-flight MRA of the circle of ___ was obtained.
COMPARISON: CT angiography of ___.
FINDINGS:
There is a focus of increased signal within the left frontal lobe (08:20) on
diffusion images with low signal on ADC map (07:20) and subtle abnormality on
the FLAIR images and subtle of postcontrast enhancement in the region
suggestive of subacute infarct. There is no evidence of blood products.
There is no mass effect midline shift or hydrocephalus. No other foci of
abnormal enhancement are seen.
MRI of the head demonstrates focal narrowing and signal loss within the distal
M1 segment of the left middle cerebral artery proximal to the bifurcation.
There is slightly decreased flow signal in the sylvian branches. Otherwise
the MRI is unremarkable.
IMPRESSION:
1. Punctate foci of diffusion abnormality in the left frontal lobe with subtle
enhancement indicative of subacute infarct.
2. Focal likely high-grade stenosis at the distal M1 segment of the left
middle cerebral artery unchanged from the CT examination of ___.
Radiology Report
EXAMINATION: US RENAL ARTERY DOPPLER
INDICATION: ___ is a ___ year old woman with a past medical history
of DMII on insulin, hypertension, and migraines with recurrent episodes of
aphasia and right arm weakness found to have L frontal ischemic infarcts and
high grade stenosis of distal L M1. Concern for possible fibromuscular
dysplasia, r/o renal artery stenosis.// R/o renal artery stenosis w/ doppler
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: None.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Right kidney: 14.4 cm
Left kidney: 14.5 cm
Renal Doppler: Intrarenal arteries show normal waveforms with sharp systolic
peaks and continuous antegrade diastolic flow. The resistive indices of the
right intra renal arteries range from 0.61-0.65. The resistive indices on the
left range from 0.59-0.64. Bilaterally, the main renal arteries are patent
with normal waveforms. The peak systolic velocity on the right is 72
centimeters/second. The peak systolic velocity on the left is 108
centimeters/second. Main renal veins are patent bilaterally with normal
waveforms.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound. No evidence of renal artery stenosis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ is a ___ year old woman with a past medical history
of DMII on insulin, hypertension, and migraines with recurrent episodes of
aphasia and right arm weakness found to have L frontal ischemic infarcts and
high grade stenosis of distal L M1.// Stroke work-up
TECHNIQUE: AP portable chest radiograph
COMPARISON: None
FINDINGS:
There is no focal consolidation, pleural effusion or pneumothorax. The size
of the cardiomediastinal silhouette is within normal limits.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal CT, Headache
Diagnosed with Cerebral infarction, unspecified
temperature: 96.9
heartrate: 92.0
resprate: 18.0
o2sat: 98.0
sbp: 148.0
dbp: 95.0
level of pain: 2
level of acuity: 2.0 | ___ is a ___ year old woman with a past medical
history of DMII, hypertension, and migraines who is admitted to
the Neurology stroke service with recurrent episodes of aphasia
and right arm weakness secondary to a subacute ischemic left
frontal strokes in the setting of high grade stenosis of distal
L M1. Neurological exam on admission only notable for slightly
decreased pinprick in the right hand compared to the left (NIHSS
0). Her strength was notably full, and she had no aphasia at the
time of evaluation. She did not have any symptoms at time of
discharge, with ___ recommended home with no needs.
Found to have M1 narrowing with small areas of L frontal infarct
in that distribution. The cause of the stenosis is not
immediately clear. She does have atherosclerotic risk factors
(DMII on insulin, HTN), but she is rather young to have a high
grade stenosis. Work-up for causes of vaculitis not able for
ANCA negative, ___ negative, trep ab neg. CNS vasculiditis and
RCVS thought less likely as no thunderclap headache to suggest
this. Systemic vasculitis also not suggested by history. Renal
U/S did not demonstrate renal artery stenosis and further review
of vascular imaging did not indicate concern for fibromuscular
dysplasia. She was started on clopidogrel monotherapy (given
NSAID allergy). Her propranolol was transitioned to verapamil to
potentially alleviate some cerebral vasoconstriction and
prophylactically treat for headaches. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
___ placement ___
History of Present Illness:
Ms. ___ is a ___ with a history of Alzheimer's dementia,
HTN, hyperlipidemia, and brittle T2DM (on insulin) who presents
for hyperglycemia.
Per history obtained in the ED, the patient's ___ checked her
fingerstick blood glucose and noted that machine read >
500mg/dL.
The patient was subsequently brought to ___ for further
evaluation. She feels fatigued but otherwise had no specific
complaints. Per her daughter-in-law, patient has suffered from
poor appetite for several years and frequently contracts urinary
tract infections. Her diabetes is very brittle, and she is
followed at the ___.
In the ED, initial vitals T 97.0 BP 135/84 HR 124 RR 18 O2 97%
RA
Exam notable for:
- General: Frail, elderly woman, cachectic
- HEENT: Temporal wasting, dry mucous membranes
- CV: Tachycardic, normal S1/S1, no m/r/g
- Neuro: A&Ox1, moving all 4 extremities with purpose
Labs notable for:
- WBC 12.0 (95% neutrophils)
- K 5.7, HCO3 22, BUN 47, Cr 0.8, glucose 683, AG 27
- VBG 7.25/60, lactate 2.5
- UA 30 protein, 1000 glucose, 80 ket
- trop 0.12, MB ___ MBI 12.3
- pro-BNP 2636
- beta-OH 7.2
Imaging/Diagnostics:
- ___ ECG: ST depressions in V4-V6, new compared to ___
- ___ CXR: Increased opacification at the right lung base is
concerning for developing pneumonia.
Patient received:
- 2L NS, Regular insulin 10 units x1, ceftriaxone, azithromycin
Past Medical History:
1. Type 2 diabetes mellitus - The patient is followed by Dr.
___ at the ___.
2. Status post syncopal episodes/falls
3. Dementia (probable Alzheimer's type)
4. Osteoarthritis
5. Hypertension
6. Depression
7. Anorexia
8. Osteopenia
PAST SURGICAL HISTORY:
1. Status post microdiscectomy - ___
2. Status post left total knee replacement - ___
Social History:
___
Family History:
Dementia - father
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VS: Afebrile, HR 104 BP 131/52 RR 24 O2 Sat 100 on 2L NC
GEN: catechetic, alert
EYES: anicteric, EOMI
HENNT: dry mucus membranes,
CV: RRR, soft systolic murmur RUSB
RESP: Scattered rhonchi bilaterally
GI: soft, non tender, non distended
SKIN: no obvious rash
NEURO: moving extremities w/ purpose
PSYCH: alert, oriented to self
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 706)
Temp: 97.4 (Tm 98.0), BP: 170/82 (134-170/73-84), HR: 96
(89-104), RR: 25 (___), O2 sat: 92% (90-92), O2 delivery: Ra
GEN: cachectic, alert and interactive. Oriented to self.
EYES: anicteric, EOMI
CV: RRR, soft systolic murmur RUSB
RESP: Bilateral rhonchi
GI: Soft, non tender, non distended
SKIN: no obvious rash
NEURO: moving extremities w/purpose
PSYCH: alert, oriented to self only
Pertinent Results:
===============
ADMISSION LABS
===============
___ 02:36AM BLOOD WBC-12.0* RBC-3.82* Hgb-11.9 Hct-40.1
MCV-105* MCH-31.2 MCHC-29.7* RDW-13.7 RDWSD-52.8* Plt ___
___ 02:36AM BLOOD Glucose-683* UreaN-47* Creat-0.8 Na-146
K-5.6* Cl-97 HCO3-22 AnGap-27*
___ 02:36AM BLOOD CK-MB-13* MB Indx-12.3* proBNP-2636*
___ 02:36AM BLOOD cTropnT-0.12*
___ 02:36AM BLOOD Beta-OH-7.2*
===============
PERTINENT LABS
===============
___ 12:15PM BLOOD Calcium-8.5 Phos-1.9* Mg-1.7
___ 02:42AM BLOOD ___ pO2-57* pCO2-60* pH-7.25*
calTCO2-28 Base XS--1
___ 02:42AM BLOOD Lactate-2.5*
___ 06:13AM BLOOD Glucose-516* UreaN-47* Creat-0.8 Na-146
K-6.9* Cl-106 HCO3-19* AnGap-21*
___ 12:15PM BLOOD Glucose-177* UreaN-37* Creat-0.5 Na-149*
K-4.5 Cl-109* HCO3-29 AnGap-11
___ 04:05PM BLOOD Glucose-190* UreaN-31* Creat-0.5 Na-146
K-5.3 Cl-107 HCO3-28 AnGap-11
___ 06:13AM BLOOD CK-MB-30* cTropnT-0.28*
___ 12:15PM BLOOD cTropnT-0.62*
___ 04:05PM BLOOD CK-MB-42* cTropnT-0.75*
___ 04:09AM URINE Color-Straw Appear-Clear Sp ___
___ 04:09AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-1000* Ketone-80* Bilirub-NEG Urobiln-NEG pH-6.0
Leuks-NEG
___ 04:09AM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
===============
DISCHARGE LABS
===============
___ 05:13AM BLOOD WBC-8.2 RBC-3.48* Hgb-10.7* Hct-36.1
MCV-104* MCH-30.7 MCHC-29.6* RDW-13.1 RDWSD-50.0* Plt ___
___ 05:29AM BLOOD Glucose-292* UreaN-28* Creat-0.5 Na-144
K-3.8 Cl-94* HCO3-39* AnGap-11
___ 05:29AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
==================
STUDIES/PATHOLOGY
==================
CXR ___: IMPRESSION: Increased opacification at the right
lung base is concerning for developing pneumonia.
CXR ___: IMPRESSION: 1. Right PICC line tip at caval atrial
junction. 2. Worsening right basilar airspace process suspicious
for pneumonia.
ECG ___: Diffuse ST-segment depressions
============
MICROBIOLOGY
============
___: Blood culture: no growth
___: Urine culture: no growth
___: Urine legionella: negative
___: Urine strep pneumo: negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. calcium carbonate-vitamin D3 200 mg (500 mg) -400 unit oral
DAILY
5. Glargine 14 Units Breakfast
NPH 8 Units Breakfast
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Glucagon 1 mg Subcut Q15MIN:PRN BG <70
2. Glucose Gel 15 g PO PRN BG <70
3. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR
Up to 2 Units QID per sliding scale Disp #*5 Syringe Refills:*0
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate [Kapspargo Sprinkle] 25 mg 1 capsule(s)
by mouth once a day Disp #*30 Capsule Refills:*0
5. Glargine 12 Units Breakfast
Insulin SC Sliding Scale using Insulin
6. Aspirin 81 mg PO DAILY
7. calcium carbonate-vitamin D3 200 mg (500 mg) -400 unit oral
DAILY
8. Escitalopram Oxalate 20 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
-----------------
Community Acquired Pneumonia
Diabetic Ketoacidosis
NSTEMI
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ female with hyperglycemia, weakness, concern for
infection. Evaluate for cardiopulmonary process, pneumonia.
TECHNIQUE: Portable AP chest
COMPARISON: Multiple prior chest radiographs, most recently ___.
FINDINGS:
Lungs are well aerated. There is mild increased opacification at the right
lung base. No evidence of acute cardiac decompensation. No large pleural
effusion or pneumothorax identified. The cardiomediastinal silhouette is
stable
IMPRESSION:
Increased opacification at the right lung base is concerning for developing
pneumonia.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with Right PICC// Right PICC 30cm, ___ ___
Contact name: ___: ___ Right PICC 30cm, ___ ___
COMPARISON: Chest x-ray ___
FINDINGS:
Distal tip of the right PICC line is at the caval atrial junction. There is
been interval worsening of the right basilar opacification with poor
visualization of the right hemidiaphragm on the current exam. No other
significant interval change.
IMPRESSION:
1. Right PICC line tip at caval atrial junction. 2. Worsening right basilar
airspace process suspicious for pneumonia.
Radiology Report
INDICATION: ___ year old woman with RLL pneumonia, concern for dysphagia.//
evaluate for dysphagia, aspiration
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: 4 min.
COMPARISON: Video swallow study of ___
FINDINGS:
There was silent aspiration with thin liquids. Limited views demonstrate a
tortuous and mildly patulous esophagus with free passage of contrast from the
mouth to the distal esophagus.
IMPRESSION:
Silent aspiration with thin liquids.
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).
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hyperglycemia
Diagnosed with Type 2 diabetes mellitus with ketoacidosis without coma, Long term (current) use of insulin
temperature: 97.0
heartrate: 124.0
resprate: 18.0
o2sat: 97.0
sbp: 135.0
dbp: 84.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ with a history of Alzheimer's dementia and
brittle T2DM (on insulin) who presented with DKA iso CAP.
ACUTE ISSUES
===============
# IDDM
# DKA (resolved):
# Anion gap metabolic acidosis (resolved):
Ms. ___ presented with glucosuria, anion gap metabolic
acidosis, and ketonuria, consistent with DKA. She was admitted
to the MICU for further management. In the MICU, patient was
placed on IV fluids and insulin gtt. Gap acidosis closed, and
patient was transitioned to subcutaneous insulin. DKA was likely
triggered by pneumonia. Patient has known brittle diabetes and
___ was consulted for insulin titration. As an outpatient,
she had been on a regimen of lantus and NPH once daily in the AM
to decrease the number of injections. Attempt was made to
stabilize the patient on a regimen with lantus and NPH, however,
this was complicated by several episodes of symptomatic
hypoglycemia. In discussion with ___, family, and the primary
team, it was decided to attempt to minimize hypoglycemia and
avoid DKA, and aim for BGs to be in to 200-300s. Patient will be
discharged on a regimen of lantus 12u qAM to be administered by
an AM visiting nurse. A second visiting nurse visit was added
for now which will include a ___ BG check. If patient's sugars
are >400 at that time, ___ can administer 2u humalog. If BG
>500, can administer 2u Humalog and contact PCP's office.
Insulin titration can continue on an outpatient basis. She was
additionally discharged with a prescription for glucagon PRN
hypoglycemia, glucose gel PRN hypoglycemia, and can additionally
use honey or maple syrup PO to treat hypoglycemia.
# RLL pneumonia:
Seen on CXR and patient presented with elevated WBC. Patient was
noted to be coughing after eating and may have chronic
aspiration. Treated for CAP with 5 day course of ceftriaxone and
azithromycin.
# Dysphagia
Evaluated by speech and swallow after concern that aspiration
was leading to development of pneumonia. Video swallow study
showed silent aspiration with thin liquids. Patient was
recommended for a pureed diet with nectar thick liquids.
# NSTEMI
# CAD
Patient had uptrending trops up 0.72 ___epression in
V4-V6. Likely type 2 NSTEMI iso demand/supply mismatch due to
hyperglycemia and dehydration. She remained chest pain free. Per
family, coronary angiography or any kind of procedural
intervention is not within goals of care. She was started on
metoprolol succinate 25mg daily to decrease cardiac demand and
continued on home ASA. Patient had been getting atorvastatin
while in house, from review of outpatient records, shared
decision making was invoked to discontinue statin therapy with
gerontologist in ___. Discontinued atorvastatin upon discharge.
CHRONIC MEDICAL PROBLEMS
==========================
# Weight loss
Continued glucerna TID
# Depression
Continued escitalopram
# HTN
Continued home Lisinopril, added metoprolol as above.
# Advanced Care Planning
1. Goals of care:
___: Advanced Directives: DNR/DNI
2. Healthcare Proxy and relationship: ___ - ___
TRANSITIONAL ISSUES
===================
[ ] ___ administer lantus 12u qAM
[ ] On ___ visit, check blood glucose, if >400 administer 2u
humalog. If >500 administer 2u Humalog and contact PCP's office.
[ ] If BG <70, can administer glucagon and glucose gel. If
unable to eat/drink can also place honey or maple syrup inside
the mouth as well.
[ ] Please continue diet of pureed foods and nectar thick
liquids
[ ] Continue to monitor blood glucose, can call PCP's office
with questions regarding insulin dosing |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Azathioprine / cephalosporins / cefuroxime /
aspirin
Attending: ___.
Chief Complaint:
Abdominal pain, emesis.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old F with history of renal transplant at ___ who
presents with two days of abdominal pain, nausea, vomiting,
diarrhea, and chills. No fever. No sick contacts. Has been
eating same food as others in family, who are not ill. Notes
vomit is dark brown to black in color, had ___ episodes over the
last day. Complains of continued upper, mid-abdominal pain that
has worsened over the last day.
Of note, the patient was recently admitted for acute on chronic
CHF exacerbation, acute toxic encephalopathy from prescription
opioid overuse. She also has had admissions to ___ this year
for anemia, workup of LLE fracture, falls, as well as abdominal
pain and emesis similar to this presentation.
In the ED, initial vitals were: 98.9 80 178/95 22 98% RA
Labs were notable for: Na139 K4.0 Cl103 BUN75 HCO3 23
creatinine 2.5 Gluc93. WBC12.8 Hgb9.2 hct 30.3 plt276,
lactate 1.1. UA significant for 100 protein.
Studies showed:
-CT abdomen with s/p cholecystectomy extrahepatic CBD up to 15
mm and mild central intrahepatic ductal dilatation, ?recommended
MRCP for further evaluation.
-Renal Transplant Ultrasound: Normal renal transplant
ultrasound.
Patient was given: Dilaudid 1g x4, 500 cc NS, Labetolol 300 mg,
Zofran 4 mg
Consults: Renal transplant was consulted and will follow along
as patient is admitted to general medicine.
On transfer to the floor, vitals were: P86 BP 183/98 RR20
SaO2 100% RA
Currently, patient is still complaining of epigastric abdominal
pain but has not had any diarrhea or vomiting since being in the
ED. She rates the pain as an ___ and is actively crying out in
pain but when distracted appears quite comfortable. She reports
that her pain is not related to eating or stooling. She reports
that they only relief of her pain came from the doses of
dilaudid that she received in the ED. She was able to eat at
home but only had one glass of apple juice today, but is now
requesting a ___ sandwich and ginger ale. She has been
having normal bowel movements at home until yesterday.
Of note, the patient reports that she took her first prograf
dose at home as well as prednisone, but has not had any of her
other medications with the exception of one dose of labetolol in
the ED.
Past Medical History:
- Chronic diastolic heart failure
- PAH with RV dilation
- Stable CAD w/reversible inferior ischemia on stress test
(___)
- Partial R MCA stroke w/ mild left hemiparesis and seizure d/o
(___)
- ESRD s/p DDRT at ___ (___) c/b CKD stage IV
- Hypertension
- Depression and anxiety
- Chronic LLE pain
- Left TKR ___ c/b MSSA PJI s/p hardware removal,
antibiotic spacer, and multiple washouts.
- Pathological left tibia fracture ___ (presumed
osteomyelitis); failed conservative therapy with ___, s/p
ORIF ___ with GPC/GPR found in wound.
Social History:
___
Family History:
Mother - CAD, ___, arthritis
Father - colorectal cancer
Sister - ___
Physical Exam:
Admission:
VS: 98.2 83 180/100 24 94%RA
General: Lying in bed, moaning in pain but pausing when
distracted and ordering dinner.
HEENT: AT/NC, dry mucosa
Neck: supple, no JVD
CV: RRR
Lungs: CTAB
Abdomen: obese, kidney left of midline, nontender. TTP in
epigastrium. Soft overall, no rebound/guarding.
Ext: well healed scar on L leg. L leg with nonpitting edema L>R,
pt reports this is baseline.
Neuro: CN ___ grossly intact. Moving all extremities equally.
No focal deficits. AOx3
Skin: No lesions
Discharge:
VS: 97.8 98.7 120-130/50-60 ___ 18 98%RA
General: Lying in bed, moaning in pain
HEENT: AT/NC, dry mucosa
Neck: supple, no JVD
CV: RRR
Lungs: CTAB
Abdomen: obese, kidney left of midline, nontender. TTP in
epigastrium but improved and very soft. Soft overall, no
rebound/guarding.
Ext: well healed scar on L leg. L leg with nonpitting edema L>R,
pt reports this is baseline.
Neuro: CN ___ AOx3
Skin: No lesions
Pertinent Results:
Admission Labs:
___ 06:57AM LACTATE-1.1
___ 06:45AM GLUCOSE-93 UREA N-75* CREAT-2.5* SODIUM-139
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
___ 06:45AM estGFR-Using this
___ 06:45AM ALT(SGPT)-7 AST(SGOT)-20 ALK PHOS-166* TOT
BILI-0.4
___ 06:45AM LIPASE-44
___ 06:45AM ALBUMIN-3.6 CALCIUM-9.6 PHOSPHATE-3.6
MAGNESIUM-1.7
___ 06:45AM URINE HOURS-RANDOM
___ 06:45AM URINE UHOLD-HOLD
___ 06:45AM WBC-12.8*# RBC-3.43*# HGB-9.2* HCT-30.3*
MCV-88 MCH-26.8 MCHC-30.4* RDW-17.2* RDWSD-55.3*
___ 06:45AM NEUTS-83.6* LYMPHS-5.1* MONOS-8.6 EOS-2.0
BASOS-0.2 IM ___ AbsNeut-10.73*# AbsLymp-0.66*
AbsMono-1.11* AbsEos-0.26 AbsBaso-0.02
___ 06:45AM PLT COUNT-276
___ 06:45AM ___ PTT-32.5 ___
___ 06:45AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
___ 06:45AM URINE RBC-1 WBC-15* BACTERIA-NONE YEAST-NONE
EPI-1
Discharge Labs:
___ 05:30AM BLOOD WBC-6.0 RBC-2.79* Hgb-7.5* Hct-24.7*
MCV-89 MCH-26.9 MCHC-30.4* RDW-17.0* RDWSD-55.2* Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD ___ PTT-33.2 ___
___ 05:30AM BLOOD Glucose-87 UreaN-55* Creat-2.4* Na-141
K-4.4 Cl-106 HCO3-24 AnGap-15
___ 05:30AM BLOOD ALT-11 AST-15 AlkPhos-197* TotBili-0.2
___ 05:30AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9
___ 05:53AM BLOOD tacroFK-7.2
Micro:
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE, PRESUMPTIVELY NOT S.
SAPROPHYTICUS. 10,000-100,000 ORGANISMS/ML..
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.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
___: Blood cultures NGTD x2
___: H. Pylori negative
___: CMV
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: Abdominal pain.
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: None.
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 0.69 to 0.71, within
the normal range. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow, with peak systolic
velocity of 69.8. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
IMPRESSION:
Normal renal transplant ultrasound.
Radiology Report
INDICATION: ___ with diarrhea and abdominal pain, evaluate for
diverticulitis.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 782 mGy-cm.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
LOWER CHEST: The visualized lung bases are clear. Atherosclerotic
calcifications of the aortic annulus and the coronary arteries are noted. No
pericardial or pleural effusion is noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. The gallbladder is surgically absent. There is prominence of the CBD
measuring up to 1.5 cm with mild central intrahepatic biliary ductal
dilatation.
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. There is small amount of nonspecific fluid around
the spleen.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The native kidneys are atrophic bilaterally. A transplant kidney is
seen within the left lower quadrant. No hydronephrosis or urolithiasis is
identified on this scan. There is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops
demonstrate normal caliber and wall thickness throughout. The colon and
rectum are within normal limits. There is no evidence of acute
diverticulitis. The appendix is not visualized but there are no secondary
signs of appendicitis.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of free fluid within the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of were is some osseous lesions. Right acetabular
and superior ramus fractures are unchanged since prior study. Spinal on
pelvic hardware are also unchanged. There is persistent anterolisthesis of L4
on L5. Small amount of fluid is seen within the right iliopsoas bursa
possibly reflecting bursitis.
SOFT TISSUES: A 6.7 x 6.1 x 15.2 cm collection is identified within the
subcutaneous soft tissues of the left gluteal region extending into the upper
thighs.
IMPRESSION:
1. Limited evaluation due to absence of IV contrast. Small amount of none
specific intra-abdominal fluid. No diverticulitis.
2. 6.7 x 6.1 x 15.2 cm collection the subcutaneous soft tissues of the left
gluteal region extending into the upper thighs. This may represent a
liquefying hematoma. Correlate with previous trauma.
3. Status post cholecystectomy with dilation of the extrahepatic CBD up to 15
mm and mild central intrahepatic ductal dilation. Correlate with symptoms and
laboratory evidence of biliary obstruction and if indicated, MRCP may be
obtained.
4. Small amount of fluid in the right iliopsoas bursa which could represent
bursitis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, n/v/d
Diagnosed with Unspecified abdominal pain, Nausea with vomiting, unspecified
temperature: 98.9
heartrate: 80.0
resprate: 22.0
o2sat: 98.0
sbp: 178.0
dbp: 95.0
level of pain: 8
level of acuity: 3.0 | Brief Hospital Course:
====================
___ with PMH of renal transplant, seizure d/o, diastolic CHF (EF
55%), L TKA with with multiple infectious complications
including pathologic tibial fx requiring ORIF on chronic
minocycline recent admission for opioid overuse and
encephalopathy, who presents with abdominal pain and report of
black colored emesis, but clinically stable and with stable
blood counts. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ Laparoscopic appendectomy
History of Present Illness:
Mr. ___ is a ___ year old man with past medical history of
abnormal LFTs (likely related to hepatic steatosis as noted on
CT) and obesity who presented to ___ ED with 20 hours of
abdominal pain and nausea.
He reports onset of abdominal pain and nausea beginning ___
evening at around 10 ___ a few hours after eating spicy ___
rice cakes and Popeye's chicken. The pain was initially
mid-epigastric, without radiation to the back, but progressively
worsened and moved to the right lower quadrant. He vomited
earlier ___ around 6 ___. The emesis was mostly liquid, yellow
in color, and without obvious blood or bile. He last ate around
noon today. He denies any diarrhea, constipation, hemtochezia,
or melena. Last bowel movement was ___. He reports taking 1
pill of amoxicillin (unknown dose) earlier today, which he
brought with him from ___.
Past Medical History:
Abnormal LFT's
Social History:
___
Family History:
No family history of appendicitis. No history of GI cancer in
mother or father.
Physical Exam:
Admission physical exam:
Physical Exam:
Vitals: T 98.2, HR 90, BP 146/90, RR 18, O2 99%, Pain ___
GEN: A&O3, overweight, pleasant young ___ man lying in bed
in 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: moderate adiposity. Soft, nondistended, tenderness to
palpation in RLQ with some guarding. Focal rebound tenderness in
RLQ. Positive Rovsing's and psoas signs. Negative obturator
sign.
Ext: No ___ edema, ___ warm and well perfused
Discharge physical exam:
VS: 98.1PO 103 / 66 Sitting 81 18 97 RA
HEENT: PERRL, EOMI, Neck supple, trachea midline.
CV: RRR
Pulm: clear to auscultation bilaterally
Abd: Soft, Tender to palp RLQ, mildly distended. Active bowel
sounds.
Ext: Warm and dry. no edema. 2+ ___ pulses.
Neuro: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 07:00AM BLOOD WBC-13.3* RBC-4.35* Hgb-13.8 Hct-40.1
MCV-92 MCH-31.7 MCHC-34.4 RDW-11.9 RDWSD-39.9 Plt ___
___ 05:50AM BLOOD WBC-14.0* RBC-4.40* Hgb-13.8 Hct-40.4
MCV-92 MCH-31.4 MCHC-34.2 RDW-11.9 RDWSD-40.4 Plt ___
___ 03:54AM BLOOD WBC-17.7* RBC-4.51* Hgb-14.0 Hct-42.5
MCV-94 MCH-31.0 MCHC-32.9 RDW-11.9 RDWSD-41.3 Plt ___
___ 04:30AM BLOOD WBC-15.7* RBC-4.37* Hgb-13.6* Hct-40.3
MCV-92 MCH-31.1 MCHC-33.7 RDW-11.9 RDWSD-40.9 Plt ___
___ 01:16PM BLOOD WBC-19.6* RBC-4.85 Hgb-15.1 Hct-44.4
MCV-92 MCH-31.1 MCHC-34.0 RDW-11.9 RDWSD-39.9 Plt ___
___ 05:15PM BLOOD WBC-19.3*# RBC-5.23 Hgb-16.3 Hct-47.2
MCV-90 MCH-31.2 MCHC-34.5 RDW-11.9 RDWSD-38.8 Plt ___
___ 11:15PM BLOOD ___ PTT-32.9 ___
___ 07:00AM BLOOD Glucose-96 UreaN-8 Creat-0.6 Na-133 K-4.0
Cl-93* HCO3-24 AnGap-20
___ 05:50AM BLOOD Glucose-110* UreaN-6 Creat-0.7 Na-132*
K-3.9 Cl-92* HCO3-26 AnGap-18
___ 03:54AM BLOOD Glucose-102* UreaN-6 Creat-0.7 Na-131*
K-3.8 Cl-91* HCO3-23 AnGap-21*
___ 04:30AM BLOOD Glucose-127* UreaN-6 Creat-0.8 Na-130*
K-3.7 Cl-94* HCO3-25 AnGap-15
___ 01:16PM BLOOD Glucose-128* UreaN-9 Creat-0.8 Na-134
K-3.6 Cl-94* HCO3-22 AnGap-22*
___ 05:15PM BLOOD Glucose-116* UreaN-12 Creat-0.7 Na-138
K-4.5 Cl-97 HCO3-23 AnGap-23*
___ 05:15PM BLOOD ALT-55* AST-27 AlkPhos-93 TotBili-1.0
___ 07:00AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.4
___ 05:50AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.1
___ 03:54AM BLOOD Calcium-8.8 Phos-2.0* Mg-1.9
___ 04:30AM BLOOD Calcium-8.3* Phos-1.6* Mg-2.2
___ 01:16PM BLOOD Calcium-9.2 Phos-2.1* Mg-1.6
___ 10:42 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 5:13 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
___ 11:30 am 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).
___ CT A/P:
1. Acute appendicitis with 4-5 mm appendicolith in the proximal
appendix. No evidence of free air or organized fluid
collection.
2. Hypoattenuation of the liver seen suggests hepatic steatosis,
incompletely evaluated on this contrast-enhanced exam. Consider
correlation with LFTs.
___ Right lower extremity ultrasound:
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ CXR:
Bibasilar atelectasis left greater than right.
___ CXR:
There are low lung volumes and bibasilar atelectasis, which
accentuates the cardiomediastinal silhouette. No pleural
effusion or pneumothorax. No strong evidence for pneumonia.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Do not exceed 4grams/24hrs
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Days
end ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*6 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
Hold for diarrhea.
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H Duration: 2 Days
end ___
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*9 Tablet Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Take lowest effective dose for least amount of time.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
Take as needed.
RX *polyethylene glycol 3350 17 gram 1 packet by mouth once a
day Disp #*14 Packet Refills:*0
7. Senna 8.6 mg PO BID:PRN Constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Simethicone 40-80 mg PO QID:PRN gas pain
as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute perforated appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old man ___ s/p lap appy c/o RLE burning mid thigh to
ankle. // ? 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.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man POD1 lap appy with new fevers // ?pna
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
Cardiomediastinal contours are normal. There are low lung volumes with
bibasilar atelectasis left greater than right. There is no pneumothorax or
pleural effusion. The osseous structures are unremarkable
IMPRESSION:
Bibasilar atelectasis left greater than right.
Radiology Report
INDICATION: ___ year old man s/p lap appy for gangrenous appendix,
persistently febrile on antibx // please eval for interval change
TECHNIQUE: Portable upright chest radiograph
COMPARISON: ___
IMPRESSION:
There are low lung volumes and bibasilar atelectasis, which accentuates the
cardiomediastinal silhouette. No pleural effusion or pneumothorax. No strong
evidence for pneumonia.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified acute appendicitis
temperature: 97.0
heartrate: 116.0
resprate: 18.0
o2sat: 99.0
sbp: 154.0
dbp: 77.0
level of pain: 9
level of acuity: 3.0 | Mr. ___ is a ___ year old man who presented with 24 hours of
abdominal pain, nausea and vomiting. Admission abdominal/pelvic
CT revealed appendicitis with associated appendicolith. WBC was
elevated at 19.3. Informed consent was obtained and the patient
underwent laparoscopic appendectomy on ___. Please see
operative report for details. Patient was extubated and taken
to PACU in stable condition. After a brief, uneventful stay in
the PACU, the patient arrived on the floor tolerating clears, on
IV fluids, and IV Dilaudid for pain control. The patient was
hemodynamically stable.
On POD1 patient was febrile to 102.3 despite Tylenol. Blood and
urine sent for culture which were negative. White blood cell
count was elevated at 19.6 Chest x-ray obtained and showed low
lung volumes and bibasilar atelectasis. Right lower extremity
ultrasound for leg burning negative for DVT. Oral antibiotics
transitioned to IV. Patient hemodynamically stable with
tachycardia to 120.
On POD2 patient again febrile to 103.0 oral. IV antibiotics
continued and he remained hemodynamically stable. White blood
cell count decreased to 15.7.
On POD4 he remained hemodynamically stable and afebrile since
POD2. He was tolerating a regular diet, voiding adequate urine,
and antibiotics were converted to oral. Continued to have left
lower quadrant pain increased with moving/coughing and improved
with PO oxycodone. Stool sample was sent for Clostridium
difficile which was negative.
On POD5, at time of discharge patient was feeling well,
afebrile, tolerating a regular diet, on oral antibiotics and
white blood cell count decreased to 13.3. He was discharged with
instructions to continue oral ciprofloxacin and flagyl for 3
more days.
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:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
___ w/recent lap CCY presents with epigastric abdominal pain,
nausea. Pt first had pain 3 days ago which resolved with
Tylenol. Pain returned yesterday after eating breakfast and was
associated with nausea. He first presented to ___ where CT
scan and right upper quadrant ultrasound which were
unremarkable. Labs showed elevated LFTs. He was transferred to
BID for ERCP evaluation.
In ED pt had repeat labs and reported that his pain had improved
with morphine
On arrival to the floor pt appears comfortable, reports pain
only with palpation since morphine.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
gerd
tonsillectomy
lap ccy ___
Social History:
___
Family History:
father with gallstones
Physical Exam:
ADMISSION EXAM:
Vitals: T:97.7 BP:131/91 P:69 R:18 O2:97%ra
PAIN: 0
General: nad
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, tender epigastrium
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
DISCHARGE EXAM:
VS: T 98.1 BP 133/86 P 66 R 18 Sat 97% on RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, mildly tender in epigastric area, non-distended, +
bowel sounds. Liver of normal size, non-tender, spleen not
palpable,
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS
--------------
___ 06:45AM BLOOD WBC-5.4# RBC-4.38* Hgb-13.3* Hct-39.9*
MCV-91 MCH-30.4 MCHC-33.3 RDW-13.2 Plt ___
___ 06:45AM BLOOD Glucose-107* UreaN-6 Creat-0.7 Na-141
K-4.3 Cl-108 HCO3-27 AnGap-10
___ 06:45AM BLOOD ALT-1602* AST-863* AlkPhos-159*
TotBili-2.7*
DISCHARGE LABS
--------------
___ 07:45AM BLOOD WBC-6.7 RBC-4.88 Hgb-14.9 Hct-44.9 MCV-92
MCH-30.6 MCHC-33.3 RDW-12.8 Plt ___
___ 07:45AM BLOOD ___ PTT-38.7* ___
___ 07:45AM BLOOD Glucose-88 UreaN-9 Creat-0.7 Na-139 K-4.1
Cl-102 HCO3-27 AnGap-14
___ 07:45AM BLOOD ALT-856* AST-139* LD(LDH)-172
AlkPhos-155* TotBili-2.0*
MICROBIOLOGY
------------
None
IMAGING
-------
Right upper quadrant ultrasound with Doppler studies ___:
1. Markedly fatty liver. Given the liver echogenicity there is
limited
evaluation of intrahepatic masses and intrahepatic bile duct
dilation.
2. Limited Doppler analysis of the intrahepatic vasculature due
to liver
echotexture, however the Doppler waveforms and vessels appear
normal.
ERCP ___:
Normal biliary tree
No stones or sludge were extracted during a balloon
pull-through.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO DAILY:PRN gerd
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY:PRN gerd
2. Outpatient Lab Work
Please check LFTs upon PCP ___
Discharge ___:
Home
Discharge Diagnosis:
Abdominal pain
Transaminase elevation
Fatty liver
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old man with severe transaminitis, recent CCY, abdominal
pain.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis from ___. Abdominal ultrasound ___.
FINDINGS:
LIVER: The echogenicity of the liver is markedly fatty. Given the echogenicity
of the liver is difficult to assess for intrahepatic lesions. There is no
ascites.
BILE DUCTS: The CBD measures 6 mm.
GALLBLADDER: The patient is status post a cholecystectomy.
PANCREAS: Views of the pancreas are obscured by bowel gas.
SPLEEN: Normal echogenicity, measuring 13.1 cm..
VASCULATURE: Views of the intrahepatic vessels are limited due to liver
echotexture however, the hepatic veins, arteries, and portal veins appear
patent and with normal Doppler waveforms on this ultrasound and CT from ___.
IMPRESSION:
1. Markedly fatty liver. Given the liver echogenicity there is limited
evaluation of intrahepatic masses and intrahepatic bile duct dilation.
2. Limited Doppler analysis of the intrahepatic vasculature due to liver
echotexture, however the Doppler waveforms and vessels appear normal.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN EPIGASTRIC
temperature: 97.2
heartrate: 58.0
resprate: 16.0
o2sat: 95.0
sbp: 134.0
dbp: 81.0
level of pain: 1
level of acuity: 3.0 | ___ year old male, s/p cholecystectomy, presents with epigastric
pain and transaminitis concerning for biliary obstruction.
ACTIVE ISSUES
-------------
# Transaminitis/abdominal pain: markedly abnormal LFTs on
admission, with no current symptoms, no jaundice. Levels
downtrended over the course of his admission. ERCP was
unremarkable. Right upper quadrant ultrasound showed fatty
liver, but no other cause of the transaminase elevation..
Albumin and INR were both close to normal. Hepatology was
consulted, and differential included passed stone, viral
hepatitis, medications, autoimmune causes or ischemia. Viral
hepatitis studies were negative. Patient will follow up with
his PCP, and LFTs should be rechecked at that time. Given fatty
liver, Nutrition consult as outpatient is recommended.
INACTIVE ISSUES
---------------
# GERD: patient was continued on calcium carbonate
TRANSITIONS OF CARE
-------------------
# ___: patient will follow up with his PCP, and LFTs
should be rechecked at that time. Given fatty liver, Nutrition
consult as outpatient is recommended. There are no pending
results at discharge.
# Code status: Full, confirmed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall with head strike
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with history of remote lung cancer (s/p
lobectomy ___, no recurrence), dyslipidemia, ___
Esophagus/GERD, and BPH who presents s/p fall at home c/b
posterior head strike.
Patient fell at home the night prior to admission, unwitnessed.
He says that he was standing in his bathroom after urinating
(which he does frequently given hx of BPH) and became acutely
nauseous. The next thing he remembers is waking up on his floor
several meters from where he had previously been standing.
There was some blood on the floor. No bowel/bladder
incontinence or sustained confusion after the fall. No report
of
lightheadedness, CP, SOB, or palpitations. No new weakness or
sensory defects. Patient was able to get himself up and get
into bed after falling. He awoke this AM noticing dried blood
on his sheets. Later on in the morning, his visiting nurse was
able to evaluate him and suggested that he present to the ___
ED for further evaluation and treatment.
Of note, patient recently saw his PCP ___ for a routine
evaluation. At that time, he was feeling generally well. He
had recently had a PPD for his daycare program which was
NEGATIVE. He also by report had a CXR, which was NEGATIVE for an
acute infiltrate.
Of note, patient was hospitalized ___ for fever and syncope,
CXR showing possible PNA. Patient was briefly treated with
antibiotics and given IVF resuscitation. Given three recent
episodes of syncope, he underwent TTE, which was NEGATIVE for
any structural heart disease (LVEF 55%).
Past Medical History:
___ Esophagus
BPH
Dyslipidemia
Lung cancer (s/p resection ___
Basal cell carcinoma
Recurrent bronchitis
Lower Back Pain
GERD
Social History:
___
Family History:
Lung cancer
Physical Exam:
ADMISSION EXAM
===========================
VS: 97.8 134/77 69 18 96 Ra
GENERAL: NAD, lying comfortably in bed.
HEENT: ~2cm occipital laceration with stable in place and
surround dried blood, EOMI, PERRL, anicteric sclera, pink
conjunctiva, MMM. ___ NEGATIVE.
NECK: JVP elevated 2cm above the clavicle with HOB at 45degrees.
HEART: Distant heart sounds, RRR, S1/S2, ___ systolic murmur
best
heard at the RUSB, no gallops or rubs.
LUNGS: CTABL, no wheezes.
ABDOMEN: Obese abdomen, normoactive BS throughout, nontender in
all quadrants, no rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing, or edema.
PULSES: 2+ radial pulses bilaterally.
NEURO: A&Ox3, CN2-12 intact, strength/sensation to light touch
intact throughout, no dysmetria or pronator drift, gait not
assessed.
SKIN: Warm and well perfused, prominent varicose veins of the
lower extremities b/l.
DISCHARGE EXAM
===========================
Vital signs stable
General: Elderly appearing man in no acute distress. ___
speaking. Comfortable. AAOx3.
HEENT: 2 cm laceration with dried blood, staples in place. EOMI.
MMM.
Cardiac: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs,
or gallops.
Pulmonary: Decreased breath sounds over left middle and inferior
lung fields. Clear to auscultation over right lung fields.
Breathing comfortably on room air.
Abdomen: Soft, non-tender, non-distended.
Extremities: Warm, well perfused, non-edematous.
Pertinent Results:
ADMISSION LABS
==========================
___ 05:55PM BLOOD WBC-24.2*# RBC-4.89 Hgb-14.2 Hct-43.5
MCV-89 MCH-29.0 MCHC-32.6 RDW-14.0 RDWSD-45.2 Plt ___
___ 05:55PM BLOOD Neuts-82.3* Lymphs-8.1* Monos-8.5
Eos-0.2* Baso-0.2 Im ___ AbsNeut-19.89*# AbsLymp-1.96
AbsMono-2.06* AbsEos-0.04 AbsBaso-0.05
___ 05:55PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 05:55PM BLOOD ___ PTT-27.4 ___
___ 05:55PM BLOOD Glucose-115* UreaN-26* Creat-1.4* Na-142
K-4.0 Cl-102 HCO3-24 AnGap-16
___ 05:55PM BLOOD ALT-13 AST-19 CK(CPK)-575* AlkPhos-67
TotBili-0.5
___ 05:55PM BLOOD cTropnT-<0.01
___ 05:55PM BLOOD Calcium-9.6 Phos-2.8 Mg-2.1
___ 05:55PM BLOOD TSH-2.1
___ 05:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:57PM BLOOD Lactate-1.4
___ 07:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:00PM URINE Blood-TR* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 07:00PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 07:00PM URINE CastHy-1*
___ 07:00PM URINE AmorphX-RARE*
___ 07:00PM URINE Mucous-OCC*
___ 08:00PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
PERTINENT LABS
==========================
___ 04:15PM BLOOD WBC-15.7* RBC-4.76 Hgb-13.6* Hct-42.9
MCV-90 MCH-28.6 MCHC-31.7* RDW-14.1 RDWSD-46.8* Plt ___
___ 05:55PM BLOOD Neuts-82.3* Lymphs-8.1* Monos-8.5
Eos-0.2* Baso-0.2 Im ___ AbsNeut-19.89*# AbsLymp-1.96
AbsMono-2.06* AbsEos-0.04 AbsBaso-0.05
___ 04:42AM BLOOD ___ PTT-26.7 ___
___ 04:42AM BLOOD Glucose-118* UreaN-26* Creat-1.3* Na-144
K-3.9 Cl-103 HCO3-25 AnGap-16
___ 05:55PM BLOOD ALT-13 AST-19 CK(CPK)-575* AlkPhos-67
TotBili-0.5
___ 05:55PM BLOOD cTropnT-<0.01
___ 04:42AM BLOOD CK-MB-6 cTropnT-<0.01
___ 05:55PM BLOOD TSH-2.1
___ 08:00PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
MICRO
==========================
BCx pending
UCx pending
DISCHARGE LABS
==========================
___ 04:15PM BLOOD WBC-15.7* RBC-4.76 Hgb-13.6* Hct-42.9
MCV-90 MCH-28.6 MCHC-31.7* RDW-14.1 RDWSD-46.8* Plt ___
PERTINENT STUDIES
==========================
CT HEAD (___)
No acute intracranial process. Left posterior parietal scalp
hematoma. No
acute fracture.
CT C-SPINE (___)
Partially imaged calcification at the left lung apex not fully
assessed on
this study, but possibly representing a granuloma
CXR (___)
Re-demonstrated postoperative changes at the left lower
hemithorax, however,
increase in opacity at the left lung base could relate to
underlying
pneumonia. Mild vascular congestion
KNEE (___)
No acute fracture or dislocation of the bilateral knees. Some
degenerative
changes, as above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Simvastatin 20 mg PO QPM
5. Tamsulosin 0.4 mg PO QHS
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
7. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 3 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth nightly Disp #*3
Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Finasteride 5 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
syncope (likely vasovagal / orthostatic)
community acquired pneumonia
SECONDARY DIAGNOSES:
BPH
Stage III CKD
dyslipidemia
lower back pain
pre-diabetes
constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with cough// ? infectious process
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___, ___ ___
FINDINGS:
Postoperative changes are re-demonstrated at the left lower lung, however,
there appears to be increase in opacity at the left lung base and underlying
pneumonia may be present. Prominence and indistinctness of the hila could
relate to mild pulmonary vascular congestion. No pleural effusion or
pneumothorax is seen. Cardiac and mediastinal silhouettes are grossly stable.
Evidence of DISH is seen along the thoracic spine.
IMPRESSION:
Re-demonstrated postoperative changes at the left lower hemithorax, however,
increase in opacity at the left lung base could relate to underlying
pneumonia.
Mild vascular congestion.
Radiology Report
INDICATION: History: ___ with knee pain s/p fall// ? fracture
TECHNIQUE: Bilateral knees, 6 total images
COMPARISON: ___
FINDINGS:
Right knee: No acute fracture or dislocation is seen. No suprapatellar joint
effusion is seen. Osteoarthritic changes are seen, including mild narrowing
of the medial joint compartment. Tiny lateral compartment spurring as well as
tiny posterior patellar spurring. There is an anterior, superior patellar
enthesophyte, similar to prior. Vascular calcifications are seen.
Left knee: No acute fracture or dislocation is seen. No suprapatellar joint
effusion is seen. There is mild prominence of the anterior tibial tubercle,
likely degenerative. Interval increase in patellar enthesopathy since the
prior study. Tiny posterior patellar spurs. Mild narrowing of the medial
joint compartment. Vascular calcifications are seen.
IMPRESSION:
No acute fracture or dislocation of the bilateral knees. Some degenerative
changes, as above.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with fall w/ headstrike// ? fracture, head bleed
TECHNIQUE: Noncontrast enhanced MDCT images of the head were obtained.
Reformatted coronal and sagittal images were also obtained.
DOSE Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.0 cm; CTDIvol = 47.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None
FINDINGS:
There is no evidence of acute intracranial hemorrhage, midline shift, mass
effect, or acute large vascular territorial infarct. Prominence of the
ventricles and sulci is consistent with involutional change. Periventricular
and subcortical white matter hypodensities are likely sequelae of chronic
small vessel disease. The visualized paranasal sinuses are clear. The
mastoid air cells are clear. No acute fracture is seen. Left posterior
parietal scalp hematoma is seen with some overlying scalp staples.
IMPRESSION:
No acute intracranial process. Left posterior parietal scalp hematoma. No
acute fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with fall w/ headstrike// ? fracture, head bleed
TECHNIQUE: Noncontrast enhanced MDCT images of the cervical spine were
obtained. Reformatted coronal and sagittal images were also obtained.
DOSE Acquisition sequence:
1) Spiral Acquisition 5.3 s, 20.8 cm; CTDIvol = 22.6 mGy (Body) DLP = 469.4
mGy-cm.
Total DLP (Body) = 469 mGy-cm.
COMPARISON: None.
FINDINGS:
No evidence of acute fracture is seen. There is no dislocation. Multilevel
degenerative changes are seen. These include facet arthropathy on the left
from C3 through C7. There also multilevel anterior and smaller posterior
osteophytes.. No prevertebral soft tissue swelling is seen.
The thyroid gland is grossly homogeneous. Partially imaged lung apices
demonstrated partially imaged left apical calcification, possibly representing
a granuloma.
IMPRESSION:
No acute fracture of the cervical spine.
Degenerative changes.
Partially imaged calcification at the left lung apex not fully assessed on
this study, but possibly representing a granuloma.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Head injury, s/p Fall
Diagnosed with Laceration without foreign body of scalp, initial encounter, Fall on same level, unspecified, initial encounter, Pneumonia, unspecified organism, Elevated white blood cell count, unspecified, Syncope and collapse
temperature: 98.5
heartrate: 76.0
resprate: 16.0
o2sat: 95.0
sbp: 135.0
dbp: 78.0
level of pain: 2
level of acuity: 2.0 | ___ ___ man with PMHx notable for remote
lung cancer s/p left upper lobe resection (___) without
recurrence, dyslipidemia, ___ esophagus/GERD, and BPH
admitted for syncope and fall and head strike. Trauma workup
including CT head / C-spine was reassuring. History overall
suggestive of vasovagal / orthostatic episode precipitated by
possible LLL pneumonia. Started on 5-day course azithromycin,
tamsulosin held and discontinued, and discharged home with ___
and plan for PCP follow up.
# SYNCOPE / FALL WITH HEADSTRIKE
Presented next day following episode of syncope with
un-witnessed fall and headstrike at home. Had just urinated and
was standing in bathroom at which time he noticed sudden onset
nausea and then blacked out. Shortly thereafter awoke on
bathroom floor and went back to sleep; later referred to ED by
___ the following morning. Denied any associated tongue biting,
incontinence, or post-ictal state. No associated chest pain,
palpitations, or dyspnea. Trauma workup including CT head /
C-spine without evidence of fracture. Scalp laceration was
stapled in ED with otherwise reassuring exam. Syncope workup
notable for possible LLL pneumonia (see below), but otherwise
negative cardiac enzymes, EKG with normal sinus rhythm,
reassuring orthostatic vital signs, negative urine tox screen,
continuous telemetry without events. Given preceding nausea and
association with micturition, episode was attributed to
vasovagal / possible orthostatic episode possibly precipitated
by pneumonia. Discontinued tamsulosin and, given asymptomatic,
discharged home with plan for PCP follow up.
# COMMUNITY ACQUIRED PNEUMONIA
Upon arrival discovered to have leukocytosis >20k with
neutrophilic
predominance. Infectious workup for CXR with increased left
lower lung opacification concerning for pleural effusion vs.
pneumonia. Evaluated by interventional pulmonary who found no
drainable effusion on ultrasound. No evidence of systemic
infection and overall reassuring clinical status, so discharged
with plan to complete brief course of azithromycin for community
acquired pneumonia. Recommend repeat CXR in 1 month to ensure
resolution of consolidation, and if persistently abnormal then
CT chest for further evaluation.
# BPH
Discontinued home tamsulosin given concern for precipitating
vasovagal / orthostatic episode. Continued home finasteride.
# CHRONIC EXERTIONAL DYSPNEA
Reported on admission as longstanding issue ever since
lobectomy. Respiratory status and oxygenation reassuring over
course of admission.
# STAGE III CKD
Discharge Cr 1.3, at baseline.
# DYSLIPIDEMIA
Continued home simvastatin.
# LOWER BACK PAIN
Continued home Tylenol.
# CONSTIPATION
Continued home bowel regimen.
# PRE-DIABETES
Most recent HbA1C 6.1% (___). Not on home medications.
TRANSITIONAL ISSUES
===============================
[ ] STARTED azithromycin 5-day course (___) for
community acquired pneumonia with evidence of new left lower
lung opacification (ultrasound from interventional pulm revealed
no effusion). Please repeat CXR in 1 month to ensure resolution.
If still abnormal then recommend obtaining CT chest for further
evaluation.
[ ] DISCONTINUED tamsulosin given concern for exacerbation of
vasovagal / orthostatic episode causing fall.
[ ] Incidentally noted mildly elevated INR (1.2). Possibly due
to poor nutrition. Recommend repeating as outpatient to ensure
normalized, or further workup for coagulopathy if abnormal.
[ ] Incidentally noted microscopic hematuria without other
evidence of renal or GU disease. Possibly related to mild
myoglobinemia related to fall (given elevated CK). Recommend
repeat UA as outpatient and further workup if persistent
hematuria.
#CONTACT: ___ (son) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine / Bactrim
Attending: ___
___ Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o CAD s/p MI, CABG, VT, MR/TR, HFrEF (EF 35%), and AF
on apixiban presenting with hemoptysis. Patient noted
development of hemoptysis 30 minutes prior to presentation to ED
while indoor biking. Cough up 12 times approximately "thimble"
sized bright red blood with clots. Denies fever/chills. Has had
bronchitis since returning from a 10-day ___ trip 1 month ago
c/b asthma requiring oral and inhaled steroids, which has
gradually resolved though patient still has cough only
productive of thin, clear mucus. No rhinorrhea or epistaxis. No
recent trauma to mouth, lacerations, dental work. No other blood
thinners or NSAIDs. No melena/hematochezia. He last took his
medications in the AM.
In the ED, initial vitals were T 98.3, HR 113, BP 149/88, RR 20,
and 100% RA. He stopped having hemoptysis around 3pm on ___.
Labs were notable for H/H 13.5/41.0, CT was negative for PE and
notable for ground-glass opacity in the RLL. ___ and IP were
consulted in the ED and plan for bronchoscopy in the morning,
possibly followed by ___ for coiling. There was concern for PNA,
but given QTc of 550ms, he only received 1x CTX. ___ recommended
adequate hydration, though he only received 1L NS given his EF
35%.
On transfer, vitals were:
On arrival to the MICU,
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
-Hypertriglyceridemia
-hypercholesterolemia
-hypothyroidism
-impaired glucose tolerance
1. Coronary artery disease s/p MI at the age of ___ in ___.
--CABG (LIMA to diagonal, SVG to LAD, OM, RCA) in ___
--Multiple PCI, most recently in ___ with DES to LAD distal to
the vein graft touchdown.
2. Ventricular tachycardia status post ablation in ___,
previously on sotalol and procainamide, currently on amiodarone
for the past ___ years.
3. Symptomatic PVCs.
4. Dyslipidemia.
5. Hypertension.
6. Asthma
7. Hypothyroidism
8. Chronic kidney disease (baseline 1.4 - GFR 50)
9. Elevated ALT since ___ with a documented history of fatty
liver by ultrasound.
10. ECHO in ___ with EF of 38%
11. L and R hip replacements
12. R femoral artery pseudoanerysm after past catheterization
13. Spinal stenosis L4-L5
14. Impaired glucose tolerance
Social History:
___
Family History:
Mother had cardiac disease, died in early ___. Cousin
on maternal side died around age ___ from cardiac disease. Father
died of colon CA.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
==================================
Vitals: T: 36.6 BP: 140/58 P: 74 R: 13 O2: 99% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregularly irregular. II/VI murmur at ___ increased with
held inspiration. II/VI murmur at apex increased with handgrip.
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: grossly intact on torso, chest, neck, face, legs
NEURO: AAOX3. Appropriately interactive.
PHYSICAL EXAMINATION ON DISCHARGE:
==================================
Vitals: T: 37 BP: 130/60 P: 70-80's R: 13 O2: 99% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregularly irregular. II/VI murmur at ___ increased with
held inspiration. II/VI murmur at apex increased with handgrip.
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: grossly intact on torso, chest, neck, face, legs
NEURO: AAOX3. Appropriately interactive.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 09:50AM BLOOD WBC-7.0 RBC-4.44* Hgb-13.5* Hct-41.0
MCV-92 MCH-30.4 MCHC-32.9 RDW-13.4 RDWSD-45.3 Plt ___
___ 09:50AM BLOOD Neuts-52.2 ___ Monos-9.6 Eos-2.9
Baso-0.4 Im ___ AbsNeut-3.65 AbsLymp-2.39 AbsMono-0.67
AbsEos-0.20 AbsBaso-0.03
___ 09:50AM BLOOD ___ PTT-33.8 ___
___ 09:50AM BLOOD Plt ___
___ 09:50AM BLOOD Glucose-121* UreaN-18 Creat-1.4* Na-137
K-3.3 Cl-96 HCO3-29 AnGap-15
___ 09:50AM BLOOD Calcium-9.6 Phos-3.5 Mg-2.1
___ 02:22PM BLOOD Lactate-1.4
LABS ON DISCHARGE:
==================
___ 12:56PM BLOOD WBC-7.2 RBC-4.23* Hgb-13.1* Hct-39.2*
MCV-93 MCH-31.0 MCHC-33.4 RDW-13.8 RDWSD-46.7* Plt ___
___ 12:56PM BLOOD Plt ___
___ 04:03AM BLOOD Plt ___
___ 04:03AM BLOOD Glucose-91 UreaN-16 Creat-1.0 Na-140
K-3.5 Cl-103 HCO3-26 AnGap-15
___ 04:03AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1
IMAGING:
========
___ CXR:
No acute cardiopulmonary abnormality.
___ CTA CHEST:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Nodular centrilobular ground-glass opacities in the right
lower lobe and mild bronchial wall thickening suggests small
airways disease. Intraluminal debris within the right mainstem
bronchus extending into the right lower lobe bronchi may
represent blood or secretions. A more confluent area of
ground-glass in the inferior right lower lobe is nonspecific and
may represent hemorrhage, infection, or inflammation.
3. A small focus of hyper enhancement in the anterior aspect of
hepatic
segment VII likely represents a transient hepatic attenuation
difference in the absence of risk factors or history of
malignancy.
___ CXR:
Compared to chest radiographs since ___, most recently
___ at 10:12.
Lower lung volumes are reflected in new mild right basal
atelectasis. Upper lungs clear. Mild cardiomegaly unchanged.
No pneumothorax or pleural effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO QHS
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
3. Flovent HFA (fluticasone) 220 mcg/actuation inhalation
BID:PRN shortness of breath
4. amLODIPine 2.5 mg PO DAILY
5. Diltiazem Extended-Release 300 mg PO DAILY
6. Rosuvastatin Calcium 20 mg PO QPM
7. Apixaban 5 mg PO BID
8. Levothyroxine Sodium 175 mcg PO DAILY
9. LORazepam 1 mg PO QHS:PRN anxiety/insomnia
10. Valsartan 320 mg PO DAILY
11. Triamterene-HCTZ (37.5/25) 2 CAP PO DAILY
12. Montelukast 10 mg PO QHS:PRN SOB
13. Metoprolol Tartrate 12.5 mg PO BID
14. Multivitamins 1 TAB PO DAILY
15. Aspirin 81 mg PO DAILY
16. Loratadine 10 mg PO DAILY
17. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO QHS
2. amLODIPine 2.5 mg PO DAILY
3. Apixaban 5 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Diltiazem Extended-Release 300 mg PO DAILY
6. Levothyroxine Sodium 175 mcg PO DAILY
7. Loratadine 10 mg PO DAILY
8. LORazepam 1 mg PO QHS:PRN anxiety/insomnia
9. Metoprolol Tartrate 12.5 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Rosuvastatin Calcium 20 mg PO QPM
12. Valsartan 320 mg PO DAILY
13. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
14. Fish Oil (Omega 3) 1000 mg PO DAILY
15. Flovent HFA (fluticasone) 220 mcg/actuation inhalation
BID:PRN shortness of breath
16. Montelukast 10 mg PO QHS:PRN SOB
17. Triamterene-HCTZ (37.5/25) 2 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Hemoptysis
Bronchitis
SECONDARY DIAGNOSES:
CAD
Atrial fibrillation
Hypertension
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with atrial fibrillation presents with hemoptysis
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Patient is status post median sternotomy, CABG, and coronary artery stenting.
Heart size remains mildly enlarged. The mediastinal and hilar contours are
unchanged. Pulmonary vasculature is normal. Lungs are mildly hyperinflated
but clear. No pleural effusion or pneumothorax is demonstrated. There are
moderate degenerative changes seen in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ presents with hemoptysis on apixiban and aspirin
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 = 10.6 mGy (Body) DLP =
5.3 mGy-cm.
2) Spiral Acquisition 4.9 s, 38.4 cm; CTDIvol = 11.9 mGy (Body) DLP = 456.7
mGy-cm.
Total DLP (Body) = 462 mGy-cm.
COMPARISON: ___ CT abdomen/pelvis, chest radiograph ___ at
10:12
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 great vessels are within normal limits. There is
hypo enhancement and thinning at the cardiac apex and inferior wall consistent
with prior infarction. Moderate cardiomegaly is noted. No pericardial
effusion is seen. There are extensive atherosclerotic calcifications, most
pronounced in the native coronary arteries. Aortic annulus calcifications are
also noted. Patient is status post CABG.
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 are subtle nodular centrilobular ground-glass opacities
in the right lower lobe with mild bronchial wall thickening and intra luminal
airway debris within the right mainstem bronchus extending into the right
lower lobe bronchi. There is a larger confluent area of ground-glass opacity
in the inferior right lower lobe. There is no suspicious mass. There is mild
bronchial wall thickening in the left lower lobe, less pronounced than on the
right. Otherwise, the left lung is unremarkable calcified granuloma is seen
along the periphery of the right upper lobe (3:101).
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen demonstrates a small focus of
a hyper enhancement in the anterior aspect of segment VII (2:93), likely
transient hepatic attenuation difference. A small calcified granuloma is
again noted in the lateral aspect of segment VIII. The liver is otherwise
unremarkable. There is a 2.8 x 2.6 cm simple cyst arising from the interpolar
right kidney and an additional too small to characterize hypoattenuating
lesion in the interpolar left kidney. The remainder of the included portion
of the abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
There are mild-to-moderate degenerative changes throughout the visualized
spine. Patient is status post median sternotomy.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Nodular centrilobular ground-glass opacities in the right lower lobe and
mild bronchial wall thickening suggests small airways disease. Intraluminal
debris within the right mainstem bronchus extending into the right lower lobe
bronchi may represent blood or secretions. A more confluent area of
ground-glass in the inferior right lower lobe is nonspecific and may represent
hemorrhage, infection, or inflammation.
3. A small focus of hyper enhancement in the anterior aspect of hepatic
segment VII likely represents a transient hepatic attenuation difference in
the absence of risk factors or history of malignancy.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/hemoptysis, RLL disease, please eval for interval change
// ___ w/hemoptysis, RLL disease, please eval for interval change ___
w/hemoptysis, RLL disease, please eval for interval change
IMPRESSION:
Compared to chest radiographs since ___, most recently ___ at 10:12.
Lower lung volumes are reflected in new mild right basal atelectasis. Upper
lungs clear. Mild cardiomegaly unchanged. No pneumothorax or pleural
effusion.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Hemoptysis
Diagnosed with Hemoptysis, Long term (current) use of anticoagulants, Unspecified atrial fibrillation
temperature: 98.3
heartrate: 113.0
resprate: 20.0
o2sat: 100.0
sbp: 149.0
dbp: 88.0
level of pain: 0
level of acuity: 2.0 | ___ with h/o CAD s/p MI, CABG, VT, MR/TR, HFrEF (EF 35%), and AF
on apixiban who presented with hemoptysis, attributed to
bronchitis.
#Hemoptysis:
Patient remained hemodynamically stable throughout his hospital
stay. He was admitted to the ICU for close monitoring but did
not require any cardio-pulmonary support measures. His chest CTA
showed no evidence of pulmonary embolism or aortic abnormality;
it was notable for nodular centrilobular ground-glass opacities
in the right lower lobe and mild bronchial wall thickening
suggestive of small airways disease. The Interventional
Pulmonary team evaluated the patient, and symptoms were
attributed to bronchitis for which bronchoscopy was not
recommended. Patient remained stable and his H/H was stable. He
was not started on any antibiotics given low suspicion for
bacterial infection. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Wellbutrin
Attending: ___.
Chief Complaint:
Dizziness, light headedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of anxiety presenting with SOB, light
headedness, blurry vision and sense of impending doom now
complicated by unsteadiness on ambulation. Patient reports that
he awoke this morning with a feeling of being "overwhelmed" with
sweating and some blurred vision (on close vision) but normal
distance vision. He felt tachycardic with mild SOB and
fluttering under his and and poking sensation in his back. He
took a shower and following the shower felt dizziness and had a
near syncopal event. He took an Ativan as some of the symptoms
felt similar to prior panic attacks. He noted some improvement
in symptoms however given ongoing symptoms, presented to the ED.
After parking, felt light headed in the stairwell and tripped,
landing and hitting his head. He denies LOC. Did have some
sweating during the episode. No chest pain, no n/v/d. No fevers
or chills recently. Denies decreased PO intake. Has had
significant life stressors due to losing his job last year and
working contract work that "hasn't gone as well as he has
wanted". He required EMS assistance to the ED.
In the ED, initial vitals were: 97.8 103 140/89 20 95%NC 1L
Exam notable for atraumatic head, no midline neck tenderness,
pain under the axilla and scapula with palpation.
EKG with no acute changes. Labs notable for: normal CBC,
chemistries, trop neg x2, LFTs, TSH, negative tox screen. INR
1.2, PTT 29.1. UA with 10
WBC, neg leuks and nitrites.
Imaging notable for CT head w/o contrast: no acute intracranial
process and CXR PA/Lateral with no acute cardiopulmonary
abnormality.
Patient was given: 1 mg PO lorazepam and 1L IVF. After fluids
and food, patient still unable to ambulate steadily and thus
neurology was consulted. Neurology evaluated for gait
unsteadiness and felt that exam was non focal, able to stand
unassisted with negative rhomberg. Felt unlikely to be
neurologic but maybe psych component. The recommended ___
evaluation, SW consult, orthostatics and Utox/serum tox. Due to
persistent unsteadiness, decision was made to admit to the floor
for further evaluation.
Vitals prior to transfer: 98.6 67 IO ___ I 00%RA
On the floor, patient reports he feels somewhat improved though
remained unsteady on going to the bathroom, feels he may fall
forward or backwards, still with mild light headedness and
blurry vision. Denies v/d, fevers, chills, SOB, CP,
palpitations, abdominal pain. no dysuria, weakness or numbness.
ROS:
(+)Per HPI
10 point review of systems otherwise negative
Past Medical History:
Anxiety with panic attacks
HLD
Low back pain
Social History:
___
Family History:
Adopted, no known family history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 97.7PO 114/86 64 18 99%RA
General: Alert, oriented, flat affect.
HEENT: ___ anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S 1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM:
========================
Vital Signs: 99.0 102/54 62 18 98%RA
General: Alert, oriented
HEENT: ___ anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: RRR, normal S 1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, rhonch1
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally. Patient
scared to walk, gait could not be assessed properly.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:10PM WBC-9.9 RBC-5.46 HGB-16.0 HCT-48.8 MCV-89
MCH-29.3 MCHC-32.8 RDW-13.4 RDWSD-43.7
___ 04:10PM NEUTS-73.4* ___ MONOS-4.4* EOS-1.1
BASOS-0.3 IM ___ AbsNeut-7.25* AbsLymp-2.04 AbsMono-0.43
AbsEos-0.11 AbsBaso-0.03
___ 04:10PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 04:10PM TSH-2.0
___ 04:10PM ALBUMIN-4.8 CALCIUM-9.6 PHOSPHATE-3.6
MAGNESIUM-2.2
___ 04:10PM cTropnT-<0.01
___ 04:10PM ALT(SGPT)-36 AST(SGOT)-30 ALK PHOS-86 TOT
BILI-0.3
___ 04:10PM GLUCOSE-74 UREA N-12 CREAT-0.9 SODIUM-139
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-18
___ 05:00PM URINE MUCOUS-FEW
___ 05:00PM URINE HYALINE-5*
___ 05:00PM URINE RBC-3* WBC-10* BACTERIA-FEW YEAST-NONE
EPI-1
___ 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
___ 05:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 05:10PM ___ PTT-29.1 ___
___ 09:39PM cTropnT-<0.01
DISCHARGE LABS:
===============
___ 05:50AM BLOOD WBC-9.1 RBC-4.77 Hgb-13.9 Hct-43.3 MCV-91
MCH-29.1 MCHC-32.1 RDW-13.5 RDWSD-45.0 Plt ___
___ 05:50AM BLOOD Glucose-106* UreaN-16 Creat-0.9 Na-141
K-4.2 Cl-104 HCO3-26 AnGap-15
IMAGING:
========
CXR (___):
Cardiac silhouette size is normal. Mediastinal and hilar
contours are within normal limits. Pulmonary vasculature is
normal. Lungs appear clear without focal consolidation. No
pleural effusion or pneumothorax is demonstrated. No acute
osseous abnormality is visualized.
CT HEAD (___):
There is no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. Aside from mild mucosal
thickening of the left maxillary sinus, the visualized portion
of the paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The visualized portion of the orbits are
unremarkable.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO DAILY:PRN heart burn
2. Cyclobenzaprine 10 mg PO BID:PRN back pain
3. Atorvastatin 80 mg PO QPM
4. LORazepam 1 mg PO DAILY:PRN panic attack
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Cyclobenzaprine 10 mg PO BID:PRN back pain
3. LORazepam 1 mg PO DAILY:PRN panic attack
4. Ranitidine 150 mg PO DAILY:PRN heart burn
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
Panic Attack
Head and Shoulder Trauma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with chest pain // Eval for cardiopulmonary
pathology
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac silhouette size is normal. Mediastinal and hilar contours are within
normal limits. Pulmonary vasculature is normal. Lungs appear clear without
focal consolidation. No pleural effusion or pneumothorax is demonstrated. No
acute osseous abnormality is visualized.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with ataxia and headache status post fall, evaluate for
bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 4.2 cm; CTDIvol = 48.0 mGy (Head) DLP =
200.7 mGy-cm.
2) Sequenced Acquisition 12.0 s, 12.5 cm; CTDIvol = 48.0 mGy (Head) DLP =
602.1 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Prior brain MRI dated ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. Aside from mild mucosal thickening of the
left maxillary sinus, the visualized portion of the paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
No evidence of acute intracranial process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with Other chest pain
temperature: 97.8
heartrate: 103.0
resprate: 20.0
o2sat: 98.0
sbp: 140.0
dbp: 89.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ is a ___ yo man with history of anxiety presenting
with light headedness, presyncope, and unsteadiness on
ambulation.
# Dizziness: Patient reports sweating, blurred near vision,
tachycardia, SOB, fluttering under his arm and poking sensation
in his back the morning of ___. He also reports dizziness and a
near syncopal event. He took an Ativan as some of the symptoms
felt similar to prior panic attacks, but his unsteadiness did
not improve. He presented to ___, walking out of the parking,
felt lightheaded in the stairwell and tripped, landing and
hitting his head. Patient had no LOC. In the ED, the patient was
hemodynamically stable. He was evaluated by neurology with a
non-focal exam. Labs were unremarkable including CBC,
chemistries, trop x2, LFTs, TSH, and tox screen. Head CT and CXR
were negative. Patient was admitted for monitoring overnight and
improved significantly. He remained neurologically intact. He
was seen by physical therapy who thought he was able to ambulate
independently and is a low fall risk based on their assessments.
Given his fall, they felt the patient would benefit from
out-patient physical therapy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o PVD, EtOH abuse p/w fall from standing while getting out
of bed to go to the bathroom 2 days ago. No presyncopal symptoms
prior to fall. -HS, -LOC. Recalls falling flat onto his abdomen.
Reports drinking a 6-pack/day of beer with occasional whiskey,
but his last drink was 3 days ago. Presented to ___, pan-scan completed.
Past Medical History:
PMH: PVD, HLD, COPD
PSH: L hip dynamic screw, LLE stent, R CIA graft, L ___ toe
amputation
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
VS: 98.4 74 122/62 20 98% Nasal Cannula
Gen: NAD
CV: RRR, no M/R/G
Resp: No respiratory distress, CTAB
Abd: soft, nt nd
Ext: WWP
Discharge Physical Exam:
VS: T: 98.0, BP: 94/62, HR: 97, RR: 18, O2: 96%
General: A+Ox3, NAD
CV: RRR
Resp: CTA b/l
Abd: soft, non-distended, non-tender
Extremities: warm, well-perfused b/l. + pulses b/l
GU: foley catheter in place
Pertinent Results:
___ 10:34PM LACTATE-1.2
___ 10:25PM GLUCOSE-95 UREA N-13 CREAT-1.1 SODIUM-133
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-25 ANION GAP-12
___ 10:25PM WBC-8.2 RBC-3.11* HGB-10.8* HCT-32.0*
MCV-103* MCH-34.7* MCHC-33.8 RDW-13.0 RDWSD-48.7*
___ 10:25PM NEUTS-73.6* LYMPHS-10.8* MONOS-15.0* EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-6.02 AbsLymp-0.88* AbsMono-1.23*
AbsEos-0.00* AbsBaso-0.02
___ 10:25PM PLT SMR-LOW PLT COUNT-88*
___ 10:25PM ___ PTT-35.3 ___
Imaging:
OSH CTA with runoff
Complete occlution of native SFA b/l with reconstitution at
popliteal. R>L narrowing of TP trunk, distal vessels, R DP not
seen. Fracture of R superior pubic rami, L greater trochanter
and
sacrum, mild T12 compression fracture
OSH CXR
No acute cardiopulmonary process
OSH CT Head
No acute intracranial process. Diffuse atrophy disproportionate
for age with scattered chronic microvascular insults
OSH CT C-spine
No cervical vertebral fracture or traumatic subluxation.
Degenerative changes
___: EKG:
Sinus tachycardia.
___: CXR:
Cardiomediastinal contours are within normal limits. Lungs are
hyperexpanded suggestive of emphysema. A subcentimeter rounded
opacity overlying the left second anterior rib is potentially
due to healed rib fracture in the setting of multiple other
healed rib fractures in left hemi thorax, but a small pulmonary
nodule is not excluded. Standard PA and lateral views of the
chest are recommended for more complete assessment when the
patient's condition permits.
Medications on Admission:
ASA 81mg daily, advair 250-50mcg 1puff BID, Spiriva daily, MVI,
simvastatin 40mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
NO strenuous exercise while taking this medication
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Nicotine Patch 21 mg TD DAILY
6. Simvastatin 40 mg PO QPM
7. Thiamine 100 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Senna 8.6 mg PO BID:PRN constipation
10. FoLIC Acid 1 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
please hold for loose stool
12. Bisacodyl 10 mg PO DAILY:PRN constipation
13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall:
-Right superior ramus fracture and left
-Greater trochanter fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with COPD // intrapulmonary process
COMPARISON: None available
IMPRESSION:
Cardiomediastinal contours are within normal limits. Lungs are hyperexpanded
suggestive of emphysema. A subcentimeter rounded opacity overlying the left
second anterior rib is potentially due to healed rib fracture in the setting
of multiple other healed rib fractures in left hemi thorax, but a small
pulmonary nodule is not excluded. Standard PA and lateral views of the chest
are recommended for more complete assessment when the patient's condition
permits.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: s/p Fall, PELVIC FX
Diagnosed with Peripheral vascular disease, unspecified, Oth fracture of right pubis, init encntr for closed fracture, Disp fx of greater trochanter of left femur, init, Fall on same level, unspecified, initial encounter, Alcohol dependence with withdrawal, unspecified
temperature: 98.4
heartrate: 74.0
resprate: 20.0
o2sat: 98.0
sbp: 122.0
dbp: 62.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ was admitted to the trauma surgery service for
monitoring for traumatic injuries sustained after a mechanical
fall as well as acute alcohol withdrawal. He was initially
transferred to the floor on a CIWA scale and intermittent
diazepam, however he began having evidence of more severe
withdrawal and so was transferred to the ICU for phenobarbital
loading.
He did well after receiving his phenobarbital load, and was thus
transferred back to the floor for further management.
On HD1, the patient the was evaluated by the Vascular Surgery
team given CTA findings consistent with bilateral SFA
occlusions. Per Vascular, the patient had dopplerable signals in
distal b/l lower extremities and collateral vessels on imaging
were suggestive of a chronic, occlusive process. There was no
concern for acute limb ischemia or acute occlusive thrombus, and
no acute vascular intervention warranted was necessary at the
time.
On HD1, the patient was evaluated by the Neurosurgical team and
they ruled out a T12 fracture. No further Neurosurgical
intervention was warranted.
The patient's Right superior ramus fracture and left greater
trochanter fractures were evaluated by the Orthopaedics Team on
HD1 and no surgical intervention was warranted. He could be
WBAT on b/l ___ with limited L hip abduction. He worked with
Physical Therapy and it was determined his mobility could be
better improved with discharge to a rehabilitation setting.
The remainder of the ___ hospital course is summarized by
systems below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral pain medication once
tolerating a diet. He was continued on a phenobarbital taper
while on the floor.
CV: On HD4, the patient was noted to have a BP of 82/52. All
other VSS and the patient was asymptomatic. A 1L LR bolus was
administered and his blood pressure increased appropriately;
vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient tolerated a regular diet. Patient's
intake and output were closely monitored. On HD5, the patient
was noted to have acute urinary retention and a foley catheter
was placed.
ID: The patient's fever curves were closely watched for signs of
infection. A UA/UCx was obtained which was concerning for a
urinary tract infection. The patient was started on a 7 day
course of oral Ciprofloxacin.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. His phenobarbital taper was discontinued. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. After discharge, his rehabilitation facility, The
___, was notified that a follow-up appointment would need
to be scheduled with the ___ clinic in 2 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year-old female here with abdominal pain started ___
suddenly. Was in USOH ___, walked to yoga, during camel pose at
yoga had acute onset pain, mostly LLQ. Wasn't able to walk home
from yoga. Pain was worse in the car with bumps in the road.
Presented to ___.
+ nausea, no emesis. no diarrhea or change in bowel habits.
While at OSH ___ was noted to be bradycardia with bigeminy after
ingestion of contrast.
ROS:
No fevers, chills, weight loss. No cough, sputum, night sweats,
wheezing. No chest pain, palpitations, difficulty breathing
while
walking. No diarrhea, constipation, black stools, red blood per
rectum, or dyspepsia. No dysuria, leaking, frequency, or bloody
urine
GYN: No discharge, excessive bleeding or abnormal bleeding
Past Medical History:
PGYNHx:
Menarche: ' after high school' due to underweight
Cycle: regular q 4 weeks
Length: 5 days, some dysmenorrhea
Flow: heavy- average
Fibroids/ Cysts/ STIs: denies.
Sexually active & satisfied: not active
Contraception: none
Last pap: ___ years ago
___ abnormal Paps: remote h/o abnl, no LEEP or colposcopy.
states mildly abnormal
POBHx: G0
PMH: h/o basal cell carcinoma s/p resection (face and left
shoulder), oral HSV
PSH: left finger surgery, basal cell carcinoma
ALLG: NKDA
MEDS: none
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
Ext: no TTP
Pertinent Results:
___ 01:20PM BLOOD WBC-10.0 RBC-4.12 Hgb-12.4 Hct-36.5
MCV-89 MCH-30.1 MCHC-34.0 RDW-13.0 RDWSD-42.3 Plt ___
___ 03:45AM BLOOD WBC-10.4* RBC-4.11 Hgb-12.6 Hct-36.8
MCV-90 MCH-30.7 MCHC-34.2 RDW-12.8 RDWSD-42.2 Plt ___
___ 01:20PM BLOOD Neuts-85.8* Lymphs-10.2* Monos-2.7*
Eos-0.5* Baso-0.3 Im ___ AbsNeut-8.57* AbsLymp-1.02*
AbsMono-0.27 AbsEos-0.05 AbsBaso-0.03
___ 03:45AM BLOOD Neuts-88.8* Lymphs-7.9* Monos-2.6*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-9.21* AbsLymp-0.82*
AbsMono-0.27 AbsEos-0.00* AbsBaso-0.03
___ 03:45AM BLOOD ___ PTT-24.3* ___
___ 03:45AM BLOOD Glucose-132* UreaN-8 Creat-0.7 Na-136
K-3.7 Cl-101 HCO3-22 AnGap-17
___ 03:45AM BLOOD ALT-9 AST-19 AlkPhos-42 TotBili-0.7
___ 03:45AM BLOOD Albumin-4.1
___ 01:36PM BLOOD Lactate-1.8
___ 04:01AM BLOOD Lactate-1.3
CT scan from outside hospital:
Suggestion of distal colitis extending to the anus, bilateral
adnexal cystic masses. possible minimal acute left pelvic
hemoperitoneum, mild abdominal retroperitoneal adenopathy and
considerable inflammation of the fat within the pelvis superior
to the urinary bladder.
Ultrasound at ___ ___:
Findings of endometriosis including left ovarian endometrioma,
right hematosalpinx/ruptured hemorrhagic cyst and a hemorrhagic
lesion within the left adnexa, either a hemorrhagic follicle or
acute hemorrhage within an endometrioma. Small to moderate
amount of blood in the pelvis. No findings of tubo-ovarian
abscess
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Azithromycin 1000 mg PO 1X/WEEK (SA) Duration: 2 Doses
RX *azithromycin 500 mg 2 tablet(s) by mouth once Disp #*2
Tablet Refills:*0
3. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
ruptured hemorrhagic cyst
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: History: ___ with abd pain// evidence of torsion vs adnexal
pathology
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: Outside hospital CT abdomen pelvis ___.
FINDINGS:
The uterus is retroflexed and measures 6.7 x 3.3 x 4.7 cm. The endometrium is
layered and measures 7 mm.
In the left adnexa, the ovary contains a dominant follicle as well as two
separate lesions, one demonstrating homogeneous low level internal
echogenicity consistent with an endometrioma, and a second complex cystic
lesion without vascularity measuring 2 cm, possibly a hemorrhagic cyst or
acute hemorrhage within an endometrioma. The ovaries are adherent to midline
concerning for adhesions posterior to the retroflexed uterus.
In the right adnexa, there a collapsed serpiginous structure measuring up to
3.3 cm, possibly representing a thickened fallopian tube/hematosalpinx or a
collapsed ruptured hemorrhagic cyst. There is a small to moderate amount of
complex fluid in the pelvis. No findings to suggest ___ abscess.
IMPRESSION:
Findings of endometriosis including left ovarian endometrioma, right
hematosalpinx/ruptured hemorrhagic cyst and a hemorrhagic lesion within the
left adnexa, either a hemorrhagic follicle or acute hemorrhage within an
endometrioma. Small to moderate amount of blood in the pelvis. No findings
of ___ abscess.
NOTIFICATION: Final impression was discussed with Dr. ___ by Dr. ___
at 09:31 on ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Unspecified ovarian cyst, left side
temperature: 99.0
heartrate: 92.0
resprate: 16.0
o2sat: 100.0
sbp: 132.0
dbp: 70.0
level of pain: 5-6
level of acuity: 3.0 | On ___, Ms. ___ was admitted to the gynecology service
after she presented to the emergency department on ___ with
abdomino-pelvic pain as a transfer from an outside hospital,
where she was found to have a bandemia and CT findings
consistent with a ruptured hemorrhagic ovarian cyst and
endometriomas. She underwent pelvic ultrasound here, which
showed "Findings of endometriosis including left ovarian
endometrioma, right hematosalpinx/ruptured hemorrhagic cyst and
a hemorrhagic lesion within the left adnexa, either a
hemorrhagic follicle or acute hemorrhage within an endometrioma.
Small to moderate amount of blood in the pelvis. No findings
of tubo-ovarian abscess." Her hematocrit was trended during her
stay and was found to be stable. Her bandemia had resolved by
the time she presented here to ___. However, given that she
did have cervical motion tenderness on pelvic exam, the decision
was made to continue outpatient treatment of pelvic inflammatory
disease with azithromycin, 1 gram weekly for 2 doses. (She was
already status post ceftriaxone at outside hospital by the time
she was admitted to ___.
By ___, her labs and abdominal exam were found to be stable,
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 specific instructions for outpatient follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left forearm pain
Major Surgical or Invasive Procedure:
ORIF L radial shaft on ___
History of Present Illness:
HPI: ___ RHD struck by a car today, with the car running over
her L forearm. No headstrike, no LOC, no other injuries. No
numbness or tingling in the LUE.
Past Medical History:
PMH/PSH: None
MEDS: None
ALL: NKDA
SHx: ___
Family History:
NC
Physical Exam:
Left forearm incision is clean and intact without erythema or
drainage.
NVI distally. Sensation intact in m/u/r distributions. +EPL,
Wrist flexors, extensors.
NAD
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
4. Aspirin 325 mg PO DAILY Duration: 30 Days
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
L mid-shaft radius fracture and L hamate.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX HAND AND WRIST
INDICATION: ___ with auto vs ped, L hand ran over by tire; + abrasions to
digits ___ + distal wrist deformity // eval for fx
TECHNIQUE: Left hand and wrist, 7 views total.
COMPARISON: None
FINDINGS:
There is a midshaft left radial fracture with displacement. The radius and
ulna are intact at the wrist. Radiocarpal articulation is maintained. Carpal
bones are intact. Imaged metacarpals and phalanges are normal.
IMPRESSION:
1. Midshaft left radial fracture.
2. No evidence of fracture at the wrist or in the left hand.
Radiology Report
INDICATION: ___ with auto vs ped, L hand ran over by tire; + abrasions to
digits ___ + distal wrist deformity // eval for fx
TECHNIQUE: Left elbow and forearm, five views total.
COMPARISON: None
FINDINGS:
There is a displaced, foreshortened fracture of the midshaft of the radius.
The ulna is intact. At the elbow, there is no obvious fracture however true
lateral was unable to be obtained. Limited images of the wrist are normal.
IMPRESSION:
Midshaft, displaced left radial fracture with foreshortening.
Radiology Report
EXAMINATION: FOREARM (AP AND LAT) LEFT
INDICATION: ___ with reduced midshaft radius fx // post reduction
post reduction
TECHNIQUE: AP and lateral radiographs of the left forearm
COMPARISON: Radiographs from earlier on the same evening
FINDINGS:
Casting material overlies the forearm, obscuring fine bony detail. The
displaced, foreshortened midshaft radial fracture is slightly improved in its
degree of foreshortening, however is persistently displaced.
IMPRESSION:
Persistent displacement of midshaft radial fracture with slight improvement in
degree of foreshortening.
Radiology Report
INDICATION: ___ year old woman with snuffbox ttp, car ran over hand; going to
OR tomorrow for radius fx // eval for occult scaphoid fx
TECHNIQUE: Contiguous axial MDCT images of the left wrist were obtained
without intravenous contrast. Multiplanar reformations were created.
DOSE: Total DLP (Body) = 186 mGy-cm.
COMPARISON: Radiographs obtained earlier on the same evening.
FINDINGS:
There is an obliquely oriented, foreshortened fracture of the midshaft of the
radius, with volar displacement of the distal fracture fragment by
approximately 4 mm of overlap of the fragments. There is a small amount of
air in the soft tissues adjacent to the fracture. Inflammatory stranding is
mild around the flexor and extensor compartments at the level of the wrist.
There is a longitudinally oriented, nondisplaced fracture of the hook of the
hamate (03:56). The remaining carpal bones are intact, specifically the
scaphoid. Metacarpals and phalanges are intact. The ulna is intact along its
entirety. There is no soft tissue fluid collection or intramuscular hematoma.
IMPRESSION:
1. Nondisplaced fracture of the hook of the hamate. No other carpal bone
fractures.
2. Re- demonstrated foreshortened, volar displaced midshaft radial fracture.
3. No intramuscular hematoma.
Radiology Report
EXAMINATION: FOREARM (AP AND LAT) IN O.R. LEFT
INDICATION: ORIF left forearm
TECHNIQUE: Screening provided in the operating room without a radiologist
present.
COMPARISON: ___
FINDINGS:
Intraoperative images demonstrate fixation of a distal radial shaft fracture
with plate and screws. Total fluoroscopy time 12.1 seconds. For details of
the procedure, please consult the procedure report.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Ped struck, L Hand injury
Diagnosed with Displaced transverse fracture of shaft of left radius, init, Pedestrian injured nontraf involving military vehicle, init
temperature: 96.8
heartrate: 92.0
resprate: 16.0
o2sat: 100.0
sbp: 129.0
dbp: 90.0
level of pain: 7
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have Left midshaft radius fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF L radius, 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 ___
hospital course was otherwise unremarkable.
At the time of discharge to home, 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 WBAT with no more than 8 pounds of
weight in the LUE , and will be discharged on Aspirin 325mg for
4 weeks 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:
Codeine
Attending: ___.
Chief Complaint:
Left finger pain and discoloration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ w/ h/o R subclavian artery stent & axillary angioplasty
who presents with 1 day of R hand ___ & ___ finger discoloration
and pain. She was evaluated at an OSH where CTA showed partial
occlusion of her R subclavian stent as well as R vertebral
artery stenosis. She was
started on a hep gtt and transferred to ___ for further
evaluation.
Past Medical History:
PMH: HL, HTN, morbid obesity, hypothyroid, bipolar, chronic knee
pain, migraines, Hep C, Vit D deficiency, tobacco use, h/o
opiate dependence on methadone, PTSD, panic disorder
PSH: ___ R subclavian artery stent and R axillary
angioplasty
Physical Exam:
Alert and oriented x 3
VS:BP 138/62 HR 68 RR 16
Resp: Lungs clear
Abd: Soft, non tender
Ext: Pulses: Bilateral upper extremity: 2+ Palpable ulnar and
radial pulses. Finger warms, well perfused, color pink with
temperature equal both hands.
Pertinent Results:
___ 08:20PM BLOOD Neuts-48.9 ___ Monos-4.6* Eos-1.9
Baso-0.5 Im ___ AbsNeut-5.06 AbsLymp-4.53* AbsMono-0.48
AbsEos-0.20 AbsBaso-0.05
___ 08:20PM BLOOD WBC-10.4* RBC-4.42 Hgb-12.7 Hct-39.3
MCV-89 MCH-28.7 MCHC-32.3 RDW-13.8 RDWSD-44.7 Plt ___
___ 07:25AM BLOOD ___
___ 07:45AM BLOOD Glucose-92 UreaN-9 Creat-0.7 Na-137 K-4.6
Cl-100 HCO3-24 AnGap-18
___ 07:45AM BLOOD Calcium-9.9 Phos-3.9 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 80 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Levothyroxine Sodium 275 mcg PO DAILY
6. ClonazePAM 2 mg PO TID:PRN Anxiety
7. Gabapentin 800 mg PO TID
8. Paroxetine 40 mg PO QAM
9. Methadone 100 mg PO DAILY
10. Warfarin 5 mg PO DAILY16 arterial thrmboembolism
Discharge Medications:
1. ClonazePAM 2 mg PO TID:PRN Anxiety
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*11
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 800 mg PO TID
5. Levothyroxine Sodium 275 mcg PO DAILY
6. Methadone 100 mg PO DAILY
7. Paroxetine 40 mg PO QAM
8. Pravastatin 80 mg PO QPM
9. Amitriptyline 25 mg PO QHS
10. Enoxaparin Sodium 120 mg SC TWICE DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
INJECT TWICE DAILY UNTIL INSTRUCTED TO STOP BY ___ CLINIC
RX *enoxaparin 120 mg/0.8 mL 1 INJECTION TWICE DAILY Disp #*14
Syringe Refills:*0
11. Acetaminophen 650 mg PO Q6H:PRN pain
12. Warfarin 5 mg PO DAILY16 arterial thrmboembolism
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral Arterial Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ART EXT (REST ONLY)
INDICATION: ___ smoker s/p R subclavian stent axillary PTA p/w R ___ ___
finger pain, weakness, and discoloration, CTA shows partial SC stent
thrombosis, vertebral a. stenosis // upper extremity PVRs and digital
pressures
TECHNIQUE: Noninvasive evaluation of the arterial system of the upper
extremities was performed with Doppler signal recording and pulse volume
recordings.
COMPARISON: None
FINDINGS:
On the right side, monophasic Doppler waveforms were seen at the right
brachial, radial and ulnar arteries.
On the left side, triphasic Doppler waveforms is seen in the left brachial and
radial arteries. Monophasic Doppler waveforms are noted in the left ulnar
artery.
Pulse volume recordings are symmetric in the digits.
IMPRESSION:
Monophasic Doppler waveforms in the right brachial, radial and ulnar arteries.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Hand pain
Diagnosed with DUE TO OTHER VASCULAR DEVICE,IMPLANT,GRAFT, OTHER ATHEROSCLEROSIS EXTREM, ACCIDENT NOS, LONG TERM USE ANTIGOAGULANT
temperature: 98.2
heartrate: 78.0
resprate: 20.0
o2sat: 96.0
sbp: 122.0
dbp: 76.0
level of pain: 6
level of acuity: 2.0 | HPI: ___ w/ h/o R subclavian artery stent & axillary angioplasty
presents to OSH with 1 day of R hand ___ & ___ finger
discoloration and pain. CTA was concernin g for occlusion of
her R subclavian stent as well as R vertebral artery stenosis.
She was started on a hep gtt and transferred to ___ for
further evaluation.
Her finger discoloration and pain improved on heparin. After
review of the CTA we felt that the right subclavian artery had
focal stenosis or partial thrombosis of the subclavian artery
just distal to the stent but the stent was patent. There was
good distal flow to the axillary artery which also had
multifocal stenoses. There is also evidence of high-grade
stenosis of the proximal right vertebral artery.
Digit pressures and waveforms were excellent. Her antiplatelet
was changed to plavix from aspirin. We felt an intervent was
not warrented and would increase the risk of thromboembolic
events.
As her symptoms resolved, we discharged her to home on coumadin
with lovenox bridge
and plavix. She will follow up her INR check on ___ with her
PCP. We will also follow her closely in the clinic. She is
instructed to call for any changes in her hand or arm. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / lamotrigine
Attending: ___
Chief Complaint:
Vertigo, headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI/EVENTS: ___ yo F h/o migraine headaches, complex partial
seizures (last ___ years ago) on trileptal presented to ED with
vertigo and migraine headache. She notes very frequent
migraines (presenting with headaches) nearly occurring on a
daily basis. Seen by Dr. ___ at ___ and received botox
with some relief. This AM, she woke up with sudden onset of
vertigo: room-spinning, N/V. This continued throughout the
morning - worse with movement. The last vomiting episode was at
noon.
Later in the day (early afternoon), she developed her
typical migraine headaches - described as throbbing on L side
with parasthesia and hypersensitivity on the left scalp and
face. No relief with sumatriptan (which she notes as not worked
lately). Notes that she has had stuffy nose and sick exposure
(husband and mother with URI symptoms) over the past ___ weeks.
Denies any diplopia, dysarthria, sore throat, weakness or
clumsiness.
In the ED, vitals stable. Head CT negative. Given Zofran,
Ativan, meclizine with no significant improvement. Seen by
neuro which did not recommend admission to neuro or any
additional imaging. Being admitted to medicine for further
management.
ROS: per HPI, denies fever, chills, night sweats, vision
changes, cough, shortness of breath, chest pain, abdominal
pain, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria. A 10 pt review of sxs was otherwise
negative.
Past Medical History:
# Migraines, gets botox injections last in ___
# Depression
# Seizure disorder
Social History:
___
Family History:
F: migraines. Otherwise noncontributory to vertigo history
Physical Exam:
Vital Signs: 98.1 75 108/61 18 99% on RA
glucose:
.
GEN: NAD, lying in bed, head fixated to the L side (resistance
to move ___ worsened nausea), interactive, pleasant
EYES: PERRL, EOMI, conjunctiva clear, anicteric, no clear
nystagmus
ENT: moist mucous membranes, no exudates
NECK: supple
CV: RRR s1s2 nl, no m/r/g
PULM: CTA, no r/r/w
GI: normal BS, NT/ND, no HSM
EXT: warm, no c/c/e
SKIN: no rashes
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands, non focal, CN II-VII intact, no facial asymmetry, 5+
strength throughout, no dysdiadokinesia or resting tremor
PSYCH: appropriate
ACCESS: PIV
FOLEY: absent
.
Pertinent Results:
# Head CT (___): There is no evidence of hemorrhage, edema, or
mass effect. Ventricles and sulci are age appropriate in size
and configuration. Gray-white matter differentiation is
preserved. There is no evidence of acute large territorial
infarction. Basal cisterns are patent. The orbits are
unremarkable. Visualized paranasal sinuses demonstrate moderate
mucosal thickening within the ethmoidal air air cells,
aerosolized secretions noted within the posterior left ethmoidal
air cells. The sphenoid sinuses appear clear as do bilateral
mastoid air cells and middle ear cavities
bilaterally. Bony calvarium appears intact. IMPRESSION: No
acute intracranial abnormality. If clinical concern for stroke
persists,
MR is a more sensitive modality in the detection of acute
ischemia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxcarbazepine 300 mg PO BID
2. Sumatriptan Succinate 50-100 mg PO ONCE:PRN headache
Discharge Medications:
1. Oxcarbazepine 300 mg PO BID
2. Meclizine 25 mg PO Q8H:PRN vertigo
It may cause drowsiness. Do not combine with alcohol.
RX *meclizine 25 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q8H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
4. Fiorcet
Discharge Disposition:
Home
Discharge Diagnosis:
Benign Paroxysmal Positional Vertigo (BPPV) or Viral
Labyrinthitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Vital signs stable.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with vertigo and ataxia // stroke
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) = 757 mGy-cm.
COMPARISON: MR head dated ___.
FINDINGS:
There is no evidence of hemorrhage, edema, or mass effect. Ventricles and
sulci are age appropriate in size and configuration. Gray-white matter
differentiation is preserved. There is no evidence of acute large territorial
infarction. Basal cisterns are patent.
The orbits are unremarkable. Visualized paranasal sinuses demonstrate
moderate mucosal thickening within the ethmoidal air air cells, aerosolized
secretions noted within the posterior left ethmoidal air cells. The sphenoid
sinuses appear clear as do bilateral mastoid air cells and middle ear cavities
bilaterally. Bony calvarium appears intact.
IMPRESSION:
No acute intracranial abnormality. If clinical concern for stroke persists,
MR is a more sensitive modality in the detection of acute ischemia.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Dizziness, L Numbness
Diagnosed with Dizziness and giddiness
temperature: 98.1
heartrate: 75.0
resprate: 18.0
o2sat: 99.0
sbp: 108.0
dbp: 61.0
level of pain: 10
level of acuity: 1.0 | ASSESSMENT & PLAN: ___ yo F h/o migraine headaches, complex
partial seizures (last ___ years ago) on trileptal presented to ED
with vertigo and migraine headache.
Patient admitted with vertigo thought to be BPPV versus
vertiginous migrains versus viral labyrinthitis. Treated
conservatively with NSAIDs, meclizine and Epley maneuver, which
improved symptoms. Patient given instructions on Epley maneuver
but would benefit from ___ for vertigo as outpatient. Given
?vertiginous migraines, neurology advised against the use of
triptans because of increased risk for stroke. Patient given Rx
for ibuprofen, fioricet and meclizine.
Patient remained on home trileptal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bacitracin / Ciprofloxacin / azithromycin
Attending: ___
Chief Complaint:
Profound fatigue, shortness of breath and dizziness
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
___ with a history of b/l breast cancers s/p mastectomies ___,
___, LUL NSCLC (___) s/p lobectomy and RUL NSCLC (___) s/p
CK therapy, left atrial clot on ASA, p/w worsening sx of
profound fatigue, shortness of breath and dizziness. She is
unable to ambulate safely at home due to lightheadedness.
The patient contacted her PCP ___ (HCA) on ___ to report
hoarseness x 3 weeks without any associated symptoms of URI. At
the time she also reported increasing dizziness and a recent
fall on ___ at which time she hit her leg and fell on her
coccyx. She started using her walker consistently due to
dyspnea on exertion.
For the last two days she has had worsening dyspnea and
increased orthopnea. She has had increased home O2 requirement
from 2 to 4 L NC. Her chronic cough is unchanged,
non-productive. She denies fever, chills, sweats. She does
endorse weight loss of 20 pounds in the last 3 months, possibly
partially due to poor appetite. She denies any worsening ___
edema, but does note some unilateral leg tenderness in her left
calf. She has had vague chest discomfort with deep inspiration.
No hemoptysis. She called her PCP office again today given
concern for dyspnea and being unable to ambulate safely at home
___ lightheadedness; she was referred to the ED.
Of note, the patient was admitted to this facility in ___
for multi-focal pneumonia. She was initially started on vanco
and tigecycline due to an extensive history of reactions to abx
including quinolones and penicillins. She was switched to
aztreonam and doxy for 10 day course. She was discharged on RA.
At that time, a left atrial clot was noted and she was started
on Lovenox anti-coagulation. Repeat CTA chest in ___ was
negative for PE, thus her Lovenox was stopped. This CT also
showed progressive mass-like consolidation around the site of
her prior cyberknife procedure as well as new R lung nodules,
concerning for infection vs. malignancy. In response to this
finding, she was seen in the ___ clinic in late ___ for
the first visit since ___. Etiology of the imaging findings
was unclear, thus the recommendation at that time was to do
follow-up imaging with CT and PET in several months to check for
interval change. No immediate treatment recommended.
In the ED, initial vitals ___ 98 68 80/44 20 100% 4L NC. Found
to have lactate 2.7, CXR showed multifocal PNA. She was started
on azithromycin PO and levofloxacin IV, received 2L NS in ED.
___ u/s negative for DVT.
On arrival to the floor, pt down to baseline 2L NC and breathing
comfortably. Denies worsened SOB or cough from baseline. No
current vertigo, although pt says that this was her main concern
this morning when she came to the ED. VS were 97.8, 101/40, 68,
20, 98%2L.
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 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:
PAST ONCOLOGIC HISTORY:
Regarding her breast cancers, she underwent a right mastectomy
in ___ and a left mastectomy in ___, and she had no
postmastectomy radiation therapy.
After her initial diagnosis of lung cancer in ___, she
underwent a left upper lobectomy for stage IA non-small cell
carcinoma of the lung; she had no postoperative adjuvant
radiation therapy or chemotherapy.
- ___: developed cough
- ___: CT chest showed a 1.9 x 1.2 cm right upper lobe lung
mass, which was suspicious for carcinoma. PET-CT on ___
showed a 1.3 x 1.1 cm right upper lobe lung lesion with an SUV
of 11.7; there were no FDG avid mediastinal or hilar lymph
nodes, and there were no liver, adrenal, or bone metastases.
Ms. ___ was evaluated by Dr. ___ consideration
of treatment of what appeared to be a right upper lobe lung
cancer. Since she was not a good candidate for surgical
treatment (DLCO was 41% of predicted), she underwent CT guided
biopsy that showed mucinous lung adenocarcinoma, acinar pattern,
moderately differentiated, and subsequently underwent CK
radiation to the lesion.
- CyberKnife SBRT to the right upper lobe lung adenocarcinoma to
a dose of 55 Gy given in five fractions of 11 Gy each completed
on ___.
- ___ repeat chest CT showed progression of the mass-like
consolidation around the fiducial marker and new multiple right
lung nodules is either cryptogenic organizing pneumonia
(perphaps triggered by radiation therapy) or unusually
aggressive recurrent lung cancer. Repeat imaging and PET
scanning planned as outpatient with follow-up appt in ___.
PAST MEDICAL HISTORY:
ANKLE FRACTURE
BREAST CANCER
CHEST NODULE
CORONARY ARTERY DISEASE
DEPRESSION
HYPERTENSION
LUNG CANCER
MEMORY DISORDER
OSTEOPOROSIS
SEIZURE DISORDER
SLEEP APNEA
SEBORRHEIC DERMATITIS
ENCHONDROMA
HOME SERVICES
LEFT ATRIAL CLOT on Lovenox ___, now on ASA
- ___: admission for significant weakness, chest
pain, and dyspnea to the point that she could barely walk. CT
angiography of the chest on ___ showed multifocal
pneumonia in the right lung; there was no pulmonary embolism;
there were right hilar lymph nodes up to 2.8 x 2.9 cm, which
were felt likely reactive; there was a small left atrial
thrombus. Ms. ___ was treated with aztreonam, doxycycline,
and Lovenox.
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.8, 101/40, 68, 20, 98%2L
GENERAL: NAD, awake and alert
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, MMM
NECK: nontender and supple, no LAD, no JVD
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: Few crackles diffusely, course breath sounds throughout,
no wheezes, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis, clubbing or edema
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal, gait deferred
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.1, HR 77, BP 134/70, RR 20, O2 sat 100% on 2L
GENERAL: NAD
HEENT: AT/NC, MMM
NECK: nontender and supple, no LAD, no JVD
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: Normal respiratory rate and effort, CTAB, no wheezes
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding
EXT: warm and well-perfused, no cyanosis, clubbing or edema
NEURO: alert and oriented x3
SKIN: warm and well perfused, dry skin on/around lips, no rashes
Pertinent Results:
ADMISSION LABS:
============
___ 12:30PM BLOOD WBC-7.9 RBC-4.77 Hgb-13.0 Hct-38.2
MCV-80* MCH-27.2 MCHC-34.0 RDW-13.6 Plt ___
___ 12:30PM BLOOD Neuts-72.1* ___ Monos-6.3 Eos-2.8
Baso-0.7
___ 12:30PM BLOOD Glucose-126* UreaN-21* Creat-0.8 Na-136
K-5.1 Cl-95* HCO3-26 AnGap-20
___ 12:30PM BLOOD Calcium-9.3 Phos-4.2 Mg-2.1
___ 06:10AM BLOOD ALT-13 AST-12 AlkPhos-129* TotBili-0.1
___ 12:40PM BLOOD Lactate-2.7*
DISCHARGE LABS:
============
___ 06:15AM BLOOD WBC-4.9 RBC-3.90* Hgb-10.4* Hct-32.0*
MCV-82 MCH-26.7* MCHC-32.6 RDW-15.2 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD Glucose-111* UreaN-6 Creat-0.5 Na-139
K-4.1 Cl-102 HCO3-29 AnGap-12
___ 06:15AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
OTHER PERTINENT LABS:
============
___ 07:33AM BLOOD ___ PTT-69.1* ___
___ 05:30AM BLOOD PTT-76.1*
___ 10:00PM BLOOD PTT-73.5*
___ 02:30PM BLOOD PTT-71.0*
___ 06:20AM BLOOD ___ PTT-25.3 ___
___ 06:23AM BLOOD CK(CPK)-24*
___ 12:00AM BLOOD CK(CPK)-14*
___ 06:10AM BLOOD ALT-13 AST-12 AlkPhos-129* TotBili-0.1
___ 06:23AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:00AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:20PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:15AM BLOOD TSH-3.0
___ 06:15AM BLOOD Free T4-1.1
___ 06:40AM BLOOD Phenyto-LESS THAN
___ 07:17AM BLOOD Lactate-1.1
IMAGING:
============
CXR ___:
FINDINGS: The lungs are hyperinflated, consistent with known
emphysema. Opacity is again seen within the right upper lobe
compatible with known malignancy with a fiducial marker
identified. There is increased opacity adjacent to tumor, most
likely representing post-obstructive infection or atelectasis.
There is a new patchy opacity in the right lung base, which
likely represents infection. Bibasilar atelectasis or scarring
is seen. The cardiomediastinal silhouette is unremarkable.
Sclerotic lesion in the left humeral head is unchanged from
___, likely representing medullary infarct or enchonroma. A
stable bone island is seen in the left glenoid.
IMPRESSION: Multifocal pneumonia in the right lung.
b/l ___ ultrasound ___:
IMPRESSION: No evidence of deep vein thrombosis in the right or
left lower extremity.
Chest CT ___:
IMPRESSION:
1. Significant interval increase in the bulk of the tissue
consolidation around the fiducial marker in the right upper
lobe, the area of thE patient's radiation-treated malignancy.
Innumerable scattered right lung nodules are overall increased
in size compared to the prior exam. Many of these nodules have
become more confluent into larger nodules.
2. Interval increase in the size of the innumerable left lung
nodules
concerning for worsening metastatic foci.
3. Interval increase in the diffuse lymphadenopathy.
ECHO ___:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). 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. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. No valvular
pathology or pathologic flow identified. ompared with the prior
study (images reviewed) of ___, the findings are similar.
CT Head ___:
FINDINGS: There is no evidence of hemorrhage, edema, mass
effect, or infarction. No evidence of metastatic disease.
Prominent ventricles and sulci most consistent with age related
involutional changes. Diffuse ___ ventricular and subcortical
white matter hypodensities consistent with small vessel ischemic
disease. The basal cisterns appear patent. Visualized major
vessels and their branches are patent. Osseous structures are
unremarkable. Mild mucosal thickening within the left
sphenoid sinus. The remainder of the visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION: No evidence of metastatic disease.
CXR ___:
FINDINGS: Following the procedure, there is no evidence of
pneumothorax. There is some increased opacification in the
right mid and upper zone, suggesting some post-procedure
hemorrhage.
CXR ___:
No pneumothorax is detected. Again seen are background COPD, a
large
mass-like opacity in the right upper zone, and interstitial and
more confluent opacities at the bases. No new CHF, effusion or
pneumothorax is detected. Note is made of an irregular
sclerotic lesion in the left proximal humerus and small rounded
sclerotic focus in the left glenoid, not fully evaluated on
these views.
IMPRESSION:
1. No pneumothorax or acute superimposed pulmonary process
detected compared with ___ at 11:59 a.m.
2. Sclerotic densities in the left proximal humerus and left
glenoid, not fully evaluated.
CTA CHEST ___:
FINDINGS: Partially visualized thyroid is normal. There is no
axillary
lymphadenopathy. Slightly prominent bilateral axillary lymph
nodes are
unchanged. Subcarinal soft tissue consolidation is seen and
there is an
increase in compressive attenuation on the adjacent right main
bronchus.
There are new bilateral small pleural effusions, right greater
than left. The consolidation in the right mid lung is increased
in size. There are multiple small nodules throughout the right
lung, some of which are slightly increased in size compared to
prior study, the right middle lobe nodule measures 1.0 cm,
increased from prior study when it measured 0.8 cm. Multiple
small left pulmonary nodules are grossly unchanged. There is no
filling defect in the pulmonary arteries to the subsegmental
level. Right hilar lymphadenopathy is unchanged. The aorta is
normal in caliber. Limited evaluation of the upper abdominal
organs is unremarkable. There is an incidental note of a gastric
fundal diverticulum. Bilateral breast implants are seen. Heart
size is normal. There is no pericardial effusion.
IMPRESSION:
1. Mild increase in size of soft tissue consolidation in the
right mid lung.
2. New bilateral small pleural effusions, right greater than
left.
3. Multiple pulmonary nodules bilaterally, some of which have
slightly
increased in size.
4. Subcarinal soft tissue consolidation is seen and there is an
increase in attenuation on the adjacent right main bronchus.
BRONCHOSCOPY REPORT ___
Impression: Flexible bronchscope passed via LMA and vocal cords
with ease. Airways visualized to the subsegmental level. There
was diffsue calcification in the airways mainly in the central
airways. LUL stump of the previous ___ lobectomy was noticed.
Then EBUS scope
Otherwise normal to tracheobronchial tree
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Benzonatate 100 mg PO TID:PRN cough
3. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
4. Omeprazole 20 mg PO BID
5. Ondansetron 4 mg PO Q6H:PRN nausea
6. Phenytoin Sodium Extended 100 mg PO BID
7. QUEtiapine Fumarate 25 mg PO QHS
8. Simvastatin 40 mg PO DAILY
9. Venlafaxine XR 225 mg PO DAILY
10. Aspirin 325 mg PO DAILY
11. Caltrate 600 + D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral daily
12. Multivitamins 1 TAB PO DAILY
13. Acetaminophen 325 mg PO Q6H:PRN TMJ pain
14. Lorazepam 0.5 mg PO Q4H:PRN prior to CT
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN TMJ pain
2. Benzonatate 100 mg PO TID:PRN cough
3. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO BID
6. Ondansetron 4 mg PO Q6H:PRN nausea
7. Phenytoin Sodium Extended 100 mg PO BID
8. QUEtiapine Fumarate 25 mg PO QHS
9. Simvastatin 40 mg PO DAILY
10. Venlafaxine XR 225 mg PO DAILY
11. Caltrate 600 + D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral daily
12. Meclizine 12.5 mg PO Q8H:PRN dizziness
13. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
14. Docusate Sodium 100 mg PO BID
15. Lorazepam 0.5 mg PO Q4H:PRN prior to CT
16. Aspirin 81 mg PO DAILY
17. Heparin IV Sliding Scale
No Initial Bolus
Initial Infusion Rate: 700 units/hr
Target PTT: 60 - 100 seconds
18. Ipratropium Bromide Neb 1 NEB IH Q6H
19. Metoprolol Succinate XL 50 mg PO DAILY
20. Warfarin 3 mg PO DAILY16
21. Acetaminophen 1000 mg PO Q8H:PRN Pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: lung cancer
Secondary: paroxsysmal atrial fibrillation with rapid
ventricular rate, anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath.
COMPARISON: Comparison is made with chest radiographs from ___,
___, an ___.
FINDINGS: The lungs are hyperinflated, consistent with known emphysema.
Opacity is again seen within the right upper lobe compatible with known
malignancy with a fiducial marker identified. There is increased opacity
adjacent to tumor, most likely representing post-obstructive infection or
atelectasis. There is a new patchy opacity in the right lung base, which
likely represents infection. Bibasilar atelectasis or scarring is seen. The
cardiomediastinal silhouette is unremarkable. Sclerotic lesion in the left
humeral head is unchanged from ___, likely representing medullary infarct or
enchonroma. A stable bone island is seen in the left glenoid.
IMPRESSION: Multifocal pneumonia in the right lung.
Radiology Report
HISTORY: Acute dyspnea.
TECHNIQUE: Grayscale and color and spectral Doppler evaluation was performed
of the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS: There is normal compressibility, flow, and augmentation of the
bilateral common femoral, proximal femoral, mid femoral, distal femoral, and
popliteal veins. Normal compressibility is demonstrated in the posterior
tibial and peroneal veins bilaterally. There is normal respiratory variation
of the common femoral veins bilaterally.
IMPRESSION: No evidence of deep vein thrombosis in the right or left lower
extremity.
Radiology Report
INDICATION: History of non-small cell lung cancer, who presents with
worsening shortness of breath and fatigue. CT chest in ___ showed
progression of mass and new right lung nodules. Please evaluate.
COMPARISONS: Chest CTA from ___.
TECHNIQUE: ___ MDCT images were obtained through the chest without the
administration of IV contrast. Multiplanar reformatted images in coronal and
sagittal axes were generated and reviewed.
FINDINGS:
Thyroid is normal. There is no axillary lymphadenopathy; however, there is a
left-sided node which measures 0.6 cm x 1.1 cm, series 2, image 18, overall
stable compared to the prior exam. There is a right axillary node measuring 1
cm in short axis, series 2, image 13, which appears overall slightly increased
compared to the prior exam. Soft tissue infiltration around the subcarinal
region extends superiorly towards the trachea and appears to have slightly
increased in size compared to the prior study with the subcarinal portion
grossly measuring 2.5 cm x 3.8 cm, series 2, image 30, compared to the prior
exam, at which time this measured 1.5 cm x 3.2 cm. There appears to have also
been a slight interval increase in the right hilar lymphadenopathy measuring
2.7 cm x 2 cm, series 2, image 28, slightly increased in size compared to the
prior exam, at which time this measured 2.3 cm x 1.5 cm.
Heart size is normal. There is a small pericardial effusion. Mild coronary
and valvular calcifications are identified. The esophagus is normal without
evidence of wall thickening or a hiatal hernia.
The mass-like consolidation around the fiducial marker in the posterior
segment of the right upper lobe abuts the fissure and has overall increased in
size compared to the prior exam. Innumerable nodular soft tissue deposits in
the right lung have overall increased in size and become more confluent to
become larger soft tissue lesions, compared to the prior exam. For example,
in the right lower lobe, there is a 2.3 cm x 1.6 cm lesion, series 102, image
172, which has increased in size compared to the prior exam, at which time
this measured 1.5 cm x 1.1 cm. In the right lower lobe, there is a second
lesion, series 102, image 163, which now measures 2.2 cm x 1.1 cm, increased
in size compared to the prior exam, at which time this measured 1.6 cm x 0.8
cm. There is a conglomerate of nodular opacities in the right middle lobe
which have fused to become a larger soft tissue mass along the right major
fissure measuring up to 3 cm, series 102, image 148.
Additional new nodules are seen, for example, in the right upper lobe, there
is a pleural-based lesion which measures 0.7 cm x 0.4 cm, series 102, image
95. There is no pleural effusion or pneumothorax. At the left lower lobe,
there has also been an interval increase in size of a 5-mm nodule, series 102,
image 167, compared to the prior exam, at which time this measured 4 mm.
There are nodular opacities in the left lower lobe, series 102, image 126,
measuring up to 0.9 cm. There is a soft tissue lesion measuring 0.9 cm x 0.6
cm, series 102, image 162, in the left lower lobe, overall increased in size
compared to the prior exam, at which time this measured 0.6 cm x 0.6 cm,
series 102, image 163. Severe centrilobular emphysema has an upper lobe
predominance bilaterally.
The patient is status post bilateral breast implants. This study is not
tailored for the evaluation of the subdiaphragmatic structures; however, the
imaged portion of the upper abdomen demonstrates no acute abnormalities. A
gastric diverticulum is noted, unchanged compared to the prior exam.
OSSEOUS STRUCTURES: No suspicious bony lesions are demonstrated. A
benign-appearing sclerotic focus in T4 has been stable since at least ___.
IMPRESSION:
1. Significant interval increase in the bulk of the tissue consolidation
around the fiducial marker in the right upper lobe, the area of the patient's
radiation-treated malignancy. Innumerable scattered right lung nodules are
overall increased in size compared to the prior exam. Many of these nodules
have become more confluent into larger nodules.
2. Interval increase in the size of the innumerable left lung nodules
concerning for worsening metastatic foci.
3. Interval increase in the diffuse lymphadenopathy.
Findings were placed in the critical results dashboard by Dr. ___ on the
day of the exam.
Radiology Report
HISTORY: ___ female with non-small cell lung cancer presenting with
vertigo and lightheadedness. Evaluate for brain metastasis.
TECHNIQUE: Contiguous axial multi detector images of the brain were obtained
after administration of intravenous contrast. DLP 1040 mGy-cm. CTDI 62 mGy.
COMPARISON: None available.
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or infarction. No
evidence of metastatic disease. Prominent ventricles and sulci most
consistent with age related involutional changes. Diffuse ___ ventricular
and subcortical white matter hypodensities consistent with small vessel
ischemic disease. The basal cisterns appear patent. Visualized major vessels
and their branches are patent.
Osseous structures are unremarkable. Mild mucosal thickening within the left
sphenoid sinus. The remainder of the visualized paranasal sinuses, mastoid
air cells, and middle ear cavities are clear.
IMPRESSION:
No evidence of metastatic disease.
Radiology Report
HISTORY: Flexible bronchoscopy.
FINDINGS: Images from the procedure are presented. Further information can
be gathered from the procedure report.
Radiology Report
HISTORY: Bronchoscopy, to assess for pneumothorax.
FINDINGS: Following the procedure, there is no evidence of pneumothorax.
There is some increased opacification in the right mid and upper zone,
suggesting some post-procedure hemorrhage.
Radiology Report
HISTORY: Chest pain, EKG changes, status post bronchoscopy, question
pneumothorax, mediastinal changes.
CHEST, SINGLE AP PORTABLE VIEW.
No pneumothorax is detected. Again seen are background COPD, a large
mass-like opacity in the right upper zone, and interstitial and more confluent
opacities at the bases. No new CHF, effusion or pneumothorax is detected.
Note is made of an irregular sclerotic lesion in the left proximal humerus and
small rounded sclerotic focus in the left glenoid, not fully evaluated on
these views.
IMPRESSION:
1. No pneumothorax or acute superimposed pulmonary process detected compared
with ___ at 11:59 a.m.
2. Sclerotic densities in the left proximal humerus and left glenoid, not
fully evaluated.
Radiology Report
INDICATION: Breast cancer and primary lung cancer, now with shortness of
breath and chest pain and paroxysmal AFib, with RVR, evaluate for pulmonary
embolism.
COMPARISON: Chest CT on ___.
TECHNIQUE: MDCT images were obtained through the chest with IV contrast.
Coronal and sagittal reformations were performed. Right and left MIP
reconstructions were performed.
FINDINGS: Partially visualized thyroid is normal. There is no axillary
lymphadenopathy. Slightly prominent bilateral axillary lymph nodes are
unchanged. Subcarinal soft tissue consolidation is seen and there is an
increase in compressive attenuation on the adjacent right main bronchus.
There are new bilateral small pleural effusions, right greater than left. The
consolidation in the right mid lung is increased in size. There are multiple
small nodules throughout the right lung, some of which are slightly increased
in size compared to prior study, the right middle lobe nodule measures 1.0 cm,
increased from prior study when it measured 0.8 cm. Multiple small left
pulmonary nodules are grossly unchanged. There is no filling defect in the
pulmonary arteries to the subsegmental level. Right hilar lymphadenopathy is
unchanged. The aorta is normal in caliber. Limited evaluation of the upper
abdominal organs is unremarkable. There is an incidental note of a gastric
fundal diverticulum. Bilateral breast implants are seen. Heart size is
normal. There is no pericardial effusion.
IMPRESSION:
1. Mild increase in size of soft tissue consolidation in the right mid lung.
2. New bilateral small pleural effusions, right greater than left.
3. Multiple pulmonary nodules bilaterally, some of which have slightly
increased in size.
4. Subcarinal soft tissue consolidation is seen and there is an increase in
attenuation on the adjacent right main bronchus.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, FTT
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPERTENSION NOS, HX-BRONCHOGENIC MALIGNAN, HX OF BREAST MALIGNANCY
temperature: 98.0
heartrate: 68.0
resprate: 20.0
o2sat: 100.0
sbp: 80.0
dbp: 44.0
level of pain: 0
level of acuity: 1.0 | ___ with a history of b/l breast cancers s/p mastectomies ___,
___, LUL NSCLC (___) s/p lobectomy and RUL NSCLC (___) s/p
CK therapy, left atrial clot on ASA, h/o BPPV, p/w worsening sx
of profound fatigue, shortness of breath and dizziness, found to
have multifocal pneumonia and progression of lung cancer as well
as newly diagnosed afib with RVR. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
fever, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ y/o M with HIV (CD4 500, VL undetectable) on
Atripla, CVID with outpatient IVIG transfusions (last one 2
weeks ago), and h/o recurrent pneumonias and bronchiectasis who
was seen by his PCP on AM ___ with likely recurrent PNA. Pt was
previously seen ___ primary care clinic 3 weeks ago where he had
cough, fevers to 103, fatigue. CXR ___ showed atypical PNA. He
was treated with 10 day course of levofloxacin with clinical
improvement. He flew to ___, for a brief trip near
the end of his 10-day course of treatment. However, ___ days ago
pt had recurrent fevers to 103, chills, rigors, night sweats,
and worsening cough productive of green/brown sputum. He denies
any sick contacts outside of his trip.
He was seen ___ clinic this morning where T 98.1, P 90, R 16,
SaO2 97% RA. Repeat CXR obtained which shows new infiltrates
___ RUL and RML and possible interval improvement on left side.
His PCP discussed the case with Dr. ___ infectious
diseases who
recommend admission for ID consult, cultures and treatment with
IV antibiotics. Dr. ___ requested evaluation by liver
service of pt's recent abnormal LFT's, which were ALT 71, AST
57, Tbili 0.5, INR 1.2 back ___ ___. Of note, he has a
history of hepatic vein thrombosis. Of note, patient had
admission at ___ for pnemonia ___ ___, where blood cx came
back positive for Shewanella.
___ the ED, initial vs were: T 102.6 P ___ BP 97/59 R 28 O2 sat
93% RA. Labs were remarkable for WBC 9.4 with 81% neutrophils,
H/H 10.1/31.8 (appears to be at baseline), Na of 132, lactate
2.2.
On the floor, VS were: T 102.6 BP 103/60 P ___ R 22 SaO2 93% RA
Past Medical History:
# HIV, diagnosed ___
--- Started on Combivir [zidovudine, lamivudine] ___ ___,
discontinued b/c of mild leukopenia
--- Viramune [nevirapine] and truvada [emtricitabine, tenofovir]
--- switched to Atripla ___ ___
# CVID - diagnosed at age ___ ___ setting of chronic sinusitis and
hypogammaglobulinemia (improved w/monthly IVIg; last IVIg
___
# h/o giardia infection, recurrent
# h/o H. pylori ___ ___ treated with clarithromycin, flagyl,
omeprazole completed on ___
# hx syphillis, multiple episodes
# hx molluscum contagiosum
# Heparic Vein Thrombosis, ?Budd Chiari ___ romiplostim
# ITP
# ICU hospitalization ___ ___ x25 days for PNA and sepsis ___ past
# Asthma
# Depression
# h/o Meningitis
# Allergic Rhinitis
# Seasonal allergies
# Recurrent sinusitis
# Gonorrhea ___
# Anal condylomata with LSIL s/p laser fulguration ___
# MSSA prepatellar septic bursitis ___
# s/p sinus surgery ___
# Mild intermittent asthma
Social History:
___
Family History:
Mother with RA. Father and sister healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T 102.6 BP 103/60 P ___ R 22 SaO2 93% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds on right side throughout, worse
near apex. Diffuse rales throughout lung fields, R worse than L.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moves all extremities well, A&Ox3
DISCHARGE PHYSICAL EXAM
=======================
Vitals: Tmax 97.7 BP 95/55 P ___ R 18 SaO2 96%
General: Pleasant, alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles greatest at right lung apex. No wheezes/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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moves all extremities well, A&Ox3
Pertinent Results:
ADMISSION LABS
==============
___ 05:15PM BLOOD WBC-9.4 RBC-3.58* Hgb-10.1* Hct-31.8*
MCV-89 MCH-28.3 MCHC-31.9 RDW-15.9* Plt ___
___ 05:15PM BLOOD Neuts-81.3* Lymphs-12.5* Monos-4.6
Eos-1.3 Baso-0.4
___ 05:15PM BLOOD ___ PTT-36.6* ___
___ 05:15PM BLOOD Glucose-121* UreaN-11 Creat-0.6 Na-132*
K-3.9 Cl-98 HCO3-24 AnGap-14
___ 05:15PM BLOOD ALT-69* AST-73* AlkPhos-257* TotBili-1.0
___ 05:36PM BLOOD Lactate-2.2*
RELEVANT LABS
=============
___ 09:19AM BLOOD Lactate-1.1
___ 08:54AM BLOOD Smooth-NEGATIVE
___ 08:54AM BLOOD ___
___ 07:30AM BLOOD IgG-643*
DISCHARGE LABS
==============
___ 07:30AM BLOOD WBC-4.9 RBC-4.20* Hgb-12.0* Hct-38.3*
MCV-91 MCH-28.5 MCHC-31.3 RDW-16.3* Plt ___
___ 07:30AM BLOOD Neuts-42.9* ___ Monos-6.9
Eos-9.2* Baso-1.6
___ 07:30AM BLOOD Glucose-87 UreaN-9 Creat-0.5 Na-141 K-4.5
Cl-107 HCO3-28 AnGap-11
___ 07:30AM BLOOD ALT-62* AST-70* AlkPhos-330* TotBili-0.6
___ 07:30AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.3
MICRO
=====
___ 11:07PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln->12 pH-8.0 Leuks-NEG
___ 11:07PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
___ 11:07PM URINE Mucous-RARE
URINE CULTURE (Final ___: NO GROWTH.
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, ___
infected patients the excretion of antigen ___ urine may
vary.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
IMAGING
=======
CXR ___:
Improvement ___ previously seen left lower opacity. Worsening
right upper and mid-lung heterogeneous opacities concerning for
worsening or new atypical or opportunistic pneumonia. Stable
bilateral lower lung bronchial wall thickening and
bronchiectasis.
ABD US with doppler ___:
IMPRESSION: 1. Patent hepatic vasculature. No hepatic vein
thrombus identified. 2. Heterogeneous hepatic architecture. No
focal liver lesion identified. 3. Splenomegaly 4. No gallstones
and no signs of cholecystitis. Several tiny polyps are
incidentally noted ___ the gallbladder.
CT chest w/ contrast ___:
FINDINGS: Assessment of aorta and pulmonary arteries reveals no
appreciable abnormality. Heart size is normal. There is no
pericardial or pleural effusion demonstrated. The imaged
portion of the upper abdomen demonstrates splenomegaly,
partially imaged and otherwise is unremarkable.
No axillary lymphadenopathy is seen. There are no lytic or
sclerotic lesions worrisome for infection or neoplasm
demonstrated.
Assessment of the lung parenchyma demonstrates right upper lobe
consolidations and areas of ground glass, for example series 4,
image 82, that appears to be substantially more progressed as
compared to prior study. There is no evidence of endobronchial
obstruction. There is evidence of bronchial wall thickening
and endobronchial secretions. The involvement of the lungs also
includes right middle lobe, right lower lobe with substantial
peribronchovascular tissue bilaterally and extensive amount of
endobronchial secretions ___ lower lobes bilaterally, highly
concerning based on the appearance for aspiration. There is
also involvement of the anterior aspect of the left upper lobe.
All the findings are substantially worse than on the prior
study. No discrete masses worrisome for neoplasm demonstrated.
There is also no evidence of interstitial lung disease. The
involvement of the lung has substantially progressed between
___ and ___.
Differential diagnosis would include recurrent aspiration versus
multifocal pneumonia, but again the extensive amount of fluid
___ the lower lobe bronchi posteriorly would favor first over
the latter. The peribronchovascular tissue is most likely
consistent with reactive inflammation, but reassessment of the
patient after treatment for this presumably multifocal
aspiration pneumonia is required.
Several tracheal diverticula are noted ___ the upper portion of
the trachea, unchanged since prior examination and most
unlikely of limited clinical significance.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 150 mg PO DAILY
2. Citalopram 40 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN post nasal
drip
4. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral
daily
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. BuPROPion 150 mg PO DAILY
3. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral
daily
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN post nasal
drip
5. CeftriaXONE 2 gm IV Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
# Pneumonia
# Hepatic vein thrombosis
SECONDARY DIAGNOSES
===================
# HIV
# Common variable immunodeficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PA and lateral chest x-ray.
INDICATION: ___ year old man with HIV, CVID, h/o PNA/bronchiectasis, ___ with
recurrent F/C, productive cough, L sided pleuritic CP after course of Levo
Thanks // ? PNA/effusion
TECHNIQUE: PA and lateral projections, upright positioning.
COMPARISON: PA and lateral chest x-ray obtained ___.
FINDINGS:
The cardiomediastinal silhouettes are normal. The bilateral hila are normal.
The previously visualized interstitial opacities involving the left lower lobe
are improved. However, there has been worsening of the involved right mid lung
and mew anterior segment right upper lobe opacities, with interval development
of a more irregularly marginated and heterogenous opacities with nodular
component which may represent new or worsening pneumonia. Again seen is
left-greater-than-right lower lung bronchial wall thickening and
bronchiectasis, stable from prior exam.
There is right apical pleural scarring, unchanged in appearance in comparison
to prior radiograph. There is no pulmonary vascular congestion. There are no
pneumothoraces or effusions.
IMPRESSION:
Improvement in previously seen left lower opacity. Worsening right upper and
mid-lung heterogeneous opacities concerning for worsening or new atypical or
opportunistic pneumonia. Stable bilateral lower lung bronchial wall thickening
and bronchiectasis.
NOTIFICATION: The above findings were discussed over the phone by Dr. ___
with Dr. ___ on ___ at 11:58, approximately 20 minutes after
review.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with known hepatic vein thrombosis // eval for
possible cholecystitis, recurrence of hepatitic vein thrombosis
TECHNIQUE: Grey scale ultrasound images of the abdomen were obtained.
COMPARISON: Doppler ultrasound ___, the report of the abdomen MRI
of ___
FINDINGS:
LIVER: The liver is normal in size. The hepatic architecture is heterogeneous
throughout. There is no focal liver mass. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 0.4
cm.
GALLBLADDER: No gallstones are visualized. Several tiny polyps measuring up to
3 mm are noted in the gallbladder.
PANCREAS: The head, body and tail of the pancreas are within normal limits,
without masses or pancreatic ductal dilatation.
SPLEEN: The spleen is enlarged measuring 13.7 cm.
KIDNEYS: No hydronephrosis is seen in either kidney. The right kidney
measures 13.8 cm and the left kidney measures 13.5 cm.
RETROPERITONEUM: The aorta is of normal caliber and the visualized portion of
the IVC is within normal limits.
DOPPLER EXAMINATION: The main, right and left portal veins are patent with
hepatopetal flow. The hepatic veins are patent and demonstrate appropriate
waveforms. The IVC is patent. Appropriate arterial waveforms are seen in the
main hepatic artery. The splenic vein and SMV are patent in the midline and
demonstrate forward flow.
IMPRESSION:
1. Patent hepatic vasculature. No hepatic vein thrombus identified.
2. Heterogeneous hepatic architecture. No focal liver lesion identified.
3. Splenomegaly
4. No gallstones and no signs of cholecystitis. Several tiny polyps are
incidentally noted in the gallbladder.
Radiology Report
REASON FOR EXAMINATION: Sepsis and pneumonia, assessment to exclude
post-obstructive process.
COMPARISON: ___.
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen after administration of IV contrast. Axial images were reviewed in
conjunction with coronal and sagittal reformats.
FINDINGS:
Assessment of aorta and pulmonary arteries reveals no appreciable abnormality.
Heart size is normal. There is no pericardial or pleural effusion
demonstrated. The imaged portion of the upper abdomen demonstrates
splenomegaly, partially imaged and otherwise is unremarkable.
No axillary lymphadenopathy is seen. There are no lytic or sclerotic lesions
worrisome for infection or neoplasm demonstrated.
Assessment of the lung parenchyma demonstrates right upper lobe consolidations
and areas of ground glass, for example series 4, image 82, that appears to be
substantially more progressed as compared to prior study. There is no
evidence of endobronchial obstruction. There is evidence of bronchial wall
thickening and endobronchial secretions. The involvement of the lungs also
includes right middle lobe, right lower lobe with substantial
peribronchovascular tissue bilaterally and extensive amount of endobronchial
secretions in lower lobes bilaterally, highly concerning based on the
appearance for aspiration. There is also involvement of the anterior aspect
of the left upper lobe. All the findings are substantially worse than on the
prior study. No discrete masses worrisome for neoplasm demonstrated. There
is also no evidence of interstitial lung disease. The involvement of the lung
has substantially progressed between ___ and ___.
Differential diagnosis would include recurrent aspiration versus multifocal
pneumonia, but again the extensive amount of fluid in the lower lobe bronchi
posteriorly would favor first over the latter. The peribronchovascular tissue
is most likely consistent with reactive inflammation, but reassessment of the
patient after treatment for this presumably multifocal aspiration pneumonia is
required.
Several tracheal diverticula are noted in the upper portion of the trachea,
unchanged since prior examination and most unlikely of limited clinical
significance.
Gender: M
Race: HISPANIC/LATINO - CUBAN
Arrive by UNKNOWN
Chief complaint: Fever, Dyspnea
Diagnosed with FEVER, UNSPECIFIED, RESPIRATORY ABNORM NEC
temperature: 102.6
heartrate: 118.0
resprate: 28.0
o2sat: 93.0
sbp: 97.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | BRIEF SUMMARY
=============
___ y/o M with HIV (CD4 500, VL undetectable) on Atripla, CVID
with outpatient IVIG transfusions (last one 2 weeks ago), and
h/o recurrent pneumonias and bronchiectasis who was seen by his
PCP on AM ___ with fever, productive sputum, likely recurrent
PNA.
ACTIVE ISSUES
===============
# Sepsis ___ pneumonia - Patient was diagnosed with pneumonia ___
early ___ and was treated with 10 days of levofloxacin.
Unfortunately, he presented to his primary care doctor with
fever, productive sputum, mild shortness of breath. CXR on ___
showed interval worsening of RUL and RML heterogeneous opacities
concerning for worsening/new atypical pneumonia. The patient
presented to the ED with fever to 102.6 on floor, tachycardia to
118, BP of 97/59 but not requiring any oxygen. Labs were notable
for WBC at 9.4 with 81% neutrophils. Urinalysis and urine
culture were negative. The patient was started on empiric
vancomycin/cefepime given his history of common variable
immunodeficiency and recurrent pneumonias (see below) and
infectious disease was consulted on ___. The patient had
subjective improvement of his symptoms on the morning of ___
and defervesced. Urine legionella was checked and found to be
negative on ___. Sputum culture from ___ started growing 2+
gram-positive cocci. The patient received CT chest ___, which
did not show post-obstructive process. There was concern for
aspiration but the patient did not have any clinical evidence of
this. Blood cultures from ___, as well as surveillance and
mycolytic blood cultures from ___ remained negative on the day
of discharge. On ___, the patient was de-escalated from
cefepime to ceftriaxone due to lower likelihood of pseudomonas
___ the setting of sputum culture findings. On ___, the patient
was discharged with a total of 14-day course of IV ceftriaxone
per infectious disease. He received a midline for administration
of IV ceftriaxone and was discharged with 9 additional days
(last dose ___, which he will receive at the outpatient
pheresis center.
# Hepatic vein thrombosis - Patient had hepatic vein thrombosis
___ ___, thought to be secondary to romiplostim for ITP and
was started on Lovenox. ___ ___, he was readmitted with fevers
and jaundice where MRCP demonstrated worsening cirrhosis and
evolving hepatic vein/IVC thrombosis. Patient states that he
self-dc'd Lovenox because he had persistently developed
cellulitis at the site of his shots. He had previously been
followed by Dr. ___ ___ ___, who at the time recommended
lifelong anticoagulation for now and repeat MRI ___ months to
evaluate for clot. However, patient had not received follow-up
for this since then. He was documented to have elevated
transaminitis ___ ___. During this hospitalization, he
underwent abdominal US with doppler on ___, which was negative
for hepatic vein thrombosis. Per further discussion via email
with Dr. ___ on ___, an MRI was recommended for further
evaluation of hepatic vein thrombosis. Dr. ___ voiced that
the patient would likely have recurrence and would require
lifelong anti-coagulation. The medical team contacted Dr.
___, for input on whether Xarelto or other oral
anti-coagulants could be used ___ place of Lovenox. She
recommended ___ consultation, which was performed on ___.
The patient was scheduled for MRI to evaluate for thrombosis but
unfortunately the study was unable to be performed due to
scheduling issues prior to discharge. The patient will require
an outpatient MRI. Pending results, he may require
anti-coagulation with Xarelto.
# Transaminitis - Patient presented with elevated transaminases,
which has been previously documented ___ his outpatient labs of
the years, likely secondary to hepatic vein thrombosis (see
above). Looking through OMR, the patient has had viral hepatitis
serologies ___ the past, which showed immunity to Hepatitis B,
negative Hepatitis C, and prior exposure to Hepatitis A but no
active infection. Autoimmune work-up was sent during this
hospitalization and negative. Patient will require outpatient
MRI to further evaluate for hepatic vein thrombosis. Should this
be negative for clot, drug-induced liver injury should be a
consideration as a cause of his transaminitis.
# Eosinophilia - Patient noted to have eosinophilia to
approximately 8% on differential on ___, which was
re-demonstrated on ___. He was not noted to have this on
admission. This may be ___ the setting of receiving vancomycin
and cefepime during this hospitalization. Patient will require
repeat CBC with differential at his outpatient appointment with
Dr. ___. to ensure resolution of eosinophilia.
# Hyperlactatemia - Patient had slightly elevated at 2.2 on
admission labs. Likely ___ dehydration ___ the setting of high
fevers. The patient received IVF and repeat lactate on ___ was
1.1.
# Hyponatremia - Patient on admission labs had Na of 132, most
likely ___ to dehydration ___ the setting of high fevers. Repeat
labs on ___ demonstrated resolution with normal Na of 138 after
receiving IVF.
CHRONIC ISSUES
==============
# HIV - Patient has had undetectable viral load ___ and
absolute CD4 count 556 ___ ___. He was continued on Atripla
during this hospitalization.
# CVID - Stable. Patient gets monthly IVIG infusions, last one
___.
# Depression - Stable. Patient was continued on home citalopram
and Wellbutrin.
TRANSITIONAL ISSUES
=====================
# Patient was found to have eosinophilia to 9.2 during this
hospitalization. Patient needs CBC with differential at his
follow-up with Dr. ___ on ___ to evaluate for resolution of
eosinophilia.
# MRI abdomen to evaluate for hepatic thrombus, pending results
of MRI he may require rivaroxaban. If MRI is negative, consider
drug-induced liver injury from anti-retrovirals or other
outpatient medicines as an explanation of his elevated LFTs.
# Patient needs hypercoagulable work-up given prolonged PTT.
However, he has been on heparin SC while inpatient. Please see
___ consult note ___ OMR for further details.
# Ceftriaxone 2g q24h to be administered at ___ with
last dose on ___.
# CODE: Full code
# CONTACT: ___, partner (___) |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with primary mediastinal lymphoma s/p 6 cycles
of dose adjusted R-EPOCH in ___ with residual disease (CHL)
now s/p ICE who is admitted from the ED with chills, low grade
temperatures and nasal congestion.
Patient reports about 3 days of nasal congestion and rhinitis
with clear discharge. He was seen in ___ clinic on ___,
and was otherwise feeling well. However, after getting home at
3pm, he noted chills. He checked his temperature and it was
99.7. Chills continued and his temperature fluctuated from mid-
99's up to 100.2. He has a mild ___ headache. No visual
changes. No ST. No CP, SOB, or cough. He remains quite active.
No N/V. Mild constipation, last BM this am. No dysuria. No new
rashes. No new joint pains or leg swelling. He reports some
close contacts with cold symptoms.
In the ED, initial VS were pain 0, T 98.6, HR 125, BP 135/99, RR
17, O2 100%RA. Initial labs were notable for WBC 7.2 (ANC 4390),
HCT 40.8, PLT 112, NA 139, K 3.8, HCO3 28, Cr 1.0, UA negative,
rapid flu swab negative. CXR showed no acute process. No
interventions were performed. VS prior to transfer were pain 4,
T 97.9, HR 76, BP 132/84, RR 18, O2 99%RA.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
PAST ONCOLOGIC HISTORY:
Patient with roughly 6 months of symptoms including weight loss
night sweats and pruritus with tachycardia leading into a GI
evaluation ___. An MRCP that was performed for the
evaluation of a history of necrotic pancreatitis demonstrated a
large mediastinal mass. CT imaging confirms the presence of a
massive mediastinal mass. The tumor extended into the left
axilla. Biopsy from that site demonstrated diffuse large B-cell
lymphoma. Patient was initiated on therapy with EPOCH as an
inpatient. Rituximab was deferred given the concern for tumor
flare in the mediastinum.
- EPOCH C1 ___
- DA-R-EPOCH dose level 2 (Rituxan on last day of chemo) ___
- DA-R-EPOCH dose level 3 ___
- DA-R-EPOCH dose level 4 ___
- DA-R-EPOCH dose level 4 ___- Vincristine cap at 2mg
- DA-R-EPOCH dose level 4 ___- Vincristine cap at 2mg
- ___ PET-CT shows residual FDG-avid disease
- ___: Right video assisted thoroscopy mediastinal lymph
node biopsy which ultimately came back positive for classical
hodgkin's lymphoma with no residual evidence for viable DLBCL.
- ___: C1D1 ICE
Past Medical History:
- Pancreas divisum
- Acute pancreatitis with necrosis s/p necrosectomy in ___
- GERD
- Nephrolithiasis
- Arrhythmia
Social History:
___
Family History:
Mother and father with hypertension. No known family history of
leukemia or lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=================================
VS: T 99.1 HR 113 BP 142/83 RR 18 SAT 93% O2 on RA
GENERAL: Pleasant, well appearing man, lying in bed comfortably
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regularly irregular rate, tachycardic, no
murmurs, rubs, or gallops; 2+ radial pulses, 2+ DP pulses
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN III-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
DISCHARGE PHYSICAL EXAM:
==================================
VS: T 99.1 HR 113 BP 142/83 RR 18 SAT 93% O2 on RA
GENERAL: Pleasant, well appearing man, lying in bed comfortably
EYES: Anicteric sclerea, EOMI
ENT: Oropharynx clear without lesion
CARDIOVASCULAR: Tachycardic, regular rhythm, no murmurs, rubs,
or gallops; 2+ radial pulses, 2+ DP pulses
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN III-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
Pertinent Results:
ADMISSION LABS:
=======================
___ 10:30AM BLOOD WBC-7.3# RBC-4.42* Hgb-13.1* Hct-38.5*
MCV-87 MCH-29.6 MCHC-34.0 RDW-12.3 RDWSD-38.7 Plt ___
___ 10:30AM BLOOD Neuts-64 Bands-2 Lymphs-13* Monos-9 Eos-0
Baso-0 ___ Metas-10* Myelos-2* AbsNeut-4.82 AbsLymp-0.95*
AbsMono-0.66 AbsEos-0.00* AbsBaso-0.00*
___ 10:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
___ 10:30AM BLOOD Plt Smr-LOW* Plt ___
___ 10:30AM BLOOD UreaN-10 Creat-0.9 Na-140 K-4.3
___ 10:30AM BLOOD Glucose-98
___ 10:30AM BLOOD ALT-44* AST-36 LD(LDH)-241 AlkPhos-129
TotBili-0.2
___ 10:30AM BLOOD Albumin-4.4 Calcium-9.6 Phos-3.4 Mg-2.2
UricAcd-5.2
DISCHARGE LABS:
=======================
___ 04:34AM BLOOD WBC-7.7 RBC-4.08* Hgb-12.1* Hct-35.7*
MCV-88 MCH-29.7 MCHC-33.9 RDW-12.3 RDWSD-39.0 Plt Ct-88*
___ 04:34AM BLOOD Neuts-80* Bands-0 Lymphs-5* Monos-14*
Eos-0 Baso-0 ___ Myelos-1* AbsNeut-6.16*
AbsLymp-0.39* AbsMono-1.08* AbsEos-0.00* AbsBaso-0.00*
___ 04:34AM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+*
Macrocy-NORMAL Microcy-1+* Polychr-1+* Spheroc-1+* Ovalocy-1+*
Tear Dr-OCCASIONAL
___ 04:34AM BLOOD Glucose-149* UreaN-7 Creat-1.0 Na-137
K-4.1 Cl-97 HCO3-27 AnGap-13
___ 04:34AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1
MICROBIOLOGY:
=======================
BLOOD/URINE CX NEGATIVE, RESPIRATORY PANEL NEGATIVE, FLU PCR
NEGATIVE
IMAGING:
=======================
___ CXR:
FINDINGS:
Lungs are fully expanded and clear. No pleural abnormalities.
Heart size is
normal. Cardiomediastinal and hilar silhouettes are
unremarkable - extensive
mediastinal lymphadenopathy previously seen on CT is not
appreciated. A dual
lumen right IJ central venous Port-A-Cath tip projects over the
right atrium.
IMPRESSION: No evidence of an acute cardiopulmonary abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. colesevelam 625 mg oral BID
2. Creon ___ CAP PO QID PRN meals and snacks
3. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia
4. Nortriptyline 10 mg PO QHS
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
6. Acyclovir 400 mg PO Q8H
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Ondansetron ODT 4 mg PO Q8H:PRN nausea
10. Filgrastim 480 mcg SC ASDIR
11. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Medications:
1. Filgrastim 480 mcg SC ASDIR
2. Acyclovir 400 mg PO Q8H
3. colesevelam 625 mg oral BID
4. Creon ___ CAP PO QID PRN meals and snacks
5. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Nortriptyline 10 mg PO QHS
8. Ondansetron ODT 4 mg PO Q8H:PRN nausea
9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Viral Sinusitis
Primary mediastina lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiographs
INDICATION: ___ with infectious work-up.
TECHNIQUE: Frontal and lateral views of the chest
COMPARISON: Chest radiographs between ___ and ___
FINDINGS:
Lungs are fully expanded and clear. No pleural abnormalities. Heart size is
normal. Cardiomediastinal and hilar silhouettes are unremarkable - extensive
mediastinal lymphadenopathy previously seen on CT is not appreciated. A dual
lumen right IJ central venous Port-A-Cath tip projects over the right atrium.
IMPRESSION:
No evidence of an acute cardiopulmonary abnormality.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Weakness
Diagnosed with Fever, unspecified
temperature: 98.6
heartrate: 125.0
resprate: 17.0
o2sat: 100.0
sbp: 135.0
dbp: 99.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with Hodgkin's lymphoma and primary
mediastinal lymphoma who presented with 1 day of low grade fever
(max 100.2F) and chills consistent with an upper respiratory
infection, likely viral in nature.
# Low-grade temperatures
# Chills
# Nasal congestion/rhinitis: No documented fever but chills, low
grade temps, and nasal congestion/rhinitis c/f acute URTI. No
other clear infectious symptoms. Young children at home with
cold-like symptoms. Flu swab negative, additional respiratory
viral panel pending. He likely has as viral process. He had no
fevers while inpatient and was able to be discharged with
follow-up.
# Primary mediastinal lymphoma
# Classical Hodgkin's lymphoma: SP 6 cycles EPOCH for
mediastinal
DLBCL. Now with residual classical Hodgkin's lymphoma. SP C1 ICE
with plan for second cycle followed by auto-SCT consolidation.
He
has recovered his counts from prior ICE cycle and is no longer
on
neupogen or levoflox ppx. He was continued on home Bactrim and
acyclovir ppx.
# Tachycardia:
Patient has history of bigeminal PVC's and sinus tachycardia.
EKG in ED showed sinus tach with PVC's. He is asymptomatic.
Appears similar to outpatient rates. Pt states that this is his
baseline. Home metoprolol was continued.
# History of pancreatitis: Continued home creon.
# Biopsychocial
- Cont home nortyptiline
- Cont home ativan |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
transferred from OSH for posterior mediastinal air seen on CT
following MVC
Major Surgical or Invasive Procedure:
___ - Chest tube placement (OSH)
History of Present Illness:
___ M orthopedic surgeon restrained driver of ___ presents with
chest pain and concern for thoracic injury on imaging. MVC
rollover with extraction from vehicle, went to OSH, transferred
to ___ with right rib fractures, right PTX and mediastinal
air, concerning for possible esophageal injury. Chest tube
placed at OSH.
Past Medical History:
HTN, Asthma, R shoulder surgeries, Left thumb UCL repair, ___ -
cervical laminotomy/foraminotomy, ___ - C5-C7 left cervical
surgery
Social History:
___
Family History:
NC
Physical Exam:
On discharge:
VSS
Gen - NAD, AO x 3
Heart - RRR
Chest - dressing on right chest at site of previous chest tube
c/d/i
Lungs - CTAB
Abd - soft, NT, ND
Extrem - ~6 cm clean laceration on right forearm, no edema
Musculoskel - no TTP C-spine or back, full ROM
Neuro - CN II -XII intact, sensory and motor intact b/l
Pertinent Results:
___ 10:00PM BLOOD WBC-9.8 RBC-4.49* Hgb-14.3 Hct-41.4
MCV-92 MCH-31.8 MCHC-34.4 RDW-12.7 Plt ___
___ 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
----
___ - CXR: small right apical pneumothorax
___ - XR Right fore-arm: 2 small relatively radiopaque
structures projecting over the lateral
subcutaneous tissues of the distal forearm. These could
potentially represent radiopaque foreign bodies, the exact
location of which is uncertain and may be superficial in nature.
Repeat exam after removal of overlying gauze could be
performed.
___ - CT C-Spine (OSH) ___ read:
1. No acute fracture or traumatic malalignment.
2. Degenerative changes, most prominent at C5-C6.
3. Small left apical pneumothorax.
___ - CT head (OSH) ___ read: No acute intracranial process
___ - CT Torso (OSH) ___ read:
1. Small bilateral pneumothoraces and small bilateral
non-hemorrhagic pleural effusions.
2. Small amount of air in the posterior mediastinum.
3. Minimally displaced fractures of the right seventh, eighth
and ninth posterior ribs and medial right fifth rib.
4. Deformity at the T2-T3 level, which may represent a
compression fracture or degenerative changes imaged out of
plane. Due to lack of reformats on this outside study,
recommend a repeat chest CT for further evaluation.
___ CT Chest:
1. Expanding right pneumothorax. Consider advancing chest tube
as side-hole is at the chest wall.
2. Small left pneumothorax.
3. Small bilateral pleural effusions, slightly increasing on
the left.
4. Very subtle lucency involving the T2 vertebral body which
may represent a fracture but no evidence of loss of height,
retropulsion or canal compromise.
___ - Barium swallow: No extravasation of contrast.
___ - CXR s/p change in CT position: Resolution of right
apical pneumothorax since 4 hours prior.
___ - CXR s/p water seal: No significant change in from 7
hours prior, with no residual pneumothorax.
___ - CXR s/p chest tube removal: No residual right
pneumothorax after chest tube removal.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxazosin 4 mg PO HS
2. Atorvastatin 20 mg PO DAILY
3. Tamsulosin 0.4 mg PO HS
4. Aspirin 325 mg PO DAILY
5. dutasteride *NF* 0.5 mg Oral Daily
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. dutasteride *NF* 0.5 mg Oral Daily
4. Doxazosin 4 mg PO HS
5. Tamsulosin 0.4 mg PO HS
6. Acetaminophen 1000 mg PO Q8H
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
right rib fractures ___, right pneumothorax s/p chest tube,
small left pneumothorax, possible T2 vertebral body fx vs.
degenerative changes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Question esophageal injury. History of MVC.
COMPARISON: CT chest from ___.
FINDINGS: Multiple fluoroscopic images were obtained while the patient
ingested thin barium in the supine position inclined approximately 30 degrees
in the AP, right and left oblique views. There is no extravasation of
contrast. Chest tube visualized in the left lower pleural space.
IMPRESSION: No extravasation of contrast.
Radiology Report
HISTORY: Change in chest tubes positioned evaluate change in pneumothorax.
COMPARISON: ___.
FINDINGS:
Chest tube remains overlying the right lower lung. The right apical
pneumothorax has resolved. Multiple right posterior rib fractures are better
visualized than on prior radiograph. Left basilar atelectasis is unchanged
from prior. Unchanged cardiomediastinal silhouette.
IMPRESSION:
Resolution of right apical pneumothorax since 4 hours prior.
Radiology Report
HISTORY: Right pneumothorax after chest tube to water seal.
COMPARISON: ___ at 209.
FINDINGS:
Right chest tube remains in unchanged position. No pneumothorax is present.
Unchanged left basilar atelectasis. Stable cardiomediastinal silhouette. No
pleural effusion.
IMPRESSION:
No significant change in from 7 hours prior, with no residual pneumothorax.
Radiology Report
INDICATION: ___ male status post MVC and right pneumothorax, status
post right chest tube removal.
COMPARISON: Chest radiograph done earlier today at 9:58 a.m.
PA AND LATERAL CHEST RADIOGRAPHS: No residual right pneumothorax is seen
after chest tube removal. The cardiomediastinal and hilar contours are
stable. Small-to-moderate left pleural effusion is stable with minimal left
basilar atelectasis. Posterior rib fractures involving seventh through ninth
ribs are unchanged.
IMPRESSION:
No residual right pneumothorax after chest tube removal.
Radiology Report
INDICATION: History of MVC with chest pain. Evaluate for thoracic injury.
Possible fracture of T2 vertebral body seen on outside hospital chest CT.
COMPARISON: CT of the torso from ___ from ___.
TECHNIQUE: MDCT axial imaging was obtained through the chest without the
administration of intravenous contrast material in 5- and 1.25-mm axial
slices. Coronal and sagittal reformats were completed. Axial maximum
intensity projection images were completed.
FINDINGS: The thyroid gland is unremarkable. No enlarged supraclavicular,
axillary or mediastinal lymph nodes. The heart and pericardium are
unremarkable. There is no pericardial effusion. There is some mild
atherosclerotic calcification involving the coronary arteries, the aortic
valve and the thoracic aorta. The right pneumothorax has increased in size
since the prior study. There is a chest tube in place with the sidehole right
at the chest wall. Associated subcutaneous emphysema is seen in the right
posterior chest wall. A small left pneumothorax is still present. Locules of
air in the posterior mediastinum persist. There is no focal consolidation.
There are small bilateral pleural effusions, slightly increased on the left
since the prior study. There is atelectasis at the bases bilaterally. The
airways are patent to the subsegmental levels.
This study is not tailored for evaluation of subdiaphragmatic structures, but
demonstrates no acute process.
OSSEOUS STRUCTURES: Again seen are fractures of the seventh, eighth and ninth
right posterior ribs, which are minimally displaced. There is subtle linear
lucency seen in the T2 vertebral body in the superior endplate which may
represent a fracture. There is no loss of height, retropulsion or canal
compromise. Degenerative changes are noted in the lower thoracic spine.
IMPRESSION:
1. Expanding right pneumothorax. Consider advancing chest tube as side-hole
is at the chest wall.
2. Small left pneumothorax.
3. Small bilateral pleural effusions, slightly increasing on the left.
4. Very subtle lucency involving the T2 vertebral body which may represent a
fracture but no evidence of loss of height, retropulsion or canal compromise.
5. Rib fractures of the right seventh, eighth and ninth posterior ribs.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P MVC
Diagnosed with TRAUM PNEUMOTHORAX-CLOSE, FRACTURE THREE RIBS-CLOS, INTERSTITIAL EMPHYSEMA, MV COLLISION NOS-DRIVER, OPEN WOUND OF FOREARM
temperature: 100.5
heartrate: 88.0
resprate: 18.0
o2sat: 98.0
sbp: 130.0
dbp: 62.0
level of pain: 2
level of acuity: 2.0 | Dr. ___ was transferred from an OSH with a right-sided
chest tube and concern for mediastinal air on imaging. His
chest tube was repositioned with resolution of his pneumothorax.
His chest tube was put to water- seal and no pneumothorax was
seen on CXR. His chest tube was pulled on ___ with no
pneumothorax seen on post-pull chest x-ray. His pain was
controlled with oral pain medication, and his posterior ___
right rib fractures remained stable.
A barium swallow was negative for extravisation, and the patient
tolerated a regular diet.
He was seen by ortho-spine for a T2 compression fracture vs.
degenerative changes seen on CT. Since he ambulated without
pain or difficulty, no intervention was recommended. If the
patient develops pain, he will follow up with this PCP for an
MRI.
He was seen by OT who noted impaired recall/ delayed memory.
The patient was educated about post-concussion syndrome.
On discharge, the patient was tolerating a regular diet,
voiding, and ambulating without difficulty. He was discharged
with follow-up in ___ clinic and CXR in 10 days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
chlorthalidone / spironolactone
Attending: ___
Chief Complaint:
leg swelling and SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of diastolic/valvular CHF, PAF, chronic
asymptomatic bradycardia, RBBB, CKD (baseline Cr 1.5-2.0),
controlled DMII who presents with increasing shortness of breath
and worsening fluid retention over the past few days with weight
gain of ___.
Most of history obtained from wife. She reports over last ___
weeks he has been having more trouble breathing while lying flat
at night. Increased leg swelling and increasing fatigue.
Worsening abdominal girth and leg swelling. Denies chest pain
and nausea. No diaphoresis. + cough last few days. Was not
lightheaded until today. Has been compliante with home diuretic
torsemide 40mg daily. Over the weekend, his weight suddenly
increased and over the last 48hrs very minimal urine output
which had never happened before. No dysuria, hematuria, or
urinary incontinence.
Of note, had been seen on ___ by his PCP. Recent colonoscopy
on ___ (tolerated well). At his ___ PCP visit reported wt up
to 150lbs (dry weight around 145lbs) and worsening leg
edema/orthopnea. Cr at that time was 1.8 with BUN 61. BNP 1426.
PCP increased his torsemide from 40mg to 80mg daily. Not
effective because today pt called PCP reporting inability to
void x 24hrs with weight up to 157lbs, so referred to the ER.
In the ED, initial vitals were 96.0 38 113/33 12 98%. Labs and
imaging significant for renal worsening with BUN 105 (baseline
40-60) and Cr 3.7 (baseline 1.5-2.0). Baseline HCO3 is ___,
currently much lower at 21. Trop 0.03. Plts 93 slightly below
low baseline. Brady to ___, but EKG unchanged from prior and
also noticed to be brady in that range on cardiology visit in
___. CXR showed significant new R sided pleural effusion
compared to prior. Difficult to elucidate if cardiac size
enlarged. Film for compare from ___. Exam consistent with
diffuse anterior wheezing and dullness on R side. Bedside
ultrasound - no pericardial effusion; bladder with small amount
of urine.
Due to K of 5.9, pt was given kayexylate. ABG with no Co2
retention, no acidosis, lactate normal. Given 160mg IV lasix x 1
with minimal output (50cc) and given his home levothyroxine
(75mcg) and warfarin (2mg). Pt reports not taking any of his
home medications today.
On arrival to the floor, patient is comfortable. He triggered
for bradycardia (HR briefly 39, range 40-50s). He states his
baseline is ___. No chest pain. He is arrousable, conversant,
warm extremities, strong pulses, SBP 140s. UO 400cc output to
160mg IV lasix.
Past Medical History:
Historical Cardiovascular Issues - Cardiology Note ___:
1. 3+ aortic regurgitation, trileaflet valve (CMR ___ with
borderline dilated left ventricular cavity size (by TTE). Low
normal left ventricular function. 2+ by TTE.
2. Hypertension/mild LVH. Metoprolol, furosemide, quinapril,
nifedipine, metolazone.
3. Chronic right bundle-branch block.
4. Dyslipidemia, simva 10 mg: 3.12: TC120/Tr34/H90/L23.
5. Paroxysmal atrial fibrillation, asymptomatic. On Coumadin.
6. Diabetes type 2, diet-controlled, HbA1c 5.8 in 7.12.
7. Moderate aortic root dilation (4.5 cm on TTE)
8. Probable CAD: extensive Ca++ on CT scan, 10.10.
9. Chronic congestive heart failure, diastolic.
Other Medical Issues:
-Chronic kidney disease, stage III-IV (___),? IgA
nephropathy.
-Left posterior parietal CVA, s.p. TPA ___.
-Prostate adenocarcinoma ___, s.p. CyberKnife ___, T2a.
-Beta-thalassemia trait.
-Hypothyroidism.
Social History:
___
Family History:
Father died of an MI at age ___
Physical Exam:
Admission Exam:
VS- 96.8 rectal, 141/46, 63, 14, 95%2L
GENERAL- NAD. Oriented x3. Mood, affect appropriate. Mildly
sleepy at times but easily arrousable
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa, has tear
production. No xanthalesma.
NECK- Supple with JVP of 9 cm.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. Has S3. systolic murmur left sternal
border.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Deacreased breath
sounds in lefto lower base. No crackles.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- No c/c/e. No femoral bruits.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES- strong pulses
Right: Carotid 2+ radial 2+
Left: Carotid 2+ radial 2+
Discharge Exam:
98.2, 122/45, 41, 18, 95%ra
Wt: 69.6->66.1kg->66.2-->68.2
Gen: nad, comfortable
Cardiac: RRR, systolic and diastolic murmurs
Pulm: no crackles, clear today
Abd: soft, non distended
Ext: edema up to upper shins
Pertinent Results:
Echo ___:
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is at least
15 mmHg. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is mildly dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. Mild to
moderate (___) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___,
findings are similar.
___ CXR:
IMPRESSION: Increased right mid and low lung opacity could
represent
consolidation or effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 0.25 mcg PO ___, WED, ___
___
2. Carvedilol 12.5 mg PO BID
hold SBP<100, HR<50
3. Finasteride 5 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. NIFEdipine CR 120 mg PO DAILY
HOLD SBP<100
6. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >
7. Quinapril 40 mg PO BID
hold SBP<100
8. Simvastatin 10 mg PO DAILY
9. Torsemide 40 mg PO DAILY
10. Warfarin 1 mg PO DAILY16
11. Vitamin D 800 UNIT PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Calcitriol 0.25 mcg PO ___, WED, ___
___
2. Finasteride 5 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Simvastatin 10 mg PO DAILY
6. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*2
7. Vitamin D 800 UNIT PO DAILY
8. Warfarin 1 mg PO DAILY16
9. PredniSONE 20 mg PO DAILY Duration: 3 Days
Tapered dose - DOWN
RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*3
Tablet Refills:*3
10. Outpatient Lab Work
Basic Metabolic Panel, INR
Dx: Acute heart failure
Please Fax results to Dr ___ ___
11. NIFEdipine CR 90 mg PO BID
RX *nifedipine 90 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic diastolic heart failure
Acute gout attack
Bradycardia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.\nActivity Status:
Ambulatory
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath. Rule out acute process.
TECHNIQUE: Portable AP upright view of the chest was obtained.
COMPARISON: Chest radiograph from ___, and MR ___ ___..
FINDINGS: There is increased opacity in the right mid and low lung, which
could represent effusion or consolidation of the right middle lobe. There is
no pneumothorax. The cardiomediastinal silhouette is unchanged. There is
atherosclerotic calcification of the aorta. Bony structures appear intact.
IMPRESSION: Increased right mid and low lung opacity could represent
consolidation or effusion.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: FLUID RETENTION
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, CARDIAC DYSRHYTHMIAS NEC, CONGESTIVE HEART FAILURE, UNSPEC
temperature: 96.0
heartrate: 38.0
resprate: 12.0
o2sat: 98.0
sbp: 113.0
dbp: 33.0
level of pain: 0
level of acuity: 1.0 | ___ with history of diastolic/valvular CHF, MR, AR, TR, PAF,
chronic asymptomatic bradycardia, RBBB, CKD (baseline Cr
1.5-2.0), DMII who is admitted for acute on chronic diastolic
heart failure.
# Acute on chronic diastolic heart failure: Etiology of this
exacerbation is not clear, enzymes neg x 2, echo unchanged, TSH
wnl. Pt did admit to some dietary indiscretion as well as a
recent colonoscopy prep that can occasionaly have a high salt
load. Improved with lasix gtt. Cardiac enzymes neg x2. Was
diuresed ___ Liters daily and had improved pedal edema and renal
failure. Quinapril was held in setting of acute renal failure.
Echo performed showed no interval change from prior. Discharge
weight 68Kg.
# RHYTHM: Pt had slow Atrial fibrillation, HR 35-55 range,
asymptomatic. Carvedilol was stopped. Coumadin 1mg daily
continued, therapeutic INR throughout hospitalization.
# Acute Renal Failure: Pt with CKD (Cr baseline 2.1) secondary
to possible IgA nephropathy. Admission Cr is 3.8 concerning for
ARF. Urine lytes consistent with pre-renal etiology. ARF likely
secondary to acute diastolic heart failure with poor forward
flow. Lasix gtt improved Cr from 3.8->3.2->2.7->2.5->2.9. His
ACE-I was held inhouse in setting of ARF (continued to be held
at discharge). Continued on calcitriol. SPEP/UPEP negative
(tested in setting of ARF and anemia).
# HTN: BP elevated to 180s during admission in setting of
holding ACE-I. He was given nifedipine 90mg BID which improved
BPs.
#Gout: Had podagra in left and right side. Similar to prior gout
attacks. Since his symptoms involved 2 joints he was treated
systemically with prednisone. Given prednisone 30mg x 3
days->20mg x1->10mg x1->stop. At time of discharge he had
completed 3 days of the prednisone 30mg.
#Hyponatremia: hypervolemic hyponatremia in setting of ARF and
heart failure. Resolved with diuresis.
# Pancytopenia: pt with mild pancytopenia. Chronic since
___. Differential includes: MDS ___ in elderly
patient), medications such as sulfas can do this, viruses
although that would have likely resolved by now. Currently
asymptomatic. CBC stable throughout admission. Would benefit
from outpatient hematology consultation.
#HLD: Continued home simva 10mg. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year old man with a PMHx of HLD and
increasing weakness since ___ in the setting of multiple
traumatic injuries, with recent diagnosis of ALS by EMG, who
presents with SOB for the past two weeks, acutely worsening over
the past 24 hours. For the past two weeks, he has been unable to
speak in full sentences, but feels fairly comfortable if lying
still. Last night, he became more SOB at rest which prompted his
presentation to the ED.
Per patient's wife, ___ was perfectly healthy until this past
___, when he fell down 9 stairs as he leaned to pet their new
puppy and hit his head on concrete. He did not have LOC, but did
sustain a large area of swelling on his head. About ___ weeks
later, he again fell off a ladder at 12 feet. He hit his head,
but did not lose consciousness. He didn't seek medical attention
for either of these events. After this second fall, his wife
starting noticing some weakness in his hands, but at this time
he didn't have any speech difficulties. Shortly after this fall
in ___, he had an episode of loss of memory for about ___
hours, and was diagnosed with transient global amnesia. MRI
brain and c-spine at that time were normal per report.
In ___ ___ had a ___ fall in the shower. He fell backwards and
again hit his head. After this fall, it seems he became weaker
in his hands, his speech became more slurred (wife can't tell me
when the slurred speech started), and his balance seemed worse.
More recently at the end of ___, patient had a follow up
with his PCP who checked labs and found that his CPK was
elevated. Because of this, his PCP sent him to the ED; at the ED
he was transferred to ___. According to his
wife, ___ was initially admitted to the ICU with concerns for
his breathing, and there they monitored him, did an EMG but no
other neuroimaging, diagnosed him with ALS and discharged him
with home nursing services and a follow up ___.
He presented to ___ on ___ due to two weeks of worsening
shortness of breath to the point where he could no longer speak
in full sentences. He was evaluated in the ED and subsequently
admitted to the ICU on ___ due to concerns of respiratory
status. He was later transferred to the ___ the next day as
his respiratory status remained stable.
Past Medical History:
HLD
Depression
? ALS
Social History:
___
Family History:
No family history of ALS or other neurodegenerative disease.
Physical Exam:
ADMIT PHYSICAL EXAMINATION
==========================
Vitals: T97.6 HR 60 BP 120/76 RR 18 SaO2 96% RA
General: Awake, appears uncomfortable lying in bed
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W. Some
supraclavicular retrations with breathing at rest, more
pronounced with speech. Can count to 4 in one breath.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Takes breaths in between
every other word, becoming very short of breath with
conversation. Able to answer historical questions with one word
answers but wants wife to do the talking. Pt was able to name
both high and low frequency objects. Speech very 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. Does not bury sclera bilaterally. Some breakdown of
smooth pursuits.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric. Eye closure
slightly weak, buries eyelashes but can be opened by examiner.
Can puff out cheeks with air and maintain. Maintaining open jaw
strong. Tongue pouching in cheeks strong bilaterally.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically. Gag reflex present.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Decreased bulk, normal tone throughout. Atrophy of
interosseous muscles and anatomical snuffbox bilaterally.
Fasiculations noted in the bilateral upper extremities
left>right, as well as bilateral legs. No fasciulations
appreciated in the trunk or on the tongue. When assisted to
sitting up can maintain sitting on his own.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4- 4+ 4+ ___ 2 4+ 4+ 5 5 5 5 5
R 4- 4+ 4+ ___ 2 4+ 4+ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 3
R 3 3 3 3 3
Plantar response was extensor bilaterally. Crossed adductors
present bilaterally. Suprapatellar reflexes present bilaterally.
Pectoral jerks present bilaterally. Jaw jerk present.
-Coordination: slow tapping of fingers bilaterally because of
weakness.
-Gait: When helped to standing, can walk, with short stride and
does not lift feet much off the ground.
DISCHARGE PHYSICAL EXAM:
========================
Pertinent Results:
ADMISSION LABS:
===============
___ 05:15PM CK(CPK)-555*
___ 01:12PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 01:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 01:12PM URINE RBC-6* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:12PM URINE AMORPH-OCC*
___ 06:23AM ___ PO2-76* PCO2-39 PH-7.42 TOTAL CO2-26
BASE XS-0 COMMENTS-GREEN TOP
___ 05:40AM GLUCOSE-94 UREA N-20 CREAT-0.7 SODIUM-144
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
___ 05:40AM estGFR-Using this
___ 05:40AM ALT(SGPT)-56* AST(SGOT)-55* ALK PHOS-69 TOT
BILI-0.3
___ 05:40AM LIPASE-21
___ 05:40AM cTropnT-<0.01
___ 05:40AM ALBUMIN-4.4 CALCIUM-9.6 PHOSPHATE-4.1
MAGNESIUM-2.0
___ 05:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:40AM WBC-8.2 RBC-4.30* HGB-13.8 HCT-39.5* MCV-92
MCH-32.1* MCHC-34.9 RDW-12.7 RDWSD-42.4
___ 05:40AM NEUTS-52.6 ___ MONOS-9.9 EOS-4.6
BASOS-0.7 IM ___ AbsNeut-4.32 AbsLymp-2.57 AbsMono-0.81*
AbsEos-0.38 AbsBaso-0.06
___ 05:40AM PLT COUNT-212
___ 05:40AM ___ PTT-26.8 ___
IMAGING:
=======
+ ___ CXR: Low lung volumes. Retrocardiac opacity likely
represents atelectasis, although superimposed consolidation is
difficult to exclude.
+ ___ MRI C/T spine:
1. Study is mildly degraded by motion.
2. No evidence of syrinx formation or spinal cord lesion.
3. Extensive spondylotic changes of the lumbar spine most
significant from
L2-L3 through L4-L5 where there is multilevel severe vertebral
canal narrowing resulting in crowding of the cauda equina nerve
roots. There is also multilevel severe bilateral neural
foraminal narrowing.
4. Spondylotic changes of the cervical spine most significant at
C4-C5 where there is mild vertebral canal narrowing and
moderate to severe bilateral neural foraminal narrowing.
5. Mild degenerative changes of the thoracic spine at T8-T9
where there is
mild vertebral canal narrowing.
6. 4 mm right iliac bone non-enhancing probable bone island.
+ ___ C MRI Head:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality.
3. No evidence of brainstem abnormality.
4. Paranasal sinus disease, as described.
5. 6 mm Tornwaldt cyst.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PARoxetine 20 mg PO DAILY
2. Simvastatin 10 mg PO QPM
Discharge Medications:
1. riluzole 50 mg oral BID
RX *riluzole [Rilutek] 50 mg 1 tablet(s) by mouth twice a day
Disp #*180 Tablet Refills:*2
2. PARoxetine 20 mg PO DAILY
3. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ALS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Video oropharyngeal swallow.
INDICATION: ___ year old man with ALS. Baseline video swallow.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 4 min 40 sec
COMPARISON: None
FINDINGS:
There is penetration of nectar thick and thin liquids secondary to delayed
closure of range of S tibial. There is intermittent aspiration with thin
liquid there is decreased with the chin tuck maneuver. There is a small
amount of pharyngeal residue from weakness.
There is no obstruction.
IMPRESSION:
Intermittent penetration and aspiration of thin liquids and intermittent
penetration of nectar thick liquids.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
INDICATION: ___ year old man with diagnosis of ALS dysphagia, evaluate for
consolidation.
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Retrocardiac opacification likely represents atelectasis in the setting of low
lung volumes, superimposed consolidation is difficult to exclude. There is no
pleural effusion, pulmonary edema, or pneumothorax. The cardiomediastinal
silhouette is within normal limits.
IMPRESSION:
Low lung volumes. Retrocardiac opacity likely represents atelectasis,
although superimposed consolidation is difficult to exclude.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with possible ALS, bulbar weakness, upper and
lower extremity fasciculations, hyperreflexia.// Evaluate for syrinx,
multifocal cord lesion, subdural, high cervical or brainstem lesion.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON None.
FINDINGS:
Study is mildly degraded by motion. There is no evidence of hemorrhage,
edema, masses, mass effect, midline shift or infarction.
The major intracranial vascular flow voids are preserved. The ventricles and
sulci are normal in caliber and configuration. There is moderate mucosal
thickening of the ethmoid air cells and mild mucosal thickening of the
maxillary sinuses and left sphenoid sinus. A 6 mm Tornwaldt cyst is noted.
The right mastoid air cells are hypoplastic, possibly congenital. The orbits
are normal.
IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality.
3. No evidence of brainstem abnormality.
4. Paranasal sinus disease, as described.
5. 6 mm Tornwaldt cyst.
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE
INDICATION: ___ year old man with possible ALS, bulbar weakness, upper and
lower extremity fasciculations, hyperreflexia.// Evaluate for syrinx,
multifocal cord lesion, subdural, high cervical or brainstem lesion.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of 9 mL of Gadavist contrast
agent, additional axial and sagittal T1 images were obtained.
COMPARISON: None.
FINDINGS:
Study is mildly degraded by motion.
CERVICAL:
There is straightening of the cervical lordosis. Vertebral body heights are
preserved. There is no marrow signal abnormality.
The visualized portion of the spinal cord is preserved in signal and caliber.
There is reduced T2 signal within the intervertebral discs extending from
C2-C3 through C5-C6, likely on a degenerative basis.
There is no evidence of infection or neoplasm. There is no prevertebral soft
tissue swelling.
The visualized portion of the posterior fossa and cervical medullary junction
are preserved.
At C2-3 there are facet osteophytes resulting in mild right neural foraminal
narrowing. No vertebral canal narrowing or left neural foraminal narrowing.
At C3-4 there is disc bulging and uncovertebral osteophytes resulting in
moderate to severe right and moderate left neural foraminal narrowing. No
vertebral canal narrowing.
At C4-5 there is disc bulging and a superimposed central disc protrusion as
well as uncovertebral osteophytes resulting in mild vertebral canal narrowing
and moderate to severe bilateral neural foraminal narrowing.
At C5-6 there is disc bulging and uncovertebral osteophytes resulting in mild
vertebral canal narrowing and moderate bilateral neural foraminal narrowing
(left greater than right).
At C6-7 there is disc bulging and a superimposed central disc protrusion with
well as uncovertebral osteophytes resulting in mild vertebral canal narrowing,
moderate left and mild right neural foraminal narrowing.
At C7-T1 there are facet osteophytes resulting in moderate left and mild right
neural foraminal narrowing. No vertebral canal narrowing.
THORACIC:
There is straightening of the lumbar spine and a 2 mm retrolisthesis at L4-5.
Vertebral body heights are preserved. There is an 8 mm T1/T2 hyperintense
lesion that suppresses on STIR images at the left T7 transverse process that
likely represents focal fatty marrow. There is otherwise no marrow signal
abnormality.
The visualized portion of the spinal cord is preserved in signal and caliber.
The conus medullaris terminates at the level at T12-L1.
There is multilevel disc height/signal loss most significant at L4-L5.
There is no paravertebral or paraspinal mass identified and there is no
evidence of infection or neoplasm.
At T8-T9 there is disc bulging, a superimposed central disc protrusion as well
as ligamentum flavum thickening resulting in mild vertebral canal narrowing.
There is no neural foraminal narrowing. There are small facet osteophytes and
a left facet joint effusion.
The remaining levels of the thoracic spine are without vertebral canal or
neural foraminal narrowing.
LUMBAR:
Vertebral body alignment is preserved. Vertebral body heights are preserved.
There are multilevel degenerative endplate signal changes most significant at
L1-L2. There is focal fatty marrow in the L1 vertebral body.
Grossly homogeneous approximately 4 mm T1, T2, and T1 postcontrast hypointense
right iliac bone lesion is noted (see 20, 21, 23:37).
The visualized portion of the spinal cord is preserved in signal and caliber.
The conus terminates at the level of T12-L1.
There is multilevel disc height/signal loss most significant from L2-L3
through L4-L5, likely on a degenerative basis.
There is no paravertebral or paraspinal mass identified and there is no
evidence of infection or neoplasm.
At T12-L1 there symmetric disc bulging, ligamentum flavum thickening and facet
osteophytes resulting in mild vertebral canal narrowing and mild right neural
foraminal narrowing. No left neural foraminal narrowing.
At L1-2 there is symmetric disc bulging, ligamentum flavum thickening and
facet osteophytes resulting in moderate vertebral canal narrowing and moderate
to severe bilateral neural foraminal narrowing.
At L2-3 there is symmetric disc bulging, ligamentum flavum thickening and
facet osteophytes resulting in moderate to severe vertebral canal narrowing
with crowding of the cauda equina nerve roots and severe bilateral neural
foraminal narrowing.
At L3-4 there is symmetric disc bulging, ligamentum flavum thickening and
facet osteophytes resulting in moderate to severe vertebral canal narrowing
with crowding of the cauda equina nerve roots and severe bilateral neural
foraminal narrowing (left greater than right).
At L4-5 there is symmetric disc bulging, ligamentum flavum thickening and
facet osteophytes resulting in mild vertebral canal narrowing and severe
bilateral neural foraminal narrowing..
At L5-S1 there is symmetric disc bulging and facet osteophytes with moderate
to severe bilateral neural foraminal narrowing. No vertebral canal narrowing.
OTHER: A 1.1 cm T2 hyperintense lesion within the right kidney is compatible
with a small cyst. A 7 mm T2 hyperintense lesion within the right hepatic
lobe is incompletely evaluated but likely represents a hepatic cyst. The
visualized portion of the lungs demonstrate mild dependent atelectasis.
IMPRESSION:
1. Study is mildly degraded by motion.
2. No evidence of syrinx formation or spinal cord lesion.
3. Extensive spondylotic changes of the lumbar spine most significant from
L2-L3 through L4-L5 where there is multilevel severe vertebral canal narrowing
resulting in crowding of the cauda equina nerve roots. There is also
multilevel severe bilateral neural foraminal narrowing.
4. Spondylotic changes of the cervical spine most significant at C4-C5 where
there is mild vertebral canal narrowing and moderate to severe bilateral
neural foraminal narrowing.
5. Mild degenerative changes of the thoracic spine at T8-T9 where there is
mild vertebral canal narrowing.
6. 4 mm right iliac bone nonenhancing probable bone island.
Gender: M
Race: PORTUGUESE
Arrive by AMBULANCE
Chief complaint: Difficulty swallowing, Weakness, Transfer
Diagnosed with Dyspnea, unspecified, Weakness
temperature: 97.6
heartrate: 60.0
resprate: 18.0
o2sat: 96.0
sbp: 120.0
dbp: 76.0
level of pain: 9
level of acuity: 2.0 | This is a ___ year old male with a clinical and physiological
diagnosis of motor neuron disease (ALS) following a 6 month
course of progressive weakness, shortness of breath, and lingual
dysarthria. The patient and his wife were informed of this
diagnosis today and would like to proceed with experimental
treatment per the ___ clinic at ___ (appointment
scheduled for next week ___.
#Dyspnea
Admission exam is significant for prominent dyspnea with just a
few words of speech, prominent dysarthria, decreased gag reflex,
NIF -30, prominent weakness in the upper extremities, preserved
sensation all over, fasiculations in the arms L>R as well as
legs, and diffuse hyperreflexia. Acute worsening of dyspnea is
not thought to be due to infection as he had no leukocytosis,
fevers or consolidation. Possible aspiration event given history
of coughing when eating, although SLP evaluation without concern
for aspiration event. His NIF/VC were monitored Q4H and were
-60/3L respectively without desaturations. NIF/VC were switched
to Q6H on ___, with initial values of -80/2.29. His
respiratory status has remained stable throughout his
hospitalization and he did not need supplemental oxygen or other
respiratory support.
#Weakness with recent diagnosis ALS
He reports several month history of progressive weakness and
recent falls. He was reportedly diagnosed with ALS at ___.
Exam notable for jaw jerk, palmomental reflex, weakness in all
extremities, fasciculations throughout, and diffuse
hyperreflexia. Given that he has both upper and lower motor
neuron findings on exam as well as confirmatory report from EMG
performed at ___ on ___ support the diagnosis of ALS
this is the most likely diagnosis at this time. In discussion
with neuromuscular service the patient was started on Riluzole
50mg BID and will be enrolled in an experimental treatment
trial. He was evaluated by ___ during his hospitalization who
recommended home services on discharge.
MRI Brain unremarkable. MRI C spine with degenerative changes
but no severe canal stenosis. MRI L spine with degenerative
changes with compression of some cauda equina nerve roots but
would not explain his symptoms or bulbar and b/l arm weakness.
Video swallow evaluation ___ showed intermittent aspiration
with regular liquids. With swallowing strategies, speech
therapists felt that he was safe to continue with diet of thin
liquids with chin tuck and soft solids. Home nursing services
and physical therapy were resumed prior to discharge ___.
#Depression
Patient has a history of depression which is likely exacerbated
in the setting of his symptoms and current diagnosis. He was
restarted on his home dose of Paxil 10mg. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall; left basal ganglia IPH
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ is a pleasant ___ hx of Afib on Coumadin who
presents as transfer from OSH s/p fall down 5 stairs with
headstrike and LOC found to have multiple facial fractures and
IPH. He was reversed with Vit K and 1 unit FFP at OSH; INR was
1.4. He was then transferred to ___ for further neurosurgical
management. He was admitted to the ___ for close monitoring.
Past Medical History:
PMHx:
Afib, HTN, HL, COPD, prior stroke with residual R facial
weakness
PSHx:
unknown
Social History:
___
Family History:
Family Hx: non-contributory.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
Physical Exam:
T 98.3, HR 72, BP 140/70, RR 16, 95% RA
GCS at the scene: 15
GCS upon Neurosurgery Evaluation: 15
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam:
Gen: NAD, resting comfortable with C-collar in place
HEENT: R eyebrow with laceration, R periorbital edema and
ecchymosis
Neck: C-collar in place
Extrem: warm and well perfused, no edema. C/o R hip pain on
palpation
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5-2mm
bilaterally, brisk. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Slight R droop, sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
Sensation: Intact to light touch.
PHYSICAL EXAMINATION ON DISCHARGE:
Alert and oriented x3. Speech fluent and clear. Comprehension
intact.
PERRL 3-2mm bilaterally. Right orbital edema and ecchymosis.
CN II-XII grossly intact.
Motor examination ___ throughout all four extremities.
Sensation intact in all four extremities.
Pertinent Results:
Please see OMR for pertinent lab and imaging results.
Medications on Admission:
Coumadin, diltiazem ER 240mg daily, lisinopril 10mg daily,
simvastatin 10mg daily, HCTZ 25mg daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Left Intraparenchymal Hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS
INDICATION: History: ___ with multiple facial fractures of the right max and
sphenoid sinus after a fall// eval for better assessment of maxillary
fractures
TECHNIQUE: Helically-acquired multidetector CT axial images were obtained
through the maxillofacial bones and mandible. Intravenous contrast was not
administered. Axial images reconstructed with soft tissue and bone algorithm
to display images with 1.25 mm slice. Coronal and sagittal reformations were
also constructed. All produced images were evaluated in production of this
report.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.2 s, 24.8 cm; CTDIvol = 26.1 mGy (Head) DLP = 646.1
mGy-cm.
Total DLP (Head) = 646 mGy-cm.
COMPARISON: Outside hospital CT head performed 5 hours early.
FINDINGS:
There is a comminuted fracture through the orbital surface of the right
greater wing of the sphenoid bone (2; 67, 72), extending through the superior
orbital fissure (series 2, image 73). Air is seen in the right superior
orbital fissure as well as the right masticator space (2; 73, 82). No
definite hematoma or soft tissue stranding involving the right orbital apex.
There is a fracture through the right palatine bone on the inferomedial aspect
of the right maxillary sinus (2; 98), extending through the wall greater
palatine nerve canal, as well as of the right maxilla constituting the floor
of the right maxillary sinus.
A subtle lucency through the right pterygoid body (series 2, image 85-86) is
concerning for a fracture in this clinical context. No definite fracture
through the pterygoid plates.
Apparent diastasis/fracture through the right zygomatic arch at the
zygomaticotemporal suture (series 2, image 63). The left zygomatic arch
appears intact.
There is opacification of the right maxillary sinus with hyperdense fluid with
an air-fluid level consistent with hemorrhage.
There is a small preseptal periorbital hematoma.
There is no evidence of abnormal fluid collections.
Bilateral mastoids appear normal.
The globes, extraocular muscles, optic nerves, and retrobulbar fat appear
normal.
The visualized upper aerodigestive tract appears normal.
The mandible and temporomandibular joints appear normal.
Air in the right cavernous sinus likely corresponds to recent line placement
(3; 76).
Parenchymal hemorrhage involving the left corona radiata and basal ganglia is
re-identified, better evaluated on outside hospital CT head of ___.
IMPRESSION:
1. Comminuted fracture through the orbital surface of the right sphenoid
greater wing as well as a fracture through the right maxilla on the floor of
the right maxillary sinus into the right palatine bone. There is linear
lucency through the right pterygoid body suspicious for a nondisplaced
fracture in this clinical context. There is also apparent diastasis/possible
fracture through the right zygomatic arch at the zygomaticotemporal suture.
2. The fracture through the right palate involves the canal for the greater
palatine nerve.
3. Air is seen within the right supraorbital fissure as well as the right
masticator space. The right orbital apex demonstrates no large hematoma or
soft tissue stranding.
4. Small right periorbital hematoma.
5. Opacification of the right maxillary sinus and sphenoid sinuses with
hyperdense fluid consistent with blood products.
6. Additional findings described above.
NOTIFICATION: The changes from initial wet read detailed in impression 1,
including subtle linear lucency through the right pterygoid body concerning
for fracture and possible diastasis/fracture of the right zygomatic arch were
discussed with Dr. ___. by ___, M.D. on the telephone on
___ at 9:50 am, 20 minutes after discovery of the findings.
Radiology Report
INDICATION: History: ___ with with IPH multiple facial fractures also has
right hip pain// Eval for right hip fracture
COMPARISON: None
IMPRESSION:
No acute fractures or dislocations are seen. Bilateral hip joint spaces are
preserved. There is normal osseous mineralization.There are moderate
degenerative changes of the lower lumbar spine with spurring.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man s/p fall down 5 stairs with multiple facial
fractures and L IPH// assess for etiology
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
COMPARISON: CT head without contrast ___.
FINDINGS:
No significant change in size of the 1.8 cm focus of intraparenchymal
hemorrhage adjacent to the body of the left lateral ventricle with associated
susceptibility artifact, slow diffusion and mild surrounding edema. The
hemorrhage extends toward the left putamen. A couple tubular foci of
enhancement on the periphery of the bleed are favored to represent blood
vessels from luxury reperfusion. Trace hemorrhage in the left occipital horn
(series 14, image 11) is noted. In addition, there is punctate focus of
gradient echo susceptibility in the right parietal temporal lobe (series 14,
image 13), potentially representing microhemorrhage.
There are mild nonspecific subcortical and deep white matter T2/FLAIR
hyperintensities that can be seen in the setting of chronic small vessel
disease. A couple small foci of increased signal on diffusion-weighted images
in the superior right frontal lobe are without corresponding abnormality on
the ADC map or T2/FLAIR images and are favored to represent artifacts, with
subacute infarct considered less likely given lack of corresponding FLAIR
signal..
The major intracranial vascular flow voids are maintained. Prominence of the
ventricles and cerebral sulci can be seen in the setting age related
involutional changes. Mild mucosal thickening is present within the right
maxillary sinus. The orbits and mastoid air cells are normal.
Please refer to the prior CT maxillofacial for details of the patient's facial
fractures.
IMPRESSION:
1. No significant change in size of the focus of intraparenchymal hemorrhage
adjacent to the body of on left lateral ventricle. A couple tubular foci of
enhancement surrounding the hemorrhage are favored to represent vessels from
luxury perfusion. Consider obtaining a follow-up MRI with contrast after
resolution to rule out abnormal enhancement.
2. Mild nonspecific subcortical and deep white matter T2/FLAIR
hyperintensities can be seen in the setting of chronic small vessel disease.
3. Generalized parenchymal volume loss is likely age related.
4. No evidence of acute infarct. A few scattered punctate foci of
diffusion-weighted hyperintense signal without corresponding ADC hypointensity
or associated FLAIR signal abnormality in the right frontal lobe are
considered artifactual.
5. Additional findings described above.
Radiology Report
EXAMINATION: MRA NECK WANDW/O CONTRAST T9716 MR NECK
INDICATION: Intraparenchymal head bleed.
TECHNIQUE: Axial T1 weighted fat saturated imaging was performed through the
neck. Two dimensional time-of-flight MRA was performed without contrast
administration.
Dynamic MRA was performed during infusion of 15 cc MultiHance intravenous
contrast.
Three dimensional maximum intensity projection images were generated. This
report is based on interpretation of all of these images.
COMPARISON: None.
FINDINGS:
Allowing for mild motion artifact and slightly suboptimal phase of contrast
bolus, the common, internal and external carotid arteries appear normal.
There is no evidence of stenosis of the cervical internal carotid arteries by
NASCET criteria. The origins of the great vessels, subclavian, and vertebral
arteries appear normal bilaterally. The common carotid bifurcations appear
normal.
IMPRESSION:
Unremarkable MRA neck.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with leukocytosis, confusion. Evaluate for PNA.//
Evaluate for PNA Evaluate for PNA
IMPRESSION:
No comparison. Bilateral parenchymal opacities at both the left and the right
lung base, with air bronchograms, highly suggestive of pneumonia in the
appropriate clinical setting. Borderline size of the heart. No signs of
pulmonary edema. No pleural effusions. Healed right clavicular fracture.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ICH, s/p Fall, Transfer
Diagnosed with Contus/lac/hem crblm w LOC of 30 minutes or less, init, Oth fracture of base of skull, init for clos fx, Fall on same level, unspecified, initial encounter, Maxillary fracture, right side, init, Laceration w/o fb of right eyelid and periocular area, init
temperature: 98.3
heartrate: 72.0
resprate: 16.0
o2sat: 95.0
sbp: 140.0
dbp: 70.0
level of pain: unable
level of acuity: 2.0 | The patient was admitted to the ___ with a left IPH on the day
of admission, ___ for close neurologic monitoring.
#IPH:
The patient was admitted on ___ with a left basal ganglia IPH.
The appearance of the hemorrhage was not typical for trauma,
differential etiology includes hypertensive hemorrhage versus
cavernoma versus ischemic stroke with hemorrhagic conversion. A
MRI/A was performed which showed abnormal enhancement or
vascular malformation. He will follow-up in 1-month for a repeat
MRI/A. The Stroke Neurology team was consulted who will see the
patient in follow-up in 2-weeks from the date of discharge.
During his hospital stay he remained neurologically intact on
examination. He was transferred from the ___ to the
Neuroscience floor during his hospitalization. He was evaluated
by the Physical Therapy service and was cleared for a discharge
to home.
# Facial fractures, right eyebrow laceration:
The patient was evaluated by the Plastic Surgery service and it
was determined he was not a surgical candidate. He was started
on a three day course of Bacitracin. He will follow-up with the
Plastic Surgery service in ___ weeks from the date of discharge.
#Right orbital fracture:
The patient was evaluated by Ophthalmology on ___ and was
noted to have a normal eye exam given the right orbital
fracture. The patient will follow-up with the Plastic Surgery
service in ___ weeks from the date of discharge.
#Right Hip pain:
The patient reported right-sided hip pain upon admission. He
underwent a Right Hip x-ray which was negative for fracture.
#Atrial Fibrillation:
The patient has Afib at baseline. The Coumadin was held in the
setting of the IPH. He remained rate controlled during this
hospitalization. Diltiazem was continued throughout his
hospitalization. The patient will follow-up with his
cardiologist, ___, MD in 2-weeks. He will remain off
of the Coumadin until seen in follow-up.
#Hypertension:
The patient was continued on his home antihypertensive
medications Lisinopril and Hydrochlorothiazide and his blood
pressure remained controlled throughout his hospitalization.
#Dispo planning:
The patient was evaluated by physical therapy and occupational
therapy and was cleared for a discharge to home. |
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:
___ F w/abdominal pain beginning ~30 hours prior to
presentation, did not remember where the pain began, but
localized to the right lower quadrant. It was associated with
mild nausea, no vomiting, no change in bowel or bladder habits.
LMP was approximately 3 weeks prior. At the time of exam she
says
her pain has essentially resolved and currently has an appetite.
Past Medical History:
Past Medical History: Cystic Fibrosis
Past Surgical History: none
Social History:
___
Family History:
Family History: no history of crohns/IBD
Physical Exam:
Admission Physical Exam:
Vitals: afebrile, stable vitals
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Regular rhythm
PULM: unlabored respirations
ABD: Soft, non-distended, mild TTP to deep palpation in RLQ, no
rebound or guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
98.0 71 100/50 20 95%RA
Gen: NAD, alert, responsive
Pulm: CTAB
CV: RRR
Abd: soft, nontender, nondistended
Ext: no c/c/e
Pertinent Results:
___ 09:38PM LACTATE-1.8
___ 09:10PM GLUCOSE-85 UREA N-3* CREAT-0.5 SODIUM-142
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16
___ 09:10PM estGFR-Using this
___ 09:10PM ALT(SGPT)-45* AST(SGOT)-34 ALK PHOS-157* TOT
BILI-0.4
___ 09:10PM LIPASE-5
___ 09:10PM ALBUMIN-4.2 CALCIUM-9.4 PHOSPHATE-4.4
MAGNESIUM-2.2
___ 09:10PM WBC-9.3 RBC-5.23 HGB-15.4 HCT-45.9 MCV-88
MCH-29.5 MCHC-33.6 RDW-12.2
___ 09:10PM NEUTS-71.5* ___ MONOS-5.1 EOS-2.6
BASOS-0.3
___ 09:10PM PLT COUNT-271
___ 09:10PM ___ PTT-34.3 ___
___ 08:42PM URINE HOURS-RANDOM
___ 08:42PM URINE HOURS-RANDOM
___ 08:42PM URINE UCG-NEGATIVE
___ 08:42PM URINE GR HOLD-HOLD
___ 08:42PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
Medications on Admission:
Medications: hypertonic saline nebulizers
Discharge Medications:
1. Hyper-Sal (sodium chloride) 3.5 % inhalation BID
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right lower quadrant pain. Assess for ovarian pathology
including evidence of torsion.
COMPARISON: None.
LMP: ___.
FINDINGS: The uterus is normal in size, measuring 5.3 x 2.5 x 4.6 cm. The
endometrial stripe is normal in thickness, measuring 12 mm. Within the right
ovary, there is a 3.9 x 3.5 x 4.0 cm thin-walled anechoic structure,
consistent with a simple cyst. The ovaries are otherwise normal. Normal
arterial and venous Doppler waveforms are seen within both ovaries. There is
a small-to-moderate quantity of simple free fluid in the pelvis, more than
expected physiologically.
Focused sonographic evaluation of the right lower abdominal quadrant using a
linear transducer does not demonstrate the appendix.
IMPRESSION:
1. Small-to-moderate quantity of simple free fluid in the pelvis, more than
expected physiologically.
2. 4 cm simple cyst within the right ovary requires no imaging followup,
although possibly could be causing the patient's right lower quadrant pain.
3. Appendix not seen. Given the aforementioned free fluid in the pelvis, if
there is concern for acute appendicitis clinically, further evaluation with CT
is recommended.
Radiology Report
INDICATION: Right lower quadrant pain. Assess for appendicitis, ovarian
pathology, or other pathology.
COMPARISON: Pelvic ultrasound from ___.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following the administration of 130 cc of intravenous Omnipaque contrast
material. Multiplanar reformats were performed.
TOTAL DLP: 337 mGy-cm.
ABDOMEN CT: There is subsegmental lingular atelectasis as well as minimal
right lower lobe atelectasis. Mosaic attenuation throughout both lung bases
could relate to expiratory phase of acquisition. Note is made of mucus
plugging within left lower lobe bronchi.
The liver is diffusely hypoattenuating, consistent with fat deposition. No
focal hepatic lesions are identified. There is no intrahepatic or
extrahepatic biliary duct dilatation. The portal vein is patent. The
gallbladder, spleen, and adrenal glands are normal. Subcentimeter renal
hypodensities are too small to characterize, but are statistically simple
cysts. The kidneys are otherwise unremarkable. The pancreas is nearly
completely replaced with fat. The stomach, small bowel, and colon are
unremarkable. The appendix is increased in caliber measuring up to 12 mm, and
contains high density material, likely inspissated mucous (2:72, ___.
There is no periappendiceal fat stranding. There is no evidence of free air
in the abdomen or periappendiceal fluid collection. Several prominent
pericecal lymph nodes are noted, none of which meet CT size criteria. The
abdominal aorta is normal in caliber.
PELVIS CT: The bladder is unremarkable. Note is made of a subseptate
configuration of the uterus (2:83). There is a 3.4 cm right adnexal cyst,
better seen on the recent ultrasound from ___. No left adnexal
abnormalities are seen. There is a small quantity of simple free fluid in the
pelvis.
BONE WINDOW: No suspicious lytic or blastic lesions are identified.
IMPRESSION:
1. Enlarged appendix containing high density material, likely inspissated
mucous. No periappendiceal fat stranding. The constellation of these
findings can be considered normal for certain patients with a history of
cystic fibrosis. Acute appendicitis is therefore thought unlikely. See
reference: TM Fields, et al. Abdominal Manifestations of Cystic Fibrosis in
Older Children and Adults. AJR Am J Roentgenol. ___ ___.
2. Hepatic steatosis, near-complete fatty replacement of the pancreas, and
left lower lobe mucus plugging, compatible with known history of cystic
fibrosis.
3. 3.4 cm right ovarian cyst, better seen on recent ultrasound from ___. No imaging followup is necessary.
4. Small quantity of simple free fluid in the pelvis.
Updated findings were discussed with Dr. ___ by Dr. ___ at 8:58 a.m.
via telephone on ___.
Gender: F
Race: WHITE
Arrive by OTHER
Chief complaint: RLQ abdominal pain, PELVIC PAIN
Diagnosed with ABDOMINAL PAIN RLQ
temperature: 98.0
heartrate: 94.0
resprate: 18.0
o2sat: 100.0
sbp: 109.0
dbp: 75.0
level of pain: 10
level of acuity: 2.0 | ___ is a ___ year old female with abdominal pain
that had largely resolved upon presentation to the hospital.
However, CT scan was consistent with acute appendicitis. Given
the poor correlation between her exam and imaging, she was
hospitalized on ___ for observation.
Her vital signs were routinely monitored, as was her pain level.
Her abdominal exam was also monitored. She had minimal pain
during her hospitalization, and denied any additional nausea or
vomiting. Upon discharge, she was tolerating regular diet. She
denied any pain, nausea, or vomiting. She was ambulating
independently. She had normal bowel function, and was voiding
without difficulty. She was discharged with instructions to
follow-up with her primary care provider within one week, and in
the acute care surgery clinic in two weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall with headstrike
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Approx ___ yo F witnessed fall 4 feet onto train tracks.
Bystanders witnessed patient to be acting strangely and then
stumble off platform onto tracks, approx 4 feet. Bystanders
jumped down to assist and pulled her off the tracks. EMS
initiated and brought patient to ___ ED.
Past Medical History:
unknown
Social History:
___
Family History:
Unknown, non-contributory
Physical Exam:
Exam on Admission:
T: 98.2 HR:97 BP:141/88 RR:15 Sat:99% RA
Gen: lethargic, falls asleep during exam
HEENT: occipital laceration
Neck: cervical collar in place
Extrem: tracks bilat UE with injection sites on left arm
Neuro:
Mental status: Lethargic, initially opens eyes to tactile
stimulation only but after Narcan administration opens eyes to
voice
Orientation: Oriented to person only
Language: Speech unclear, minimal verbal
Exam on Discharge:
Pertinent Results:
___ 09:03PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-POS mthdone-NEG
___ 08:54PM LACTATE-1.2
___ 08:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ CT C-spine
No evidence of fracture dislocation. Findings which may suggest
some degree of fluid overload.
___ ___
Counter-coup injury with extensive left frontal subarachnoid
hemorrhage with subdural hematoma and temporal lobe contusion.
Mild rightward shift of midline structures. Right parietal
subgaleal hematoma with non-displaced right parietal fracture.
___ CT torso
No evidence of acute traumatic injury in the torso.
___ ___
1. Stable left subarachnoid hemorrhage and subdural hemorrhage
with suggestion of redistribution of blood products along the
posterior falx and the left temporal convexity.
2. New hyperdensity seen in sulci of the right frontal lobe
concerning for new subarachnoid hemorrhage.
3. Stable left inferior frontal hemorrhagic contusion.
4. Stable nondisplaced left parietal bone fracture.
5. Slightly enlarged right parietal subgaleal hematoma.
6. Stable, 4 mm rightward shift of the normally midline
structures.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
11:42 AM
IMPRESSION:
1.Increased pattern of vasogenic edema is identified in the left
fontal and temporal lobe surrounding the hemorrhagic contusions,
with unchanged midline shifting of the normal midline
structures towards the right.
2. Additionally there is persistent subdural hematoma on the
right tentorial reflection.
Medications on Admission:
Unknown
Discharge Medications:
1. CloniDINE 0.1 mg PO TID
2. Doxepin HCl 100 mg PO QHS:PRN insomnia
3. Famotidine 20 mg PO BID
4. Gabapentin 800 mg PO TID
5. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*1
6. Lorazepam 0.5 mg PO Q4H:PRN anxiety
7. QUEtiapine Fumarate 100 mg PO QHS
8. Codeine Sulfate ___ mg PO Q4H:PRN headache
hold for rr < 12, or oversedation, do not drive
RX *codeine sulfate 15 mg ___ tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
L SDH, traumatic SAH
Discharge Condition:
neurologically intact
alert to person/place/time
strength and sensation intact
pupils were equal and reactive
face symetric
speech clear
patient ambulation and talking on the phone independently
without difficulty.
Followup Instructions:
___
Radiology Report
EXAMINATION:
CT HEAD W/O CONTRAST
INDICATION: History: ___ with fall from train platform with head trauma,
intoxicated, ?abd. pain // eval trauma
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 891 mGy-cm; CTDI: 53 mGy
COMPARISON: None.
FINDINGS:
There is substantial subarachnoid hemorrhage along left frontal convexities.
In addition, there are two areas of extra-axial hemorrhage, overlying the left
temporal lobe (02:13) and left temporal-frontal lobes (2: 18) extending
approximately 4 mm from the inner table at greater width. Two small
hemorrhagic contusions are present in the anterior left frontal lobe. A
subgaleal hematoma is noted over the right occipital lobe with a non-displaced
right parietal bone fracture. Relatively white matter hypodense in areas
affected by trauma in the left frontal lobe suggests parenchymal edema. A
small amount of subarchnoid hemorrhage lies anterior to the midbrain, probably
from redistribution. There is 7 mm shift of the normally midline structures
toward the right side. The uncus intrudes minimally into the suprasellar
cistern. There is considerable streak artifact obscuring the anterior margin
of the left frontal lobe but there is some suspicious for small contusions and
foci of subarchnoid hemorrhage. There is no hydrocephalus. There is a large
nasal septal defect. Visualized paranasal sinuses and mastoid air cells are
clear.
IMPRESSION:
Counter-coup injury with extensive left frontal subarachnoid hemorrhage with
subdural hematoma and temporal lobe contusion. Mild rightward shift of
midline structures. Right parietal subgaleal hematoma with non-displaced
right parietal fracture.
Radiology Report
EXAMINATION: CT OF THE CERVICAL SPINE
INDICATION: Intoxication, head trauma and abdominal pain after fall from
train platform.
COMPARISON: None.
TECHNIQUE: Multidetector CT images of the cervical spine were obtained
without intravenous contrast. Sagittal and coronal reformations were also
performed.
DOSE: 749.4 mGy-cm.
FINDINGS:
The vertebral body heights and interspaces appear preserved. There is no
spondylolisthesis. The cervical spine curves slightly to the left, although
this may be positional. There is no evidence for fracture, dislocation or
bone destruction. Lung apices show thickening of interlobular septal
thickening, which could be seen with some degree of fluid overload, perhaps
after fluid resuscitation.
IMPRESSION:
No evidence of fracture dislocation. Findings which may suggest some degree of
fluid overload.
Radiology Report
INDICATION: History: ___ with fall from train platform with head trauma,
intoxicated, ?abd. pain // eval trauma
TECHNIQUE: CT of the Chest, Abdomen and Pelvis with IV contrast and without
oral contrast
DOSE: DLP: 536 mGy-cm
COMPARISON: None
FINDINGS:
CHEST:
Mediastinum and Heart: Within normal limits
Lungs: Within normal limits aside from minimal atelectasis
Vasculature: Within normal limits
ABDOMEN:
Liver: Within normal limits
Gallbladder: Within normal limits
Spleen: Within normal limits
Kidneys and Ureters: Within normal limits
Adrenals: Within normal limits
Pancreas: Within normal limits
Lymph Nodes: Within normal limits
Aorta and Branches: Within normal limits
Stomach: Within normal limits
Small Bowel: Within normal limits
Large Bowel: Within normal limits
Appendix: Within normal limits
Free Fluid: None
PELVIS:
Reproductive Organs: Within normal limits
Rectum: Within normal limits
Bladder: Within normal limits
Inguinal Region: Within normal limits
Lymph Nodes: Within normal limits
Free Fluid: None
BONES AND SOFT TISSUES: No suspicious blastic or lytic lesions. The superior
endplates of T5 through T8 show minimal loss in height but probably chronic.
IMPRESSION:
No evidence of acute traumatic injury in the torso.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: Left traumatic subarachnoid and subdural hemorrhage. Evaluate for
interval change.
TECHNIQUE: Contiguous axial images MDCT images of the brain were obtained
without intravenous contrast. Coronal and sagittal as well as thin
bone-algorithm reconstructed images were obtained.
DLP: 891 mGy-cm
COMPARISON: CT head from ___ at 21:36.
FINDINGS:
Since the prior CT, there has been redistribution of left frontotemporal
subarachnoid blood, with slightly more hemorrhage overlying the left temporal
lobe, extending 9 mm from the inner table (02:12). This may represent
redistribution. Hyperdensity along the posterior falx also likely represent
redistribution of blood products.
New since the prior study are subtle hyperdense foci seen within sulci of the
right frontal lobe, which may represent subarachnoid hemorrhage (601b:61).
Subarachnoid hemorrhage in the left cerebral hemisphere is unchanged.
Hyperdensity in the parenchyma of the left inferior frontal lobe (2:80) is
indicative of a hemorrhagic contusion. This is stable since the initial head
CT.
There is minimal rightward shift of normally midline structures, by 4 mm, not
significantly changed. Ventricular size is stable with no evidence of
hydrocephalus.
Nondisplaced left parietal bone fracture. Left parietal subgaleal hematoma is
slightly larger, measuring approximately 8 mm from the skull.
IMPRESSION:
1. Stable left subarachnoid hemorrhage and subdural hemorrhage with suggestion
of redistribution of blood products along the posterior falx and the left
temporal convexity.
2. New hyperdensity seen in sulci of the right frontal lobe concerning for new
subarachnoid hemorrhage.
3. Stable left inferior frontal hemorrhagic contusion.
4. Stable nondisplaced left parietal bone fracture.
5. Slightly enlarged right parietal subgaleal hematoma.
6. Stable, 4 mm rightward shift of the normally midline structures.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with traumatic SAH, SDH, complaining of HA //
eval for increase in hemorrhage, edema.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
CTDIvol: 54.63 mGy
DLP: 891.93 mGy-cm
COMPARISON: Head CT dated ___.
FINDINGS:
There is redistribution of blood products with residual subdural hematoma on
the left temporal region with edema. There is increase in the pattern of
vasogenic edema with 4 mm of midline shift. There is an additional region of
subdural hematoma along the right tentorial reflection. Frontal contusions
are again visualized. At the right parietal region there is soft tissue
swelling with adjacent surgical material. Left temporal parietal subarachnoid
hemorrhage remains relatively unchanged. No osseous abnormalities seen. The
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
orbits are unremarkable.
IMPRESSION:
1.Increased pattern of vasogenic edema is identified in the left fontal and
temporal lobe surrounding the hemorrhagic contusions, with unchanged midline
shifting of the normal midline structures towards the right.
2. Additionally there is persistent subdural hematoma on the right tentorial
reflection.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FALL
Diagnosed with TRAUM SUBARACHNOID HEM, TRAUMATIC SUBDURAL HEM, OPEN WOUND OF SCALP, 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 | The patient was admitted to ___ surgical intensive care unit
on ___ for management of her acute subdural hematoma and her
subarachnoid hemorrhage.
On ___, the patient had a repeat ___ which showed evolution
of a temporal intraparenchmal hemorrhage and repeated
subarachnoid hemorrhage which was stable. An attempt was made to
clinically clear her cervical collar, however, the patient
remained too lethargic to do reliably. She got several doses of
haldol for agitation.
___, the patient's identity was found and merged with her
previous files found in the ___ system. She was started on her
home doses of clonidine and gabapentin. HE clonidine dosage was
then reduced because of somulence. Transfer orders for the floor
were written.
On ___, patient was intact on exam. ___ evaluated the
patient. Social work determined that patient was safe for
discharge back to ___. However, OT was concerned
about patient's safety for discharge, and Psychiatry evaluated
the patient and deemed that she did not have capacity was not
safe for discharge.
On ___, the patient had increased headaches, but head CT shows
stable SDH and SAH. OT re-evaluated the patient and stated that
she was improving.
On ___ to ___,
The patient was independent for ambulation and ADLs. The
patient was neurologically intact. She states that she had
headache which was expected. Occupational therapy and
psychiatry evaluated the patient on ___ and deemed her
compentant. The patient was discharged. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / adhes. band-tape-benzalkonium / Vancomycin / Lipitor /
Benzalkonium
Attending: ___.
Chief Complaint:
LUQ pain
Major Surgical or Invasive Procedure:
Hemodialysis on ___
Diagnostic/therapeutic paracentesis 1L on ___
History of Present Illness:
Ms. ___ is a ___ with h/o ESRD ___ FSGS s/p DDRT (___) c/b
graft failure due to medication non-adherence now on HD (still
on tacro/pred), hx recurrent DVT (on warfarin), who presented to
___ ___ with severe LUQ abdominal pain and was transferred
to ___ after she was found to have new ascites.
Patient felt well on ___ evening (___) and went out to
celebrate her birthday (had three glasses of wine), but awoke
___ morning (___) with new sharp LUQ abdominal pain. She
thought at first it was gas and took Tums but the pain did not
improve. Pain is worse with movement. No alleviating factors. No
nausea or vomiting. No constipation, diarrhea, melena, or BRBPR.
No fever, chills, fatigue, weight loss or gain. Of note, she is
up-to-date on all cancer screening (negative colonoscopy ___ years
ago, Pap in early ___, mammogram ___.
She initially presented to ___ where CT A/P found new
ascites but no acute pathology. She was transferred to ___
because her transplant doctors are here.
In the ED, initial VS were: 97 58 131/103 19 94% RA
Exam notable for:
Large distended abdomen with positive fluid wave significant
tenderness to palpation in the left upper
Labs notable for:
- WBC 4.0, Hgb 9.8 (baseline ~7), Plt 166
- K 5.3, bicarb 26
- LFTs wnl except AP 249
- lactate 0.9
- INR 4.2
Studies notable for:
- CT with new ascites, hepatic steatosis and splenomegaly.
- RUQ U/S with patent but pulsatile flow of the main portal
vein, which may be due to right heart failure or tricuspid
regurgitation
- EKG: sinus at 59, normal axis, Q waves in II/F, no ST changes,
diffuse TW flattening
Consults:
- Renal Dialysis was consulted, planning for HD tomorrow ___
- Transplant Surgery recommended admission to Medicine for w/u
of new ascites
Patient received:
___ 18:49IVHYDROmorphone (Dilaudid) 1 mg
___ 21:23POTacrolimus 5 mg
___ 21:23POPredniSONE 5 mg
On arrival to the floor, patient reports ongoing ___ LUQ pain.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
PAST MEDICAL HISTORY:
#ESRD ___ FSGS - s/p ECD DDRT (___), c/b recurrent rejection
due
to medication non-adherence, now on HD via LUE AVG
#Recurrent DVTs - LLE, RIJ - on warfarin (at time non-adherent
in
past)
#HTN
#Anemia of chronic inflammation
#Obesity
#Right pleural effusion requiring thoracentesis
PAST SURGICAL HISTORY:
-ECD deceased donor renal transplant (___)
-Left upper extremity AV fistula x2
-Right subclavian dialysis catheter
-Peritoneal dialysis catheter
Social History:
___
Family History:
Renal failure - mother, cousin
___ cancer - father
___ cancer - maternal grandmother (age ___, great aunt (age
~___)
No uterine/ovarian, GI, or other cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=====================
VS: Reviewed, afebrile and hemodynamically stable.
General: Appears well, friendly and not in distress.
HEENT: No icterus or injection. MMM.
CV: RRR, no murmurs.
Resp: Normal work of breathing. CTAB.
Abd: Obese. Soft. Distended. Point tenderness over 1cm area in
LUQ. ___ sign. No rebound or guarding. NABS.
Extr: Warm, trace edema.
Neuro: Alert, oriented, intact attention and memory.
DISCHARGE PHYSICAL EXAM:
======================
VS: ___ 0321 Temp: 98.4 PO BP: 123/66 L Lying HR: 59 RR: 18
O2 sat: 96% O2 delivery: RA
Pre HD weight standing 94.3kg ___
General: Appears well, not in distress
HEENT: No icterus or injection. MMM.
CV: RRR, no murmurs.
Resp: Normal work of breathing. CTAB.
Abd: Obese. Soft. Distended. Point tenderness over 1cm area in
LUQ. ___ sign. No rebound or guarding. NABS.
Extr: Warm, no lower extremity edema.
Neuro: Alert, oriented, intact attention and memory.
Pertinent Results:
ADMISSION LABS:
=============
___ 05:52PM BLOOD WBC-4.0# RBC-3.60*# Hgb-9.8*# Hct-32.3*#
MCV-90 MCH-27.2 MCHC-30.3* RDW-17.4* RDWSD-57.2* Plt ___
___ 05:52PM BLOOD Neuts-55.3 ___ Monos-13.1*
Eos-3.7 Baso-0.7 Im ___ AbsNeut-2.23# AbsLymp-1.09*
AbsMono-0.53 AbsEos-0.15 AbsBaso-0.03
___ 06:38PM BLOOD ___ PTT-54.8* ___
___ 05:52PM BLOOD Ret Aut-2.0 Abs Ret-0.07
___ 05:52PM BLOOD Glucose-68* UreaN-38* Creat-6.4* Na-139
K-5.3* Cl-98 HCO3-26 AnGap-15
___ 05:52PM BLOOD ALT-5 AST-19 AlkPhos-249* TotBili-0.8
___ 05:52PM BLOOD Lipase-27 GGT-124*
___ 05:52PM BLOOD Albumin-3.9 Calcium-9.4 Phos-4.9* Mg-2.2
Iron-42
___ 05:52PM BLOOD calTIBC-238* VitB12-548 ___
TRF-183*
INTERVAL LABS:
============
___ 05:39AM BLOOD ___
___ 05:33AM BLOOD ___ PTT-51.6* ___
___ 07:24AM BLOOD ___
___ 05:05AM BLOOD ___
___ 12:44PM BLOOD ___
___ 03:27PM ASCITES TNC-797* RBC-2839* Polys-0 Lymphs-18*
___ Mesothe-57* Macroph-24* Other-1*
___ 03:27PM ASCITES TotPro-4.9 LD(LDH)-114 Albumin-2.6
DISCHARGE LABS:
=============
___ 05:24AM BLOOD WBC-4.6 RBC-3.55* Hgb-9.6* Hct-32.0*
MCV-90 MCH-27.0 MCHC-30.0* RDW-17.4* RDWSD-57.1* Plt ___
___ 05:24AM BLOOD ___
___ 05:24AM BLOOD Glucose-84 UreaN-25* Creat-5.8*# Na-144
K-4.9 Cl-101 HCO3-29 AnGap-14
___ 05:24AM BLOOD Calcium-9.3 Phos-5.1* Mg-2.1
MICROBIOLOGY:
============
___ 08:20PM STOOL HELICOBACTER ANTIGEN DETECTION,
STOOL-NEGATIVE
___ 3:27 pm PERITONEAL FLUID PERITONEAL FLUID.
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 (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ CULTUREBlood Culture,
Routine-FINALNO GROWTH
___ CULTUREBlood Culture,
Routine-FINALNO GROWTH
___ CULTUREBlood Culture,
Routine-FINALNO GROWTH
___ CULTUREBlood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram
Stain-FINAL
___ CULTUREBlood Culture,
Routine-FINALNO GROWTH
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tacrolimus 3 mg PO Q12H
2. Lanthanum 1000 mg PO TID W/MEALS
3. Labetalol Dose is Unknown PO TID
4. Warfarin 10 mg PO DAILY16
5. Omeprazole 20 mg PO DAILY
6. Lidocaine-Prilocaine 1 Appl TP PRN pre-HD
7. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H Duration: 7 Doses
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth DAILY
Disp #*7 Tablet Refills:*0
2. Warfarin 5 mg PO DAILY16 TAKE UNTIL YOUR INR IS CHECKED ON
___. ___. ___ WILL CALL YOU AND TELL YOU WHAT DOSE TO
TAKE.
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth DAILY Disp
#*15 Tablet Refills:*0
3. Labetalol 300 mg PO TID
RX *labetalol 300 mg 1 tablet(s) by mouth three times per day
Disp #*90 Tablet Refills:*0
4. Tacrolimus 1 mg PO Q12H
RX *tacrolimus 1 mg 1 capsule(s) by mouth every 12 hours Disp
#*30 Capsule Refills:*3
5. Lanthanum 1000 mg PO TID W/MEALS
6. Lidocaine-Prilocaine 1 Appl TP PRN pre-HD
7. Omeprazole 20 mg PO DAILY
8. PredniSONE 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left abdominal wall pain
Ascites
Moderate-severe tricuspid regurgitation
Moderate right ventricle dilation
Supra therapeutic INR
History of recurrent DVT on warfarin
Endstage renal disease on HD (___)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Ultrasound-guided paresis
INDICATION: ___ year old woman with ESRD with RLQ renal graft on
immunosuppressionwith new ascites; ddx includes right sided heart failure vs
occult malig vs infectionus// diagnostic
TECHNIQUE: Ultrasound guided paracentesis
COMPARISON: CT scan 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.
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 1 L of clear, straw-colored fluid was removed. Specimens
sent for requested labs, culture and cytology.
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. 1 L of fluid was removed.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Ascites, LUQ abd pain, Transfer
Diagnosed with Other ascites
temperature: 97.0
heartrate: 58.0
resprate: 19.0
o2sat: 94.0
sbp: 131.0
dbp: 103.0
level of pain: 7
level of acuity: 2.0 | ___ with h/o ESRD s/p failed renal transplant now on HD (still
on tacro/pred), admitted as a transfer from ___
with LUQ abdominal pain and new ascites. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lactose / gluten / iodine
Attending: ___
Chief Complaint:
facial numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ RH F with a history of HTN,
abdominal migraines, and PE who presents with right-sided eye
pain followed by right sided sensory changes and subjective
weakness. She reports that for the last few days, she has been
feeling weak and short of breath. She was seen two days ago at
an
OSH where a PE/CT was negative and improved after fluids. Last
night, at about midnight, she developed pain behind her right
eye
that she describes as a poking, pushing sensation radiating back
across her temple, worse with eye movements. She also has been
having a general sense of anxiety with occasional SOB. The pain
has been present throughout the day but does wax and wane in
intensity. At about 11:30am ___, she noticed gradually that she
felt numb throughout her right side; she has had this happen
once
before so did not get overly worried about this. Then, she
decided to check herself for "stroke symptoms" and noticed that
it took more effort to smile on the right side and her mouth was
slightly open, that she has more trouble moving objects with her
right hand and that she had a mild foot drag on the right. She
also noted a sense of swelling in her right face. She called a
friend and felt like her speech was slightly slurred, but the
friend did not comment on this; she did not have trouble
understanding anyone. She denied any loss of visual fields or
dark spots, but did endorse feeling like her vision was slightly
blurry bilaterally and that she has slight diplopia with images
offset both vertically and horizontally, worse with near vision.
Ms. ___ reports the weakness improved within ___ but
the
numbness and eye pain persisted.
Ms. ___ went to an OSH and it seems had a normal exam
on evaluation there. Her d-dimer was slightly elevated at 322
but
other labs were unremarkable. She was sent to ___ for imaging.
On neuro ROS, the pt reports slight headache now but none the
remainder of the day, blurred vision and diplopia as above, and
chronic "unsteadiness" unchanged. She denies 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 but had
some chills a few nights ago. No night sweats or recent weight
loss or gain. Denies cough but has had intermittent shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain; +
soft stools. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rash. No recent
medication changes except some herbal medications that she does
not know the names of.
Past Medical History:
(from PCP ___ ___, confirmed with patient):
1. s/p pulmonary embolus - diagnosed in ___ at
___ for which she was on anticoagulation therapy
until ___. This was in setting of meniscal tear and
estrogen patch.
2. GERD and gastritis - H pylori positive and was treated.
3. Chronic back pain
4. Irritable bowel syndrome
5. Chronic sinusitis
6. Asthma
7. Allergic rhinitis
8. Complex migraine headaches
9. Malabsorption syndrome/steatorrhea
10. Anemia
11. Myalgias: she has had ongoing discomfort in most of her
joints. She is able to function but the pains do impact her on a
daily basis. The patient was recently evaluated by a
rheumatologist and all her inflammatory markers including CK
were negative.
Social History:
___
Family History:
(per PCP note, reviewed with patient): There is a
family history of ovarian cancer and HTN in the mother, HTN in
the father and sister, and breast cysts in sister who is ___,
and breast cancer in an aunt who is ___. The patient is BRCA-.
Physical Exam:
Vitals: 98.2, 72, 123/85, 18, 99%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no swelling, complains of some right-sided
temporal
tenderness and sinus tenderness. TM pearly bl.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. Pt. was able to register 3 objects and
recall ___ at 5 minutes. The pt. had good knowledge of current
events. There was no evidence of apraxia or neglect.
Calculation
was intact. There was no evidence of left-right confusion as the
patient was able to accurately follow the instruction to tough
left ear with right hand.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation. Acuity
___
on R and ___ on L. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages.
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 IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 4* 5 5 5 5
*reports weakness since meniscus surgery
-Sensory: Decreased sensation to pinprick and light touch
through
whole R face, arm, leg and trunk. She reports cold feels colder
on right than left. Vibration and propioception intact bl. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
LABS
___ 06:00PM GLUCOSE-77 UREA N-5* CREAT-0.7 SODIUM-139
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-24 ANION GAP-13
___ 06:00PM estGFR-Using this
___ 06:00PM WBC-4.7 RBC-4.12* HGB-12.1 HCT-38.7 MCV-94
MCH-29.3 MCHC-31.2 RDW-13.7
___ 06:00PM NEUTS-53 BANDS-0 ___ MONOS-8 EOS-6*
BASOS-0 ___ MYELOS-0
___ 06:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 06:00PM PLT SMR-NORMAL PLT COUNT-182
___ 05:40AM BLOOD %HbA1c-5.5 eAG-111
___ 05:40AM BLOOD Triglyc-42 HDL-64 CHOL/HD-3.1 LDLcalc-128
___ 05:40AM BLOOD CRP-1.0
___ 05:40AM BLOOD CK-MB-1
___ 05:40AM BLOOD CK(CPK)-68
MRI/MRA/MRV brain
1. There is no evidence of acute or subacute intracranial
process, essentially
normal MRI of the brain with no evidence of intracranial
hemorrhage or
diffusion abnormalities to suggest acute or subacute ischemic
changes.
2. Normal MRA of the head with no evidence of flow stenotic
lesions or
aneurysms.
3. Normal MRA of the neck.
4. There is no evidence of venous sinus thrombosis.
5. Unchanged mucosal thickening on the right maxillary sinus,
likely
consistent with mucous retention cyst.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. esomeprazole magnesium 40 mg oral every other day
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Ranitidine 300 mg PO BID
5. Sucralfate 1 gm PO TID with meals
6. Docusate Sodium 100 mg PO BID
7. lactobacillus acidophilus 1 mg oral daily
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Docusate Sodium 100 mg PO BID
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Ranitidine 300 mg PO BID
5. Sucralfate 1 gm PO TID with meals
6. esomeprazole magnesium 40 mg oral every other day
7. lactobacillus acidophilus 1 mg oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
1. complex migraine vs. anxiety
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 Head, MRA of the neck.
INDICATION: ___ woman with history of PE, right-sided tingling,
evaluate for possible stroke, venous sinus thrombosis, cavernous sinus
thrombosis.
TECHNIQUE: Multi planar multi sequence MR images of the brain were obtained
without contrast.
MRA of the head, non contrast 3D time-of-flight MRA of the brain was
performed.
MRA of the neck, 2D time-of-flight MRA of the neck was obtained, axial source
images and maximum intensity projection images were reviewed.
MRV of the head, 2D time-of-flight venography of the head was obtained,
oblique source images and maximal intensity projections were reviewed. Phase
contrast technique venography of the head was also obtained at 30 cm /sec of
venc.
COMPARISON: MRI of the brain dated ___ from an outside
institution (___), and prior MRI and MRA of the brain dated ___
from ___.
FINDINGS:
MR Head: There is no intracranial hemorrhage, mass, mass effect or shifting of
the normally midline structures. Diffusion weighting imaging does not
demonstrate evidence of acute infarct. Gray white matter differentiation is
maintained. Ventricles and extra axial spaces are normal.
The paranasal sinuses are notable for persistent mucosal thickening on the
left maxillary sinus, likely consistent with mucous retention cyst. The sella
turcica, craniocervical junction, and orbits are unremarkable.
MRA Head: Normal flow signal is noted in the petrous, cavernous, and
supraclinoid segments of the internal carotid arteries. The anterior and
middle cerebral arteries are normal. The anterior communicating artery region
is normal.
The posterior cerebral arteries and basilar artery are unremarkable. The
superior cerebellar arteries are normal. The intradural segments to both
vertebral arteries are patent; the vertebral arteries are codominant. Normal
bilateral posterior communicating arteries are identified. No arterial
stenosis, saccular aneurysm, or AVM is identified. .
MRA of the neck: Both common carotid arteries are patent, there is no evidence
of dissection, the cervical carotid bifurcations are unremarkable, with no
evidence of stenosis, both vertebral arteries are patent with normal flow
signal.
MRV of the head. There is no evidence of venous sinus thrombosis, the major
dural venous sinuses are patent and unchanged since the prior examination on
___, the right transverse sinus is dominant. .
IMPRESSION:
1. There is no evidence of acute or subacute intracranial process, essentially
normal MRI of the brain with no evidence of intracranial hemorrhage or
diffusion abnormalities to suggest acute or subacute ischemic changes.
2. Normal MRA of the head with no evidence of flow stenotic lesions or
aneurysms.
3. Normal MRA of the neck.
4. There is no evidence of venous sinus thrombosis.
5. Unchanged mucosal thickening on the right maxillary sinus, likely
consistent with mucous retention cyst.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: R Facial numbness
Diagnosed with TRANS CEREB ISCHEMIA NOS, SKIN SENSATION DISTURB
temperature: 98.2
heartrate: 72.0
resprate: 18.0
o2sat: 99.0
sbp: 123.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | ___ year old woman w PMH PE, HTN, abdominal migraines, who
follows with ___ who presents with R sided retroorbital
headache and R sided sensory complaints an weakness. Of note,
she saw Dr. ___ on ___ for similar complaints of R sided
sensory changes, and has been to the ED for multiple visits
prior to this. She was seen in the ED and was admitted for
repeat MRI/MRA/MRV to rule out stroke or cortical vein
thrombosis given h/o PE in the past. MRI showed no acute
process, so her presentation was likely accounted for by a
complex migraine vs. anxiety. She will follow up with Dr.
___ as an outpatient in addition to her reguarly
scheduled GI doctors. LDL was 128, and she could warrent further
follow up for this, although she was not started on a statin at
this time due to lack of stroke or other risk factors. ESR/CRP
wnl. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Norvasc / spironolactone
Attending: ___.
Chief Complaint:
Right Jaw Pain and Scalp Tenderness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o woman with history of multivessel CAD, sCHF (LVEF 56%
___, AF s/p PPM on warfarin, HTN, HLD, depression presenting
with right jaw pain and dyspnea on exertion. Patient
interviewed in ED with interpreter on phone. Patient presents
after 3 days of sore throat, body pain, shortness of breath,
nausea, and fevers. She also endorses severe right sided jaw
pain, and temporal pain. No changes in vision. Endorses
shortness of breath that is worse while walking around. Endorses
fevers at home for the past 3 days. She has not been eating and
drinking well for the past few days as well. Jaw pain has been
present for 10days, and per family went to another hospital
where they wanted to do an "oral surgery" family unsure what,
but decided against it due to her age. She continues to complain
of jaw pain and right sided temporal pain. No new changes in
vision. No swelling in area, no lesions to gums or in mouth. She
says it hurts to eat. She also endorses left sided chest pain
for the past week than has been constant. Pain increases with
movement but no palpitations or sob associated with pain.
On exam saw that patient has ~1cm left leg ulceration that was
wrapped in dressing. Family says that she has a wound nurse who
comes in to see the wound. They think it is getting better but
think that erythema surrounding the wound is getting larger.
Patient endorses pain in leg but says it's not worse than prior.
Denies drainage from area. Denies cough, sputum production,
nasal congestion, headache, abdominal pain, vomiting, diarrhea,
constipation.
In the ED, initial VS were: 100.6 76 131/78 18 100% RA
Exam notable for:
Elderly woman, NAD, oropharynx erythematous, no tonsilar
exudates, no lesion on gum or buccal membranes, no parotid
swelling noted, ttp of right jaw, right temporal ttp, tender
anterior cervical LAD, RRR, systolic murmur best heard at apex,
breathing comfortably on room air, crackles at right base, no
wrr, left chest tender to palpation, abd soft, NT, +bs, 1+
pitting edema in bilateral lower extremities, erythematous area
on left shin around ~1cm wound, dressing in place over wound
which has bloody white discharge.
ECG: V-paced
Labs showed: WBC 8 H/H 9.3/28.6 plt 93; CRP 214; ___ 40679;
Na 3.4 HCO3 19 BUN/Cr 57/2.0
Imaging showed:
- CXR: 1. No evidence of pneumonia. 2. Mild pulmonary edema.
- CT Maxillofacial:
1. Mild bilateral temporomandibular joint degenerative changes.
2. A soft tissue lesion or prominent venous plexus extending
from the the inferior left parotid gland measures up to 2.8 cm,
minimally enlarged since ___. Could consider further assessment
with nonemergent contrast-enhanced neck CT or MRI.
3. Possible acute on chronic sphenoid sinusitis.
Consults: Rheumatology
Patient received:
___ 14:41 PO Acetaminophen 1000 mg
___ 14:41 PO/NG Potassium Chloride (Powder) 40 mEq
___ 14:41 IV Vancomycin
___ 15:48 IV Vancomycin 750 mg
___ 15:52 IV CefTRIAXone
___ 17:42 IV CefTRIAXone 1 g
Transfer VS were: 97.7 73 117/66 18 96% RA
On arrival to the floor, patient is interviewed via ___
translator over the phone. The patient confirms that she has had
severe right jaw pain for several days. She also endorses
subjective fevers for several days at home. She denies any
headaches, visual changes. She denies chest pain, palpitations,
shortness of breath, abdominal pain, nausea, vomiting, diarrhea,
leg pain.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
HFpEF (EF 45% in ___, but EF 55% in ___
HTN
HLD
Obesity
Depression
Glaucoma
UGIB
H.pylori gastritis
Uterine prolapse and leiomyata
Iron deficiency anemia
Chronic atrial fibrillation
C.diff colitis
s/p gallstone pancreatitis ___
R frontal lobe CVA per ___ CT
AVB s/p s/p ___ pacemaker on ___
Social History:
___
Family History:
Mother with gum cancer. No heart disease that she is aware of.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.0 135/80 71 18 94 RA
GENERAL: Lying in bed, appears in pain
HEENT: Anicteric sclerae, exquisite point tenderness of right
mid-mandible, edentulous, no oral lesions or gum lesions
NECK: JVD difficult to assess in setting of TR
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Poor air movement, bibasilar crackles
ABDOMEN: Soft, NTND
EXTREMITIES: 1+ bilateral peripheral edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: Warm and well perfused, left anterior shin with 3x3 cm
shallow ulcer without purulence with surrounding erythema;
bilateral venous stasis changes
DISCHARGE PHYSICAL EXAM:
Vitals: 1445 T97.8 PO BP 129 / 78, HR 72 RR 16 O2Sat 96
General: alert, oriented, ___ speaking, no acute distress,
overall appears more comfortable than earlier in admission
Eyes: Sclera anicteric, conjugaze gate
Face: bilateral temple tenderness R>L. Left mid check/jaw with
pain on light palpation, no fluctuances/indurance/eryemtha. OP
clear. NO oral lesions.
Neck: supple, no LAD, prominent left EJ, non-tender,
collapsible, no erythema/induration; prominent V wave but no
clear JVD
Resp: breathing comfortably while lying in bed, crackles, no
wheezes or rhonchi
CV: regular rate and rhythm, holosystolic murmur best heard at
___, exaggerated with inspiration
GI: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
GU: Erythema around buttocks consistent with a diaper rash, no
evidence of external hemorrhoids or fissure, no blood or black
on gloved finger ?trace green, at 1 oclock prominent external
vein on posterior aspect 3 cm from anus that was tender to
palpation
Neuro: CNs2-12 intact, motor function grossly normal
Ext: Warm and well perfused, left anterior shin with 3x3 cm
shallow ulcer without purulence with mild surrounding erythema;
Exam has been consist during hospital stay; c/d/i; bilateral
venous stasis changes, trace pitting edema
Pertinent Results:
ADMISSION LABS:
==================
___ 11:20AM WBC-8.2 RBC-3.23* HGB-9.3* HCT-28.6* MCV-89
MCH-28.8 MCHC-32.5 RDW-15.1 RDWSD-49.1*
___ 11:20AM NEUTS-85.7* LYMPHS-6.7* MONOS-6.2 EOS-0.2*
BASOS-0.1 IM ___ AbsNeut-7.04* AbsLymp-0.55* AbsMono-0.51
AbsEos-0.02* AbsBaso-0.01
___ 11:20AM GLUCOSE-103* UREA N-57* CREAT-2.0* SODIUM-140
POTASSIUM-3.4* CHLORIDE-101 TOTAL CO2-19* ANION GAP-20*
___ 11:17PM CALCIUM-8.5 PHOSPHATE-3.3 MAGNESIUM-2.0
___ 11:17PM CK-MB-2 cTropnT-<0.01
___ 11:20AM cTropnT-<0.01
___ 11:20AM ___
___ 11:20AM CRP-214.2*
DISCHARGE LABS:
================
___ 06:00AM BLOOD WBC-8.6 RBC-3.18* Hgb-8.9* Hct-27.7*
MCV-87 MCH-28.0 MCHC-32.1 RDW-15.6* RDWSD-49.1* Plt ___
___ 10:30AM BLOOD ___ PTT-33.0 ___
___ 06:00AM BLOOD Glucose-105* UreaN-70* Creat-1.7* Na-142
K-4.3 Cl-102 HCO3-26 AnGap-14
___ 06:00AM BLOOD AlkPhos-169* TotBili-0.5
___ 06:00AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.7*
___ 06:00AM BLOOD CRP-46.6*
IMAGING:
============
CHEST XR (___)
1. No evidence of pneumonia.
2. Mild pulmonary edema. Severe chronic cardiomegaly, left
atrial enlargement
and pulmonary arterial hypertension.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST (___)
1. Mild bilateral temporomandibular joint degenerative changes.
2. A soft tissue lesion or prominent venous plexus extending
from the the
inferior left parotid gland measures up to 2.8 cm, minimally
enlarged since ___. Could consider further assessment with
nonemergent contrast-enhanced neck CT or MRI.
3. Possible acute on chronic sphenoid sinusitis.
US Temporal Arteries (___)
Temporal arteritis involving both the right and left temporal
arteries.
Left Leg XR (___)
No acute bony injury seen. No radiographic evidence for
osteomyelitis.
Please note MRI is more sensitive for the detection of early
osteomyelitis
MICRO:
========
___ FLU NEGATIVE
___ URINE URINE CULTURE-FINAL <10K
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
4. Cetirizine 5 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO DAILY
7. FLUoxetine 10 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Senna 17.2 mg PO QHS:PRN constipation
12. Torsemide 60 mg PO DAILY
13. Valsartan 80 mg PO DAILY
14. estradiol 0.01 % (0.1 mg/gram) vaginal 2X/WEEK
15. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN
itching
16. urea 40 % topical DAILY
17. Warfarin 1 mg PO 5X/WEEK (___)
18. Warfarin 2 mg PO 2X/WEEK (MO,FR)
Discharge Medications:
1. Atovaquone Suspension 1500 mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN
Hemorrhoid
4. OxyCODONE (Immediate Release) 2.5 mg PO Q8H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 8
hours as needed for severe pain Disp #*10 Tablet Refills:*0
5. PredniSONE 60 mg PO DAILY
6. Ramelteon 8 mg PO QHS:PRN Insomnia
Should be given 30 minutes before bedtime
7. Vitamin D 1000 UNIT PO DAILY
8. Acetaminophen 1000 mg PO Q8H
9. Warfarin 1 mg PO DAILY16 pending INR, goal ___. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
11. Betamethasone Dipro 0.05% Cream 1 Appl TP BID:PRN itch
12. Cetirizine 5 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Estradiol 0.01 % (0.1 mg/gram) vaginal 2X/WEEK (MO,TH)
15. Ferrous Sulfate 325 mg PO DAILY
16. FLUoxetine 10 mg PO DAILY
17. Fluticasone Propionate NASAL 1 SPRY NU BID
18. Metoprolol Succinate XL 50 mg PO DAILY
19. Omeprazole 20 mg PO DAILY
20. Senna 17.2 mg PO QHS:PRN constipation
21. Torsemide 60 mg PO DAILY
22. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN
itching
23. urea 40 % topical DAILY
24. HELD- Valsartan 80 mg PO DAILY This medication was held. Do
not restart Valsartan until you are told to by a doctor.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Giant Cell Arthritis, Trigeminal Neuralgia
Secondary Diagnosis: Lower extremity ulcer, heart failure with
reduced ejection fraction, mitral regurgitation, tricuspid
regurgitation
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 radiographs
INDICATION: ___ with dyspnea, sore throat.
TECHNIQUE: Frontal and lateral views of the chest
COMPARISON: Chest radiographs between ___ and ___
___ chest CT
FINDINGS:
Mildly diminished lung volumes results in crowding of the bronchovascular
structures and exaggeration of mild pulmonary edema as well as chronic
moderate to severe cardiomegaly with stable severe left atrial and pulmonary
artery enlargement. There is no focal consolidation.
A pacemaker lead projects over the expected location of the right ventricle.
The descending thoracic aorta is tortuous but not dilated. A severe mid
thoracic spine compression deformity is unchanged since at least ___.
IMPRESSION:
1. No evidence of pneumonia.
2. Mild pulmonary edema. Severe chronic cardiomegaly, left atrial enlargement
and pulmonary arterial hypertension.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: ___ year old woman with jaw pain, fever, elevated CRP, right
temporal pain.
TECHNIQUE: Helical axial images were acquired through the facial bones. Bone
and soft tissue reconstructed images were generated. Coronal and sagittal
reformatted images were also obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.5 s, 19.3 cm; CTDIvol = 26.8 mGy (Head) DLP = 518.7
mGy-cm.
Total DLP (Head) = 519 mGy-cm.
COMPARISON: Head and sinus CTs between ___ and ___
___ cervical spine CT
___ MRI and MRA brain.
FINDINGS:
The temporomandibular joints are well aligned, with mild joint space narrowing
and osteophytosis.
There is a 2.8 x 1.8 x 1.8 cm well-circumscribed soft tissue lesion extending
from the the inferior aspect of the left parotid gland.
There is no facial bone fracture. Pterygoid plates are intact. There is no
mandibular fracture. The orbits are intact. There is no orbital hematoma.
Mild hyperostosis frontalis interna. Partial sphenoid sinus opacification
with few aerosolized secretions and sphenoid sinus wall hyperostosis.
Otherwise mild diffuse paranasal sinus mucosal thickening. The ostiomeatal
units are patent. The adjacent orbital and pterygopalatine fossa fat planes
are preserved. The mastoid air cells and middle ear cavities are clear. Soft
tissue in the external auditory canals probably reflects cerumen. Bilateral
lens replacements are noted. Moderate carotid siphon and V4 segment
calcification.
Limited assessment of the intracranial structures reveals unchanged right
frontal encephalomalacia.
IMPRESSION:
1. Mild bilateral temporomandibular joint degenerative changes.
2. A soft tissue lesion or prominent venous plexus extending from the the
inferior left parotid gland measures up to 2.8 cm, minimally enlarged since
___. Could consider further assessment with nonemergent contrast-enhanced
neck CT or MRI.
3. Possible acute on chronic sphenoid sinusitis.
RECOMMENDATION(S): A soft tissue lesion or prominent venous plexus in the
inferior left parotid gland measures up to 2.8 cm, minimally enlarged since
___. Could consider further assessment with nonemergent contrast-enhanced
neck CT or MRI.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFT
INDICATION: ___ year old woman with left leg ulceration and elevated
inflammatory markers// Radiographic evidence for osteo?
TECHNIQUE: Two views left tibia and fibula
COMPARISON: Left knee and tibia and fibula radiographs ___
FINDINGS:
Bones appear diffusely demineralized. This limits sensitivity for detecting
acute fracture, nonetheless no fracture is seen. No destructive lytic or
sclerotic bone lesions. No radiopaque subcutaneous foreign body or soft
tissue calcification except note moderate vascular calcification. Probable
loose body in the knee joint.
IMPRESSION:
No acute bony injury seen. No radiographic evidence for osteomyelitis.
Please note MRI is more sensitive for the detection of early osteomyelitis.
Radiology Report
EXAMINATION: ART DUP EXT UP BILAT COMP
INDICATION: ___ year old woman with jaw claudication and elevated inflammatory
markers, concern for GCA// Please evaluate for temporal arteritis
TECHNIQUE: Grayscale and Doppler color ultrasound images were obtained of the
temporal arteries.
COMPARISON: None
FINDINGS:
Left:
There is thickening and hypoechogenicity involving the wall of the common
superficial temporal artery on the left consistent with inflammation (halo
sign). There is patent flow and normal arterial waveforms within the left
common superficial temporal artery.
There is normal flow and appropriate waveforms within the left frontotemporal
artery. The wall of the left frontotemporal artery is within normal limits.
There is minimal thickening and increased hypoechogenicity of the wall of the
left temporal artery at the level of the mandibular ramus consistent with
inflammation (a low sign). There is patent flow and normal arterial waveforms
within the left temporal artery at the level of the mandibular ramus.
Right:
There is thickening and hypoechogenicity involving the wall of the common
superficial temporal artery on the right consistent with inflammation (halo
sign). There is patent flow and normal arterial waveforms within the right
common superficial temporal artery.
There is normal flow and appropriate waveforms within the left frontotemporal
artery. The wall of the left frontotemporal artery is within normal limits.
There is minimal thickening and increased hypoechogenicity of the wall of the
right temporal artery at the level of the mandibular ramus consistent with
inflammation (a low sign). There is patent flow and normal arterial waveforms
within the right temporal artery at the level of the mandibular ramus.
IMPRESSION:
Temporal arteritis involving both the right and left temporal arteries.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, N/V
Diagnosed with Acute kidney failure, unspecified, Cellulitis of left lower limb, Dyspnea, unspecified
temperature: 100.6
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 131.0
dbp: 78.0
level of pain: 0
level of acuity: 3.0 | SUMMARY STATMENT
=================
___ y/o ___ speaking woman with history of multivessel CAD,
sCHF (LVEF 56% ___ ECHO), AF s/p PPM on warfarin, HTN, HLD,
depression presenting with right jaw pain and dyspnea on
exertion found to have GCA (bilateral temporal arteritis on US),
trigeminal neuralgia, and volume overload.
ACUTE ISSUES:
=================
#Giant Cell Artheritis
#C/f trigeminal neuralgia
Patient presented with unrelenting right jaw/face pain and
subjective fevers at home for ___ days prior to presentation.
Upon admission, she was found to have markedly elevated CRP and
exquisite R facial sensitivity described as electric shocks with
R>L temporal artery tenderness of exam. CT maxillofacial without
evidence of acute pathology to explain patient's symptoms and no
obvious oral pathology per OMFS consultation. Temporal artery US
concerning for temporal arteritis involving both the right and
left temporal arteries and there was a very high concern for GCA
after consultation with Rheumatology. Biopsy was not necessary
for confirmation. She notably had already had decreased visual
acuity in her R eye over ___ years ago in the setting of glaucoma,
but has perhaps has had recent worsening acuity. She was
evaluated by ophthalmology and there was no evidence of retinal
whitening. Due to high concern for GCA, high-dose
methylprednisone was started for a 3 days course (___).
She will continue on 1 mg/kg/daily of prednisone (60mg) upon
discharge with further steroid course to be determined by
Rheumatology as outpatient. As she will be on long-term
steroids, she was started on vitamin D and calcium. We continued
her omeprazole for GI ppx. On discharge, plan to start
atovaquone for PJP ppx. Hepatitis serologies were obtained as
follows: HAV-Ab+, HBsAg-, HBsAb-, HBcAB-, HCV-Ab-. Quantiferon
gold was negative. Interestingly, the facial pain she is
describing is consistent with trigeminal neuralgia, which is an
association with GCA. She endorsed improvement of the trigeminal
pain after starting treatment with steroids. For pain she
received acetaminophen 1000 mg PO/NG Q8H and oxycodone 2.5 mg as
needed, has been receiving ___ per day at time of discharge.
Carbamazepine was considered for her neuropathic pain, but was
not needed as pain symptoms improved significantly with steroid
therapy.
#Chronic Left Lower Extremity Ulcer
Patient presented with bilateral stasis dermatitis, but she also
has left anterior shin ulcer with surrounding erythema c/w
chronic stasis dermatitis. Per patient and daughter, wound has
been chronic for 6 months. There was no purulence. Ulcer is
shallow and did not probe to bone. Plain film showed no evidence
of osteomyelitis. Was started on vancomycin upon presentation,
but discontinued on ___ as concern for infection was low. Wound
care was provided.
#Dyspnea on exertion:
#Acute on chronic systolic CHF (last LVEF of 56% ECHO TTE):
#Valvular heart disease (2+MR, 3+TR):
Upon presenting, her exam was notable for crackles on
auscultation, BNP 40K, CXR with pulmonary edema. On presentation
creatinine was slightly elevated to 2.0 from her baseline of
1.3-1.7. She has prominent V wave and JVD hard to interpret. She
was given IV Lasix 60mg for diuresis as needed, before she was
restarted on home torsemide. Creatinine improved to 1.7 on
discharge. Daily weights were obtained and she was net 1L
negative. On discharge, should continued home torsemide and
metoprolol. Held valsartan on discharge given resolving ___ as
below.
___:
Baseline Cr 1.3-1.7, 2.0 on admission, likely secondary to
decreased effective arterial blood volume in setting of acute on
chronic systolic heart failure exacerbation as above. Creatinine
has downtrended to 1.7 on discharge.
#Hemorrhoids/Rash:
Patient has history of painful hemorrhoids. On exam no evidence
of external hemorrhoids, though prominent vein noted on superior
aspect of gluteal fold. Butock noted to erythematous consistent
with diaper rash. Stool is noted to be dark but she is on oral
iron. Was provided with barrier cream, topical steroid cream,
and hydration was encouraged in additional to stool softeners
prn.
#HTN:
Held valsartan in setting of ___. Her systolic blood pressures
have been 130-140. Can consider adding back valsartan for
hypertension management, would also benefit from afterload
reduction given history of heart failure with reduced EF.
#Atrial fibrillation
#Tachy-brady syndrome s/p PPM:
Her INR was supratherapeutic >3.0 during admission and thus
warfarin was held. On discharge, her INR was 2.5 and she was
restarted warfarin 1mg daily. Goal INR ___. Please recheck on
___ and titrate accordingly. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Shortness of breath and running out of hydroxyurea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP:
Name: ___.
Address: ___, ___
Phone: ___
Fax: ___
Email: ___
.
Oncologist: Dr. ___
_
________________________________________________________________
HPI: > or equal to 4 ( location, quality, severity, duration,
timing, context, modifying factors, associated signs and sx)
___ with myeloproliferative d/o sent in for elevated K, possible
admission for restarting hydrea and K monitoring. Patient states
he feels fine. Has been off hydrea for 1 week because rx ran out
because he has had 3 changes of doctors at the ___ where he
usually gets his medications. He has been feeling well
otherwise. He did an hour and a half of exercise class today. He
has been having SOB for 1 month with exertion. He is not SOB
during his exercise class but if he is rushing to go somewhere
he becomes sob. He can climb 13 steps without stopping. No
associated chest pressure, nausea or diaphoresis. No associated
edema or pnd. He has sleep apnea and he uses CPAP at night. He
takes a ___ min nap daily for the past 6 months.
.
In ER: (Triage Vitals:98.2 80 160/92 20 96%
Meds Given: nONE,
Fluids given: NONE
.
PAIN SCALE: ___
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [x] All Normal
[ ] Fever [ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ ] _____ lbs. weight loss/gain over _____ months
Eyes
[x] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT [x] WNL
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [] All Normal
[X ] Shortness of breath [X ] Dyspnea on exertion [ ] Can't
walk 2 flights [ +] Cough- occasional productive of
brown/yellow phlegm x 1 month [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [x] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [x] All Normal
[ ] Nausea [] Vomiting [] Abd pain [] Abdominal swelling [
] Diarrhea [ ] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [] All Normal
[ ] Dysuria [ ] Incontinence or retention [ x] Frequency -
over the past ___ months for Dr ___ at ___ [ ] Hematuria
[]Discharge []Menorrhagia
SKIN: [] All Normal
[ ] Rash [ ] Pruritus [+] bruise on L hand when he tried
to keep an elevator door from closing
MS: [x] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [x] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy [+] itchy scalp
HEME/LYMPH: [] All Normal
[x ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [x] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
ALLERGY:
[X ]Medication allergies- codeine -> nausea [ ] Seasonal
allergies
[X]all other systems negative except as noted above
Past Medical History:
Hypertension
Chronic Renal Insufficiency (baseline of 1.8 - 2)
CML
Gout
Chronic Low Back Pain
Carpal Tunnel Syndrome
BPH
Social History:
SOCIAL HISTORY/ FUNCTIONAL STATUS: I< 65
Cigarettes: [x ] never [ ] ex-smoker [] current Pack-yrs:
quit: ______
ETOH: [] No [+ ] Yes 3x per week
Drugs: none
Occupation: ___
Marital Status: [x ] Married [] Single
Lives: [ ] Alone [x] w/ family - wife [ ] Other:
Received influenza vaccination in the past 12 months [x ]Y [ ]N
Received pneumococcal vaccinationin the past [x ]Y [ ]N
wife is HCP
>65
ADLS:
Independent of ALL ADLS:
IADLS:
Independent of IADLS: [ ]shopping [ x] accounting [ ]telephone
use [ ]food preparation
Requires assitance with IADLS: [X ]shopping [ ] accounting [x
]telephone use [X ]food preparation
[x ]He has a cleaning person once per week
At baseline walks: [x ]independently [ ] with a cane [
]wutwalker [ ]wheelchair at ___
H/o fall within past year: []Y [x]N
Visual aides [ x]Y [ ]N
Dentures [ ]Y [ x]N
Hearing Aides [ ]Y [ x] N
Family History:
Father died at age ___ with ? Heart disease. Mother with CVA and
died at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM: I3 - PE >8
PAIN SCORE: ___
1. VS: Tm = 96.5 T P = 89 BP 152/94 RR 29 O2Sat on __RA =
99% __
GENERAL: Elderly well appearing male. As we talk he becomes
noticably short of breath and has to take a breath at times
between sentences.
Nourishment: good
Grooming: good
Mentation
2. Eyes: [X] WNL
PERRL, EOMI without nystagmus, Conjunctiva:
clear/injection/exudates/icteric Ears/Nose/Mouth/Throat: MMM, no
lesions noted in OP
3. ENT [X] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[X] Regular [] Tachy [X] S1 [X] S2 [] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[] Edema RLE 3+ [] Bruit(s), Location:
[] Edema LLE None 2+ [+] PMI
[] Vascular access [+] Peripheral [] Central site:
5. Respiratory [ ]
[] CTA bilaterally [ x] Rales AT THE bases [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ X] WNL
[] Soft/firm [] Rebound [] No hepatomegaly [] Non-tender []
Tender [] No splenomegaly
[] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
7. Musculoskeletal-Extremities [x] WNL
[ ] Tone WNL [ ]Upper extremity strength ___ and symmetrical [
]Other:
[ ] Bulk WNL [] Lower extremity strength ___ and symmetrica [
] Other:
[x] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [X] WNL
[ ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
[] Warm [] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
Multiple ecchymoses
10. Psychiatric [X] WNL
[] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated
[] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
11. Hematologic/Lymphatic [ ]WNL
[x] No cervical ___ [] No axillary ___ [] No supraclavicular
___ [] No inguinal ___ [] Thyroid WNL [] Other:
TRACH: []present [x]none
PEG:[]present [x]none [ ]site C/D/I
COLOSTOMY: :[]present [x]none [ ]site C/D/I
.
.
DISCHARGE PHYSICAL EXAM:
VS: T 98.4 BP 153/80 HR 86 RR 20 SaO2 96%RA
Gen: WD/WN, elderly white male, in NAD
HEENT: PERRL, EOMI, clear oropharynx
Neck: no cervical LAD, brisk carotid upstrokes, no carotid
bruits, no JVD
Lungs: CTAB, good excusrion with inspiration, no
wheezes/crackles
Heart: RRR, normal S1/S2, II/VI SEM at RUSB
Abd: Spleen tip palpable with inspiration, normoactive bowel
sounds, no TTP
Extr: 1+ pitting edema, R slightly worse than L
Skin: no rashes or skin breakdown
Neuro: Alert, awake and oriented x3, CNs II-XII intact and
equal, ___ strength in upper and lower extremities, sensation
intact and equal bilaterally, 2+ reflexes in upper and lower
extremities
Psych: mood and affect appropriate
Access: PIV
Pertinent Results:
ADMISSION LABS:
___ 09:20PM URINE HOURS-RANDOM
___ 09:20PM URINE GR HOLD-HOLD
___ 09:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 09:20PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 05:50PM K+-4.6
___ 05:47PM GLUCOSE-100 UREA N-45* CREAT-2.5* SODIUM-143
POTASSIUM-5.2* CHLORIDE-111* TOTAL CO2-18* ANION GAP-19
___ 05:47PM CK(CPK)-77
___ 05:47PM cTropnT-0.11*
___ 05:47PM CK-MB-5
___ 05:47PM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-1.9 URIC
ACID-6.5
___ 05:47PM WBC-24.7* RBC-3.93* HGB-11.4* HCT-36.0*
MCV-92 MCH-29.0 MCHC-31.7 RDW-17.4*
___ 05:47PM NEUTS-77* BANDS-4 LYMPHS-1* MONOS-3 EOS-5*
BASOS-1 ATYPS-1* METAS-7* MYELOS-1*
___ 05:47PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 05:47PM PLT COUNT-771*
___ 02:18PM UREA N-49* CREAT-2.6* SODIUM-143
POTASSIUM-6.0* CHLORIDE-111* TOTAL CO2-20* ANION GAP-18
___ 02:18PM estGFR-Using this
___ 02:18PM ALT(SGPT)-29 AST(SGOT)-37 LD(LDH)-482* ALK
PHOS-131* TOT BILI-0.5
___ 02:18PM CALCIUM-9.1 PHOSPHATE-3.6 MAGNESIUM-2.0 URIC
ACID-6.5
___ 02:18PM WBC-24.9* RBC-3.93* HGB-11.5* HCT-35.6*
MCV-91 MCH-29.1 MCHC-32.1 RDW-17.5*
___ 02:18PM NEUTS-72* BANDS-0 LYMPHS-8* MONOS-16* EOS-1
BASOS-0 ___ METAS-2* MYELOS-1*
___ 02:18PM PLT SMR-VERY HIGH PLT COUNT-766*
.
DISCHARGE LABS:
___ 03:50AM BLOOD WBC-24.4* RBC-3.70* Hgb-10.8* Hct-33.5*
MCV-91 MCH-29.2 MCHC-32.2 RDW-17.7* Plt ___
___ 03:50AM BLOOD Neuts-70 Bands-0 Lymphs-10* Monos-14*
Eos-2 Baso-1 ___ Metas-1* Myelos-2*
___ 03:50AM BLOOD Glucose-85 UreaN-42* Creat-2.4* Na-142
K-4.9 Cl-111* HCO3-17* AnGap-19
___ 03:50AM BLOOD Glucose-85 UreaN-42* Creat-2.4* Na-142
K-4.9 Cl-111* HCO3-17* AnGap-19
___ 03:50AM BLOOD ALT-21 AST-27 LD(LDH)-397* CK(CPK)-55
AlkPhos-104 TotBili-0.5
___ 03:50AM BLOOD CK-MB-4 cTropnT-0.10*
___ 03:50AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.8 UricAcd-6.6
Iron-36*
___ 03:50AM BLOOD calTIBC-317 VitB12-1641* Folate-GREATER
TH ___ Ferritn-46 TRF-244
___ 03:50AM BLOOD TSH-4.0
.
IMAGING:
___ CXR PA/lat: Frontal and lateral views of the chest were
obtained. There is upper zone pulmonary vascular re-distribution
and perivascular haze. Additionally, there is blunting of the
posterior bilateral costophrenic angles consistent with trace to
small bilateral pleural effusions. More confluent opacity at the
right infrahilar region most likely relates to vascular
structures and is somewhat similar as compared to the prior
radiograph as opposed to underlying consolidation. There is
focal thickening of the white matter fissure which may be due to
thickening or fluid within. The cardiac silhouette remains top
normal. The mediastinal contours are stable.
IMPRESSION: Elevated central venous pressure and trace bilateral
pleural effusions suggest degree of fluid overload/CHF. More
consolidative opacity at the right infrahilar region may be
related to vascular structures although underlying consolidation
not excluded.
.
___ TTE:
Results
Left Atrium - Long Axis Dimension: *4.6 cm
Left Atrium - Four Chamber Length: *5.3 cm
Right Atrium - Four Chamber Length: *5.2 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm
Left Ventricle - Diastolic Dimension: 4.7 cm
Left Ventricle - Ejection Fraction: 45%
Left Ventricle - Stroke Volume: 50 ml/beat
Left Ventricle - Cardiac Output: 4.27 L/min
Left Ventricle - Cardiac Index: 2.39
Left Ventricle - Lateral Peak E': *0.06 m/s
Left Ventricle - Septal Peak E': *0.04 m/s
Left Ventricle - Ratio E/E': *24
Aorta - Sinus Level: 2.9 cm
Aorta - Ascending: 3.0 cm
Aortic Valve - Peak Velocity: *2.4 m/sec
Aortic Valve - Peak Gradient: *23 mm Hg
Aortic Valve - Mean Gradient: 14 mm Hg
Aortic Valve - LVOT pk vel: 1.00 m/sec
Aortic Valve - LVOT VTI: 16
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *1.3 cm2
Mitral Valve - Mean Gradient: 2 mm Hg
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.71
Mitral Valve - E Wave deceleration time: 141 ms
TR Gradient (+ RA = PASP): *59 mm Hg
Pulmonic Valve - Peak Velocity: 1.0 m/sec
Findings
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous
hypertrophy of the interatrial septum. No ASD by 2D or color
Doppler. Normal IVC diameter (<=2.1cm) with <50% decrease with
sniff (estimated RA pressure ___ mmHg).
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild
regional LV systolic dysfunction. No LV mass/thrombus. TDI E/e'
>15, suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Mild AS (area 1.2-1.9cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
MS. ___ to moderate (___) MR.
___ VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Mild [1+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: Trivial/physiologic pericardial effusion. No
echocardiographic signs of tamponade.
.
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild regional left ventricular systolic dysfunction with
inferior and infero-lateral hypokinesis (c/w CAD). No masses or
thrombi are seen in the left ventricle. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The diameters of aorta at the sinus, ascending and
arch levels are normal. There are three aortic valve leaflets.
The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild to
moderate (___) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
.
___ Left lower extremity ultrasound: Grayscale and color
Doppler ultrasounds were performed. There is normal
compressibility, color flow and Doppler signal within the common
femoral, superficial femoral and popliteal veins.
IMPRESSION: No evidence of DVT.
Medications on Admission:
Meds as listed in OMR but also reviewed with patient upon
arrival to the floor
allopurinol ___ mg Tablet Tablet(s) by mouth once a day
atorvastatin [Lipitor] 20 mg Tablet Tablet(s) by mouth
betamethasone dipropionate 0.05 % Lotion apply to scalp nightly
as needed for
finasteride 5 mg Tablet Tablet(s) by mouth once a day
hydroxyurea [Hydrea] 500 mg Capsule 1 (One) Capsule(s) by mouth
once a day ___ Hold drug on ___ and ___. (Dose
adjustment - no new Rx) levothyroxine 100 mcg Tablet
omeprazole 20 mg Capsule, Delayed Release(E.C.) 1 Capsule(s) by
mouth twice a
zolpidem 10 mg Tablet 1 Tablet(s) by mouth once a day
___
* OTCs *
calcium
Dosage uncertain
(Prescribed by Other Provider) ___
chondroitin sulfate A [Chondroitin Sulfate]
ginseng
multivitamin Tablet 1 (One) Tablet(s) by mouth once a day
(Prescribed by
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*0*
3. allopurinol ___ mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. betamethasone dipropionate 0.05 % Lotion Sig: One (1)
application Topical at bedtime.
6. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. zolpidem 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. calcium Oral
11. chondroitin sulfate A Oral
12. ginseng Oral
13. multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Myeloproliferative disorder
.
Secondary diagnosis:
Congestive heart failure
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: ___ male with history of elevated white blood
cell count, shortness of breath.
___ and ___.
FINDINGS: Frontal and lateral views of the chest were obtained. There is
upper zone pulmonary vascular re-distribution and perivascular haze.
Additionally, there is blunting of the posterior bilateral costophrenic angles
consistent with trace to small bilateral pleural effusions. More confluent
opacity at the right infrahilar region most likely relates to vascular
structures and is somewhat similar as compared to the prior radiograph as
opposed to underlying consolidation. There is focal thickening of the white
matter fissure which may be due to thickening or fluid within. The cardiac
silhouette remains top normal. The mediastinal contours are stable.
IMPRESSION: Elevated central venous pressure and trace bilateral pleural
effusions suggest degree of fluid overload/CHF. More consolidative opacity at
the right infrahilar region may be related to vascular structures although
underlying consolidation not excluded.
Radiology Report
UNILATERAL LOWER EXTREMITY VEINS, RIGHT
INDICATION: ___ man with MDS and shortness of breath along with
asymptomatic right leg swelling. Evaluate for DVT.
UNILATERAL LOWER EXTREMITY VEINS, RIGHT: Grayscale and color Doppler
ultrasounds were performed. There is normal compressibility, color flow and
Doppler signal within the common femoral, superficial femoral and popliteal
veins.
IMPRESSION: No evidence of DVT.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HYPERKALEMIA
Diagnosed with HYPERKALEMIA, RENAL & URETERAL DIS NOS
temperature: 98.2
heartrate: 80.0
resprate: 20.0
o2sat: 96.0
sbp: 160.0
dbp: 92.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is an ___ gentleman, with myelodysplastic syndrome,
hypothyroidism, prior EF 48% on stress, who presented with
elevated blood counts and falsely-elevated hyperkalemia, as well
as dyspnea on exertion over the past three weeks.
.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydralazine And Derivatives / Bumex / Sulfa (Sulfonamide
Antibiotics) / Lactose / banax / Neurontin
Attending: ___.
Chief Complaint:
Left-sided abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with history of prior volvulus and C. Diff colitis,
presents with 2 weeks of melenic stool & 1 day of severe L-sided
abdominal pain with bloody diarrhea.
The patient states that her problems began roughly 2 weeks ago
when she noted intermittent dark black stool with constipation.
She was frequently straining to defecate leading to intense
abdominal pain. The patient has a longstanding history of
diarrhea thought to be due to IBS, and she usually has bowel
movements after every meal. For the past two weeks, however, she
has only been having ___ bowel movements per day, which were all
hard and melenic. She has chronic DOE, which she states has been
worse over the past 2 weeks and also associated with some
lightheadedness.
For the past week, she felt "chilled" with sweats throughout the
day, but no recorded fever. During this time she has had some
intermittent non-bloody diarrhea, but denies cough, nausea,
vomiting, UTI symptoms.
This AM, she started developing nausea with non-bloody emesis.
She had multiple episodes of nausea & vomiting with eventual dry
heaves. She felt extremely poorly during the day with
lightheadedness. Later in the day she developed severe L-sided
abdominal pain which prompted her to seek medical treatment. She
has never experienced this sort of pain in the past.
The patient has chronic dyspepsia and dysphagia (which is due to
a diverticulum, according to the patient's daughter), but denies
food avoidance and weight loss. Also denies eating raw foods of
any sort, drinking well-water, or being in contact with anyone
who shares her symptoms, recent travel, pets, or recent
antibiotics. Last colonoscopy was in ___ which was normal and
EGD showed a diverticulum in the esophagus. ACS saw patient in
the ED and determined that surgery was not necessary.
VS in ED: 97.6 87 120/79 18 99%. CT of abdomen showed L-sided
colitis that was also present in ___. CXR was negative. IV
protonix bolus and drip was started. IV cipro was started but
discontinued after arm itching. She was switched to IV
ceftriaxone 1mg. Guaic positive. The patient states that in the
ED she developed a couple of episodes of "loose, bloody stool"
although her daughter says it was brownish-red.
Patient has excellent long-term memory and able to record events
from her past. However, poor historian of recent events. This
morning, continues to complain of L sided abdominal pain only
when pressing her abdomen. Denies fevers/chills, sob, cp,
difficulty urinating, dysuria.
REVIEW OF SYSTEMS:
(+): As above
(-): Hematemesis, hematuria, dysuria, urinary frequency or
urgency, chest pain, headaches
Past Medical History:
- Gastric volvulus ___ yrs ago) s/p repair
- Internal hemorrhoids
- legally blind
- IBS
- C diff colitis
- HTN
- Hyperlipidemia
- CAD
- RBBB
- DOE s/p extensive negative work up
- Hypothyroidism
- OA
- PUD
- Prior GYN surgeries remotely
- GERD
- Depression
- s/p hiatal hernia repair
- s/p cholecystectomy
- s/p appendectomy
- s/p ORIF L radius ___
Social History:
___
Family History:
- Mother: CAD, CVA
- Aunt: ___ cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
98 110/62 72 18 98/RA
GEN: Resting in bed, appears weak, NAD.
HEENT: PERRLA, EOMI, NCAT. Dry MM, OP clear
NECK: Supple, no LADF
COR: + S1S2, RRR, no m/g/r.
PULM: CTAB no c/w/r
___: + NABS in 4Q. Soft with exquisite TTP of LUQ, LLQ which is
out of proportion to exam. No rebound or involuntary guarding.
Small umbilical hernia that is reducible. No masses felt.
EXT: WWP, no c/c. Mild edema b/l. Right hand with decreased
sensation and movement in ulnar aspects of hand.
NEURO: CN II-XII within normal limits given age, ___ strength
throughout, sensation to soft touch intact, A&Ox3, good long
term memory, however some difficulty remembering recent events
DISCHARGE PHYSICAL EXAM
97.4 138/63 72 20 98%RA
GEN: Resting in bed, NAD.
COR: + S1S2, RRR, no m/g/r.
PULM: CTAB no c/w/r
___: + NABS in $4Q. Soft, small 2cm umbilical hernia that can
be reduced. mild tenderness to palpation on one location at mid
L side of abdomen but much improved since admission, no rebound
or involuntary guarding.
EXT: WWP, no c/c. Mild edema b/l. 1+ ___ pulses.
NEURO: A&Ox3
Pertinent Results:
ADMISSION LABS
___ 02:42PM BLOOD WBC-15.9*# RBC-5.23 Hgb-13.9 Hct-43.4
MCV-83 MCH-26.5* MCHC-32.0 RDW-17.2* Plt ___
___ 02:42PM BLOOD Neuts-89.9* Lymphs-4.7* Monos-4.9 Eos-0.4
Baso-0.1
___ 02:42PM BLOOD ___ PTT-26.9 ___
___ 02:42PM BLOOD Glucose-171* UreaN-19 Creat-1.1 Na-137
K-3.4 Cl-98 HCO3-31 AnGap-11
___ 02:42PM BLOOD ALT-14 AST-24 AlkPhos-147* TotBili-0.4
___ 07:00AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.8
___ EKG: 73bpm, Sinus rhythm. Right bundle-branch block. Low
precordial lead voltage. Compared to the previous tracing of
___ the rate has slowed. The precordial voltage has
diminished. Atrial ectopy is absent. The repolarization
abnormalities previously recorded are less prominent in the
precordial leads. Otherwise, no diagnostic interim change.
RELEVANT LABS
___ 02:44PM BLOOD Lactate-2.8*
___ 08:17AM BLOOD Lactate-2.2*
___ 02:09PM BLOOD Lactate-1.0
DISCHARGE LABS
___ 07:45AM BLOOD WBC-5.9 RBC-4.13* Hgb-10.6* Hct-33.8*
MCV-82 MCH-25.7* MCHC-31.5 RDW-19.1* Plt ___
___ 07:45AM BLOOD Glucose-125* UreaN-3* Creat-1.0 Na-140
K-3.3 Cl-106 HCO3-27 AnGap-10
___ 07:45AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.5* Iron-PND
___ 07:45AM BLOOD Ferritn-PND TRF-PND
MICRO
___ 5:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 8:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 3:54 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
MODERATE POLYMORPHONUCLEAR LEUKOCYTES.
MODERATE RBC'S.
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.
___ 6:00 pm STOOL CONSISTENCY: NOT APPLICABLE
OVA + PARASITES (Preliminary):
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.
IMAGING:
___ CTA ABDOMEN & PLEVIS
IMPRESSION:
1. Colitis involving the descending and sigmoid ___, which
may be ischemic, infectious, or inflammatory in etiology.
2. Major mesenteric vessels are patent.
3. Chronic intra- and extra-hepatic biliary ductal dilatation,
unchanged.
___ CXR:
IMPRESSION: No acute cardiopulmonary process.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Losartan Potassium 50 mg PO DAILY
2. Fosfomycin Tromethamine 3 g PO PRN UTI
Dissolve in ___ oz (90-120 mL) water and take immediately PRN
UTI
3. Multivitamins 1 TAB PO DAILY
4. Nystop *NF* (nystatin) 100,000 unit/g Topical TID
5. Aspirin 81 mg PO DAILY
6. Citalopram 20 mg PO DAILY
7. Clotrimazole 1 TROC PO TID:PRN thrush
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
11. Omeprazole 20 mg PO BID
12. Simvastatin 20 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Simvastatin 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Clotrimazole 1 TROC PO TID:PRN thrush
9. Fosfomycin Tromethamine 3 g PO PRN UTI
Dissolve in ___ oz (90-120 mL) water and take immediately PRN
UTI
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
11. Nystop *NF* (nystatin) 100,000 unit/g Topical TID
12. Omeprazole 20 mg PO BID
13. Heparin 5000 UNIT SC TID
14. Metoprolol Tartrate 12.5 mg PO BID
Please hold for SBP < 100 or HR < 55. thank you.
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*1
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Left sided and sigmoid ischemic colitis
Secondary: Coronary artery disease, Peptic ulcer disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___.
HISTORY: ___ female with right upper quadrant and right lower
quadrant pain and dark bloody stool.
FINDINGS: AP and lateral views of the chest are compared to previous exam
from ___. The lungs are clear of focal consolidation. Opacity
at the left lung base most suggestive of atelectasis or scar. There is no
effusion. Cardiomediastinal silhouette is within normal limits. Osseous and
soft tissue structures are unremarkable. No free air is seen below the
diaphragm.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
HISTORY: ___ female with right upper and right lower quadrant pain as
well as dark stools. Rule out diverticulitis or mesenteric ischemia.
COMPARISON: Multiple priors including ___, and ___,
as well as MRCP performed ___.
TECHNIQUE: Helical CT images were acquired of the abdomen and pelvis
following the uneventful administration of 150 cc of Omnipaque intravenously
in the arterial, venous, and non-contrast phases. These were reformatted into
coronal and sagittal planes.
FINDINGS:
Bibasilar atelectasis is present, without pleural or pericardial effusion.
Small hiatal hernia is present.
ABDOMEN: Moderate intrahepatic biliary ductal dilatation is not significantly
changed from ___, with enlargement of the common bile duct, also unchanged,
measuring up to 1.4 cm. There is a 1.0-cm peripheral wedge shaped hypodensity
in segment VI which is unchanged and likely reflects prior infarct. A cyst in
segment VI measures 7mm and is unchanged from the ___ MRCP. The spleen,
adrenals, and pancreas appear normal. A 1.0-cm fat-containing lesion within
the medial pole of the left kidney is unchanged, compatible with an
angiomyolipoma. The kidneys demonstrate symmetric contrast enhancement and
brisk bilateral excretion without hydronephrosis. Small fat containing
umbilical hernia is present.
The stomach and loops of small bowel are normal in caliber without wall
thickening or differential enhancement of loops. Small bowel mesentery
appears normal. The aorta is normal in caliber, its major branches appear
patent, without evidence of SMA, ___, or celiac axis occlusion. Replaced right
hepatic artery is noted arising from the SMA.
PELVIS: There is wall thickening and inflammatory change involving the left
colon and sigmoid colon, reflecting colitis. No pneumatosis is present.
Specifically, adherent fecal material within the cecum containing air bubbles
is present, but not felt to be pneumatosis. There is diverticulosis, with no
evidence of diverticulitis. There is no intraperitoneal free air. The
uterus and adnexa are unremarkable. There is no pelvic side wall or
retroperitoneal lymph node enlargement.
BONES: There is multilevel degenerative change of the lumbar spine with
retrolisthesis of L1 on L2, and anterolisthesis of L5 on S1, both mild in
degree. Note is made of a hemangioma within the L5 vertebral body. There is
multilevel degenerative disc change with vacuum disc phenomenon.
IMPRESSION:
1. Colitis involving the descending and sigmoid colon, which may be ischemic,
infectious, or inflammatory in etiology.
2. Major mesenteric vessels are patent.
3. Chronic intra- and extra-hepatic biliary ductal dilatation, unchanged.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BLACK STOOL ,N,V
Diagnosed with ABDOMINAL PAIN LLQ, GASTROINTEST HEMORR NOS
temperature: 97.6
heartrate: 87.0
resprate: 18.0
o2sat: 99.0
sbp: 120.0
dbp: 79.0
level of pain: 6
level of acuity: 2.0 | ___ F with chronic diarrhea, prior remote volvulus and C. diff,
internal hemorrhoids p/w 2 weeks melanotic stools, 1 week of
diarrhea & chills, and 1 day of severe L-sided abdominal pain &
bloody diarrhea.
# ISCHEMIC COLITIS: Patient's symptoms and imaging findings
reflect a process in ___. Colitis most likely ischemic
due to recent dehydration secondary to nausea/vomiting/diarrhea
coupled with concomitant use of diuretics, which precipitated a
low flow state. No fevers, C. diff negative, negative stool
cultures ruling out an infectious process. Inflammatory causes
like diverticulitis could be a possibility however last
colonoscopy in ___ did not show any diverticulosis and the
radiographic findings are not consistent with diverticulitis.
Patient was started in IVF and kept NPO. Orthostatics were
checked daily. Her lactate on admission was 2.8 but normalized
the following day. Leukocytosis also normalized the next day.
Patient was also started on ceftriaxone and metronidazole to
prevent an infection, which was discontinued on the day of
discharge as she showed no signs of infection and her cultures
were negative. She completed a 7 day course.Blood cultures
remained negative as well.
Patient's diet was advanced as tolerated. By discharge, she was
able to tolerate a regular diet with her baseline abdominal
cramping and loose stools. Her pain was significantly improved,
and she only experienced mild tenderness on palpation of the
left lower quadrant.
# GI BLEED: Pt endorsed 2 weeks of melenic stool which was
concerning for upper GI source. She has a h/o of PUD and
internal hemorrhoids. In ED, patient had BRBPR but subsequent
stools while on floor were guaiac negative. She was started on
protonix drip then switched to protonix 40mg BID. Aspirin was
held initially but then restarted at the time of discharge. GI
saw patient and determined that no interventions were needed.
Her hematocrit and BP remained stable throughout her
hospitalization. Her protonix was changed back to her home dose
on discharge.
# DIARRHEA: States that she has chronic diarrhea/constipation
with cramping pain associated with meals secondary to IBS.
Diarrhea was greenish, liquid, guaiac negative. GI was consulted
and recommended probiotics.
# WORSENING DYSPNEA: Reports worsening dyspnea and angina in
past few months. H/o CAD. During her hospitalization, she denied
any chest pain. Last ECHO was in ___ which showed LVH with
preserved systolic function and mild mitral regurgitation. CXR
on admission was normal, EKG demonstrated chronic RBBB and no
acute changes. She remained stable during this hospitalization
and did not require further work-up. Further evaluation and
management may be performed per her PCP. She was started on a
low-dose beta-blocker at the time of discharge for
cardioprotection.
# CHRONIC ISSUES:
-PUD: she was kept on protonix 40mg BID and switched to her home
dose at the time of discharge
-HTN: all antihypertensive medications were held during
admission due to dehydration. They were restarted once patient
was stabilized and had negative orthostatics. She was newly
started on a beta-blocker at the time of discharge
-HYPOTHYROIDISM: continued on levothyroxine
-DEPRESSION: Continued on citalopram
-HLD: Continued on simvastatin
# TRANSITIONAL ISSUES
- please follow-up with iron studies to determine etiology of
anemia
- please monitor blood pressure given the new addition of
metoprolol tartrate 12.5mg po BID |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending: ___.
Chief Complaint:
chest pain and dyspnea
Major Surgical or Invasive Procedure:
___: cardiac catheterization
___: TEE with cardioversion
History of Present Illness:
___ year old man with a history of CHF (EtOH related dilated
cardiomyopathy, EF 35% in ___, history of alcohol abuse, CVA
x3, HTN, CKD (baseline creatinine , Hepatitis C, presenting with
dyspnea and chest pain for one day.
Patient states that ___ has not been able to fill his medications
for two weeks. Initially when ___ ran out ___ planned to get them
refilled, but as ___ developed a some shortness of breath ___
found it hard to get out of the house to do so. His wife, who
lives in a different house said she had offered to fill his
medications; patient is unable to provide other reason why ___
did not fill his medications, states that affordability was not
an issue.
One day prior to presentation, ___ developed pain in his chest.
___ had been seen by his PCP earlier in the day and was somewhat
short of breath at that time, and so was instructed to fill his
medications. Chest pain was described as heaviness that made if
more difficult to breath. Pain radiates to right shoulder. No
associated nausea or diaphoresis. ___ notes that ___ was unable to
sleep for the night prior to presentation, and had to sit
upright in order to breath more comfortably. Also notes
increasing lower extremity edema over the past week. Notable,
states his last drink was one month ago.
___ notes sporadic nonproductive cough. Denies palpitations,
nausea, abdominal pain, diarrhea, fevers, chills, or any other
pain.
___ presented to the ___ ED on the morning of ___. ___ was
tachypneic on arrival with crackles noted on exam, and was
started on BIPAP.
In the ED intial vitals were: 10 97.0 91 137/110 20 95% RA.
Placed on BiPAP for tachypnea (RR 28), given 80 IV lasix and SLN
x1 (with relief). Able to be weaned off BiPAP to 3L NC with RR
24 with these interventions.
EKG: Atrial flutter with HR 86
CXR: 1. Moderately severe cardiomegaly in a background of volume
overload. 2. Left lower lobe collapse and/or consolidation.
Labs/studies notable for: BNP 10000, Cr 1.8, mild bump in LFTs,
and mild anemia.
Patient was given: lasix and SLN as above, in addition to 324mg
asprin.
Vitals on transfer: HR 75, BP 110/89, RR 24, SPO2 100% on 3L
On the floor ___ continues to note shortness of breath, which was
relieved after a dose of SL nitroglycerin. Denies chest pain,
but continues to have right neck/shoulder pain.
REVIEW OF SYSTEMS: On review of systems, denies any prior
history of deep venous thrombosis, pulmonary embolism, bleeding
at the time of surgery, 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 paroxysmal
nocturnal dyspnea, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-Dilated cardiomyopathy (LVEF 35%, possibly ETOH related)
- Severe mitral regurgitation
-Hypertension
- CRI (Creatinine 1.7)
- Hx of 3 strokes, last was an L ACA/MCA stroke in ___
- Alcohol abuse
- Tobacco abuse
- HCV
- Impaired glucose tolerance
- Major depressive disorder
- History of hematochezia
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98, bp 118-130/75-98, HR 83, RR 26, SPO2 100 on 3L
GENERAL: WDWN man 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.
Moist oral mucosa
NECK: Supple with JVP of 8-9 cm.
CARDIAC: PMI enlarged, located in ___ intercostal space,
midclavicular line. RR, normal S1, S2. III/VI blowing systolic
murmur loudest at apex radiating to axilla. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Mildly
tachypneic, with bibasilar rales, no wheezing/rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pitting edema to knees bilaterally. Warm and
well perfused. SKIN: No stasis dermatitis, ulcers, scars, or
xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
==========================
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Moist oral
mucosa
NECK: Supple with JVP of 6 cm (decreased)
CARDIAC: PMI enlarged, located in ___ intercostal space,
midclavicular line. RR, normal S1, S2. III/VI blowing systolic
murmur loudest at apex radiating to axilla. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB
without wheezing, rhonchi or rales
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No lower extremity edema. Warm and well perfused.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
========================
___ 06:50AM BLOOD WBC-5.3 RBC-4.25* Hgb-13.1* Hct-38.8*
MCV-91 MCH-30.9 MCHC-33.9 RDW-18.5* Plt ___
___ 06:50AM BLOOD Neuts-63.2 ___ Monos-6.4 Eos-3.4
Baso-0.3
___ 08:03AM BLOOD ___ PTT-30.7 ___
___ 06:50AM BLOOD Glucose-121* UreaN-34* Creat-1.8* Na-139
K-4.7 Cl-107 HCO3-21* AnGap-16
___ 06:50AM BLOOD ALT-57* AST-47* AlkPhos-91 TotBili-1.5
___ 06:50AM BLOOD Lipase-56
___ 06:50AM BLOOD ___
___ 06:50AM BLOOD cTropnT-<0.01
___ 06:50AM BLOOD Albumin-4.1 Calcium-9.1 Phos-4.4 Mg-2.3
___ 07:18AM BLOOD ___ pO2-41* pCO2-31* pH-7.41
calTCO2-20* Base XS--3
___ 08:31AM URINE Color-Yellow Appear-Clear Sp ___
___ 08:31AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 08:31AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
PERTINENT LABS:
==========================
___ 09:30AM BLOOD ___ PTT-122.0* ___
___ 06:30AM BLOOD ___ PTT-38.4* ___
___ 01:09PM BLOOD Glucose-92 UreaN-35* Creat-1.6* Na-140
K-4.0 Cl-105 HCO3-24 AnGap-15
___ 05:12AM BLOOD Glucose-80 UreaN-38* Creat-1.6* Na-142
K-4.4 Cl-104 HCO3-23 AnGap-19
___ 06:30AM BLOOD Glucose-100 UreaN-45* Creat-1.9* Na-139
K-4.4 Cl-101 HCO3-23 AnGap-19
___ 04:40AM BLOOD ALT-49* AST-38 AlkPhos-70 TotBili-1.6*
___ 05:02AM BLOOD proBNP-2315*
___ 05:12AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.0
___ 05:12AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.1
___ 06:30AM BLOOD Calcium-9.6 Phos-5.1* Mg-2.3
DISCHARGE LABS:
===========================
___ 06:30AM BLOOD WBC-6.7 RBC-4.95 Hgb-14.6 Hct-45.6 MCV-92
MCH-29.5 MCHC-32.0 RDW-18.0* RDWSD-59.7* Plt ___
___ 06:30AM BLOOD Glucose-100 UreaN-48* Creat-2.0* Na-138
K-4.2 Cl-98 HCO3-25 AnGap-19
IMAGING:
===================================
#TTE ___:
The left atrial volume index is severely increased. The right
atrium is markedly dilated. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is severely dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is severely depressed (LVEF= 25 - 30 %). No
masses or thrombi are seen in the left ventricle. The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. Tricuspid annular plane systolic
excursion is depressed (1.4 cm) consistent with right
ventricular systolic dysfunction. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. An
eccentric, posteriorly directed jet of Severe (4+) mitral
regurgitation is seen. The mechanism of the mitral regurgitation
is likely to be due to posterior ___ leaflet tethering
___ 3b). The tricuspid regurgitation jet is eccentric
and may be underestimated. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Severe global biventricular systolic dysfunction
with severe mitral regurgitation due to posterior mitral valve
leaflet tethering.
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, if not previously known or
a change, a follow-up echocardiogram is suggested in ___ year; if
previously known and stable, a follow-up echocardiogram is
suggested in ___ years.
Compared with the prior study (images reviewed) of ___,
findings are similar. RV function is less vigorous and LV
function appears to be slightly less vigorous.
#CXR
Lordotic positioning .there is moderately severe cardiomegaly.
Relativeprominence of the superior mediastinum is likely
accentuated by a lordoticpositioning. There is increased
retrocardiac density, consistent with leftlower lobe collapse
and/or consolidation, with obscuration of lefthemidiaphragm and
faint air bronchograms. Equivocal minimal left pleuraleffusion.
Upper zone redistribution and mild vascular plethora,
consistentwith CHF. Hazy density at the right base could
represent a combination ofatelectasis and overlying soft
tissues. Attention to this area on followupfilms is requested.
A small right effusion would be difficult to exclude.There is no
pneumothorax or large pleural effusion. IMPRESSION: 1.
Moderately severe cardiomegaly in a background of volume
overload.2. Left lower lobe collapse and/or consolidation.
#CARDIAC CATHETERIZATION:
HEMODYNAMICS:
LV 106/17
Aorta 106/75
RA mean 6
RV ___
PA ___
PCW 25mean
CO 3.24
CI 1.44
PVR 4.0 ___
CORONARY
Dominance: right
LMCA: long LMCA had minimal luminal irregularities
LAD: mid LAD had mild plaquing. The proximal D1 had mild
plaquing. the distal LAD wrapped slightly around the apex. Flow
in the LAD was delayed and pulsatile, consistent with
microvascular dysfunction.
LCX: proximal LCX had minimal luminal irregularites. The LCX
supplied a small very high take-off OM1, a modest caliber high
OM2, a large OM3, a modest caliber OM4 that ran parallel to the
AV groove, and a small short LPL. Flow in the CX was slow,
consistent with microvascular dysfunction.
RCA: the RCA had a mild angulated plaque proximally (possibly
catheter induced spasm). The mid RCA had minimal luminal
irregularities and the distal RCA before the RPDA had mild
plaquing. the distal AV groove RCA just beyond the origin of the
RPDA had a 40% stenosis. The RPDA gave off an early sidebranch
that was functionally a short RPL. The RPDA and the angulated
RPL2 were large, although the RPDA, RPL1 and RPL2 were all long
vessels.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Ketoconazole 2% 1 Appl TP BID
3. Minerin (mineral oil-isopropyl myristat;<br>white
petrolatum-mineral oil) unknown topical DAILY:PRN
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Spironolactone 25 mg PO DAILY
7. Aspirin 325 mg PO DAILY
8. Nephrocaps 1 CAP PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Furosemide 120 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Ketoconazole 2% 1 Appl TP BID
6. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Renal Caps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
8. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Vitamin D ___ UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
10. HydrALAzine 25 mg PO Q8H
RX *hydralazine 25 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
11. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
12. Minerin (mineral oil-isopropyl myristat;<br>white
petrolatum-mineral oil) 1 application TOPICAL DAILY:PRN pruritus
13. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
RX *isosorbide mononitrate 30 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
14. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth once daily Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
-Acute exacerbation of chronic congestive heart failure
-Dilated cardiomyopathy
-Atrial flutter
-Acute kidney injury
SECONDARY DIAGNOSES:
=========================
-Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION:
___ with sob, evaluate for pneumonia or CHF..
COMPARISON: None Available.
TECHNIQUE
Portable view of the chest.
FINDINGS:
Lordotic positioning .there is moderately severe cardiomegaly. Relative
prominence of the superior mediastinum is likely accentuated by a lordotic
positioning. There is increased retrocardiac density, consistent with left
lower lobe collapse and/or consolidation, with obscuration of left
hemidiaphragm and faint air bronchograms. Equivocal minimal left pleural
effusion. Upper zone redistribution and mild vascular plethora, consistent
with CHF. Hazy density at the right base could represent a combination of
atelectasis and overlying soft tissues. Attention to this area on followup
films is requested. A small right effusion would be difficult to exclude.
There is no pneumothorax or large pleural effusion.
IMPRESSION:
1. Moderately severe cardiomegaly in a background of volume overload.
2. Left lower lobe collapse and/or consolidation.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea, Chest pain
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 97.0
heartrate: 91.0
resprate: 20.0
o2sat: 95.0
sbp: 137.0
dbp: 110.0
level of pain: 10
level of acuity: 2.0 | ___ year old man with a history of CHF (EtOH related dilated
cardiomyopathy, EF 35% in ___, history of alcohol abuse, CVA
x3, HTN, CKD (baseline creatinine , Hepatitis C, presenting with
dyspnea and chest pain, admitted for exacerbation of systolic
congestive heart failure.
# Dilated Cardiomyopathy/Decompensated Systolic Heart Failure:
Patient stated that ___ has not been able to fill his medications
for two weeks. Initially when ___ ran out ___ planned to get them
refilled, but as ___ developed a some shortness of breath ___
found it hard to get out of the house to do so. ___ is unable to
provide other reason why ___ did not fill his medications, states
that affordability was not an issue.
One day prior to presentation, ___ developed pain in his chest.
___ had been seen by his PCP earlier in the day and was somewhat
short of breath at that time, and so was instructed to fill his
medications. Chest pain was described as heaviness that made if
more difficult to breath. Pain radiates to right shoulder. No
associated nausea or diaphoresis. ___ notes that ___ was unable to
sleep for the night prior to presentation, and had to sit
upright in order to breath more comfortably. Also notes
increasing lower extremity edema over the past week. Notable,
states his last drink was one month ago.
On arrival to ___ ___ was noted to have dyspnea, tachypnea,
elevated JVP, pulmonary rales, lower extremity edema, and CXR
showed pulmonary edema. Echo in ___ showed LVEF 35% with
global biventricular dysfunction and dilation, consistent with
dilated cardiomyopathy. Given that ___ has risk factors for CAD
(make smoker in ___, underwent left heart cath which showed
clean coronary arteries. RHC showed:
RA 5
RV ___
PA ___ (40)
PCWP 25
PA sat 40% (CO ~3, CI ~1.4-1.5)
RHC ndicated euvolemia with left sided pressure overload, as
well as severely reduced cardiac output. ___ was tarted on
afterload reduction with hydralazine and isordil, and ___
tolerated uptitrating doses. Repeat echo confirmed previous
findings, with biventricular dilation and dysfunction, severe
MR.
___ improved with medical management (as expected given his lack
of medications for 2 weeks prior to admission), with furosemide
(transitioned to torsemide), metoprolol, lisinopril,
spironolactone, hydralazine, and isosorbide mononitrate.
#ATRIAL FLUTTER:
Patient presented with atrial fibrillation and maintained normal
heart rate while in this arrhythmia.
New onset this admission. Possibly triggered by decompensated
heart failure vs underlying cardiomyopathy. CHADS2 score 4. ___
underwent successful TEE cardioversion on ___, and remained
in sinus rhythm thereafter. ___ was started on apixaban.
# ___ on CKD: Cr baseline appears near 1.5; Cr elevated to 1.8
on admission, underlying etiology unclear but likely component
of cardiorenal syndrome. Outpatient renal ultrasound shows only
simple cysts. No significant protienuria on outpatient UA.
Creatinine improved initially with diuresis. Creatinine had
improved but ___ was increased to 1.9 likely due to
overdiuresis. Continued home nephrocaps
# CVAs
- continued home atorva 80, aspirin 81mg
# Hep C: LFTs near baseline. Had plans to follow up in liver
clinic on ___ to establish care, however ___ missed this
appointment since ___ was hospitalized. Does have evidence of
cirrhosis on ultrasound.
TRANSITIONAL ISSUES:
====================
- to follow up with Dr ___: further mangement and work up
of underlying cardiomyopathy
- continue to encourage smoking cessation and alcohol abstinence
as outpatient
- noted to have severe (4+) mitral reguritation during this
admission when euvolemic; C-surg evaluation was defered in
setting of patient being an active smoker/drinker
- dry weight: 97 kg
- Torsemide 40mg daily to start the day after discharge with
followup electrolytes and ___ visit in one week |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old man PMHx of chronic sCHF (40-45%), IDDM, HTN/HL,
ESRD on HD (___), AFib/flutter who presents with L
sided chest pain at the end of HD. He developed acute SOB, L
sided chest pain (___), and bilateral hand cramping immediately
after being disconnected from the HD machine at dialysis. He
reports similar chest pain prior, but this was different due to
both hand cramping and SOB. Reports recent ___ edema stating he
required an extra session of dialysis yesterday. Pt currently
pain free. He states last crack cocaine use as last week.
Persantine stress ___ showed mild reversible inferolateral
perfusion abnormality is improved since ___. Exam notable or
irreg irreg rhythm. Of note patient recently hosp at BI for PNA
and afib w/ RVR d/c ___.
.
In the ED, initial vitals were 98.8, 92, 118/78, 20, 99% 2Lnc.
A CXR was negative as well as CE x 1. A serum tox was negative
for ASA, ETOH, acetominophen, benzo, barb, or tricyc.
.
After admission to the floor reports the pain is much improved,
now at ___ and he no longer has SOB or hand cramping. He also
denies recent f/c, n/v, diarrhea or constipation, dysuria,
rashes, or joint pain. He c/o long standing right side foot
drop and pain in calf.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
1. ESRD on HD ___ at ___ Dialysis, ___,
___
2. Type 2 diabetes mellitus c/b peripheral neuropathy
3. Chronic systolic CHF with EF 30% ___ TTE)
4. Atrial fibrillation/AFlutter
- s/p ablation ___ s/p ablation x 2 in ___
- not on coumadin due to history of GIBs.
5. Hypertension
6. Dyslipidemia
7. History of GI bleeds: Duodenal, jejunal, and gastric AVMs s/p
thermal therapy; diverticulosis throughout colon
8. Chronic pancreatitis
9. ? HCV: HCV Ab + ___, but neg ___
10. GERD
11. Gout: s/p arthroscopy with medial meniscectomy ___
12. Depression with multiple hospitalizations due to SI
13. Polysubstance abuse: crack cocaine, EtOH, tobacco
14. recurrent chest pain following crack/cocaine use
- no evidence CAD on cath ___
15. Erectile dysfunction s/p inflatable penile prosthesis ___
16. H/o C diff in ___
17.thyrotoxicosis
Social History:
___
Family History:
Mother died of MI; per OMR multiple sibs with T2DM
Physical Exam:
On Admission
VS: T= 97.6 BP=109/76 HR=91 RR=20 O2 sat=100% on 2L BS=156
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no elevated JVP
CARDIAC: irregularly irregular HR RR, normal S1, S2. No m/r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
CHEST: pain with palpation from ___ intracostal space to 8
intracostal space approximatley 2 inch on either side of mid
clavicular line. HD catheter in place on L, C/D/I
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
Neuro: CNS II-VII intack, ___ on dorse flexion of R foot
otherwise symetry muscle strength throughout, sensation to light
touch intact throughout
PULSES: radial and DP +2 bilaterally
.
On Discharge
VS: afebrile BP=normotensive HR=100-110 RR=20 O2 sat=100% on RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no elevated JVP
CARDIAC: irregularly irregular HR, normal S1, S2. No m/r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
CHEST: HD catheter in place on L, C/D/I
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
Neuro: CNS II-VII intack, ___ on dorse flexion of R foot
otherwise symetry muscle strength throughout, sensation to light
touch intact throughout
PULSES: radial and DP +2 bilaterally
Pertinent Results:
On Admission:
___ 12:00PM BLOOD WBC-7.8 RBC-4.17* Hgb-13.1* Hct-40.0
MCV-96 MCH-31.5 MCHC-32.8 RDW-15.8* Plt ___
___:00PM BLOOD Neuts-75.0* ___ Monos-3.7 Eos-2.2
Baso-0.6
___ 12:00PM BLOOD ___ PTT-26.4 ___
___ 12:00PM BLOOD Glucose-247* UreaN-22* Creat-4.0*# Na-138
K-3.3 Cl-97 HCO3-23 AnGap-21*
___ 12:00PM BLOOD Calcium-10.2 Phos-3.9# Mg-2.3
___ 12:00PM BLOOD CK-MB-9
___ 12:00PM BLOOD cTropnT-0.27*
___ 08:42PM BLOOD CK-MB-8 cTropnT-0.29*
___ 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
On Discharge:
___ 10:10AM BLOOD Digoxin-0.7*
___ 05:55AM BLOOD WBC-8.8 RBC-4.06* Hgb-13.1* Hct-39.9*
MCV-98 MCH-32.3* MCHC-32.9 RDW-15.6* Plt ___
___ 05:55AM BLOOD Glucose-289* UreaN-47* Creat-6.1*# Na-135
K-6.5* Cl-96 HCO3-21* AnGap-25* (hemolysed)
___ 10:10AM BLOOD Glucose-184* UreaN-50* Creat-6.4* Na-138
K-5.2* Cl-97 HCO3-26 AnGap-20
___ 10:10AM BLOOD Calcium-11.0* Phos-7.5* Mg-2.8*
___ CXR:
FINDINGS: Compared to most recent prior exam, there has been
interval resolution of pulmonary edema. Linear density along the
minor fissure may represent residual fluid or scarring. No
pleural effusion or pneumothorax is seen. No focal consolidation
is seen, although lateral evaluation is slightly limited due to
low lung volumes. Heart size is enlarged. Mediastinal contours
are within normal limits. A left-sided subclavian line is in
similar position.
IMPRESSION: Interval resolution of pulmonary edema with
persistent borderline cardiomegaly.
Medications on Admission:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q6H (every 6 hours) as needed for SOB,
wheezing.
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for itching.
7. insulin glargine 100 unit/mL Solution Sig: ___ (26)
Units Subcutaneous at bedtime.
8. insulin lispro 100 unit/mL Solution Sig: ___ Units
Subcutaneous three times a day as needed for As directed by
sliding scale.
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical BID (2 times a day).
10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. methimazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet
Sublingual Every 5 minutes up to 3 as needed for chest pain: If
pain persists after 3 tablets, STOP and call your doctor or go
to the ED.
13. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO At HD as needed for pain.
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
17. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
18. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
19. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
21. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
22. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. cinacalcet 90 mg Tablet Sig: One (1) Tablet PO once a day.
3. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
5. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for itching.
6. insulin glargine 100 unit/mL Solution Sig: One (1) 26 units
Subcutaneous at bedtime.
7. insulin lispro 100 unit/mL Solution Sig: One (1) ___ units
Subcutaneous three times a day as needed for As directed by
sliding scale.
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical once a day.
9. methimazole 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain.
11. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO at HD as needed for pain.
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
13. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
15. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
20. digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
21. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation once a day as needed for shortness of breath
or wheezing.
22. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
23. Outpatient Lab Work
Please have your digoxin level check at dialysis and faxed to
your cardiologist, Dr. ___. fax# ___ His phone
number is ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
atypical chest pain
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
CLINICAL INDICATION: ___ male with chest pain.
___.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
FINDINGS: Compared to most recent prior exam, there has been interval
resolution of pulmonary edema. Linear density along the minor fissure may
represent residual fluid or scarring. No pleural effusion or pneumothorax is
seen. No focal consolidation is seen, although lateral evaluation is slightly
limited due to low lung volumes. Heart size is enlarged. Mediastinal
contours are within normal limits. A left-sided subclavian line is in similar
position.
IMPRESSION: Interval resolution of pulmonary edema with persistent borderline
cardiomegaly.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERCHOLESTEROLEMIA
temperature: 98.8
heartrate: 62.0
resprate: 20.0
o2sat: 100.0
sbp: 111.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | This is a ___ year old man with past medical history significant
for chronic sCHF (LVEF of 40-45%), IDDM, HTN/HL, ESRD on HD
(___), AFib who presents with L sided chest pain at
the end of HD, and ruled out for ACS.
.
#. chest pain- The patient developed L sided non-radiating chest
pain immediately after being disconnected from the HD machine,
which giving the time was concerning for a possible air
embolism. Although, the patient was rule out with two negative
sets of CE and with no EKG changes. He was continued on
supplemental O2 for 12 hours. By the next morning, the chest
pain had completely resolved and the patient was discharged with
follow up with HD per home schedule of TTS.
.
# Afib- The patient was continued on his home medication with
exception of starting ___ his home dose of diltizem. Although
he has a CHADS2 score of >2, given multiple prior GI bleeds
requiring transfusion, he was not started on warfarin. Of note,
a beta blocker is contra-indicated given ongoing cocaine use.
He was monitored on telemetry demonstrating at time RVR up to
120's, but returned to 100's once given his full home dose of
diltizem. He was asymptomatic. The patient was told to stop
using cocaine.
.
#. Systolic CHF with EF of 40-45%. His home dose of lisinopril
was continued. A beta-blocker is contraindicated given ongoing
cocaine use. Spironolactone is not indicated for ___ class II
with an EF >35 and creatine >2.5 to due concerns of
hyperkalemia. He is not currently on a statin given a history
of myalgias while on prior statin therapy.
.
# ESRD- He home medication of sevelamer, nephrocaps, cinacelcet
were continued. He should continue HD on his home schedule of
TTS.
.
# Amiodarone induced hyperthyroidism, likely type II: He should
followed up with his outpatient endocrine specialist. His home
doses of methimazole and prednisone were continued.
.
# Chronic lower extremity pain. He was continued on lidocaine
patches and his home dose of gabapentin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old gentleman with history of type 1
diabetes who presents with 2 weeks of generalized weakness.
___ reports he was in his usual state of health until 2 weeks
ago. He has noted worsening generalized weakness, weight loss,
increased urinary frequency, hypersomnolence. He also mentions
bilateral lower extremity numbness, weakness x 1 month. He has
not had fevers, chills, cough, chest pain, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, dysuria. He has been
a type 1 diabetic since age ___, does not recall being
hospitalized with DKA. He takes insulin lantus 40U qhs, was
previously using Humalog SS TID and checking fingersticks TID,
however has not been taking Humalog x 1 month. He sees
endocrinologist and NP at ___, most recent nurse retired, his
new nurse has prescribed him insulin syringes when he prefers
the insulin pens. He has therefore not picked up the
prescriptions for his insulin Humalog.
In the ED, initial vitals:
T 98.0 HR 110 BP 121/66 RR 18 O2 100% RA
Labs notable for WBC 9.3, H/H and plts wnl, hemolyzed lytes Na
126, K 6.2, bicarb 14, Cr 1.5 glucose 705, AG 22. Lactate 1.9.
VBG pH 7.28/32/54. UA negative nitrites, negative leuks, glucose
1000, ketones +40.
Patient received 3L IVF, started on insulin gtt, 40mEq K
On transfer, vitals were:
HR 90 BP 109/60 RR 18 O2 sat 100% RA
On arrival to the MICU, patient is very comfortable, no
infectious symptoms. He is hungry, no abdominal pain, nausea,
vomiting, diarrhea. He reports leg weakness x 1 month. No
incontinence of urine or stool. No impotence. No saddle
anesthesia. He denies financial insecurity, with ___ has
$1 copay for insulin which is affordable for him.
Past Medical History:
Type 1 Diabetes diagnosed at age ___
Asthma
Social History:
___
Family History:
grandfather with DM2, aunt with DM2, no other known family
medical conditions
Physical Exam:
ADMISSION EXAM:
=================
Vitals: T:98.5 BP: 117/72 P: 90 R: 15 O2:100% on RA
GENERAL: Alert, oriented, very pleasant, very comfortable
appearing, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: warm, well perfused, no rashes or lesions
NEURO: axox3, CNII-XII intact, moving all 4 extremities,
sensation to light touch grossly intact plantar flexion ___
strength bilaterally
DISCHARGE EXAM
================
VS - 98.2 124/71 92 18 95%
FSBG: 140-256
GENERAL: Alert, oriented, very pleasant, very comfortable
appearing, no acute distress
HEENT: Sclera anicteric, moist mucous membranes, oropharynx
clear,
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: warm, well perfused, no rashes or lesions
NEURO: aaox3, CNII-XII intact, moving all 4 extremities,
sensation to light touch grossly intact as well as pain. Noted
weakness ___ in dorsi-flexion. ___ strength in
plantarflexion. ___ strength at ___ knees. ___ strength hip and
UE. Cerebellar function intact (FTN). No clonus. Arreflexia at
Achilles and knees. High stepping gait with bilateral foot drop
Pertinent Results:
ADMISSION LABS:
___ 02:45PM BLOOD WBC-9.3 RBC-4.87 Hgb-15.2 Hct-42.7 MCV-88
MCH-31.2 MCHC-35.6 RDW-12.9 RDWSD-40.5 Plt ___
___ 02:45PM BLOOD Neuts-82.0* Lymphs-11.8* Monos-4.9*
Eos-0.5* Baso-0.4 Im ___ AbsNeut-7.59* AbsLymp-1.09*
AbsMono-0.45 AbsEos-0.05 AbsBaso-0.04
___ 02:45PM BLOOD Glucose-705* UreaN-18 Creat-1.5* Na-126*
K-6.2* Cl-90* HCO3-14* AnGap-28*
___ 09:00PM BLOOD Calcium-8.7 Phos-2.0* Mg-1.7
___ 02:57PM BLOOD ___ Temp-36.7 pO2-54* pCO2-32*
pH-7.28* calTCO2-16* Base XS--10 Intubat-NOT INTUBA
___ 02:57PM BLOOD Lactate-1.9 K-3.9
___ 06:31PM BLOOD O2 Sat-67
Micro: none
Images:
MRI ___: 1. Mild disc bulging at L4-5 and L5-S1 levels. Mild
bilateral neural foraminal stenosis at the L4-L5 disc space.
Moderate bilateral neural foraminal stenosis at the L5-S1 level.
No evidence of spinal canal stenosis, disc herniation, or nerve
root displacement in the lumbar spine.
2. Bony island in the left side of the sacrum.
DISCHARGE LABS:
___ 07:25AM BLOOD WBC-5.6 RBC-5.05# Hgb-15.8# Hct-47.1#
MCV-93# MCH-31.3 MCHC-33.5 RDW-13.4 RDWSD-45.8 Plt ___
___ 02:45PM BLOOD Neuts-82.0* Lymphs-11.8* Monos-4.9*
Eos-0.5* Baso-0.4 Im ___ AbsNeut-7.59* AbsLymp-1.09*
AbsMono-0.45 AbsEos-0.05 AbsBaso-0.04
___ 07:45AM BLOOD Glucose-288* UreaN-13 Creat-0.8 Na-136
K-3.8 Cl-98 HCO3-28 AnGap-14
___ 07:25AM BLOOD Cortsol-15.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Equipment
Crutches
Dx: Bilateral Polyneuropathy (ICD 10 G62.9)
Px: good
Length of need: 13 months
2. Glargine 40 Units Bedtime
Humalog 18 Units Breakfast
Humalog 18 Units Lunch
Humalog 18 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
40 Units before BED; Disp ___ Milliliter Refills:*0
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR 18u
before meals, ASDIR per sliding scale Disp ___ Milliliter
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diabetic Ketoacidosis
Diabetes Mellitus Type 1
Peripheral Motor Neuropathy
Chronic Issues:
Asthma
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 ___ SPINE W/O CONTRAST ___ MR SPINE
INDICATION: ___ year old man with one month history of progressive bilateral
plantar/dorsiflexion weakness suspicious for L4-L5 nerve root compression //
Evidence of lumbar nerve root pathology Evidence of lumbar nerve root
pathology
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: None.
FINDINGS:
No evidence of disc bulging or neural foraminal stenosis in the T12-L1, L1-L2,
L2-L3 levels.
L4-L5: Mild disc bulging. Mild bilateral neural foraminal stenosis. No
spinal canal stenosis. No nerve root displacement. No disc herniation.
L5-S1: Mild disc bulging. Moderate bilateral neural foraminal stenosis. No
spinal canal stenosis. No nerve root displacement to no disc herniation.
Alignment is normal. There are focal areas of degenerative change in the
superior endplates of the sacrum and the L5 vertebral body from (3: Level).
In the left side of the sacrum there is a hypo intense focus measuring 10 mm
on T1 weighted, T2 weighted, and STIR sequences (03:17) that likely represents
a bony island. No evidence of discitis or spondylolysis.
IMPRESSION:
1. Mild disc bulging at L4-5 and L5-S1 levels. Mild bilateral neural
foraminal stenosis at the L4-L5 disc space. Moderate bilateral neural
foraminal stenosis at the L5-S1 level. No evidence of spinal canal stenosis,
disc herniation, or nerve root displacement in the lumbar spine.
2. Bony island in the left side of the sacrum.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Weakness
Diagnosed with Type 1 diabetes mellitus with ketoacidosis without coma, Long term (current) use of insulin
temperature: 98.0
heartrate: 110.0
resprate: 18.0
o2sat: 100.0
sbp: 121.0
dbp: 66.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old gentleman with history of type 1
diabetes who presented with DKA secondary to insulin
noncompliance. His condition improved in the ICU with fluids and
insulin and his anion gap closed. On the floor, patient was
stable with continued hyperglycemic control, but was noted to
have ___ month history of progressive dorsi/plantarflexion
weakness. He was evaluated by neurology. TSH and AM cortisol
WNL. Hb A1C 17.9% this admission and may account for some of his
neuropathy. MRI revealed mild bilateral neural foraminal
stenosis at the L4-L5 disc space and moderate bilateral neural
foraminal stenosis at the L5-S1 level; the impression of
neurology was that this likely represented the etiology of his
weakness, however, per my discussion with neurology attending,
nothing on imaging to suggest a need for surgery - furthermore,
the etiology was not entirely clear, also on the differential
remain diabetic neuropathy, or an inflammatory disorder such as
CIDP. He will continue to work with ___ and will follow up with
outpatient EMG and neurology.
#Diabetic Ketoacidosis:
Patient is type 1 diabetic presented with hyperglycemia, AG
acidosis, urine ketones consistent with DKA. Patient had not
been taking his Humalog secondary to a switch from pens to
syringes. No infectious symptoms, leukocytosis, or fevers to
suggest active infection. Anion gap closed with insulin. Patient
resumed on his home insulin regimen and provided prescription
with insulin pens. Patient to follow up with his
endocrinologist, A1c of 17.9%.
- continued home lantus 40U qhs
- 18u Humalog with meals; back to home regimen
- A1c 17.9%
#Lower extremity weakness:
Best characterized as symmetric peripheral motor neuropathy,
appears to be ascending. Patient with lower extremity weakness,
intact sensation, no red flag symptoms. Notes progressive loss
of strength primarily in plantar/dorsiflexion over past month.
Appears to have started before discontinuation of Humalog. ___
be an element of diabetic neuropathy/myopathy, but seems to be
more consistent with a compressive neuropathy. MRI L spine
reveals lumbar stenosis at L5-S1 level which could be implicated
in patient's weakness. Pt will receive further EMG testing and
follow up with neurology. Alternative possibility is
CIDP-likeneuropathy particuarly given the areflexia.
- EMG studies outpatient and Neuromuscular follow up
- TSH WNL, LFTs WNL, B12 ___, AM cortisol WNL
- ___ + AFOs
#Anemia: Resolved. Appeared secondary to hemodilution but back
to baseline. Pt denies active bleeding. Iron studies WNL,
Hemolysis labs WNL
===================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
___ - Atrial Flutter Ablation
History of Present Illness:
This is a ___ woman with a past medical history
significant for hypothyroidism who was transferred from
___ for atrial flutter now s/p ablation.
Patient states that starting 4 days prior to admission in the
morning at 3 AM she awoke feeling a rapid heart beat. She states
that she was extremely dyspneic and mildly lightheaded. She went
back to sleep, awoke the next morning, felt much better. When
she woke up she was seen at her PCP's office and noted to be in
atrial flutter with a ventricular rate in the 150s. In the
emergency room, she was given IV metoprolol and IV diltiazem;
and shortly thereafter, did convert to normal sinus rhythm but
was noted to be bradycardic in the ___ with hypotension. She was
then given atropine and 3 L of normal saline and admitted to
___. She was started on Eliquis, metoprolol 12.5 bid and
arranged for consultation with Dr ___ on ___. She took her
first dose of Eliquis on ___ AM, last dose ___ morning.
She remained in NSR until morning of admission when felt
palpitations again after walking up a flight of stairs with
subjective lightheadedness. She was HDS and symptoms free. At
that time decision was made to transfer her to ___.
In the ED initial vitals were: 97.5 149 117/68 14 98% RA. EKG
showed narrow complex regular tachycardia to 150 bpm.
Labs/studies notable for: wbc 6.4, Hgb 13.5, plts 298, Cr 0.6,
inr 1.2. Patient was started on a diltiazem drip and given 1L
IVF
She was taken to the EP lab for successful ablation via femoral
approach. On arrival to the floor vitals were 98 101/60 78 12
97% RA. She was feeling well with no acute complaints.
Past Medical History:
-Atrial Flutter s/p ablation (___)
-Knee pain.
-Ventral hernia.
-Osteoporosis.
-Hypothyroidism.
-Scoliosis.
-Hyperlipidemia.
-Chronic back pain, w/ 2 prior surgeries
Social History:
___
Family History:
Mother with alcoholic cirrhosis, DMII, and colon cancer. Father
with heart failure and colon cancer.
Physical Exam:
Admission Physical Exam:
VS: 98 101/60 78 12 97% RA
GENERAL: NAD pleasant female, AAOx3.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no JVD
CARDIAC: RRR, no m/r/g
LUNGS: Clear to auscultation, no w/r/r
ABDOMEN: Soft, NTND. No HSM or tenderness.
GROIN: R dressing C/D/I, no hematoma/bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: DP, ___ pulses 2+ bilaterally
Discharge Physical Exam:
Afebrile, HR 70-80s, sinus rhythm. Exam otherwise unchanged.
Pertinent Results:
===============
Admission Labs:
===============
___ 01:30PM BLOOD WBC-6.4 RBC-4.21 Hgb-13.5 Hct-40.8 MCV-97
MCH-32.1* MCHC-33.1 RDW-12.3 RDWSD-43.7 Plt ___
___ 01:30PM BLOOD Neuts-52.8 ___ Monos-11.1 Eos-1.7
Baso-0.9 Im ___ AbsNeut-3.38 AbsLymp-2.13 AbsMono-0.71
AbsEos-0.11 AbsBaso-0.06
___ 02:57PM BLOOD ___ PTT-38.9* ___
___ 01:30PM BLOOD Glucose-90 UreaN-10 Creat-0.6 Na-133
K-4.3 Cl-98 HCO3-23 AnGap-16
===============
Discharge Labs:
===============
___ 06:00AM BLOOD WBC-7.3 RBC-3.73* Hgb-11.9 Hct-36.6
MCV-98 MCH-31.9 MCHC-32.5 RDW-12.4 RDWSD-44.8 Plt ___
___ 06:00AM BLOOD Glucose-78 UreaN-10 Creat-0.6 Na-135
K-4.3 Cl-100 HCO3-28 AnGap-11
___ 06:00AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2
========
Imaging:
========
CXR ___
Impression: No acute intrathoracic process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Gabapentin 300 mg PO TID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Alendronate Sodium 70 mg PO QMON
5. Cyclobenzaprine ___ mg PO HS:PRN muscle pain
6. Apixaban 5 mg PO BID
7. Metoprolol Succinate XL 12.5 mg PO DAILY
8. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Atorvastatin 10 mg PO QPM
3. Cyclobenzaprine ___ mg PO HS:PRN muscle pain
4. Gabapentin 300 mg PO TID
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Alendronate Sodium 70 mg PO QMON
7. Metoprolol Succinate XL 12.5 mg PO DAILY
8. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Atrial Flutter s/p Ablation
Secondary:
- Hypothyroidism
- Back Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with sob and tachy pls eval for edema or pna
COMPARISON: ___
FINDINGS:
AP portable upright view of the chest.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
Dextroscoliosis of the lumbar spine is partially visualized.
IMPRESSION:
No acute intrathoracic process
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Tachycardia
Diagnosed with Unspecified atrial flutter
temperature: 97.5
heartrate: 149.0
resprate: 14.0
o2sat: 98.0
sbp: 117.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman with a past medical history
significant for hypothyroidism who was transferred from
___ for atrial flutter.
# Atrial Flutter: She was taken to the EP lab where she
underwent successful atrial flutter ablation. She was monitored
overnight and did well. She remained in sinus rhythm. There were
no complications. She was discharged on her home metoprolol and
apixaban.
# Hypothyroidism: Her home levothyroxine was continued.
# Chronic back pain: Continue gabapentin and flexeril.
# Hyperlipidemia: Continue statin.
# Osteoporosis: Continue alendronate.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Allopurinol And Derivatives
Attending: ___
Chief Complaint:
Dyspnea and orthopnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old male with h/o HTN and ESRD on HD
pending transplant who presents with dyspnea and orthopnea.
Patient reports that he has had 1.5 weeks exertional dyspnea and
orthopnea. Yesterday the SOB was markedly worse and he felt
quite anxious due to the discomfort. He also had ___ hours of
nausea/vomiting/diarrhea associated with subjective fever which
started and resolved rapidly. He went to dialysis yesterday as
well. He admits having had some barbeque the day before
although no mayonnaise/egg/undercooked foods.
In the ED vitals were T 97.8 P 82 BP 95/36 R 16 SPO2 100% on RA.
CXR nonacute. Labs from the ED are below. Troponins were flat
x 2.
Past Medical History:
PMHx:
ESRD with AVF on HD, on transplant list
HTN
___ esophagus with high grade dysplasia
Gout
Distant h/o asthma
Social History:
___
Family History:
No family history of kidney disease. Father died of MI at age
___, mom died of breast ca at age ___. No DM in family.
Physical Exam:
ON ADMISSION:
VS: T 97.7 BP 105/69 P 85 R 18 SPO2 94% on RA
Wt 98.5 kg
General: Alert, NAD, comfortably reclining in bed
HEENT: Moist mucous membranes
Neck: Jugular venous pulse meniscus visualized at 2-3 cm above
sternal notch, neck is obese/thick
CV: RRR, S1 and S2 present, no murmurs gallops or rubs.
Lungs: CTAB
Abdomen: + BS, soft, nontender, obese
Ext: No edema. Warm and well-perfused. AVF noted in right
upper arm.
Neuro: WNL
Pulses: 2+ throughout UE and ___
UPON DISCHARGE:
VS: T 97.6 BP 125/79 P 67 R 18 SPO2 99% on RA
Wt 98.7
General: Alert, NAD, comfortably reclining in bed
HEENT: Moist mucous membranes
Neck: Jugular venous pulse meniscus not visualized, neck is
obese/thick
CV: RRR, S1 and S2 present, no murmurs gallops or rubs.
Lungs: CTAB
Abdomen: + BS, soft, nontender, obese
Ext: No edema. Warm and well-perfused. AVF noted in right
upper arm.
Neuro: WNL
Pulses: 2+ throughout UE and ___
Pertinent Results:
ADMISSION LABS
___ 09:30AM GLUCOSE-124* UREA N-30* CREAT-8.0*#
SODIUM-140 POTASSIUM-4.5 CHLORIDE-91* TOTAL CO2-35* ANION GAP-19
___ 09:30AM CK-MB-4 cTropnT-0.07*
___ 09:30AM ALBUMIN-4.1 CALCIUM-9.4 PHOSPHATE-6.5*#
MAGNESIUM-1.7
___ 09:30AM TSH-1.7
___ 09:30AM WBC-6.0 RBC-3.43* HGB-12.3* HCT-35.7*
MCV-104* MCH-35.7* MCHC-34.3 RDW-14.3
___ 12:20AM CK-MB-5 cTropnT-0.07* ___
___ 7:30AM Na 138 K 5.7 Cl 94 HCO3 29 BUN 49 Cr 10.3 Gluc 88
___ 7:30AM Ca 9.4 Mg 1.9 Phos 6.4
___ 7:30AM ___ ___
DISCHARGE LABS
___ 06:17AM BLOOD WBC-8.1 RBC-3.38* Hgb-12.1* Hct-35.0*
MCV-103* MCH-35.7* MCHC-34.5 RDW-13.8 Plt ___
___ 06:17AM BLOOD Glucose-92 UreaN-77* Creat-12.3*# Na-140
K-6.0* Cl-95* HCO3-24 AnGap-27*
___ 06:17AM BLOOD Calcium-9.0 Phos-7.7* Mg-1.8
REPORTS
___ Cardiovascular ECHO
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). There is no left
ventricular outflow obstruction at rest or with Valsalva. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets
(?#) appear structurally normal with good leaflet excursion. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Mild pulmonary artery hypertension. Dilated
ascending aorta.
Compared with the prior study (images reviewed) of ___,
the findings are similar
AVF doppler ___: INDICATION: AV fistula and heart failure.
Duplex evaluation was performed of the surgical AV fistula. The
diameter of
the outflow vein ranges from 0.6-2.3 cm. Arterial inflow has a
velocity of
120, venous outflow 226, the access 474 and 538 and the volume
of flow was
243.
IMPRESSION: Patent AV fistula, very dilated area of stenosis in
the outflow
vein at the anastomosis. Determination of whether this is
related to a high
output heart failure cannot be made from ultrasound.
Note: as per radiology tech these units are cm/s except flow
volume which is mL/min
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. testosterone *NF* 1.25 gram/ actuation (1 %) Transdermal
three pumps per day
2. Lisinopril 20 mg PO DAILY
hold for SBP<100
3. Sodium Bicarbonate 1300 mg PO BID
4. Colchicine 0.6 mg PO DAILY
5. HydrALAzine 25 mg PO Q8H
6. Simvastatin 20 mg PO DAILY
7. Calcium Acetate 1334 mg PO TID W/MEALS
8. esomeprazole magnesium *NF* 40 mg Oral BID
9. Aspirin 81 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Acetate 1334 mg PO TID W/MEALS
3. Colchicine 0.6 mg PO DAILY
4. esomeprazole magnesium *NF* 40 mg Oral BID
5. Lisinopril 10 mg PO HS
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Nephrocaps 1 CAP PO DAILY
7. Simvastatin 20 mg PO DAILY
8. testosterone *NF* 1.25 gram/ actuation (1 %) Transdermal
three pumps per day
9. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
10. Carvedilol 12.5 mg PO BID heart failure
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Diastolic heart failure
End stage renal disease on hemodialysis
Secondary Diagnosis:
___ esophagus with focal and high grade dysplasia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Shortness of breath and dyspnea on exertion. Rule out an acute
process.
COMPARISON: Chest radiograph, ___.
FINDINGS: Frontal and lateral views of the chest. No pleural effusion,
pneumothorax, or focal airspace consolidation. Cardiac size is normal. Hilar
and mediastinal structures are unremarkable. The pulmonary vasculature is
normal. An old right rib fracture is noted.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: AV fistula and heart failure.
Duplex evaluation was performed of the surgical AV fistula. The diameter of
the outflow vein ranges from 0.6-2.3 cm. Arterial inflow has a velocity of
120, venous outflow 226, the access 474 and 538 and the volume of flow was
243.
IMPRESSION: Patent AV fistula, very dilated area of stenosis in the outflow
vein at the anastomosis. Determination of whether this is related to a high
output heart failure cannot be made from ultrasound.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: SOB
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 97.8
heartrate: 82.0
resprate: 16.0
o2sat: 100.0
sbp: 95.0
dbp: 36.0
level of pain: 0
level of acuity: 3.0 | ___ year old male with h/o ESRD with AVF and HTN presents with
1.5 weeks dyspnea and yesterday worsened in the setting of
nausea, vomiting, diarrhea.
#Dyspnea - Dyspnea was felt to be secondary to diastolic cardiac
failure due to fast heart rate and high outputs, likely related
to presence of AV fistula and hemodynamically destabilized by
acute gastroenteritis. Hydralazine was held due to concern for
high cardiac output. Carvedilol was added to reduce heart rate
and allow for diastolic filling. The patient's symptoms
improved with these interventions. Previous TTE ___ showed
hyperdynamic LV, CO 9.8 L/min with CI of 4.66 L/min/m^2. A TTE
on ___ status post dialysis and off hydralazine showed
reduction in cardiac index to 3.23 without hyperdynamicity. The
TTE also showed dilated ascending aorta measuring 4.0 cm.
Doppler of the fistula showed flow rates well within hemodynamic
tolerance (mean 243 mL/min), however this was felt to be
erroneous because it was well below his normal hemodialysis flow
rate of 450+ mL/min.
The patient improved with medical treatment, and by ___ he was
able to sleep flat and denied dyspnea. On ___ the patient
underwent HD in an attempt to remove fluid more aggressively.
On ___ the patient's carvedilol was titrated down due to 12.5
mg daily an episode of symptomatic hypotension. These symptoms
resolved by the morning of ___. He should have continued
adjusted of antihypertensive regimen going forward
#ESRD - The patient's renal function remained relatively stable
throughout his admission. On ___ he was dialyzed and an
attempt to remove more fluid than his typical dialysis was made.
He successfully was dialyzed of approx 3 L of fluid without
complications. He was dialized again as per his regular
schedule on ___.
# HTN: patient's antihypertensive regimen was adjusted -
carvedilol was added and lisinopril reduced to 10 mg daily due
to symptomatic hypotension post dialysis. He would benefit from
continued titration of antihypertensive regimen.
Chronic issues: remained stable
TRANSITIONAL
- patient needs continued monitoring of antihypertensive regimen
going forward
- patient should have repeat TTE in 6 months to assess stability
of dilated ascending aortia (4cm on ECHO this admission)
- patient will have ___ with heart failure clinic |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / G6PD
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o asthma (recently diagnosed), G6PD def, and anemia
presenting w/ worsening SOB, cough, and chest tightness.
Symptoms have been steadily worsening since ending recent
prednisone taper 6 days ago (___). She has been trying nebs
at home without improvement. She denies any fevers/chills.
Denies leg swelling or pain. States that her first asthma
exacerbation was 3 weeks ago. 3 days prior to that, the
___ that she teaches at had farm animals visit. Since
then, she has been to the ED several times for worsening chest
tightness/SOB. She has been d/c'd from the ED twice with 5-day
tapers of prednisone, starting at 20mg, only to have symptoms
recur immediately upon cessation of steroids. More recently,
after seeing new pulmonologist (Dr. ___ at ___
___, she was started on Advair, Singulair, and a prednisone
taper, starting at 60mg. This taper ended 6 days ago. Since then
she has been having progressively worsening shortness of breath,
non-productive cough, and chest tightness. Denies fevers/chills,
abdominal pain, nausea, vomiting. States that her DuoNebs at
home have been giving partial relief, but only lasting for ___
hours.
In the ED, initial vitals 98.6 100 114/61 20 100%
Labs notable for UA w/ moderate ___, Pos Nit., 1WBC, Few
Bacteria.
WBC 4.9, HCT 35.9.
Bicarb 18, AG 16
Phos 1.0
CXR showed no acute intrathoracic process.
Patient was dyspneic, but able to speak in full sentences. Her
peak flow was measured at 320 L/m (baseline is 420)
The pt received duonebs, methylprednisolone, and 1 packet of
NeutraPhos.
Vitals prior to transfer: 99.6 100 113/68 24 99%.
Currently, complains of chest tightness and only mild shortness
of breath.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, shortness
of breath, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Asthma
G6PD deficiency
Anemia
Social History:
___
Family History:
Mother: G6PD deficiency, asthma, allergic rhinitis
Sister: eczema
Physical ___:
ADMISSION PHYSICAL EXAM:
VS - 98.2 108/60 130 20 99%RA
GENERAL - well-appearing young ___ female in NAD,
comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, somewhat diminished air-movement,
resp unlabored, no accessory muscle use. Peak flow 300L/m (bl
450)
HEART - PMI non-displaced, tachycardic, regular rhythm no MRG,
nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
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 - 98.2 108/60 85 16 99%RA
GENERAL - well-appearing young ___ female in NAD,
comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air-movement, resp
unlabored, no accessory muscle use. Peak flow 400L/m (bl 450)
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, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3
Pertinent Results:
LABS:
___ 02:40PM BLOOD WBC-4.9 RBC-4.42 Hgb-11.4* Hct-35.9*
MCV-81* MCH-25.7* MCHC-31.6 RDW-14.6 Plt ___
___ 07:55AM BLOOD WBC-8.2# RBC-4.27 Hgb-11.0* Hct-35.1*
MCV-82 MCH-25.6* MCHC-31.2 RDW-14.8 Plt ___
___ 02:40PM BLOOD Neuts-47.1* Lymphs-45.2* Monos-5.8
Eos-1.3 Baso-0.6
___ 02:40PM BLOOD Glucose-91 UreaN-8 Creat-1.0 Na-137 K-4.9
Cl-103 HCO3-18* AnGap-21
___ 07:55AM BLOOD Glucose-122* UreaN-9 Creat-0.8 Na-138
K-4.3 Cl-105 HCO3-22 AnGap-15
___ 02:40PM BLOOD Calcium-9.3 Phos-1.0* Mg-1.9
___ 07:55AM BLOOD Calcium-9.1 Phos-5.3*# Mg-1.8
___ 08:00AM BLOOD Phos-3.6#
___ 07:55AM BLOOD Hapto-123
___ 08:00AM BLOOD ANCA-PND
___ 08:00AM BLOOD ___
___ 09:02PM BLOOD Type-ART pO2-121* pCO2-25* pH-7.44
calTCO2-18* Base XS--4
=
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================================================================
IMAGING/OTHER STUDIES:
EKG ___: Sinus tachycardia. Otherwise, normal ECG. No
previous tracing available for comparison.
CXR ___: FINDINGS: PA and lateral views of the chest
provided demonstrate no focal consolidation, effusion,
pneumothorax. The heart and mediastinal contours are normal.
Bony structures are intact. No free air below the right
hemidiaphragm.
IMPRESSION: No signs of pneumonia or other acute intrathoracic
process.
Medications on Admission:
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
2. Ipratropium Bromide MDI 2 PUFF IH QID
3. Gildess FE *NF* (norethindrone-e.estradiol-iron) 1.5-30
mg-mcg Oral qhs
4. Advair diskus 250/50 1 INH IH BID
5. Singulair 10 mg daily
6. Omeprazole 20mg
Discharge Medications:
1. Gildess FE *NF* (norethindrone-e.estradiol-iron) 1.5-30
mg-mcg Oral qhs
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. PredniSONE 60 mg PO DAILY
RX *prednisone 10 mg as directed tablet(s) by mouth daily Disp
#*31 Tablet Refills:*0
4. Lorazepam 0.5 mg PO Q8H:PRN shortness of breath/anxiety/chest
tightness Duration: 1 Doses
RX *lorazepam [Ativan] 0.5 mg one tab by mouth three times a day
Disp #*30 Tablet Refills:*0
5. Montelukast Sodium 10 mg PO DAILY
6. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
7. Ipratropium Bromide MDI 2 PUFF IH QID
8. Ipratropium Bromide Neb 1 NEB IH Q2H:PRN shortness of breath
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 nebulizer inhaled
every 2 hours as needed Disp #*30 Vial Refills:*0
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, chest tightness
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) one neb inhaled
every 6 hours as needed Disp #*30 Vial Refills:*0
10. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: cough-variant asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
___.
CLINICAL HISTORY: Asthma and shortness of breath and cough, question
pneumonia.
FINDINGS: PA and lateral views of the chest provided demonstrate no focal
consolidation, effusion, pneumothorax. The heart and mediastinal contours are
normal. Bony structures are intact. No free air below the right
hemidiaphragm.
IMPRESSION: No signs of pneumonia or other acute intrathoracic process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ASTHMA
Diagnosed with ASTHMA, UNSPECIFIED, WITH ACUTE EXACERBATION
temperature: 99.6
heartrate: 100.0
resprate: 24.0
o2sat: 99.0
sbp: 113.0
dbp: 68.0
level of pain: 10
level of acuity: 2.0 | ___ yo female w/ h/o asthma presents with 6 days of worsening
shortness of breath, chest tightness, non-productive cough since
recently finishing steroid taper.
#Shortness of breath: History and physcial exam are most
consistent with asthma exacerbation in the setting of recent
prednisone taper. CXR is clear, and there is no leukocytosis,
making infection very unlikely. Her peak flow on presentation
was 320L/m (baseline 450). This improved to 400L/m on day of
discharge. Her O2 sats remained around 100% on RA. She received
Solumedrol 125mg IV in the ED, as well as Duonebs, and Ativan.
On the floor she was treated with DuoNebs PRN, Prednisone 60mg
daily, and Ativan 0.5mg PO q8h PRN. Her shortness of breath
improved significantly and peak flow improved to 400L/m, near
her baseline of 450. Her home singulair and advair were
continued as well. There was questionable contribution of
anxiety to patient's subjective shortness of breath. She
improved significantly with low-dose ativan. In speaking with
her outpatient pulmonologist, the diagnosis of asthma remains in
question as her symptoms rebound so precipitously as soon as
prednisone is discontinued. ANCA and ___ were sent as part of
initial work-up for other inflammatory/rheumatologic processes
which may explain patient's symptoms. She was discharged on 14
day taper of prednisone, starting at 60mg daily. She was also
discharged with 10 day supply of ativan 0.5mg PO q8h PRN
shortness of breath. She is scheduled for f/u with o/p
pulmonologist on ___ for furthur evaluation of her
respiratory symptoms. She was continued on home DuoNebs, advair,
and singulair. Her pulmonologist has also recommended ENT
evaluation as an outpatient for evaluation of her upper airway
symptoms.
#Tachycardia - Sinus tachycardia likely ___ volume depletion
from decreased PO intake as well as albuterol administration.
This improved with hydration and decreased nebulizer
utilization.
#Hypophosphatemia: Pt. presented with an extremely low phosphate
of 1.0. She was repleted overnight to phos of 5. Etiology of
hypophosphatemia may be intracellular movement of phosphate in
setting of respiratory alkalosis. Phosphate was down to 3.6 upon
discharge. Given normal renal function, her serum phosphate
level should return to normal with resolution of her respiratory
alkalosis.
=
=
=
=
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================================================================
TRANSITIONAL ISSUES
-___ and ANCA pending and will be followed-up by outpatient
pulmonologist to look for alternative inflammatory/rheumatologic
causes of patient's respiratory symptoms
-Patient will see ENT as an outpatient for evaluation of upper
respiratory symptoms |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro
Attending: ___.
Chief Complaint:
weakness/hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms ___ is a ___ year female with history of
___ disease who presents with diffuse weakness, fatigue
and dysarthria.
Reports memory of this AM is a little hazy; had difficulty
waking up, speach therapist came by for the first time to
evaluate patient, noted her to be very lethargic and acutely
increased stuttering/sluring of speach from already abnormal
baseline, OT who regularly sees her came by soon after,
concerned, took her BP and noted it to be 64/40, and so EMS was
called.
Patient reports progressive fatigue over the past several months
as well as worsened speach (decreased volume, increased
stuttering/sluring of words). She has also had several recent
admissions ___, ___) for labile BPs
(either hypotensive to a similar degree, or hypertensive with
SBPs in 200s) and fatigue/lethargy, similar to today. Somewhat
recently was started on fludricortisone by someone (unsure if it
was PCP or if it was started during a recent hospitalization) to
help with her labile blood pressures. Unsure if she carries a
diagnosis of adrenal insufficiency.
Denies specific infectious symptoms; no fevers/chills, no URI
symptoms, no h/a, no vision changes, no cough, no CP, no SOB, no
abd pain, no N/V/D, no dysuria. Does report various intermittent
joint pains over the past few weeks (her left shoulder, left
elbow, right foot) of brief duration. Also notes "bruising" over
hands/feet which is transitent - unable to describe this skin
finding further. Has been taking good PO, reports conciously
trying to stay hydrated as she has been told she was dehydrated
on previous admissions.
Still feels very weak despite IV fluids and improvement in her
BP. Some slight low back pain, but denies chest pain, shortness
of breath, abdominal pain, dysuria, fever, cough.
EMS vitals: Pulse: 90 BP: 110/60 RR: 16 SpO2%: 95 RA.
In the ED, initial VS were 97.6 93 104/55 20 99% RA. Received 1L
NS and caradopa/levadopa. Cultues sent. CXR unremarkable.
Patient had difficulty urinating, required straight cathing.
Transfer VS were 93 166/95 18 98% RA.
On arrival to the floor, patient reports feeling fatigued, but
otherwise back to her baseline. Reports mental status has
cleared, speach is back to her previous baseline.
Past Medical History:
- ___ diagnosed ___ yrs ago; presented with gait ataxia
and right sided tremor
- h/o gout
- isolated seizure last ___, cause unknown
- HTN
- Recurrent UTIs and urinary retention
- Osteoarthritis s/p L knee replacement
- ? recent diagnosis of adrenal insufficiency
- Seasonal allergy
- Anxiety
- s/p appendectomy at age ___
Social History:
___
Family History:
- several second cousins with ___
- "lots of cancer"
- no heart disease
Physical Exam:
ADMISSION EXAM:
===========
VS - afebrile 175/94 98 20 100% RA
unable to obtain orthostatics as pt unable to stand (not
positive going from lying to sitting)
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, midly injected sclera, pink
conjunctiva, patent nares, dry MM, mild facial asymmetry
CARDIAC: RRR, S1/S2, ___ SEM at RUSB
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: WWP
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ strenght in all four extremeties,
diffuse resting tremor (in all extremeties and face), soft voice
with intermittent stutering, ridgidity with passive movement
SKIN: warm and well perfused, errythematous face, blotchy
blanching errythema over arms/chest, ___ nails
DISCHARGE EXAM:
================
VS - 98.2 149/97 18 100% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, midly injected sclera, pink
conjunctiva, patent nares, dry MM, mild facial asymmetry
CARDIAC: RRR, S1/S2, ___ SEM at RUSB
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: WWP
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ strenght in all four extremeties,
diffuse resting tremor (in all extremeties and face), soft voice
with intermittent stutering, ridgidity with passive movement
SKIN: warm and well perfused, errythematous face, blotchy
blanching errythema over arms/chest, ___ nails
Pertinent Results:
ADMISSION LABS:
==========
___ 01:53PM LACTATE-2.1*
___ 01:51PM GLUCOSE-114* UREA N-25* CREAT-0.9 SODIUM-143
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-29 ANION GAP-14
___ 01:51PM CK-MB-3 cTropnT-<0.01
___ 01:51PM WBC-4.7# RBC-4.34 HGB-13.0 HCT-40.1 MCV-92
MCH-30.0 MCHC-32.5 RDW-12.9
___ 01:51PM NEUTS-56.4 ___ MONOS-8.4 EOS-10.1*
BASOS-2.8*
___ 01:51PM PLT COUNT-298
___ 01:51PM ___ PTT-31.9 ___
___ 01:51PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:51PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
IMAGING:
======
CXR ___: Patient is rotated somewhat to the left. There is
minor left basilar atelectasis. There is possible minimal
vascular congestion. No focal consolidation, pleural effusion,
or evidence of pneumothorax is seen. Cardiac and mediastinal
silhouettes are unremarkable.
MICROBIOLOGY:
==========
___ Urine Culture: <10,000 colonies
___ Blood Culture: NGTD, pending
DISCHARGE LABS:
==============
___ 06:00AM BLOOD WBC-5.4 RBC-4.19* Hgb-12.4 Hct-38.6
MCV-92 MCH-29.6 MCHC-32.1 RDW-12.5 Plt ___
___ 06:00AM BLOOD Glucose-82 UreaN-22* Creat-0.7 Na-143
K-3.7 Cl-106 HCO3-31 AnGap-10
___ 06:00AM BLOOD TSH-1.5
___ 06:00AM BLOOD Cortsol-7.3
___ 08:44AM BLOOD Lactate-1.7
___ 06:00AM BLOOD CK-MB-2 cTropnT-0.01
Medications on Admission:
The Preadmission Medication list ___ be inaccurate and requires
futher investigation.
1. Amantadine 100 mg PO BID
2. Bethanechol 25 mg PO TID
3. Loratadine 10 mg PO DAILY
4. ClonazePAM 0.5 mg PO BID:PRN anxiety
5. Docusate Sodium 100 mg PO QHS
6. Fludrocortisone Acetate 0.2 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. LeVETiracetam 500 mg PO BID
9. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Multivitamins 1 TAB PO DAILY
12. Pantoprazole 40 mg PO Q12H
13. rasagiline 1 mg oral daily
14. Carbidopa-Levodopa (___) 2.5 TAB PO 0700, 1000, 1300,
___
15. Carbidopa-Levodopa (___) 2 TAB PO 1600
16. Tamsulosin 0.4 mg PO HS
17. Tasmar (tolcapone) 100 mg oral QID
18. Venlafaxine XR 225 mg PO DAILY
19. CeleBREX (celecoxib) 200 mg oral TID
20. Carbidopa-Levodopa CR (50-200) 1 TAB PO QHS
21. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Amantadine 100 mg PO BID
2. Bethanechol 25 mg PO TID
3. Carbidopa-Levodopa (___) 2 TAB PO 1600
4. Carbidopa-Levodopa (___) 2.5 TAB PO 0700, 1000, 1300,
___
5. Carbidopa-Levodopa CR (50-200) 1 TAB PO QHS
6. CeleBREX (celecoxib) 200 mg oral TID
7. ClonazePAM 0.5 mg PO BID:PRN anxiety
8. Docusate Sodium 100 mg PO QHS
9. Fludrocortisone Acetate 0.2 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. LeVETiracetam 500 mg PO BID
12. Loratadine 10 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY
15. Pantoprazole 40 mg PO Q12H
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. rasagiline 1 mg oral daily
18. Tamsulosin 0.4 mg PO HS
19. Tasmar (tolcapone) 100 mg ORAL QID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# PRIMARY:
- ___ Diease with Dysautonomia
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: Weakness, low blood pressure.
COMPARISON: None.
FINDINGS: Patient is rotated somewhat to the left. There is minor left
basilar atelectasis. There is possible minimal vascular congestion. No focal
consolidation, pleural effusion, or evidence of pneumothorax is seen. Cardiac
and mediastinal silhouettes are unremarkable.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Hypotension
Diagnosed with OTHER MALAISE AND FATIGUE
temperature: 97.6
heartrate: 93.0
resprate: 20.0
o2sat: 99.0
sbp: 104.0
dbp: 55.0
level of pain: 13
level of acuity: 2.0 | Ms ___ is a ___ year female with history of
___ disease who presents with diffuse weakness, fatigue
and dysarthria.
ACTIVE ISSUES:
=========
# Weakness/Lethargy/Dysarthria/Hypotension: Suspect general
trend of patient's symptoms over past months to weeks represents
a progression of her PD (see below) with dysautonomia. Suspect
symptoms yesterday AM could all be consistent with PD, though
difficult to explain acute worsening/improvement. Could be
medication related (patient uncertain if she ___ have missed a
few meds that AM). Could represent underlying infection
exacerbating PD symptoms, though infectious work up during this
hospitalization was negative and patient had no localizing
symptoms. Acute confusion/dysarthria concerning also for
TIA/Stroke/Siezure, but event was witnessed, and no focal
neurological deficits other than dysarthria was reported and no
seizure like-activity was noted. Did not report CP, but ACS
could cause hypotension (though presumably with other symptoms
of heart failure); ACS rule out was negative. This diffuse
weakness/fatigue could also represent another systemic process
altogether (though this is highly unlikely in the setting of a
pre-exisitng systemic disease which readily explains her
symtpoms); hypothyroidism (TSH normal), adrenal insufficiency
(AM cortisol normal), myopathy or myasthenia ___ (though
acutally surprsingly strong on strenght testing). During
hosptialization patient continued to endorse fatigue which she
had been experiencing for past several weeks, but the symptoms
which brought her into the hospital had resolved and did not
recur.
# ___: Diagnosed ___ yrs ago. Presented with gait ataxia
and tremor, current decline has been complicated with
dysautonomia. Could also be consistent with Multiple Systems
Atrophy (MSA). Symptoms that suggest MSA: urinary issues,
dysautonomia, Raynaud's (which I suspect ___ be this transient
"bruising" of her hands she has been describing). Outpatient
neurologist seems to also have suspicion for MSA (suggesting
outpatient DATscan to add in differentiating the two). Overall,
patient's current presentation seems most consistent with a
gradual decline in her PD (or possibly MSA), worsened over past
several months. Given this, patient would probably benefit most
from close follow up with existing neurologist for evaluation of
MSA vs PD as well as adjustment of medications. For this reason,
inpatient neurology consult was deferred. Patient was was also
evaluated by ___ who cleared patient for home ___ with current
high level of services. Continued home amantidine,
Carbidopa-Levodopa, Tasmar and rasagiline. Left message with Dr
___ at ___ (outpatient neurologist) requesting an earlier
appointment date for patient (currently scheduled for ___,
unable to schedule any sooner or reach the doctor).
CHRONIC ISSUES:
===========
# Urinary Retention: normally doesn't straight cath. presumably
___ PD. Follows with outside urologist. Suspect urinary
retention in ED was from missing AM bladder meds. No further
issues during this hosptialization. Continued home bethanechol
and tamsulosin. Of note, tamsulosin ___ contribute to episodes
of hypotension; would recommend reevaluation with outpatient
urologist. Continued home nitrofurantoin for prophylaxis of
chronic UTIs in setting of urinary retention.
# h/o isolated seizure: unclear etiology, unknown work up
(preformed at OSH). Continued home keppra.
# OA: continued home celebrex.
# Seasonal Allergies: continued home loratadine and fluticasone
nasal spray.
# Anxiety: continued home clonazepam. Held home venlafaxine and
sertraline given risk of seratonin syndrome with rasagiline.
TRANSITIONAL ISSUES:
====================
- blood pressure surveillance by ___ advised
- to follow up with neurologist for further management of
___ (versus Multiple Systems Atrophy (MSA)) and
associated dysautonomia, ataxia
- consider d/c'ing tamsulosin as outpatient in consultation with
urologist, as could be contributing to issues of hypotension
- combination of rasagiline and venlafaxine puts patient at high
risk of seratonin syndrome; would recommend discontinuation of
venlafaxine for now, with re-assessment of these two medications
by outpatient prescriber
- further medication reconciliation advised in the outpatient
setting, given difficulty reconciling medications with absolute
certainty following discussion with patient and call to pharmacy
- CODE: FULL |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Azulfidine / atorvastatin / lisinopril
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 09:54PM K+-6.1*
___ 08:42PM GLUCOSE-60* UREA N-123* CREAT-5.9* SODIUM-140
POTASSIUM-6.1* CHLORIDE-111* TOTAL CO2-10* ANION GAP-19*
___ 08:42PM GLUCOSE-60* UREA N-123* CREAT-5.9* SODIUM-140
POTASSIUM-6.1* CHLORIDE-111* TOTAL CO2-10* ANION GAP-19*
___ 08:42PM ALT(SGPT)-58* AST(SGOT)-106* ALK PHOS-359*
TOT BILI-1.1
___ 08:42PM LIPASE-80*
___ 08:42PM ALBUMIN-4.2 CALCIUM-8.9 PHOSPHATE-7.3*
MAGNESIUM-2.1
___ 08:42PM WBC-9.3 RBC-2.75* HGB-8.0* HCT-24.3* MCV-88
MCH-29.1 MCHC-32.9 RDW-18.7* RDWSD-60.1*
___ 08:42PM NEUTS-76.9* LYMPHS-16.8* MONOS-5.4 EOS-0.2*
BASOS-0.4 IM ___ AbsNeut-7.11* AbsLymp-1.55 AbsMono-0.50
AbsEos-0.02* AbsBaso-0.04
___ 08:42PM PLT COUNT-167
___ 08:42PM ___ PTT-37.5* ___
INTERVAL LABS:
===============
___ 09:20AM BLOOD VitB___-___
___ 09:20AM BLOOD TSH-1.1
___ 09:20AM BLOOD Trep Ab-NEG
___ 04:54AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS:
===============
___ 05:50AM BLOOD WBC-9.4 RBC-2.39* Hgb-6.9* Hct-21.7*
MCV-91 MCH-28.9 MCHC-31.8* RDW-19.2* RDWSD-63.6* Plt Ct-74*
___ 05:50AM BLOOD ___ PTT-35.6 ___
___ 05:50AM BLOOD Glucose-90 UreaN-79* Creat-5.3* Na-137
K-5.2 Cl-106 HCO3-16* AnGap-15
___ 05:50AM BLOOD ALT-35 AST-54* LD(LDH)-278* AlkPhos-260*
TotBili-1.1
___ 05:50AM BLOOD Albumin-4.0 Calcium-9.0 Phos-3.1 Mg-2.5
___ 05:50AM BLOOD Ret Aut-1.7 Abs Ret-0.04
MICROBIOLOGY:
==============
___ 1:13 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
IMAGING:
==========
- ___ CT head w/o contrast
No evidence of fracture, of infarction, hemorrhage or mass.
Internal carotid artery calcifications. Otherwise normal study.
- ___ CT C-spine w/o contrast
1. Minimally displaced fractures of the T1 and T2 spinous
processes.
2. No other fractures identified. Normal alignment.
3. Moderate multilevel degenerative changes.
- ___ CXR
1. Continued enlargement of the cardiac silhouette with mild
elevation of
pulmonary venous pressure.
- ___ CT abdomen/pelvis w/o contrast
1. Nondisplaced acute fractures of the spinous process of T1 and
T2 vertebral bodies are again demonstrated. No additional acute
fractures are identified.
2. No acute traumatic solid organ injury within the torso.
3. Ankylosis of bilateral sacroiliac joints suggest ankylosing
spondylitis
which can be seen in patients with ulcerative colitis.
4. 6 mm non-obstructing renal stone in the left lower pole.
5. Cirrhotic liver. No ascites. No splenomegaly.
6. Bilateral pulmonary nodules measuring up to 5 mm. See below
for ___ recommendations.
7. Sclerotic appearance of the T10 vertebral body is similar to
most recent prior but increased since ___, consider further
evaluation with MRI T-spine or bone scan if the patient has a
history of malignancy.
8. Cholelithiasis without evidence of cholecystitis.
- ___ Renal US
No interval change in size of multiple non-obstructing renal
stones in the
lower pole of the left kidney measuring up to 0.8 cm. No
hydronephrosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. CARVedilol 12.5 mg PO BID
3. HydrALAZINE 10 mg PO TID
4. Omeprazole 40 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Sodium Bicarbonate 1300 mg PO TID
7. Thiamine 100 mg PO DAILY
8. Torsemide 40 mg PO DAILY
9. Gabapentin 100 mg PO BID neuropathy
10. sevelamer CARBONATE 800 mg PO TID W/MEALS
11. Vitamin D 4000 UNIT PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Glargine 35 Units Breakfast
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Glargine 35 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Sodium Bicarbonate ___ mg PO TID
RX *sodium bicarbonate 650 mg 3 tablet(s) by mouth three times a
day Disp #*270 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. CARVedilol 12.5 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Gabapentin 100 mg PO BID neuropathy
7. HydrALAZINE 10 mg PO TID
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 40 mg PO DAILY
10. sevelamer CARBONATE 800 mg PO TID W/MEALS
11. Thiamine 100 mg PO DAILY
12. Vitamin D 4000 UNIT PO DAILY
13. HELD- Torsemide 40 mg PO DAILY This medication was held. Do
not restart Torsemide until talking to your doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
Mechanical fall
Alcohol use disorder
Acute on chronic normocytic anemia
SECONDARY DIAGNOSIS:
=====================
Type II diabetes mellitus
Alcoholic cirrhosis
Coronary artery disease
Atrial fibrillation
Hypertension
Hyperlipidema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall // Assess for bleed, fracture
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 1,706 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
There is no evidence of fracture, infarction,hemorrhage,edema,or mass. There
is prominence of the ventricles and sulci suggestive of involutional changes.
There are atherosclerotic calcifications of the bilateral intracranial
internal carotid arteries. Note is made of an empty sella.
There is a tiny mucous retention cyst within the frontal sinus. The
visualized portion of the remaining paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The visualized portion of the orbits are
normal.
IMPRESSION:
No evidence of fracture, of infarction, hemorrhage or mass.
Internal carotid artery calcifications. Otherwise normal study.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with fall // Assess for bleed, 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 6.4 s, 25.0 cm; CTDIvol = 23.1 mGy (Body) DLP = 578.6
mGy-cm.
Total DLP (Body) = 579 mGy-cm.
COMPARISON: CT cervical spine ___.
FINDINGS:
Alignment is normal. There are mildly displaced fractures of the T1 and T2
spinous processes. No other fractures are identified.
Again seen is fusion of the C1 lateral mass to the occipital condyles
bilaterally. There is fusion of the C2 and C3 vertebral bodies and facet
joints. There are moderate multilevel degenerative changes of the cervical
spine with loss of intervertebral disc space height, anterior and posterior
osteophytosis and multilevel facet and uncovertebral joint hypertrophy. Facet
and uncovertebral joint hypertrophy results in severe bilateral neural
foraminal stenosis at C3-C4, similar to prior. There is no severe spinal
canal stenosis.There is no prevertebral edema.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
1. Minimally displaced fractures of the T1 and T2 spinous processes.
2. No other fractures identified. Normal alignment.
3. Moderate multilevel degenerative changes.
NOTIFICATION: The revised findings of fractures of the T1 and T2 spinous
processes were emailed to the ED QA nurses at 10:49 a.m. ___
immediately upon review of the images by Dr. ___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with fall renal failure // CXR?
TECHNIQUE: Chest AP and lateral
COMPARISON: Chest radiograph from ___.
FINDINGS:
Moderate enlargement of the cardiac silhouette is unchanged. There is
engorgement of indistinct pulmonary vessels, consistent with some elevation in
pulmonary venous pressure. No evidence of pleural effusion or acute focal
pneumonia..
IMPRESSION:
1. Continued enlargement of the cardiac silhouette with mild elevation of
pulmonary venous pressure.
Radiology Report
EXAMINATION: CT CHEST/ABD/PELVIS W/O CONTRAST
INDICATION: History: ___ with s/p fall, trauma, has acute renal failure // ?
traumatic injuries
TECHNIQUE: Contiguous axial images were obtained through the chest, abdomen
and pelvis without intravenous contrast. Coronal and sagittal reformats were
performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.9 s, 70.1 cm; CTDIvol = 22.8 mGy (Body) DLP =
1,596.7 mGy-cm.
Total DLP (Body) = 1,597 mGy-cm.
COMPARISON: CT abdomen pelvis ___ abdomen pelvis ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury based on an unenhanced scan. Common origin of the
right brachiocephalic artery and the left carotid artery is incidentally
noted. Moderate atherosclerotic disease is noted in the thoracic aorta. The
main pulmonary artery measures 3.6 cm in caliber, which may be seen in chronic
pulmonary hypertension. Moderate coronary artery calcifications. The blood
pool is hypodense with respect to the myocardium suggestive of anemia. There
is mild mitral annulus calcifications. The heart size is borderline enlarged.
Pericardium and great vessels are unremarkable. 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:A 5 mm ground glass nodule is noted in the right upper lobe (2;
46). There is a subpleural 4 mm nodule in the left lower lobe (2; 84). There
is mild bibasilar atelectasis. There is no focal consolidation. The airways
are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: Nodular contour of the liver is consistent with known
cirrhosis. There is hypertrophy of the left hepatic lobe. 1.3 cm hypodense
lesion in segment IV B is again demonstrated similar to prior, previously
characterized as a cyst (2; 123). There is no perihepatic free fluid. There
is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder contains gallstones without wall thickening or surrounding
inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. 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 a nonobstructing 6 mm
renal stone in the left lower pole (2; 57). There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable.An endoclip is again
demonstrated within the duodenum. Small bowel loops demonstrate normal
caliber. The colon and rectum are within normal limits. The appendix is
normal. There is no evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Moderate atherosclerotic disease is noted.
BONES: Nondisplaced acute fracture of the spinous processes of T1 and T2
vertebral bodies are again demonstrated (2; 6, 12). There is a stable
appearance of the sclerotic appearance of the T10 vertebral body. There is
ankylosis of bilateral sacroiliac joints. There is ankylosis of bilateral
T9-T10 facet joints.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
Subcutaneous stranding in the buttock regions bilaterally is likely from prior
injection.
IMPRESSION:
1. Nondisplaced acute fractures of the spinous process of T1 and T2 vertebral
bodies are again demonstrated. No additional acute fractures are identified.
2. No acute traumatic solid organ injury within the torso.
3. Ankylosis of bilateral sacroiliac joints suggest ankylosing spondylitis
which can be seen in patients with ulcerative colitis.
4. 6 mm non-obstructing renal stone in the left lower pole.
5. Cirrhotic liver. No ascites. No splenomegaly.
6. Bilateral pulmonary nodules measuring up to 5 mm. See below for ___
recommendations.
7. Sclerotic appearance of the T10 vertebral body is similar to most recent
prior but increased since ___, consider further evaluation with MRI T-spine
or bone scan if the patient has a history of malignancy.
8. Cholelithiasis without evidence of cholecystitis.
RECOMMENDATION(S):
1. MRI T-spine or bone scan
2. 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: RENAL U.S.
INDICATION: ___ year old man with ___ on CKD and left flank pain, found to
have 6mm stone on CT // hydronephrosis, re-eval of calculi seen on CT
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT torso dated ___.
FINDINGS:
Right kidney: 10.7 cm
There is no hydronephrosis, stones, or masses. Normal cortical echogenicity
and corticomedullary differentiation is preserved.
Left kidney: 13.2 cm
In the lower pole of the left kidney are two punctate echogenic foci which
demonstrate posterior shadowing and twinkle artifact on color Doppler
consistent with nonobstructing renal stones. The nonobstructing renal stones
measure 0.8 and 0.5 cm respectively, grossly unchanged when compared to prior
CT torso dated ___.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
No interval change in size of multiple non-obstructing renal stones in the
lower pole of the left kidney measuring up to 0.8 cm. No hydronephrosis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ETOH, s/p Fall
Diagnosed with Alcohol abuse with intoxication, unspecified, Fall (on) (from) unspecified stairs and steps, init encntr
temperature: 96.6
heartrate: 78.0
resprate: 16.0
o2sat: 98.0
sbp: 118.0
dbp: nan
level of pain: u/a
level of acuity: 2.0 | Mr. ___. is a ___ with history of EtOH cirrhosis c/b
esophageal varices, UC (previously on remicade), CAD s/p DES (on
ASA), CKD, HFrEF, and afib (on apixaban) who presents s/p
mechanical fall presumed in the setting of acute alcohol
intoxication c/b T1-T2 fracture, found to have ___ on CKD that
has now improved and encephalopathy that has now resolved. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lescol / Methotrexate
Attending: ___.
Chief Complaint:
Edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo with advanced and end-stage ischemic
cardiomyopathy (EF 20%), chronic AF NOT on coumadin due to fall
risk, BiV/ICD, UTIs, hematuria, and severe RA (scooter bound)
presenting from outpatient ___ clinic with volume overload.
.
Over the past few weeks he has been having increasing ___ edema
and SOB. He was seen in ___ clinic ___ where he was
relatively symptom free and at his dry weight of 155 lbs. Since
then, he has had increasing edema and SOB and PND/orthopnea,
being compliant with medications and diet. Denied any chest
pain, palpitations. Most recently over the past 2 weeks, has
had increasing dyspnea on exertion with transfer out of scooter
(basically scooter bound). He was hospitalized at ___ ~1wk
prior for 2 days for volume overload, however he was not
diuresed initially (according to the patient) because of his
creatinine and blood pressure. He was placed on coumadin, which
has been stopped again, and restarted on his home diuretics. He
is on torsemide at home, and uptitrated this as an outpatient
from 160mg to 180mg a day without effect. He denies chest pain,
palpitations, near syncope or syncope, diaphoresis, nausea. No
recent F/C, vomiting, diarrhea, abdominal pain. His appetite has
been affected and he has been on appetite stimulants for that.
.
In the ED, initial vitals were 98.1 59 93/62 28 100%. EKG was
paced with rate in ___. Labs sig for baseline anemia, CRI with
creatinine of 1.4, hyponatremia to 129, elevated BNP.
Past Medical History:
1. Severe ischemic cardiomyopathy with LVEF of 20%.
2. End-stage heart failure.
3. Coronary artery disease, s/p CABG x ___ SVG->RCA patent,
other grafts down .
4. S/p Guidant BiV/ICD with non-functioning CS lead.
5. Chronic atrial fibrillation no longer on warfarin due to fall
risk Pacemaker/ICD, in ___ (VVIR 60-100, for atrial
fibrillation).
6. Severe rheumatoid arthritis, who receives Remicade infusions
every five weeks. Severely limited mobility and gets around by
motorized scoter.
7. Severe weakness
Social History:
___
Family History:
Father died of MI around ___, mother with cardiomyopathy
Physical Exam:
Admission Physical Exam:
VS: 97.9 98/66 72 18 100RA 400/620 8hrs, weight 163lbs on admit,
161 this AM, dry weight 155
GENERAL: Chronically ill appearing male, cachectic in NAD.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No pallor or
cyanosis of the oral mucosa. Dry MM.
NECK: Supple with JVP to angle of the mandible.
CARDIAC: RR, normal S1, S2. ___ holosystolic murmur at the LLSB
and apex. PMI laterally displaced
LUNGS: Rales appreciated ___ to ___ up the posterior lung
fields, also appreciated over the lower anterior fields, resp
were unlabored, no accessory muscle use.
ABDOMEN: Soft, NDNT. No HSM or tenderness.
EXTREMITIES: 3+ pitting edema to the mid thigh with skin
breakdown on the right foot. Has a healed ulcer over the tip of
the left great toe and second toe. Several joint abnormalities
with synovitis and hypertrophied synovium in the wrists and
elbows as well as ankles
SKIN: stasis changes in ___ bilaterally and skin breakdown on the
right foot and buttocks
NEURO: CN ___ intact, moving all extremities, strength ___
throughout
Discharge Physical Exam:
97.5, 89/57, 59, 18, 99RA I/O 1400/1000
General: chronically ill appearing male, ___ comfortably in bed
in NAD
JVP- mildly elevated
Cardiac: RRR, ___ holosystolic mumur at ___
Lungs: Rales at the lower bases, no accessory muscle use,
speaking in full sentences
Abd: Soft, nontender, nondistended
Extremities: 2+ pitting warm edema on the anterior shins
bilaterally. Skin breakdown on the beet as per above. Hands
with contractions of the fingers.
Pertinent Results:
___ 04:20PM BLOOD WBC-5.7 RBC-3.05* Hgb-10.7* Hct-32.7*
MCV-107* MCH-35.0* MCHC-32.6 RDW-16.2* Plt ___
___ 07:15AM BLOOD WBC-4.5 RBC-2.90* Hgb-10.4* Hct-30.8*
MCV-106* MCH-36.0* MCHC-33.9 RDW-16.8* Plt ___
___ 07:15AM BLOOD WBC-4.1 RBC-2.91* Hgb-10.4* Hct-31.1*
MCV-107* MCH-35.8* MCHC-33.5 RDW-16.4* Plt ___
___ 07:30AM BLOOD WBC-4.1 RBC-2.92* Hgb-10.4* Hct-31.4*
MCV-108* MCH-35.7* MCHC-33.2 RDW-16.0* Plt ___
___ 07:56AM BLOOD WBC-3.8* RBC-2.94* Hgb-10.6* Hct-32.0*
MCV-109* MCH-35.9* MCHC-33.0 RDW-16.2* Plt ___
___ 06:47AM BLOOD WBC-3.6* RBC-2.81* Hgb-10.0* Hct-29.9*
MCV-107* MCH-35.7* MCHC-33.5 RDW-15.8* Plt ___
___ 07:35AM BLOOD WBC-3.4* RBC-2.68* Hgb-9.7* Hct-28.4*
MCV-106* MCH-36.2* MCHC-34.2 RDW-16.2* Plt ___
___ 04:20PM BLOOD Neuts-88.2* Lymphs-6.9* Monos-3.0 Eos-1.6
Baso-0.3
___ 07:35AM BLOOD Neuts-74.0* Lymphs-16.7* Monos-2.9
Eos-5.3* Baso-1.0
___ 04:20PM BLOOD ___ PTT-37.9* ___
___ 07:15AM BLOOD ___ PTT-36.7* ___
___ 07:15AM BLOOD ___ PTT-36.6* ___
___ 07:30AM BLOOD ___ PTT-37.6* ___
___ 07:56AM BLOOD ___ PTT-37.5* ___
___ 06:47AM BLOOD ___ PTT-36.1* ___
___ 04:20PM BLOOD Glucose-130* UreaN-28* Creat-1.4* Na-129*
K-4.0 Cl-90* HCO3-29 AnGap-14
___ 07:15AM BLOOD Glucose-86 UreaN-26* Creat-1.2 Na-130*
K-3.6 Cl-93* HCO3-29 AnGap-12
___ 03:20PM BLOOD Glucose-107* UreaN-28* Creat-1.3* Na-129*
K-3.7 Cl-93* HCO3-27 AnGap-13
___ 07:15AM BLOOD Glucose-74 UreaN-29* Creat-1.2 Na-130*
K-3.1* Cl-95* HCO3-30 AnGap-8
___ 07:10PM BLOOD Glucose-136* UreaN-33* Creat-1.4* Na-131*
K-4.1 Cl-94* HCO3-26 AnGap-15
___ 07:30AM BLOOD Glucose-76 UreaN-32* Creat-1.3* Na-132*
K-3.4 Cl-94* HCO3-33* AnGap-8
___ 11:39PM BLOOD Glucose-111* UreaN-35* Creat-1.2 Na-130*
K-4.9 Cl-93* HCO3-28 AnGap-14
___ 07:56AM BLOOD Glucose-70 UreaN-32* Creat-1.0 Na-129*
K-3.8 Cl-94* HCO3-27 AnGap-12
___ 05:35PM BLOOD Glucose-136* UreaN-37* Creat-1.2 Na-131*
K-4.3 Cl-95* HCO3-28 AnGap-12
___ 06:47AM BLOOD Glucose-84 UreaN-37* Creat-1.1 Na-129*
K-3.9 Cl-95* HCO3-27 AnGap-11
___ 07:35AM BLOOD Glucose-74 UreaN-42* Creat-1.1 Na-132*
K-3.8 Cl-94* HCO3-30 AnGap-12
___ 04:20PM BLOOD CK-MB-4 cTropnT-0.05* ___
___ 06:47AM BLOOD Albumin-3.2* Calcium-8.8 Phos-3.3 Mg-2.2
Pertinent labs:
___ 05:33PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:33PM URINE RBC-28* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
___ 05:33PM URINE CastHy-18*
Micro:
___ 5:33 pm URINE **FINAL REPORT ___ CULTURE
(Final ___: KLEBSIELLA PNEUMONIAE. >100,000
ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
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-------- 32 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ ECG: Ventricular pacing with premature beats. Since the
previous tracing the rate is slower. Atrial mechanism is now
uncertain.
___ TTE
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF= ___
%) with global hypokinesis to akinesis (basal segments contract
best). The apex is frankly akinetic. No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is dilated with depressed
free wall contractility. There is abnormal septal
motion/position. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
(___) mitral regurgitation is seen. Moderate to severe [3+]
tricuspid regurgitation is seen. There is moderate to severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___,
LVEF and RVEF have decreased.
___ CXR
1. Enlarged cardiac silhouette, bilateral pleural effusions and
pulmonary
vascular congestion suggests CHF.
2. Irregularity of the right humeral head may be degenerative,
although
underlying avascular necrosis cannot be excluded.
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - Tab by mouth
CITALOPRAM - 10 mg Tablet - 1 Tab by mouth daily
DIGOXIN - 125 mcg Tablet - 1 Tab by mouth ___
FINASTERIDE - 5 mg Tablet - 1 Tab by mouth daily
FOLIC ACID - 1 mg Tablet - 1 Tab by mouth daily
LIDOCAINE (PF) - Dosage uncertain
LISINOPRIL - 2.5 mg Tablet - 1 Tab by mouth DAILY (on hold/Low
BP)
METOPROLOL SUCCINATE - 50 mg Tab - 1 Tablet(s) PO HS (on
hold/Low BP)
OMEPRAZOLE - 20 mg Capsule - 1 Cap by mouth daily
OXYCODONE - Dosage uncertain
TAMSULOSIN - 0.4 mg Cap - 1 Cap by mouth daily ___ hour after a
meal
TORSEMIDE - 20 mg Tablet - two Tablet(s) by mouth in am; 3tabs
in
afternoon depending on swelling
ACETAMINOPHEN - 325 mg Tablet - 3 Tablet(s) by mouth twice a day
DOCUSATE SODIUM - 100 mg Caps - 1 Caps by mouth BID
POLYETHYLENE GLYCOL 3350 [MIRALAX]
SENNA
REMICAID ?
Discharge Medications:
1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK
(___).
2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
10. morphine 20 mg/5 mL Solution Sig: ___ PO q1hour as
needed for respiratory distress or pain.
Disp:*30 cc* Refills:*0*
11. Lorazepam Intensol 2 mg/mL Concentrate Sig: ___ PO
q2hours as needed for anxiety.
Disp:*30 cc* Refills:*0*
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
13. acetaminophen 325 mg Tablet Sig: Three (3) Tablet PO twice a
day.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
15. infliximab Intravenous
16. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day
as needed for constipation.
17. senna Oral
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Acute on chronic congestive heart failure, NHYA Class IV
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest, single AP upright portable view.
CLINICAL INFORMATION: ___ male with history of shortness of breath.
___.
FINDINGS: Single AP upright portable view of the chest was obtained. Single
lead left-sided AICD is again seen with lead extending to the expected
position of the right ventricle. Patient is status post median sternotomy.
There is blunting of the bilateral costophrenic angles, left greater than
right, consistent with bilateral pleural effusions. Prominence of the
perihilar vasculature is consistent with pulmonary vascular congestion. Left
retrocardiac opacity may relate to the combination of atelectasis and
effusion, although underlying consolidation cannot be excluded. The cardiac
silhouette is enlarged. The aortic knob is calcified. Marked degenerative
changes are seen at the right humerus which may be post-traumatic, although
underlying avascular necrosis cannot be excluded. There is diffuse
osteopenia.
IMPRESSION:
1. Enlarged cardiac silhouette, bilateral pleural effusions and pulmonary
vascular congestion suggests CHF.
2. Irregularity of the right humeral head may be degenerative, although
underlying avascular necrosis cannot be excluded.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: LE EDEMA
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 98.1
heartrate: 59.0
resprate: 28.0
o2sat: 100.0
sbp: 93.0
dbp: 62.0
level of pain: 13
level of acuity: 2.0 | Mr. ___ is a ___ yo with advanced and end-stage ischemic
cardiomyopathy (EF ___ on TTE ___, chronic AF NOT on
coumadin due to fall risk, BiV/ICD, UTIs, hematuria, and severe
RA who was admitted with CHF acute exacerbation who is being
discharged on hospice.
.
# Acute on chronic systolic heart failure: Patient with stage 4
heart failure with ___ weeks of increasing ___ edema and
worsening dyspnea. There was concern for ischemia as the
precipitating cause. However, due to his end-stage prognosis,
stress imaging/cardiac catheterization were not pursued in
discussion with his outpatient attending as the end result would
likely be similar with or without intervention. His home beta
blocker/ACE were held due to low BPs and he was diuresed with a
lasix drip with good result in terms of I/O and weight, however
he remained with JVD to above the ear, 3+ lower extremity
pitting edema and rales on lung exam. on ___ (5 days into
diuresis) he started to become symptomatically hypotensive to
the ___ previously, he was tolerating SBP in the low ___,
responsive to fluids. It is possible that his UTI was partially
responsible for his symptomatic hypotension, but more likely he
was overdiuresed in spite of his physical exam. His symptomatic
hypotension occurred only when he was sitting upright for
prolonged periods of time. There were discussions with the
patient about this problem and he chose not to pursue any
medications to help with his blood pressure.
.
# UTI: on ___ after he started to become hypotensive, an
infectious workup was pursued as he had mild progressive
leukopenia and a low temperature. His urine was floridly
positive for infection. Initially he was started on
vancomycin/ceftriaxone as his previous UTI grew enterococcus
sensitive only to vanco (not cephalosporins). This was narrowed
to ciprofloxacin. He will finish a total of 7 day course of this
on discharge.
.
#Goals of care: patient expressed understanding that his
condition is terminal and that he would not like to pursue any
further aggressive treatments. He was seen by the palliative
care team and he decided to go home on hospice today. Because
of this he asked to have his the defibillator portion of his
pacer to be turned off. This was done on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___
Chief Complaint:
dysphagia
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ with no significant chronic medical problems, recent
campylobacter infection in setting of travel to ___, who
presents for dysphagia, among other issues.
Starting from the beginning, she was in ___ ___
for a recreational trip. He had a bike crash on ___ where she
hit her head (was wearing helmet). She was given a pain med (a
COX-2 inhibitor that is not FDA approved in USA per pt) and also
took Ibuprofen. She then subsequently developed an episode of
throat swelling on ___. She was given Benadryl "on the street"
and initially improved, then later had another episode the same
day for which she was brought to a hospital. She was given
steroids and more Benadryl. Apparently she was diagnosed with
"altitude sickness." She also might have had a UTI based on
___ UA.
On ___, a bartender had to give her the Heimlich x3 for a pill
that was stuck while swallowing. Apparently this was
unsuccessful in dislodging the pill. Just prior to leaving on
her flight back to the ___ ___ ___, she required 3 "shots" of
"something," given at the airport, prior to boarding the plane.
It is entirely unclear what this shot was. Her flight landed in
___ for a layover, and she was apparently seen at an ER there,
and diagnosed with a panic attack.
Of note, she started having diarrhea while in ___ around
___. On return to ___, she continued having diarrhea which
was bloody, and also had an episode of passing out. She was
diagnosed with Campylobacter in the ___ ED on ___, where stool
culture showed 1+ Campylobcter Jejuni. She was treated with
Cipro x3 days. She had stool cultures done elsewhere on ___,
___, which were positive again for Campylobacter, and she
continued to have postprandial non-bloody diarrhea. Her ___
PCP thus reached out to ___ ID, who recommended that 3 days of
Azithromycin be the first line Rx for this, so this was
prescribed to her. Her diarrhea has been improving since. She
only had one episode of loose stools ___.
Regarding her dysphagia, she notes a feeling of food and pills
getting "stuck" at approximately the level of her neck. It has
been going on for about 3 weeks, and was not present prior to
her ___ trip. She reports she attempted to eat soup
today, and feels like the chicken is caught in her throat, thus
presenting to ED. She has lost 25 pounds since ___, and has
decreased appetite and decreased PO intake due to these
symptoms. She is drinking liquids, not solids, due to the
symptoms. She takes Ativan prior to eating but it does not help.
She also has post-prandial epigastric pain. She also has a sore
throat, but just on the left side. She feels the left side of
her neck is "hard."
She reports she had a similar problem at Age ___, with spaghetti
squash that she swallowed "going up instead of down," and coming
out of her nose.
She is supposed to see ENT and allergist on ___. Reports no
GI visit is scheduled at this time. She has ongoing trouble with
anxiety, though did not have these troubles prior to the last
month or so. She also reports a cough with post nasal drip.
Reports insomnia, and has been reliant on Ativan for sleep. She
denies fever, chills, chest pain.
Of note, multiple recent outpatient visits for multiple
problems.
- Neuro visit ___: Felt her symptoms were post-concussive from
the head trauma, scheduled an outpatient MRI brain
- HCA epi visit ___: Seen for dysphagia, ordered a CT neck
which was normal
- HCA epi visit ___: Seen for sinusitis and anxiety, no
antibiotics, recommended Flonase, azelastine nasal spray,
oxymetalozine nasal spray, Neti Pot, and ENT follow up.
- HCA epi visit ___: Seen for similar complaints
- HCA establish care ___
- Orthopedics visit ___: ordered XR and MRI of shoulder joints
Also of note, had a court hearing on ___ for a reckless
driving charge.
She presented to the ED today because her symptoms had continued
to worsen and not improved.
In the ED, initial vitals were:
97.1, HR 77, 142/81, 16, 99% RA
Labs showed BUN 3
Received 1L NS
Decision was made to admit to medicine for further management of
weight loss and dysphagia.
Review of systems:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Anxiety
Recent campylobacter infection
ACL surgery ___ yrs ago
Social History:
___
Family History:
mom - NHL
Sister/Aunt - ___
Aunt - ___ cancer
Physical Exam:
ADMISSION EXAM:
Vital Signs: 97.6, 113/72, HR 54, RR 20, 100% RA
General: NAD, Alert
HEENT: Sclerae anicteric, Oropharynx clear, MM slightly dry. No
sinus tenderness.
NECK: Supple, no LAD
CV: RRR no murmur
Lungs: Normal resp effort, no distress, CTAB
Abdomen: Soft, non-tender, non-distended, BS+
Ext: Warm, well perfused, no edema
Neuro: CNII-XII intact
DISCHARGE EXAM:
VS: 97.4 107/67 60 18 99RA
GEN: NAD, Alert
HEENT: Sclerae anicteric, Oropharynx clear, MM slightly dry. No
sinus tenderness; no posterior pharyngeal erythema
NECK: Supple, no LAD
CV: RRR no murmur
LUNGS: Normal resp effort, no distress, CTAB
ABD: Soft, non-tender, non-distended, BS+
EXT: Warm, well perfused, no edema
NEURO: CNII-XII intact
Pertinent Results:
ADMISSION LABS:
___ 08:45PM BLOOD WBC-7.4 RBC-4.14 Hgb-12.2 Hct-37.1 MCV-90
MCH-29.5 MCHC-32.9 RDW-12.3 RDWSD-40.2 Plt ___
___ 08:45PM BLOOD Neuts-53.2 ___ Monos-7.1 Eos-1.5
Baso-0.5 Im ___ AbsNeut-3.91 AbsLymp-2.76 AbsMono-0.52
AbsEos-0.11 AbsBaso-0.04
___ 08:45PM BLOOD ___ PTT-30.4 ___
___ 08:45PM BLOOD Glucose-91 UreaN-3* Creat-0.6 Na-137
K-4.6 Cl-99 HCO3-24 AnGap-19
___ 05:50AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0
DISCHARGE LABS:
None
IMAGING/STUDIES:
___ EGD:
Normal mucosa in the esophagus (biopsy)
Normal mucosa in the stomach
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
___ UGI+SBFT:
Normal esophagram
___ Video Swallow:
Normal oropharyngeal swallowing videofluoroscopy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 0.5 mg PO BID:PRN anxiety
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. azelastine 137 mcg (0.1 %) nasal BID:PRN
4. Loratadine 10 mg PO DAILY
5. Oxymetazoline 1 SPRY NU BID:PRN nasal congestion
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*14
Capsule Refills:*0
2. Sertraline 25 mg PO QHS
RX *sertraline 25 mg 1 tablet(s) by mouth at bedtime Disp #*14
Tablet Refills:*0
3. azelastine 137 mcg (0.1 %) nasal BID:PRN
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Loratadine 10 mg PO DAILY
6. LORazepam 0.5 mg PO BID:PRN anxiety
7. Oxymetazoline 1 SPRY NU BID:PRN nasal congestion
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- dysphagia
Secondary diagnosis:
- weight loss
- anxiety
- campylobacter infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW
INDICATION: ___ y/o F with no pertinent PMH presenting with 3 weeks of
dysphagia and weight loss, in the setting of multiple recent medical
evaluations for multiple different problems. // ? orphoaryngeal dysphagia
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 2 minutes 29 seconds.
COMPARISON: None.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There was no gross aspiration or penetration.
IMPRESSION:
Normal oropharyngeal swallowing videofluoroscopy.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ with no pertinent PMH presenting with 3 weeks of dysphagia
and weight loss, in the setting of multiple recent medical evaluations for
multiple different problems. // ? oropharyngeal vs esophageal etiology of
dysphagia
TECHNIQUE: Barium esophagram.
DOSE: Acc air kerma: 4 mGy; Accum DAP: 45.83 uGym2; Fluoro time: 1 minutes 32
seconds
COMPARISON: None.
FINDINGS:
The esophagus was not dilated. There was no stricture within the esophagus.
There was no esophageal mass. The esophageal mucosa appear normal.
The primary peristaltic wave was normal, with contrast passing readily into
the stomach. The lower esophageal sphincter opened and closed normally.
There was no gastroesophageal reflux. There was no hiatal hernia.
No overt abnormality in the stomach or duodenum on limited evaluation.
IMPRESSION:
Normal esophagram.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with admission for weight loss, dysphagia //
please evaluate for evidence of object stuck in throat, interval change in CXR
TECHNIQUE: Chest single view
COMPARISON: None
FINDINGS:
Shallow inspiration accentuates heart size. No pulmonary edema, normal
pulmonary vascularity. Lungs are clear. No effusion. No pneumothorax.
Residual contrast in the bowel loops upper abdomen.
IMPRESSION:
No acute findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Throat foreign body sensation, Sore throat
Diagnosed with Dysphagia, unspecified
temperature: 97.1
heartrate: 77.0
resprate: 16.0
o2sat: 99.0
sbp: 142.0
dbp: 81.0
level of pain: 5
level of acuity: 3.0 | ___ with no pertinent PMH presenting with 3 weeks of dysphagia
and weight loss following a bike accident during travel in
___ for initiation of dysphagia workup as inpatient.
# Dysphagia: The patient reported symptoms of dysphagia with
some sensation of swelling as her chief complaint on admission.
There is a lengthy history of her travel and misadventure while
in ___ which began with administration of COX2 inhibitors
not approved for use in USA inhibitors for shoulder/neck pain
from her bike accident. She may have experienced allergy
symptoms with this medication w/ complaints of throat swelling,
and was seen at a clinic where she was treated for a UTI as well
as given antihistamines and a dose of IM hydrocortisone. She was
taking an antibiotic pill at a bar when she first experienced
dysphagia which required the Heimlich maneuver to be performed
by a bartender. Since then these sensations of dysphagia with
solids have worsened, and she has been in contact with her PCP
about this. She was admitted for both worsening dysphagia to
solids as well as ~25lbs. weight loss. While inpatient she was
seen by several consulting services and had speech/swallow
evalution with video swallow which ruled out penetration or
aspiration. GI was consulted and recommened UGI+SBFT and EGD
which both showed no obstruction and no anatomic abnormalities;
biopsies were taken and patient will follow up with
multi-disciplinary team (GI, ENT, allergy, neurology, and PCP)
as outpatient. The patient receives some relief from lorazepam
suggesting contribution of anxiety/panic attacks to her
symptoms. She was amenable to starting a low-dose SSRI, and was
discharged with new sertraline 25mg PO QHS as a trial as well as
omeprazole 20mg PO daily.
# weight loss: Likely due to poor PO in setting of above
dysphagia/globus sensations. Albumin reassuring at 3.8. BUN low
at 3. Standing weight 135.6 on admission, down from reports of
~160. No clear etiology discovered during this admission,
however data-acquisition process initiated and patient will have
close follow-up with multiple disciplines as outpatient and
encouraged to increase PO intake as tolerated.
# anxiety: No longstanding history of this but has been
prescribed Ativan recently by PCP. Her PO Lorazepam PRN was
continued while inpatient. Started on low dose SSRI at time of
discharge after discussion with PCP.
# sinus symptoms: No sinus tenderness on exam, but the patient
states she had been taking several allergy medications for this
problem. Review of CT neck shows no overt or acute sinus
pathology. Her home regimen including Loratadine, Nasal Flonase,
Nasal Oxymetazoline was continued during admission.
# Campylobacter infection: Previously treated as outpatient with
first ciprofloxacin then azithromycin. Ordered stool culture to
verify clearance as inpatient, but will need outpatient f/u
regarding results as still pending. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Cipro / sulfamethoxazole / trimethoprim
Attending: ___.
Chief Complaint:
Draining wound post R hip girdelstone
Major Surgical or Invasive Procedure:
Incision and drainage of R hip seroma ___
History of Present Illness:
___ s/p R TFN ___ s/p fall w/ R TFN cutout now s/p ___,
conversion to R hip girdlestone (Krod ___ admitted from clinic
with concern for post-operative seroma.
Presented to clinic on ___ with concern for draining seroma
about
incision. Send to ED for admission to hospital. States she was
doing well at rehab until started to have some drainage a few
day
ago. Some concern she was picking at the incision at rehab.
Denies fever or chills. Denies nausea or emesis. Denies
increased
pain in the area.
Past Medical History:
- Dementia
- Anxiety
- Depression v. Bipolar
Social History:
___
Family History:
Patient denies any family history of medical disease. However
chart review shows: Notable for significant history of
psychiatric disease (specifics unknown). No known h/o cardiac
disease, cancer.
Physical Exam:
Vitals:
24 HR Data (last updated ___ @ 2147)
Temp: 97.2 (Tm 97.9), BP: 103/66 (103-119/66-70), HR: 85
(85-90), RR: 17 (___), O2 sat: 95% (94-95), O2 delivery: RA
General: sleeping this am. Pleasant when woken up. Interactive
MSK:
- RLE incision: Incision approximated.
- Serosanguinous drainage from drain sites. Reinforced with
pressure dressing. ok for nursing to reinforce and change as
needed.
- SILT s/s/sp/dp/t n dist
- Motor intact ___
Pertinent Results:
___ 06:10AM BLOOD WBC-8.0 RBC-3.07* Hgb-9.1* Hct-29.9*
MCV-97 MCH-29.6 MCHC-30.4* RDW-14.7 RDWSD-51.8* Plt ___
___ 06:10AM BLOOD Glucose-100 UreaN-12 Creat-0.4 Na-137
K-4.7 Cl-98 HCO3-27 AnGap-12
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Cyanocobalamin 1000 mcg PO DAILY
3. Divalproex (DELayed Release) 250 mg PO QHS
4. Docusate Sodium 100 mg PO BID
5. Latuda (lurasidone) 40 mg oral QHS
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Mirtazapine 7.5 mg PO QHS
8. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
9. Senna 8.6 mg PO DAILY
10. Thiamine 100 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
13. Polyethylene Glycol 17 g PO DAILY
14. Ramelteon 8 mg PO QPM:PRN Delirium
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen 325 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO BID
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth twice a day Disp #*76 Tablet Refills:*0
3. Doxycycline Hyclate 50 mg PO BID
RX *doxycycline hyclate 50 mg 1 capsule(s) by mouth twice a day
Disp #*76 Tablet Refills:*0
4. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 1 syringe SQ once a day Disp #*14
Syringe Refills:*0
5. LORazepam 0.25 mg PO QHS:PRN Agitation
RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth At night as
needed for agitation Disp #*20 Tablet Refills:*0
6. LORazepam 0.25 mg PO QAM
Give lorazepam once a day in the morning.
7. QUEtiapine Fumarate 25 mg PO BID for agitation
RX *quetiapine [Seroquel] 25 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
8. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth Every 6
hours as needed for pain Disp #*15 Tablet Refills:*0
9. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
10. Cyanocobalamin 1000 mcg PO DAILY
11. Divalproex (DELayed Release) 250 mg PO QHS
12. Docusate Sodium 100 mg PO BID
13. Latuda (lurasidone) 40 mg oral QHS
14. Levothyroxine Sodium 50 mcg PO DAILY
15. Mirtazapine 7.5 mg PO QHS
16. Polyethylene Glycol 17 g PO DAILY
17. Ramelteon 8 mg PO QPM:PRN Delirium
18. Senna 8.6 mg PO DAILY
19. Thiamine 100 mg PO DAILY
20. Vitamin D 1000 UNIT PO DAILY
21. HELD- Apixaban 5 mg PO BID This medication was held. Do not
restart Apixaban until after lovenox therapy completed in 2
weeks.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right hip wound hematoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT
INDICATION: ___ with right hip pain// eval for fx
TECHNIQUE: Frontal view radiograph of the pelvis with additional views of the
right hip.
COMPARISON: Radiographs dated ___
FINDINGS:
As seen on prior plain films, patient is status post resection of the prior
hardware from right femoral neck ORIF. Additionally, the femoral head is not
clearly delineated and may have been removed, similar appearance to prior.
Superior displacement of the distal femur with respect to its expected
location is unchanged. Degree of adjacent heterotopic ossification has not
significantly changed. Ghost tracks from prior hardware is noted. No
definite acute fracture. Overlying skin staples are noted.
IMPRESSION:
Unchanged appearance of the right hip. Patient is status post removal of
prior proximal right femoral ORIF hardware and possible femoral head
resection. Heterotopic ossification and superior displacement of the distal
femur is similar compared to postoperative films.
Radiology Report
INDICATION: ___ with pre-op workup// eval for intrathoracic process
TECHNIQUE: Single AP view of the chest.
COMPARISON: Chest x-ray from ___. chest CT from ___.
FINDINGS:
Lung volumes are low. Lungs are clear besides minimal left basilar
atelectasis. There is no edema or effusion. Focal indentation along the left
lateral aspect of the trachea at the thoracic inlet corresponds to left-sided
thyroid enlargement seen on prior CT. Cardiomediastinal silhouette is stable.
Thoracolumbar S-shaped scoliosis identified. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with Postproc seroma of skin, subcu following other procedure, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause
temperature: 98.4
heartrate: 80.0
resprate: 16.0
o2sat: 98.0
sbp: 115.0
dbp: 51.0
level of pain: 0
level of acuity: 3.0 | Patient presented to the emergency department and was evaluated
by the orthopedic surgery team. The patient was found to have a
Right hip seroma and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___ for
and I&D of her R hip, 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 rehabilitation was appropriate. The
___ hospital course was complicated by her baseline
dementia and agitation. Geriatrics team was consulted as well as
conservative attempts to manage her delirium implemented.
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 Lovenox for DVT prophylaxis. She will need
to be transitioned to her home eliquis once she is done with her
home eliquis. The patient will follow up with Dr. ___ at
the trauma clinic. A thorough discussion was had with the
patient and her family 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: NEUROSURGERY
Allergies:
carvedilol / clindamycin / felodipine / ibuprofen / oxycodone /
pravastatin / sertraline
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___ - Left craniectomy for subdural empyema
History of Present Illness:
___ is an ___ male with dementia who
presented to ___ ED on ___ with failure to thrive and
fevers. He is known to the Neurosurgery service for left SDH s/p
evacuation ___ and MMA embolization ___. He was last
seen in ___ clinic ___ with NCHCT that showed
interval
decrease in subdural collection. He was brought to an OSH by HCP
with concern for worsening mental status. OSH CT showed stable
SDH. He was transferred to ___ for further management and
neurosurgery was consulted. Patient was ultimately admitted to
the medicine service and found to have meningitis on LP. He was
started on empiric antibiotics.
Past Medical History:
Dementia
Hypertension
Hyperlipidemia
TIA
CKD
Prostate cancer
CABD (___)
V+CABG
s/p amputation of distal phalange of first digit left hand
s/p right shoulder surgery
Left subdural hematoma s/p left mini-craniotomy for evacuation
(___) and s/p left MMA embolization (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
ON ADMISSION: ___:
Gen: Frail elderly gentleman lying in stretcher
HEENT: Pupils: 3-2mm bilaterally reactive
EOMs - unable to assess but tracks examiner
Extrem: Warm and well-perfused. Bulk diminished throughout.
Neuro:
EO to voice and command
Oriented to self -
only answered orientation question - unable to assess full
orientation
Intermittently followed commands
Motor:
BUE antigravity to command distal to the elbow
BUE withdrawal to noxious
BLE withdrawal to noxious
ON DISCHARGE: ___:
General:
___ 0822 Temp: 97.9 AdultAxillary RR: 20
Exam:
No EO, no verbal response, no commands.
Moving all extremities spontaneously.
Wound:
Left cranial incision -
[x]Staples
[x]No surrounding erythema or active drainage
Pertinent Results:
Please see OMR for pertinent results.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Losartan Potassium 50 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID:PRN Heartburn
4. Ramelteon 8 mg PO QPM:PRN sleep
5. QUEtiapine Fumarate 12.5 mg PO QHS PRN agitation
6. Metoprolol Tartrate 12.5 mg PO BID
7. Senna 8.6 mg PO BID
8. Atorvastatin 80 mg PO QPM
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. Levothyroxine Sodium 88 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PR Q4H:PRN fever over 100
Do not exceed 4 suppositories per day
2. Atropine Sulfate 1% ___ DROP SL Q1H:PRN oral secretions
2 drops for moderate secretions, 4 drops for severe secretions
3. Bisacodyl ___AILY:PRN constipation
4. Bisacodyl 5 mg PO DAILY:PRN constipation
5. haloperidol lactate ___ mL oral Q2H:PRN agitation, nausea
6. LORazepam ___ mL oral Q2H:PRN seizure, anxiety,
restlessness, nausea
7. morphine ___ mL oral Q2H:PRN pain, air hunger
8. Senna 8.6-17.2 mg PO DAILY:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Subdural empyema
Bacterial meningitis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with fever // ?pneumonia
TECHNIQUE: Single AP upright portable view of the chest
COMPARISON: ___
FINDINGS:
Skin fold overlies the patient's left hemithorax. Patient is status post
median sternotomy. No focal consolidation is seen. There is no large pleural
effusion or pneumothorax. Cardiac and mediastinal silhouettes are stable as
compared to ___ when patient was in similar position. Evidence
of a probable hiatal hernia is seen.
IMPRESSION:
No focal consolidation to suggest pneumonia.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: Mr. ___ is an ___ year-old male admitted to ___ on
___ an unwitnessed fall, found to have an acute on chronic
leftholohemispheric SDH s/p left mini-craniotomy for evacuation on___
followed buy MMA embolization on ___ and who developedworsening mental
status over the last week and was admitted withfever and found to have
meningitis. // left arm - concerning for DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The left internal jugular, axillary, and brachial veins are patent, show
normal color flow, spectral doppler, and compressibility. The left cephalic
veins are patent, compressible and show normal color flow. Given positioning,
the left basilic vein is not seen. There is diffuse soft tissue edema in the
left arm.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with bacterial meningitis // *with diffusion
weighting*want to make sure this subdural is not an empyema
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CT head dated ___
FINDINGS:
Study is severely degraded by motion artifact.
There are postsurgical changes related to a left parietal craniotomy with a
small amount of susceptibility related to hemorrhagic byproducts. There is
increased size of the subdural fluid collection overlying the left cerebral
hemisphere and measuring up to 1.8 cm in thickness with adjacent dural
thickening and enhancement demonstrating slow diffusion. There is a focus of
slow diffusion in the dependent portion of the lateral ventricle (series 4,
image 8). There is a small amount of fluid in the cerebral sulci of the left
parietal and occipital lobes with small foci of diffusion restriction along
the posterior aspect of the parietal lobe (series 4, image 15).. There is
persistent regional sulcal effacement and mass effect including 7 mm rightward
midline shift at the level of the septum pellucidum. Similar encephalomalacia
is noted in the left cerebellar hemisphere related to chronic infarct. The
ventricles are similar in size with scattered subcortical and periventricular
white matter T2/FLAIR signal hyperintensity. There is no acute territorial
infarction..
There is mucosal thickening within the ethmoid air cells and bilateral
maxillary sinuses. Postsurgical changes related to bilateral lens replacement
is noted. There is fluid opacification of the right mastoid air cells and
several left mastoid air cells.
IMPRESSION:
1. Study is severely degraded by motion artifact, within these confines:
2. Postsurgical changes related to a left parietal craniotomy with a 1.8 cm
thick peripherally enhancing extra-axial fluid collection overlying the left
cerebral hemisphere with associated peripheral and dural enhancement and
diffusion restriction with worsening regional edema and mass effect including
7 mm rightward midline shift. The appearance could be due to a subdural
hematoma and diffusion restriction could be due to blood products but
underlying empyema could not be excluded.
3. Small foci of diffusion restriction in the dependent portion of the left
lateral ventricle, possibly related to hemorrhagic byproducts or
ventriculitis.
4. Paranasal sinus mucosal disease and predominately right mastoid fluid.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with L subdural empyema // assess for hemorrhage
hydro PERFORM AT 5:00 AM
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.0 s, 24.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
1,121.4 mGy-cm.
Total DLP (Head) = 1,121 mGy-cm.
COMPARISON: Outside reference MR ___ ___, outside reference CT
head ___
FINDINGS:
Patient is status post left parietal craniotomy for evacuation of a subdural
collection with expected postprocedural changes. There is approximately 7 mm
of midline shift, substantially improved from the prior CT on ___
in which midline shift measured approximately 1 cm. There is no evidence of
infarction, edema, or mass. There is no new or additional intracranial
hemorrhage. The basal cisterns and foramen magnum are patent. The ventricles
are stable in configuration with persistent prominence suggestive of
involutional changes.
There is mucosal thickening of the bilateral ethmoid air cells. The
visualized portion of the remaining paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The patient is status post bilateral lens
replacement. Otherwise, the visualized portion of the orbits are normal.
IMPRESSION:
1. Status post left parietal craniotomy for evacuation of a subdural
collection with expected postsurgical changes and interval improvement in
midline shift.
2. No new or additional intracranial hemorrhage.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: SDH, Transfer
Diagnosed with Fever, unspecified
temperature: 98.7
heartrate: 90.0
resprate: 16.0
o2sat: 98.0
sbp: 180.0
dbp: 94.0
level of pain: 0
level of acuity: 2.0 | ___ is an ___ male who presented to ___ ED
on ___ with concern for failure to thrive. He became febrile
in the emergency room and an LP was done, which was concerning
for bacterial meningitis. Patient was admitted to the medicine
service and empiric Cefepime, ampicillin, vancomycin, and
acyclovir were started. Repeat CT showed a stable subdural
collection. Neurosurgery was consulted and followed the patient
closely while on the medicine service. ID was consulted and
recommended continuing the vanco, cefepmine, and ampicillin.
Patient had decline in neurologic exam on ___. MRI brain was
done which was concerning for subdural empyema. Patient was
taken to the OR for left craniectomy for subdural empyema
washout on ___. Please see separate operative report by Dr.
___ more information. Postop, patient was
transferred onto the Neurosurgery service. For further details
regarding events prior to the OR, please see the medicine team
progress notes.
# s/p L craniectomy for subdural empyema
Postop, patient was extubated and brought to the PACU for close
monitoring. He was continued on empiric Vancomycin, Cefepime,
and Ampicillin per ID recommendations. Culture was sent in the
OR and grew pseudomonas aeruginosa. Helmet was ordered and worn
at all times when out of bed. Patient continued with poor exam
on POD #2, despite antibiotics administration. Patient was not
febrile on POD #2. Palliative care was consulted on ___ to
re-assess goals of care for patient, especially if he were not
to medically improve. He was made CMO on ___.
# Hypotension
Postop, patient was hypotensive to SBP ___. He remained on
continuous IV fluids. He was found to have a Hct of 19.2 and
received 1 unit of PRBC. Hypotension resolved. He became
hypotensive again to SBPs 70-80s. He received a second unit of
PRBC. Hypotension resolved.
# Anemia
Patient was found to be anemic on admission. Postop, patient Hct
dropped to 19.2. He received a total of 2 units PRBC on ___,
which brought Hct up to 30.5. Patients H&H continued to be
monitored while inpatient and continued to remain stable.
Monitoring of his H&H was discontinued when he was made CMO.
# Dysphagia
Patient with ongoing dysphagia since prior admission, secondary
to waxing/waning mental status. Family/HCP accepted aspiration
risk with liquids/purees. He was continued on this diet as his
mental status allowed, However since admission patient unable to
cooperate with nursing staff and SLP for appropriate nutrition.
Palliative care was consulted to discuss goals of care regarding
artificial nutrition, and it was decided that a feeding tube
would not be within his goals of care.
# Goals of Care
Palliative care met with the healthcare proxy, ___, on ___
to discuss patient's goals of care. It was decided to transition
patient to comfort measures only with discharge to home hospice.
Primary team confirmed with ___ that these were her wishes.
All invasive monitoring and all non-essential medications were
discontinued. Per request of ___, antibiotics were still
continued at that time, and were discontinued on ___ when he
lost peripheral IV access. He was discharged to home hospice on
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
dyspnea on exertion / cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old man w/PMHx significant for CAD s/p CABG / DES, sCHF
(EF = ___ presents with 2 weeks of worsening dyspnea on
exertion and lower extremity edema, acutely worsening over the
past several days. The patient also reports worsening
orthopnea/PND. He denies fevers/chills. He has had some cough
productive of pink, frothy sputum, without frank blood. He was
seen by his PCP ~1 week PTA and his Lasix was uptitrated from
80mg to 120mg daily. Despite this, pt.'s symptoms continued to
worsen. Of note, the patient and his family report that 1 month
prior to this presentation, he was able to walk from room to
room without too much dyspnea. On the day PTA, he was barely
able to transfer from bed to chair without extreme dyspnea. He
and his family further report a recent development of stool
passing at the time or urination, which they have discussed with
his internist. The note that in this setting, as well as
decreased oral intake several weeks prior to admission, the
patient was having difficulty with oral intake and ultimately
experienced constipation. His sons note that he tolerated oral
soup, at times which may have had significant sodium content, to
help with his GI symptoms, but later developed ___ edema
following ongoing intake of the soup which is not a typical
aspect of his diet.
He denies fevers/chills, chest pain, abdominal pain, diarrhea,
constipation. Pt. notes that his dry weight is ~165 lbs. Also
reported some left neck pain and left arm pain. He attributes
this to the way he was sleeping the last few days prior to
admission, due to his shortness of breath. He has had anginal
pain in the past, and states that this is not at all similar to
previous episodes of angina. No associated diaphoresis/nausea.
Not exertional. More pain with movement.
In the ED, initial vs were: 97.3 71 ___ 100%
Labs were remarkable for Cr 2.0 (at baseline); BNP 8834; INR 1.6
Patient was given ASA 324mg.
Currently, no acute complaints at rest on the floor. Breathing
comfortably at rest.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CABG: in ___ and 2 vessel SVG stenting in ___ followed by
failed attempt to open an occluded OM branch on ___ due to
persistent angina.
-PERCUTANEOUS CORONARY INTERVENTIONS:
s/p DES to SVG-RCA and SVG-LAD (___). SVG to OM known occluded.
3. OTHER PAST MEDICAL HISTORY:
- CAD s/p MI, CABG, PCI as above.
- AAA s/p repair
- Chronic systolic CHF (EF ___
- Hyperlipidemia
- Chronic kidney disease (baseline creatinine 1.6-2.2)
- s/p L carotid endarterectomy ___
- s/p cholecystectomy
- GERD
- hearing loss
- Nephrolithiasis
- Mesenteric ischemia (celiac artery stenosis, occluded ___
- Dizziness
- Chronic pleural effusion s/p talc pleuridesis
Social History:
___
Family History:
Father died of MI in ___
Physical Exam:
ADMISSION:
Vitals: 98.4 ___ 18 100%/2L Wt. 74.4 kgs
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated at 13cm
Lungs: bibasilar crackles, diminished breath sounds on left.
Dullness to percussion over LLL. no wheezes, ronchi, breathing
comfortably
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. 2+
pitting edema b/l ___ to level of knees.
Neuro: a&ox3. no focal deficits
DISCHARGE:
Vitals: 98.0 112/60 68 18 96%RA
I/O 1050/940: 24h Wt. 70.6kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat
Lungs: crackles half-way up right lung field, diminished breath
sounds on left. Dullness to percussion over LLL. no wheezes,
ronchi, breathing comfortably
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. 2+
pitting edema b/l ___ to level of knees.
Neuro: a&ox3. no focal deficits
Pertinent Results:
LABS:
___ 03:45PM BLOOD WBC-7.6 RBC-5.15 Hgb-11.8* Hct-41.7
MCV-81* MCH-22.9* MCHC-28.2* RDW-18.7* Plt ___
___ 08:30AM BLOOD WBC-8.1 RBC-4.92 Hgb-11.2* Hct-39.0*
MCV-79* MCH-22.8* MCHC-28.7* RDW-19.2* Plt ___
___ 03:45PM BLOOD ___ PTT-36.6* ___
___ 07:50AM BLOOD ___ PTT-40.0* ___
___ 07:15AM BLOOD ___ PTT-45.8* ___
___ 08:30AM BLOOD ___ PTT-38.4* ___
___ 03:45PM BLOOD Glucose-127* UreaN-34* Creat-2.0* Na-141
K-3.7 Cl-101 HCO3-25 AnGap-19
___ 08:15AM BLOOD Glucose-112* UreaN-37* Creat-1.9* Na-144
K-4.0 Cl-105 HCO3-29 AnGap-14
___ 07:45AM BLOOD Glucose-86 UreaN-39* Creat-1.7* Na-144
K-3.8 Cl-102 HCO3-33* AnGap-13
___ 08:30AM BLOOD Glucose-95 UreaN-45* Creat-1.9* Na-144
K-3.7 Cl-102 HCO3-31 AnGap-15
___ 07:50AM BLOOD ALT-17 AST-33 AlkPhos-68 TotBili-1.1
___ 03:45PM BLOOD proBNP-8834*
___ 03:45PM BLOOD cTropnT-0.03*
___ 07:50AM BLOOD Albumin-3.3* Calcium-8.7 Phos-3.2 Mg-2.1
___ 08:30AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.4
=============================================================
MICROBIOLOGY:
___ 3:00 pm SPUTUM
**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.
__________________________________________________________
___ 4:47 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Pending):
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
__________________________________________________________
___ 4:13 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 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.
__________________________________________________________
___ 3:00 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 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.
=====================================================
IMAGING/OTHER STUDIES:
EKG ___:
Atrial pacing with prolonged A-V conduction. Intraventricular
conduction
delay. Diffuse non-specific repolarization abnormalities.
Compared to the
previous tracing of ___ the findings are similar.
CXR ___:
FINDINGS: The patient is status post sternotomy. A dual-lead
pacemaker/ICD device appears unchanged with leads terminating in
the right atrium and ventricle, respectively, without change.
The heart appears mildly enlarged. The aorta shows unfolding
and mural calcification. Hemidiaphragms are flattened. There
is probably a small pleural effusion on the right and a slightly
larger one on the left, as well as increased thickening alongthe
minor fissure. Although this finding suggests a component of
fluid overload,
focal opacities projecting over the right lower and left upper
lungs are most suggestive of pneumonia with areas of spared lung
elsewhere. Biapical pleural thickening is unchanged. Bony
structures are unremarkable.
IMPRESSION: Findings most suggestive of multifocal pneumonia.
Small pleural effusions.
CXR ___:
HISTORY: Brown sputum and right lower lobe pneumonia.
FINDINGS: In comparison with the study of ___, there has been
substantial increase in the right lower lobe pneumonia. There
is also some suggested patchy opacification in the left mid to
upper zone, which could represent another focus of
consolidation.
CHEST CT W/O CONTRAST ___:
INDICATION: ___ male with hemoptysis and right lower
lobe infiltrate. Evaluate for evidence of neoplasm, hemorrhage,
or any other explanation for hemoptysis.
COMPARISON: CT chest from ___.
TECHNIQUE: Axial helical MDCT images were obtained from the
suprasternal
notch to the upper abdomen without the administration of IV
contrast.
Coronal, sagittal, and thin slice reformations were generated.
Axial MIP
reformats were generated on an independent workstation.
DLP: 321.22 mGy-cm.
CTDI: 8.42 mGy.
FINDINGS: There is no supraclavicular lymphadenopathy. The
airways are
patent to the subsegmental level. Multiple small mediastinal
lymph nodes are not enlarged by CT size criteria, nor
significantly changed compared with ___. A large calcified
lymph node in the right hilum measuring 1.4 cm is also stable.
There is no axillary lymphadenopathy. Dense coronary artery
calcifications are present. Pacemaker leads are noted ending in
the right atrium and the right ventricle, these are new from
___. Sternotomy wires are intact. There is no pericardial
effusion. No hiatal hernia is present.
Dense atherosclerotic calcifications of the aorta are present,
but there is no aneurysmal dilatation. Compared with ___,
there is extension of the atherosclerotic calcifications within
the lumen of the aorta (2:60) right at the level of its path
through the aortic hiatus and posterior to the origin of the
celiac trunk. Although the lack of contrast limits exam, the
appearance of this calcification in the sagitttal views
(___:36) is that of a focal calcified intramural thrombus at
this level rather than dissection.
Lung windows demonstrate bilateral diffuse ground-glass
opacities, more
prominent in the right lung and the left upper lobe. A moderate
non-hemorrhagic pleural effusion is noted on the left. The
patient is s/p talc pleurodesis in the right in ___,
with an irregular thickened pleural surface and plaques of
hyperdense material along the right lung base which are
sequealae of the procedure.
Although this study is not tailored for the assessment of
subdiaphragmatic structures, the visualized liver, pancreas, and
spleen are unremarkable. The patient is status post
cholecystectomy. The kidneys are atrophic with multiple
exophytic cysts, not significantly changed from prior exam.
Limited assessment of these cysts is made due to lack of IV
contrast.
OSSEOUS STRUCTURES: There are no lytic or blastic lesions
concerning for
malignancy.
IMPRESSION:
1. Bilateral ground-glass opacities, more prominent in the
right lung, are compatible with multifocal pneumonia.
2. Moderate left sided non-hemorrhagic pleural effusion.
3. Severe atherosclerotic calcifications of the coronary
arteries and aorta.
A calcified intramural thrombus at the level of the origin of
the celiac trunk
is new from ___.
4. Irregular right pleural surface with hyperdense material in
the right lung
base are sequealae of prior talc pleurodesis.
5. Pacemaker leads in appropriate position.
CXR ___
INDICATION: Right lower lobe opacity and hemoptysis, evaluation
after
diuresis.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no
relevant change in extent and severity of the pre-existing right
lower lobe opacity. A subtle new opacity has appeared at the
bases of the right upper lobe. In turn, the pre-described left
perihilar opacity is minimally decreased in severity and extent.
Unchanged position of the pacemaker and its leads. Unchanged
mild
cardiomegaly. Unchanged bilateral symmetrical apical
thickening.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 80 mg PO DAILY
2. Furosemide 40 mg PO QPM
3. Finasteride 5 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
hold for SBP<100; HR<60
5. Amiodarone 200 mg PO DAILY
6. Ranitidine 150 mg PO BID
7. Pravastatin 40 mg PO DAILY
8. Spironolactone 25 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
hold for SBP<100
11. Nitroglycerin SL 0.4 mg SL PRN chest pain
can give SL x3, doses separated by minutes. Call ___ if having
chest pain
12. Clopidogrel 75 mg PO DAILY
13. Aspirin EC 81 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Nitroglycerin SL 0.4 mg SL PRN chest pain
9. Pravastatin 40 mg PO DAILY
10. Ranitidine 150 mg PO DAILY
11. Spironolactone 25 mg PO DAILY
12. Benzonatate 100 mg PO TID
13. Levofloxacin 750 mg PO Q48H Duration: 7 Days
14. Torsemide 60 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Acute on chronic systolic congestive heart failure
Atypical pneumonia
Hemoptysis
Secondary:
Coronary artery disease
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Dyspnea on exertion.
COMPARISONS: ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The patient is status post sternotomy. A dual-lead pacemaker/ICD
device appears unchanged with leads terminating in the right atrium and
ventricle, respectively, without change. The heart appears mildly enlarged.
The aorta shows unfolding and mural calcification. Hemidiaphragms are
flattened. There is probably a small pleural effusion on the right and a
slightly larger one on the left, as well as increased thickening along the
minor fissure. Although this finding suggests a component of fluid overload,
focal opacities projecting over the right lower and left upper lungs are most
suggestive of pneumonia with areas of spared lung elsewhere. Biapical pleural
thickening is unchanged. Bony structures are unremarkable.
IMPRESSION: Findings most suggestive of multifocal pneumonia. Small pleural
effusions.
Radiology Report
HISTORY: Brown sputum and right lower lobe pneumonia.
FINDINGS: In comparison with the study of ___, there has been substantial
increase in the right lower lobe pneumonia. There is also some suggested
patchy opacification in the left mid to upper zone, which could represent
another focus of consolidation.
This information was conveyed to Dr. ___.
Radiology Report
INDICATION: ___ male with hemoptysis and right lower lobe infiltrate.
Evaluate for evidence of neoplasm, hemorrhage, or any other explanation for
hemoptysis.
COMPARISON: CT chest from ___.
TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal
notch to the upper abdomen without the administration of IV contrast.
Coronal, sagittal, and thin slice reformations were generated. Axial MIP
reformats were generated on an independent workstation.
DLP: 321.22 mGy-cm.
CTDI: 8.42 mGy.
FINDINGS: There is no supraclavicular lymphadenopathy. The airways are
patent to the subsegmental level. Multiple small mediastinal lymph nodes are
not enlarged by CT size criteria, nor significantly changed compared with
___. A large calcified lymph node in the right hilum measuring 1.4 cm is
also stable. There is no axillary lymphadenopathy. Dense coronary artery
calcifications are present. Pacemaker leads are noted ending in the right
atrium and the right ventricle, these are new from ___. Sternotomy wires are
intact. There is no pericardial effusion. No hiatal hernia is present.
Dense atherosclerotic calcifications of the aorta are present, but there is no
aneurysmal dilatation. Compared with ___, there is extension of the
atherosclerotic calcifications within the lumen of the aorta (2:60) right at
the level of its path through the aortic hiatus and posterior to the origin of
the celiac trunk. Although the lack of contrast limits exam, the appearance of
this calcification in the sagitttal views (602B:36) is that of a focal
calcified intramural thrombus at this level rather than dissection.
Lung windows demonstrate bilateral diffuse ground-glass opacities, more
prominent in the right lung and the left upper lobe. A moderate
non-hemorrhagic pleural effusion is noted on the left. The patient is s/p talc
pleurodesis in the right in ___, with an irregular thickened
pleural surface and plaques of hyperdense material along the right lung base
which are sequealae of the procedure.
Although this study is not tailored for the assessment of subdiaphragmatic
structures, the visualized liver, pancreas, and spleen are unremarkable. The
patient is status post cholecystectomy. The kidneys are atrophic with
multiple exophytic cysts, not significantly changed from prior exam. Limited
assessment of these cysts is made due to lack of IV contrast.
OSSEOUS STRUCTURES: There are no lytic or blastic lesions concerning for
malignancy.
IMPRESSION:
1. Bilateral ground-glass opacities, more prominent in the right lung, are
compatible with multifocal pneumonia.
2. Moderate left sided non-hemorrhagic pleural effusion.
3. Severe atherosclerotic calcifications of the coronary arteries and aorta.
A calcified intramural thrombus at the level of the origin of the celiac trunk
is new from ___.
4. Irregular right pleural surface with hyperdense material in the right lung
base are sequealae of prior talc pleurodesis.
5. Pacemaker leads in appropriate position.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Right lower lobe opacity and hemoptysis, evaluation after
diuresis.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant change
in extent and severity of the pre-existing right lower lobe opacity. A subtle
new opacity has appeared at the bases of the right upper lobe. In turn, the
pre-described left perihilar opacity is minimally decreased in severity and
extent.
Unchanged position of the pacemaker and its leads. Unchanged mild
cardiomegaly. Unchanged bilateral symmetrical apical thickening.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: DYSPNEA
Diagnosed with SHORTNESS OF BREATH
temperature: 97.3
heartrate: 71.0
resprate: 20.0
o2sat: 100.0
sbp: 108.0
dbp: 79.0
level of pain: 4
level of acuity: 2.0 | ___ w/PMHx CAD s/p CABG / DES, sCHF (EF = ___ presents with
2 weeks of worsening dyspnea on exertion and lower extremity
edema, acutely worsening over the past several days. Overall,
we noted acute volume overload on admission, attirubted to
dietary changes in the setting of his recent changed in intake.
However, following diuresis, we noted a persistent if not mildly
worsened infiltrate, and in consultation with pulmonary
medicine, we elected to perform some baseline testing and
proceed with an empiric antibiotic treatment. We discussed with
the patient and his family that there was a need for close
pulmonary follow-up to monitor his progress, and proceed with
further testing as indicated if he did not continue to improve,
as noted during his admission.
# Acute on chronic systolic congestive heart failure: Patient's
primary, initial clinical presentation was very consistent with
exacerbation of chronic CHF. In terms of precipitation of
exacerbation, his history was not consistent with ACS, acute
valvular dysfunction, nor medication non-compliance. His recent
history of increased soup intake likely represented a large salt
load, and this dietary indescretion, likely precipitated this
exacerbation. He continued to deteriorate despite increased PO
Lasix, likely ___ gut edema. As patient had clear dietary
indiscression, we did not pursue repeat TTE (last in ___
showing EF = 30%). Patient responded well to boluses of 80mg IV
Lasix. Transitioned to PO torsemide 80mg on ___. This
resulted in consistent diuresis of ___ net negative daily.
This diuresis slowed between ___ as he approached
euvolemia. On discharge he appeared euvolemic with a discharge
weight of 70.6 kg (74.4kg on admission). He was discharged on
torsemide 60mg with goal of euvolemia at this point. This dose
may need to be adjusted based on patient's volume status over
first few days at rehab. Other CHF meds were continued,
including home doses of spironolactone, metoprolol, and Imdur.
# CAD: No historical or EKG evidence of ACS. Continue
metoprolol, pravastatin, Plavix, and ASA 81mg
# Coagulopathy: INR elevated at 1.7. Albumin was low at 3.3,
while other LFTs, including TBili were wnl. This suggested
malnutrition as primary etiology of INR elevation. Given risk of
bleed in this elderly man on ASA/Plavix, we elected to reverse
with 2mg PO Vit. K. INR was 1.4 on discharge. Aside from
aforementioned hemoptysis, patient did not exhibit any evidence
of significant bleeding during admission.
# Hemoptysis: Initially attributed to pulmonary edema, but
evolved into frankly bloody sputum. CXR showed near total
opacification of right lower lobe. Chest CT showed ground glass
opacities prominent in RLL, interpreted as pneumonia. Repeat CXR
showed worsening right sided opacity. While the differential for
patient's hemoptysis was broad, his lack of hemodynamic
instability/massive hemoptysis, as well as his prodrome of
decreased appetite, weight loss, malaise prior to CHF
exacerbation leave top differential diagnoses as a subacute
bacterial infection, particularly atypical bacterial pneumonia,
non-tuberculosis mycobaterial infection, vs.
bronchogenic/endobronchial malignancy. Pulmonology was consulted
and believed that atypical bacterial infection is likely
explanation for patient's continuing hemoptysis and general
malaise and recommended empiric treatmentent with levofloxacin.
Respiratory viral panel was negative. Patient was started on
renally dosed levofloxacin (750mg every other day) on ___
(finish ___. Plan is for repeat CXR and evaluation by Dr.
___ as outpatient. If symptoms / radiography are not
improving, will consider furthur diagnostic tests (i.e.
bronchoscopy).
======================================================= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L arm pain
Major Surgical or Invasive Procedure:
L both bone forearm ORIF
History of Present Illness:
___ who states that he fell onto his left adducted arm during a
fight at approximately 0100 this morning. Patient initially
went to ___ where splint was placed and
transferred here for further evaluation. c/o pain in left arm.
No other ijuries identified.
Past Medical History:
asthma
Social History:
___
Family History:
nc
Physical Exam:
NAD,
AOx3
AVSS
sitting up in bed
symmetric chest rise
LUE:
in sling
wwp 2+cr 2+R/u
Exam limited ___ pain w/ active motion. Fires
EPL/FDP/EDC/EIP/Volar&Dorsal IO; SITLT U M; mild paresthesias on
dorsal aspect of hand and thumb; senses/differentiates moderate
pressure. SILT forearm/arm
Compartments soft; incision c/d/i; wrapped in kerlex and casted
in SAC
Pertinent Results:
___ 05:00AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 04:50AM estGFR-Using this
___ 04:50AM GLUCOSE-93 UREA N-7 CREAT-0.9 SODIUM-138
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-23 ANION GAP-17
___ 04:50AM estGFR-Using this
___ 04:50AM WBC-14.8* RBC-4.98 HGB-14.6 HCT-44.7 MCV-90
MCH-29.3 MCHC-32.7 RDW-14.0
___ 04:50AM NEUTS-83.9* LYMPHS-11.8* MONOS-3.5 EOS-0.2
BASOS-0.5
___ 04:50AM PLT COUNT-236
___ 04:50AM ___ PTT-27.1 ___
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4hr Disp #*60 Tablet
Refills:*0
5. Senna 1 TAB PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
status post L Both bone forearm fracture ORIF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Trauma.
No comparison studies available.
SECOND READ, TWO VIEWS OF THE LEFT FOREARM: A transverse fracture of the
proximal ulnar and radial shafts is seen, with one shaft-width ulnar deviation
of the distal fragments. The bone mineralization is normal. No embedded
radiopaque foreign body is seen.
Radiology Report
INDICATION: Post reduction.
COMPARISON: Radiographs available from 1:22 a.m.
THREE VIEWS OF THE LEFT FOREARM: A fiberglass cast overlies the left forearm,
obscuring the finer cortical detail. There has been interval reduction of
transverse fractures of the proximal ulna and radial shafts, with improved
anatomical alignment.
Radiology Report
STUDY: Two intraoperative fluoroscopic images of the left forearm ___.
COMPARISON: Radiographs ___.
INDICATION: Left forearm fracture ORIF.
FINDINGS AND IMPRESSION: Two views of the proximal forearm. Status post ORIF
of both bones. The hardware appears intact. Improved alignment of the
fractures. Total intraoperative fluoroscopic imaging time 7.2 seconds.
Please see operative report for further details.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PAIN LEFT ARM
Diagnosed with FX SHAFT RAD W ULNA-CLOS, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING
temperature: 98.3
heartrate: 80.0
resprate: 14.0
o2sat: 99.0
sbp: 161.0
dbp: 103.0
level of pain: 9
level of acuity: 3.0 | The patient was admitted to the Orthopaedic Trauma Service for
repair of a L forearm both bone fracture. The patient was taken
to the OR and underwent an uncomplicated L both bone forearm
ORIF. 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: NWB LUE, ROM AT, sling for comfort.
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. 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: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Positive outpatient blood culture
Major Surgical or Invasive Procedure:
___ Central venous line replacement ___
History of Present Illness:
Pt is a ___ with HTN, DM Type 1, and ESRD on HD since ___ now
with tunnelled RIJ dialysis catheter who presented to the ED one
day after his HD nurse told him she believed that his catheter
was infected. He reports that he has been feeling well and in
his usual state of health, and he denies any fevers, chills,
rigors, nausea or vomiting. He had not noticed any skin
changes, tenderness, or discharge at the site of his catheter
and is uncertain as to why he was sent to the ___ for
evaluation.
Pt was recently admitted to the ___ ___ also for a line
infection, but at the time had presented to HD with a fever.
Blood cultures from that admission were negative, but he was
treated empirically with IV antibiotics and was discharged to
complete a 10 day course of vancomycin dosed by HD consisting of
3 additional doses to be given as an outpatient.
In the ED, his vitals were T 97.8, HR 78, BP 102/62, RR 15,
O2sat 100% on RA. His physical exam was unremarkable, and his
catheter site appeared clean without evidence of erythema or
discharge. Because his catheter was not sewn in, Transplant
Surgery, who had placed the line, saw the patient, sutured the
line in place, and also agreed that the line did not appear
infected. The ED obtained outside records from the ___ that
showed positive blood cultures on ___ which grew out
pan-sensitive Staph epidermidis. According to the patient, he
did not receive any antibiotics at HD yesterday; however, the ED
notes indicate that the patient received vancomycin x 1 at HD
prior to admission. Given these positive blood cultures and a
potential source of infection, the patient was admitted to
medicine for IV antibiotics.
The patient's labs were notable for a Cre 10.6, glucose 75, WBC
8.3, Hct 36.8, and lactate 1.2. Blood cultures x 2 were sent and
CXR showed no acute pulmonary process.
.
On the floor, the patient's VS 98.2 120/82 81 18 96% on RA, FSBG
135. The patient was feeling well, and again endorsed that he
has been in his usual state of health with no fevers, chills,
nausea/vomiting, and that he has not observed any erythema or
discharge at his catheter site. He only reported some tenderness
at his catheter site after it was sutured in the ED.
Of note, the patient is a poor historian. He was also unaware of
what medications he should be taking nor did he appear to be
taking any of his medications.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- ESRD on HD (___) s/p multiple failed AVF
- DM Type 1 c/b peripheral neuropathy
- Hypertension
- Diabetic Myonecrosis (wheelchair-bound)
- Left knee charcot joint
- H/o alcohol dependence (last drink ___ ago)
- H/o mood disorder (reports "swings in his mood" none
currently)
- s/p L knee I+D
Social History:
___
Family History:
Many family members with DM and HTN
Physical Exam:
ADMISSION:
Vitals: T:98.2 BP:120/82 P:81 R:18 18 O2:96% on RA
General- Alert, oriented, no acute distress, sitting in
wheel-chair comfortably wearing wheel-chair gloves
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no cervical, submandibular,
supraclavicular LAD
Chest- Tunneled catheter exiting right superior chest secured
with sutures, clean no drainage, no appreciable erythema, mild
tenderness to palpation only at site of sutures
Lungs- CTAB, no wheezes rales or rhonchi
CV- Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen- soft, NTND, positive bowel sounds, no rebound
tenderness or guarding, no organomegaly
Ext- Left leg with enlarged left knee ___ position) with
well-healed scar. No edema or cyanosis. Bilateral 2+ pulses
distally .
Neuro- AOx3, no focal deficits except for decreased sensation of
left foot up to knee
.
DISCHARGE:
VS - T 98.4, BP 100/50, HR 84, RR 18, O2sat 98% on RA.
General- Sleepy, oriented, no acute distress, lying in bed
wearing wheel-chair gloves
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no cervical, submandibular,
supraclavicular LAD
Chest- Previous catheter site at right superior chest clean and
well-healed.
Lungs- CTAB, no wheezes rales or rhonchi
CV- Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen- soft, NTND, positive bowel sounds, no rebound
tenderness or guarding, no organomegaly
Ext- Left leg with enlarged left knee ___ position) with
well-healed scar. No edema or cyanosis. Bilateral 2+ pulses
distally. Right femoral hemodialysis line sutured in place.
Neuro- AOx3, no focal deficits except for decreased sensation of
left foot up to knee
Pertinent Results:
___ 09:30AM WBC-8.3 RBC-4.18* HGB-11.9* HCT-36.8* MCV-88
MCH-28.5 MCHC-32.4 RDW-15.0
___ 09:30AM NEUTS-69.8 ___ MONOS-3.6 EOS-5.0*
BASOS-0.3
___ 09:30AM PLT COUNT-306
___ 09:30AM GLUCOSE-75 UREA N-66* CREAT-10.6* SODIUM-137
POTASSIUM-4.8 CHLORIDE-96 TOTAL CO2-23 ANION GAP-23*
___ 09:30AM ___ PTT-26.6 ___
___ 10:05AM LACTATE-1.2
___ 09:30AM VANCO-2.0*
.
___ CXR
IMPRESSION: Right-sided central line seen with distal tip in
the right atrium but slightly more proximal in location when
compared to prior exam.
.
___ DIALYSIS CATHETER REMOVAL
IMPRESSION:
Successul removal of a right internal jugular tunneled dialysis
catheter. The tip was sent for culture.
.
___ DIALYSIS CATHETER PLACEMENT (Preliminary report)
IMPRESSION:
1. Placement of 15.5 ___, 50 cm tip-to-cuff tunneled
hemodialysis catheter with ulsound and fluoro guidance via the
right femoral vein.
2. Near complete thrombosis of the right internal jugular vein.
3. Occlusion of the left brachiocephalic vein.
.
___
WOUND CULTURE (Final ___:
___ PARAPSILOSIS. >15 colonies.
IDENTIFICATION AND FLUCONAZOLE SENSITIVITY REQUESTED
PER ___.
___ ___ ___.
SENSITIVE TO Fluconazole , sensitivity testing
performed by ___
___.
This test has not been FDA approved but has been
verified
following Clinical and Laboratory Standards Institute
guidelines
by ___ Clinical
___
Laboratory.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from ___ HemoDialysis.
1. Renagel *NF* 800 mg Other PO
Take 3 tabs PO with meals/snacks
2. Aspirin 81 mg PO DAILY
3. Nephrocaps 1 CAP PO DAILY
4. Sodium Polystyrene Sulfonate 15 gm PO BID
Take PO BID, ___
5. 70/30 8 Units Breakfast
70/30 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Calcium Acetate ___ mg PO TID W/MEALS
7. Cinacalcet 30 mg PO QHS
8. Lanthanum 500 mg PO TID W/MEALS
9. Haloperidol 2 mg PO BID
Discharge Medications:
1. Calcium Acetate ___ mg PO TID W/MEALS
2. Cinacalcet 60 mg PO QHS
3. 70/30 8 Units Breakfast
70/30 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Nephrocaps 1 CAP PO DAILY
5. Haloperidol 2 mg PO BID
6. Lanthanum 1000 mg PO QID
7. Aspirin 81 mg PO DAILY
8. Renagel *NF* 800 mg Other PO
Take 3 tabs PO with meals/snacks
9. Sodium Polystyrene Sulfonate 15 gm PO BID
Take PO BID, ___
10. Fluconazole 200 mg PO Q24H
RX *fluconazole 200 mg 1 Tablet(s) by mouth once a day Disp #*11
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
- Catheter-related blood stream infection
- End-stage renal disease
.
Secondary
- Hypertension
- Diabetes Type 1
- Mood Disorder
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, TWO VIEWS: ___.
HISTORY: ___ male with hemodialysis line, unsecured. Evaluate for
line placement.
FINDINGS: AP and lateral views of the chest are compared to previous exam
from ___. The lungs are clear. Cardiomediastinal silhouette is
within normal limits. Right-sided hemodialysis central catheter is seen,
slightly retracted when compared to prior with distal tip within the right
atrium but slightly more proximal when compared to prior. Right upper
extremity vascular stent is partially visualized. Osseous and soft tissue
structures are otherwise unremarkable.
IMPRESSION: Right-sided central line seen with distal tip in the right atrium
but slightly more proximal in location when compared to prior exam.
Radiology Report
PROCEDURE: Right femoral tunneled hemodialysis catheter placement.
INDICATION: ___ year-old man with type 1 diabetes and end-stage renal disease.
His previous right internal jugular hemodialysis catheter was removed
secondary to bacteremia.
RADIOLOGISTS: Dr. ___ (fellow), Dr. ___, Dr.
___, and Dr. ___ (attending) performed the procedure.
ANESTHESIA: Moderate intravenous sedation was provided by administering
divided doses of 100 mcg of fentanyl and 2 mg of Versed throughout the total
intraservice time of 4 hours.
TECHNIQUE/FINDINGS:
Informed consent was obtained after explaining the risks and benefits of the
procedure. The patient was brought to the angiography suite and positioned
supine on the imaging table. The neck and groin were prepped and draped in
the usual sterile fashion. A preprocedural huddle and timeout were performed
as per ___ protocol.
Initial ultrasound demonstrated near complete thrombosis of the right internal
jugular vein.
Attention was turned to the left side of the neck. Following successful
puncture of both the left internal jugular and left infraclavicular subclavian
vein, a micropuncture sheath was inserted and a venogram performed. This
demonstrated occlusion of the left brachiocephalic vein and contrast
opacification of a large thoracic tubular structure, which may either
represent the thoracic duct or a large collateral vein. Attempts to pass a
wire centrally were unsuccessful.
Attempts were made to access to the nearly completely thrombosed right
internal jugular vein. Multiple attempts to puncture the residual lumen or
collateral vessels proved unsuccessful.
The referring team was contacted and permission obtained to access the groin.
The right common femoral vein was then accessed under ultrasound guidance.
Following placement of a micropuncture sheath, a 0.035 inch ___ wire was
advanced to the right atrium. Attention was then directed towards
construction of a subcutaneous tunnel approximately 5 cm caudal and lateral to
the site of intravenous access. For this approximately 10 mL of 1% lidocaine
with epinephrine was injected, and the blunt tunneling device was used to
create the tunnel. A 15.5 ___, 50 cm tip-to-cuff dialysis catheter was
then advanced through the tunnel and inserted through the peel-away sheath.
The tip lies in the lower right atrium. Both lumens of the new catheter were
flushed and aspirated. The catheter was secured to the skin using a 0-silk
suture. and covered with a sterile dressing.
IMPRESSION:
1. Placement of 15.5 ___, 50 cm tip-to-cuff tunneled hemodialysis catheter
via the right femoral vein.
2. Near complete thrombosis of the right internal jugular vein.
3. Occlusion of the left brachiocephalic vein.
Radiology Report
INDICATION: ___ man with history of hypertension and diabetes
mellitus presenting with bacteremia. Please remove line and send the tip for
culture.
PROCEDURE: Dr. ___ performed the procedure. Dr. ___ was
present during the procedure. Dr. ___ was supervising.
Following informed consent explaining the risks, benefits, and alternatives to
the procedure, 1% lidocaine was injected subcutaneously at the exit site of
the tunneled catheter. The catheter was removed using manual pressure.
Pressure was held over the venotomy site and at the site of the IJ insertion
to ensure hemostasis. No immediate complications ensued. The tip was sent
for culture.
IMPRESSION: Successful removal of a right internal jugular tunneled dialysis
catheter. The tip was sent for culture.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: ? INFECTED PORT
Diagnosed with BACTEREMIA NOS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 98.4
heartrate: 88.0
resprate: 15.0
o2sat: 100.0
sbp: 106.0
dbp: 59.0
level of pain: 0
level of acuity: 3.0 | ___ with PMHx ESRD on HD, recent line infection treated with
vancomycin who presented with a positive surveillance culture
for Staph epidermidis drawn off of his dialysis catheter, now
s/p line change, with tip culture growing fluconazole-sensitive
___
.
ACTIVE
# Positive Line Cultures - This is a pt with a history of
positive line culture in the prior month who received 2 weeks of
vancomycin therapy, then had a surveillance culture checked ___
by his ___ dialysis center which returned ___ positive for
Staph Epi. He was afebrile at that time and felt well.
Discussion was had regarding whether this represented true
infection versus line colonization; while it was felt pt did not
have infection (negative cultures drawn on admission), given his
history of prior positive line cultures for which he had
received antibiotic therapy, Nephrology recommended changing of
the HD line. Line pulled and patient had a 24hour line holiday
prior to replacement on tunneled HD line ___ unable to place IJ,
so placed femoral). Patient's catheter tip culture grew out
Fluconazole-sensitive ___ parapsilosis. Patient was
discharged to complete 2 wk course of fluconazole 200 mg PO q24h
(last day ___. At discharge, all cultures remained negative /
without growth.
.
#Hypertension: Patient with BPs in the ___ without
accomanpying symptoms, so labetalol was discontinued with good
effect. He subsequently remained normotensive for the remainder
of the hospital stay.
INACTIVE
#DM Type I: Patient does not know his home regimen. Patient was
continued on previously documented humalog premix ___ with a
humalog sliding scale.
.
#ESRD on HD: Patient on HD MWF at ___. Home nephrocaps,
Phoslo, and Cinacalcet were continued.
.
# Mood disorder: Patient has a history of mood disorder
maintained with haldol 2mg PO BID. Mood currently stable, and
patient received home Haldol. Daily EKGs showed no QTc
prolongation.
.
TRANSITIONAL
- Full code
- Medication noncompliance - patient was unfamiliar with his
home medication regimen, was discharged with ___ to help with
medication organization / administration |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ with history of breast cancer (s/p
mastectomy w/o Chemo or radiation in ___ who presents with 1
week of diffuse abdominal pain. Patient reports pain was
initially left sided and associated with naausea, one episode of
vomiting as well as 4 episodes of diarrhea. Her nausea, vomiting
and diarrhea has resolved however she continues to have
abdominal pain. She reports pain happens 30 minutes after eating
meals and last for few hours. She has minimal appetite and has
been eating soft meals to avoid discomfort. She went to OSH
hospital few days ago where CT abd showed "mild intrahepatic
ductal dilation, markedly distended bladder, large left lobe of
the liver and mild ascistes". Labs were reassuring and patient
was discharged with PCP follow up. ___ followed up with her PCP
today and reported worsening of her abdominal pain and sent to
the ED.
In the ED, initial vitals were: 100.2 102 134/81 16 100%. Labs
notable for WBC 7.2; HCT 33.1, PLT 343. Chem 7, LFTs and lipase
normal. Lactate normal. UA negative. RUQ ultrasound showed
normal intrahepatic and extrahepatic ducts, moderate amouont of
pericholecystic fluid and moderate ascites. CT abd/pelvis with
contrast was performed which showed only small amount of asictes
without any intraabdominal process. Patient was given 2L IVF and
2 gm ceftriaxone and admitted for observation. Bedside
ultrasound did not reveal any tapable asictes
Upon arrival to the floor, patient reports some bloating in her
abdominen over the past one week. No relevant travel history or
sick contacts. No fevers, chills, night sweats or weight loss at
home.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias.
Past Medical History:
Breast Cancer; R side (DCIS),mastectomy ___, L mastectomy,
prophylactic, multiple calcifications, path benign ___
Angiomyolipoma of the right kidney
Gallblader polyp
Osteoporosis s/p Fosamax x ___ years stopped in ___
Osteoarhtritis of knee
Diverticulosis
s/p cataact surgery in ___
s/p retinal surgery in ___
s/p left elbow ORIF in ___
s/p tonsillectomy at age ___
s/p appendectomy at age ___
Social History:
___
Family History:
Mother ___ at age ___ CAD, Dementia, Osteoporosis, Macular
degenerationC
Father ___ at age ___ Myocardial Infarction
Sister Living ___ ___, Macular Degeneration
Maternal Aunt ___ at age ___ from Colon cancer dx at age ___
Physical Exam:
Admission:
Vitals: 98.2 120/60 98 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, mild tenderness to palpation inin
the epigastric area and lower quadrants, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No rashes
Discharge:
Vitals: 98.1, 114/72, 95, 18, 100% RA
General: Alert, oriented, no acute distress, thin appearing
female
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, no LAD
CV: RRR, normal S1 + S2, no MRG
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, nontender, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No rashes
Pertinent Results:
ADMISSION:
___ 01:30PM PLT COUNT-343
___ 01:30PM NEUTS-79.7* LYMPHS-13.4* MONOS-5.2 EOS-1.2
BASOS-0.4
___ 01:30PM WBC-7.2# RBC-3.68* HGB-11.3* HCT-33.1*
MCV-90# MCH-30.8 MCHC-34.2 RDW-13.8
___ 01:30PM CRP-8.3*
___ 01:30PM calTIBC-244* FERRITIN-89 TRF-188*
___ 01:30PM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-3.3
MAGNESIUM-2.1 IRON-25*
___ 01:30PM LIPASE-38
___ 01:30PM ALT(SGPT)-18 AST(SGOT)-21 LD(LDH)-240 ALK
PHOS-66 TOT BILI-0.3
___ 01:30PM GLUCOSE-111* UREA N-9 CREAT-0.6 SODIUM-135
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-27 ANION GAP-14
___ 01:36PM LACTATE-0.8
___ 01:36PM TYPE-ART COMMENTS-GREEN TOP
___ 01:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:40PM URINE COLOR-Straw APPEAR-Clear SP ___
DISCHARGE:
___ 08:16AM BLOOD WBC-3.9* RBC-3.39* Hgb-10.6* Hct-29.9*
MCV-88 MCH-31.1 MCHC-35.2* RDW-13.5 Plt ___
___ 02:45PM BLOOD Hgb-10.3* Hct-29.1*
___ 08:16AM BLOOD Glucose-122* UreaN-6 Creat-0.5 Na-139
K-3.7 Cl-105 HCO3-25 AnGap-13
___ 01:30PM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.3 Mg-2.1
Iron-25*
___ 01:30PM BLOOD calTIBC-244* Ferritn-89 TRF-188*
___ 13:30
SED RATE
Test Result Reference
Range/Units
SED RATE BY MODIFIED 6 < OR = 30 mm/h
___
Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) Study
Date of ___ 1:32 ___
FINDINGS:
LIVER: Incomplete visualization of the left lobe. The hepatic
parenchyma
appears within normal limits. No focal hepatic mass. The main
portal vein is patent with hepatopetal flow. There is moderate
ascites and a small amount of free fluid in the pelvis as well.
BILE DUCTS: No evidence of intrahepatic biliary dilation. The
CBD measures 4 mm.
GALLBLADDER: The gallbladder is not markedly distended. There
is biliary
sludge. There is a 2-mm anterior gallbladder polyp. There is
nonspecific wall edema and nonspecific tiny amount of
pericholecystic fluid. No obstructing echogenic shadowing
gallstone is identified.
PANCREAS: The imaged portion of the pancreas appears within
normal limits, without masses or pancreatic ductal dilation,
with portions of the pancreatic tail obscured by overlying bowel
gas.
SPLEEN: The spleen is incompletely visualized. Visualized
portions of the spleen, however, appear normal and echogenicity.
KIDNEYS: The right kidney measures 10.1 cm. The left kidney
measures 10.7 cm. No hydronephrosis on limited views.
RETROPERITONEUM: Visualized portions of the abdominal aorta and
IVC are within normal limits.
IMPRESSION:
1. No sonographic evidence of acute cholecystitis. Tiny amount
of
pericholecystic fluid and wall edema is nonspecific particularly
in the
setting of moderate ascites. Biliary sludge.
2. No intrahepatic or extrahepatic biliary ductal dilatation.
3. 2-mm gallbladder polyp - no followup needed.
4. Moderate ascites.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 5:23 ___
IMPRESSION:
1. No evidence of acute intra-abdominal abnormality.
2. Small amount of ascites.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
2. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
3. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Outpatient Lab Work
Please check Hemoglobin and hematocrit on ___ and fax
results to ___ Phone: ___
Fax: ___
ICD9: 280
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: abdominal pain, ascites, anemia
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: ___ woman with history of breast cancer and a week of
abdominal pain, now more pronounced in the epigastrium with fever. Outside
hospital CT showed ? dilated bile ducts. Evaluate for cholecystitis and
biliary dilation.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound dated ___.
FINDINGS:
LIVER: Incomplete visualization of the left lobe. The hepatic parenchyma
appears within normal limits. No focal hepatic mass. The main portal vein is
patent with hepatopetal flow. There is moderate ascites and a small amount of
free fluid in the pelvis as well.
BILE DUCTS: No evidence of intrahepatic biliary dilation. The CBD measures 4
mm.
GALLBLADDER: The gallbladder is not markedly distended. There is biliary
sludge. There is a 2-mm anterior gallbladder polyp. There is nonspecific wall
edema and nonspecific tiny amount of pericholecystic fluid. No obstructing
echogenic shadowing gallstone is identified.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: The spleen is incompletely visualized. Visualized portions of the
spleen, however, appear normal and echogenicity.
KIDNEYS: The right kidney measures 10.1 cm. The left kidney measures 10.7 cm.
No hydronephrosis on limited views.
RETROPERITONEUM: Visualized portions of the abdominal aorta and IVC are within
normal limits.
IMPRESSION:
1. No sonographic evidence of acute cholecystitis. Tiny amount of
pericholecystic fluid and wall edema is nonspecific particularly in the
setting of moderate ascites. Biliary sludge.
2. No intrahepatic or extrahepatic biliary ductal dilatation.
3. 2-mm gallbladder polyp - no followup needed.
4. Moderate ascites.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with lower abdominal pain, diffuse tenderness // evaluate for
acute process, metastasis
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technqiue.
Coronal and sagittal reformations were performed and submitted to PACS for
review. Oral contrast was administered.
DOSE: DLP: 338 mGy-cm (abdomen and pelvis.
COMPARISON: Correlation is made to same day ultrasound.
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 prominence of the central
biliary ducts. The gallbladder is within normal limits.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. A 5 mm accessory spleen is noted along the
superior aspect of the spleen.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation.
ADRENALS: The right and left adrenal glands are normal.
URINARY: The kidneys show no evidence of hydronephrosis, stones or focal
lesions. Numerous sub cm hypodensities are noted within the kidneys,
bilaterally which are too small to characterize but likely cysts.
GASTROINTESTINAL: The small and large bowel are normal in course and caliber
without obstruction. Colon and rectum are within normal limits. Appendix is
not visualized.
MESENTERY AND RETROPERITONEUM: There is no evidence of retroperitoneal and
mesenteric lymphadenopathy. There is no free air.
VASCULAR: There is no abdominal aortic aneurysm. There is minimal calcium
burden in the abdominal aorta and great abdominal arteries. There is no
evidence of clot within the main portal vein, splenic vein and SMV.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. Reproductive organs are within
normal limits, prominent periuterine vessels are seen on the left. There is a
small amount of ascites within the pelvis.
BONES AND SOFT TISSUES: No bone finding suspicious for infection or malignancy
is seen. Degenerative changes are noted in the spine as well as a lower
thoracic upper lumbar dextroscoliosis. Abdominal and pelvic wall is within
normal limits.
IMPRESSION:
1. No evidence of acute intra-abdominal abnormality.
2. Small amount of ascites.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN UNSPEC SITE, OTHER ASCITES
temperature: 100.2
heartrate: 102.0
resprate: 16.0
o2sat: 100.0
sbp: 134.0
dbp: 81.0
level of pain: 5
level of acuity: 3.0 | ___ with history of breast cancer (s/p mastectomy w/o Chemo or
radiation in ___ who presents with 1 week of diffuse abdominal
pain.
# Abdominal Pain: Differential includeD gastroenteritis, PUD and
SBP. Low grade fever, nausea, episode of vomiting and diarrhea
suggests resolving gastroenteritis. CT abd/pelvis with contrast
reveals mild ascites however no intraabdominal pathology
specifically no signs of cholesystitis, pancraetitis, hepatitis,
appendicities, diveritculitis or intraabdominal malignancy. Exam
rather benign. CRP mildly elevated but very nonspecific.
Overall, etiology of abdominal pain not clear. Given post
prandial nature, hemocult positive, would suggest an EGD as
outpatient to evaluate for ulcer. Pt. started on ranitidine.
- Consider outpatient vs inaptient endoscopy if symptoms do not
resolve with PUD treatment
# Ascites: Unclear etiology. Minimal on CT abd/pelvis and no
tapable pocket on bedside ultrasound. LFTs within normal limits
and albumin normal. No proteinuria on UA. CT abd/pelvis w/out
evidence of malignancy. Colonoscopy one year ago with one polyp
removed. Breast cancer treated with b/l mastectomy, however
recurrence is possible. ___ consulted and reviewed imaging,
however not enough ascites for them to tap.
# Anemia: Fe low however ferritin normal and transferrin and
TIBC low so not completely consistent with iron deficiency
anemia and normal indices. Reports colonoscopy one year ago.
- consider outpatient endoscopy |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vitamin B-1
Attending: ___.
Chief Complaint:
abnormal outpatient labs
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ ___ gentleman with HTN who
was referred to the ED due to hyperkalemia on outpatient labs.
He had a routine visit to his PCP ___ ___ and was found to have
K+ 5.8 so he was referred to the ED. He has no complaints;
specifically, he denies any chest pain, palpitations, weakness,
numbness, or tingling. He denies eating many bananas or oranges.
He is on Lisinopril which was increased from 20 to 40mg a few
months ago, but no recent medication changes. No
over-the-counter meds and no herbal supplements.
.
In the ED, initial VS were: T 98, HR 69, BP 114/60, RR 14. Labs
were notable for K+ 5.3, Cr 1.7 (which is baseline). CXR was
unremarkable. EKG had peaked T waves. He received:
-Calcium gluconate 10mL of 10% solution
-Insulin regular 10u IV x1
-D50 1 amp
-Albuterol neb x1
-Kayexalate 30g PO x1
-1L NS
Repeat EKG was without peaked T waves. He was admitted to
Medicine for further workup and management of hyperkalemia.
.
Upon arrival to the floor, he has no complaints. His biggest
worry is that he is currently staying with various friends; his
daughter with whom he previously lived has moved to the D.R. for
some time and he is worried about his unstable living situation.
.
REVIEW OF SYSTEMS:
Positive for some polyuria over these past few days - but no
change in the color of his urine.
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:
1. Pulmonary hypertension.
2. Heart murmur, likely aortic stenosis.
3. Abdominal bruit.
4. Hypertension.
5. History of adrenal adenoma.
6. Paget's disease.
7. Kidney stones
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.6F, BP 157/89, HR 70, R 18, O2-sat 98% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
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, steady gait
.
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
.
___ 05:05PM BLOOD WBC-10.4# RBC-4.44* Hgb-13.8* Hct-40.5
MCV-91 MCH-31.0 MCHC-34.0 RDW-13.1 Plt ___
___ 05:05PM BLOOD Neuts-81.3* Lymphs-13.8* Monos-3.1
Eos-0.4 Baso-1.4
___ 09:25AM BLOOD UreaN-28* Creat-1.7* Na-140 K-5.8* Cl-103
HCO3-30 AnGap-13
___ 09:25AM BLOOD Glucose-100
___ 09:25AM BLOOD ALT-21 AST-20
___ 07:20AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.0
___ 09:25AM BLOOD VitB12-1262*
___ 09:25AM BLOOD %HbA1c-5.9 eAG-123
___ 09:25AM BLOOD Triglyc-124 HDL-53 CHOL/HD-3.8
LDLcalc-123
.
DISCHARGE LABS:
.
___ 06:30AM BLOOD WBC-6.0 RBC-4.25* Hgb-12.7* Hct-37.4*
MCV-88 MCH-30.0 MCHC-34.0 RDW-13.5 Plt ___
___ 06:30AM BLOOD Glucose-92 UreaN-33* Creat-1.7* Na-141
K-4.6 Cl-105 HCO3-27 AnGap-14
___ 06:30AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.0
.
MICRO/PATH: NONE
.
IMAGING/STUDIES:
.
CXR PA/LAT ___:
IMPRESSION: No acute cardiopulmonary process.
Medications on Admission:
Aspirin 81 mg daily
Lisinopril 40 mg daily
Hydrochlorothiazide 25 mg daily
Amlodipine 10 mg daily
Vitamin B-12 500 mcg daily
cholecalciferol (vitamin D3) 2,000 unit daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
5. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*
6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Vitamin D-3 2,000 unit Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: hyperkalemia
Secondary: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, SINGLE VIEW: ___
HISTORY: ___ male with hyperkalemia and EKG changes.
FINDINGS: Single portable AP view of the chest is compared to previous exam
from ___. The lungs are clear of focal consolidation. There is
no evidence of pulmonary vascular congestion. Cardiomediastinal silhouette is
within normal limits. Osseous and soft tissue structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: ABNL EKG
Diagnosed with HYPERKALEMIA, RENAL & URETERAL DIS NOS, HYPERTENSION NOS
temperature: 98.2
heartrate: 66.0
resprate: 20.0
o2sat: 100.0
sbp: 121.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | ___ with HTN on an ACE inhibitor who presents with hyperkalemia
in the absence of symptoms but with EKG changes.
.
# Hyperkalemia: Patient was found to be hyperkalemic to 6.3 on
routine screening labs but without symptoms. His EKG in the ED
was significant minor T wave changes. He was treated with
calcium gulconate, insulin, dextrose, albuterol and kayexelate
and admitted to the floor. His serum potassium level quickly
returned to within normal limits. His renal function, while not
normal (Cr of 1.7 which could qualify him for stage III CKD) was
not far from his baseline and not bad enough to explain the
hyperkalemia in and of itself. Of note, he had been on ace
inhibitors for a period of months and a couple months ago his
dose of lisinopril was doubled from 20 to 40mg daily. Serum and
urine lytes comparison demonstrated he had a TTKG of 4.9 (being
off his ace for 24 hours) suggesting hypoaldosteronism and
perhaps Type IV RTA. He was discharged on a low potassium diet
with instructions in ___, we continued his home HCTZ and
amlodipine and had his lisinopril reduced to 5mg with labetolol
200mg BID added to manage his HTN. He was established with
outpatient follow-up and will likely benefit from outpatient
nephrology follow-up.
.
# HTN: His blood pressure was well controlled during this
admission with changes in his regimen of decreasing his
lisinopril from 40mg to 5mg daily and starting labetolol 200mg
PO BID to make up the difference.
.
# Life stressors: Patient described being homeless and staying
with friends. He would likely benefit from an outpatient social
worker.
.
# CKD Stage III: His Cr of 1.7 was slightly above baseline of
1.5. He would likely benefit from outpatient nephrology
follow-up.
.
# Paget's disease: Stable. Continued on Vitamin D.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Polytrauma
Major Surgical or Invasive Procedure:
1. Open reduction and internal fixation of right ulna, right
femur, and right tibia (___)
2. Fasciotomies of right thigh and leg (___)
3. Irrigation and debridement of fasciotomy wounds, primary
closure of right leg lateral fasciotomy wound (___)
4. Debridement & preparation of the right lower leg medial
wound; local muscle flap advancement for exposed bone;
split-thickness skin graft from right thigh to right medial leg,
25 x 10 cm (___)
History of Present Illness:
___ hx of PE on coumadin presents after MCC versus vehicle at
approximately 40 mph. GCS 15 at the scene, no drug or EtOH. Take
to OSH where he remained hemodynamically stable and transferred
to ___ for further care. Given tetanus, gentamicin, and ancef
prior to arrival. Here there are obvious deformities of right
thigh and leg with open fracture. Pt also complaining of right
forearm and hand pain. No numbness or tingling distally. Given
initial concern for inability to obtain a pulse, pt rushed for
CTA with runoff, which was negative for vascular injury. Of
note, pt given FFP en route to ___.
Past Medical History:
History of pulmonary embolus (~8 mos prior; on warfarin)
Asthma
Social History:
___
Family History:
Non-contributory.
Physical Exam:
AFVSS
A&O x 3
Visibly uncomfortable
Pelvis stable to AP and lateral compression.
RUE:
incision c/d/i
SILT R/U/M distribution
+EPL/FPL/DIO
radial pulse 2+
RLE:
donor site: clean and dry
splint place
staples c/d/i
___
SILT in DP/SP/S/S/T distribution
no pain with passive ___ of the toes
Pertinent Results:
IMAGING (per radiology)
CXR (___):
No acute cardiopulmonary process.
CT Head (___):
No acute intracranial abnormality or skull fracture. Right
frontal scalp
contusion.
CT Cervical Spine (___):
No acute cervical spine fracture or subluxation.
CTA (___):
1. No evidence of vascular injury of the chest, abdomen, pelvis,
or bilateral lower extremities, with normal 3 vessel runoff into
the right foot.
2. No evidence of traumatic injury to the chest, abdomen, or
pelvis.
3. Multiple orthopedic injuries including open distal right
tibial and fibular fractures, proximal right fibular fracture,
right femoral midshaft fracture, and distal right ulnar
fracture. The right elbow was not imaged on CT and radiographs
should be considered.
Right Upper Extremity X-ray (___):
Mildly displaced fracture of the distal third diaphysis of the
ulna.
Right Lower Extremity X-rays (___):
Comminuted fracture involving the mid diaphysis of the right
femur with medial and dorsal displacement of the dominant distal
fracture fragment by approximately 1 shaft width is again noted.
Imaged aspect of the right hip appears grossly unremarkable. A
comminuted mildly displaced fracture of the proximal fibular
diaphysis is present with mild angulation of the fracture apex
anteriorly. Comminuted open fractures involving the distal
diaphyses of the tibia and fibula are again noted with the
dominant distal tibial fracture fragment displaced anteriorly
and laterally by approximately 1 shaft width and the fracture
apex remains medially located. The dominant distal fibular
fracture fragment is anteriorly displaced by approximately 2
shaft widths as well as laterally displaced by approximately a
half shaft width. The ankle mortise is difficult assess on these
views, but on the previous CT appeared congruent. No sizable
knee joint effusion is present. Subcutaneous gas is seen about
the proximal leg.
Chest CTA (___):
1. No segmental or larger pulmonary embolism.
2. Bilateral subsegmental atelectasis, but evidence for an acute
infiltrative process in the lungs.
3. Lucency in the sternal body more likely represents a vascular
channel than a nondisplaced fracture, but evaluation for point
tenderness could be considered when clinically feasible.
Medications on Admission:
Warfarin 7.5 mg po daily
Albuterol
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H pain
Never exceed 4000 mg in 24 hours.
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q3h Disp #*120 Tablet
Refills:*0
___ MD to order daily dose PO DAILY16 Duration: 3
Months
6. Ascorbic Acid ___ mg PO BID
7. Sarna Lotion 1 Appl TP TID:PRN itching
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right femur fracture
Right open tibia fracture
Right ulna fracture
Right thigh & leg compartment syndrome
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: ___ motorcycle accident, on coumadin for history of
pulmonary embolism
TECHNIQUE: Supine AP view of the chest
COMPARISON: None. Patient is currently listed as EU critical.
FINDINGS:
Overlying trauma board slightly limits assessment. Cardiac, mediastinal and
hilar contours are normal. Lungs are clear without focal consolidation. No
pleural effusion or pneumothorax is identified on this supine exam. No
displaced fractures are seen.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ man with head trauma and neck pain.
TECHNIQUE: Contiguous multidetector CT scan through the head was performed
without intravenous contrast. Axial images displayed as separate 5 mm soft
tissue and 2.5 mm bone algorithm image series. Multiplanar reformation was
performed to construct coronal and sagittal images.
DOSE: DLP: 1003.42 mGy-cm. CTDIvol: 48.28 mGy.
COMPARISON: None available.
FINDINGS:
There is no acute intracranial hemorrhage, edema, mass effect, or evidence of
large vascular territorial infarction. The ventricles and sulci are normal in
size and configuration. There is a probable small calcified meningioma in the
right vertex (2:26). There is no fracture. The imaged paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. There is a small right
frontal scalp contusion.
IMPRESSION:
No acute intracranial abnormality or skull fracture. Right frontal scalp
contusion.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ man with head trauma and neck pain.
TECHNIQUE: Non-contrast multidetector helical CT scan through the cervical
spine was performed. Image data processed to generate 2.5 mm axial soft
tissue algorithm, 2.5 mm axial bone algorithm, coronal, and sagittal image
series.
DOSE: DLP: 768.71 mGy-cm; CTDIvol: 36.88 mGy.
COMPARISON: None available.
FINDINGS:
There is no acute fracture or alignment abnormality. There is no prevertebral
soft tissue swelling. There are no significant degenerative changes.
Limited, non-contrast appearance of the included soft tissues is unremarkable.
No concerning abnormality is seen in the included upper lungs.
IMPRESSION:
No acute cervical spine fracture or subluxation.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ man status post 40 mph motorcycle accident, on
Coumadin for pulmonary emboli, with open tib fib fracture. Evaluate for
vascular injury.
TECHNIQUE: After rapid administration of intravenous contrast, early
arterial-phase axial MDCT images were acquired from the lung apices through
the feet. Coronal and sagittal multiplanar reformats and MIPS were provided.
DOSE: DLP: 2552.31 mGy-cm.
COMPARISON: None available.
FINDINGS:
CTA CHEST:
The thoracic aorta is normal in caliber, without evidence of aneurysm or
dissection. The main, lobar, segmental, and subsegmental pulmonary arteries
are well opacified and without filling defect. The remaining great vessels are
normal in appearance.
CTA ABDOMEN/PELVIS:
The abdominal aorta is normal in caliber and without evidence of aneurysmal
dilation or dissection. The celiac axis, SMA, bilateral renal arteries, and
___ are patent. The bilateral common iliac arteries and external iliac
arteries are patent. No atherosclerotic disease is identified. The hepatic
arterial anatomy is conventional. Assessment of the venous vasculature is
limited by the timing of contrast.
CTA LOWER EXTREMITIES:
The common femoral, superficial femoral, and deep femoral arteries are patent,
without aneurysm or stenosis. The popliteal arteries are patent, without
aneurysm or high-grade stenosis. After the trifurcation, there is normal
contrast enhancement of the anterior tibial, posterior tibial, and peroneal
arteries. In the feet, normal contrast enhancement is seen in the dorsalis
pedis, peroneal, and plantar arteries. No evidence of contrast extravasation
is present.
CHEST:
The imaged thyroid is normal. There is no axillary, supraclavicular,
mediastinal, or hilar lymphadenopathy by CT size criteria. The heart is
structurally normal and there is no pericardial effusion. The lungs are clear
without parenchymal or interstitial abnormality. The airways are patent. There
are no concerning pulmonary nodules. There is no pneumothorax or pleural
effusion.
ABDOMEN:
Evaluation is limited by the arterial phase of image acquisition. The liver is
without concerning focal lesion. The gallbladder and biliary tree are normal.
The pancreas is normal, without focal lesion or duct dilation. The spleen is
normal in size, without focal lesion. The adrenal glands are normal. The
kidneys enhance normally. There are no solid renal lesions or hydronephrosis.
The stomach and duodenum are normal. The small bowel and large bowel are
normal in caliber, without wall thickening or mass. There is no intra- or
retroperitoneal lymphadenopathy. There is no ascites, fluid collection, or
pneumoperitoneum.
PELVIS:
The urinary bladder is without wall thickening or mass. The rectum is
unremarkable. There is no pelvic mass. There is no free fluid. There is no
pelvic or inguinal lymphadenopathy. The reproductive organs are within normal
limits.
BONES AND SOFT TISSUES:
There are comminuted open fractures of the distal right tibia and fibula with
surrounding hematoma and subcutaneous gas but no active extravasation. There
is a minimally displaced proximal right fibular fracture. There is a displaced
and minimally comminuted right femoral midshaft fracture with surrounding
hematoma but no active extravasation. There is a right mid ulnar minimally
displaced fracture. No other acute fracture is seen.
IMPRESSION:
1. No evidence of vascular injury of the chest, abdomen, pelvis, or bilateral
lower extremities, with normal 3 vessel runoff into the right foot.
2. No evidence of traumatic injury to the chest, abdomen, or pelvis.
3. Multiple orthopedic injuries including open distal right tibial and fibular
fractures, proximal right fibular fracture, right femoral midshaft fracture,
and distal right ulnar fracture. The right elbow was not imaged on CT and
radiographs should be considered.
Radiology Report
INDICATION: Right lower extremity fractures post trauma
TECHNIQUE: Right femur, two views, right tibia and fibula, two views
COMPARISON: CTA run off ___ at 17:20
FINDINGS:
Overlying splint limits fine osseous detail. Assessment of the the right knee
is limited as it was not completely imaged on the AP view.
Comminuted fracture involving the mid diaphysis of the right femur with medial
and dorsal displacement of the dominant distal fracture fragment by
approximately 1 shaft width is again noted. Imaged aspect of the right hip
appears grossly unremarkable. A comminuted mildly displaced fracture of the
proximal fibular diaphysis is present with mild angulation of the fracture
apex anteriorly. Comminuted open fractures involving the distal diaphyses of
the tibia and fibula are again noted with the dominant distal tibial fracture
fragment displaced anteriorly and laterally by approximately 1 shaft width and
the fracture apex remains medially located. The dominant distal fibular
fracture fragment is anteriorly displaced by approximately 2 shaft widths as
well as laterally displaced by approximately a half shaft width. The ankle
mortise is difficult assess on these views, but on the previous CT appeared
congruent. No sizable knee joint effusion is present. Subcutaneous gas is
seen about the proximal leg.
Radiology Report
INDICATION: History: ___ with right elbow pain
TECHNIQUE: Right forearm, two views, right elbow, three views, right wrist
and hand, three views
COMPARISON: None.
FINDINGS:
Transverse fracture involving the distal third diaphysis of the ulna is
demonstrated with radial displacement of the distal fracture fragment by
approximately ___ shaft width.
The elbow appears without fracture or dislocation. Joint spaces are preserved.
A joint effusion is not seen.
Within the right wrist and hand, there is no acute fracture or dislocation
identified. Assessment of the index finger is limited due to overlying pulse
oximeter device. There are no radiopaque foreign bodies or soft tissue
calcifications otherwise identified. Joint spaces are preserved.
IMPRESSION:
Mildly displaced fracture of the distal third diaphysis of the ulna.
Radiology Report
INDICATION: History: ___ with left knee pain
TECHNIQUE: Left knee, three views
COMPARISON: CT lower extremity ___ at 17:20
FINDINGS:
No acute fracture or dislocation is identified. Joint spaces are preserved.
No concerning lytic or sclerotic osseous abnormalities are demonstrated.
Small joint effusion is noted. There are no soft tissue calcifications.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: Fluoroscopy
INDICATION: Open reduction internal fixation.
TECHNIQUE: Fluoroscopic images
COMPARISON: ___ radiograph
FINDINGS:
A series of 70 intraoperative fluoroscopic images were acquired without a
radiologist present.
Images show documentation of open reduction and internal fixation of fractures
involving the right femur, tibia and fibula. A total of 253.2 seconds of
fluoro time were recorded, with cumulative estimated dose of 2.41 rads.
IMPRESSION:
Intraoperative fluoroscopic images were obtained during open reduction
internal fixation of right femoral, tibial and fibular fractures. Please refer
to the operative note for details of the procedure.
Radiology Report
INDICATION: Open reduction internal fixation
TECHNIQUE:
Fluoroscopy
FINDINGS:
2 fluoroscopic images document open reduction and internal fixation of a
transverse fracture involving the ulna. No radiologist was involved in the
procedure. Please see the operative report for complete details.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with polytrauma s/p surgery requiring
reintubation in PACU // Eval for ETT placement
IMPRESSION:
Interval intubation with endotracheal tube in satisfactory position.
Cardiomediastinal contours are normal. New bibasilar atelectasis versus
aspiration, with otherwise clear lungs.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old man with resp failure // Please eval for pulmonary
embolism
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: 415 mGy-cm
COMPARISON: CTA torso with runoff ___.
FINDINGS:
Respiratory motion degrades many of the images such that the subsegmental
pulmonary arteries are not well evaluated. There is no evidence of filling
defect within the main, right, left, lobar, or segmental pulmonary arteries.
The main and right pulmonary arteries are normal in caliber and there is no
evidence of right heart strain.
The aorta and its major branch vessels are patent with no evidence of
dissection or aneurysm. Cardiac chambers are normal in size. There is no
pericardial effusion.
An endotracheal tube is in place terminating just above the carina. Center
airways are clear to the segmental level. Lung volumes are mildly diminished
with subsegmental atelectasis bilaterally. A 4 mm nodule in the right middle
lobe along the horizontal fissure (02:32) could be a focus of atelectasis. No
pneumothoraces or pleural effusions are present.
Mediastinal, hilar, and axillary lymph nodes are not pathologically enlarged.
Limited images of the upper abdomen are unremarkable.
A transversely oriented, a thin linear lucency is noted in the sternal body
with undulating contour (601b: 11), without surrounding soft tissue hematoma.
Otherwise no fracture or concerning osseous lesion is identified.
IMPRESSION:
1. No segmental or larger pulmonary embolism.
2. Bilateral subsegmental atelectasis, but evidence for an acute infiltrative
process in the lungs.
3. Lucency in the sternal body more likely represents a vascular channel than
a nondisplaced fracture, but evaluation for point tenderness could be
considered when clinically feasible.
Radiology Report
INDICATION: ___ year old man post-op ortho // RIJ multi lumen catheter
placement Contact name: ___: ___
IMPRESSION:
SINCE ___ RADIOGRAPH AT 12:36, A RIGHT INTERNAL JUGULAR CATHETER
HAS BEEN PLACED, TERMINATING IN THE BODY OF THE RIGHT ATRIUM, WITH NO VISIBLE
PNEUMOTHORAX. ENDOTRACHEAL TUBE IS BEEN SLIGHTLY WITHDRAWN, NOW TERMINATING
5.1 CM ABOVE THE CARINAL, JUST ABOVE THE THORACIC INLET LEVEL. NASOGASTRIC
TUBE TERMINATES IN THE DISTAL STOMACH. EXAM IS OTHERWISE SIMILAR TO THE PRIOR
STUDY EXCEPT FOR SLIGHT WORSENING OF LEFT BASILAR ATELECTASIS.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p MCC and R tib fib, femur fx s/p repair now w/ R IJ pulled
back // Confirm R IJ CVL placement
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the patient has been extubated and
nasogastric tube was removed. The right internal jugular vein catheter was
pulled back. The tip of the catheter now projects over the mid SVC. No
evidence of complications, notably no pneumothorax. Left basal atelectasis.
Otherwise unremarkable lung parenchyma. Borderline size of the cardiac
silhouette.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p R femer, tibfib fx repair still requiring O2 // ?
interval change
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen.
Retrocardiac and left basilar atelectasis. Overall low lung volumes. No
pulmonary edema. No pneumonia, no pleural effusions. Right internal jugular
vein catheter is in unchanged position.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with mvc with rle injury // hypoxia unclear
source
TECHNIQUE: Portable AP radiograph of the chest from ___.
COMPARISON: ___.
FINDINGS:
A right IJ central venous catheter is unchanged in position. There is no
pneumothorax. Left basilar linear atelectasis has cleared. The lungs are
clear. The heart and mediastinum are within normal limits despite the
projection.
IMPRESSION:
Resolved left basilar linear atelectasis. Clear lungs.
Radiology Report
EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY
INDICATION: ___ year old man with sustained tachycardia // ? PE vs.
intrapulmonary process, CT PE Protocol
TECHNIQUE: Volumetric multidetector CT acquisition of the chest was
performed. Images are presented are display in the axial plane at 2.5 mm and
1.25 mm collimation. A series multiplanar reformations images are submitted
for review. Due to poor pulmonary artery opacification on the first scan, a
new IV was placed and a repeat scan was performed given patient's prior
history of pulmonary blood clots (per the patient) and recent orthopedic
surgery.
DLP: 918.08 mGy-cm
COMPARISON: CT ___, CXR ___
FINDINGS:
CTA CHEST: Evaluation of the bilateral lower lobe subsegmental pulmonary
arteries is somewhat limited by pulmonary opacities. There is no evidence of
filling defect in the main, right, left, lobar, segmental or visualized
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber and there is no evidence of right heart strain.
The aorta and its major branch vessels are patent without evidence of
dissection or aneurysm. The heart and pericardium are unremarkable. No
pericardial effusion.
No pathologically enlarged axillary, mediastinal or hilar lymph nodes are
identified.
Lung window images demonstrate bilateral lower lobe subsegmental atelectasis,
improved from ___. Central airways are patent. A 4 mm nodule in
the right middle lobe along the horizontal fissure (05:31) is unchanged and
likely represents focal pleural thickening, of no clinical significance. There
is no pleural effusion. Please note that the most inferior lung bases and
lung apices are not imaged in this young patient.
The imaged portions of the liver, stomach and spleen are unremarkable.
BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.
A linear lucency within the sternal body (602b:38) is unchanged from the prior
study, without surrounding hematoma, corresponding to a nutrient channel.
IMPRESSION:
1. No acute aortic pathology or pulmonary embolism.
2. Subsegmental linear atelectasis in the bilateral lower lobes, improved
from ___.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: MCA
Diagnosed with FX FEMUR SHAFT-CLOSED, FX SHAFT TIBIA W FIB-OPN, FX ULNA SHAFT-CLOSED, LONG TERM USE ANTIGOAGULANT, MV COLLIS NOS-MOTORCYCL
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right femoral shaft fracture, right open distal third
tibia/fibula fracture, and right midshaft ulna fracture. The
patient was admitted to the orthopedic surgery service under the
care of the trauma ICU. The patient was taken to the operating
room on ___ for open reduction and internal fixation of
right ulna, intramedullary nail for right femur, intramedullary
nail for right tibia, and fasciotomies of right thigh and leg.
For full details please see the separately dictated operative
report. The patient was taken from the OR to the ICU. He was
transfused 2 U pRBCs post-operatively. Of note, the patient was
on warfarin for history of pulmonary embolus approximately 8
months prior to admission. He underwent CT-PE to evaluate for
the presence of PE on ___, which was negative. He was
kept on prophylactic enoxaparin 40 mg sc qhs, and his warfarin
was restarted, though his INR remained subtherapeutic.
The patient subsequently returned to the OR on ___ for
I&D, vac change over fasciotomy wounds, and primary closure of
the right lateral leg fasciotomy wound. For full details please
see the separately dictated operative report. The patient was
taken fom the OR to the ICU. He was transfused 1 U pRBCs
post-operatively.
On ___, the patient was transferred to the orthopaedic
floor for further care. He returned to the OR on ___ for
I&D, vac change over right leg medial fasciotomy wound, and
primary closure of thigh fasciotomy wound. For full details
please see the separately dictated operative report. After
recovery from anesthesia, the patient was transferred from the
PACU to the orthopaedic floor.
On ___, the patient returned to the OR with the plastic
surgery service for rotational muscle flap to cover the medial
tibia in addition to split thickness skin graft. Please see the
separately dictated operative report for full details. After
recovery from anesthesia, the patient was transferred from the
PACU to the orthopaedic floor. The patient was kept on bed rest
for 48 hours post op and then was returned to weight bearing as
tolerated with no plantar flexion.
The patient was initially given IV fluids and IV pain
medications post-operatively, and progressed to a regular diet
and oral medications. The patient was given perioperative
antibiotics. On ___, the patient was tachycardic to
heart rate 130s with fever to 102; CT-PE was repeated that was
again negative for PE. He remained on prophylactic enoxaparin 40
mg sc qhs while warfarin was titrated to therapeutic range. A
fever work up was also performed which was negative for
infection. 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 was afebrile with stable
vital signs that were within normal limits, 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 (no planta flexion), and will be
discharged on warfarin for DVT prophylaxis with INR goal of ___.
The patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___
Chief Complaint:
dehydration
Major Surgical or Invasive Procedure:
Central Tunneled Line Placement ___
History of Present Illness:
Patient is a ___ with a complex PMHx including ___ disease
short bowel syndrome secondary to mesh erosion from surgery for
MCV, CKD (Cr ___ in ___, s/p removal of Hickman and
abscess I&D in ___, chronic pain on methadone, recently
left AMA from ___ when admitted with renal failure (underwent
renal biopsy c/b hematoma), and Stenotrophomonas bacteremia, now
presenting with concern for persistent dehydration.
To briefly summary his ___ course, patient was admitted
___ with R sided flank pain, found to have acute on
chronic renal failure (Cr 8.2) and Stenotrophamonas bacteremia.
Patient was seen by renal while inpatient and underwent renal
biopsy. There was concern that his renal failure may have been
worsened by NSAID and/or anabolic steroid use. CT and renal
ultrasound showed2mm non-obstructing, right sided stone and
absence of hydronephrosis. Biopsy showed collapsing
glomerulopathy, IgA nephropathy and focal global and segmental
glomerulosclerosis. Biopsy showed combination of lesions that
were most likely related to three different and potentially
independent disease processes: collapsing glomerulopathy, IgA
nephropathy, and severe vascular sclerosis. He was started on
sevelamer during hospitalization.
In terms of his bacteremia, source was though to be his port,
given that he gives himself TPN and LR at home. ___ removed his
port on ___ and ID recommended that he remain line-free for at
least one 1 week. He was initially started on ceftazidime then
switched to levofloxacin based on sensitivities. TTE was
negative for vegetations. Per discharge summary, patient was
discharged on IV levofloxacin for 14 day course (last day
___. However, patient states that he was discharged without
any antibiotics.
He was also found to have anemia consistent with Fe deficiency.
U/S after renal biopsy showed stable hematoma. He received 2U
PRBCs on ___. H/H could not be reliably trended due to
patient's refusal to have blood draws.
He was also hypertensive to 200s requiring IV labetalol. He was
not discharged on anti-HTN.
Care was difficult has patient refused blood draws, frequently
left floor with abusive outbursts towards staff, delaying
treatment such as blood transufions. He left AMA on ___. He was
seen by psych, ID, renal, and colorectal surgery while admitted.
In the ED, initial vitals:
98.3 ___ 18 100% RA
- Labs notable for: WBC 16.8 (10.5 on discharge from ___), Hgb
9.6, Cr 10.0
- Patient given: 1L LR
Foley placement was attempted however patient was unable to
tolerate.
- Vitals prior to transfer:
98.2 100 130/90 20 100% RA
On arrival to the floor, pt reports that he feels like he was
getting dehydrated. he states that he feels "tired and
lethargic", exhausted. Just "feels like I'm dehydrated". No
confusion, n/v, CP, fevers/chills, abdominal pain. No cough. No
dysuria. He notes that the output from his ostomy is slightly
looser than usual. He does note a different taste in his mouth
than usual. He states that he left AMA because he was "losing
faith" in their care and was hearing different things from
different teams. He denies being discharged on any antibiotics.
He was not discharged with any IV access. He states that he got
dehydrated because he didn't have any access.
He has not noticed any changes in his urination. Has noticed
some decreased UOP, which he attributes to being dehydrated. He
was "heavy" in to Advil (15 per day), last before ___
hospitalization. He was using these in attempt to wean
methadone.
He states that he uses anabolic steroids, 200mg per week,
injected. He does this because of short gut syndrome - to help
retain fluids.
Past Medical History:
___ disease: Dx ___, s/p total colectomy w ileostomy ___
c/b enterocutaneous fistula, perianal fistulas
#short bowel syndrome
#HTN
#chronic pain - states due to nerve damage in extremities (from
flagyl use and h/o surgeries)
#h/o abscess
#vit B12 deficiency
#GERD
#s/p appendectomy
#s/p open cholecystectomy c/b small bowel injury
#hip replacement
#multiple abdominal surgeries
Social History:
___
Family History:
Father- ___
Brother- ?___ vs. IBS
Aunt and 2 cousins also w ___
Physical Exam:
==============
ADMISSION EXAM
==============
Vitals: 98.8 131/83 102 19 97 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
Chest: dressing over prior port site c/d/I without any
surrounding erythema or skin changes.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding. Multiple scars from prior
abdominal surgeries. Ostomy in place.
Ext: Warm, well perfused, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
===============
DISCHARGE EXAM
===============
Vitals: 97.9 163/83 73 18 98% RA
General: Alert, oriented, no acute distress, very muscular
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Heart: Regular rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Chest: central line in place without erythema or discharge.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding. Multiple scars from prior
abdominal surgeries. Ostomy in place.
Ext: Warm, well perfused, no cyanosis or edema.
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
Pertinent Results:
================
ADMISSION LABS
================
___ 08:50PM BLOOD WBC-16.8*# RBC-3.87* Hgb-9.6* Hct-30.9*
MCV-80*# MCH-24.8*# MCHC-31.1* RDW-21.0* RDWSD-60.4* Plt ___
___ 06:37AM BLOOD ___ PTT-30.4 ___
___ 08:50PM BLOOD Glucose-105* UreaN-57* Creat-10.0*#
Na-134 K-4.8 Cl-93* HCO3-18* AnGap-28*
___ 08:50PM BLOOD Albumin-2.9* Calcium-8.1* Phos-6.6*
Mg-1.6 Iron-37*
___ 08:50PM BLOOD calTIBC-352 Ferritn-110 TRF-271
================
DISCHARGE LABS
================
___ 07:19AM BLOOD WBC-6.7 RBC-2.99* Hgb-7.4* Hct-24.7*
MCV-83 MCH-24.7* MCHC-30.0* RDW-19.9* RDWSD-60.4* Plt ___
___ 10:46AM BLOOD ___ PTT-34.8 ___
___ 07:19AM BLOOD Glucose-95 UreaN-50* Creat-8.6* Na-143
K-3.7 Cl-109* HCO3-20* AnGap-18
___ 07:19AM BLOOD Calcium-8.6 Phos-4.9* Mg-2.0
==========
IMAGING
==========
- RUQ US ___:
1. No hydronephrosis seen in either kidney.
2. Two small simple left renal cysts.
3. Perinephric fluid collection around the right kidney, with
internal echogenicity, consistent with known history of hematoma
after recent kidney biopsy at outside hospital, as detailed in
OMR.
- UPPER EXTREMITY VEIN MAPPING ___:
On the right, the cephalic vein measures 0.1-0.2 cm. The
basilic vein measures 0.1-0.2 cm. Of note, the proximal aspect
of the right cephalic vein is very thick-walled likely due to
prior thrombus. The brachial artery measures 0.___rtery measures 0.2 cm.
On the left, cephalic vein ranges from 0.1-0.3 cm. The
distal-most aspect of the cephalic vein on the left appears to
be clotted. The the basilic vein measures 0.1-0.2 cm. The
brachial artery measures 0.___rtery measures 0.3
cm.
- TUNNELED LINE PLACEMENT ___:
Successful placement of a double-lumen ___ tunneled line via
the right internal jugular venous approach. The tip of the
catheter terminates in the right atrium. The catheter is ready
for use.
========
MICRO
========
___: NO GROWTH TO DATE
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with acute on chronic ___ // eval for cause of
acute ___
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Renal ultrasound from ___.
FINDINGS:
The right kidney measures 11.0 cm. The left kidney measures 11.0 cm. There is
no hydronephrosis, or stones. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally.
Again seen is a small exophytic simple cyst in the lower pole of the left
kidney measuring 1.7 x 0.9 x 1.4 cm. A small simple cyst is noted at the
lower pole of the left kidney measuring 1.1 x 0.8 x 1.1 cm.
A perinephric fluid collection with internal echogenicity is noted around the
right kidney, consistent with known history of hematoma after recent kidney
biopsy at outside hospital, as described in OMR.
The bladder is only minimally distended and can not be fully assessed on the
current study.
IMPRESSION:
1. No hydronephrosis seen in either kidney.
2. Two small simple left renal cysts.
3. Perinephric fluid collection around the right kidney, with internal
echogenicity, consistent with known history of hematoma after recent kidney
biopsy at outside hospital, as detailed in OMR.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:54 ___, 7 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT BILATERAL
INDICATION: ___ year old man with acute on chronic kidney disease // vein
mapping for future dialysis access
TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral
upper extremity veins.
COMPARISON: None.
FINDINGS:
On the right, the cephalic vein measures 0.1-0.2 cm. The basilic vein
measures 0.1-0.2 cm. Of note, the proximal aspect of the right cephalic vein
is very thick-walled likely due to prior thrombus. The brachial artery
measures 0.5 cm. The radial artery measures 0.2 cm.
On the left, cephalic vein ranges from 0.1-0.3 cm. The distal-most aspect of
the cephalic vein on the left appears to be clotted. The the basilic vein
measures 0.1-0.2 cm. The brachial artery measures 0.6 cm. The radial artery
measures 0.3 cm.
IMPRESSION:
Venous doppler mapping with measurements as above. For additional
measurements please see the PACs.
Radiology Report
INDICATION: ___ year old man with ___ with PMHx of short gut syndrome on
chronic TPN // please place right side double lumen non-power tunneled access
line for TPN. ___ discussed with ___.
COMPARISON: Tunneled central line placement dated ___.
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 30 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: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.3 min, 1 mGy
PROCEDURE:
1. Tunneled non-dialysis line placement
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 access site was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a 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 double-lumen ___ catheter was selected. The catheter
was tunneled from the entry site towards the venotomy site from where it was
brought out using a tunneling device. The venotomy tract was dilated using the
introducer of the peel-away sheath supplied. Following this, the peel-away
sheath was placed over the ___ wire through which the catheter was threaded
into the right side of the heart with the tip in the right atrium. The sheath
was then peeled away. 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 each lumen was capped. The catheter was sutured in
place with 0 silk sutures. Steri-strips were used to close the venotomy
incision site. Sterile dressings were applied. The patient tolerated the
procedure well.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing internal
jugular approach double lumen Hickman catheter with tip terminating in the
right atrium.
IMPRESSION:
Successful placement of a double-lumen Hickman tunneled line via the right
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Dehydration
Diagnosed with Acute kidney failure, unspecified, Dehydration
temperature: 98.3
heartrate: 114.0
resprate: 18.0
o2sat: 100.0
sbp: 156.0
dbp: 100.0
level of pain: 7
level of acuity: 3.0 | ___ year old male with PMHx of short gut syndrome on chronic TPN,
___ disease, CKD (unclear etiology), recent hospitalization
for renal failure and Stenotrophamonas bacteremia, now
presenting with fatigue and concern for dehydration, found to
have renal failure and leukocytosis.
==============
ACUTE ISSUES
==============
# Acute renal failure on CKD: Patient with known CKD of unclear
etiology. Review of OMR and ___ hospital show that he has had
multiple episodes of ___. He was recently admitted to ___ where
he underwent a renal biopsy which revealed multiple pathologies
(collapsing glomerulopathy, IgA nephropathy, and severe vascular
sclerosis). In terms of collapsing glomerulopathy, can be
associated with infections such as HIV, however his HIV ab is
negative. Can also be related to anabolic steroids, which he
uses. Vascular sclerosis can be secondary to HTN, however path
report states that primary causes are more likely. Primary forms
of vascular/endotherlial injury include pro-coagulant state,
autoimmune d/o, drug-induced, paraproteinemia. This acute
episode is likely related to recent dehydration and lack of TPN
(as his central line was removed during OSH hospitalization due
to bacteremia), as his Cr started to improve with aggressive
hydration and resumption of TPN.
# HTN: Patient without a diagnosis of HTN, but with BPs ranging
from 130s-170s/60s-90s. He was started on amlodipine while in
the hospital which was uptitrated to 10 mg prior to discharge.
# Recent Stenotrophamonas bacteremia: Patient presented with WBC
16.8 from ~10.5 at discharge from ___. No fevers or no
localizing symptoms. His central line, through which he was
receiving TPN for short gut syndrome) was removed during his ___
hospitalization. He was not discharged on antibiotics (per DC
summary, were planning on discharging on levofloxacin 500mg
Iq48h but patient left AMA and did not receive antibiotic
script). He was restarted on levofloxacin PO renally dosed 250
mg q48h to complete previously prescribed course. Leukocytosis
resolved prior to discharge and blood cultures without any
growth x 4 days.
# Anemia: Stable. Patient with a history of anemia. Iron: 37,
Ferritin: 110, likely a combination of iron deficiency and
chronic disease/renal failure. Trended down slightly with
administration of IVF (likely a component of dilution) and he
remained stable while in the hospital.
# Short gut syndrome: Patient is chronically on TPN, however has
not been on this due to lack of access (port dc'ed due to
bacteremia as above). He underwent vein mapping to determine
which side to replace his TPN line and which side to save for
potential dialysis in the future. He was restarted on TPN prior
to discharge through newly placed tunneled line.
==============
CHRONIC ISSUES
==============
# Chronic pain: Continued home methadone and oxycodone.
====================
TRANSITIONAL ISSUES
====================
* Renal
[] repeat BMP ___ sent to PCP
[] Patient needs outpatient renal follow up
[] Patient needs outpatient renal transplant follow up in the
event he will require renal transplant in the future
* HTN
[] f/u BPs, Started on amlodipine for HTN
* Anemia:
[] repeat CBC ___ sent to PCP
*ID
[] bcx final result pending on discharge
*OTHER:
# CODE STATUS: Full Code
# CONTACT: roommate/girlfriend ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lamotrigine / gabapentin
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old male with a history of COPD and
morbid obesity (___ 43) who presents with worsening left sided
chest pain after he recently completed 5 day levofloxacin course
for presumed community acquired pneumonia. About 10 days ago,
he developed fevers, shortness of breath, and dry cough and then
went to his PCP who started him on levaquin.
Following the five day course, he felt better, however 3 days
prior to admission, he had recurrent left sided chest pain and
cough intermittently productive but occasionally bringing up
blood.
In the ED, his O2 sat was 85-90% on room air. He does not use
oxygen at home. Chest x-ray reveals bibasilar pneumonia. He
was admitted to medicine for further evaluation.
Review of systems otherwise positive for abdominal tenderness
diffusely with no bowel movements in 5 days.
Otherwise, of note, his brother-in-law recently passed away
suddenly at age ___ of presumed heart disease; the deceased's
brother also passed away suddenly recently at age ___.
Consequently, the patient is somewhat anxious about the
possibility that his current symptomatology reflects his heart.
Past Medical History:
- COPD
- Hypertension
- anxiety
- depression
- asthma
- chronic back pain
- obesity
- glaucoma
- migraine headaches
- benign prostatic hypertrophy
- fatty liver
- s/p right knee arthroscopic partial medial and lateral
meniscectomy, doing well
- s/p post left knee arthroscopic partial medial meniscectomy on
___ with persistent pain
Social History:
___
Family History:
Mother HYPERTENSION possible lymphoma in her ___
Father LUNG CANCER metastatic to the brain.
Sister HYPERTENSION
Other COLON CANCER Maternal great uncle. ___.
Physical Exam:
Admission PHysical Exam
VS: 99, 122/68, 103, 20, 92% RA
GEN: Caucasian male, morbidly obese, sitting up in bed,
pleasant
HEENT: Anicteric
Cardiac: Nl s1/s2 RRR no m/r/g
Pulm: clear bilaterally, no wheezes appreciable
Abd: mildly and diffusely tender, obese abdomen
Ext: warm, 2+ lower extremity pitting edema
Discharge Physical Exam
97.2 151/95 ___ on 3L
Consitutional: mild distress due to pain, frustrated, obese,
barrel chested, alert and conversant
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, chronic ___ edema, no JVD
Resp: mild increased respiratory effort, decreased BS across
entire R hemithorax however breath sounds are present (which is
improved since ___, R sided occasional wheezes, prolonged
expiratory phase. Areas where chest tubes were removed appear
clean, dry, and intact.
GI: distended but soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. CNs II-XII intact. MAEE.
Psych: Full range of affect
Pertinent Results:
ADMISSION LABS
___ 01:45PM WBC-12.6* RBC-4.14* HGB-11.4* HCT-36.7*
MCV-89 MCH-27.5 MCHC-31.1* RDW-13.8 RDWSD-44.6
___ 01:45PM NEUTS-75.2* LYMPHS-14.6* MONOS-7.1 EOS-1.7
BASOS-0.4 IM ___ AbsNeut-9.47*# AbsLymp-1.84 AbsMono-0.90*
AbsEos-0.22 AbsBaso-0.05
___ 01:45PM %HbA1c-6.0* eAG-126*
___ 01:45PM ALBUMIN-3.8 CALCIUM-9.4 PHOSPHATE-2.6*
MAGNESIUM-1.9
___ 01:45PM CK-MB-1 proBNP-53
___ 01:45PM cTropnT-<0.01
___ 01:45PM LIPASE-17
___ 01:45PM ALT(SGPT)-23 AST(SGOT)-18 CK(CPK)-111 ALK
PHOS-81 TOT BILI-0.6
___ 01:45PM GLUCOSE-105* UREA N-12 CREAT-1.0 SODIUM-134
POTASSIUM-4.3 CHLORIDE-93* TOTAL CO2-32 ANION GAP-___hest ___
IMPRESSION:
1. Unchanged position of 2 left lung base pigtail catheters with
slightly
decreased associated loculated pleural effusions.
2. Persistent loculated fluid within the left fissure.
3. Slight interval increase in small left upper and left lower
pneumothoraces
without associated midline shift.
4. Persistent left lung base consolidation and extensive
subsegmental
atelectasis.
5. Hepatic steatosis.
ECHO
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). No masses or thrombi are
seen in the left ventricle. Right ventricular chamber size and
free wall motion are normal. The aortic valve is not well seen.
The mitral valve leaflets are not well seen. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Limited study. Preserved
global biventricular systolic function Unable to assess for
possible valvular disease. Indeterminate pulmonary artery
systolic pressure.
CXR ___
In comparison with the study of ___, there is little change
in the
cardiomediastinal silhouette. Continued increased opacification
at the left
base consistent with pleural effusion and underlying atelectasis
or pneumonia.
A left chest tube is in place at the base an there is no
evidence of
pneumothorax.
The right lung is essentially clear and there is no vascular
congestion.
CT CHEST ___
IMPRESSION:
Loculated peripherally enhancing moderate effusion on the left
suggestive of empyema. Left-sided pleural catheter enters
anterior and the tip is abutting the mediastinal border
anteriorly and is anterior to the moderate loculated fluid.
Extensive opacification of the left lower with areas of lung
necrosis.
Reviewed in OMR and outside records:
CT Chest ___ pleural based density in superior LLL w/minimal
pleural thickening.
CT Chest ___ patchy GGO LUL
CT Chest ___-
IMPRESSION:
1. Evaluation of the pulmonary arteries is limited by poor
opacification and respiratory motion especially the left upper
and left lower lobe segmental branches, however, there is no
evidence of obvious pulmonary embolism.
2. Right upper lobe consolidation with surrounding ground-glass
most
compatible with pneumonia. Following treatment repeat
radiographs should be obtained to ensure resolution.
3. 3 mm left lower lobe pulmonary nodule. Please see
recommendations section.
4. Small nonhemorrhagic right pleural effusion.
5. Fatty liver.
RECOMMENDATION(S): In the case of pulmonary nodules less than
or equal to 4 mm no follow-up is needed in low-risk patients.
For high risk patients, recommend follow-up at 12 months and if
no change, no further imaging needed.
CT ___ abnormality left lung; resolved per note but no
report available
Echo ___ Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size and free wall motion are normal. The aortic valve
is not well seen. The mitral valve leaflets are not well seen.
The pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Limited study. Preserved
global biventricular systolic function Unable to assess for
possible valvular disease. Indeterminate pulmonary artery
systolic pressure.
CT CHEST ___ EXAMINATION: CT CHEST W/O CONTRAST
COMPARISON: Prior Chest CTs dated ___ and ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE: The visualized thyroid is
normal.
Supraclavicular and axillary lymph nodes are not enlarged.
MEDIASTINUM: Numerous enlarged mediastinal lymph nodes are
unchanged from
recent prior studies.
HILA: There is no right-sided hilar adenopathy. Left-sided
hilar lymph nodes
are difficult to distinguish from underlying consolidation.
HEART: The heart is not enlarged and there is no coronary
arterial
calcification. There is a trace pericardial effusion.
VESSELS: There is a common origin of the left common carotid
and the right
brachiocephalic artery, a normal anatomic variant. Aortic
caliber is normal.
The main, right, and left pulmonary arteries are normal caliber.
PULMONARY PARENCHYMA: Left lower lobe consolidation is grossly
unchanged from
the prior study. Multiple areas of subsegmental atelectasis are
noted
throughout the left lung. The right lung is relatively clear.
There is no
suspicious pulmonary nodule. There is no emphysema.
AIRWAYS: The airways are patent to the subsegmental level
bilaterally. There
is marked collapse of the distal trachea and main stem bronchi
on this
expiratory study suggesting underlying tracheobronchomalacia.
PLEURA: A left pigtail catheter is in unchanged location in the
left lung
base with interval decrease in size of the complex loculated
pleural effusion
(04:41). Left lung base pneumothorax and anterior left upper
lobe
pneumothorax are increased compared with the prior study (5:
59, 203).
Loculated pleural fluid within the inferior left fissure is
increased compared
with the prior study while fluid in the superior aspect of the
fissure has
decreased, possibly the result the redistribution, as the
overall volume
appears similar. A lateral approach left lung base pigtail
drainage catheter
is in unchanged position with overall slightly decreased
collection of fluid
and air in the left lung base.
CHEST WALL AND BONES: There is no worrisome lytic or sclerotic
lesion.
Multilevel degenerative changes are mild.
UPPER ABDOMEN: This study is not tailored for evaluation of the
abdomen.
Allowing for this, the partially visualized upper abdomen is
notable for
hepatic steatosis and fatty atrophy of the pancreatic head
(3:66)..
IMPRESSION:
1. Unchanged position of 2 left lung base pigtail catheters with
slightly
decreased associated loculated pleural effusions.
2. Persistent loculated fluid within the left fissure.
3. Slight interval increase in small left upper and left lower
pneumothoraces
without associated midline shift.
4. Persistent left lung base consolidation and extensive
subsegmental
atelectasis.
5. Hepatic steatosis.
CXR ___ EXAMINATION: Chest radiograph
FINDINGS:
The left pigtail drainage catheter has been removed. Lung
volumes remain low
with increased bibasilar atelectasis. Left lower lobe
opacifications are
slightly improved. Loculated air overlying the spine at site of
prior
drainage catheter remains without evidence of worsening
collection. The
moderate left-sided pleural effusion is stable. No
pneumothorax.
IMPRESSION:
1. No pneumothorax.
2. Slightly improved left lower lobe opacities
3. Stable moderate left pleural effusion.
PROCEDURES:
___: chest tube placement
___: chest tube placement
___: chest tubes discontinued
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H
2. Aspirin 81 mg PO DAILY
3. Diazepam 10 mg PO Q12H:PRN anxiety
4. Docusate Sodium 100 mg PO BID
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Furosemide 20 mg PO 4X/WEEK (___)
7. Hydrochlorothiazide 25 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Lisinopril 40 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Mirtazapine 60 mg PO QHS
12. Montelukast 10 mg PO DAILY
13. Morphine SR (MS ___ 30 mg PO Q12H
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 20 mg PO DAILY
16. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
17. Polyethylene Glycol 17 g PO DAILY
18. Pramipexole 0.5 mg PO QHS
19. QUEtiapine Fumarate 100 mg PO BID
20. QUEtiapine Fumarate 300 mg PO QHS
21. Tiotropium Bromide 1 CAP IH DAILY
22. TraZODone 200 mg PO QHS:PRN insomnia
23. Levofloxacin 750 mg PO DAILY
24. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
25. varenicline 1 mg oral BID
26. ClonazePAM 1 mg PO BID: PRN anxiety
27. Zolpidem Tartrate 12.5 mg PO QHS
Discharge Medications:
1. ClonazePAM 1 mg PO BID: PRN anxiety
RX *clonazepam 1 mg 1 tablet(s) by mouth two times a day as
needed Disp #*10 Tablet Refills:*0
2. Diazepam 10 mg PO Q12H:PRN anxiety
RX *diazepam 10 mg 1 tablet by mouth up to two times a day Disp
#*10 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Furosemide 20 mg PO 4X/WEEK (___)
6. Mirtazapine 60 mg PO QHS
7. Montelukast 10 mg PO DAILY
8. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine 30 mg 1 tablet(s) by mouth every 12 hours Disp #*10
Tablet Refills:*0
9. Multivitamins 1 TAB PO DAILY
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Omeprazole 20 mg PO DAILY
12. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
13. Polyethylene Glycol 17 g PO DAILY
14. Pramipexole 0.5 mg PO QHS
15. QUEtiapine Fumarate 100 mg PO BID
16. QUEtiapine Fumarate 300 mg PO QHS
17. TraZODone 200 mg PO QHS:PRN insomnia
18. Ampicillin-Sulbactam 3 g IV Q6H
19. Albuterol Inhaler 2 PUFF IH Q6H
20. Aspirin 81 mg PO DAILY
21. Hydrochlorothiazide 25 mg PO DAILY
22. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
23. Lisinopril 40 mg PO DAILY
24. Metoprolol Succinate XL 50 mg PO DAILY
25. Tiotropium Bromide 1 CAP IH DAILY
26. varenicline 1 mg oral BID
27. Zolpidem Tartrate 12.5 mg PO QHS
RX *zolpidem 12.5 mg 1 tablet(s) by mouth nightly as needed Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pneumonia with Complicated Parapneumonic effusion with
loculations requiring chest tube placement.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Dyspneic on exertion (stable since pneumonia)
Pleuritic chest pain ongoing (overall improved this
hospitalization)
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with dyspnea, COPD, recent PNA // acute
intrathoracic process?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
There are bibasilar opacities, with a correlate projecting over the spine on
the lateral view, findings concerning for pneumonia. Upper lungs are clear.
Specifically, previously noted right upper lobe opacity in ___ has
resolved. No wall pleural effusion or pneumothorax. Mild cardiomegaly.
Mediastinal contours are normal. No subdiaphragmatic free air.
IMPRESSION:
New bibasilar pneumonia.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with pna, COPD; hpoxia, persistent fever // r/o
pleural effusion, volume overload r/o pleural effusion, volume overload
IMPRESSION:
Heart size and mediastinum are unchanged but there is interval progression of
left basal consolidation with increase in left pleural effusion, concerning
for progression of left lower lung pneumonia. Right basal opacity is minimal,
unchanged most likely representing atelectasis.
Upper lungs are clear. There is no pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ___ chest tube // ? ptx ? ptx
IMPRESSION:
In comparison with the study of ___, there is little change in the
cardiomediastinal silhouette. Continued increased opacification at the left
base consistent with pleural effusion and underlying atelectasis or pneumonia.
A left chest tube is in place at the base an there is no evidence of
pneumothorax.
The right lung is essentially clear and there is no vascular congestion.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with recurrent pneumonias, pulmonary nodules and
now with CAP which failed outpatient treatment and now with complicated
parapneumonic effusion on left, s/p chest tube placement // please evaluate
to characterize effusion and clarify parenchymal disease including pneumonia
and nodules. (Please schedule for tomorrow AM (___) if possible d/t patient
discomfort likely will not be able to tolerate tonight)
TECHNIQUE: CT chest with IV contrast
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.8 s, 37.5 cm; CTDIvol = 23.7 mGy (Body) DLP = 851.3
mGy-cm.
Total DLP (Body) = 851 mGy-cm.
COMPARISON: ___
FINDINGS:
CTA CHEST WITH IV CONTRAST: The partially imaged thyroid is unremarkable.
There is no supraclavicular or axillary lymphadenopathy. Mediastinal lymph
nodes have increased measuring up to 1.7 x 1.2 cm in the right lower
paratracheal station and 14 x 28 mm in the left lower paratracheal. These
lymph nodes are likely reactive. Increased stranding in the anterior
mediastinal fat on the left likely related to infection and recent chest tube
insertion.
Heart size is normal with trace pericardial effusion. The thoracic aorta and
proximal great vessels are normal in caliber there is no evidence of aneurysm
or dissection. Incidentally, there is common origin of the left common
carotid and right brachiocephalic arteries, a common variant.
The main pulmonary artery is normal in caliber.
There are minimal secretions in the distal trachea and right mainstem bronchus
.The airways are otherwise patent to the subsegmental level. Mild septal
paraseptal emphysema. Minimal linear opacities in the left lung can be
atelectasis. Multifocal airspace opacification of the left lung involving the
lingula and substantial opacification of the left lower lobe. Air-fluid
levels and locules of gas in the left lower lobe with surrounding
consolidation and adjacent pleural fluid may reflect lung necrosis Series 4,
image 177. Moderate loculated left-sided pleural effusion with smooth pleural
enhancement and with fluid along the major fissure. The loculated fluid
posteriorly measuring 10 x 8.5 cm on the sagittal view. Left-sided pigtail
catheter enters between the 6 seventh rib space tracking anteriorly with the
tip near the left cardiophrenic space abutting the mediastinum. Tiny left
locules of gas within the pleural space related to chest tube insertion.
OSSEOUS STRUCTURES: There is no worrisome blastic or lytic lesion.
UPPER ABDOMEN: This study is suboptimal for evaluation of the subdiaphragmatic
structures however the following findings are noted. There is diffuse
hypoattenuation of the liver.
IMPRESSION:
Loculated peripherally enhancing moderate effusion on the left suggestive of
empyema. Left-sided pleural catheter enters anterior and the tip is abutting
the mediastinal border anteriorly and is anterior to the moderate loculated
fluid.
Extensive opacification of the left lower with areas of lung necrosis.
Increasing lymphadenopathy, likely related to multifocal pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with chest tube x2 // ? ptx ? ptx
IMPRESSION:
Compared to chest radiographs ___ through ___.
MILD PULMONARY EDEMA IS NEW. ATELECTASIS AND SMALL LEFT PLEURAL EFFUSION
OBSCURE THE ABNORMALITY AT THE BASE OF THE LEFT LUNG WHICH DEVELOPED BETWEEN
___ AND ___. INDWELLING LEFT PIGTAIL DRAINAGE CATHETER ABOVE THE PLANE
OF THE LEFT HEMIDIAPHRAGM UNCHANGED IN POSITION. NEW PIGTAIL DRAIN MORE
INFERIORLY COULD BE IN THE LEFT UPPER ABDOMINAL QUADRANT OR THE POSTERIOR
PLEURAL SULCUS.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with left pleural effusion and PNA s/p chest tube
placement x2, had CXR overnight showing now right pleural effusion with chest
tube in place and I think the image is reversed // please re-evaluate for
pleural effusion s/p 2 chest tubes
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs since ___.
FINDINGS:
A left lower lobe opacification with air-fluid level adjacent to the posterior
pigtail drainage catheter is new since chest radiograph on ___. A
loculated effusion that did not contain air was present in this area on CT
examination on ___, prior to pigtail catheter insertion. The two left
pigtail drainage catheters appear unchanged. The moderate loculated
left-sided pleural effusion is stable. Lung volumes are slightly improved
with stable mild pulmonary edema. No pneumothorax.
IMPRESSION:
1. Left lower lobe opacification with air-fluid level is new since radiograph
on ___. A loculated effusion that did not contain air was seen in
this area on CT examination on ___, prior to pigtail catheter
insertion. Constellation of findings is concerning for bronchogenic fistula or
less likely lung abscess.
2. Stable moderate left-sided pleural effusion.
3. Stable mild pulmonary edema.
4. No pneumothorax.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with left pleural effusion complicated with
loculations and now 2 chest tubes, need to evaluate whether patient will need
further intervention, possibly tpa // please evaluate for updated
characterization of left pleural effusion
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.8 s, 36.2 cm; CTDIvol = 27.1 mGy (Body) DLP =
922.5 mGy-cm.
Total DLP (Body) = 923 mGy-cm.
COMPARISON: Chest CT ___. Read in conjunction with conventional
chest radiographs, ___ through ___ and axillary lymph
nodes are not enlarged. There is no soft tissue abnormality in the chest wall
suspicious for malignancy or infection, including two pleural drainage
catheter insertion sites one lateral and one posterior.
This study is not appropriate for subdiaphragmatic diagnosis but shows diffuse
severe hepatic steatosis.
There is no thyroid abnormality warranting further evaluation. Mediastinal
adenopathy starting at the thoracic inlet, involving both upper and lower
paratracheal stations, left and right and the subcarinal space is minimally
smaller, and there is no new adenopathy. Adenopathy may be present in the
left hilus, indistinguishable from low-attenuation perihilar consolidation,
but there is no extrinsic narrowing of the bronchial tree.
The indwelling, lateral entry left pigtail pleural drainage catheter is
unchanged in position, terminating along the diaphragmatic surface at at the
insertion of the major fissure alongside the mediastinum. Small pericardial
effusion at that level is unchanged. The new, posterior entry pleural
drainage tube is curled in the posterior paraspinal gutter, where the larger
pleural fluid loculation was on ___. That pleural loculation is smaller
and now contains air as well as substantial residual pleural fluid. The
fissural component of pleural effusion has increased. Whether the new gas
collection was introduced with pleural drainage or is due to bronchopleural
fistula is best determined by clinical inspection, since bronchopleural
fistula is generally not corroborated by CT scanning.
The extent of consolidation in the left lower lobe, mostly the superior,
posterior basal and lateral basal segments is slightly improved, a smaller
region of lingular consolidation is stable.
There is no evidence of infection in the right lung.
FINDINGS:
New posterior entry left pleural drainage catheter has decreased the amount of
fluid and is probably responsible for new air in the posterior pleural
loculation. Determination of a Bronchopleural fistula is better assessed by
inspection of drainage characteristics. Fissural exudate has increased
slightly. Pneumonia it is minimally improved.
Reactive mediastinal adenopathy improved minimally.
Hepatic steatosis suggests metabolic syndrome.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with complicated parapneumonic effusion on left
s/p 2 chest tubes and TPA instilled on ___. Would like to check on status of
effusions/loculations to determine if more TPA needed, evaluate for interval
change in complicated parapneumonic effusion
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent and reconstructed as contiguous 5 mm and 1.25 mm
thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.8 s, 37.9 cm; CTDIvol = 24.3 mGy (Body) DLP = 905.3
mGy-cm.
2) Spiral Acquisition 5.8 s, 37.9 cm; CTDIvol = 10.8 mGy (Body) DLP = 400.7
mGy-cm.
Total DLP (Body) = 1,306 mGy-cm.
COMPARISON: Prior Chest CTs dated ___ and ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE: The visualized thyroid is normal.
Supraclavicular and axillary lymph nodes are not enlarged.
MEDIASTINUM: Numerous enlarged mediastinal lymph nodes are unchanged from
recent prior studies.
HILA: There is no right-sided hilar adenopathy. Left-sided hilar lymph nodes
are difficult to distinguish from underlying consolidation.
HEART: The heart is not enlarged and there is no coronary arterial
calcification. There is a trace pericardial effusion.
VESSELS: There is a common origin of the left common carotid and the right
brachiocephalic artery, a normal anatomic variant. Aortic caliber is normal.
The main, right, and left pulmonary arteries are normal caliber.
PULMONARY PARENCHYMA: Left lower lobe consolidation is grossly unchanged from
the prior study. Multiple areas of subsegmental atelectasis are noted
throughout the left lung. The right lung is relatively clear. There is no
suspicious pulmonary nodule. There is no emphysema.
AIRWAYS: The airways are patent to the subsegmental level bilaterally. There
is marked collapse of the distal trachea and main stem bronchi on this
expiratory study suggesting underlying tracheobronchomalacia.
PLEURA: A left pigtail catheter is in unchanged location in the left lung
base with interval decrease in size of the complex loculated pleural effusion
(04:41). Left lung base pneumothorax and anterior left upper lobe
pneumothorax are increased compared with the prior study (5: 59, 203).
Loculated pleural fluid within the inferior left fissure is increased compared
with the prior study while fluid in the superior aspect of the fissure has
decreased, possibly the result the redistribution, as the overall volume
appears similar. A lateral approach left lung base pigtail drainage catheter
is in unchanged position with overall slightly decreased collection of fluid
and air in the left lung base.
CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion.
Multilevel degenerative changes are mild.
UPPER ABDOMEN: This study is not tailored for evaluation of the abdomen.
Allowing for this, the partially visualized upper abdomen is notable for
hepatic steatosis and fatty atrophy of the pancreatic head (3:66)..
IMPRESSION:
1. Unchanged position of 2 left lung base pigtail catheters with slightly
decreased associated loculated pleural effusions.
2. Persistent loculated fluid within the left fissure.
3. Slight interval increase in small left upper and left lower pneumothoraces
without associated midline shift.
4. Persistent left lung base consolidation and extensive subsegmental
atelectasis.
5. Hepatic steatosis.
Radiology Report
EXAMINATION: PA and lateral chest radiograph
INDICATION: ___ year old man with 2 chest tubes on left with pleural effusion
now s/p TPA, please eval for interval change // eval interval change in left
effusion eval interval change in left effusion
IMPRESSION:
Compared to chest radiographs since ___, most recently ___
through ___.
Decrease in the volume of air in the loculated left posterior hydro
pneumothorax. Overall volume of left pleural effusion probably smaller.
Consolidation in the left lung is difficult to assess, grossly unchanged.
Right lung is grossly clear. Cardiac silhouette is larger. Pulmonary
vasculature is engorged in the upper lobes, but there is no pulmonary edema.
No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ?empyema, requested by thoracic surgery. //
rule out progression of effusion (loculated) rule out progression of
effusion (loculated)
IMPRESSION:
Compared to chest radiographs ___ through ___.
2 left lower pleural pigtail drainage catheter is unchanged in position.
Moderate size, Multi loculated left pleural effusion probably got smaller
between ___ and ___, subsequently unchanged difficult to distinguish
from areas of atelectasis in the left lower lobe and lingula. There is no
pulmonary edema. Cardiac silhouette is partially obscured but probably not
enlarged. No pneumothorax.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with recent L sided chest tube (removed ___ //
r/o pneumothorax, evaluate interval change of effusion. requested by thoracic
surgery
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph since ___.
CT of the chest from ___.
FINDINGS:
The left pigtail drainage catheter has been removed. Lung volumes remain low
with increased bibasilar atelectasis. Left lower lobe opacifications are
slightly improved. Loculated air overlying the spine at site of prior
drainage catheter remains without evidence of worsening collection. The
moderate left-sided pleural effusion is stable. No pneumothorax.
IMPRESSION:
1. No pneumothorax.
2. Slightly improved left lower lobe opacities
3. Stable moderate left pleural effusion.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with PICC // Pt had a L ___ ___
Contact name: ___: ___ Pt had a L ___ ___
IMPRESSION:
In comparison with the earlier study of this date, there is an placement of a
left subclavian PICC line that extends to the mid portion of the SVC. Lower
lung volumes with continued extensive opacification in the left mid and lower
zones.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Pneumonia, unspecified organism
temperature: 98.6
heartrate: 90.0
resprate: 20.0
o2sat: 92.0
sbp: 103.0
dbp: 65.0
level of pain: 7
level of acuity: 2.0 | Mr. ___ is a ___ yo Man w/COPD with hx of pleural nodules and
plaques, obesity, HTN, asthma and very severe anxiety p/w chest
pain, who preseted with question of bilateral lower lobe
pneumonias failing outpatient treatment for which he was
initially started on ctx/azithro however was spiking fevers on
___ and repeat CXR revealed left effusion s/p placement of 2
pigtail catheters by IP on ___ and ___ d/t 2 separate areas of
pleural effusion/ parapneumonic/empyema (subsequently removed on
___. TPA infused into chest tube to break up loculations ___.
CT chest showed e/o necrotic PNA. ABX switched from
vanc/flagyl/CTX then to pip-tazo and finally IV unasyn alone on
discussion with AST/ID for complicated parapneumonic effusion.
He remains hypoxic on 2L NC and mildly tachypneic (although
seems near is baseline) with pleuritic chest pain that is
overall improving (albeit slowly). Course also complicated by
hyponatremia (likely relating to SIADH int the context of the
above lung issues), now improved on fluid restriction. PICC line
was placed on ___ and he will need a total of 2 weeks of IV
unasyn followed by PO antibiotics after that. ___ recommended
rehab. Rest of hospital course/plan are outlined below by issue:
#Left parapneumonic effusion and pneumonia with sepsis
(tachycardia/tachypnea): failed outpatient tx with levofloxacin.
Developed effusion while in-house while he had been on
ceftriaxone+azithro for CAP. The gram stain from the pleural
fluid showed no organisms unfortunately so could not guide
therapy based on this. Finally changed to IV unasyn in
discussion with AST/ID however a definitive pathogen was never
identified.
-He is s/p pleurexplacement for drainage but CT scan showed
large pocket of fluid ikely not accessed by the tube, therefore
___ chest tube was placed. TPA instilled ___ into posterior
tube to help break up loculations and he had significant
increase in output but this had briefly stopped draining;
?possibly due to clogging. The lung had not re-expanded despite
drainage and therefore IP recommended
thoracic surgery consult for question of decortication but
ultimately decortication was deferred given eventual drainage,
improvement in aeration, and removal of the chest tubes on ___.
-Regarding imaging: A Repeat CT chest done ___ and CXR on ___
showed lung has not completely re-expanded; there is still area
of pneumothorax. CXR on ___ prior to pigtail catheters removed
showed no pneumothorax. Daily CXRs were done after the chest
tubes were removed up until ___ which showed no significant
changes.
-For antibiotics: he was changed to IV unasyn on ___, will need
total 2 weeks IV abx (start day 1= date of last chest tube
insertion ___ then switched to PO antibiotics at the 2 week
mark (day 14 ___
#Left lower chest pain/LUQ pain: this is most likely d/t
pneumonia with areas of necrosis and parapneumonic effusion.
EKG
and cardiac enzymes have been negative.
-MSER briefly increased to 45mg q12h, reduced back to usual dose
30mg q12h on ___.
-PRN oxycodone ___ q6h PRN
-He was not given acetaminophen given do not want to hide fevers
per IP but this would be reasonable to start as outpatient given
he has been stable and afebrile.
#Hyponatremia: Difficult to determine the etiology and I think
this was multifactorial. Though he appeared fluid overloaded
peripherally with ___ edema, he had a low BNP, no true e/o heart
failure on Echo, it is unclear if he was eating and drinking
normally, and his urine studies with urine Na<20 and Osms in the
600s were suggestive actually of hypovolemia. The Na got a
little worse after IV fluids so this was most likely SIADH in
the setting of both the ongoing lung process and severe pain.
-improved after fluid restriction started 2L per day. This will
likely resolve over time as his lung issues resolve over time.
# COPD: no wheezing to suggest exacerbation. continue albuterol,
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Tiotropium Bromide 1 CAP IH DAILY. Add albuterol PRN.
# Anxiety: Throughout his hospitalization, Mr. ___
struggled with anxiety surrounding his illness and weakness
relating to his pneumonia. He was frustrated by his loss of
independence (particularly over the last ___ years) and
occasionally tearful about his condition.
-Prior to admission, the patient was taking home doses of benzos
Diazepam 10 mg PO
Q12H:PRN anxiety AND ClonazePAM 1 mg PO QID:PRN anxiety which is
an odd regimen but this was continued inpatient and will
continue as outpatient as well. Ultimately, benzodiazepines are
not ideal and these should be tapered as outpatient or at least
consolidated to one type of benzodiazepine.
CHRONIC ISSUES:
# Constipation - Docusate Sodium 100 mg PO BID plus PEG
# Chronic Lower extremity edema - resumed his home lasix
# Hypertension - resumed home antihypertensives
# Depression - Mirtazapine 60 mg PO QHS, QUEtiapine Fumarate 100
mg PO BID and QUEtiapine Fumarate 300 mg PO QHS
# Asthma - Montelukast 10 mg PO DAILY
# Chronic back pain - continue home Morphine SR (MS ___ 30
mg
PO Q12H and will increase oxycodone dose temporarily d/t pain
from chest tube
# GERD - Omeprazole 20 mg PO DAILY
# Restless leg - Pramipexole 0.5 mg PO QHS
# Smoking cessation - varenicline 1 mg oral BID; quit in ___
# Insomnia - Zolpidem Tartrate 12.5 mg PO QHS
#Transitional Issues:
-wean oxygen as able
-physical therapy
-taper benzodiazepines as outpatient.
-BMP drawn within 1 week to evaluate serum sodium
-Will be followed by OPAT, safety lab monitoring: minimum weekly
CBC with diff, Bun/Cr, LFTs faxed to ___ clinic, see separate
OPAT intake note for details. Eventual PICC removal.
-outpt ID f/u at 2 weeks to switch to oral therapy and re-image
the chest.
spent > 30 minutes seeing the patient and organizing discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ male with history of hypertension,
CHF, COPD, diabetes, stage III CKD, and aortic stenosis who
presents with ___ days of fatigue. He reports daytime somnolence
with nighttime insomnia. He feels better after he eats. He
denies congestion, cough, chest pain, shortness of breath,
vomiting/diarrhea, abdominal pain, leg swelling. He states about
a 2lb weight gain from baseline.
He was seen by his PCP on day of admission and noted to have a
blood pressure of 91/52. He felt back to normal after he ate.
Patient was treated with 2 aspirin 81mg tablets and sent to the
emergency department. In the ED he had no complaints.
In the ED, initial vital signs were: 0 97.5 74 122/64 19 99% RA
- Na 128(130 corrected for glycemia) Cl 87 BUN 84 K 5.1 HCO3 26
Cr 2.8
- CK: 87 MB: 5 Trop-T: 0.09
- ___: 10302
- WBC 9.0 H/H 9.4/29.5 PLT 189
- ekg- SR, worsening TWI laterally
- The patient was given: Lasix 40mg IV X 1
- Consults: At___ cardiology
Vitals prior to transfer were: 97.9 66 116/63 18 100% RA.
Upon arrival to the floor, he looks well and has no complaints.
Laying supine with no shortness of breath. denies chest pain or
palpitations. denies shortness of breath, nausea/vomiting or
abdominal pain.
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
pharyngitis, rhinorrhea, nasal congestion, cough, fevers,
chills, sweats, weight loss, dyspnea, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, hematochezia,
dysuria, rash, paresthesias, and weakness.
Past Medical History:
- Heart failure with reduced ejection fraction (LVEF 35-40%)
- Aortic stenosis ___ 1.1-1.2 cm2)
- Ischemic cardiomyopathy with inferior/inferolateral and global
hypokinesis
- Diabetes mellitus c/b neuropathy and nephropathy, followed at
___
- Chronic kidney disease (baseline Cr 1.5)
- Hypertension
- Hypercholesterolemia
- COPD
- GERD
- Anemia
- Anxiety
- Obesity
- Gout
- Osteoarthritis
- Chronic pain syndrome
Social History:
___
Family History:
Brother has CAD/PVD, valve replacement. Otherwise
noncontributory.
Physical Exam:
Admission Exam:
=====================
VITALS: 97.7 114/53 hr 91 rr18 98%ra 220lbs (Of note dry weight
is 210lbs)
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes
or rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: ___ ___ edema bilaterally
Discharge Exam:
===========================
VS: T=97.8 BP=114/53-130/60 ___ RR=18 O2 sat=100%RA
I/O: 8hr: ___ 24h:
Wt: 100.2kg
GENERAL: older man in NAD
HEENT: EOMI, no scleral icterus, significant ___ edema
NECK: Supple with JVP to angle of jaw at 45 degrees
CARDIAC: RRR, ___ systolic murmur heard best at LUSB
LUNGS: crackles at b/l bases, normal respiratory effort
ABDOMEN: soft, NTND, +BS
EXTREMITIES: warm, 1+ b/l ___ edema, 2+ DP pulses b/l
SKIN: No stasis dermatitis, ulcers
Pertinent Results:
Admission Labs:
========================
___ 07:37PM BLOOD WBC-9.0 RBC-3.17* Hgb-9.4* Hct-29.5*
MCV-93 MCH-29.7 MCHC-31.9* RDW-14.6 RDWSD-48.9* Plt ___
___ 07:37PM BLOOD Glucose-280* UreaN-84* Creat-2.8* Na-128*
K-5.1 Cl-87* HCO3-26 AnGap-20
___ 07:37PM BLOOD CK-MB-5 cTropnT-0.09* ___
___ 05:15AM BLOOD cTropnT-0.08*
___ 05:15AM BLOOD Calcium-9.8 Phos-4.2 Mg-1.5*
Discharge Labs:
========================
___ 05:15AM BLOOD WBC-8.7 RBC-3.11* Hgb-9.2* Hct-29.0*
MCV-93 MCH-29.6 MCHC-31.7* RDW-14.7 RDWSD-49.0* Plt ___
___ 03:05PM BLOOD Glucose-175* UreaN-78* Creat-2.3* Na-134
K-5.2* Cl-92* HCO3-26 AnGap-21*
___ 03:05PM BLOOD Calcium-10.2 Phos-4.0 Mg-2.1
Other Studies:
========================
CXR ___
IMPRESSION:
Mild cardiomegaly, hilar congestion with mild interstitial
edema.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO TID:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Methylprednisolone 4 mg PO DAILY
8. Pramipexole 0.125 mg PO QHS
9. Ranitidine 150 mg PO QHS
10. TraMADOL (Ultram) 50 mg PO BID:PRN pain
11. Vitamin D 1000 UNIT PO DAILY
12. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
13. linagliptin 5 mg oral DAILY
14. Carvedilol 25 mg PO BID
15. Lisinopril 5 mg PO DAILY
16. Bumetanide 2 mg PO Q8H
17. Guaifenesin ER 600 mg PO Q12H
18. Glargine 14 Units Breakfast
Glargine 20 Units Bedtime
Discharge Medications:
1. Acetaminophen 1000 mg PO TID:PRN pain
2. Aspirin 81 mg PO DAILY
3. Bumetanide 4 mg PO BID
RX *bumetanide 2 mg 2 tablet(s) by mouth twice daily Disp #*120
Tablet Refills:*0
4. Carvedilol 12.5 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Glargine 14 Units Breakfast
Glargine 20 Units Bedtime
7. Methylprednisolone 4 mg PO DAILY
8. Pramipexole 0.125 mg PO QHS
9. Ranitidine 150 mg PO QHS
10. TraMADOL (Ultram) 50 mg PO BID:PRN pain
11. Vitamin D 1000 UNIT PO DAILY
12. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
13. Allopurinol ___ mg PO DAILY
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY
15. FoLIC Acid 1 mg PO DAILY
16. Guaifenesin ER 600 mg PO Q12H
17. linagliptin 5 mg oral DAILY
18. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
acute on chronic systolic heart failure
acute kidney injury
Secondary diagnosis:
hyponatremia
COPD
HTN
Diabetes mellitus Type 2
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 weakness, hx of chf // eval for infiltrate, effusion,
edema
COMPARISON: ___.
FINDINGS:
PA and lateral views of the chest provided. Overall there has been no
significant change from the prior exam. The heart remains mildly enlarged
with hilar congestion and minimal interstitial edema. No large effusion or
pneumothorax is seen. Bony structures are intact.
IMPRESSION:
Mild cardiomegaly, hilar congestion with mild interstitial edema.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Weakness, Hypotension
Diagnosed with Heart failure, unspecified
temperature: 97.5
heartrate: 74.0
resprate: 19.0
o2sat: 99.0
sbp: 122.0
dbp: 64.0
level of pain: 0
level of acuity: 3.0 | This is an ___ year old male with PMH of severe sCHF (EF 20%),
CAD, CKD presenting with signs/symptoms of volume overload and
complaining of fatigue.
#Acute on chronic systolic heart failure. Up about 10lbs from
outpatient notes but only 2lbs from "dry weight" at previous
discharge in ___. BNP elevated to 10K but was 11K in ___ while outpatient. Likely chronicly elevated and could
benefit from increased outpatient diuretic regimen. Unclear BB
dose that he is taking because was on 25 BID but changed this
past month to 12.5mg BID, unclear if he actually changed the
dose. Given that we are increasing his diuretic regimen on
discharge we will confirm the 12.5mg BID dose. Given 120mg IV
Lasix x1 with good output (1.5L). Discharge weight 110.2kg.
#Demand ischemia: Likely in setting of acute CHF. Vague symptoms
of fatigue and worsened lateral TWI. 0.09->0.08
# Acute on CKD: likely pre-renal from acute CHF. Baseline 2.0,
to 2.8 at admission. Down to 2.3 by discharge.
#Hyponatremia: Likely hypervolemic hyponatremia. mild (sodium
130), Improved with diuresis to 134.
#Diabetes Mellitus: held PO medications, given ISS and half home
dose lantus while in house. Resumed oral meds on discharge.
#COPD: Unclear why on methylprednisone, continued in house. Also
given ipratropium nebs.
#HTN: on lisinopril 5mg plus carvedilol 12.5mg BID. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol
Attending: ___.
Chief Complaint:
Somnolence
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
Mr. ___ is a ___ y/o M with PMH of bipolar disorder, anxiety,
and depression who was found slumped over a car earlier today
and BIBA to ___. The patient was very somnolent when found
although was able to state that he had taken Seroquel and Xanax
in doses "more than usual." A suboxone tablet and a Flexeril
tablet were found in his pocket. On interview here the patient
reports taking 1200mg Seroquel, 16mg Klonipin and 13 shots of
EtOH on ___. No recollection of events between ___ and
arriving in ED today. The patient recently underwent treatment
for 30 days at ___ and was released ___.
.
In the ED the patient was found to be lethargic. ECG was
remarkable for sinus tach. Utox was negative. Labs otherwise
notable for a lactate of 3.6. Given Narcan with slight
improvement in MS. 2L of IV fluids given with improvement in
lactate to 0.8. Was initially admitted to OBS in the ED although
spiked a fever to 102.4. A CXR showed a righ sided opacity in
the RML. Given vanc, levaquin and an additional 3L of NS.
Swithced abx to vanc/ceftriaxone/azithro due to rash with
levaquin. Transferred to the MICU for further monitoring given
high risk of EtOH withdrawal and respiratory depression with
Seroquel overdose.
.
On arrival to the FICU initial vitals are 100.3 168/94 144
94%RA. Patient appears manic with pressured speech. Easily
agitated.
.
ROS: (+) as per HPI. Also endorses cough productive of green
sputum over the past week. Otherwise denies CP, palp, SOB,
fever/chills, N/V/D, changes in bowel/bladder habits, recent
weight loss, HA or vision changes.
Past Medical History:
Depression
Anxiety
Bipolar disorder
Umbilical hernia
Asthma
Right foot fracture
ADD
Social History:
___
Family History:
Mother - alcoholism
Physical ___:
Admission PEx:
Vitals- 100.3 168/94 144 94%RA
General- Patient appears agitated, pressured speech, easily
distracted
HEENT- PERRLA, EOMI, anicteric, MMM, OP clear
Neck- Supple, no JVP
CV- Tachycardic, S1 and S2 appreciated, no m/r/g
Chest- Good air entry b/l. Diffuse wheezes.
Abdomen- Soft, ND. Umbilical hernia that could not be reduced
secondary to pain.
Extremity- Well ehaled surgical scar over right lateral heel.
TTP.
Neuro- Awake, alert and oriented. Moving all extremities.
Discharge Exam:
Vitals- 98.3, 116/69, 74, 95% RA
General- Patient appears agitated, pressured speech, easily
distracted
HEENT- PERRLA, EOMI, anicteric, MMM, OP clear
Neck- Supple, no JVP
CV- Tachycardic, S1 and S2 appreciated, no m/r/g
Chest- Good air entry b/l. Diffuse wheezes.
Abdomen- Soft, ND. Umbilical hernia that could not be reduced
secondary to pain.
Extremity- Well ehaled surgical scar over right lateral heel.
TTP.
Neuro- Awake, alert and oriented. Moving all extremities.
Pertinent Results:
ADMISSION LABS:
___ 02:30PM BLOOD WBC-6.2 RBC-4.04* Hgb-11.0* Hct-33.4*
MCV-83 MCH-27.2 MCHC-32.8 RDW-14.6 Plt ___
___ 02:30PM BLOOD Neuts-51.2 ___ Monos-5.7 Eos-7.2*
Baso-0.7
___ 02:30PM BLOOD ___ PTT-32.8 ___
___ 02:30PM BLOOD UreaN-17 Creat-0.8
___ 12:47AM BLOOD ALT-18 AST-22 CK(CPK)-150 AlkPhos-57
TotBili-0.4
___ 12:47AM BLOOD Albumin-3.9 Calcium-8.5 Phos-2.7 Mg-2.0
___ 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:03PM BLOOD Glucose-98 Lactate-3.6* Na-143 K-3.5
Cl-101 calHCO3-27
___ 03:03PM BLOOD freeCa-1.17
IMAGING:
CXR: As compared to the previous radiograph, the extensive
multifocal
opacities have substantially decreased. However, a right upper
lobe opacity with air bronchograms is still clearly visible and
likely to correspond to pneumonia. No evidence of pleural
effusions. No pulmonary edema. Borderline size of the cardiac
silhouette.
Medications on Admission:
Presently no home medications. Reports all home medications were
stopped during his stay at ___ last month.
Discharge Medications:
1. Combivent ___ mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation three times a day.
2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. salmeterol 50 mcg/dose Disk with Device Sig: One (1) puff
Inhalation twice a day.
5. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*0*
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*0*
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*0*
9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*0*
10. clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO every
eight (8) hours for 14 days.
Disp:*84 Capsule(s)* Refills:*0*
11. Robaxin-750 750 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
overdose/intoxication of medications
RML pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: Fevers, questionable pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there are extensive newly
occurred bilateral basal and right apical alveolar opacities. The patchy
distribution, the presence of air bronchograms, and the absence of
interstitial markings make pneumonia the most likely differential diagnosis.
There is no evidence of accompanying pleural effusions. Borderline size of
the cardiac silhouette. No pulmonary edema.
The referring physician, ___ was paged for notification at the
time of dictation, 8:31 a.m., on ___.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Fevers, evaluation for pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the extensive multifocal
opacities have substantially decreased. However, a right upper lobe opacity
with air bronchograms is still clearly visible and likely to correspond to
pneumonia.
No evidence of pleural effusions. No pulmonary edema. Borderline size of the
cardiac silhouette.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ALTERED MENTAL STATUS
Diagnosed with POISON-ANTIPSYCHOTIC NEC, POIS-BENZODIAZEPINE TRAN, ALTERED MENTAL STATUS , ACC POISN-TRANQUILZR NEC, ACC POISN-BENZDIAZ TRANQ, PNEUMONIA,ORGANISM UNSPECIFIED
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ y/o M with h/o psychiatric d/os and substance abuse who
presents after being found somnolent on the street likely due to
Seroquel overdose. Now with new fever concerning for PNA vs.
early EtOH withdrawal.
# Drug overdose: The patient was found slumped over a car and
was somnolent on arrival to the ED. He endorsed using large
amounts of Seroquel, EtOH, and Xanax. Urine tox was (-); patient
reports his last drink being >1 day prior. Recieved naloxone in
the ED with minimal response. Admitted to ICU for close
monitoring of resp status given long Seroquel wash-out period.
EKG unremarkable, no QTc prolongation. Pt was alert by the time
he reached FICU floor, where he became agitated and verbally
abusive. Pt became more calm with ativan and pain medication
(has h/o chronic pain and drug abuse, so concern was for
withdrawal). He was monitored on CIWA but did not score. His
respiratory status was stable throughout FICU stay so he was
transferred to the floor where he did not show any signs of
continued withdrawl and was given 0.5 mg PO ativan PRN for
aggiation. Patient was not discharged on any anxiolytic
medicaitons.
.
# Fever: While being obs'ed in the ED, the patient developed a
fever to 102.4. A CXR showed a RML consolidation which was new
since a prior film in ___, though lung volumes were
decreased. Blood, urine, and sputum cultures were obtained. Pt
was started on vanc/azithro/CTX for empiric treatment of CAP.
Pt was placed on CIWA for possible EtOH withdrawal but did not
score. Vanc was given in ED but discontinued on the floor
because there was no indication for MRSA coverage. Repeat CXR
confirmed likely presence of PNA but in RUL. Pt was doing well
so was continued on azithro/CTX and was transferred to the
floor. Sputum cultures grew pan-sensitive S. aureus and the
patient was treated with IV vancomycin while inpaitent and
discharged to complete a 14 day course of PO clindamycin 600 mg
Q8H.
.
# EtOH abuse: pt has a h/o EtOH abuse. Reports last drink was
___. Recently detoxed at ___ making withdrawal at this
time less likely. Kept on CIWA in ___ but did not score.
Given MVI, folate, thiamine. SW was consulted as well as psych.
Pt expressed desire to be treated by inpatient psych facility
once medically stable. Patient will follow up with pshyciatric
providers and an appointment was made for him at ___
___ - ___ -
Day Treatment for ___ at 4 pm.
# Asthma: gave albuterol and ipratropium nebs as well as
montelukast. Stopped salmeterol because pt was not on a
steroid, which should be combined with ___ to reduce
cardiovascular side effects. Would recommend fluticasone or
advair as a replacement, to be outpatient PCP.
# Chronic pain: patient c/o chronic pain in right foot, neck,
and umbilical hernia site. Had prior surgery on right foot for
unknown reason. Held home gabapentin given somnolence. Added
tylenol for pain and oxycodone 15mg po q6h prn, which pt said
worked well in managing pain. Patient was discharged on 750 mg
Robaxin Q6H PRN for pain per psychiatry, patient was not
discharged with any opiates.
# Psych (Bipolar D/o, depression): Continued Clozaril and
cymbalta at home dosing. Psych consulted. Pt reports having
psych meds discontinued in ___ facility, which he did not
like. Pt expressed desire to be treated by inpatient psych
facility once medically stable. Psych agreed to make
arrangements for this once pt was medically cleared. Psych
rec'd restarting seroquel at 100mg po q6h prn while in house,
but declined to send patient on out on standing antipsychotics
given his abuse history and need to establish long term
pshyciatric care. Patient will follow up with pshyciatric
providers and an appointment was made for him at ___
___ - Day Treatment
for ___ at 4 pm.
# Anemia: The patient has had mild normocytic anemia since
___. Hgb on admission was 11.0. Most likely due to chronic
malnutrition and marrow supression due to EtOH/substance abuse.
Also considered GI bleeding given recent h/o ?UGI bleed and
continued NSAID use. GI consulted and recommended outpatient
EGD and colonoscopy.
TRANSITIONAL ISSUES:
Patient will require an outpatient workup for his anemia as
above. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Biaxin / Morphine
Attending: ___.
Chief Complaint:
Back pain, chills, sweats, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old woman with a history of bipolar d/o,
recurrent UTI who was admitted with back pain, dyspnea on
exertion, chills, sweats and vomiting. She came to ___ earlier
in the week with back pain, and was given prescriptions for
oxycodone and ibuprofen, both of which she took and she found to
be helpful. However, she has had some DOE for the past few
days. No chest pain. She has chronic right leg swelling, maybe
slightly increased recently. Yesterday, she had a poor
appetite, and threw up five times in the evening. + sweats
yesterday and chills this morning. She called the ED for advice
regarding her symptoms and was told to come in for evaluation.
She feels thirsty but denies lightheadedness. No shortness of
breath at rest or pleuritic chest pain. Her back pain is
improved. She has a history of cystitis but only has "cloudy
urine" when she gets a UTI. She does not have dysuria with
UTIs, nor did she recently experience any. She does have
constipation and this may be worse after the oxycodone that she
recently took for back pain. She has a history of a distended
bladder - told by a urologist that her bladder is always
distended. She thinks it is because she did not like to use
public bathrooms when she was a kid and this stretched out her
bladder.
Past Medical History:
1. Bipolar D/O: Managed by ___, ___ psychiatry. Feels
that mood is "stable".
2. Lung CA, Bronchoalveolar, s/p lung resection, followed by CT
scans.
3. Cystitis
Social History:
___
Family History:
Colon CA in grandmother.
Physical Exam:
AF 120/70 HR 120 T 99.8
Gen: NAD, covered in many blankets, pleasant
Lung: CTA B
CV: Tachycardic
Abd: mild distension, nabs, soft
Ext: Right ___ larger than L, non pitting edema
No flank tenderness
Affect: Answers questions appropriately
Discharge Exam
VSS
Gen: Appearing very well, pleasant
Lung CTA B
CV: RRR
Abd: Soft, nt
Ext: Right ___ greater than left
Pertinent Results:
___ 08:30AM BLOOD WBC-23.5*# RBC-3.65* Hgb-11.2* Hct-32.8*
MCV-90 MCH-30.6 MCHC-34.0 RDW-12.3 Plt ___
___ 08:30AM BLOOD Neuts-91.1* Lymphs-5.9* Monos-2.7 Eos-0.1
Baso-0.2
___ 08:30AM BLOOD Glucose-130* UreaN-19 Creat-1.0 Na-127*
K-4.1 Cl-94* HCO3-22 AnGap-15
___ 08:30AM BLOOD ALT-45* AST-33 AlkPhos-225* TotBili-1.0
___ 10:45AM URINE Color-Straw Appear-Hazy Sp ___
___ 10:45AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 10:45AM URINE RBC-5* WBC-41* Bacteri-MANY Yeast-NONE
Epi-<1 RenalEp-<1
___ 09:10AM BLOOD WBC-12.8* RBC-3.69* Hgb-11.1* Hct-33.3*
MCV-90 MCH-30.1 MCHC-33.4 RDW-13.7 Plt ___
___ blood culture:
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
COMPARISON: None available.
FINDINGS: There is normal phasicity in the common femoral veins
bilaterally.
There is normal compression, augmentation and flow in the common
femoral,
superficial, popliteal, peroneal and posterior tibial veins of
the right leg.
___ cyst is seen measuring 3.8 x 6.2 x 1.2 cm.
IMPRESSION:
1. No evidence of DVT in the right leg.
2. ___ cyst.
INDICATION: Abdominal pain and vomiting. Evaluate for
obstruction.
COMPARISONS: CT of the chest from ___. PET-CT
from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through
the abdomen and pelvis after the administration of IV contrast
only. Sagittal and coronal reformatted images were obtained and
reviewed.
TOTAL DLP: 726.34 mGy-cm.
FINDINGS:
LUNG BASES: At the right base, there is a 7-mm solid nodule (2,
9), which is stable from the prior PET-CT in ___, suggesting it
is benign. No other discrete nodule is identified. There is
minimal atelectasis at the bilateral bases. There is no
consolidation, pulmonary edema, or pleural effusion. The base
of the heart is normal in size. There is no pericardial
effusion.
ABDOMEN: The liver is normal in shape and contour. In the dome
of the liver, there is an 8 mm hypdense lesion, which is too
small to fully characterize but was unchanged in size from the
prior non-contrast CTs. It may be a small hemangioma. No new
hepatic lesions are identified. There is no intra- or
extra-hepatic biliary duct dilation. The portal veins are
patent. The gallbladder is completely filled with hyperdense
material, which are presumably multiple small stones. Several
discrete stones are identified within the neck. The gallbladder
is not distended and there is no CT evidence of cholecystitis.
The spleen, pancreas, and right adrenal gland are normal.
There is a small 9 mm nodule in the left adrenal gland (2, 25),
unchanged from prior PET-CT in ___, and likely a tiny adenoma.
In the upper pole of the left kidney, the cortex is slightly
heterogeneous, with a hypodensity extending to the capsule.
This is likely pyelonephritis, or less likely, the sequelae of
an old infection. There is no discrete fluid collection or
significant surrounding stranding. There is no renal lesion.
There is no hydronephrosis. The kidneys enhance and excrete
contrast symmetrically.
Incidentally noted is a duodenal diverticulum. The stomach and
small bowel are otherwise normal in course and caliber. There
is no small bowel dilation or focal inflammatory changes to
suggest an obstruction or colitis. There is no free air or free
fluid. The abdominal vasculature is normal with minimal
atherosclerotic calcifications along the infrarenal abdominal
aorta. There is no periportal, mesenteric, or retroperitoneal
lymphadenopathy.
PELVIS: The large bowel is normal without evidence of a mass or
focal
inflammatory changes. There is a moderate-to-large fecal load.
The appendix is not definitely visualized, though there is no
evidence of appendicitis in the right lower quadrant. The
bladder is distended with air layering anteriorly. The uterus
is surgically absent. There are no adnexal masses. Surgical
clips are noted along the pelvic sidewalls. There is no pelvic
or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic
osseous
lesions. No fracture is identified. Moderate multilevel
degenerative changes are noted in the lower lumbar spine, most
marked at L4-L5. There is associated anterolisthesis of L4 on
L5.
IMPRESSION:
1. Heterogeneity of the right renal cortex, particularly in
upper pole,
likely represents pyelonephritis. Alternatively, it could be
the sequela of old injury/infection. Recommend correlation with
the site of the patient's pain and a UA.
2. Distended bladder with layering air. Recommend correlation
with a recent history of instrumentation.
3. No evidence of a small bowel obstruction. Moderate-to-large
fecal load in the colon.
4. Cholelithiasis without cholecystitis.
5. Unchanged sub-cm left adrenal lesion, likely a tiny adenoma.
6. Unchanged 7-mm left lower lobe pulmonary nodule, stable
since at least ___, suggesting it is benign.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benztropine Mesylate 0.5 mg PO BID
2. ClonazePAM 0.25 mg PO QHS
3. ClonazePAM 0.5 mg PO PRN anxiety
4. Thiothixene 5 mg PO QAM
5. Thiothixene 10 mg PO QHS
Discharge Medications:
1. Thiothixene 10 mg PO QHS
2. Thiothixene 5 mg PO QAM
3. Benztropine Mesylate 0.5 mg PO BID
4. ClonazePAM 0.25 mg PO DINNER
5. ClonazePAM 0.25 mg PO PRN anxiety
6. Ascorbic Acid ___ mg PO BID
7. Centrum Silver
(
m
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l
t
i
v
i
t
-
m
i
n
-
F
A
-
lycopen-lutein;<br>multivitamin-minerals-lutein;<br>mv-min-folic
acid-lutein) 0.5 tablet oral BID
8. cranberry extract ___ mg oral 2 tablets PO BID
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk
(with sugar);<br>psyllium seed (sugar)) 0 dose ORAL DAILY:PRN
constipation
11. RISperidone 0.25 mg PO DAILY:PRN agitation or irritability
12. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*20 Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 gm by
mouth mixed in water daily Refills:*0
14. Senna 2.5 tablets PO HS
15. Acetaminophen 1000 mg PO QAM:PRN pain
16. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl [Dulcolax (bisacodyl)] 5 mg 2 tablet(s) by mouth
daily as needed Disp #*20 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Urosepsis
2. Pyelonephritis
3. Bipolar d/o
4. Urinary retention/distension
5. Constipation
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: Abdominal pain and vomiting. Evaluate for obstruction.
COMPARISONS: CT of the chest from ___. PET-CT from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the abdomen and
pelvis after the administration of IV contrast only. Sagittal and coronal
reformatted images were obtained and reviewed.
TOTAL DLP: 726.34 mGy-cm.
FINDINGS:
LUNG BASES: At the right base, there is a 7-mm solid nodule (2, 9), which is
stable from the prior PET-CT in ___, suggesting it is benign. No other
discrete nodule is identified. There is minimal atelectasis at the bilateral
bases. There is no consolidation, pulmonary edema, or pleural effusion. The
base of the heart is normal in size. There is no pericardial effusion.
ABDOMEN: The liver is normal in shape and contour. In the dome of the liver,
there is an 8 mm hypodense lesion, which is too small to fully characterize
but was unchanged in size from the prior non-contrast CTs. It may be a small
hemangioma. No new hepatic lesions are identified. There is no intra- or
extra-hepatic biliary duct dilation. The portal veins are patent. The
gallbladder is completely filled with hyperdense material, which are
presumably multiple small stones. Several discrete stones are identified
within the neck. The gallbladder is not distended and there is no CT evidence
of cholecystitis. The spleen, pancreas, and right adrenal gland are normal.
There is a small 9 mm nodule in the left adrenal gland (2, 25), unchanged from
prior PET-CT in ___, and likely a tiny adenoma. In the upper pole of the
left kidney, the cortex is slightly heterogeneous, with a hypodensity
extending to the capsule. This is likely pyelonephritis, or less likely, the
sequelae of an old infection. There is no discrete fluid collection or
significant surrounding stranding. There is no renal lesion. There is no
hydronephrosis. The kidneys enhance and excrete contrast symmetrically.
Incidentally noted is a duodenal diverticulum. The stomach and small bowel
are otherwise normal in course and caliber. There is no small bowel dilation
or focal inflammatory changes to suggest an obstruction or colitis. There is
no free air or free fluid. The abdominal vasculature is normal with minimal
atherosclerotic calcifications along the infrarenal abdominal aorta. There is
no periportal, mesenteric, or retroperitoneal lymphadenopathy.
PELVIS: The large bowel is normal without evidence of a mass or focal
inflammatory changes. There is a moderate-to-large fecal load. The appendix
is not definitely visualized, though there is no evidence of appendicitis in
the right lower quadrant. The bladder is distended with air layering
anteriorly. The uterus is surgically absent. There are no adnexal masses.
Surgical clips are noted along the pelvic sidewalls. There is no pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis.
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic osseous
lesions. No fracture is identified. Moderate multilevel degenerative changes
are noted in the lower lumbar spine, most marked at L4-L5. There is
associated anterolisthesis of L4 on L5.
IMPRESSION:
1. Heterogeneity of the right renal cortex, particularly in upper pole,
likely represents pyelonephritis. Alternatively, it could be the sequela of
old injury/infection. Recommend correlation with the site of the patient's
pain and a UA.
2. Distended bladder with layering air. Recommend correlation with a recent
history of instrumentation.
3. No evidence of a small bowel obstruction. Moderate-to-large fecal load in
the colon.
4. Cholelithiasis without cholecystitis.
5. Unchanged sub-cm left adrenal lesion, likely a tiny adenoma.
6. Unchanged 7-mm left lower lobe pulmonary nodule, stable since at least
___, suggesting it is benign.
Radiology Report
INDICATION: Right lower extremity swelling.
COMPARISON: None available.
FINDINGS: There is normal phasicity in the common femoral veins bilaterally.
There is normal compression, augmentation and flow in the common femoral,
superficial, popliteal, peroneal and posterior tibial veins of the right leg.
___ cyst is seen measuring 3.8 x 6.2 x 1.2 cm.
IMPRESSION:
1. No evidence of DVT in the right leg.
2. ___ cyst.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with PYELONEPHRITIS NOS
temperature: 98.3
heartrate: 91.0
resprate: 18.0
o2sat: 98.0
sbp: 125.0
dbp: 67.0
level of pain: 3
level of acuity: 3.0 | ___ year old woman admitted with chills, sweats, back pain. W/u
reveals pyuria, signs of pyelonephritis on CT scan. Initial
blood and urine cultures positive for E Coli
1. Urosepsis/Pyelonephritis: Patient initially required
boluses of IVF, and mounted fevers for 48 hours of
hospitalization. With antibiotics (ceftriaxone initially, and
then oral ciprofloxacin for E coli urosepsis) she defervesced.
She has a history of recurrent cystitis, and her initial symptom
was back pain. She did not have dysuria. She has a very
distended bladder and is known to chronically retain urine. She
has a ___ urologist. We decompressed her bladder with foley
catheter during the hospitalization to drain infected urine, but
then discharged her home without the catheter. Given her lack
of symptoms to her initial cystitis, she is interested in
submitting regular samples to the lab for evaluation. She will
discuss this at PCP ___. She was discharged on ciprofloxacin to
complete a 14 day course. Repeat cx negative at time of
discharge and need to ___ at outpatient appt.
2. Bipolar D/O: Continue home medications.
3. Dyspnea: LIkely secondary to infection. Does have
tachycardia (but this improved with fluids), but no pleuritic
chest pain or hypoxia concerning for PE. WIll check ___ of
right ___. Patient now stating that she gets short of breath when
she becomes nervous. This resolved by the time of her
discharge. Has right leg chronically enlarged than right; ___
negative.
4. Constipation: Noted on imaging, and given aggressive bowel
regimen during her hospitalization. Constipation likely
occurred in context of receiving narcotics for her back pain.
She will stop the narcotics.
5. Lung CA: S/p resection. Has ___ CT scan scheduled.
6. Hyponatremia: Chronic, mild. Seen on previous labs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / Reglan
Attending: ___.
Chief Complaint:
symptomatic bradycardia
Major Surgical or Invasive Procedure:
Dual Chamber Permanent Pacemaker Placement via L cephalic vein
___
History of Present Illness:
___ with CAD s/p CABG and PCI, HTN, mild AS, and bradycardia
with multiple presentations in the past for symptomatic
bradycardia who p/w symptomatic bradycardia.
Pt has had multiple presentations for symptomatic bradycardia
with HR in ___. He was previously on atenolol which has been on
hold since ___. More recently, he was seen in ___ on
___ for fatigue and dyspnea. He was found to have HR in
___. ECG showed RBBB with AV delay. At that time it was felt to
be unclear whether his symptoms were related to bradycardia or
worsening AS. He was therefore scheduled for a stress echo on
___. He returned home but symptoms persisted and he presented to
the ED.
In the ED,
- Initial vitals: T 97.3 HR 35, BP 140/58, RR 16, SpO2 100% RA
- EKG: Sinus with RBBB, HR ___
- Labs/studies notable for:
CBC: WBC 8.9, Hgb 12.6, plt 159
Chem: BUN 58, Cr 2.1 (bl 1.7-2.0 in last ___ yrs), bicarb 21
Coags: INR 1.1
Trop 0.02 -> <0.01, CK: 55 MB: 3
Consults-
Cards- It was recommended that he have a stress echo to evaluate
for worsening conduction disease and valvular pathology which
was ordered but not yet completed. The patient now presents with
similar symptoms compared to prior. Given the nature of the
patients symptoms and multiple presentations for the same
complaint, would agree with admission to ___ service for
inpatient work up of his bradycardia with stress echo. Would
hold all nodal blocking agents and atenolol as previously noted
per ___ note on ___.
- Patient was given: Nothing
On the floor, he denies any chest pain, shortness of breath or
abdominal pain. He does endorse feeling gassy. Denies any
nausea, vomiting or diarrhea. He is feeling more tired and
feels like he has very little energy. He has stopped taking
atenolol for a little while. He notices that when he was in
___ he was able to go up and down the stairs without any
problem. He left ___ oh ___ and has been having some
shortness of breath with exertion. Endorses that he has had
chronic lower extremity
edema for a couple of years. Says it is 170 pounds is a good
weight for him.
REVIEW OF SYSTEMS:
Per HPI
Past Medical History:
# Hypertension
# Hyperlipidemia
# CAD s/p CABG in ___ at ___ (LIMA to LAD, SVG to PDA, SVG to
RI/ OM). S/p multiple angioplasties and rotablations to the RCA,
stents x 3 to RCA in ___ complicated by ISR, followed by
multiple angioplasties and rotablations as well as one
additional stent to RCA in ___, multiple angioplasties to the
PLV, stent to SVG-ramus-OM graft in ___ which is now occluded,
stents to LCx and LAD at ___ in ___, ___ ___ to ostial
LCx and mid LCx, and most recently DES to ___ ___.
# CKD
# Spinal stenosis
# Lower back pain s/p epidural injections
# Osteoarthritis, s/p left knee replacement ___ needs right
knee replacement in the future
# Erectile dysfunction s/p penile prosthesis
# GERD
# BPH
# s/p Right cataract surgery
Social History:
___
Family History:
Dad died from MI at age ___. Mother with heart condition in
her ___ and died at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS 24 HR Data (last updated ___ @ 533)Temp: 97.8 (Tm 97.9),
BP:
172/82 (170-173/72-82), HR: 70 (70-74), RR: 18 (___), O2 sat:
97% (97-99), O2 delivery: Ra, Wt: 165.78 lb/75.2 kg
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP not elevated
CARDIAC: RRR, normal S1, S2. Crescendo decrescendo murmur
appreciated through the precordium, radiating to the carotids.
No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace pitting edema to the mid shins bilaterally.
No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 97.8 ___ 96%Ra
GEN: NAD, sitting up on edge of bed
HEENT: Clear OP, moist mmm
___: NSR, III/VI crescendo-decrescendo murmur with radiation to
carotids, dressing over left anterior chest wall
RESP: CTAB, No wheezing, rhonchi or crackles
ABD: soft abdomen, NTND No HSM
EXT: Warm to touch, no edema
Pertinent Results:
ADMISSION LABS
==============
___ 04:13PM ___ PTT-28.1 ___
___ 04:13PM NEUTS-67.9 ___ MONOS-7.7 EOS-3.1
BASOS-0.3 IM ___ AbsNeut-6.01 AbsLymp-1.83 AbsMono-0.68
AbsEos-0.27 AbsBaso-0.03
___ 04:13PM WBC-8.9 RBC-3.99* HGB-12.6* HCT-38.7* MCV-97
MCH-31.6 MCHC-32.6 RDW-14.5 RDWSD-51.6*
___ 04:13PM CALCIUM-8.8 PHOSPHATE-3.0 MAGNESIUM-1.7
___ 04:13PM CK-MB-3
___ 04:13PM cTropnT-0.02*
___ 04:13PM GLUCOSE-100 UREA N-58* CREAT-2.1* SODIUM-140
POTASSIUM-5.2 CHLORIDE-106 TOTAL CO2-21* ANION GAP-13
___ 09:38PM cTropnT-0.01
DISCHARGE LABS
==============
___ 07:50AM BLOOD WBC-7.7 RBC-4.13* Hgb-12.9* Hct-39.9*
MCV-97 MCH-31.2 MCHC-32.3 RDW-14.7 RDWSD-51.3* Plt ___
___ 07:50AM BLOOD Glucose-96 UreaN-35* Creat-1.5* Na-141
K-4.6 Cl-106 HCO3-23 AnGap-12
___ 07:50AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.8
OTHER LABS
==========
___ 06:18AM BLOOD TSH-5.9*
OTHER IMAGING
=============
___ TTE
FINDINGS:
LEFT ATRIUM (LA)/PULMONARY VEINS: Normal LA volume index.
RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC):
Normal RA size. No atrial septal defect by 2D/color Doppler.
Normal IVC diameter with normal inspiratory collapse==>RA
pressure ___ mmHg.
LEFT VENTRICLE (LV): Mild symmetric hypertrophy. Normal cavity
size. Mild focal systolic dysfunction. The visually estimated
left ventricular ejection fraction is 45-50%. No resting outflow
tract
gradient.
RIGHT VENTRICLE (RV): Normal cavity size. Moderate global free
wall hypokinesis.
AORTA: Normal sinus diameter for gender. Mildly increased
ascending diameter. Focal calcifications in aortic sinus.
AORTIC VALVE (AV): Severely thickened leaflets. Moderate
stenosis (area 1.0-1.5 cm2). Peak gradient from apical 5 chamber
orientation. Mild [1+] regurgitation.
MITRAL VALVE (MV): Mildly thickened leaflets. No systolic
prolapse. Mild MAC. Trivial regurgitation.
PULMONIC VALVE (PV): Normal leaflets. Mild regurgitation.
TRICUSPID VALVE (TV): Normal leaflets. Mild [1+] regurgitation.
Undertermined pulmonary artery systolic pressure.
PERICARDIUM: Trivial effusion.
ADDITIONAL FINDINGS: Sinus bradycardia.
___ CXR
Left-sided pacemaker leads project to the right atrium and right
ventricle. Lungs are low volume. There is bibasilar
atelectasis. Cardiomediastinal silhouette is stable. No
pneumothorax is seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Omeprazole 20 mg PO QHS
3. Losartan Potassium 50 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. amLODIPine 5 mg PO DAILY
7. Allopurinol ___ mg PO DAILY
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
9. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE TID
10. Ezetimibe 10 mg PO DAILY
11. Ranolazine ER 500 mg PO BID
12. Ketorolac 0.5% Ophth Soln 1 DROP LEFT EYE TID
13. Pilocarpine 1% 1 DROP LEFT EYE Q8H
14. Ranitidine 150 mg PO QAM
15. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
16. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Losartan Potassium 100 mg PO DAILY
RX *losartan 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Allopurinol ___ mg PO DAILY
4. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
8. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE TID
9. Ezetimibe 10 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. Ketorolac 0.5% Ophth Soln 1 DROP LEFT EYE TID
12. Omeprazole 20 mg PO QHS
13. Pilocarpine 1% 1 DROP LEFT EYE Q8H
14. Ranitidine 150 mg PO QAM
15. Ranolazine ER 500 mg PO BID
16. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until your PCP tells you to do so
17. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until your PCP
tells you to do so
Discharge Disposition:
Home
Discharge Diagnosis:
# Symptomatic Bradycardia
# Mobitz II with 2:1 block: s/p PPM ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Purple chest radiograph
INDICATION: ___ year old man with new Mobitz II and RV hypokinesis// eval PNA
or edema
TECHNIQUE: Portable chest radiograph
COMPARISON: Prior chest radiograph on ___
FINDINGS:
Lung volumes are normal. There is no focal consolidation, pleural effusion,
or pneumothorax. No pulmonary edema. Cardiac silhouette is mildly enlarged.
No acute osseous abnormalities are identified. The upper most sternotomy wire
is broken, unchanged from ___. Degenerative changes about the bilateral
glenohumeral joints, more pronounced on the right where there is a large
inferior osteophyte.
IMPRESSION:
No acute cardiopulmonary process. Mild cardiomegaly.
Radiology Report
INDICATION: ___ year old man with new PPM via L cephalic// Lead position
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Left-sided pacemaker leads project to the right atrium and right ventricle.
Lungs are low volume. There is bibasilar atelectasis. Cardiomediastinal
silhouette is stable. No pneumothorax is seen.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Bradycardia
Diagnosed with Bradycardia, unspecified
temperature: 97.3
heartrate: 35.0
resprate: 16.0
o2sat: 100.0
sbp: 140.0
dbp: 58.0
level of pain: 0
level of acuity: 1.0 | ___ year old man with CAD s/p CABG and PCI, HTN, moderate AS, and
bradycardia with multiple prior presentations in the past who
was admitted to ___ for expedited workup of symptomatic
bradycardia now s/p permanent dual chamber pacemaker placement
on ___.
# Symptomatic Bradycardia
# Mobitz II with 2:1 block
Patient admitted with bradycardia (HR ___ with varying
block. He was previously on atenolol, but this was held due to
the above. His last dose was over weeks ago. EKG on admission
showed Mobitz II with 2:1 block. He was also noted to have
strips in Mobitz I on telemetry. Patient endorsed fatigue while
in this rhythm but otherwise was asymptomatic. He underwent
uncomplicated device placement via the L cephalic vein. CXR
confirmed that pacemaker leads project to the right atrium and
right ventricle. The pacer was evaluated by EP and showed normal
pacer function with acceptable lead measurements and battery
status. Patient will follow up in device clinic in 1 week.
# CAD s/p CABG(___-LAD) and multiple PCI (most recent ___
DES to ___ LAD).
Chronic and stable. No ischemic changes on EKG. TTE ___ was
notable for mild regional left ventricular systolic dysfunction
with hypokinesis of the inferoseptum and inferior walls in the
RCA distribution. Though the hypokinesis did not appear apparent
on our review of images, patient should have an exercise nuclear
stress test in the outpatient setting to further work up.
Patient was continued on home ASA 81mg and atorvastatin 80mg.
Following pacemaker placement, low dose metoprolol succinate XL
25mg was started for cardioprotective effects.
# HTN: Home hydrochlorothiazide and amlodipine were held on
arrival to prevent hypotension and possible nodal blockade
respectively. Losartan was uptitrated from 50 to 100mg daily
with better control in blood pressure. Due to well-controlled
pressures, HCTZ and amlodipine were not restarted.
# CKD: Baseline Cr ~1.6-1.8. Creatinine was trended as losartan
was uptitrated. Cr on discharge 1.5.
# GERD: Continued on omeprazole
# BPH: Continued on home finasteride
# Gout: Continued on home allopurinol
TRANSITIONAL ISSUES
===================
[] TTE with regional wall motion abnormalities in RCA
distribution. Patient will need an exercise stress test with
nuclear perfusion in two weeks to further evaluate. He was
started on a low dose beta blocker for cardioprotective effects
now that pacer is preventing bradycardia.
[] Home hydrochlorothiazide and amlodipine were held on
admission. Losaratan was uptitrated to 100mg daily with adequate
control of blood pressure. Patient may require further titration
of medications in the outpatient setting.
[] Patient is awaiting follow-up in device clinic with Dr.
___ in one week. He will be called when an appointment
is made.
[] TSH 5.9. Consider rechecking and further evaluating in
outpatient setting |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Weakness and abdominal pain
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
History of Present Illness:
___ with history of NASH cirhosis with associated hepatic
encephalopthay, SBP, portal hypertension, esophageal varices on
liver transplant list here with abdominal pain since this
morning and increase in abdominal girth. She reports waking up
with abominal pain and weakness and felt "unable to get up from
bed". She also felt feverish with chills, though no documented
fever. She denied N/V/D or constipation. She denies blood in
the stool or melena.
In the ED, triage vitals were 98.8 109 116/56 20 99%. She was
AAOx3. Bedside ultrasound did not view significant ascites to
perform paracentesis. Formal US showed moderate ascites. CT
scan showed Edematous bowel wall involving the stomach, duodenum
and proximal jejunum may reflect third-spacing or,
alternatively, infectious or inflammatory gastroduodenitis, as
well as increased ascites from prior. ED did not feel
comfortable performing tap in ED.
On the floor, VS are 99.6 119/57 110 18 99% ra. She
endorses abdominal pain and headache currently.
ROS: per HPI, denies vision changes, rhinorrhea, congestion,
sore throat, cough, shortness of breath, chest pain, diarrhea
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
# type 2 diabetes.
# NASH Cirrhosis complicated by:
-- esophageal varices (two cords of grade one varices) with
prior banding procedures.
-- portal vein and splenic vein thrombosis, chronic,
nonocclusive
-- ascites
--SBP early ___
-- reactivated on transplant list ___
# iron deficiency anemia
# migraine headaches
# hypercholesterolemia
# psoriatic arthritis
# History of positive PPD s/p INH therapy.
# Psoriasis
Social History:
___
Family History:
Mother with previous CVA. Father has DM2 and prostate cancer.
Physical Exam:
Admission:
VS: 99.6 119/57 110 18 99% ra
GENERAL: Pleasant female, mild distress from abdominal pain,
mildly jaundiced
HEENT: Sclera icteric. MMM.
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Distended but Soft, large ventral hernia. Abomden is
mildly tender to palpation throughout. +Caput medusae
EXTREMITIES: No edema. Warm and well perfused, no clubbing or
cyanosis.
NEUROLOGY: No asterixis
SKIN: + Spiders, evidence of psoriasis over abdomen, elbows, and
lower extremities.
NEURO: A/O x3, no asterixis
Pertinent Results:
Admission:
___ 02:00PM BLOOD WBC-4.7# RBC-3.20* Hgb-8.9* Hct-28.8*
MCV-90 MCH-27.7 MCHC-30.7* RDW-18.6* Plt Ct-60*
___ 02:00PM BLOOD Neuts-86.4* Lymphs-7.8* Monos-4.4 Eos-1.2
Baso-0.3
___ 02:00PM BLOOD ___ PTT-34.0 ___
___ 02:00PM BLOOD Glucose-230* UreaN-15 Creat-1.1 Na-130*
K-3.9 Cl-100 HCO3-21* AnGap-13
___ 02:00PM BLOOD ALT-28 AST-51* AlkPhos-86 TotBili-2.7*
___ 02:00PM BLOOD Albumin-3.1* Calcium-8.4 Phos-2.7 Mg-1.8
Discharge:
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Betamethasone Dipro 0.05% Lot. 1 Appl TP BID
to psoriasis on weekends avoid face-folds-genitals
2. Calcipotriene 0.005% Cream 1 Appl TP BID
___ through ___
3. Desonide 0.05% Cream 1 Appl TP ONCE DAILY
apply to folds/genitals as needed for ___ days then stop
4. Enbrel *NF* (etanercept) 50 mg/mL (0.98 mL) Subcutaneous once
weekly
50mg sc once per week
5. Humalog ___ 55 Units Breakfast
Humalog ___ 30 Units Dinner
6. Furosemide 60 mg PO DAILY
hold for sbp< 90
7. Ketoconazole Shampoo 1 Appl TP ASDIR
8. Lactulose 15 mL PO TID
titrate to ___ BM/day
9. Nadolol 20 mg PO DAILY
hold for sbp<90, HR<55
10. Omeprazole 20 mg PO DAILY
11. Pravastatin 10 mg PO DAILY
12. Rifaximin 550 mg PO BID
13. Spironolactone 150 mg PO DAILY
hold for sbp <90
14. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN
psoriasis
BID to psoriasis on arms/legs/back/abdomen on weekends avoid
face,folds,genitals---medium potency topical steroid
15. Aspirin 325 mg PO DAILY
16. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral daily
17. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Betamethasone Dipro 0.05% Lot. 1 Appl TP BID
to psoriasis on weekends avoid face-folds-genitals
3. Ferrous Sulfate 325 mg PO DAILY
4. Humalog ___ 55 Units Breakfast
Humalog ___ 30 Units Dinner
5. Lactulose 15 mL PO TID
titrate to ___ BM/day
6. Nadolol 20 mg PO DAILY
hold for sbp<90, HR<55
7. Omeprazole 20 mg PO DAILY
8. Pravastatin 10 mg PO DAILY
9. Rifaximin 550 mg PO BID
10. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral daily
11. Desonide 0.05% Cream 1 Appl TP ONCE DAILY
apply to folds/genitals as needed for ___ days then stop
12. Enbrel *NF* (etanercept) 50 mg/mL (0.98 mL) Subcutaneous
once weekly
50mg sc once per week
13. Furosemide 60 mg PO DAILY
hold for sbp< 90
14. Ketoconazole Shampoo 1 Appl TP ASDIR
15. Spironolactone 150 mg PO DAILY
hold for sbp <90
16. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN
psoriasis
BID to psoriasis on arms/legs/back/abdomen on weekends avoid
face,folds,genitals---medium potency topical steroid
17. CeftriaXONE 2 gm IV Q24H Duration: 3 Days
Last dose ___
RX *ceftriaxone 2 gram 1 bag daily Disp #*3 Bag Refills:*0
18. Calcipotriene 0.005% Cream 1 Appl TP BID
___ through ___
19. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
Start taking this medication on ___
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Spontaneous Bacterial Peritonitis
NASH Cirrhosis
Pancytopenia
Secondary Diagnosis:
Psoriasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of NASH cirrhosis, now with abdominal pain and increasing
abdominal distention, here to evaluate for ascites.
COMPARISON: Abdominal sonogram with Dopplers dated ___.
TECHNIQUE: Complete abdominal sonogram.
FINDINGS: The liver is nodular and shrunken, with coarsened echotexture,
compatible with patient's known cirrhosis. No focal liver lesion is detected
on this limited study due to decreased acoustic penetration. No biliary
dilation is seen with the common bile duct measuring 5-6 mm. The patient is
status post cholecystectomy. The spleen is enlarged, measuring 16.7 cm.
There is moderate abdominal ascites which is predominantly perihepatic with
fluid in the right lower quadrant. Fluid in the left lower quadrant is
loculated.
The main portal vein shows some hepatopetal flow. The prior ultrasound
demonstrated cavernous transformation of the porta hepatis, which is not well
seen on the current study due to poor acoustic penetration.
Limited evaluation of the kidneys shows no hydronephrosis.
IMPRESSION:
1. Nodular, shrunken liver with coarsened echotexture consistent with
cirrhosis.
2. Moderate abdominal ascites, which is increased from ___ and appears
loculated in the left lower quadrant.
3. Hepatopetal flow along the main portal vein, previously shown to have
cavernous transformation and not well assessed on the current study.
Radiology Report
HISTORY: History of Nash cirrhosis now with abdominal pain, here to evaluate
for intra-abdominal pathology.
COMPARISON: CT of the abdomen and pelvis with contrast dated ___.
TECHNIQUE: Multi detector CT imaging was performed from the lung bases to the
pubic symphysis following the uneventful administration of 130 cc Omnipaque
intravenous contrast. Coronal and sagittal reformatted images were generated
and reviewed.
FINDINGS:
The visualized lung bases are clear. Limited imaging of the heart shows no
pericardial effusion.
ABDOMEN: The pancreas is enlarged with mild diffuse peripancreatic stranding,
similar in appearance to the most recent prior CT. There is no area of
hypoenhancement or peripancreatic fluid collection. No pancreatic ductal
dilation or calcifications.
The liver is shrunken and nodular consistent with the patient's known
cirrhosis. No focal liver lesion is seen within the limitations of
single-phase technique. There is perihepatic ascites, which is increased from
the most recent prior CT. Again seen is cavernous transformation of the
portal vein, not significantly changed, with partially calcified chronic
thromboses of the left and main portal vein. There is thrombosis of the
splenic vein which remains nonocclusive but not significantly changed from the
prior study. The SMV remains patent with a large collateral noted. The spleen
remains enlarged. The bilateral adrenal glands are unremarkable.
The stomach is relatively collapsed. There is apparent progressive bowel wall
thickening of the distal duodenum and very proximal jejunum, which is more
prominent compared to ___. This may represent ___ spacing or,
alternatively an infectious or inflammatory etiology, although it not well
assessed due to relative collapsed state. Note is again made of a large
ventral wall abdominal hernia containing loops of nondilated small bowel and
simple appearing ascites, unchanged from ___. There is no free
intraperitoneal air. There is moderate abdominal ascites, which is increased
from the most recent prior CT.
PELVIS: The rectum and sigmoid colon are within normal limits. The uterus,
bilateral adnexae, and urinary bladder are normal.
OSSEOUS STRUCTURES: No lytic or sclerotic lesions are detected.
IMPRESSION:
1. Mild peripancreatic stranding and enlarged pancreas, little changed from ___ which may represent pancreatitis in the clinical setting of
elevated lipase.
2. Cirrhotic liver with unchanged cavernous transformation of the portal vein
and chronic left and main portal vein thromboses.
3. Apparent bowel wall thickening involving the distal duodenum and proximal
jejunum may reflect third-spacing or, alternatively, infectious or
inflammatory cause.
4. Stable large ventral wall hernia containing small bowel without evidence
of obstruction and fluid.
5. Moderate abdominal ascites, increased from ___.
Radiology Report
CHEST RADIOGRAPH.
INDICATION: Cough and bacteremia, evaluation for cardiopulmonary process.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the lung volumes are
constant and remain relatively low. Borderline size of the cardiac
silhouette. There is no evidence of pleural effusions or pneumonia. The
diameter of the pulmonary vessels has minimally increased but the patient
shows no signs of fluid overload or pulmonary edema. Unchanged hilar and
mediastinal contours. No pneumothorax.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: WEAKNESS/ABD PAIN
Diagnosed with ABDOMINAL PAIN UNSPEC SITE, CIRRHOSIS OF LIVER NOS, OTHER ASCITES
temperature: 98.8
heartrate: 109.0
resprate: 20.0
o2sat: 99.0
sbp: 116.0
dbp: 56.0
level of pain: 8
level of acuity: 2.0 | ___ female w/hx of Class C NASH cirrhosis c/b SBP, ascites,
esophageal varices, and hepatic encephalopathy presenting with 3
days of increasing weakness, fatigue, and abdominal pain being
treated emperically for SBP.
# SBP: Patient presented with worsening abdominal pain and
malaise for several days. She was afebrile on admission but was
tachycardic with WBC of 2. In the ED and on admission, a safe
pocket for paracentesis could not be identified on ultrasound.
Given clinical picture and history of SBP in past, decision was
made to empirically treat for SBP and she received ceftriaxone
2gm and albumin at SBP dosing (first and third days). She did
have 1 set of ED blood cultures that grew strep viridans but
this was felt to be a contaminate by ID consult. Within 24
hours of admission, patient was feeling well and had no active
complaints or complications. LFTs were at baseline during
admission. A PICC line was placed and Ms. ___ complete a
10 day course of ceftriaxone at ID recommendation in setting of
neutopenia. She had been on cipro prophylaxis but will be
transitioned to Bactrim prophylaxis at discharge in setting of
possible treatment failure.
#Bacteremia: Pt found to have strep viridans in ___ bottles on
admission (unfortuantely only 1 set drawn). Symptoms and
rapidity of improvement along with organism make this most
likely a contaminant (roughly 80% of all strep viridans
bacteremias are due to transient bacteremia or skin
contaminant). ID consult felt comfortable not treating
infection. She did not show any septic physiology. A TTE was
negative for vegetations. Surveillance cultures have been
negative. There was no signs of dental infection on gross exam.
She completed a course of ceftriaxone as above.
# Pancytopenia:Patient has a known history of pancytopenia and
has been followed by hematology in past but has not followed up
in several years. Hematocrit was 28.8 on admission but found to
drop following admission to 19. There was no clear source of
bleeding on endoscopy, colonscopy and on CT imaging. She
received 1 uint of PRBC. It is believed she was hemoconcentrated
on admission and drop is in setting of receiving albumin. While
pancytopenia can be attributed to liver disease, it is more
severe than is normally seen. We recommend outpatient heme/onc
follow up with consideration of bone marrow biopsy.
# NASH cirrhosis: Class C, complicated by polymicrobial SBP,
hepatic encephalopathy, portal hypertension and esophageal
varices. Has history of grade I esophageal varices with banding
in the past, but no evidence of esophageal varices on recent EGD
in ___. Liver function at baseline this admission without signs
of further decompensation. MELD 16 on admission. Currently on
transplant list but on hold due to surgical anatomy being
difficult. She was continued on lactulose, rifaxamin, and
nadalol. Spironolactone and lasix were held in setting of
infection and restarted at discharge. Her SBP prophylaxis was
changed to Bactrim from cipro.
# Psoriasis: Evidence of plaques on exam. Held enbrel in setting
of possible infection (gets on ___. Continued
betamethasone dipropionate 0.05% BID
and Dovonex 0.005% cream to affected areas twice daily ___
through ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Levofloxacin / Cephalosporins / betalactams /
Carbapenems / Quinolones / Penicillin V / cefepime
Attending: ___.
Chief Complaint:
Fever, loose stools
Major Surgical or Invasive Procedure:
___ PRBC Transfusion x 1 unit
History of Present Illness:
___ y/o M PMH significant for COPD (not on home O2), afib (on
coumadin), recurrent Cdiff (previously requiring vancomcyin
taper) who was recently admitted to MICU for pneumonia / COPD
treated with vancomycin/azithromycin/aztroenam who presents with
fevers, 8 episodes of diarrhea after starting azithromycin,
concerning for Cdiff infecton.
The patient reports that he was given azithromcyin for question
of a pneumonia and subsequently since midnight prior to
presentation developed 8 episodes of nonbloody, nonmelenic
diarrhea that he reports is similar to his previous episodes of
C.diff. Reportedly, WBC 31 at rehab. Hypotensive to 90/50.
Last time he had PO vanco for C. Diff was ___. Multiple
episodes in the past.
Of note in terms of his pneumonia, he believed he was having
increasing SOB and was therefore started on azithromcyin. The
patient reports that the furosemide that he received drastically
improved his symptoms. He reports that since he stopped smoking
that he has had a cough in the morning and there has not been a
change in that. He did endorse some orthopnea, but no PND. He
reports that fevers began after the diarrhea started, but denied
any fevers prior to that.
In the ED initial vitals were: 98.3, 122, 84/53, 16, 99% 2L
- Labs were significant for WBC 26.9, Creat 1.3
- Patient was given IV metronidazole, PO vanco, PO metoprolol,
and oxycodone
Vitals prior to transfer were: 98.7, 100, 95/61, 21, 100%
.
ROS: 10 point ROS negative except at mentioned above in HPI
Past Medical History:
- CAD
- Atrial fibrillation on warfarin
- PVD status post left BKA
- Status post fall in ___, with resultant shoulder and tibial
fractures
- COPD not on supplemental oxygen
- History of hip fracture status post repair
- History of peptic ulcer disease in the remote past
- History of pernicious anemia
- History of alcoholism with an isolated episode of DTs
- History of presumed thromboembolic CVA with resultant
disconjugate gaze
- History of recurrent C. difficile infection
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Vitals - T:98 BP:98/60 HR:102 RR:18 02 sat:100% 3L
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, difficult to assess JVD given facial
hair
NECK: nontender supple neck,
CARDIAC: irregular rhythm S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
At discharge:
98.8, 97.9, 96-114, 96/60-111/73, 18, 94-96% 2L NC
I/O: 24 hr: 1560 PO/ 450 GU+ BMx4
8hr: 120/NR
GENERAL: Lying in bed, NAD
HEENT: AT/NC, EOMI, PERRL.
NECK: Supple neck, no cervical lymphadenopathy.
CARDIAC: Irregular rhythm S1/S2, no murmurs, gallops, or rubs
LUNG: Posterior lung exam notable for bibasilar inspiratory
crackles extending to mid-lung fields.
ABDOMEN: nondistended, +BS, nontender in all quadrants.
+ecchymoses in lower abdomen
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
.
Pertinent Results:
On admission:
=============
___ 04:05PM BLOOD WBC-26.9*# RBC-2.14* Hgb-7.2* Hct-23.9*
MCV-112* MCH-33.5* MCHC-30.0* RDW-17.9* Plt ___
___ 04:05PM BLOOD Neuts-84* Bands-1 Lymphs-7* Monos-6 Eos-1
Baso-0 ___ Metas-1* Myelos-0
___ 04:05PM BLOOD ___ PTT-38.5* ___
___ 04:05PM BLOOD Glucose-103* UreaN-21* Creat-1.3* Na-135
K-3.9 Cl-96 HCO3-29 AnGap-14
___ 04:05PM BLOOD ALT-12 AST-15 AlkPhos-152* TotBili-0.7
___ 04:05PM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.3 Mg-1.7
___ 04:07PM BLOOD Lactate-1.5
.
At discharge:
=============
___ 08:35AM BLOOD WBC-8.6 RBC-2.26* Hgb-7.5* Hct-25.0*
MCV-110* MCH-33.3* MCHC-30.2* RDW-18.6* Plt ___
___ 08:35AM BLOOD ___ PTT-36.1 ___
___ 08:35AM BLOOD Glucose-124* UreaN-10 Creat-0.8 Na-137
K-3.5 Cl-101 HCO3-29 AnGap-11
___ 08:35AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.9
.
In the interim:
=============
___ 09:45AM BLOOD ___
___ 08:00AM BLOOD ___ PTT-38.5* ___
___ 08:05AM BLOOD ___ PTT-39.6* ___
.
Microbiology:
=============
___ C. difficile stool assay: Positive
___ Blood culture: No growth (FINAL)
Studies:
=============
___ EKG:
Baseline artifact. Underlying atrial fibrillation or less likely
flutter with overall rapid ventricular response. Poor R wave
progression. Borderline voltage in limb leads. Compared to the
previous tracing of ___ the findings are similar.
IntervalsAxes
___
___
___ Portable CXR:
IMPRESSION: Increased hazy opacification along the right heart
border may represent developing consolidation and should be
clinically correlated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
2. Atorvastatin 10 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. FoLIC Acid 1 mg PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
7. Paroxetine 40 mg PO DAILY
8. Acetaminophen ___ mg PO Q6H:PRN Pain, fever
9. Tiotropium Bromide 1 CAP IH DAILY
10. Furosemide 40 mg PO DAILY
11. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO Q4H:PRN
dyspepsia
12. Ascorbic Acid ___ mg PO BID
13. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Multivitamins 1 TAB PO DAILY
16. Tamsulosin 0.4 mg PO HS
17. Omeprazole 40 mg PO BID
18. Sodium Chloride 1 gm PO DAILY
19. Vitamin D ___ UNIT PO DAILY
20. Metoprolol Succinate XL 100 mg PO DAILY
21. Warfarin Dose is Unknown PO DAILY16
22. Lisinopril 20 mg PO DAILY
23. Milk of Magnesia 30 mL PO DAILY:PRN Constipation
24. Cyanocobalamin 100 mcg PO DAILY
25. Cholestyramine 4 gm PO DAILY
26. Magnesium Citrate Dose is Unknown PO DAILY:PRN Constipation
27. Fleet Enema ___AILY:PRN Constipation
28. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
29. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain, fever
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO Q4H:PRN
dyspepsia
3. Ascorbic Acid ___ mg PO BID
4. Atorvastatin 10 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 40 mg PO BID
10. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
11. Paroxetine 40 mg PO DAILY
12. Tamsulosin 0.4 mg PO HS
13. Tiotropium Bromide 1 CAP IH DAILY
14. Vitamin D ___ UNIT PO DAILY
15. ___ MD to order daily dose PO DAILY16
Please see attached warfarin dosing schedule for details.
16. Metoprolol Tartrate 50 mg PO BID
17. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
Please do not combine with albuterol inhaler.
18. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
Please do not combine with albuterol nebs.
19. Cyanocobalamin 100 mcg PO DAILY
20. FoLIC Acid 1 mg PO DAILY
21. Vancomycin Oral Liquid ___ mg PO Q6H
Continue until ___.
22. Vancomycin Oral Liquid ___ mg PO Q12H Duration: 7 Days
___ to ___
23. Vancomycin Oral Liquid ___ mg PO DAILY Duration: 7 Days
___ to ___
24. Vancomycin Oral Liquid ___ mg PO EVERY OTHER DAY Duration: 8
Days
___ to ___
25. Vancomycin Oral Liquid ___ mg PO EVERY 3 DAYS Duration: 15
Days
___ to ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Severe C. difficile colitis
Supratherapeutic INR
Acute on chronic macrocytic anemia
Atrial fibrillation with rapid ventricular response
Secondary:
Chronic diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with fever and hypotension, evaluate for
pneumonia.
COMPARISON: ___.
FINDINGS: A single portable AP upright view of the chest was obtained.
Cardiomediastinal silhouette is stable. There is increased hazy opacification
along the right cardiophrenic region. There is no pleural effusion or
pneumothorax. Upper zone redistribution, with mild vascular plethora. Old
fractures noted in the left ___ and ___ posteiror ribs.
IMPRESSION: Increased hazy opacification along the right heart border may
represent developing consolidation and should be clinically correlated.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Hypotension
Diagnosed with DIARRHEA
temperature: 98.3
heartrate: 122.0
resprate: 16.0
o2sat: 99.0
sbp: 84.0
dbp: 53.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ with history of recurrent C. difficile colitis,
atrial fibrillation on warfarin, chronic diastolic heart
failure, COPD not on supplemental oxygen, and recent admission
for COPD and healthcare associated pneumonia who presented from
rehabilitation with fever and loose stools in the setting of
initiation of azithromycin for possible pneumonia.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
heparin,porcine
Attending: ___.
Chief Complaint:
?GIB and NSTEMI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of CAD s/p CABG (LIMA - LAD, SVG - Diag and
PDA) in ___, severe aortic stenosis ___ 1.78, mean gradient
40), COPD (2L O2 at night at home), HITT, who is transferred
from ___ for GI bleed. Pt was admitted to ___
___ on ___ for weakness and COPD exacerbation. He was
treated with IV steroids, nebs, and supplemental O2. CTA neg for
PE. He desatted with ambulation yesterday, and continues on IV
solumedrol. During the hospitalization, he was noted to have an
NSTEMI with a peak troponin of 1.7, anticoagulated with
fondaparinux due to HITT, and he is chest pain free. He has not
had an echo or cath to evaluate this. Last Echo was ___ EF, diastolic dysfunction, with severe AS (gradient 40),
could not find valve area on report (will be sent).
Hemoglobin/HCT noted to be dropping (33.7 on admission, 27.1
today) while on anticoagulation. Guaiac positive, dark stool.
Not
on PPI. GI was consulted and recommended EGD, but required
cardiac clearance for EGD and thought he would need to be
intubated for EGD. Cards evaluated and recommeded transfer to
___ for complexity of issues and further evaluation of his
valve.
In the ED, initial VS were 99.1 77 132/77 18 93% 2L Nasal
Cannula.
Currently pt denies complaints, no bleeding currently. AAOx3.
Patient states breathing is near baseline. Has not chest pain
throughout entire admission.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
dysuria. Denies arthralgias or myalgias. Ten point review of
systems is otherwise negative.
Past Medical History:
1) Coronary Artery Disease, S/P. Coronary Artery Bypas
Grafting*3 grafts (LIMA - LAD, SVG - Diag and PDA) in ___
2) H/O. Complications of CABG (As per Cardiology note, confirm
what complications)
3) Chronic Obstructive Pulmonary Disease (Uses Home O2 therapy,
2 liters at night)
4) H/O. Alcohol Dependence
5) H/O. Depression (with suicidal ideation, S/P. inpatient
admissions in the past)
6) Hypercholesterolemia
7) H/O. Heparin-induced thrombocytopenia ___
8) Osteoarthritis
9) Severe Aortic Stenosis ___ 1.0, mean gradient 40)
Social History:
___
Family History:
Mother- MI at age ___
Father- COPD
Physical ___:
ADMISSION EXAM:
Vitals- 99.4, 144/79, 16, 96 on 2L NC
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Distant breath sounds, clear to auscultation bilaterally,
no wheezes, rales, ronchi
CV- Regular rate and rhythm, normal S1 + S2, ___ sytolic murmur
heard throughout the precordium
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, +splenomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
O: T 98.8 BP 130/68 HR 79 RR 18 O2 97 RA
General--Ill-appearing, NAD
HEENT--NCAT, sclera anicteric, conjunctiva noninjected, MMM.
Neck--Supple, no cervical LAD.
CV--RRR, III/VI cresendo-decresendo systolic mumur. No rubs or
gallops.
Lungs--Symmetrical expansion. Diminished breath sounds
throughout, with prolonged expiratory phase. Lungs CTA
Abdomen--NABS, nontender, nondistended.
GU--no foley in place
Extremities--(-)cyanosis (-)clubbing (-)edema.
MSK--In RUE, marked joint swelling + inability to fully extend
digits.
Skin--Spider angiomas on face and upper chest. Midline scar on
chest from CABG. Scar in RUQ of abdomen from PEG. Hypopigmented
scars on upper back from healed scratches, per pt. Depigmented
macules scattered throughout upper and lower extremities.
Neuro--AOx3, CN II-XII intact (except diminished hearing in R
ear). No gross motor/ sensory deficits.
Pertinent Results:
ADMISSION LABS
___ 12:18AM BLOOD WBC-15.6* RBC-3.58* Hgb-9.2* Hct-29.4*
MCV-82 MCH-25.6* MCHC-31.3 RDW-17.1* Plt ___
___ 06:20AM BLOOD Neuts-95.3* Lymphs-1.8* Monos-2.9 Eos-0.1
Baso-0
___ 07:10AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
___ 06:20AM BLOOD ___ PTT-23.6* ___
___ 06:20AM BLOOD Ret Aut-4.7*
___ 12:18AM BLOOD Glucose-183* UreaN-34* Creat-1.4* Na-133
K-4.6 Cl-96 HCO3-28 AnGap-14
___ 06:20AM BLOOD ALT-63* AST-44* LD(LDH)-262* CK(CPK)-45*
AlkPhos-85 TotBili-0.7
___ 06:20AM BLOOD CK-MB-4 cTropnT-0.05*
___ 12:18AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.1
___ 06:20AM BLOOD Hapto-191
___ 08:30AM BLOOD Type-ART pO2-79* pCO2-32* pH-7.53*
calTCO2-28 Base XS-4
___ 08:30AM BLOOD Lactate-1.9
PERTINENT LABS
___ 03:30PM BLOOD WBC-20.7*# RBC-3.52* Hgb-9.0* Hct-28.3*
MCV-81* MCH-25.7* MCHC-32.0 RDW-17.3* Plt ___
___ 07:35AM BLOOD WBC-8.4 RBC-3.58* Hgb-9.2* Hct-29.1*
MCV-81* MCH-25.6* MCHC-31.5 RDW-16.5* Plt ___
___ 06:20AM BLOOD Ret Aut-4.7*
___ 03:30PM BLOOD Glucose-131* UreaN-40* Creat-1.8* Na-133
K-5.1 Cl-94* HCO3-27 AnGap-17
___ 07:10AM BLOOD Glucose-117* UreaN-34* Creat-1.2 Na-134
K-4.6 Cl-95* HCO3-30 AnGap-14
___ 07:35AM BLOOD Glucose-100 UreaN-29* Creat-1.1 Na-136
K-4.7 Cl-97 HCO3-30 AnGap-14
___ 07:10AM BLOOD ALT-65* AST-38 AlkPhos-66 TotBili-0.6
___ 06:00AM BLOOD ALT-80* AST-40 AlkPhos-95 TotBili-0.6
___ 03:30PM BLOOD CK-MB-5 cTropnT-0.09*
___ 01:12AM BLOOD CK-MB-6 cTropnT-0.04*
___ 06:25AM BLOOD CK-MB-6 cTropnT-0.03*
___ 03:30PM BLOOD Calcium-8.4 Phos-5.7*# Mg-2.1
___ 07:35AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 06:00AM BLOOD HIV Ab-NEGATIVE
___ 09:15PM BLOOD Vanco-13.1
___ 07:35AM BLOOD Vanco-21.4*
___ 04:53AM BLOOD Vanco-25.0*
___ 07:35AM BLOOD HCV Ab-NEGATIVE
DISCHARGE LABS
___ 04:53AM BLOOD WBC-9.3 RBC-3.19* Hgb-8.1* Hct-25.0*
MCV-78* MCH-25.4* MCHC-32.5 RDW-17.0* Plt ___
___ 04:53AM BLOOD Glucose-85 UreaN-25* Creat-1.0 Na-133
K-3.8 Cl-98 HCO3-30 AnGap-9
___ 04:53AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.9
MICRO
___ Blood Culture, Routine (Final):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
___ 11:10 am BLOOD CULTURE **FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # ___-___ ___.
___ 7:26 pm URINE **FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
URINE CULTURE (Final ___: NO GROWTH.
___ 1:06 pm BLOOD CULTURE x2
___ 7:15 am BLOOD CULTURE
___ 7:15 am BLOOD CULTURE x2
___ 9:30 am SPUTUM - extensive contamination with upper
respiratory secretions. Bacterial culture results are invalid
___ 5:51 am BLOOD CULTURE
PERTINENT IMAGING
___ Portable TTE
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is moderate symmetric left ventricular
hypertrophy. Left ventricular systolic function is hyperdynamic
(EF 75%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The aortic valve is not well seen. There is severe aortic
valve stenosis (valve area 1.0 cm2). Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
___ CHEST (PORTABLE AP)
IMPRESSION: No focal consolidation to suggest pneumonia. Mild
right basilar atelectasis.
___ ABDOMEN US (COMPLETE STUDY)
IMPRESSION: No evidence of thrombosis. No focal hepatic lesions
identified. Splenomegaly. Aorta is enlarged measuring 6.9 cm,
consistent with prior history of AAA repair.
___ CHEST (PORTABLE AP)
IMPRESSION: Probable bibasilar atelectasis. An early infiltrate
at the left base is considered less likely, but remains in the
differential. Attention to opacity at the left base is
recommended to confirm resolution. Compared with ___, the
overall appearance is similar, except for slight clearing of
changes at the right base.
___ CTA ABD & PELVIS
IMPRESSION: Hyperdense material in the AAA sac not present on
the non-contrast scan is compatible with an endoleak. A small
feeding lumbar artery is seen suggestive of a type 2 endoleak.
The size of the AAA sac is 7.4 cm x 7.9 cm. Please compare with
prior imaging to assess for stability of the excluded AAA.
Patent left aortoiliac bypass graft. There is evidence of
stenosis at the origin of the celiac trunk and SMA with
immediate reconstitution of flow. The fem-fem bypass graft is
patent with flow seen in both SFA and deep femoral arteries.
There is occlusion of the origin right common iliac artery with
reconstitution of flow before the bifurcation likely from reflux
from the fem-fem bypass graft. No fluid collection or evidence
of abdominal or pelvic source of infection. Cholelithiasis
without evidence of cholecystitis. Mild splenomegaly.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO BID
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Metoprolol Tartrate 50 mg PO BID
5. Gabapentin 900 mg PO QID
6. Albuterol-Ipratropium 2 PUFF IH Q6H:PRN wheeze, SOB
7. Rosuvastatin Calcium 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO BID
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Gabapentin 600 mg PO Q8H
5. Metoprolol Tartrate 50 mg PO BID
6. Rosuvastatin Calcium 40 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN fever, pain
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, SOB
9. Docusate Sodium 100 mg PO BID
10. Ipratropium Bromide Neb 1 NEB IH Q6H
11. Nicotine Patch 14 mg TD DAILY
12. Pantoprazole 40 mg PO Q24H
13. PredniSONE 40 mg PO DAILY
14. Senna 1 TAB PO BID:PRN constipation
15. Sodium Chloride Nasal ___ SPRY NU PRN while on O2
16. Vancomycin 750 mg IV Q 12H
17. Albuterol-Ipratropium 2 PUFF IH Q6H wheeze, SOB
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
MRSA bacteremia
COPD exacerbation
SECONDARY DIAGNOSES:
Aortic Stenosis - Severe, ___ 1.0cm2
Cirrhosis - Child's class A
Grade II aortic endoleak
thrombocytopenia - possible history of HITT but unknown
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Patient with acute COPD exacerbation, now with fevers and worsening
shortness of breath, rule out infection.
COMPARISON: None available.
FINDINGS: Portable single frontal chest radiograph was obtained.
There is mild atelectasis at the right lung base. No focal consolidation,
pleural effusion, pneumothorax, or pulmonary edema is seen. The heart size is
normal. Mediastinal and hilar contours are within normal limits. Median
sternotomy wires and closure devices are intact.
IMPRESSION: No focal consolidation to suggest pneumonia. Mild right basilar
atelectasis.
Radiology Report
HISTORY: Status post CABG, severe aortic stenosis, COPD, HITT from moderate to
heavy alcohol use transferred from outside hospital for suspected GI bleed,
found to have mild transaminitis. Evaluate for cirrhosis, splenomegaly.
COMPARISON: None available.
FINDINGS:
The liver demonstrates normal echotexture. There is no focal lesions
identified. Multiple gallstones are seen within the bladder however there is
no evidence of acute cholecystitis. CBD measures 5 mm. Visualized portions of
pancreas are within normal limits. The left kidney measures 12.3 cm. The
right kidney measures 11.3 cm. A 6 mm cyst is seen in the right kidney.
Otherwise, no masses or hydronephrosis is seen. Visualized images of the
bladder are within normal limits. The spleen is enlarged measuring 16.7 cm.
The aorta is enlarged measuring 6.9 cm, consistent with prior history of AAA
repair.
Color doppler and spectral waveform analysis was performed. The right, middle
and left hepatic veins are patent. The main and left portal veins are patent.
The anterior and posterior segments of the right portal vein are patent. The
IVC is within normal limits.
IMPRESSION:
1. No evidence of thrombosis.
2. No focal hepatic lesions identified.
3. Splenomegaly.
4. Aorta is enlarged measuring 6.9 cm, consistent with prior history of AAA
repair.
Radiology Report
HISTORY: Hypoxia, probable MRSA pneumonia.
___.
CHEST, SINGLE AP VIEW.
Slightly rotated positioning. The patient is status post sternotomy. Mild
cardiomegaly is similar to the prior film. Right paratracheal soft tissues
are consistent with vascular ectasia in someone of this age. There is
borderline upper zone redistribution, but no overt CHF. There is some patchy
opacity at left greater than right lung bases. Findings on the left are
similar to the prior film. No other focal infiltrate is identified. No
gross effusion.
IMPRESSION:
1) Probable bibasilar atelectasis. An early infiltrate at the left base is
considered less likely, but remains in the differential. Attention to opacity
at the left base is recommended to confirm resolution.
2) Compared with ___, the overall appearance is similar, except for slight
clearing of changes at the right base.
Radiology Report
HISTORY: Patient with new right PICC line, eval placement.
COMPARISON: ___.
FINDINGS: Portable single frontal chest radiograph was obtained.
A right PICC line terminates in the mid SVC. There is no evidence of
pneumothorax or other complications. There is persistent left basilar
opacity, unchanged from prior study. The heart size is normal. Mediastinal
and hilar contours are stable. There is no pleural effusion.
IMPRESSION:
1. Right PICC line terminates in the mid SVC without complication.
2. Persistent left basilar opacity likely reflective of basilar atelectasis.
Findings were communicated with ___, IV nurse, ___ at time of
observation at 2:47 p.m. on ___.
Radiology Report
INDICATION: History of MRSA bacteremia and known abdominal aortic and femoral
grafts. Please assess for graft infection or fluid or abscess.
COMPARISONS: None.
TECHNIQUE: ___ MDCT images were obtained through the abdomen and pelvis after
the administration of IV contrast. Multiplanar reformatted images in coronal
and sagittal axis were generated and reviewed.
FINDINGS: The bases of the lungs are clear. Note is made of mild atelectasis
at the right middle lobe. Note is made of thinning of the left ventricular
apex.
The liver is normal without evidence of focal lesions or intrahepatic biliary
ductal dilatation. The gallbladder is normal without evidence of
cholecystitis; however, note is made of cholelithiasis within the body of the
gallbladder. The portal vein is patent. The adrenal glands bilaterally are
unremarkable. The kidneys bilaterally enhance symmetrically without evidence
of focal solid lesions. There is a hypodense lesion in the mid pole of the
right kidney measuring 0.9 cm (series 3, image 66) too small to characterize
by CT, however, likely secondary to a simple renal cyst. The spleen enhances
homogenously, however, measures 16 cm and is mildly enlarged. The pancreas is
normal without evidence of focal lesions or peripancreatic stranding.
The stomach, duodenum and small bowel are normal without evidence of wall
thickening or obstruction. Colon is normal. The appendix is visualized and
is unremarkable. There is no mesenteric or retroperitoneal lymphadenopathy.
There is no free fluid or free air within the abdomen.
CT PELVIS: The urinary bladder is normal. The prostate and seminal vesicles
are unremarkable. There is no pelvic wall or inguinal lymphadenopathy. Note
is made of a dense structure anterior to the rectum, likely a phlebolith.
There is no pelvic free fluid.
CTA: There is a AAA sac measuring 7.4 cm x 7.9 cm (series 3, image 83).
Hyperdense material in the AAA sac not present on the non-contrast scan is
compatible with an endoleak. A small feeding lumbar artery is seen suggesting
a type 2 endoleak, best seen on series 3, image 56.
There appears to be marked stenosis to occlusion of the celiac trunk and
origin of the SMA with evidence of reconstitution of flow. The renal arteries
bilaterally are patent. The fem-fem bypass graft is patent with flow seen in
both superficial and deep femoral arteries. The origin of the right common
iliac artery is occluded with retrograde filling likely from the fem-fem
bypass. The left aortoiliac bypass graft also appears to be patent. There
appears to be an occluded left, calcified vessel parallel to the aorto-iliac
graft, which could be an occluded left internal iliac artery, or the native
common iliac artery. There is no fluid collection or evidence of abdominal or
pelvic source of infection.
OSSEOUS STRUCTURES: No lytic or blastic lesions concerning for malignancy are
identified.
IMPRESSION:
1. Hyperdense material in the AAA sac not present on the non-contrast scan is
compatible with an endoleak. A small feeding lumbar artery is seen suggestive
of a type 2 endoleak. The size of the AAA sac is 7.4 cm x 7.9 cm. Please
compare with prior imaging to assess for stability of the excluded AAA.
2. Patent left aortoiliac bypass graft. There is evidence of stenosis at the
origin of the celiac trunk and SMA with immediate reconstitution of flow. The
fem-fem bypass graft is patent with flow seen in both SFA and deep femoral
arteries.
3. There is occlusion of the origin right common iliac artery with
reconstitution of flow before the bifurcation likely from reflux from the
fem-fem bypass graft.
4. No fluid collection or evidence of abdominal or pelvic source of
infection.
5. Cholelithiasis without evidence of cholecystitis.
6. Mild splenomegaly.
These findings were discussed with Dr. ___ by Dr. ___ on ___ at
7:20 p.m. immediately after discovery via telephone.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI BLEED
Diagnosed with AORTIC VALVE DISORDER
temperature: 99.1
heartrate: 77.0
resprate: 18.0
o2sat: 93.0
sbp: 132.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | ___ with history of CAD, AS, COPD, transferred from Brokton s/p
COPD exacerbation and NSTEMI for ?GI bleed. Course complicated
by respiratory distress, found to have MRSA bacteremia,
cirrhosis, and severe aortic stenosis.
# MRSA Bacteremia: Found to be bacteremic during trigger for
respiratory distress with fevers and confusion. Treated
empirically with vanc/zosyn/azithro prior to culture data coming
back. Cultures +MRSA. Continued broad spectrum abx for ?PNA.
TTE was negative for vegetations but showed hyperdynamic LV w/
EF >75% and an LV dependent on atrial kick for filling. Concern
for seeding as pt has endovascular graft and severe AS (1.0cm2).
Consulted ID who felt that only vanc was indicated, so d/c'ed
zosyn and azithro. ID not concerned for potential endocarditits
and did not recommend TEE given that he would need to be treated
for 6 weeks anyway with the graft. First negative blood culture
was on ___ and 6 week abx course will start on that day.
Last (+)Bcx ___, pt likely no longer bacteremic, but unable to
rule out localized seeding (aortic valve, endovascular graft)
though CT abdomen/pelvis suggested no graft infection or fluid
collection. At the time of discharge pt had elevated vanc trough
on 1g vanc Q12 and dose was adjusted to 750mg q12. Pt needs ___
clinic follow up and ___ clinic is scheduling this. He needs
weekly CBC and chemistry faxed to the ___ clinic as noted below
under "transitional".
# COPD exacerbation: Pt has known O2 dependent COPD with recent
hx of hospitalizations for SOB/DOE. Pt has improved clinically
and reports that breathing has improved, (-)DOE. He appears to
be at baseline at the time of discharge. HE was treated with
prednisone at ___, which was being tapered on arrival to
___. Here he was given prednisone 60mg daily and started 40mg
daily on ___. He is being discharged on a prednisone taper. He
should take 40mg prednisone ___, 30mg prednisone daily
___, 20mg prednisone ___, and 10mg prednisone daily ___-
___, then stop. He should continue Q6prn albuterol and
ipratropium as well as fluticasone.
# Child's A Cirrhosis: Splenomegaly, mildly elevated AST, ALT,
and spider angiomas on exam suggest early liver disease. We have
discussed pt's cirrhosis with him. Hep B(-) Hep C(-) HIV(-).
LFTs were trending up at the time of discharge (both in the ___
with normal alk phos and TBili. This needs to be followed and
rechecked at ECF.
# Depression: Pt has hx of depression (+)SI in the past. Has
felt overwhelmed during this hospitalization, but reports
improvement in mood, denies SI today. Pt would likely benefit
from outpatient psych f/u, but expresses concerns with insurance
coverage for services. Continued bupropion 150 mg PO BID.
# Endoleak on CTA: Pt will require intervention in the future.
CTA abdomen/pelvis showed type II endoleak and ___ vascular
surgery was consulted who felt pt would need coiling. An
appointment was made for pt to follow up wiht his primary
vascular surgeon at ___ as noted below.
# Severe AS: ___ echo confirmed severe AS (1.0cm2). Per his TTE
his ouptut was completely dependent on his atrial kick, so his
metoprolol was kept at 50mg BID. He has follow up arranged to
see one of our cardiology interventionalists at ___ for
consideration of percutaneous valve, as below.
# Thrombocytopenia: Pt's platelets nadired in the 90 range and
stabilized in the . Initial drop in platlets may be attributabe
to PPIs vs. sepsis. Of note, splenomegaly in hospitalized
alcoholics often results in chronic thrombocytopenia.
# Anemia: Hct stable, no evidence of GI bleed. Anemia likely ___
chronic inflammation, as pt may have been bacteremic for several
days to weeks before diagnosis. Pt was also discharged on PO
pantoprazole as there had been concern for GI bleed, but also
because he was on steroids and aspirin as well. His pantoprazole
can ideally be tapered in the distant future when off steroids
and comorbidities have stabilized.
# ___: Creatinine elevated on arrival to ___, likely ___
hypotension and subsequent prerenal failure in setting of MRSA
bacteremia/sepsis. Resolved with treatment of bacteremia and
fluid resuscitation.
# CAD: On arrival to ___ his troponin T was 1.72.
He was started on ___ given questionable history of
HITT though we have no clear documentation that any HITT studies
were ever positive; this may have been clinical suspicion given
thrombocytopenia in setting of unrecognized cirrhosis and
splenomegaly, but given concerns heparin was avoided during this
hospitalization. He had been cathed recently in ___ so was not
re-cathed, it was felt this represented demand ischemia.
# Neuropathy - given his ___, his home 900mg TID gabapentin was
downtitrated to 600mg TID. THis can be uptitrated again as
needed if renal function remains stable.
# Insomnia: Pt able to sleep relatively well without zolpidem.
Pt does not like zolpidem as it causes confusion so this
medication was DCd. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with type I DM diagnosed age ___, presented
with nausea and hyperglycemia. She had discontinued her insulin
pump this ___ because the pump was disconnecting with
activity. She transitioned herself to basal bolus regimen, but
has been having trouble staying with her schedule since college
began a few weeks ago. She has been having epigastric pressure
the past two weeks, and this morning had nausea, headache, and
fatigue with decreased appetite and increased abd pressure. She
noticed her BS 400's at home and went to the ED. Had nonbloody
emesis en route to ED. She denies fever, cough, sore throat. She
denies chest pain, SOB, or chest pressure. Denies diarrhea.
Denies dysuria, frequency, or urgency. No vaginal dc, LMP two
months ago, no oral contraceptive in past year, irregular menses
since then.
In the ED initial VS were: 98.9 122 ___ 97%
Remained afebrile, remained tachycardic, abdomen soft.
Initial K 4.6, AG 32, HCO3 12, BG 444.
ALT 103, AST 99, Alk Ph 200, T Bili 0.2, Alb 4.4, Lipase 28.
UA with glucose 1000, ketones 150, 8WBC, few bact, trace ___, 2
epi UCG -ve
WBC 6.4, H/H 15.3/46.7, MCV 101, platelets 444
RUQ US-> hepatomeg, no gallstone, no acute process
Given 40 IV K, 10U insulin, started on insulin gtt, given 2.5L
NS before transfer and 1gm cefriaxone.
Repeat K Glucose fell to 161 on insulin gtt, D5W started,
insulin gtt stopped.
On arrival to the MICU, she feels like her normal self, except
with some epigastric discomfort. She does not feel short of
breath.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies diarrhea,
constipation, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Type I DM, diagnosed age ___, only prior episode DKA at ___
secondary to EtOH use
Social History:
___
Family History:
Family History:
Cousin and grandfather with T1DM, father had gallbladder removed
Physical Exam:
Vitals: T:98.9 BP: 128/109 P: 115 R: 33 O2:97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils
round/reactive
Neck: supple, no LAD
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: No accessory muscle use, good air movement, bibasilar
crackles, no wheezes, rales, ronchi
Abdomen: Soft, some epigastric tenderness to deep palpation,
non-distended, hypoactive bowel sounds, no organomegaly.
Ext: warm, well perfused, 2+ pulses bilaterally, no clubbing,
cyanosis or edema
Neuro: ___ strength upper/lower extremities, grossly normal
sensation
Pertinent Results:
___ 05:27PM BLOOD WBC-6.4 RBC-4.64 Hgb-15.3 Hct-46.7
MCV-101* MCH-33.0* MCHC-32.9 RDW-13.0 Plt ___
___ 05:27PM BLOOD Neuts-51.8 Lymphs-43.3* Monos-3.1 Eos-0.7
Baso-1.0
___ 08:22PM BLOOD ___ PTT-27.3 ___
___ 05:27PM BLOOD Glucose-520* UreaN-12 Creat-0.9 Na-135
K-4.6 Cl-91* HCO3-12* AnGap-37*
___ 05:27PM BLOOD ALT-103* AST-99* AlkPhos-200* TotBili-0.2
___ 05:27PM BLOOD Lipase-28
___ 05:27PM BLOOD Albumin-4.4
___ 10:43PM BLOOD ___ Temp-36.9 pO2-34* pCO2-33*
pH-7.17* calTCO2-13* Base XS--16
___ 07:49PM BLOOD Lactate-2.3* K-3.6
___ 05:50PM URINE Color-Straw Appear-Clear Sp ___
___ 05:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
___ 05:50PM URINE RBC-<1 WBC-8* Bacteri-FEW Yeast-NONE
Epi-2
___ 05:50PM URINE UCG-NEGATIVE
Radiology Report
INDICATION: Evaluation of patient with vomiting and abnormal LFTs.
COMPARISON: None available.
FINDINGS: The liver is enlarged, but the echotexture is normal. There are no
focal liver lesions. There is no intra- or extra-hepatic biliary dilatation
with the common bile duct measuring 2 mm. The portal vein is patent with
hepatopetal flow. Imaged intrahepatic IVC is unremarkable. The gallbladder is
normal with no evidence of gallstones. The visualized spleen is normal
measuring 10.9 cm. The pancreas and aorta are not clearly visualized due to
overlying bowel gas. The right kidney measures 12.0 cm and the left kidney
measures 13.5 cm. Bilateral kidneys are normal with no evidence of
hydronephrosis or stones.
IMPRESSION: Hepatomegaly. No focal hepatic lesions. Normal gallbladder with
no gallstones.
Radiology Report
HISTORY: Elevated blood sugars.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: None.
FINDINGS:
The cardiac, mediastinal and hilar contours are normal. The lungs are clear
and the pulmonary vascularity is normal. No pleural effusion or pneumothorax
is present. There is marked gaseous distention of the stomach. No acute
osseous abnormality is seen.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HYPERGLYCEMIA/N/V
Diagnosed with DIAB KETOACIDOSIS IDDM
temperature: 98.4
heartrate: 120.0
resprate: 18.0
o2sat: 97.0
sbp: 138.0
dbp: 95.0
level of pain: 6
level of acuity: 3.0 | ___ yo F type I DM presenting with DKA.
MICU Course:
# DKA: Secondary to noncompliance. Not pregnant with neg HCG,
CXR clear for PNA, EKG unconcerning for MI, denies drug use. K
not sig elevated, anion gap closed with insulin bolus and gtt.
Sugars dropped swiftly prior to transfer to MICU, 444->141, gtt
was paused, sugars returned to 300's after gtt was restarted,
remained on ICU insulin protocol thereafter, pH 7.17.
Transitioned to SQ insulin with overlap 2hrs on gtt. Maintained
on ___ with 40mEq K at 125/hr. ___ consulted and
recommended Lantus 27, HISS 5 units breakfast, 4 before lunch, 7
before dinner, correct 1:40 above 120, self reported carb
consumption 40g with breakfast, 30 with lunch, 60 with dinner.
Following transition to diabetic PO diet the patient's anion gap
was noted to remain closed and the patient was without
complaints.
# ?UTI: Patient with 7WBC on initial UA, received dose of
Ceftriaxone. Patient was asymptomatic and urine culture was
negative. No plan for further antibiotics. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Bactrim / Nafcillin / Lisinopril / difficult intubation requires
LMA
Attending: ___.
Chief Complaint:
Right hand pain and discoloration
Major Surgical or Invasive Procedure:
___: EGD
History of Present Illness:
___ w/ h/o CAD s/p CABG x4, multiple cardiac stents, ESRD on PD,
DM2, and LLE osteo who presents with painful R fingers for past
week. She noticed "pins and needles" sensation in her right ___
digits since last ___. A few days later, she noticed color
changes to her fingers, up to dark purple hue. She saw her PCP
today, who referred her to a vascular surgeon, who recommended
she come to the ED for further evaluation. She has not had any
other symptoms, denies fevers, chills, nausea, vomiting, chest
pain, or shortness of breath. Her left had has not had any
symptoms. She denies specifically a history of atrial
fibrillation, and she is a non-smoker.
Past Medical History:
PMH: CAD s/p CABG and multiple cath/stents, DM2 c/b retinopathy
and neuropathy, HTN, HL, dCHF, ESRD on PD, obesity, LLE charcot
ankle c/b osteomyelitis ___ s/p debridement, dieulafoy's lesion
c/b massive GI bleed
PSH: CABG x5v ___, PD catheter placement
Social History:
___
Family History:
significant for CAD
Physical Exam:
Vitals: 98.0, 73, 101/59, 18, 100 3LNC
Gen: NAD, AOx3
CV: RRR, no murmurs
Pulm: CTAB, unlabored
Abd: soft, nontender, nondistended
Ext: WWP lower extremities, minimal edema. faintly palpable
radial pulses in bilateral upper extremity, RUE: ___ digit with
distal ischemia, ___ - ___ digit w/ light purple discoloration
and slow capillary refill, tender to palpation, dopplerable arch
signals
Pertinent Results:
___ 06:40AM BLOOD WBC-13.2* RBC-2.57* Hgb-8.3* Hct-27.1*
MCV-106* MCH-32.2* MCHC-30.5* RDW-16.6* Plt ___
___ 06:40AM BLOOD ___ PTT-35.1 ___
___ 06:40AM BLOOD Glucose-144* UreaN-55* Creat-11.1* Na-135
K-4.0 Cl-89* HCO3-27 AnGap-23*
___ 06:00AM BLOOD ALT-16 AST-15 AlkPhos-95 TotBili-0.3
___ 06:40AM BLOOD Calcium-9.4 Phos-8.6* Mg-2.1
Medications on Admission:
crestor 40', epogen 2000unit/mL, Humalog SSI, Lantus 12u qam 36u
qpm, renal caps', renvela 800 w/ meals TID, zetia 10', ASA 325',
ferrous gluconate 324mg', gabapentin 100'', gentamicin topical
cream to PD site, lorazepam 1' prn, metoclopramide 5'''',
midodrine 10'', omeprazole 20', sertraline 100'
Discharge Medications:
1. Rosuvastatin Calcium 40 mg PO DAILY
2. Nephrocaps 1 CAP PO DAILY
3. sevelamer CARBONATE 2400 mg PO TID W/MEALS
4. Ezetimibe 10 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Ferrous GLUCONATE 324 mg PO DAILY
7. Gabapentin 100 mg PO BID
8. Lorazepam 1 mg PO DAILY:PRN anxiety
9. Nystatin Cream 1 Appl TP BID
10. Omeprazole 40 mg PO DAILY
11. Metoclopramide 5 mg PO QIDACHS
12. Midodrine 10 mg PO BID
13. Sertraline 100 mg PO DAILY
14. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q4HRS
Disp #*80 Tablet Refills:*0
15. Warfarin 2 mg PO DAILY16
Please start this dose on ___. Follow INR closely while on
coumadin and adjust dose as needed
RX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth Daily Disp
#*20 Tablet Refills:*0
16. Senna 1 TAB PO BID:PRN constipation
17. Docusate Sodium 100 mg PO BID
18. Glargine 12 Units Breakfast
Glargine 36 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
19. Glucose Gel 15 g PO PRN hypoglycemia protocol
20. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Discharge Disposition:
Home
Discharge Diagnosis:
Right hand ischemia
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: Question of emboli to right digits, associated ischemia, evaluate
for embolic source.
TECHNIQUE: MDCT images were obtained through the right upper extremity before
and following the administration of IV contrast. Coronal and sagittal MIP
reconstructions were performed.
COMPARISON: None available.
FINDINGS:
Mild atherosclerotic disease is seen within the aortic arch. The proximal left
subclavian and both common carotid arteries are patent with mild
atherosclerotic calcification seen at the carotid bifurcations.
The right brachiocephalic artery, subclavian, axillary, and brachial arteries
are widely patent without stenosis or thrombus. Minimal calcified
atherosclerosis of the proximal and mid right subclavian artery as well as
scattered minimal calcified atherosclerotic disease of the right brachial
artery is seen. Diffuse and extensive atherosclerotic calcifications of the
radial, ulnar, superficial and deep palmar arches, and digital branches are
present. The radial and ulnar artery appear patent to the level of the wrist
without high grade stenosis or occlusion, though there is multifocal moderate
to severe stenosis within the distal ulnar artery. The interosseous artery is
also patent. Assessment for arterial patency beyond the level of the wrist
cannot be clearly made given the extensive atherosclerotic calcifications of
the arteries within the hand and the small caliber of these vessels.
There is no acute bone abnormality. The musculature and soft tissues are
intact.
IMPRESSION:
1. Patent flow from the aortic arch, right brachiocephalic artery to the
radial and ulnar arteries at the level of the wrist, without occlusion or high
grade stenosis. Multifocal moderate to severe narrowing of the distal ulnar
artery.
2. Assessment of patency of the arteries distal to the wrist within the hand
is markedly limited due to extensive atherosclerotic calcifications and the
small caliber of these arteries. MRA of the hand should be considered for
further assessment.
Radiology Report
HISTORY: History of congestive heart failure with possible digit cortical
ischemia.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest radiograph ___. Chest CTA ___ at 18:25.
FINDINGS:
The patient is status post median sternotomy and CABG. Lung volumes are
reduced compared to the prior chest radiograph. Heart size is mildly
enlarged. Aortic knob is calcified. There is crowding of the bronchovascular
structures with possible mild pulmonary vascular congestion. Consolidative
opacity in the left lower lobe with associated small left pleural effusion is
re- demonstrated. No pneumothorax is identified. There are no acute osseous
abnormalities.
IMPRESSION:
Left lower lobe consolidative opacity may reflect pneumonia or rounded
atelectasis with adjacent small pleural effusion, as seen on the recent chest
CT. There was a suggestion of possible pleural enhancement on the chest CT, a
finding which can be seen with empyema, and clinical correlation is
recommended.
Radiology Report
HISTORY: Ischemia or right digits, evaluate for embolic source.
TECHNIQUE: MDCT images were obtained through the chest following
administration of IV contrast. Coronal and sagittal reformations are
performed. Right and left MIP reconstructions were performed.
COMPARISON: CT chest on ___.
FINDINGS:
The partially visualized thyroid is unremarkable. There is no axillary or
hilar lymphadenopathy. There are prominent mediastinal lymph nodes, similar
to prior study. There is no filling defect in the pulmonary arteries to the
subsegmental level. The aorta opacifies normally, and is normal in caliber.
There is no evidence of aortic dissection or aneurysm. The origins of the
vessels at the aortic arch are unremarkable. There are mild aortic arch
atherosclerotic calcifications. There is moderate cardiomegaly. There are
calcifications of the native coronary arteries and a circumflex artery stent.
There is a left lower lobe consolidative opacity which may represent pneumonia
or rounded atelectasis. There is a small left pleural effusion with
suggestion of pleural enhancement and a split pleural sign which can be seen
in empyema. Mild right lower lobe atelectasis is present. No pneumothorax.
Within the upper abdomen, perihepatic and perisplenic ascites is noted.
Vertebral heights are preserved. No acute bony abnormality. Sternotomy wires
are seen in place.
IMPRESSION:
1. Widely patent thoracic aorta. No evidence of thoracic aortic aneurysm or
dissection. The origins of the great vessels arising from the aortic arch are
patent. There are mild aortic arch atherosclerotic calcifications.
2. Left lower lobe consolidative opacity may represent pneumonia or perhaps
rounded atelectasis. Small left pleural effusion with suggestion of split
pleural sign can be seen in empyema and clinical correlation is recommended.
3. Ascites noted in the upper abdomen.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R HAND PAIN
Diagnosed with CIRCULATORY DISEASE NEC, CYANOSIS, DIAB RENAL MANIF ADULT, END STAGE RENAL DISEASE, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 97.7
heartrate: 74.0
resprate: 16.0
o2sat: 99.0
sbp: 145.0
dbp: 76.0
level of pain: 10
level of acuity: 2.0 | Patient was admitted to the vascular surgery service on ___
with pain and discoloration of her right ___ digit. A CTA was
obtained which was significant for:
Patent flow from the aortic arch, right brachiocephalic artery
to the
radial and ulnar arteries at the level of the wrist, without
occlusion or high
grade stenosis. Multifocal moderate to severe narrowing of the
distal ulnar
artery. Assessment of patency of the arteries distal to the
wrist within the hand
is markedly limited due to extensive atherosclerotic
calcifications and the
small caliber of these arteries.
Due to concern for arterial embolic disease, she was started on
a heparin drip. Because she had a history of GI bleed ___
dieulafoy's lesion, a GI consult was obtained to determine risk
of anticoagulation. On ___, she was started on coumadin, 5 mg,
and also received 5 mg on ___. She was started on high dose
omeprazole, and on ___, GI performed an EGD. They did not see
any bleeding or nidus for bleed, however, they were unable to
perform a full evaluation ___ food in the stomach. GI
determined that the area of her previous bleed appeared stable,
and she would be safe to anticoagulate with a goal INR of
2.0-3.0 while on omeprazole 40 mg daily. She was deemed
appropriate for discharge on ___, and will follow up with Dr.
___ INR and coumadin dosing. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
___ year old male with Left L3-L4 disc herniation and
radiculopathy
Major Surgical or Invasive Procedure:
Left L3-L4 microdiscectomy by Dr. ___ on ___
History of Present Illness:
___ year old male with Left L3-L4 disc herniation and
radicalopathy
Past Medical History:
HTN
Social History:
___
Family History:
non-contributory
Physical Exam:
General: NAD, A&Ox4
nl resp effort
Sensory:
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT diminished SILT SILT SILT SILT
Motor:
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Pertinent Results:
___ 06:15AM WBC-8.1 RBC-5.18 HGB-15.7 HCT-46.9 MCV-91
MCH-30.3 MCHC-33.5 RDW-12.2 RDWSD-40.4
___ 06:15AM NEUTS-51.7 ___ MONOS-13.0 EOS-5.1
BASOS-0.4 IM ___ AbsNeut-4.19 AbsLymp-2.38 AbsMono-1.05*
AbsEos-0.41 AbsBaso-0.03
Medications on Admission:
Losartan Potassium 100 mg PO DAILY
Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*1
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*36 Tablet Refills:*0
3. Losartan Potassium 100 mg PO DAILY
4. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left L3-L4 dics herniation with radiculopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: L3-L4 microdiskectomy.
COMPARISON: MRI from ___ l
IMPRESSION:
Lateral views of the lumbar spine from the operating room demonstrate
posterior markers at the level of the L2/L3 disc level on the first image and
at the L3/L4 this level on the second image. Please refer to the operative
note for additional details. There are multilevel mild degenerative disc
disease with loss disc height.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with L4 spinal compression.// Pre-op
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
Lungs are well inflated and clear. No pleural abnormality. Heart size is
normal. Apparent mediastinal widening with convexity of the right mediastinal
contour is likely secondary to aortic tortuosity.
IMPRESSION:
No acute cardiopulmonary abnormality. Apparent mediastinal widening with
convexity of the right knee mediastinal contour is likely due to aortic
tortuosity which is not well assessed on this frontal only view. If
indicated, dedicated frontal and lateral radiographs may be obtained for
better evaluation as aortic dilatation cannot be excluded.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Lower back pain, Transfer
Diagnosed with Lumbosacral root disorders, not elsewhere classified, Low back pain, Chest pain, unspecified
temperature: 99.0
heartrate: 81.0
resprate: 16.0
o2sat: 93.0
sbp: 140.0
dbp: 91.0
level of pain: 0
level of acuity: 2.0 | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was 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 IV and PO pain medications. Diet was
advanced as tolerated. The patient was transitioned to oral
pain medication when tolerating PO diet. Foley was removed
postoperatively without issue. 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: M
Service: NEUROLOGY
Allergies:
Bactrim / Iodine / Cephalosporins / bee pollen
Attending: ___.
Chief Complaint:
Right facial droop, Right extremity weakness and numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH significant for a hypothalamic hamartoma (Dx
___, last MR at ___ ___ stable in size at 20mm x 17mm)
and
gelastic epilepsy who noted several minutes of right-sided
facial
twitching around noon that resolved, and then around 5pm
developed R facial droop and numbness as well as RUE and RLE
weakness and numbness while at grocery store with his wife. Wife
drove him to ___ where a ___ showed his
known hypothalamic lesion and was felt to possibly be larger
(unclear what comparison was) and was transferred to ___ for
further care. The patient states that his symptoms began to
resolve while in the ambulance from ___ on the way to ___, and
currently has regained facial muscle control and much of his RUE
and RLE motor function but still has some weakness and ongoing
numbness.
Past Medical History:
hypothalamic hamartoma (Dx ___ at ___ by Dr. ___,
gelastic siezures (occur most days, triggered by humor and
laughing), migraines
stereotactic biopsy (___),
stereotactic depth electrode insertion (___)
Social History:
___
Family History:
No family history of seizures
Physical Exam:
Exam on Admit
O: T 98.0 HR 67 BP 107/65 RR 17 SPO2 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4->2 b/l EOMs intact b/l
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.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: LUE and LLE ___ throughout. RUE ___ deltoid, ___ biceps,
___ WE, ___ grip, ___ WF, ___ triceps. RLE ___ hip flexor, ___
quad, ___ tib ant, ___ plantar flex, ___ ham.
Mild Right pronator drift
Sensation: Intact to light touch but complains of "wierd"
sensation in face on touch
Coordination: slightly slowere on right on finger-nose-finger
and
heel to shin although not dysmetric
Handedness: Right
###########################################
Discharge Exam:
T 97.4-98.5, BP 102-130/64-88, HR 64-79, RR ___, O2 97-100% on
RA
Gen- Awake, alert
Pulm- Breathing comfortably
Extr- No swelling, no rashes, tattoos present
Neuro- Awake, relates history well, no paraphasic errors. Face
activates symmetrically, tongue movement full, VFFC, EOMI. Full
strength bilat bi/tri/TA/gastroc. No pronator drift, no
orbiting.
Pertinent Results:
___ 09:30PM BLOOD WBC-10.1# RBC-5.43 Hgb-15.7 Hct-42.6
MCV-79* MCH-28.8 MCHC-36.8* RDW-13.4 Plt ___
___ 09:30PM BLOOD Glucose-93 UreaN-16 Creat-1.2 Na-140
K-3.9 Cl-105 HCO3-25 AnGap-14
___ 09:30PM BLOOD ALT-52* AST-28 AlkPhos-88 TotBili-0.4
___ 09:30PM BLOOD Albumin-4.8
MRI/MRA BRAIN ___ 15:42PM)
1. Study is degraded by motion.
2. No significant interval change in left hypothalamus mass
lesion as
described above.
3. Unremarkable MRA of the head and neck.
Extended routine EEG- No epileptiform activity or seizures.
Medications on Admission:
Topamax 50 BID
Multivitamin daily
Propanolol 20 mg BID
Amitriptyline 20 qHS
Ibuprofen PRN
Discharge Medications:
1. Propranolol 20 mg PO/NG BID
2. Topiramate (Topamax) 50 mg PO BID
3. Amitriptyline 50 mg PO QHS
RX *amitriptyline 50 mg 1 tablet(s) by mouth at bedtime Disp
#*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Migraine headache
Left hypothalamic hamartoma s/p radiosurgery
H/o gelastic 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 AND MRA NECK
INDICATION: ___ year old man with history of left hypothalamic hamartoma, now
with right sided weakness, facial droop, paresthesias, numbness. Evaluate for
stability of hypothalamic MR, or infarct.
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain and neck with MIP reconstructions. Brain imaging was
performed with sagittal T1 and axial FLAIR, T2, gradient echo and diffusion
technique.
COMPARISON: ___ brain MRI. No prior MRA for comparison.
FINDINGS:
MRI Brain: Please note the study is degraded by motion. Again visualized is a
T1 isointense in T2/FLAIR hyperintense nonenhancing mass lesion in the region
of the left hypothalamus. This has not significantly changed in size measuring
approximately 19 (AP) x 15 (TV) mm. Extension into involvement of the left
optic tract is again noted and unchanged. Grossly stable findings suggestive
of prior left frontal approach biopsy tract is again noted.
No enhancing lesions or new mass lesions are identified. There is no evidence
of hemorrhage, edema, extra-axial collection or infarction. There is
susceptibility artifact noted on gradient echo images in the left frontal lobe
which appears similar to prior study. Ventricles and sulci are normal in
caliber and configuration. Major vascular flow voids are preserved. The
orbits are unremarkable. The paranasal sinuses and mastoid air cells are
clear.
ASL and dynamic contrast images reveal no regions of increased perfusion.
MRA brain: The intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm formation.
MRA neck: The common, internal and external carotid arteries appear normal.
There is no evidence of stenosis by NASCET criteria. The origins of the great
vessels, subclavian and vertebral arteries appear normal bilaterally.
IMPRESSION:
1. Study is degraded by motion.
2. No significant interval change in left hypothalamus mass lesion as
described above.
3. Unremarkable MRA of the head and neck.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with OTHER MALAISE AND FATIGUE, BENIGN NEOPLASM BRAIN
temperature: 98.6
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 131.0
dbp: 82.0
level of pain: 5
level of acuity: 1.0 | ___ y/o M with known hypothalamic hamartoma and gelastic epilepsy
presents with right facial droop and numbness as well as right
sided weakness. OSH NCHCT showing
known hypothalamic lesion with no definitive evidence of growth.
Mr. ___ was admitted to ___ Neurosurgery Service for
further evaluation and diagnostic testing. A MRI Head/Neck was
obtained on ___ to r/o stroke which showed no evidence of
stroke and no significant change in left hypothalamus mass
lesion. Neurologically Mr. ___ facial droop and numbness
have resolved and now exhibits ___ right bicep and tricep
strength.
On ___ Mr ___ remains neurologically intact with full
strength throughout all extremities. MRI/MRA BRAIN (___)
with no significant interval change in left hypothalamus mass
lesion. Unremarkable MRA of the head and neck.
Extended routine EEG- No epileptiform activity or seizures.
Episode likely a migrainous phenomenon- increasing prophylactic
amitriptyline 50mg qhs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
Angiogram
History of Present Illness:
This is a ___ year-old woman with a history of HTN who presents
as
a transfer from ___ for intraparenchymal bleed.
Per records the patient was teaching a "boot camp" fitness class
when she suddenly felt lightheaded at 640pm. She had
right-sided
weakness and expressive aphasia at that time. She was brought
urgently to ___, where BP on arrival was 182/102 and
went down to the 160s with labetolol and hydralazine. She was
intubated and transported here for neurosurgical evaluation.
ROS unable to obtain
Past Medical History:
HTN
Hypothyroidism
Social History:
___
Family History:
one sister with multiple cerebral aneurysms s/p
coiling.
Physical Exam:
Physical Exam: ___ (by ___
Vitals:36.4 70 123/72 14 100%
General: eyes open and awake, intubated
HEENT: NC/AT, no scleral icterus noted
Neck: Supple
Pulmonary: Lungs CTA
Cardiac: RRR, nl
Neurologic:
-Mental Status: Awake, responsive with head nod to questions.
Follows commands. Potential neglect to the right side.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. Does not seem to see fingers on
the right side.
III, IV, VI: can look all the way to the left, not to the right
though will cross the midline to voice, not to following
fingers.
V: Facial sensation intact to light touch.
VII: Right eye seems weaker to closure
-Motor: Left arm and leg are antigravity. Right arm occasionally
flexes but not to clear stimulation. Otherwise flaccid. Right
leg
with no voluntary movement, does flex foot to scratch.
-Sensory: reports feeling light touch in all limbs except right
leg.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
Pertinent Results:
___ 10:20PM BLOOD WBC-10.4 RBC-3.65* Hgb-11.4* Hct-33.4*
MCV-91 MCH-31.1 MCHC-34.1 RDW-13.2 Plt ___
___ 10:20PM BLOOD ___ PTT-31.3 ___
___ 10:20PM BLOOD Glucose-138* UreaN-11 Creat-0.5 Na-131*
K-2.9* Cl-98 HCO3-22 AnGap-14
___ 10:20PM BLOOD ALT-16 AST-32 AlkPhos-43 TotBili-1.1
___ 10:20PM BLOOD Lipase-34
___ 10:20PM BLOOD cTropnT-<0.01
___ 10:20PM BLOOD Albumin-3.9 Calcium-8.6 Phos-2.1* Mg-1.8
___ 10:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CXR ___. ET tube in appropriate position.
2. Large left retrocardiac opacity may reflect pleural
effusion, aspiration
or atalectasis; pneumonia is not excluded.
CTA head and neck ___. No evidence for vascular malformation to explain the
patient's large left temporal lobe hemorrhage which causes mass
effect and mild shifting of the midline structures.
2. Mild atherosclerotic disease of the head and neck without
significant stenosis.
CT Head ___. No significant interval change in left temporoparietal
intraparenchymal hemorrhage. No new hemorrhage identified.
2. Tubular structure in the left orbit which may be contiguous
with the ophthalmic vein could represent a cavernous
malformation or venous varix, orbital MRI or CT can be obtained
on a nonurgent basis.
Angio ___. Right vertebral artery: The vertebral artery fills normally
and fills the left vertebral artery down below the level of the
___ vessel. There is no significant atherosclerotic disease,
plaque or vessel narrowing. There was excellent filling of the
basilar artery and bilateral posterior cerebral arteries.
2. Right common carotid artery. The roadmap image of the
carotid artery bifurcation demonstrates no significant plaque,
stenosis or dissection. Intracranial AP and lateral injection
demonstrates good filling of the anterior cerebral artery and
middle cerebral artery. Oblique images were obtained, and there
was no evidence of aneurysmal disease, or AV malformation.
3. Left common carotid artery. Roadmap imaging of the cervical
carotid artery demonstrates good filling of the internal and
external carotid vessels with no obvious plaque or stenosis.
Intracranial AP and lateral injection demonstrates good flow in
the anterior and middle cerebral arteries. There is obvious
displacement of the middle cerebral artery medially from the
temporal lobe mass. This can be seen on the AP injection with
displacement of the sylvian system medially, and on the lateral
injections, there is paucity of vasculature in the area of the
hematoma.
MRI Brain and orbit with and without contrast
1. Large subacute hemorrhage within the left temporal lobe with
unchanged mass effect and midline shift. There is scattered
subarachnoid hemorrhage, a small amount of intraventricular
hemorrhage, and a small subdural hematoma overlying the left
cerebrum. There is no evidence for underlying mass. A followup
exam after resolution of the hematoma is recommended.
2. Dilated, tortuous superior ophthalmic veins and dilated scalp
veins, left greater than right. There is no MR evidence for
carotid cavernous fistula or cavernous sinus thrombosis.
CT Head ___
ReportNo significant interval change in left temporoparietal
intraparenchymal
Preliminary Reporthemorrhage. No new hemorrhage identified.
NCHCT ___
Mild increase in left temporoparietal intraparenchymal
hemorrhage with more
Preliminary Reportextension into the anterior temporal lobe. No
new hemorrhage identified. No
Preliminary Reportchange in mass effect.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 20 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Thyroid 15 mg PO BID
Discharge Medications:
1. Amlodipine 7.5 mg PO DAILY
2. Enalapril Maleate 20 mg PO DAILY
3. Thyroid 15 mg PO BID
4. Heparin 5000 UNIT SC BID
5. Labetalol 300 mg PO TID
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID:PRN constipation
8. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intraparenchymal hemorrhage - left temporal-parietal
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - sometimes.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with intraparenchymal hemorrhage within the for
interval change.
TECHNIQUE: Helical axial MDCT images were obtained through the brain without
the administration of IV contrast. Reformatted images in coronal and sagittal
axes were generated.
DOSE: DLP: 780 mGy-cm
COMPARISON: Head CTA ___.
FINDINGS:
Over an 8 hour interval, there has been no significant interval change in a
left temporoparietal intraparenchymal hemorrhage and minimal surrounding
edema. Additionally, there is a small amount of interventricular blood within
the occipital horn of the left lateral and fourth ventricle. The
intraparenchymal hemorrhage exerts local mass effect with slight effacement of
the left lateral ventricle. There is approximately 3 mm of shift of midline
structures to the right, not significantly changed from prior. The basal
cisterns are patent.
There is no acute fracture. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. Incidental note is made of a tubular
structure in the left orbit which may be contiguous with the ophthalmic vein.
IMPRESSION:
1. No significant interval change in left temporoparietal intraparenchymal
hemorrhage. No new hemorrhage identified.
2. Tubular structure in the left orbit which may be contiguous with the
ophthalmic vein could represent a cavernous malformation or venous varix,
orbital MRI or CT can be obtained on a nonurgent basis.
Radiology Report
EXAMINATION: MRI BRAIN AND ORBITS
INDICATION: Intraparenchymal hemorrhage. Eval for stroke, underlying mass or
vascular malformation
TECHNIQUE: Multiplanar, multi sequence MR images of the head and orbits were
obtained before and after the administration of intravenous contrast.
COMPARISON: CTA head ___ and CT head ___.
FINDINGS:
MRI head: There is a large intraparenchymal hemorrhage centered within the
left temporal lobe which is quite similar to hyperintense on the T1 weighted
images and heterogeneous but mainly hyperintense on T2 weighted images. The
hemorrhage causes local mass effect and partial effacement of the left lateral
ventricle with mild shifting of the midline structures to the right, unchanged
from the previous examination. There is no abnormal enhancement. A punctate
focus of enhancement centrally within the hemorrhage (series 15, image 13)
likely represents a small vessel as seen on the CTA examination.
A thin subdural collection overlies the left cerebral hemisphere. There are
scattered areas of FLAIR sulcal hyperintensity overlying both frontal and
parietal lobes and some with associated diffusion abnormality compatible with
scattered subarachnoid hemorrhage. A small amount of hemorrhage is seen in
the posterior horn of the left lateral ventricle.
There is abnormal diffusion signal related to the blood products, but no acute
infarct.
MRI orbits: Both superior ophthalmic veins are dilated and tortuous, left
greater than right. And a focal area of ectasia of the left superior
ophthalmic vein measures 10 x 8 mm on coronal images, and the right superior
ophthalmic vein measures up to 6 mm in maximal dimension. No filling defects
or abnormal flow voids are seen within the cavernous sinuses. The globes and
orbits are otherwise unremarkable.
The veins within the temporal scalp bilaterally are dilated and tortuous, left
greater than right.
IMPRESSION:
1. Large subacute hemorrhage within the left temporal lobe with unchanged mass
effect and midline shift. There is scattered subarachnoid hemorrhage, a small
amount of intraventricular hemorrhage, and a small subdural hematoma overlying
the left cerebrum. There is no evidence for underlying mass. A followup exam
after resolution of the hematoma is recommended.
2. Dilated, tortuous superior ophthalmic veins and dilated scalp veins, left
greater than right. There is no MR evidence for carotid cavernous fistula or
cavernous sinus thrombosis.
Radiology Report
PROCEDURE PERFORMED: Diagnostic cerebral angiogram.
INDICATION: Patient had a large left temporoparietal hematoma, and it was
decided to proceed with angiography to investigate for any potential vascular
malformation as the etiology of the lesion.
ATTENDING: ___, MD.
ASSISTANT: ___, NP.
ANESTHESIA: Conscious sedation with the patient intubated.
MATERIALS EMPLOYED: 5 ___ sheath, 4 ___ Berenstein catheter, 0.038
Glidewire, 6 ___ Angio-Seal.
DESCRIPTION OF PROCEDURE: The patient was brought into the neuroangio suite
and placed on the angiographic table. Bilateral groins were prepped and
draped in the usual sterile fashion. A timeout was performed. The right
femoral artery was accessed using anatomical radiographic landmarks, and a
micropuncture needle tip was used to secure a 5 ___ sheath. This was
sutured in place and connected to a continuous heparinized saline flush.
Next, a Berenstein 2 catheter was connected to an RHV, a three-way stopcock
and a continuous heparinized saline flush placed within the sheath. Once good
backflow of blood was obtained, the three-way stopcock was connected to a
contrast power injector. Then, using the catheter and 0.038 Terumo Glidewire,
the catheter was brought over the aortic arch and was used to select the right
vertebral artery. AP and lateral angiography was performed. The catheter was
then navigated back into the right common carotid artery, and AP and lateral
angiography was performed. Next, the catheter was brought back into the
aortic arch, and the left common carotid artery was selected. Intracranial AP
and lateral angiography was performed. The patient was stable throughout the
procedure and returned to the intensive care unit. Prior to concluding the
procedure, the roadmap was performed of the right femoral artery, and a 6
___ Angio-Seal was placed within the cerebral artery.
IMAGING FINDINGS:
1. Right vertebral artery: The vertebral artery fills normally and fills the
left vertebral artery down below the level of the ___ vessel. There is no
significant atherosclerotic disease, plaque or vessel narrowing. There was
excellent filling of the basilar artery and bilateral posterior cerebral
arteries.
2. Right common carotid artery. The roadmap image of the carotid artery
bifurcation demonstrates no significant plaque, stenosis or dissection.
Intracranial AP and lateral injection demonstrates good filling of the
anterior cerebral artery and middle cerebral artery. Oblique images were
obtained, and there was no evidence of aneurysmal disease, or AV malformation.
3. Left common carotid artery. Roadmap imaging of the cervical carotid
artery demonstrates good filling of the internal and external carotid vessels
with no obvious plaque or stenosis. Intracranial AP and lateral injection
demonstrates good flow in the anterior and middle cerebral arteries. There is
obvious displacement of the middle cerebral artery medially from the temporal
lobe mass. This can be seen on the AP injection with displacement of the
sylvian system medially, and on the lateral injections, there is paucity of
vasculature in the area of the hematoma.
CONCLUSIONS:
1. Normal filling of the right carotid system and vertebrobasilar system.
2. Obvious mass effect with shift of the sylvian system on the left side.
There is no evidence of AV malformation or aneurysm.
3. No evidence of thromboembolic complication.
At the conclusion of the procedure, the 6 ___ Angio-Seal device was used.
The patient tolerated the procedure well with no obvious cardiovascular
changes. She was returned to the intensive care unit in stable cardiovascular
condition. Dr. ___ performed the procedure.
Radiology Report
INDICATION: ___ woman with intraparenchymal hemorrhage, evaluate for
interval change.
COMPARISON: Head CTs from ___ and ___. MRI brain and
orbit, ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of contrast. Coronal and sagittal reformatted images
were acquired.
TOTAL EXAM DLP: 780 mGy-cm.
FINDINGS: Since prior, there is no significant interval change in a large
left temporoparietal intraparenchymal hemorrhage with minimal surrounding
edema. There is stable 3-mm shift of midline structures to the right. Basal
cisterns remain patent. Ventricular size and configuration is unchanged.
No acute fracture is identified. The visualized paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. Venous varices within the
orbits are again noted.
IMPRESSION:
No significant interval change in left temporoparietal intraparenchymal
hemorrhage. No new hemorrhage identified.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with wheeze // eval for interval change
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the patient has been extubated and the
nasogastric tube was removed. The lung volumes are normal. Moderate
cardiomegaly persists. Minimal atelectasis in the retrocardiac lung regions.
No overt pulmonary edema. No pneumonia.
Radiology Report
INDICATION: ___ year old woman with l temporal-parietal stroke with worsened
aphasia, assess interval change
TECHNIQUE: Helical axial MDCT images were obtained through the brain without
the administration of IV contrast. Reformatted images in coronal and sagittal
axes were generated.
DOSE: DLP: 934 mGy-cm
COMPARISON: CT head dating back to ___.
FINDINGS:
Since prior there is mild increase in the left temporoparietal
intraparenchymal hemorrhage with more extension into the anterior temporal
lobe. The degree of surrounding edema is unchanged. There are no new areas of
hemorrhage identified. Stable 3 mm midline shift to the right and effacement
of the atrium of the left lateral ventricle. Basal cisterns remain patent.
Ventricular size and configuration is unchanged.
There is no acute fracture. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The patient is status post right
lens surgery.
IMPRESSION:
Mild increase in left temporoparietal intraparenchymal hemorrhage with more
extension into the anterior temporal lobe. No new hemorrhage identified. No
change in mass effect.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: IPH
Diagnosed with INTRACEREBRAL HEMORRHAGE
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Ms. ___ was admitted to the neurology ICU on ___, intubated
as a transfer from ___ with a left temporal-parietal
intraparenchymal bleed. Her exam was notable for right-sided
weakness as well as aphasia. As she was poorly compliant with
her medications at home, this bleed was thought to be
hypertensive in etiology. Angiogram was performed for spot sign
seen on CT head and was negative, and MRI was without evidence
of vascular malformation. While in the ICU, she had extremely
difficult to control HTN in the ICU initially requiring
labetalol gtt. This was eventually weaned off after PO labetalol
was started and her home dose of amlodipine was uptitrated.
She was transferred to the floor on ___. Her neurologic exam
fluctuated somewhat and on ___ a repeat NCHCT was performed
showing a very slight increase in the size of her hemorrhage.
Blood pressures remained at goal, below 140.
She was followed by speech and swallow and eventually was
advanced to a regular diet with no modifications. She was also
seen by physical and occupational therapy who recommended rehab.
Infectious workup was negative, except for an equivocal UA (___
14) just after foley was removed. Urine culture is pending.
Her home dose of ___ Thyroid was continued.
OUTSTANDING ISSUES
[ ] F/U urine culture
[ ] Has stroke clinic follow up
[ ] Continue to monitor blood pressures, goal systolic <140 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
skin abscesses
Major Surgical or Invasive Procedure:
Incision and drainage
History of Present Illness:
___ w/ PMHx notable for IVDU now seen ___ consultation for
possible surgical drainage of multiple abscesses of chest and
thighs ___ the setting of skin popping of fentanyl approximately
one week ago. Pt reports that he injected into his ___ proximal
UE
and thighs. Over the past week he has developed progressive
cellulitis of these areas along with fevers and chills over the
past day. Worsening pain prompted him to seek medical
evaluation.
He has previously required operative drainage of similar
abscesses on his abdomen.
Past Medical History:
PMHx: IVDU, skin abscesses
PSHx: I&D of multiple prior abscesses
Social History:
___
Family History:
FamHx: denies
Physical Exam:
AFVSS
Gen: NAD, AOx3
HEENT: no icterus, grossly NCAT
CV: RRR
R: CTAB
Abd: prior scars from popping and I&D, nontender, no masses, no
hernias
Ext: no c/c/e, areas of previous abscess s/p I&D clean and dry
with packing inside
Pertinent Results:
___ 10:00AM BLOOD WBC-8.4 RBC-3.60* Hgb-8.1* Hct-27.1*
MCV-75* MCH-22.5* MCHC-29.9* RDW-14.9 RDWSD-40.6 Plt ___
___ 07:13PM BLOOD WBC-10.6* RBC-4.21* Hgb-9.6* Hct-32.7*
MCV-78* MCH-22.8* MCHC-29.4* RDW-14.7 RDWSD-41.1 Plt ___
___ 12:20AM BLOOD WBC-13.8* RBC-4.25* Hgb-9.7* Hct-31.1*
MCV-73* MCH-22.8* MCHC-31.2* RDW-14.5 RDWSD-38.5 Plt ___
___ 12:20AM BLOOD Neuts-77.8* Lymphs-10.7* Monos-10.3
Eos-0.2* Baso-0.2 Im ___ AbsNeut-10.75* AbsLymp-1.48
AbsMono-1.43* AbsEos-0.03* AbsBaso-0.03
___ 10:00AM BLOOD Glucose-91 UreaN-14 Creat-0.9 Na-137
K-4.5 Cl-102 HCO3-26 AnGap-9*
___ 11:59AM BLOOD Glucose-101* UreaN-16 Creat-1.1 Na-139
K-4.3 Cl-102 HCO3-26 AnGap-11
___ 05:11PM BLOOD Glucose-83 UreaN-13 Creat-1.0 Na-141
K-5.6* Cl-106 HCO3-19* AnGap-16
___ 07:13PM BLOOD Glucose-97 UreaN-12 Creat-0.8 Na-138
K-4.4 Cl-101 HCO3-25 AnGap-12
___ 12:20AM BLOOD Glucose-125* UreaN-13 Creat-0.9 Na-130*
K-4.1 Cl-90* HCO3-25 AnGap-15
___ 10:00AM BLOOD ALT-8 AST-14 AlkPhos-72 TotBili-<0.2
___ 10:00AM BLOOD Lipase-36
___ 10:00AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.2
___ 05:11PM BLOOD Calcium-8.4 Phos-4.4 Mg-2.3
___ 10:00AM BLOOD CRP-53.5*
___ 07:13PM BLOOD Vanco-23.0*
___ 10:50AM BLOOD Vanco-22.7*
___ 12:32AM BLOOD Lactate-1.5
CT CHEST W/CONTRAST Study Date of ___ 2:56 AM
IMPRESSION:
1. Multiple soft tissue fluid and gas collections ___ the right
pectoralis
major muscle, left anterior deltoid muscle, left anterior arm,
and ___ the
subcutaneous fat ___ the right lower anterior abdomen and right
lateral thigh, which measure up to 9.2 cm, as detailed above.
2. Left axillary lymphadenopathy is likely reactive.
3. Splenomegaly of 17.7 cm.
4. Mild central intrahepatic biliary dilatation and prominence
of the common bile duct is nonspecific. If clinically
warranted, MRCP may be performed for further evaluation.
___ 12:20 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 0.5 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___,
___.
GRAM POSITIVE COCCI ___ CLUSTERS.
___ 8:27 am SWAB Site: SHOULDER LEFT SHOULDER
ABSCESS.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
3+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Preliminary):
WORK UP ALL ORGANISMS (ID AND SENSITIVITIES) REQUEST BY ___
___
___ ___.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
BETA STREPTOCOCCUS GROUP B. RARE GROWTH.
GRAM POSITIVE BACTERIA. SPARSE GROWTH.
OF THREE COLONIAL MORPHOLOGIES.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
ANAEROBIC CULTURE (Final ___:
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. Bacterial growth was screened for
the presence
of B.fragilis, C.perfringens, and C.septicum. None of
these species
was found.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*18 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 300 mg PO BID
RX *gabapentin 300 mg 1 capsule(s) by mouth twice a day Disp
#*30 Capsule Refills:*0
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every six
(6) hours Disp #*28 Tablet Refills:*0
6. Linezolid ___ mg PO Q12H
RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*18
Tablet Refills:*0
7. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*27 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Skin abcsess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT TORSO WITH CONTRAST
INDICATION: ___ year old man with abscess, history of IV drug injections into
the skin.//evaluate extent of abscess
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
2) Spiral Acquisition 11.2 s, 88.1 cm; CTDIvol = 21.0 mGy (Body) DLP =
1,844.9 mGy-cm.
Total DLP (Body) = 1,858 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
NECK, THORACIC INLET, AXILLAE, CHEST WALL:
There is a large collection of fluid and gas centered in the right pectoralis
major muscle, measuring at least 9.2 x 5.0 cm (TV by AP) (03:18), which
extends into the right upper arm and to the right clavicle.
A 5.4 x 2.5 cm fluid and gas collection is seen in the anterior left deltoid
muscle (03:18). A second 2.8 x 2.2 cm fluid collection is seen in the
subcutaneous tissues of the anterior left upper arm (03:26).
Enlarged left axillary lymph nodes measure up to 2.0 cm (03:22) and are likely
reactive. The imaged thyroid is unremarkable. There is no supraclavicular
lymphadenopathy. The esophagus is unremarkable. Mild bilateral gynecomastia
is noted.
MEDIASTINUM: There is no mediastinal mass or lymphadenopathy.
HILA: There is no hilar mass or lymphadenopathy.
HEART and PERICARDIUM: Heart size is normal. The thoracic aorta is normal in
caliber. There is no pericardial effusion.
PLEURA: No pleural effusion or pneumothorax.
LUNG:
1. PARENCHYMA: The lungs are clear, without evidence of suspicious masses,
nodules or focal consolidations. No diffuse lung disease.
2. AIRWAYS: The airways are patent to the level of the segmental bronchi
bilaterally.
3. VESSELS: Main pulmonary artery diameter is within normal limits.
Suboptimal evaluation of the pulmonary vasculature demonstrates no evidence of
central pulmonary embolism.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration. There is mild central
intrahepatic biliary dilatation. The CBD is borderline in size at 7 mm. 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 is enlarged at 17.7 cm, but demonstrates homogeneous
attenuation without evidence of focal lesion or laceration.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is 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 not visualized. There is no
evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate 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 or retroperitoneal hematoma.
No atherosclerotic disease is noted.
BONES: There is no acute fracture. No focal suspicious osseous abnormality.
SOFT TISSUES: In the right lower anterior abdominal subcutaneous fat, there is
a 2.2 x 1.7 cm rim enhancing fluid collection (3:97). In the subcutaneous fat
in the right lateral thigh, there is a 3.4 x 3.2 cm fluid and gas collection
(3:126). Inferior to this, in the subcutaneous fat of the right anterolateral
thigh, there is a 2.0 x 1.7 cm phlegmon (03:137).
IMPRESSION:
1. Multiple soft tissue fluid and gas collections in the right pectoralis
major muscle, left anterior deltoid muscle, left anterior arm, and in the
subcutaneous fat in the right lower anterior abdomen and right lateral thigh,
which measure up to 9.2 cm, as detailed above.
2. Left axillary lymphadenopathy is likely reactive.
3. Splenomegaly of 17.7 cm.
4. Mild central intrahepatic biliary dilatation and prominence of the common
bile duct is nonspecific. If clinically warranted, MRCP may be performed for
further evaluation.
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT
INDICATION: ___ w/ IVDU here with numerous superficial and deep abscesses in
setting of skin popping with palpable non drained abscess in right
ante-cubital fossa.// Please eval RUE collection, ?drainage
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right antecubital fossa.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right antecubital fossa.
There is a 4.1 x 2.8 x 2.7 cm lobulated, heterogeneously echoic subcutaneous
collection, without flow seen on color Doppler evaluation. This collection is
partly compressible.
IMPRESSION:
4.1 cm avascular complex subcutaneous fluid collection in the right
antecubital fossa may represent abscess or hematoma.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Cutaneous abscess of other sites, Other psychoactive substance abuse, uncomplicated
temperature: 99.7
heartrate: 99.0
resprate: 16.0
o2sat: 100.0
sbp: 150.0
dbp: 98.0
level of pain: 10
level of acuity: 3.0 | Mr ___ was admitted to the hospital on ___ for management
of his multiple skin abscesses causes by IVDU and skin popping.
He was taken to the operating room on ___ for incision and
drainage of the abscesses. The operation was uncomplicated and
the patient was taken to the floor after an uncomplicated stay
___ the PACU (please see the full operative report). He was
started on IV antibiotics and cultures were sent.
On ___ he was again taken to the operating room for an I+D
of Right antecubital fossa abscess. The operation was
uncomplicated and the patient did well after that ___ the PACU
and was taken back to the surgical floor.
His blood culture grew MSSA, and his vancomycin was DC'd and he
was continued on Zosyn. However, his IV access was lost and the
patient was switched to PO linezolid/ciprofloxacin/Flagyl for
coverage of MSSA and mixed culture of his abscesses by the
infectious disease service, which he will continue until
___.
His pain was managed initially with methadone which was later
changed to oral Tylenol, dilaudid and gabapentin. He was offered
methadone therapy but the patient refused it.
On ___ he was ready to be discharged from the hospital ___
stable conditions.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Patient's intake and output were closely monitored.
patient voided on his own.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. His antibiotic course is
described above.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Protonix
Attending: ___
___ Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Upper endoscopy ___
History of Present Illness:
Ms. ___ is a ___ with a PMHx of hemochromatosis c/b
MI (___) w/o known cirrhosis, alcohol abuse (currently ___
drinks/day), recurrent PNA (most recently ___ treated with
azithromycin, levofloxacin, and 2 five-day pulses of steroid),
bronchiectasis (on last CT ___ w/ persistent cough and SOB
who presented overnight with 2 episodes of 500 cc coffee ground
hematemesis. The patient was initially brought to ___
where she had another episode of hematemesis and was found to be
hypotensive to the ___ and tachycardic to the 150s. She was
given 2u pRBCs, octeotide gtt, and pantoprazole and was
transferred to ___ for further management as there were no ICU
beds available.
Regarding her diagnosis of hemochromatosis, the patient states
that she knew she had family history, but that she was only just
diagnosed ___. She undergoes therapeutic phlebotomy q3months.
States that she had an EGD ___ years ago that did not show
varices.
In the ___ ED, initial vitals: 98.9 79 ___ 96% RA. Exam
was notable for clear lungs and a soft, nontender abdomen. The
patient denied any abdominal pain, chest pain or SOB.
Labs were notable for WBC 9.2, H/H 11.7/35.5 Plt 110
Na 141 K 4.0 Cl 107 HCO3 19 BUN 32 Cr 0.5
Lactate elevated to 3.7
LFTs were WNL, albumin 3.3.
INR 1.0 (___)
GI/hepatology was consulted and recommended ICU admission.
On arrival to the MICU, patient is comfortable, AAOx3. Denies
any further episodes of hematemesis. Denies chest pain, SOB,
abdominal pain, hematochezia, melena, dysuria.
Review of systems:
(+) Per HPI
Past Medical History:
Hemochromatosis (heterozygous HFE ___
Hx of panic attacks
Hx of non-cardiac chest pain
Social History:
___
Family History:
Mother alive at ___, has breast cancer and restrictive lung
disease.
Father had CAD.
Sister alive at ___, had MI at age ___. Also has hemochromatosis.
Brother alive at ___.
Physical Exam:
ADMISSION/DISCHARGE EXAM:
=========================
Vitals: T 99 BP 128/87 HR 93 R 16 SpO2 95%RA
GENERAL: Well-appearing middle aged female resting comfortably
in bed in NAD, pleasant
HEENT: Sclera anicteric, MMM, one 0.5 cm ulcer in L buccal
mucosa.
NECK: supple, JVP not elevated
LUNGS: CTAB
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No jaundice, slightly hyperpigmented skin
NEURO: AAOx3, no asterixis
Pertinent Results:
ADMISSION LABS:
===============
___ 05:31AM ___
___ 05:31AM LACTATE-3.7*
___ 05:00AM GLUCOSE-105* UREA N-32* CREAT-0.5 SODIUM-141
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-19* ANION GAP-19
___ 05:00AM estGFR-Using this
___ 05:00AM ALT(SGPT)-23 AST(SGOT)-30 ALK PHOS-62 TOT
BILI-0.5
___ 05:00AM LIPASE-29
___ 05:00AM ALBUMIN-3.3* CALCIUM-7.4* PHOSPHATE-2.5*
MAGNESIUM-1.7
___ 05:00AM WBC-9.2 RBC-3.60* HGB-11.7 HCT-35.5 MCV-99*
MCH-32.5* MCHC-33.0 RDW-13.4 RDWSD-48.8*
___ 05:00AM NEUTS-78.7* LYMPHS-9.7* MONOS-11.0 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-7.21*# AbsLymp-0.89* AbsMono-1.01*
AbsEos-0.00* AbsBaso-0.02
___ 05:00AM PLT COUNT-110*
DISCHARGE LABS:
===============
___ 12:07PM BLOOD WBC-7.6 RBC-3.65* Hgb-11.9 Hct-35.1
MCV-96 MCH-32.6* MCHC-33.9 RDW-14.7 RDWSD-52.0* Plt ___
___ 04:26PM BLOOD ___ PTT-22.7* ___
___ 12:07PM BLOOD %HbA1c-5.4 eAG-108
___ 12:42PM BLOOD Lactate-1.8
MICRO:
=====
IMAGING/STUDIES:
================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. ALPRAZolam 0.5 mg PO DAILY
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI Bleed
Gastric Ulcer
Hemochromatosis
Hepatic Steatosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hx hemochromatosis, hx PNAs s/p steroid
courses and abx // evaluate for infiltrate
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest CT ___.
FINDINGS:
Cardiac size is normal. Aside from minimal atelectasis in the left base, The
lungs are clear. There is no pneumothorax or pleural effusion. Non-healed
left rib fracture with adjacent pleural abnormality is again noted
IMPRESSION:
No acute cardiopulmonary abnormality
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with hx hemochromatosis, p/w hematemesis //
evaluate for presence of cirrhosis; splenomegaly
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT thorax ___.
FINDINGS:
LIVER: The hepatic parenchyma appears mildly echogenic suggesting mild
steatosis. 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 0.7
cm, unchanged.
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.
SPLEEN: Normal echogenicity, measuring 9.5 cm.
KIDNEYS: The right kidney measures 10 cm. The left kidney measures 11.4 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones, or hydronephrosis in the
kidneys.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Hepatic steatosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hematemesis
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 98.9
heartrate: 79.0
resprate: 18.0
o2sat: 96.0
sbp: 110.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ with a PMHx of hemochromatosis c/b
MI (___) w/o known cirrhosis, alcohol abuse (currently ___
drinks/day), recurrent PNA (most recently ___ treated with
azithromycin, levofloxacin, and 2 five-day pulses of steroid),
bronchiectasis (on last CT ___ w/ persistent cough and SOB
who presented overnight with 2 episodes of 500 cc coffee ground
hematemesis. She was placed on octreotide, IV PPI and underwent
endoscopy that showed GEJ erosions and multiple gastric ulcers
that were not actively bleeding. She had no further episodes of
emesis post procedure. We recommended staying for hemodynamic
monitoring overnight with CBC check but she decided to leave
AMA.
# Hematemesis: Pt presented with a suspected upper GIB with 2
episodes of coffee ground emesis, concerning for variceal bleed
given the patient's history of hemochromatosis. Patient was
tachycardic at ___, given 2u pRBCs, and subsequently
transferred to ___ on octreotide gtt and protonix, which were
continued upon admission to the MICU. Upon arrival to ___,
patient was mildly tachycardic to HR 110, which responded to IV
fluid boluses, otherwise patient was hemodynamically stable. RUQ
ultrasound was significant for only mild hepatic steatosis. She
underwent endoscopy that showed GEJ erosions and multiple
gastric ulcers that were not actively bleeding.
# Hemochromatosis: Heterozygous HFE ___, recently diagnosed
___. She receives therapeutic phlebotomy q3months. LFTs
unremarkable despite Alb 3.3, INR 1.0. Right upper quadrant
ultrasound showed mild steatosis. CXR without evidence of
cardiomegaly.
# Cough/SOB: Patient reported significant cough and dysnea for
the past 2 months. She is s/p two courses of steroids and
antibiotics (azithromycin and levofloxacin) in ___. Patient
had CT on ___ that was significant for a left ninth rib
fracture and bronchiectasis, which could both be contributing to
the patient's symptoms. Her respiratory status was monitored
during the admission. She was intermittently treated with duoneb
nebulizer treatments and was never hypoxic.
# Thrombocytopenia: The patient's platelets were 110 on
admission, likely from a consumptive process from her GI
bleeding. There was no evidence of splenomegaly on abdominal
ultrasound.
# Anxiety: Patient was treated with her home dose of Xanax 0.5
mg daily.
***TRANSITIONAL ISSUES:***
- Will need repeat endoscopy in ___ weeks for resolution of her
gastric ulcers.
- Should continue pantoprazole 40mg BID until resolution of
ulcers.
- Should undergo H. Pylori testing (Left AMA before obtaining
stool sample)
- Should establish care with hepatologist given hepatic
steatosis seen on liver US and known hemochromatosis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old man with a history of atrial
fibrillation on warfarin, vascular dementia, history of
aspiration pneumonia, who presented to the ___ ED from his
living facility (___) with fever and hypoxia. Patient
reportedly had a witnessed aspiration event earlier in the day
associated with coughing. EMS was called. Patient was febrile to
100.0, hypotensive into the 80's, hypoxic to 88%. On arrival to
the ED, he was oriented only to self, not to place or time,
which
per the patient's son, is close to the patient's baseline.
Overall, the patient is a limited historian due to mental status
and the majority of history is provided by the patient's son.
___, the patient has been admitted multiple times over the
past several years most recently ___ for aspiration with
subsequent pneumonias (requiring ICU admission on ___.
In the ED, initial vitals were:
97.8F HR:86 BP: 89/49 RR: 18 95% RA
- Exam:
End expiratory wheezes in the bilateral bases
- Labs:
Cr: 1.8
Mg: 1.5 (given Mg)
Lactate: 3.2 --> 1.3 (2L fluid)
WBC: 10.2
INR: 3.5
- Imaging:
___: Chest X-Ray: CHEST (PORTABLE AP)
-no distinct focal consolidation
(Most Recent):
___: LVEF: 60% (nl >=55%)
___: LVEDD: 4.4 cm (nl <= 5.6 cm)
___: LVESD: 2.7 cm
___: TR Gradient: 19 mm Hg (nl <= 25 mm Hg)
- Micro:
Blood cultures pending
UA pending
- Consults:
None
- EKG:
13:54 and 13:57 - Irregularly irregular bradycardia consistent
with rate controlled A-fib; no signs of ischemia
- Patient was given:
Vanc
Cefepime
Metronidazole
1L NS
1L LR
Mg sulfate 2g
Acetaminophen 1gm
Upon arrival to the floor, patient reports feeling well but has
a
coarse non-productive cough. Per the patient's son who is at the
bedside, the patient appears to be mentating at baseline and
notes that his cough is new. He denies current fever, chills,
nausea, vomiting, chest pain or diarrhea. The patient was
hypertensive upon arrival to the floor and was saturating well
on
room air.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
-HTN
-Atrial Fibrillation on Coumadin
-Hyperlipidemia
-Prostate cancer
-Bladder cancer
-Chronic Kidney disease
-Vascular dementia
Social History:
___
Family History:
Mother passed from gastric cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: 97.6F PO BP:181 / 103 HR: 65 97% Ra
___: Weight: 146.2
GEN: Alert, cooperative, no distress, appears stated age
HENT: NC/AT, MMM. Nares patent, no drainage or sinus
tenderness. missing left incisor, gums normal.
EYES: PERRL, EOM intact, conjunctivae clear, no scleral
icterus.
NECK: No cervical lymphadenopathy. No JVD, no carotid bruit.
Neck supple, symmetrical, trachea midline.
LUNG: coarse breath sounds with ronchi in right and left lower
base, expiratory wheezes noted throughout all lung fields
HEART: RRR, Normal S1/S2, No ___ systolic murmur with radiation
to axilla
BACK: Symmetric, no curvature. ROM normal. No CVA tenderness.
ABD: Soft, non-tender, non-distended; nl bowel sounds; no
rebound or guarding, no organomegaly
GU: Not examined
EXTRM: Extremities warm, no edema, no cyanosis, positive ___
pulses bilaterally
SKIN: Skin color and temperature, appropriate. No rashes or
lesions
NEUR: CN II-XII intact grossly. Moving all extremities,
strength, sensation equal and intact throughout. A&O1 oriented
to
self only, pleasant
PSYC: Mood and affect appropriate
DISCHARGE PHYSICAL EXAM
___ 1109 Temp: 97.5 PO BP: 159/80 R Lying HR: 70 RR: 18 O2
sat: 98% O2 delivery: Ra
GEN: Awake, no distress
HENT: NC/AT, MMM. missing left incisor
EYES: PERRL, EOM intact, conjunctivae clear, no scleral icterus
NECK: No elevated JVP, no carotid bruit.
LUNG: decreased BS in bases, mild wheezes
HEART: RRR, Normal S1/S2, ___ systolic murmur with radiation to
axilla
ABD: Soft, ntnd, normoactive bs
EXTRM: warm, no edema, symmetric
SKIN: Skin color and temperature, appropriate. No rashes or
lesions
NEUR: CN II-XII intact grossly. Moving all extremities. AOx0
PSYC: pleasant
Pertinent Results:
ADMISSION LABS
___ 10:51AM BLOOD WBC-10.2* RBC-4.14* Hgb-11.8* Hct-38.0*
MCV-92 MCH-28.5 MCHC-31.1* RDW-14.6 RDWSD-48.3* Plt ___
___ 10:51AM BLOOD Neuts-55.5 ___ Monos-9.8 Eos-1.9
Baso-1.0 Im ___ AbsNeut-5.64 AbsLymp-3.19 AbsMono-0.99*
AbsEos-0.19 AbsBaso-0.10*
___ 10:51AM BLOOD ___ PTT-39.6* ___
___ 10:51AM BLOOD Glucose-130* UreaN-21* Creat-1.8* Na-140
K-4.0 Cl-100 HCO3-27 AnGap-13
___ 10:51AM BLOOD Albumin-3.8 Calcium-9.1 Phos-2.3* Mg-1.5*
___ 10:51AM BLOOD ALT-12 AST-21 AlkPhos-90 TotBili-0.6
___ 10:51AM BLOOD Lactate-3.2*
___ 03:30PM BLOOD Lactate-1.3
PERTINENT STUDIES
CHEST X-RAY ___
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or
pneumothorax. Cardiac and mediastinal silhouettes are stable.
There is calcification of the aortic knob. There may be mild
pulmonary vascular congestion. Mitral annulus calcification is
noted.
IMPRESSION: No definite focal consolidation.
DISCHARGE LABS
___ 07:41AM BLOOD WBC-8.6 RBC-3.78* Hgb-10.6* Hct-34.9*
MCV-92 MCH-28.0 MCHC-30.4* RDW-14.6 RDWSD-50.0* Plt ___
___ 07:41AM BLOOD ___ PTT-29.5 ___
___ 07:41AM BLOOD Glucose-100 UreaN-22* Creat-1.2 Na-145
K-4.4 Cl-107 HCO3-26 AnGap-12
___ 07:41AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO BID
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Tamsulosin 0.4 mg PO QHS
5. Vitamin D 1000 UNIT PO DAILY
6. Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H Duration: 9 Doses
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every 12
hours Disp #*9 Tablet Refills:*0
2. Gabapentin 100 mg PO BID
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Tamsulosin 0.4 mg PO QHS
6. Vitamin D 1000 UNIT PO DAILY
7. Warfarin 2.5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
Community acquired pneumonia
Acute hypoxemic respiratory failure
Acute uncomplicated urinary tract infection
Atrial fibrillation
SECONDARY DIAGNOSES
Gastroesophageal reflux disease
Peripheral neuropathy
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with sepsis, ?aspiration// pna
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or pneumothorax.
Cardiac and mediastinal silhouettes are stable. There is calcification of the
aortic knob. There may be mild pulmonary vascular congestion. Mitral annulus
calcification is noted.
IMPRESSION:
No definite focal consolidation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Hypotension
Diagnosed with Sepsis, unspecified organism
temperature: 97.8
heartrate: 86.0
resprate: 18.0
o2sat: 95.0
sbp: 89.0
dbp: 49.0
level of pain: 0
level of acuity: 2.0 | SUMMARY STATEMENT:
==================
Pt is a ___ yo M with dementia (lives in ___
home), atrial fibrillation on warfarin, history of recurrent
admissions for pneumonia ___ aspiration who was admitted for
fever, hypoxia, shortness of breath, hypotension, and
leukocytosis following an aspiration event at his nursing home.
On admission had SBP to ___, responsive to fluids. Chest x-ray
showed no opacity. Was initiated on broad coverage with vanc,
cefepime, and flagyl initially. This was switched to ceftriaxone
and azithro due to concern for community acquired pneumonia.
Patient had MRSA swab return positive so received additional
dose of vanc and then switched to oral doxycycline prior to
discharge for 5 day course to end ___. Patient also found to
have UA concerning for UTI. He was treated empirically for
simple cystitis with a three day course of IV ceftriaxone.
#Aspiration pneumonitis vs community acquired pneumonia
Patient admitted for respiratory/systemic symptoms as above. SLP
was not consulted this admission, instead started pureed
solids/nectar prethickened liquids per recommendation from last
admission given that this is a recurring event for him and based
on goals of care discussion w/ patient and family he would not
want to cease eating regardless of SLP recommendation despite
knowing risks of aspiration.
#Supratherapeutic INR:
INR 3.5 on admission, warfarin was held for one day and INR then
became therapeutic and patient restarted on home 2.5 daily
warfarin. Can consider transition to DOAC as outpatient.
#Urinary retention
___ on CKD
#Bacteriuria
Patient has CKD w/ baseline Cr of 1.2. Presented with Cr 1.8
which downtrended to normal with fluids. Patient was retaining
urine and required intermittent straight cath.
==============
Chronic Issues
==============
#Atrial fibrillation
Warfarin as noted above. Continued home metoprolol.
#Prostate cancer
Continued home tamsulosin
#GERD
Continued home pantoprazole
#Neuropathy
Continued home gabapentin
TRANSITIONAL ISSUES
===================
[ ] 5 day course of doxycycline to continue through ___.
Please give after meals.
[ ] Continue pureed solids/nectar prethickened liquids as diet
as outpatient given history of multiple aspiration events. Can
liberalize diet pending decision regarding goals of care with
family.
[ ] Patient continues to take warfarin. Consider DOAC for this
patient to eliminate need for monitoring. Given Cr<1.5 and
weight>60 kg could receive 5 mg bid. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / metformin
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ speaking female with history of CVA, HTN/HL, DMII,
and CAD s/p 3 vessel CABG (lima-lad (patent), svg-om (40-50%
stenosis), svg-rpda (subtotal occlusion) and PCI (BMS to RCA
___ on plavix) presenting with chest pain.
Pt reports that chest pain began around 6:30 pm, radiating to
her back, similar to prior episodes of chest pain. Her ___ was
at her house and had just administered her evening medications
prior to calling EMS. On EMS arrival, pt noted 1 hour of
substernal chest pressure radiating to her left neck and back,
no associated shortness of breath but did endorse nausea. She
was given an aspirin and SLN en route to the hospital.
Of note, pt has had multiple recent admissions for chest pain,
___ at which time she presented with EKG showing 1-2mm STE
in II, aVF, 1mm in V2-V3 and a code STEMI was called. She was
taken urgently to the cath lab but no obstructive lesions were
seen. She was then admitted again from ___ with chest pain
and uncontrolled blood sugars, ruled out for MI, chest pain
attributed to reflux.
In the ED, initial vitals were 10 66 204/59 18 98%. Labs
notable for CBC at baseline, cr 1.1 (baseline), tropononin
<0.01. Serum tox was negative. EKG showed NSR with stable TW
changes from prior. She had a chest xray that showed no acute
process. Pt was given morphine and nitroglycerine with reported
resolution of her chest pain. Vitals prior to transfer: 98.4 66
162/56 22 100% RA
On the floor, pt denied CP or SOB. She c/o pain in her upper
back at the site of old skin lesions. She also endorses migraine
in the front of her head between the eyes, stuffy nose, and
cough which is worse with eating. Also c/o incontinence and
constipation. Endorses palpitations, chills, ankle edema. ROS is
essentially pan-positive. All of these issues are chronic.
ROS:
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She 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, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: CABG in ___ ___ (LIMA-LAD,
SVG-OM, SVG-RPDA)
-PERCUTANEOUS CORONARY INTERVENTIONS: BMS to the RCA in ___
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- CAD 3VD s/p BMS to RCA ___, on Plavix; CABG in ___
- DM2
- HTN w/ LVH on ___ ECHO
- Hypercholesterolemia
- Prurigo nodularis
- Asthma (on albuterol?)
- H/o lumbar surgery for "tumor" in ___
- H/o left Bell's palsy w/ some residual droop (pt notes h/o
stroke)
- Stress incontinence
- h/o migraines
- h/o gastric ulcers (per patient)
- GERD
Social History:
___
Family History:
Her mother had an MI in her ___. Both mother and brother have
had CABG. Many siblings with DM.
Physical Exam:
Admission Physical Exam:
VS: T __ 190/50 70 18 95% on RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Skin- On the upper back, multiple 0.5cm wide nodules with
various stages of healing. No surrounding erythema or purulence.
.
Discharge Physical Exam:
VS: T=98.2 BP=155/89 (134/60-184/57) HR=57 (57-64) RR=16 O2
sat=96% on RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Skin- On the upper back, multiple 0.5cm wide nodules with
various stages of healing.
Pertinent Results:
Admission Labs:
___ 07:32PM ___ PTT-27.3 ___
___ 07:32PM NEUTS-55.2 ___ MONOS-5.1 EOS-3.6
BASOS-0.5
___:32PM NEUTS-55.2 ___ MONOS-5.1 EOS-3.6
BASOS-0.5
___ 07:32PM WBC-6.0 RBC-3.74* HGB-11.2* HCT-32.7* MCV-87
MCH-29.9 MCHC-34.2 RDW-15.0
___ 07:32PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:32PM CALCIUM-9.6 PHOSPHATE-3.1 MAGNESIUM-1.9
___ 07:32PM proBNP-815*
___ 07:32PM cTropnT-<0.01
___ 07:32PM estGFR-Using this
___ 07:32PM GLUCOSE-186* UREA N-28* CREAT-1.1 SODIUM-142
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-23 ANION GAP-14
___ 08:41PM URINE MUCOUS-RARE
___ 08:41PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 08:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:41PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:41PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 08:41PM URINE HOURS-RANDOM
___ 08:47PM LACTATE-1.3
.
Interval Labs:
___ 03:27AM BLOOD WBC-6.9 RBC-3.63* Hgb-10.8* Hct-31.7*
MCV-87 MCH-29.7 MCHC-34.1 RDW-15.2 Plt ___
___ 03:27AM BLOOD Glucose-137* UreaN-26* Creat-1.1 Na-142
K-4.5 Cl-110* HCO3-25 AnGap-12
___ 03:27AM BLOOD cTropnT-<0.01
___ 03:27AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.9
.
Discharge Labs:
___ 05:30AM BLOOD WBC-6.5 RBC-3.61* Hgb-10.5* Hct-31.7*
MCV-88 MCH-29.2 MCHC-33.2 RDW-14.8 Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-97 UreaN-22* Creat-1.1 Na-140
K-4.6 Cl-105 HCO3-28 AnGap-12
.
Microbiology: None.
.
Pathology: None.
.
Imaging/Studies:
# ECG (___): Sinus rhythm. Old inferior wall myocardial
infarction. Compared to the previous tracing no change.
# ECG (___): Sinus rhythm. Old inferior wall myocardial
infarction. Compared to the previous tracing of ___ no
change.
# ECG (___): No acute cardiopulmonary process.
# ECG (___): Sinus bradycardia. Old inferior wall myocardial
infarction. Compared to the previous tracing rate is slower.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Chlorthalidone 25 mg PO DAILY
6. Citalopram 40 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
11. Lisinopril 40 mg PO DAILY
12. Senna 1 TAB PO BID
13. Calcium Carbonate 500 mg PO TID W/MEALS
14. Nitroglycerin SL 0.3 mg SL PRN chest pain
15. Ranitidine 150 mg PO BID
16. 70/30 40 Units Breakfast
70/30 30 Units Dinner
17. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Calcium Carbonate 500 mg PO TID W/MEALS
4. Carvedilol 25 mg PO BID
5. Chlorthalidone 25 mg PO DAILY
6. Citalopram 40 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. 70/30 40 Units Breakfast
70/30 30 Units Dinner
11. Lisinopril 40 mg PO DAILY
12. Ranitidine 150 mg PO BID
13. Senna 1 TAB PO BID
14. Nitroglycerin SL 0.3 mg SL PRN chest pain
15. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
16. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
17. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
18. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
RX *isosorbide mononitrate 120 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary: hypertension, chest pain
secondary: CAD, Diabetes
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - sometimes.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with chest pain.
COMPARISON: ___.
FINDINGS:
AP and lateral views of the chest. The lungs are clear. The
cardiomediastinal silhouette is unchanged given differences in positioning.
Degenerative change seen at the shoulders bilaterally. Median sternotomy
wires again noted.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS
temperature: nan
heartrate: 66.0
resprate: 18.0
o2sat: 98.0
sbp: 204.0
dbp: 59.0
level of pain: 10
level of acuity: 2.0 | ___ yo female with history of CVA, HTN/HL, DMII, and CAD s/p 3
vessel CABG (lima-lad (patent), svg-om (40-50% stenosis),
svg-rpda (subtotal occlusion) and PCI (BMS to RCA ___ on plavix
presenting with recurrent chest pain in setting of blood
pressure to 200s.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Chlor-Trimeton Allergy 12 hour
Attending: ___.
Chief Complaint:
back pain, weakness
Major Surgical or Invasive Procedure:
___ T5-9 Posterior Lami and Fusion
History of Present Illness:
Mrs. ___ is an ___ right-handed woman presenting with
bilateral leg weakness on a background of hypertension,
osteoporosis, breast cancer.
On ___ she was walking outside and slipped on ice. Her
feet slipped ahead and she fell on to her back, without hitting
her head. She managed to get into her house, but her brother,
___, then drove her to ___. Radiology at ___
noted a compression fracture, but this seems to have been on
plain film. She was referred to ___ and CT then demonstrates
a
transverse fracture through the T7 vertebral body. She has pain
alternating between the left and right chest which has prevented
her from lying down. She has been sleeping in a chair, but able
to get up and walk around, even lifting her arms above her head
and engaging in some daily tasks. She again slept in her chair
last night. She was able to get up and even got to the bathroom
to shower. She then noted that her legs were very weak and did
not feel that she could safely shower in the bathtub, into which
the shower flows. She managed to get into the tub, but noticed
that her saddle region and legs were numb. Then numbness
started just above the waist. Her abdomen then felt as it were
pregnant.
She has been having difficulty with constipation since starting
oxycodone and thus stopped taking it for two days. She returned
to taking Advil about five days ago. She was able to void this
morning, but it seemed to be a small volume that did not flow as
quickly as normal - this was before her numbness worsened in the
bath. Since that time she has not been to the bathroom. She
presently has some involuntary movements of her legs, flexion
and
more on the right. Further review of systems negative except as
above.
Past Medical History:
- Hysterectomy
- Breast cancer, lumpectomy, bilateral, ___, no
chemoradiation, but took Tamoxifen
- Appendicectomy
- Hypertension
- Osteoporosis, prior Fosamax
- Polypectomy
- T7 fracture as above
Social History:
___
Family History:
No back or neurological problems in family. ___ has some mild
back arthritis with thecal sac indentation, but he still plays
hockey.
Physical Exam:
ADMISSION
General Appearance: Comfortable, no apparent distress.
HEENT: NC, OP clear, MMM.
Neck: Supple. No bruits.
Lungs: CTA bilaterally.
Cardiac: RRR. Normal S1/S2. No M/R/G.
Abdominal: Soft, NT, BS+
Extremities: Warm and well-perfused. Peripheral pulses 2+.
Neurologic:
Mental status:
Awake and alert, cooperative with exam, normal affect.
Orientation: Oriented to person, place, date and context.
Language: Normal fluency, comprehension, repetition, naming. No
paraphasic errors.
Registration of three words at one trial and recall of all at
five minutes without hints.
Fund of knowledge for recent events within normal limits.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation. Normal
fundi.
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 symmetric.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Posture normal and no truncal ataxia.
Tone normal throughout. Normal bulk.
Power
D B T WE FE FF FAb | IP Q H AT G/S EDB TF
R 4+ 5 4+ ___ 5 | ___ ___
L ___ 5 4+ 5 4+ | ___ 4+ 5 4
Reflexes: B T Br Pa Ac
Right ___ 2 2
Left ___ 2 2
Increased amplitude of reflexes without spread, except for
bilateral cross-adductor.
Toes floridly upgoing bilaterally
Sensation intact to light touch, crudely. Vibration is
diminished on right costal margin, normal on left, trace at left
anterior spine of pelvis. Joint position with quite gross
errors
in both feet. Pin prick is reduced from about two inches above
the navel on the left and from about three inches above the
navel
on the right. There is no higher sensory level.
Normal finger nose, RAM's bilaterally in arms.
DISCHARGE
VS: 98.2 111/57 66 18 98% RA
Power
D B T WE FE FF FAb | IP Q H AT G/S EDB TF
R 4+ 5 4+ ___ 5 | 3* ___ 5 4-
L ___ 5 4+ 5 4+ | 3* 5- 4 4+ 5 4
* pain limited
Reflexes
Toes floridly upgoing bilaterally
Sensory deficits resolved.
Otherwise unchanged from admission above.
Pertinent Results:
___ 12:00PM BLOOD WBC-16.7*# RBC-4.63 Hgb-13.7 Hct-43.3
MCV-93 MCH-29.5 MCHC-31.6 RDW-13.0 Plt ___
___ 06:40AM BLOOD WBC-9.7 RBC-2.95* Hgb-8.6* Hct-27.3*
MCV-93 MCH-29.1 MCHC-31.4 RDW-13.2 Plt ___
___ 06:40AM BLOOD Glucose-127* UreaN-22* Creat-0.7 Na-138
K-4.2 Cl-99 HCO3-27 AnGap-16
___ 05:59AM BLOOD ALT-21 AST-31 AlkPhos-127* TotBili-0.5
___ 06:40AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.6
___ 05:35PM BLOOD PEP-NO SPECIFI
___ 04:49PM URINE U-PEP-NO PROTEIN
___ 09:12AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 09:12AM URINE RBC-0 WBC-3 Bacteri-MANY Yeast-NONE Epi-6
___ 9:12 am URINE Site: NOT SPECIFIED
ADDED TO ___ ON ___ AT 14:25.
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
___ MR ___ spine + contrast
1. Redemonstration of T7 vertebral body compression fracture
with progressive loss of vertebral body height with increase in
posterior retropulsion along with a likely associated hematoma
which results in increased encroachment upon the spinal canal
however without abnormal spinal cord signal or evidence of
edema.
2. New superior endplate compression fracture of the T8
vertebral body.
___ CT T spine
1. Chance type fracture of the T7 vertebral body as reported on
___ with a fracture extending from the anterior endplate
through the posterior elements where prior fusion has taken
place. Further loss of T7 vertebral height compared to ___.
2. Anterior superior endplate fracture of the T8 vertebral body
is unchanged from yesterday's MR, but new since ___.
___ XR T spine
Patient is status post spinal fusion between T5 and T8.
Scoliosis is present. Current film shows position of the
intrapedicular screws and the posterior rods. The alignment
appears satisfactory.
Medications on Admission:
1. Lisinopril 20 mg PO DAILY
2. Gabapentin 300 mg PO TID
3. Atenolol 100 mg PO DAILY
Discharge Medications:
1. Lisinopril 20 mg PO DAILY
2. Gabapentin 400 mg PO TID
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Atenolol 100 mg PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
___
Discharge Diagnosis:
T7 fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with weakness. Question pneumonia.
COMPARISONS: MRI of the thoracic spine from ___.
FINDINGS: Single supine AP view of the chest was provided. There is no focal
consolidation, pleural effusion or pneumothorax. The lungs are well expanded.
Cardiomediastinal silhouette is notable for aortic calcifications. The known
fracture of the T7 vertebral body is not clearly visualized on this single
projection. The visualized upper abdomen is unremarkable.
IMPRESSION: No focal consolidation.
Radiology Report
HISTORY: History of T7 compression fracture, now with acute onset extremity
weakness.
TECHNIQUE: Routine enhanced ___ MR examination of the cervical, thoracic
and lumbar spine was performed including axial T1-T1 post, T2 as well as
sagittal T1-T2 and stare sequences.
COMPARISON: MRI thoracic spine ___.
FINDINGS:
MR cervical spine: The cervical vertebral body heights and alignment are well
maintained. A hemangioma is noted within the C7 vertebral body. No other
osseous lesion is seen. Degenerative disk disease at the levels of C3 to C7
indent the ventral thecal sac and is most severe at C6-7. Ligamentum flavum
hypertrophy at the levels of C2-C4 as well as C5-C7 indent the posterior
thecal sac. There is no evidence of associated cord edema with normal spinal
cord size and signal. No epidural mass or collection is seen. No ligamentous
injury is identified. Multilevel facet joint arthropathy narrows the neural
foramina at multiple levels.
Thoracic spine: There is redemonstration of a compression fracture of the T7
vertebral body where there has been progressive loss of vertebral body height
with associated posterior buckling of the vertebral body margin which in
addition to a small of amount of abnormal material in the canal compresses the
spinal canal with minimal encroachment compared the prior exam but still
without evidence of cord edema or abnormal cord signal. The material in the
canal likely reflects hemorrhage, but the signal intensity is not
characteristic, perhaps because the process is too acute. There is new signal
abnormality in the superior endplate of the T8 vertebral body compatible with
new superior endplate compression fracture. Posterior disk protrusions from
T1-T3 and T4-T5 minimally indent the ventral thecal sac. There is no
high-grade neural foraminal stenosis.
MR lumbar spine: There is re-demonstration of an old moderate compression
deformity of the L1 vertebral body. The remainder of the lumbar vertebral
body heights are well preserved. There is mild associated retropulsion of the
superior aspect of the L1 vertebral body which indents the ventral thecal sac.
Redemonstration of type ___ ___ changes along the superior endplate of L3. No
expansile or destructive osseous lesion is seen. The conus and cauda equina
appear normal. The conus terminates at the L1 level. No epidural mass or
collection is seen.
IMPRESSION:
1. Redemonstration of T7 vertebral body compression fracture with progressive
loss of vertebral body height with increase in posterior retropulsion along
with a likely associated hematoma which results in increased encroachment upon
the spinal canal however without abnormal spinal cord signal or evidence of
edema.
2. New superior endplate compression fracture of the T8 vertebral body.
Results were discussed over the telephone with Dr. ___ by Dr.
___ at 14:40, ___ at time of initial review.
Radiology Report
HISTORY: Subacute T7 and new T8 compression fracture. Evaluate for fracture.
COMPARISON: MR total spine ___ MR thoracic spine ___.
TECHNIQUE: Axial helical MDCT images were obtained of the thoracic spine
without contrast. Multiplanar reformatted images were generated in the
coronal and sagittal planes.
DLP: 355 mGy-cm.
FINDINGS: Again appreciated is a mixed compression/Chance type fracture of
the T7 vertebral body with unchanged vertebral height compared to yesterday's
MR examination and progressive loss of vertebral body height compared to MR
examination from ___. As reported on prior MR examination from ___,
there is horizontal extension of the fracture line extending completely
throughout the vertebral body and the posterior elements with a visible
fracture line through the anterior endplate, extending all the way posteriorly
with a mildly displaced fracture through the posterior elements which appear
to be fused from prior fusion surgery from the level of T5 through to the
lumbar spine out of the imaged range of the study. The fracture extends
throughout the anterior and posterior columns. There is associated
retropulsion of the superior portion of the posterior vertebral body with
moderate stenosis of the spinal canal at this level as reported on prior MR.
___ addition, there is an anterior superior endplate compression fracture of T8
vertebral body, unchanged from yesterday's MR studies but new since the ___ examination. There is no significant loss of vertebral body height at
this level. No other fracture is identified.
There is S-shaped scoliosis of the thoracic spine with levoscoliosis of the
upper thoracic portion and dextroscoliosis of the lower thoracic portion.
There are multilevel degenerative changes as previously reported with
multilevel disc space narrowing, which appears most severe at T4/5.
Uncovertebral and facet hypertrophy narrow the neural foramina at multiple
levels. The imaged osseous structures are globally osteopenic in appearance.
The visualized portions of the lungs are unremarkable. The thoracic aorta is
of normal caliber. The visualized aspect of the retroperitoneum is
unremarkable.
IMPRESSION:
1. Chance type fracture of the T7 vertebral body as reported on ___ with
a fracture extending from the anterior endplate through the posterior elements
where prior fusion has taken place. Further loss of T7 vertebral height
compared to ___.
2. Anterior superior endplate fracture of the T8 vertebral body is unchanged
from yesterday's MR, but new since ___.
Results were discussed over the telephone with Dr. ___ by Dr. ___
___ at 2:12 p.m. on ___ immediately after initial review.
Radiology Report
HISTORY: T5 through T8 spinal fusion.
TECHNIQUE: Seven intra operative fluoroscopic images of the thoracic spine.
COMPARISON: CT examination performed ___.
FINDINGS:
Multiple intraoperative fluoroscopic images demonstrate posterior surgical
fixation hardware of indeterminant level. The surgical hardware appears
grossly intact on these limited provided images.
IMPRESSION:
Intraoperative fluoroscopic imaging was provided for T5 through T8 posterior
spinal fusion.
Please refer to the operative report for further evaluation.
Radiology Report
CLINICAL HISTORY: Status post thoracic fusion.
THORACIC SPINE, AP AND LATERAL
Patient is status post spinal fusion between T5 and T8. Scoliosis is present.
Current film shows position of the intrapedicular screws and the posterior
rods. The alignment appears satisfactory.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: WEAKNESS LOWER EXTREMITIES
Diagnosed with MUSCSKEL SYMPT LIMB NEC, SKIN SENSATION DISTURB, HYPERTENSION NOS
temperature: 99.5
heartrate: 50.0
resprate: 16.0
o2sat: 99.0
sbp: 128.0
dbp: 60.0
level of pain: 0
level of acuity: 1.0 | Patient was admitted to Neurology. Concern for cord compression
given histo CT scan though T7 demonstrated ___ fracture of
the vertebral body, with fracture of her prior fusion for the
scoliosis, rendering the spine unstable. MR revealed cord
signal changes. Neurosurgery was consulted.
On ___ the patient was taken to the OR with Dr ___ Dr
___ were no OR complications and the patient
recovered in the PACU and was transferred to ___ under
Neurosurgery. On POD 1, the patient was awake, comfortable, and
her motor strength seemed improved. Her diet was advanced. She
was measured for a TLSO brace. She was transferred back to the
Neurology Service.
Post-operatively the patient did well, with pain under good
control and some improvement in her strength. Urine culture was
positive for infection so ciprofloxacin was started x3 days.
Patient discharged to rehab for further physical therapy and
mobility needs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tetracycline / Zithromax /
Keflex / Macrodantin / Macrobid / Avelox / penicillin G /
Generic Cipro / Bee stings / Augmentin / sumatriptan /
Cephalosporins / clindamycin / azithromycin / methenamine /
trimethoprim
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
C: RLQ pain and lumps under skin
HPI(4): Ms. ___ is a ___ female with history of
diverticulitis s/p partial colectomy, hx of complicated C. diff
infection s/p fecal transplant, chronic functional abdominal
pain, CKD s/p right total and partial left nephrectomy, and
suspected CVID on q4week IVIG who presents with two days of
acute
onset right lower quadrant pain.
Current symptoms started suddenly 2 days ago with severe sharp
RLQ pain that woke her up from sleep. She notes that the pain
radiates down to the right groin and is worse after passing
stool. Her stool has been well formed and she denies
constipation
or straining to pass BM's recently. She notes lumps under the
skin in the area where the pain is. Her pain would come and go
when it first started but over the past 2 days it has become
more
frequent, longer lasting and more severe. She also reports
subjective fevers and chills as well as nausea with NBNB
vomiting
reportedly x8 total last episode last night. She is passing
flatus and denies symptoms of dyspepsia / reflux.
She presented to local ED 2 days ago when this pain first
started
where CT A/P showed diverticulosis without diverticulitis. She
was discharged home but continued to have pain as above and
called her PCP as well as GI clinic to try to be seen earlier
but
was advised to present to the ED after she described her pain as
so severe she was about to pass out.
Notably, she has had recurrent admissions including several so
far this year. She presented with RLQ abd pain prompting
admission in ___ which was felt to be largely functional in
nature.
In the ED:
VS: AFVSS PExam: Tearful, appears uncomfortable. Well-healed
scar
RLQ. Soft, ND. Severely tender RLQ without rebound or guarding.
Subcutaneous nodules b/l abdomen with overlying ecchymosis
Labs: lactate 1.0, CBC/CMP all wnl / at baseline
Imaging: CT A/P without acute process to explain RLQ pain
Impression: intractable pain with nausea, admit for pain control
Interventions: 4mg IV morphine x7, 1g IV tylenol, 1L LR
Consults: Chronic pain service consulted by ___ team
Course: "Had long discussion with the patient regarding normal
lab work and CT scan and being safe to be discharged. Trialed
p.o., which she vomited. Start discussing that outpatient
gastroenterology would be the best way to manage with these
symptoms, but patient fell unsafe to be home. Will admit for
intractable pain."
On arrival to the floor patient was again tearful stating that
she's doing her part including calling PCP and GI and attempted
to move her GI appointment up when she developed this new pain
but they were unable to see her before ___ (currently scheduled
follow up with Dr. ___. She states that she's not supposed
to be on the pepcid nor the hysocamine per Dr. ___. She also
notes that there was an issue with the Rifaximin prescription
and
she was never able to fill it after recent discharge. She notes
that her current pain which is in the RLQ and radiates down the
right groin is different from her known chronic back pain and
right hip pain. She states she has never had joint injections
due
to concern about immune suppression. She notes that her BM's
have
been well formed but her current pain has been worse after bowel
movements and she doesn't understand why that is. She denies
f/c,
diarrhea, dysuria, hematuria. She states she doesn't want to be
on narcotics including oral narcotics and is frustrated and
tearful because she's back in the hospiotal after a very recent
discharge.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
#CKD II (baseline Cr 1.0) s/p remote R nephrectomy and partial L
nephrectomy
#Recurrent nephrolithiasis s/p multiple lithotripsies
#Recurrent UTI/pyelonephritis
#Chronic abdominal pain
#C diff ___ and again ___ treated with vancomycin and
FMT ___, stopped PO vanco ___
#Diverticulitis complicated by abscess (s/p ___ R
hemicolectomy)
#H/o "pancreatic cyst" NOS and of unclear etiology
#Possible CVID, receives monthly IVIG
#Iron deficiency anemia
#Multiple provoked DVTs -- not on anticoagulation now
#HTN
#HLD
#Endocarditis (___)
#Asthma/COPD
#OSA, wears CPAP/BIPAP at home
#Hypothyroidism
#Parathyroid adenomas (three) s/p resection
#Steroid-induced hyperglycemia
#Glaucoma
#Migraines
#Allergic rhinitis
#H/o ventricular tachycardia
#Osteoporosis c/b L wrist fracture ___ ___nd old L
leg
fracture on x-ray
#H/o optic neuritis ___
#R hemicolectomy ___
#Lumbar laminectomy/fusion L4-L5, S1
#C3-7 ACDF by Dr. ___ ___
#Hx of b/l oophorectomy
Social History:
___
Family History:
PGF Deceased COLON CANCER
Mother ___ ___ MULTISYSTEM ORGAN FAILURE
BREAST CANCER
CAD
Pancreatic cysts, died in ___
Father ___ ___ CAD, CONGESTIVE HEART FAILURE
SMOKER, COPD
5 siblings: alive and well
Physical Exam:
EXAM(8)
VITALS: Temp: 98.6 (Tm 98.6), BP: 152/76, HR: 70, RR: 18, O2
sat:
95%, O2 delivery: RA
___: Weight: 141; ___: BMI: 24.2
GENERAL: Alert and tearful but otherwise comfortable appearing
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema. Oropharynx without
visible lesion, erythema or exudate
CV: Heart regular, +LUSB systolic 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, + ttp in RLQ with palpable
lumpy
subcutaneous nodules and echymosis. +Bowel sounds, no HSM.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly
symmetric, ttp at right hip with strength / motor testing
limited
by pain and poor effort
SKIN: No obvious rashes or ulcerations noted on cursory skin
exam
NEURO: Alert, oriented, face symmetric, speech fluent, moves all
limbs
PSYCH: pleasant, tearful, appropriate affect
Discharge physical exam
___ 1114 Temp: 98.5 PO BP: 116/69 HR: 68 RR: 18 O2 sat: 98%
O2 delivery: RA
General: lying on side, rubbing right hip, friendly and
interactive.
HEENT: OP moist, no LAD,
Resp CTA B, no rales, wheezes
CV RRR without murmurs
GI soft, tender in right lower quadrant. Few small subcutaneous
nodules.
MS: no edema. Negative straight leg raise on both legs. Pain
in right hip only with abduction with straight leg. Pain in SI
joint on right.
Neuro: alert/oriented X3, moving all extremities.
Pertinent Results:
DATA: I have reviewed the relevant labs, radiology studies,
tracings, medical records, and they are notable for:
WBC: 6.4 > HGB: 11.2 / HCT: 34.3 < Plt Count: 313; INR: 1.1
Na: 141 / K: 4.6 > Cl: 100 / CO2: 26 < BUN: 23* / Creat: 1.0
Glucose: 87; eGFR: 55/67; Ca: 8.8, Mg: 2.2, PO4: 4.1
AST: 19, ALT: 19; Alk Phos: 93, Total Bili: 0.2; Alb: 4.1
Micro:
UA:
___: Urine pH (Hem): 6.5
___: Urine Glucose (Hem): NEG
___: Urine Protein (Hem): NEG
___: Urine Bilirubin (Hem): NEG
___: Urobilinogen: NEG
___: Urine Ketone (Hem): NEG
___: Urine Blood (Hem): NEG
___: Urine Nitrite (Hem): NEG
___: Urine Leuks (Hem): SM*
UCx: ___: Urine Culture: URINE
CT abdomen:
OWER CHEST: The imaged lung bases are clear. There is no
evidence of
pericardial or pleural effusion.
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal mass lesions within the limitations of an unenhanced scan.
Multiple
cystic lesions are better appreciated on prior MRCP from ___.
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 right kidney is absent. There are stable
postsurgical changes of the left kidney, with tethering of the
left kidney to the posterior body wall again noted. There is no
evidence of focal renal lesions within the
limitations of an unenhanced scan. There is no hydronephrosis.
There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstratenormal caliber and wall thickness throughout.
Patient is post partial rightcolectomy, with anastomosis sutures
seen in the right mid abdomen. Diverticulosis of the remaining
colon is again noted, without evidence of diverticulitis. No
evidence of gastrointestinal obstruction. The appendix isnot
visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within
normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate
atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
Patient is post L4-S1 laminectomy and posterior fusion, which
appears
unchanged.
SOFT TISSUES: Injection granulomas are noted in the anterior
abdominal
subcutaneous fat.
IMPRESSION:
No acute findings in the abdomen or pelvis to correlate with
patient's
symptoms.
Discharge labs:
___ 08:15AM BLOOD WBC-4.0 RBC-3.74* Hgb-10.5* Hct-32.0*
MCV-86 MCH-28.1 MCHC-32.8 RDW-14.2 RDWSD-44.2 Plt ___
___ 08:15AM BLOOD Neuts-47.5 ___ Monos-8.2 Eos-2.2
Baso-0.0 Im ___ AbsNeut-1.90 AbsLymp-1.68 AbsMono-0.33
AbsEos-0.09 AbsBaso-0.00*
___ 08:15AM BLOOD Glucose-90 UreaN-21* Creat-1.0 Na-142
K-4.8 Cl-102 HCO3-23 AnGap-17
___ 08:15AM BLOOD ALT-18 AST-21 LD(LDH)-193 AlkPhos-84
TotBili-0.3
___ 08:15AM BLOOD Albumin-3.8 Calcium-8.6 Phos-4.9* Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Fosfomycin Tromethamine 3 g PO Q10DAYS
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Lisinopril 10 mg PO QHS
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Rosuvastatin Calcium 20 mg PO QPM
10. Senna 17.2 mg PO BID:PRN constipation
11. TraMADol 50 mg PO Q6H:PRN Pain - Severe
12. vancomycin 125 mg oral BID
13. Ondansetron ODT 4 mg PO Q8H:PRN nausea
14. Citracal + D Maximum (calcium citrate-vitamin D3) 3 tablets
oral Q12H
15. bimatoprost 0.01 % ophthalmic (eye) QHS
16. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
17. Gabapentin 300 mg PO TID
18. Lidocaine 5% Patch 2 PTCH TD QAM
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. bimatoprost 0.01 % ophthalmic (eye) QHS
4. Carvedilol 12.5 mg PO BID
5. Citracal + D Maximum (calcium citrate-vitamin D3) 3 tablets
oral Q12H
6. Diltiazem Extended-Release 180 mg PO DAILY
7. Fosfomycin Tromethamine 3 g PO Q10DAYS
8. Gabapentin 300 mg PO TID
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Lidocaine 5% Patch 2 PTCH TD QAM
11. Lisinopril 10 mg PO QHS
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Ondansetron ODT 4 mg PO Q8H:PRN nausea
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Rosuvastatin Calcium 20 mg PO QPM
16. Senna 17.2 mg PO BID:PRN constipation
17. TraMADol 50 mg PO Q6H:PRN Pain - Severe
18. vancomycin 125 mg oral BID
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Chronic right hip and back pain
Hypertension
Nausea and vomiting
Chronic C. diff infection
Discharge Condition:
tolerating diet, ambulating
Followup Instructions:
___
Radiology Report
EXAMINATION: CT TORSO WITH CONTRAST
INDICATION: ___ with partial hemicolectomy p/w severe RLQ pain x 2d// Please
evaluate for hernia, diverticulitis, or other intra-abdominal pathology. Will
need PO contrast, no IV contrast given CKD
TECHNIQUE: Axial multidetector CT images were obtained through the torso
after the uneventful administration of intravenous contrast. 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.
Oral contrast was administered.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.7 s, 44.6 cm; CTDIvol = 11.9 mGy (Body) DLP = 528.7
mGy-cm.
Total DLP (Body) = 529 mGy-cm.
COMPARISON: None.
CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: The imaged lung bases are clear. There is no evidence of
pericardial or pleural effusion.
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal mass lesions within the limitations of an unenhanced scan. Multiple
cystic lesions are better appreciated on prior MRCP from ___.
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 right kidney is absent. There are stable postsurgical changes of
the left kidney, with tethering of the left kidney to the posterior body wall
again noted. There is no evidence of focal renal lesions within the
limitations of an unenhanced scan. There is no hydronephrosis. There is no
nephrolithiasis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. Patient is post partial right
colectomy, with anastomosis sutures seen in the right mid abdomen.
Diverticulosis of the remaining colon is again noted, without evidence of
diverticulitis. No evidence of gastrointestinal obstruction. 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 uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Patient is post L4-S1 laminectomy and posterior fusion, which appears
unchanged.
SOFT TISSUES: Injection granulomas are noted in the anterior abdominal
subcutaneous fat.
IMPRESSION:
No acute findings in the abdomen or pelvis to correlate with patient's
symptoms.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: N/V, RLQ abdominal pain
Diagnosed with Nausea with vomiting, unspecified
temperature: 96.6
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 180.0
dbp: 76.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is a ___ female with history of
diverticulitis s/p partial colectomy, hx of complicated C. diff
infection s/p fecal transplant, chronic functional abdominal
pain, CKD s/p right total and partial left
nephrectomy, and suspected CVID on q4week IVIG who presents with
two days of acute onset right lower quadrant pain, likely reated
to either exacerbation of her chronic abdominal pain syndrome,
or referred pain from her right si joint and back pain.. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Progressive gait unsteadiness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with history of complex
cardiac risk factors including diastolic heart failure, aortic
and mitral valve replacement, atrial fibrillation on Coumadin,
pacemaker for tachy-brady syndrome (___), HTN, HLD and
cervical sponylosis s/p C3-7 fusion who presents with subacute,
progressive gait unsteadiness, to the point of being acutely
unable to walk today. History provided by Mr. ___ and
___.
Mr. ___ reports that for the last several months, he has had
progressive unsteadiness of his gait. This began in ___,
___
after he underwent pacemaker placement for tachy-brady syndrome.
He noticed that he felt "wobbly" when talking around the house,
but would not sway in one direction of the other. No vertigo, no
lightheadedness, no focal weakness or sensory changes. He had
several falls at home which he did not make of and attributed to
normal changes with age. He had no head trauma or loss of
consciousness.
However, for the last few days, his gait has been more unsteady,
to the point that he was unable to ambulate at all today. He has
difficulty describing why exactly he cannot walk, other than
saying "it feels like I want to walk backwards instead of
forwards." Denies that it is due to weakness or sensory
changes.
This is unusual for him as he usually is still able to ambulate
without an assistive device, despite having the subacute
unsteady
gait and falls described above. When it got the point that he
could not get out of bed, he came to ___ this evening
for
further evaluation.
On arrival to ___, Mr. ___ had benign vitals
(afebrile, HR ___ in afib). The medical team there did not
appreciate any focal neurologic deficits, but he was unable to
walk even with significant assistance. Remainder of workup was
notable for elevated BUN/Cr (___), INR 2.6 and CTA Head/Neck
revealing critical stenosis of right ICA, distal to the carotid
bifurcation, with good collateralization of the remainder of its
course.
Throughout this time, he denies any neurologic deficits
associated with positional changes.
Past Medical History:
-Aortic and mitral valve replacement (___ mechanical valve;
___
-Diastolic heart failure
-Atrial fibrillation on Coumadin
-Pacemaker for tachy-brady syndrome (___), HTN, HLD and
cervical sponylosis s/p C3-7 fusion
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused; irregularly irregular on
telemetry
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate basic history without difficulty,
though does not provide much detail. He takes frequent pauses
during the examination. He is somewhat inattentive, able to name
___ backward until ___, then starts going forward again (i.e.
back to ___. 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. The pt had
good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI with 2 beats of left beating nystagmus on
leftward gaze that extinguishes, as well as 2 beats of right
beating nystagmus on rightward gaze which extinguishes. 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, mildly increased tone present in legs
bilaterally. Left arm cupping present on drift testing; no
pronator drift. 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
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, proprioception
throughout in toes and index finger bilaterally. No extinction
to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 ___ beats of clonus
R 3 3 3 3 2
Plantar response was mute on L, flexor on R
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF, HKS or mirroring testing bilaterally.
-Gait: Delayed initiation. Narrow-based, shuffling gait with
significantly decreased stride length. Very unsteady, sways
alternating between R and L directions. Had to be directed back
to bed shortly after due to unsteadiness.
DISCHARGE PHYSICAL EXAM:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused; NSR on telemetry
Abdomen: soft, NT/ND
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation, conversational, requesting to go home. Normal
fluent
speech with no paraphasic errors. Speech was not dysarthric.
There was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. Intact visual fields to
confrontation.
III, IV, VI: Mildly restricted upgaze. Otherwise Extraocular
movements intact. 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:
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, proprioception
throughout in toes and index finger bilaterally. No extinction
to
DSS. Proprioception accurate b/l to large movements, inaccurate
with small movements. Cool touch intact b/l lower and upper
extremities. Vibration: 2 seconds at great toe b/l, 5 seconds at
ankles b/l, 4 seconds at knees b/l, hands ___ seconds. No
sensory level b/l back.
Vibration: 2 seconds at great toe b/l, 5 seconds at ankles b/l,
4 seconds at knees b/l, hands ___ seconds. No sensory level
b/l
back.
-Coordination: No pronator drift. No dysmetria on FTN b/l.
-Gait: Patient ambulated using walker with fairly steady, normal
based gait.
Pertinent Results:
___ 03:08AM BLOOD WBC-4.2 RBC-3.57*# Hgb-11.7* Hct-35.2*
MCV-99*# MCH-32.8*# MCHC-33.2 RDW-13.6 RDWSD-49.3* Plt ___
___ 04:42AM BLOOD ___ PTT-35.8 ___
___ 03:08AM BLOOD Glucose-99 UreaN-21* Creat-1.1 Na-140
K-3.1* Cl-103 HCO3-28 AnGap-12
___ 03:08AM BLOOD ALT-17 AST-24 AlkPhos-158* TotBili-0.6
___ 03:08AM BLOOD Lipase-68*
___ 03:08AM BLOOD Albumin-3.3* Cholest-185
___ 03:08AM BLOOD VitB12-1000* Folate-6
___ 06:47AM BLOOD %HbA1c-6.0 eAG-126
___ 03:08AM BLOOD Triglyc-103 HDL-42 CHOL/HD-4.4
LDLcalc-122
___ 03:08AM BLOOD TSH-1.4
___ 03:08AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ CTA H&N
Shows significant R ICA stenosis distal to carotid bifurcation
___ 07:10AM BLOOD WBC-4.3 RBC-3.76* Hgb-12.2* Hct-37.0*
MCV-98 MCH-32.4* MCHC-33.0 RDW-13.6 RDWSD-49.4* Plt ___
___ 07:10AM BLOOD ___ PTT-33.2 ___
___ 07:10AM BLOOD Glucose-89 UreaN-23* Creat-1.1 Na-137
K-3.9 Cl-99 HCO3-27 AnGap-15
ECHO ___:
Conclusions
No left atrial mass/thrombus seen (best excluded by
transesophageal echocardiography). The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). The estimated cardiac index is normal (>=2.5L/min/m2).
Right ventricular chamber size and free wall motion are normal.
A mechanical aortic valve prosthesis is present. The transaortic
gradient is higher than expected for this type of prosthesis.
Trace aortic regurgitation is seen. [The amount of regurgitation
present is normal for this prosthetic aortic valve.] A
mechanical mitral valve prosthesis is present. The gradients are
higher than expected for this type of prosthesis. No mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation ___ be significantly UNDERestimated.]
There is mild moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Well seated mechanical aortic valve prosthesis with
mobile leaflets but increased gradient. Well seated mechanical
mitral valve prosthesis with mobile leaflets but increased
gradient. Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function.
Mild-moderate pulmonary artery systolic hypertension.
If clinically indicated, a TEE would be better able to identify
an atrial thrombus and to characterize mitral valve disc motion.
Medications on Admission:
Esomeprazole 40mg PO Q12H
Ferrous sulfate 325mg daily
Cyanocobalamin 1000mcg daily
Diltiazem CD 360mg daily
Metoprolol succinate 200mg daily
Warfarin 9mg PO daily
Furosemide 100mg daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg PO BID
2. Rolling Walker
Dx: Cervical Spinal Disease
Px: Good
___: 13 months
3. Cyanocobalamin 1000 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Warfarin 9 mg PO DAILY16
6. HELD- Diltiazem Extended-Release 180 mg PO DAILY This
medication was held. Do not restart Diltiazem Extended-Release
until follow up with primary care provider
7. HELD- Esomeprazole 40 mg Other Q12H This medication was
held. Do not restart Esomeprazole until follow up with primary
care provider
8. HELD- Furosemide 100 mg PO DAILY This medication was held.
Do not restart Furosemide until follow up with primary care
provider.
9. HELD- Metoprolol Succinate XL 400 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until follow up with primary care provider
10.Rolling Walker
Dx: Cervical Spinal Disease
Px: Good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
acute worsening of pre-existing progressive gait difficulties
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 dizziness// Eval for PNA, pulm edema, acute
process
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
Patient has had median sternotomy and at least aortic and mitral valve
replacements and coronary bypass graft surgery. Heart size is normal.
Transvenous right atrial lead is in standard placement; right ventricular lead
intercepts the upper anterior wall of the right ventricle after traversing the
inferior cavoatrial junction.
Lungs are clear. No pleural effusion.
Hiatus hernia transmits a large portion of stomach. Allowing for
diaphragmatic eventration is, lung volumes suggest hyperinflation due to
emphysema.
Lateral view shows moderate compression of 2 mid thoracic vertebral bodies and
mild loss of height of other vertebral bodies, all severely osteopenic..
Cervical spine stabilization hardware is not fully imaged on this study.
IMPRESSION:
1. Possible non standard course, right ventricular pacer lead. Clinical
correlation advised.
2. Possible emphysema.
3. Large hiatus hernia.
4. Moderately severe mid thoracic vertebral compression fractures.
Radiology Report
EXAMINATION: CAROTID DOPPLER ULTRASOUND
INDICATION: ___ year old man with critical R ICA stenosis per OSH CTA, please
eval for ICA stenosis// eval ICA stenosis
TECHNIQUE: Real-time grayscale and color and spectral Doppler ultrasound
imaging of carotid arteries was obtained.
COMPARISON: CTA from ___
FINDINGS:
RIGHT:
The right carotid vasculature has moderate calcified atherosclerotic plaque.
The right common carotid artery had peak systolic/diastolic velocities of
53/15 cm/sec.
The right internal carotid artery had peak systolic/diastolic velocities of
71/29 cm/sec in its proximal portion, 119/37 cm/sec in its mid portion and
124/40 cm/sec in its distal portion.
The external carotid artery has peak systolic velocity of 115 cm/sec.
The vertebral artery has peak systolic velocity of 49 cm/sec with normal
antegrade flow.
The right ICA/CCA ratio is 2.3.
LEFT:
The left carotid vasculature has mild heterogeneous plaque atherosclerotic
plaque.
The left common carotid artery had peak systolic/diastolic velocities of 68/23
cm/sec.
The left internal carotid artery had peaks systolic/diastolic velocities of
73/25 cm/sec in its proximal portion, 88/35 cm/sec in its mid portion and
105/41 cm/sec in its distal portion.
The external carotid artery has peak systolic velocity of 99 cm/sec.
The vertebral artery has peak systolic velocity of 49 cm/sec with normal
antegrade flow.
The left ICA/CCA ratio is 1.2.
IMPRESSION:
Approximately 50% stenosis in the right internal carotid artery. Mild
atherosclerotic plaque without significant stenosis in the left internal
carotid artery.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with worsening gait and ?hypodensity in L MCA
territory// ?evolution of L hypodensity, please obtain ___ at 5am
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
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: Outside hospital CTA and CT head of ___
FINDINGS:
There is no intra or extra-axial mass effect, acute hemorrhage or large
territory infarct. Minimal periventricular and subcortical white matter
hypodensities, most prominently noted in the left subinsular region are
nonspecific and may represent sequela of chronic microangiopathy in a patient
this age, unchanged from prior exam. The sulci, ventricles and cisterns are
within expected limits for the degree of mild to moderate senescent related
global cerebral volume loss. There is mild atherosclerotic calcification of
the internal carotid arteries and right vertebral artery. The visualized
paranasal sinuses are essentially clear. The orbits are unremarkable. The
mastoid air cells and middle ears are well pneumatized and clear. No acute
osseous abnormality.
IMPRESSION:
1. No evidence of acute intracranial abnormality on noncontrast head CT.
Specifically no large territory infarct or intracranial hemorrhage.
2. Additional findings as described above.
Radiology Report
EXAMINATION: CT THORACIC WANDW/O CONTRAST Q323 CT SPINE
INDICATION: ___ year old man with mid thoracic fracture on cxr presenting with
worsening gait. Vertebral compression, ? hematoma/abscess
TECHNIQUE: Contrast enhanced helical multidetector CT was performed. Soft
tissue and bone algorithm images were generated. Coronal and sagittal
reformations were then constructed. 130 cc Omnipaque 350 administered.
DOSE: Acquisition sequence:
1) Spiral Acquisition 35.3 s, 54.0 cm; CTDIvol = 15.2 mGy (Body) DLP =
798.8 mGy-cm.
Total DLP (Body) = 821 mGy-cm.
COMPARISON: PA and lateral chest radiograph of ___..
FINDINGS:
Evaluation for fine detail is limited due to diffuse osteopenia. The
alignment is overall anatomic. Anterior wedging deformities at T3 and T7 with
less than 50% vertebral height loss, and T6 with greater than 50% vertebral
body height loss are age indeterminate. Subtle cortical irregularity and mild
anterior wedging deformity at T12 is also noted. There is disc space loss at
L5-S1. There is no evidence of high-grade spinal canal or neural foraminal
stenosis. Patient is status post partial laminectomy at L5 with bone graft
material in place. There is neural stimulator with leads at L5-S1. Posterior
to the laminectomy site, there is a fluid collection with slight enhancement
of the rim measuring 4.0 x 2.8 cm (3:151). The central hypodensity measures
fluid density. There is no evidence of infection or neoplasm.
Calcified granuloma is seen in the right lower lobe (03:56). There is also 4
mm right lower lobe (series 3, image 77). Patient is status post left chest
wall pacemaker with leads partially imaged. There is large hiatal hernia
containing more than 50% of the stomach. There is no evidence of bowel
obstruction. A 1 cm hypoattenuating nodule in the right lobe of the thyroid
requires no further follow-up per current ACR recommendations for incidentally
noted thyroid nodules in the absence of more worrisome clinical history.
IMPRESSION:
1. Multiple anterior wedging deformities, without significant prevertebral
swelling, felt likely to represent chronic compression fractures however,
determination of chronicity is limited due to absence of prior exams.
2. Status post partial laminectomy at L5 with postsurgical changes. Slightly
heterogeneous fluid collection with evidence of rim enhancement in the
surgical bed measuring 4.0 x 2.8 cm, likely represents a postoperative seroma.
However, clinical correlation is recommended, with low threshold for reimaging
if there is high clinical concern for infectious process.
3. No evidence of high-grade spinal canal or neuroforamen narrowing. However,
if patient is able to tolerate, MRI would be helpful for evaluation of spinal
cord and exiting nerve roots.
4. A 4 mm right lower lobe pulmonary nodule.
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 recommend in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
NOTIFICATION: The findings were discussed with ___. by ___
___, M.D. on the telephone on ___ at 3:07 pm, 10 minutes after discovery
of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Unsteady gait, Transfer
Diagnosed with Cerebral infarction, unspecified
temperature: 97.7
heartrate: 65.0
resprate: 16.0
o2sat: 96.0
sbp: 136.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | Pt initially presented with subacute, progressive gait
unsteadiness, to the point of being acutely unable to walk with
R ICA stenosis seen on CTA H&N at OSH. He was transferred to
___ for further evaluation and was subsequently admitted to
the Stroke Service.
While admitted, pt was monitored on telemetry and underwent
laboratory workup to look for stroke risk factors. He was noted
to have LDL of 122 with Atorvastatin 40mg being started as
treatment. He was evaluated by ___ who recommended home
services and provision of rolling walker.
He had a normal folate and B12 level, and other labs including
copper, RPR, and vitamin E were checked but had not resulted by
discharge. He had a chest x ray showing mid thoracic vertebral
compression fractures. CT thoracic/lumbar spine showed Multiple
anterior wedging deformities, without significant prevertebral
swelling. Status post partial laminectomy at L5 with
postsurgical
changes. Slightly heterogeneous fluid collection in the surgical
bed measuring 4.0 x 2.8 cm is noted. Evaluation for superimposed
infection is limited and cannot be excluded on the basis of
current imaging. If clinically indicated, contrast enhanced exam
would be helpful. No evidence of spinal canal or neuroforamen
narrowing. Also noted was A 4 mm right lower lobe pulmonary
nodule. 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 recommend in a high-risk patient. See the ___
___ Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___. Patient should
follow up with PCP to determine need for follow up CT in one
year.
Patient's home blood pressure regimen was held as patient's
systolic blood pressures running low. Patient started on
metoprolol tartrate at 25mg BID, which kept his blood pressure
and heart rate adequately controlled. Patient had improvement in
ambulation, and with the aid of a walker and assistance of ___ he
was able to ambulate.
Patient had episode of chest pain associated with pacer spikes
while at ECHO ___. EP consulted to determine nature of
pacemaker firing. Chest pain similar to episodes of chest pain
patient experiences regularly at home.
EP changed mode to RYTHMIQ AAI with VVI backup at programmed
search
AV delay of 400ms. Autocapture was turned off and RV output was
set at 1.5V at 0.40ms. Reproducible chest pain symptoms which
correlated directly
with ventricular pacing; pacemaker otherwise functioning
normally. EP recommended follow up with Outpatient EP
cardiologist Dr. ___ for consideration of elective
pacemaker lead repositioning. Patient deemed stable for
discharge home with outpatient follow up with PMD/Cardiologist
Dr. ___ neurology, as well as in ___ clinic ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Cipro
Attending: ___.
Chief Complaint:
nausea, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of bipolar disorder who is ___ s/p recent
laparoscopic cholecystectomy ___ with Dr. ___ who presented to the ER today with complaint of
nausea, emesis, and abdominal pain x 1 day. The patient reports
eating this morning and experiencing sudden-onset severe
post-prandial RUQ/epigastric abdominal pain with associated
nausea. The pain was non-radiating. She subsequently had
multiple
bouts of non-bloody, reportedly bilious emesis and has been
unable to tolerate oral intake since. Last BM was ___ prior
to
surgery but she reports she is passing flatus. Does not feeling
distended. Has been taking 5mg oxycodone q8hours at home
post-operatively. Denies fevers, chills, chest pain, SOB.
Past Medical History:
PMH:
Bipolar d/o
Graves disease
DJD
HTN
HL
PSH:
lap cholecystectomy ___
left total knee replacement
Social History:
___
Family History:
FH: noncontributory
Physical Exam:
VS: 98.4 152/77 73 16 94RA
GEN: Pleasant female in NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI
CARDIAC: RRR, no murmurs
CHEST: No increased work of breathing, (-) cyanosis.
ABDOMEN: soft, non-tender, non-distended, port incision sites
are c/d/i
EXTREMITIES: Warm, well perfused, no edema
NEURO: AA&O x 3
Pertinent Results:
___ 01:33PM BLOOD WBC-15.8*# RBC-4.90 Hgb-14.1 Hct-45.6*#
MCV-93 MCH-28.8 MCHC-30.9* RDW-12.0 RDWSD-41.7 Plt ___
___ 09:41AM BLOOD WBC-15.0* RBC-4.31 Hgb-12.5 Hct-39.2
MCV-91 MCH-29.0 MCHC-31.9* RDW-11.9 RDWSD-39.8 Plt ___
___ 05:10AM BLOOD WBC-11.8* RBC-3.99 Hgb-11.6 Hct-35.8
MCV-90 MCH-29.1 MCHC-32.4 RDW-12.1 RDWSD-40.2 Plt ___
___ 01:33PM BLOOD Glucose-107* UreaN-11 Creat-0.7 Na-138
K-5.6* Cl-99 HCO3-25 AnGap-20
___ 12:14AM BLOOD Glucose-113* UreaN-8 Creat-0.6 Na-137
K-4.2 Cl-101 HCO3-23 AnGap-17
___ 05:20AM BLOOD Glucose-95 UreaN-8 Creat-0.6 Na-140 K-3.9
Cl-101 HCO3-27 AnGap-16
___ 05:10AM BLOOD Glucose-93 UreaN-7 Creat-0.5 Na-135 K-3.5
Cl-100 HCO3-24 AnGap-15
___ 03:08PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 01:33PM BLOOD ALT-38 AST-60* AlkPhos-90 TotBili-0.4
___ 05:20AM BLOOD ALT-28 AST-23 AlkPhos-93 TotBili-0.5
Medications on Admission:
Trazodone 100 qHS
Gabapentin 300''
Trileptal 300'
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Docusate Sodium 100 mg PO BID
Hold for loose stools
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
3. Ondansetron ___ mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
RX *ondansetron 4 mg ___ tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
4. Senna 8.6 mg PO BID
Hold for loose stools.
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30
Tablet Refills:*0
5. Gabapentin 300 mg PO BID
6. TraZODone 100 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
post-operative nausea
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: ___ recent ccy eval for free air w abd pain// ___ recent ccy eval
for free air w abd pain
TECHNIQUE: Single frontal view of the chest
COMPARISON: None
FINDINGS:
The lungs are relatively hyperinflated. No focal consolidation is seen.
There is no pleural effusion or pneumothorax. The cardiac silhouette is
mildly enlarged. Mediastinal contours are unremarkable. No evidence of free
air is seen beneath the diaphragms.
IMPRESSION:
No evidence of free air beneath the diaphragm.
Radiology Report
EXAMINATION: CT ABDOMEN PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; ___ w/ severe abd pain after lap chole. evaluate
for bowel perforation, hematoma.NO_PO contrast// ___ w/ severe abd pain after
lap chole. evaluate for bowel perforation, hematoma.
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 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP =
10.8 mGy-cm.
2) Spiral Acquisition 4.8 s, 52.0 cm; CTDIvol = 10.6 mGy (Body) DLP = 548.1
mGy-cm.
Total DLP (Body) = 559 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is mild bibasilar atelectasis. There is no evidence of
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is surgically absent.
Trace free fluid is seen around the liver.
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. Trace free fluid is seen around the spleen.
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. Multiple small foci
at of intraperitoneal air is seen which is most likely secondary to
postoperative changes for focal bowel perforation cannot be completely
excluded though no bowel edema or drainable fluid collections are seen.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
trace free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Multiple small foci of subcutaneous free air is seen compatible
with recent history of laparoscopic cholecystectomy.
IMPRESSION:
Multiple small foci of subcutaneous and free intraperitoneal air, centered on
the right, with trace free fluid around the liver, spleen and within the
pelvis that is felt to most likely be secondary to postoperative changes
however underlying bowel perforation cannot be completely excluded. No focal
sites of bowel wall edema or drainable fluid collections are seen.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephoneon ___ at 3:34 pm, 5 minutes after discovery of
the findings.
Radiology Report
INDICATION: ___ F ___ s/p lap cholecystectomy p/w abd pain, n/v,
leukocytosis, and new tachycardia// please eval for pneumoperitoneum
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
No focal consolidation, pleural effusion or pneumothorax identified. Right
apical pleuroparenchymal thickening is unchanged. The size of the cardiac
silhouette is within normal limits. No evidence of free air below the
diaphragm.
IMPRESSION:
No evidence of free air beneath the diaphragm.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, N/V
Diagnosed with Unspecified abdominal pain
temperature: 97.4
heartrate: 76.0
resprate: 20.0
o2sat: nan
sbp: 156.0
dbp: 78.0
level of pain: 8
level of acuity: 2.0 | The patient is a ___ with history of bipolar disorder who
presented to the ER on ___ s/p laparoscopic cholecystectomy
___ with Dr. ___ with complaint of nausea,
emesis, and abdominal pain x 1 day. Her labwork was notable for
a WBC of 15.8 but LFTs were normal. CT abdominal imaging
demonstrated no drainable fluid collections and no evidence of
bowel perforation or obstruction. Cardiac work-up (EKG,
troponins) were negative. Given the patient's po intolerance and
leukocytosis without clear source, she was admitted for
observation, IV fluid hydration, and IV anti-nausea medication.
Her nausea and pain gradually improved with Zofran and a
scopolamine patch. Her diet was advanced from clears to regular,
which she tolerated by time of discharge. She will go home with
a prescription for standing Zofran for 4 days and then prn
Zofran subsequently. Her WBC improved from 15.8 to 15 to 11.8 by
time of discharge. She remained afebrile and hemodynamically
stable.
During her stay, she was also noted to be hypertensive with SBP
between 150-170. She was therefore started on amlodipine 5mg
with good results. She was advised to follow up with her primary
care physician ___ 1 weeks regarding blood pressure management.
She will follow up in general surgery clinic in ___ weeks as
previously scheduled. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Acetaminophen / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
protracted vomiting, weight loss, loss of appetite, fatigue and
mental status changes.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH significant for DM, depression and rectal
incontinence presents evaluation of altered mental status,
weight loss, nausea, vomiting. The history is somewhat limited
from the patient as she denies all symptoms, although this is a
feature of her overall mental status. Per a detailed primary
care visit from earlier today, the patient is reportedly had
many months of uncontrolled nausea and vomiting as well as
approximately 100 pounds of weight loss over the past ___ years.
She claims that this was all done through dieting and portion
control. She reports 2 episodes of stomach pain and dry heaving
on the way to Dr. ___ today. Per pt, she had a 1 wk
of bilious vomiting and diarrhea ___ weeks ago. She denies any
sick contacts or eating out during this time. She had a 3lb wt
loss during the week long episode. Denies fever, chills,
hematemesis, melena, hematochezia, HA, dizziness, cough, SOB,
CP, dysuria, frequency.
Coinciding with this, the patient has reportedly a long history
of cognitive decline mainly feature of multiple falls,
disorganization with her ADLs as well as poor self care. She
reportedly lives in a ___ in ___, and the owner of the
___ is unwilling to have her live there anymore due to
concerns for the patient's overall well being. On my interview,
the patient denies any abuse features and her only complaint is
her persistent nausea and vomiting. Additional history obtained
from the patient's daughter confirms these features of likely
cognitive decline, and she insists that we did not tell the
patient she likely to be admitted patient will likely try to
leave.
In the ___, vitals were 98.4 98 120/59 18 100% RA. Labs were
remarkable for potassium of 5.9 (hemolyzed - recheck 5.1), BUN
30, AST 51, ALT 17. UA was positive for nitrates with few
bacteria and 7 WBCs. CXR showed no acute process. CTA abd/pelvis
showed no acute intraabdominal process with a small
non-obstructing stone in R kidney lower pole. CT head w/o
contrast showed no acute intracranial process. She received CTX
1gm IV.
At the time of transfer, vitals were 97.8 90 155/80 17 100% RA.
On the floor, pt reports that she feels well and is eating
during the interview. For me, pt is AAOx3 and answer all
questions correctly and appropriately.
Review of Systems:
(+) as per HPI, +urgency
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria, frequency.
Past Medical History:
DIABETES MELLITUS
DEPRESSION
H/O FREQUENT FALLS
CHRONIC PANCREATITIS
OBESITY
RECTAL INCONTINENCE
RIGHT ARM PARESTHESIAS
H/O UROLITHIASIS
Social History:
___
Family History:
Grandmother, father, brother all have colorectal cancer.
Physical Exam:
ADMISSION EXAM:
Vitals- 97.9, 122/58, 82, 16, 100%RA
General- Alert, oriented x3, no acute distress, sitting up in
bed, pleasant
HEENT- Atraumatic, Sclera anicteric, PERRL, EOMI, MMM,
oropharynx clear, poor dentition
Neck- supple, JVP not elevated, no anterior LAD, small 1cm lump
on right posterior neck just below hair line (mobile, nontender,
well circumscribed)
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1 + S2, +S4, no murmurs or
rubs
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, lots of
excess skin
GU- no foley, no suprapubic tenderness, no CVA tenderness
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM:
Vitals- 97.5, 131/66, 87, 18, 99%RA
General- Alert, oriented x3, no acute distress, lying in bed,
pleasant
HEENT- Atraumatic, Sclera anicteric, PERRL, EOMI, MMM,
oropharynx clear, poor dentition
Neck- supple, JVP not elevated, no anterior LAD, small 1cm lump
on right posterior neck just below hair line (mobile, nontender,
well circumscribed)
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs or rubs
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, lots of
excess skin/tissue
GU- no foley, no suprapubic tenderness, no CVA tenderness
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 10:30AM BLOOD WBC-8.7 RBC-4.02* Hgb-12.7 Hct-36.2
MCV-90 MCH-31.5 MCHC-35.0 RDW-14.0 Plt ___
___ 10:30AM BLOOD Neuts-69.0 ___ Monos-4.9 Eos-2.8
Baso-0.7
___ 10:30AM BLOOD Glucose-104* UreaN-30* Creat-0.9 Na-136
K-5.9* Cl-99 HCO3-25 AnGap-18
___ 10:30AM BLOOD ALT-17 AST-51* AlkPhos-44 TotBili-0.3
___ 10:30AM BLOOD Lipase-31
___ 10:30AM BLOOD Albumin-4.1
___ 11:58AM BLOOD K-5.1
___ 04:47PM BLOOD Lactate-1.0
___ 03:30PM URINE Color-Straw Appear-Hazy Sp ___
___ 03:30PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
___ 03:30PM URINE RBC-<1 WBC-7* Bacteri-FEW Yeast-NONE
Epi-<1
___ 03:30PM URINE CastHy-1*
PERTINENT LABS:
___ 06:35AM BLOOD WBC-5.7 RBC-3.81* Hgb-11.8* Hct-34.7*
MCV-91 MCH-30.9 MCHC-33.9 RDW-13.4 Plt ___
___ 06:35AM BLOOD Glucose-89 UreaN-18 Creat-0.8 Na-138
K-4.0 Cl-103 HCO3-30 AnGap-9
___ 06:35AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.5*
___ 06:00AM BLOOD VitB12-783 Folate-17.7
___ 06:00AM BLOOD TSH-0.32
___ 06:00AM BLOOD WBC-5.1 RBC-4.02* Hgb-12.5 Hct-35.7*
MCV-89 MCH-31.0 MCHC-34.9 RDW-13.6 Plt ___
___ 06:00AM BLOOD Glucose-92 UreaN-19 Creat-0.8 Na-139
K-3.9 Cl-104 HCO3-29 AnGap-10
___ 06:00AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.5*
DISCHARGE LABS: NONE ON THE DAY OF DISCHARGE
MICRO:
___ 3:30 pm URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 4:20 pm BLOOD CULTURE x2: NO GROWTH.
___ 6:00 am SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST (Final
___:
NONREACTIVE.
PERTINENT IMAGING:
___ ECG
Sinus rhythm. Non-specific intraventricular conduction delay.
Early R wave
transition in the precordial leads. Compared to the previous
tracing
of ___ the heart rate is modestly slower.
___ CHEST (PA & LAT)
IMPRESSION: No acute cardiopulmonary process.
___ CT ABD & PELVIS WITH CONTRAST
IMPRESSION: No acute intra-abdominal process. Unchanged
intrahepatic biliary ductal dilation after cholecystectomy.
Probably lower right renal pole, non-obstructing calculi.
___ CT HEAD W/O CONTRAST
IMPRESSION: No acute intracranial process.
___ MR ___ SPINE W/O CONTRAST
IMPRESSION: Severe canal stenosis at L4-5 due to thickening of
the ligamentum flavum, disc bulge and uncovertebral hypertrophy
with bilateral severe foraminal stenosis. Mild-to-moderate canal
stenosis at L3-4 and mild stenosis at L5-S1 with mild bilateral
foraminal narrowing.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. BuPROPion (Sustained Release) 100 mg PO BID
2. Diphenoxylate-Atropine 3 TAB PO BID
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Naproxen 500 mg PO Q12H:PRN pain
5. Paroxetine 40 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
8. Amitriptyline 75 mg PO HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 100 mg PO BID
3. Cyanocobalamin 1000 mcg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Naproxen 500 mg PO Q12H:PRN pain
6. Paroxetine 40 mg PO DAILY
7. Diphenoxylate-Atropine 3 TAB PO BID
8. Psyllium 1 PKT PO DAILY:PRN loose stool
RX *psyllium [Metamucil] 4 wafers by mouth once a day Disp
#*120 Packet Refills:*0
9. Outpatient Physical Therapy
Home physical therapy for balance training.
Discharge Disposition:
Home With Service
Facility:
___
with patient.
Discharge Diagnosis:
PRIMARY DIAGNOSES
altered mental status
chronic nausea and vomiting
SECONDARY DIAGNOSES
Diabetes mellitus
Depression
Rectal incontinence
Discharge Condition:
Mental Status: Clear and coherent, documented and examined with
MMSE.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Altered mental status. Evaluate for the presence of an infiltrate.
COMPARISON: Chest radiograph ___ and CT torso ___.
FINDINGS: Frontal and lateral views of the chest. There is no pleural
effusion, pneumothorax or focal airspace consolidation. Elevation of the left
hemi-diaphragm is unchanged. The heart size is normal and the mediastinal
contours are unremarkable. Multiple chronic appearing rib fractures are seen
within the left upper hemithorax. There are anterior osteophytes of the
thoracic spine, unchanged.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
HISTORY: Altered mental status. Evaluate for an acute intracranial process.
TECHNIQUE: Continuous axial sections were acquired through the brain without
administration IV contrast. Coronal and sagittal reformations were provided
and reviewed.
DLP: 1025.72 mGy/cm.
CTDIvol: 62.93 mCi.
COMPARISON: Head CT ___ and ___.
FINDINGS:
There is no acute hemorrhage, edema or shift of the midline structures. The
ventricles and sulci are of normal size and configuration for age, showing
global age involutional changes. A focal hypodensity within the left frontal
white matter is likely a small lacunar infarction (5:16) and is unchanged.
Otherwise, the gray-white matter differentiation is preserved, without
evidence for an acute territorial vascular infarction. The basal cisterns
remain patent. Dense calcifications are noted within the carotid siphons.
The right lens is surgically absent. The included paranasal sinuses and
mastoid air cells are essentially clear noting trace opacification in the
right mastoids. There is no fracture.
IMPRESSION:
No acute intracranial process.
Radiology Report
HISTORY: Altered mental status with weight loss, nausea, vomiting and
diarrhea. Evaluate for colitis or the presence of a mass.
TECHNIQUE: MDCT axial images were acquired from the dome of the liver to the
pubic symphysis after the uneventful administration of 130 mL of Omnipaque and
oral contrast. Coronal and sagittal reformations were provided and reviewed.
DLP: 685.60 mGy/cm.
COMPARISON: CT torso ___.
FINDINGS:
Abdomen: The imaged lung bases show bibasilar atelectasis. There is no
pleural effusion or pneumothorax. Included portion of the heart is normal in
size and there is no pericardial effusion. Focal calcifications are seen
within the aortic valve and coronary arteries.
The liver enhances homogeneously without focal lesions. The gallbladder is
surgically absent. There is unchanged, mild intrahepatic biliary ductal
dilation. Again, the common bile duct is prominent, measuring 9 mm. There is
persistent kinking of the common bile duct (___). The spleen, pancreas
and adrenal glands are normal. The kidneys enhance symmetrically and excrete
contrast without hydronephrosis. A 5.5 cm cyst in the right kidney is
unchanged. Multiple left parapelvic cysts are present. There are likely
lower right renal pole, non-obstructing calculi.
The stomach, large and small bowel are normal. There is no bowel wall
thickening or evidence for obstruction. Contrast has progressed to the
transverse colon. The appendix is not definitely seen, however, there are no
secondary signs for appendicitis. There is no free air or free fluid. There
is no retroperitoneal or mesenteric lymphadenopathy.
The aorta shows mild atherosclerosis with dense calcifications at the origins
of the celiac and superior mesenteric arteries.
Pelvis: Air is seen within the bladder, presumably from recent intervention.
The uterus and rectum are normal. There is no free pelvic fluid. There is no
inguinal or pelvic sidewall lymphadenopathy.
Bones: There are no concerning lytic or blastic osseous lesions. A
hemangioma within L3 is unchanged. An old-appearing left 11th rib fracture is
appreciated (02:34). The right rectus is atrophic.
IMPRESSION:
1. No acute intra-abdominal process.
2. Unchanged intrahepatic biliary ductal dilation after cholecystectomy.
3. Probably lower right renal pole, non-obstructing calculi.
Radiology Report
INDICATION: History of diabetes, depression and rectal incontinence.
Presenting for evaluation of altered mental status, weight loss, nausea and
vomiting. Evaluate the lumbar spine for source of rectal incontinence and
sensory deficits in the lower extremities.
COMPARISON: CT abdomen and pelvis from ___.
TECHNIQUE: Multisequence, multiplanar imaging through the lumbar spine was
obtained without administration of IV contrast.
FINDINGS: Normal lumbar lordosis is preserved. Lumbar vertebral heights and
alignment are maintained. Multiple areas of T1 and T2 hyperintensity are
consistent with fatty marrow replacement or hemangiomas. No expansile or
destructive osseous lesion is seen. The conus and cauda equina appear normal.
The conus terminates at the L1-2 level. No epidural mass or collection is
seen. Prominent epidural veins are noted.
At T12-L1 level there is no significant canal stenosis or foraminal narrowing.
At L1-2 level there is no significant canal stenosis or foraminal narrowing.
At L2-3 there is no significant canal stenosis or foraminal narrowing.
At L3-4 there is mild-to-moderate canal stenosis caused by disc osteophyte
complexes with bilateral foraminal stenosis.
At L4-5, thickening of the ligamentum flavum, disc bulge and uncovertebral
hypertrophy causes severe canal stenosis with compression of the nerve roots.
There is bilateral severe foraminal stenosis.
At L5-S1, a disc bulge causes left lateral recess narrowing and mild bilateral
foraminal narrowing.
Incidental note is made of a far lateral right-sided synovial cyst at L4-5
external to the facet joint. There are bilateral parapelvic renal cysts,
greater on the right than the left.
IMPRESSION:
1. Severe canal stenosis at L4-5 due to thickening of the ligamentum flavum,
disc bulge and uncovertebral hypertrophy with bilateral severe foraminal
stenosis.
2. Mild-to-moderate canal stenosis at L3-4 and mild stenosis at L5-S1 with
mild bilateral foraminal narrowing.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with VOMITING, URIN TRACT INFECTION NOS
temperature: 98.4
heartrate: 98.0
resprate: 18.0
o2sat: 100.0
sbp: 120.0
dbp: 59.0
level of pain: 0
level of acuity: 3.0 | ___ yo female with PMH significant for DM, depression, obesity,
h/o nephrolithiasis and rectal incontinence since early ___,
presents to the ___ from her PCP's office for intermittent
abdominal pain, AMS, N/V/D and 100lb wt loss in a ___ year period
with hospital course complicated by a UTI.
ACUTE ISSUES:
#UTI: Pt noted to have mildly dirty UA and started on CTX in the
___. She remained afebrile without leukocytosis throughout
hospitalization. She had no episodes of abdominal pain or CVA
tenderness. UCx grew E.coli sensis to CTX. She was treated for
an uncomplicated UTI and received a total of 3 doses of CTX in
house. Pt was evaluated by ___ who felt that aside from minor
balance issues, that the patient was safe for discharge to home
with short term home ___ services.
#concern for altered mental status: No evidence of cognitive or
new neurologic deficits during this hospital stay. Pt was
determined to be competent to make her own medical decisions.
Per PCP notes and daughter (via ___, pt not at her baseline
recently. Upon interviewing the pt, she is alert, answering
questions appropriately and oriented x3. MMSE was ___ with
only difficulty being 3 object recall after a few minutes. Seen
by Neurology who felt that she is neurologically and cognitively
intact. Neurology did recommend a MRI lumbar spine to evaluate
rectal incontinence and mildly spastic gait. MRI lumbar spine
showed severe canal stenosis at L4-5 due to thickening of the
ligamentum flavum, disc bulge and uncovertebral hypertrophy with
bilateral severe foraminal stenosis along with mild-to-moderate
canal stenosis at L3-4 and mild stenosis at L5-S1 with mild
bilateral foraminal narrowing. She had no back or pelvic pain,
and her neuro exam was repeated and was reassuring- there was no
evidence of upper motor neuron signs on exam. She was discharged
from the hospital because there was no acute need for her to be
admitted as an inpatient (her rectal incontinence was not new,
and she had no other signs of worsening neurologic function). We
recommended that the pt stop taking her amitriptyline as this
can cause confusion in the elderly and lead to balance issues
and falls.
#Abdominal pain: Intermittent in nature since ___ and not
present during this admission. Associated with N/V. No known
etiology but pt does notice that it happens more often while
riding as a passenger of a car. Had EGD in ___ which only
showed gastritis. Had EUS in ___ which showed fatty
infiltration of the pancreas consistent with chronic
pancreatitis but otherwise no acute findings.
#Weight loss: She reports a 100lb wt loss via diet and portion
control. Unclear if there is another process at work but can
consider malabsorption from chronic pancreatitis, malnutrition,
hyperthyroidism or (unlikely) an occult malignancy. Pt did not
lose any weight while in the hospital and had a hearty appetite
throughout, tolerating PO without difficulty. TSH was WNLs.
Nutrition was consulted but upon observing the patient, they did
not feel that their services were needed acutely, but did note
that the patient reported a sensation of food getting suck in
her throat. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Loss of Consciousness
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
Ms. ___ is a ___ yo woman with a significant PMH for history
HIV (CD4 351 HIV PCR 332), HCV (>1million copies), HTN, bipolar
deperssion and PTSD who recently began HIV therapy with Triumeq
who p/w a syncopal vs. seizure episode and 3 weeks of watery
diarrhea.
She was initially diagnosed with HIV in ___ (asymptomatic at
the time). Her CD4 at the time was 264 and VL was 98K. She was
initiated on Stribild and continued on treatment until ___
when her Creatnine was noted to rise from a baseline of 0.9 to
1.64. At this time she was transitioned to Triumeq and tolerated
this medication well. Her Labs in ___ reflected improvement on
threrapy and shw asnoted to have CD4 of 351, VL332, BUN7 Cr
0.93, ALT/AST of 83/34.
Then 3 weeks ago, she began having 2 loose large volume stools
per day a/w diffuse cramping. The diarrhea was never bloody or
melenic, but was associated with tenesmus. Began having episodes
of lightheadness, seeing stars, and diaphoresis with sudden
standing. The diarrhea has also been waking her from sleep. Last
night, she woke up from sleep with a sudden urge make stool.
When she stood up, she began having blurry vision,
lightheadedness, and sweating, and she passed out. Denies head
trauma. Found down by daughter with hands clenches, some arm
jerking, and swallowing her tongue. Ms. ___ believes she was
down roughly 10 minutes. When she awoke, her daughter called an
ambulance, and she was taken to this hospital.
In the ED, initial vitals: T:96 HR: 78 BP: 87/64 SpO2: 100%
Physical exam was unremarkable. Basic lab work notable for AG
20, Cr 1.1, BUN 15, lactate 3.2, WBC 5.3, Hct 32.2 with 58%
lymphs. ___ showed no bleed/fracture. CXR clear. XR hip, knee,
foot w/o fx. Because of concern for seizures ___ CNS pathology,
LP performed with 0WBC's and 0RBC's. She was treated with IVF
bolus of 2L with improvement in her blood pressure. She also
received 1g IV ceftriaxone and 40meq of K. Vitals prior to
transfer: T: 98.6 HR: 63 BP: 129/89 RR: 16 SpO2100% RA
She has not had N/V. No fevers/chills. Has had night sweats and
hot flashes since beginning menopause recently. Has had 20lb
weight loss since ___. Developed cough 1 week ago
productive of green sputum. Denies SOB/chest pain. No travel in
past year. No recent sick contacts. Has a dog, but the dog has
been healthy.
Currently, she denies light-headedness. She has mild lower
abdominal pain that is crampy in nature. Has not had diarrhea
since coming to the ED.
ROS:
No fevers, chills. No changes in vision or hearing, no changes
in balance. No shortness of breath, no dyspnea on exertion. No
chest pain or palpitations. No nausea or vomiting. No
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits. No rashes.
Past Medical History:
HIV (diagnosed ___
HCV
HTN
PTSD
Bipolar Depression
Polysubstance abuse including IV drugs since age ___.
Tubal ligation
right hand abscess
Social History:
___
Family History:
- mother passed away at age ___ from gastric cancer also with
hypertension, and had polysubstance abuser
- father has alcohol abuse
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T: 99.2 HR 76 BP: 135/96 RR: 18 SpO2: 100 RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, PERRL bilaterally, no conjunctival
injection. MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD. Thyroid not enlarged.
trachea midline
RESP: CTAB without advential sounds, diaphragmatic excursion was
equal
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, mildy tender in the hypogastrium but w/o
rebound/guarding. ND. Mildly hyperactive bowel sounds present,
no hepatosplenomegaly.
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema Normal skin turgor. Cap refill ~1 second.
NEURO: Speech Coherent. Cognition intact. No dysdiokinesia, no
pronator drift. CNs2-12 intact, strength ___ in b/l upper and
lower extremities. Gait not assessed. Heel to shin normal.
SKIN: No excoriations or rashes.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: Tm 99.4 HR 64-102 BP 135/90-156/117 RR 18 SpO2 100%
RA
I/O's: 2430/brp wt: 50.1 kg
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
CHEST: CTAB, no wheezes, crackles, or rhonchi
CV: Loud heart sounds. RRR, Nl S1, S2, No MRG
ABD: Soft, NT/ND. Mildly hyperactive bowel sounds present, no
hepatosplenomegaly.
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema Normal skin turgor. Cap refill ~1 second.
NEURO: Speech Coherent. Cognition intact. Difficult to engage in
conversation.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:21AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 POLYS-0
___ ___ 10:20AM CEREBROSPINAL FLUID (CSF) PROTEIN-36
GLUCOSE-67
___ 08:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 08:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-SM
___ 08:45AM URINE RBC-<1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-6 TRANS EPI-<1
___ 06:49AM LACTATE-3.2* NA+-140 K+-3.0*
___ 06:44AM GLUCOSE-160* UREA N-15 CREAT-1.1 SODIUM-137
POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-26 ANION GAP-20
___ 06:44AM ALT(SGPT)-52* AST(SGOT)-112* CK(CPK)-141 ALK
PHOS-84 TOT BILI-0.4
___ 06:44AM LIPASE-183*
___ 06:44AM ALBUMIN-3.5 CALCIUM-9.5 PHOSPHATE-3.6
MAGNESIUM-2.1
___ 06:44AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:44AM WBC-5.3 RBC-3.24* HGB-11.2* HCT-32.2* MCV-99*
MCH-34.6* MCHC-34.8 RDW-12.7
___ 06:44AM NEUTS-30* BANDS-0 LYMPHS-58* MONOS-11 EOS-1
BASOS-0 ___ MYELOS-0
___ 06:44AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
___ 06:44AM PLT SMR-NORMAL PLT COUNT-201
DISCHARGE LABS:
===============
___ 06:47AM BLOOD WBC-4.5 RBC-3.34* Hgb-11.9* Hct-32.7*
MCV-98 MCH-35.7* MCHC-36.5* RDW-12.5 Plt ___
___ 06:47AM BLOOD Neuts-37.1* Lymphs-46.5* Monos-13.6*
Eos-2.3 Baso-0.6
___ 06:47AM BLOOD Plt ___
___ 06:47AM BLOOD Glucose-77 UreaN-7 Creat-0.9 Na-134 K-3.6
Cl-99 HCO3-24 AnGap-15
___ 06:47AM BLOOD ALT-46* AST-84* LD(LDH)-221 AlkPhos-87
TotBili-0.6
___ 06:47AM BLOOD Calcium-9.6 Phos-3.8 Mg-1.6
PERTINENT LABS:
===============
___ 06:44AM BLOOD Lipase-183*
___ 06:49AM BLOOD Lactate-3.2* Na-140 K-3.0*
___ 08:14AM BLOOD Lactate-1.6
___ 10:21AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
___ ___ 10:20AM CEREBROSPINAL FLUID (CSF) TotProt-36 Glucose-67
___ 10:20AM CEREBROSPINAL FLUID (CSF) TOXOPLASMA GONDII BY
PCR-Test
___ 10:20AM CEREBROSPINAL FLUID (CSF) ___ VIRUS,
QUAL TO QUANT, PCR-PND
MICROBIOLOGY:
=============
___ 6:44 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 10:20 am CSF;SPINAL FLUID Source: LP.
**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.
___ 10:20 am CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 1:48 pm STOOL CONSISTENCY: FORMED Source:
Stool.
MICROSPORIDIA STAIN (Preliminary):
CYCLOSPORA STAIN (Preliminary):
FECAL CULTURE (Preliminary):
CAMPYLOBACTER CULTURE (Preliminary):
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Preliminary):
FECAL CULTURE - R/O YERSINIA (Preliminary):
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Preliminary):
VIRAL CULTURE (Preliminary):
IMAGING:
========
CT HEAD W/O CONTRAST ___:
IMPRESSION:
No evidence of acute intracranial hemorrhage or mass effect.
Correlate clinically to decide on the need for further workup
with MRI if not contraindicated. Enlarged adenoids, narrowing
the nasopharynx along with fullness in the fossae of ___
on both sides, partly included and not completely targeted.
RIGHT HIP FILMS ___:
IMPRESSION:
No evidence of acute fracture or dislocation. Sclerotic lesion
involving the distal right femur is most consistent with a bone
infarct or osteochondroma
RIGHT FOOT FILMS ___:
IMPRESSION:
No acute fracture or dislocation. Moderate midfoot degenerative
change.
CXR PA/LATERAL ___:
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are
normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or
pneumothorax is seen.
IMPRESSION:
No acute cardiopulmonary abnormality.
MRI HEAD W/O CONTRAST ___:
IMPRESSION:
1. There is no evidence of mass, hemorrhage or infarct.
2. Nonspecific T2/FLAIR white matter hyperintensities. This may
be seen in the setting of chronic microangiopathy, chronic
headache, inflammatory/infectious process, prior trauma or
demyelinating process. Clinical correlation is recommended.
EEG ___: pending
CARDIOVASCULAR:
===============
EKG ___:
Sinus rhythm. Prolonged QTc interval. Compared to the previous
tracing
of ___ QTc interval now appears more prolonged.
TRACING #1
EKG ___:
Sinus rhythm. Prolonged QTc interval. Compared to the previous
tracing
of ___ no change
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Citalopram 40 mg PO DAILY
3. RISperidone 1 mg PO QHS
4. TraZODone 50 mg PO QHS insomnia
5. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
6. Divalproex (DELayed Release) 500 mg PO QHS
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. TraZODone 50 mg PO QHS insomnia
3. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
4. LeVETiracetam 1000 mg PO BID seizure ppx
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth qdaily Disp
#*30 Tablet Refills:*3
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Citalopram 40 mg PO DAILY
8. RISperidone 1 mg PO QHS
9. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
========
Syncope
?Seizure
Dehydration
Chronic Diarrhea
Alcohol Abuse
Secondary:
==========
HIV
Macrocytic Anemia
HCV cirrhosis
Transaminitis
Hypokalemia
Bipolar Disorder
Hypertension
PTSD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX HIP AND KNEE
INDICATION: History: ___ with HIV, seizure v. syncope with knee pain //
evaluate for acute process evaluate for acute process
TECHNIQUE: AP view of the pelvis, AP view of the right hip, frog-leg lateral
view, AP and lateral view of the right hip
COMPARISON: None
FINDINGS:
No fracture, or dislocation is detected. There is a small right knee effusion.
No SI joint or pubic symphysis diastases is identified. There is mild
tricompartmental degenerative change seen involving the right knee. A
sclerotic lesion centered in the distal right femur could represent an area of
bone infarct or possibly an enchondroma however it does not show any
aggressive features. No soft tissue calcification or radiopaque foreign body
is seen.
IMPRESSION:
No evidence of acute fracture or dislocation. Sclerotic lesion involving the
distal right femur is most consistent with a bone infarct or osteochondroma.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with HIV, seizure v. syncope with knee pain //
evaluate for acute process
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: 55 mGy
COMPARISON: CT head dated ___.
FINDINGS:
There is no evidence of acute hemorrhage, edema, or mass effect. Small
hypodense foci in the sub lentiform location on both sides, similar to the
prior study and may represent chronic lacunar infarcts or prominent
perivascular spaces series 2, image 12, 13.
The lateral and the third ventricles are mildly prominent related to mild
parenchymal volume loss, similar to the prior study. There is preservation of
gray-white matter differentiation. The basal cisterns are patent.
No suspicious osseous lesion is seen. Mucosal thickening is noted within the
left maxillary sinus. The remainder of the paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The orbits are unremarkable.
Enlarged adenoids, narrowing the nasopharynx along with fullness in the fossae
of ___ on both sides, partly included and not completely targeted.
IMPRESSION:
No evidence of acute intracranial hemorrhage or mass effect.
Correlate clinically to decide on the need for further workup with MRI if not
contraindicated.
Enlarged adenoids, narrowing the nasopharynx along with fullness in the fossae
of ___ on both sides, partly included and not completely targeted.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with cough // acute process?
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ with right foot pain and swelling s/p fall
TECHNIQUE: AP lateral and oblique views of the right foot
COMPARISON: None
FINDINGS:
No fracture, or dislocation is detected. There is mild to moderate
degenerative change seen throughout the midfoot. No obvious focal lytic or
sclerotic lesion detected. No soft tissue calcification or radio-opaque
foreign body identified.
IMPRESSION:
No acute fracture or dislocation. Moderate midfoot degenerative change.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old female w/Hx of recently diagnosed HIV (unknown CD4
"low"), HCV who complains of syncope v. seizure. // was ordered in ED.
Possibly duplicate order. Neurology requesting to evaluation for underlying
structural lesion or change
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 6cc of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CT head without contrast of ___, CT sinus of
___. .
FINDINGS:
The examination is slightly motion degraded. Within these confines:
There is no evidence of mass, hemorrhage or infarct. Sulci, ventricles and
cisterns are within expected limits. There are nonspecific periventricular and
subcortical T2/FLAIR white matter hyperintensities. The major intracranial
flow voids are preserved. The dural venous sinuses are paste. There is no
abnormal enhancement. Moderate mucosal thickening of an atretic left maxillary
sinus is noted. The orbits are unremarkable. Fluid signal is seen in the right
mastoid tip.
IMPRESSION:
1. There is no evidence of mass, hemorrhage or infarct.
2. Nonspecific T2/FLAIR white matter hyperintensities. This may be seen in the
setting of chronic microangiopathy, chronic headache, inflammatory/infectious
process, prior trauma or demyelinating process. Clinical correlation is
recommended.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: SYNCOPE VS SZ
Diagnosed with HYPOTENSION NOS, SYNCOPE AND COLLAPSE, ASYMPTOMATIC HIV INFECTION
temperature: 96.0
heartrate: 78.0
resprate: nan
o2sat: 100.0
sbp: 87.0
dbp: 64.0
level of pain: 0
level of acuity: 1.0 | ___ yo woman with a significant PMH for history HIV (CD4 351 HIV
PCR 332), HCV (>1 million copies), HTN and PTSD who recently
began HIV therapy with Triumeq who p/w a syncopal vs. seizure
episode and 3 weeks of watery diarrhea.
ASSESSMENT & PLAN: ___ yo woman with a significant PMH for
history HIV (CD4 351 HIV PCR 332), HCV (>1 million copies), HTN
and PTSD who recently began HIV therapy with Triumeq who p/w a
syncopal vs. seizure episode and 3 weeks of watery diarrhea.
# Syncope vs. Seizure: Patient's presentation is most consistent
with orthostatic hypotension in the setting of volume depletion
from significant diarrhea resulting in syncopal episode, as well
as a potential seizure disorder. She came in hypotensive,
orthostatic, with elevated lactate that responded to IVF. The
report of rigidity and prior episode raised concern for possible
seizure and neurology was consulted, LP results nl ___ nl,
crypto nl, pending EBV/toxo/OP), CT/MRI head w/o notable
pathology, EEG not concerning, however neurology felt Keppra
should be started and recommended follow up in 8 weeks with
them. EKG nl. DDx also included medication-related (striuvec)
vs. EtOH abuse vs. Postural orthostatic tachycardia syndrome
(but doesn't explain hypovolemia) vs. cardiogenic syncope (nl
exam/EKG/24hr tele).
# Subacute loose Diarrhea: Has had 2 BM's/day for past 3 weeks.
Describes as loose, not watery, nonbloody, not melena, no
travel. She has had significant volume depletion as a result.
DDx includes infectious diarrhea in immunocompromised host vs.
medication related (stribeld highly a/w diarrhea) vs.
inflammatory vs. irritable bowel syndrome (although doesn't
explain marked volume depletion). 1 large solid bowel movement
yesterday, stool studies not sent as patient had no further
diarrhea on the wards.
# Abnormal CBC: WBC 5.3 (30% Neut)->3.2 today, smudge cells
present on peripheral smear. Hct stable at 32.3, plt stable at
211. Concerning for CLL with smudge cells and relatively low
neutrophil count. H
# HIV: Stable. Most recent CD4 351 VL 332. Received Triumeq in
house.
# Transaminitis: AST/ALT and lipase slightly elevated,
downtrended through this hospitalization. Possibly related to
anti-retroviral therapy vs. alcohol intake as she notes she has
at least 8 alcoholic drinks per week. Stable
# HTN: On amlodipine at home, although hasn't been taking it.
SBP's in 150's here. Restarted on her home amlodipine.
#Alcohol abuse: Patient has significant alcohol abuse history.
Labs show macrocytosis as well. No w/d seizures or DT's or
hospitalizations in the past. No known history of withrdrawal or
seizures. CIWA=0, given thiamine, folate, MVI. She was seen by
social work and noted to be in the contemplation stage of
change; she acknowledges that she is concerned about her alcohol
use, but has indefinite plans to pursue treatment. She was
provided with resources to help her pursue treatment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amlodipine / lisinopril / Hydrocodone / morphine / Ambien
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
right and left sided Thoracentesis
History of Present Illness:
This is a ___ with recent ascending + ___ descending aortic
aneurysm repaired (at ___), complicated by CHF, pleural effusion
(not drained) presenting initially to PCP ___ ___ days of SOB
with minimal activity. She recently underwent AA repair and was
in the hospital 2 week post-op. She was at rehab for another 2
weeks. There she developed PNA and has now completed levaquin.
She denies cough, fever, or any respiratory sx's. Also at rehab,
she was found to be anemic and started on Fe, but that was
D/C'ed ___ GI side effects. She had been home for the past 2
weeks. She has been having progressive DOE for these past 2
weeks. She can only walk 15 steps before she develop weakness
and SOB. Per records, she has been intermittently hypotensive
and desats to high ___ while walking. She denies CP, f/c, n/v,
dysuria, abdominal pain, or diarrhea. She has not change in
weight currently 131 lb (typically between 130-134lbs). She
report feeling constipated, last BM yesterday.
.
In the ED, her initial vitals were: Initial ED vitals:98 58
108/48 18 98% on RA. Her initial labs demonstrated Cr 1.4 and
anemia - Hct 31.8. Her pro-BNP ___. A CXR demonstrated moderate
bilateral pleural effusions. She was hemodynamically stable and
admitted to the floor for likely thoracentesis. NO medications
were given in the ED. Her admission vitals were: 50 23 117/60
99% on 2L.
On the floor, she is talking in complete sentences, had mild
tachypnea in bed, but denies dyspnea. She was sleeping.
10 poit ROS is otherwise negative
Past Medical History:
- Temporal arteritis, presented as jaw pain, HA, but no visual
symptoms
- HTN
- GERD
- Hypothyroidism
- Macular degeneration
- Osteoporosis
- Episode of transient global amnesia ___ years ago (sitting at
dinner table with son, and suddenly amnestic of past events)
- ascending + ___ descending aortic aneurysm repaired (BWH),
complicated by CHF, pleural effusion (not drained).
Social History:
___
Family History:
Brother with seizures in setting of meningitis. Father with DM,
HTN, died of intracranial hemorrhage at age ___. Sister with
stroke. Son with bipolar disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.5 114/54 56 24 ___ on 2L; ___ on RA
GENERAL: well appearing female with mild tachypnea, but no
accessory muscle use.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no JVD
LUNGS: decreased BS at bases bilaterally, crackles at mid lung
field, good air movement in apexes, resp mildly labored, no
accessory muscle use
HEART: RR, no MRG, nl S1-S2
ABDOMEN: obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES: WWP, 2+ edema bilaterally in lower extremities
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM:
VS: 97.8 HR 65 BP 117/52 RR 16 95% on RA
GENERAL: Sitting in chair, appears very comfortable, in no acute
distress
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM
NECK: supple
LUNGS: very mild crackles at both bases, no wheezes/rales
HEART: RR, no MRG, nl S1-S2; sternal scar
ABDOMEN: NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES: WWP, left leg slightly larger than right, 1+
non-pitting lower extremity edema
NEURO: awake, A&Ox3, CNs III-XII grossly intact
Pertinent Results:
IMAGING:
___ LENIs:
IMPRESSION:
No evidence of deep vein thrombosis in either leg.
.
___ Chest X-ray
IMPRESSION:
1. Interval improvement of right lung re-expansion edema
compared to the
prior exam.
2. New left lung base mild re-expansion edema. No evidence of a
pneumothorax.
3. Wedge-compression deformity of the low-thoracic spine,
progressed from CT of ___, but stable since the exam from
___.
.
___ ECHOCARDIOGRAM
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is an anterior space which most likely represents
a prominent fat pad.
.
Compared with the prior study (images reviewed) of ___,
the ascending aorta does not appear dilated on the current
study. Mild symmetric LVH is seen on the current study. Other
findings are similar.
.
___ CXR
Right pleural effusion has substantially decreased after
thoracocentesis with no pneumothorax currently seen. Left
pleural effusion is unchanged, large. No change in the heart
and mediastinal silhouette is noted. Small amount of right
pleural effusion is still present.
.
PATHOLOGY: ___
Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS.
Reactive mesotheLial cells.
Predominately lymphocytes and some neutrophils.
.
IMPRESSION:
1. Small to moderate size bilateral pleural effusions with
bibasilar
atelectasis.
2. Progression of T12 compression deformity which is now severe.
.
LABS:
___ 05:46PM PLEURAL WBC-303* RBC-920* Polys-5* Lymphs-85*
Monos-8* Macro-2*
___ 05:46PM PLEURAL TotProt-3.3 Glucose-114 LD(LDH)-95
Amylase-20 Cholest-72 ___ Misc-PROBNP=167
___ 05:05PM PLEURAL WBC-1025* RBC-4475* Polys-8* Lymphs-59*
Monos-0 Eos-4* Macro-29*
___ 05:05PM PLEURAL TotProt-2.9 Glucose-118 LD(LDH)-137
Albumin-1.8 Cholest-63
.
___ 06:35AM BLOOD WBC-6.1 RBC-3.51* Hgb-10.4* Hct-33.0*
MCV-94 MCH-29.7 MCHC-31.5 RDW-14.4 Plt ___
___ 07:00AM BLOOD WBC-5.8 RBC-3.27* Hgb-9.5* Hct-30.7*
MCV-94 MCH-29.0 MCHC-30.9* RDW-14.3 Plt ___
___ 06:40PM BLOOD WBC-7.3 RBC-3.47* Hgb-10.2*# Hct-31.9*
MCV-92 MCH-29.4 MCHC-32.0 RDW-14.2 Plt ___
___ 06:40PM BLOOD Neuts-69.2 Lymphs-17.5* Monos-7.9
Eos-5.1* Baso-0.3
.
___ 06:35AM BLOOD Glucose-92 UreaN-19 Creat-1.2* Na-142
K-3.3 Cl-100 HCO3-32 AnGap-13
___ 07:00AM BLOOD Glucose-80 UreaN-19 Creat-1.3* Na-140
K-3.7 Cl-102 HCO3-31 AnGap-11
___ 06:40PM BLOOD Glucose-92 UreaN-20 Creat-1.4* Na-140
K-4.2 Cl-100 HCO3-27 AnGap-17
.
___ 06:40PM BLOOD ___ 06:35AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.1
___ 07:00AM BLOOD TotProt-5.0* Calcium-7.6* Phos-3.8 Mg-2.1
___ 07:00PM BLOOD Lactate-1.8
.
DISCHARGE LABS:
___ 06:05AM BLOOD WBC-5.2 RBC-3.42* Hgb-10.1* Hct-32.7*
MCV-96 MCH-29.4 MCHC-30.8* RDW-14.7 Plt ___
___ 06:05AM BLOOD Glucose-87 UreaN-18 Creat-0.9 Na-137
K-4.1 Cl-100 HCO3-28 AnGap-13
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 10 mg PO DAILY
2. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QWED
3. Fluticasone Propionate NASAL 1 SPRY NU Frequency is Unknown
4. Furosemide 40 mg PO DAILY
5. Gabapentin 300 mg PO HS
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. Levothyroxine Sodium 112 mcg PO DAILY
8. Metoprolol Succinate XL 150 mg PO BID
9. Klor-Con M20 *NF* (potassium chloride) 20 mEq Oral daily
10. Pravastatin 80 mg PO DAILY
11. Ascorbic Acid ___ mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
14. Senna 1 TAB PO HS constipation
15. Fish Oil (Omega 3) 1000 mg PO DAILY
16. PreserVision Lutein *NF* (vit C-vit E-copper-ZnOx-lutein)
226-200-5-0.8 mg-unit-mg-mg Oral ___
17. Acetaminophen 500 mg PO QNOON
18. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation PRN SOB
Discharge Medications:
1. Acetaminophen 500 mg PO QNOON
2. Aspirin 81 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Gabapentin 300 mg PO HS
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. Levothyroxine Sodium 112 mcg PO DAILY
8. Pravastatin 80 mg PO DAILY
9. Senna 1 TAB PO HS constipation
10. Ascorbic Acid ___ mg PO DAILY
11. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral daily
12. Fluticasone Propionate NASAL 1 SPRY NU DAILY
13. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation PRN SOB
14. PreserVision Lutein *NF* (vit C-vit E-copper-ZnOx-lutein)
226-200-5-0.8 mg-unit-mg-mg Oral ___
15. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
16. Klor-Con M20 *NF* (potassium chloride) 20 mEq Oral daily
RX *potassium chloride [Klor-Con M20] 20 mEq 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
17. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bilateral pleural effusions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The patient is status post median sternotomy and CABG. Heart size is
difficult to assess given the presence of small to moderate size bilateral
pleural effusions, new compared to the prior radiographs. Bibasilar opacities
likely reflect compressive atelectasis. There is no pulmonary vascular
engorgement. The aorta is tortuous and calcified. There is no pneumothorax.
Clips are seen projecting over the right superolateral chest. Severe
compression deformity at T12 appears progressed since the prior CT from ___.
IMPRESSION:
1. Small to moderate size bilateral pleural effusions with bibasilar
atelectasis.
2. Progression of T12 compression deformity which is now severe.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with bilateral effusions
after right thoracotomy.
Portable AP radiograph of the chest was reviewed in comparison to ___.
Right pleural effusion has substantially decreased after thoracocentesis with
no pneumothorax currently seen. Left pleural effusion is unchanged, large.
No change in the heart and mediastinal silhouette is noted. Small amount of
right pleural effusion is still present.
Radiology Report
INDICATION: ___ female status post left thoracentesis who presents
for evaluation.
COMPARISON: Chest radiographs from ___ and
CT torso from ___.
TECHNIQUE: Single AP portable exam of the chest.
FINDINGS: There is mild cardiomegaly, stable compared to prior exams at least
dating back to ___. The aorta is tortuous, otherwise the hilar
and mediastinal contours are stable. There is a small left pleural effusion
status post left thoracentesis. No definite pneumothorax is seen. There are
heterogeneous right lower lung opacities likely secondary to re-expansion
edema given patient's thoracentesis on ___. There is mild left
lower lobe atelectasis.
IMPRESSION:
1. Interval improvement of the small left pleural effusion status post
thoracentesis. No definite pneumothorax.
2. New heterogeneous right lower lung opacity, likely secondary to
re-expansion edema s/p patient's right sided thoracentesis on ___.
Radiology Report
HISTORY: ___ female with recent aortic repair and asymmetry of lower
leg, evaluate for DVT.
COMPARISON: No previous exam for comparison.
FINDINGS:
Grayscale, color and Doppler images were obtained of bilateral common femoral,
femoral, popliteal and tibial veins. Normal flow, compression and
augmentation is seen in all of the vessels. Superficial edema is noted
bilaterally in the calf tissues.
IMPRESSION:
No evidence of deep vein thrombosis in either leg.
Radiology Report
INDICATION: ___ female status post left thoracentesis who presents
for interval evaluation. Question of right lung process.
COMPARISON: Chest radiographs from ___,
___ and ___.
TECHNIQUE: PA and lateral radiographs of the chest.
FINDINGS: There is stable mild cardiomegaly. The aorta is mildly tortuous,
otherwise the hilar and mediastinal contours are stable. There has been
interval improvement of the right lower right lung base heterogeneous
opacities, which were likely from re-expansion edema. New left lung base
opacities may be secondary to re-expansion edema. There are small bilateral
pleural effusions and mild bibasilar atelectasis. No definite pneumothorax is
seen. There is kyphosis of the spine. There is a wedge-compression deformity
of the low-thoracic spine, which appears to be progressed from the CT of ___, but stable since the exam from ___.
IMPRESSION:
1. Interval improvement of right lung re-expansion edema compared to the
prior exam.
2. New left lung base mild re-expansion edema. No evidence of a pneumothorax.
3. Wedge-compression deformity of the low-thoracic spine, progressed from CT
of ___, but stable since the exam from ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SOB
Diagnosed with SHORTNESS OF BREATH, HYPOXEMIA, PLEURAL EFFUSION NOS
temperature: 98.0
heartrate: 58.0
resprate: 18.0
o2sat: 98.0
sbp: 108.0
dbp: 48.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is an ___ woman with recent ascending and
proximal descending aortic aneurysm repair complicated by dCHF
and pleural effusion, possible recent pneumonia, who is
presenting with increased dyspnea.
# Bilateral pleural effusions:
Demonstrated on physical exam, as well as imaging. Given lack of
fever or cough, non-infectious cause of this pleural effusion
would seem most likely. She may have inflammation following
recent surgery or some diastolic heart failure, given elevated
proBNP. Patient underwent thoracentesis on ___ with
immediate improvement in oxygenation and no complications.
Pleural fluid studies completed. The pleural fluid meets Light's
criteria for exudative process. She does not meet the more
specific criteria: effusion cholesterol > 45 but effusion LDH
not greater than 200. Cholesterol is greater than 60, which
suggests chronic effusion, which may be secondary to CHF or may
be remnant of inflammation from recent surgery. A second
thoracentesis was performed the following day, with similar
pleural fluid results. Echo demonstrated no new systolic
failure, and the patient did not have any chronic heart failure
in her history, although she was being diuresed before this
admission. Discharge material from recent admission to ___ was
obtained: on discharge, patient had small bilateral pleural
effusions. Following bilateral thoracentesis, patient still had
crackles on exam. Follow-up CXR showed possible re-expansion
pulmonary edema. The patient was restarted on furosemide and
discharged on the same dose she was admitted: 40mg PO daily.
#. Hypertension: Patient was normotensive to hypotensive during
admission. Her metoprolol was kept at her home dose of 12.5mg
daily.
#. Lower leg asymmetry: Patient's left leg is slightly larger
than right. Negative ___ sign. No pitting edema. Patient has
been less mobile since surgery one month ago. LENIs demonstrated
no evidence of DVT.
#. Hyperlipidemia: Continued home pravastatin.
#. Hypothyroidism: Continued home levothyroxine 112mcg daily.
#. Depression: Continued home citalopram.
#. GERD: Continued home lansoprazole.
.
# Transitional Issues:
- Follow up final pleural fluid cultures results from ___
- Follow up with PCP and ___ in ___ weeks for routine
hospital follow up and clinical monitoring of dCHF and
recurrence of pleural effusions
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Haldol / Morphine / Dilaudid (PF) / Demerol / Percocet /
Ketamine / remifentanil / Singulair
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman PMH asthma, anxiety, TBM s/p Y stent
placed at ___ ___ (removed ___, ___ s/p ablation who
presents with dyspnea and SOB. Since ___ had sore throat
and dyspnea as well as yellow sputum. She started using
albuterol every three hours. On ___ she had decadron
injection and z-pack when she was seen at urgent care. She
initially felt better then last night started to feel worse.
She had been using albuterol every three hours. Given her
worsening SOB she presented to the ___.
___ ED course:
When she arrived in the ___ she had subjective respiratory but
no tachypnea. She was wheezy throughout and had some inspiratory
stridor. Initial vitals were 98 113 137/75 19 100% RA. She
received stack neublizers and methylprednisone but became more
tachypnic while in the ED. She was initiated on bipap and
reported feeling that her breathing had improved.
The IP service who knows her well was contacted while she was in
the ED. They said that may consider heliox, racemic
epinephrine, and guafenisin if she is not improving.
Past Medical History:
-TBM s/p Y stent placed at ___ ___, now s/p removal in
___
-Asthma--treated since ___ despite normal PFTs; has been
intubated three times, most recently ___. Baseline peak flow
450
-Paradoxical vocal cord motion (Dx by ENT fiberoptic exam ___
though repeat exam by ___ MD in ___ was reportedly normal;
patient reports exhaustive speech therapy work in the past that
has not been helpful)
-Depression
-Anxiety
-GERD--empirically treated in light of vocal cord dysfunction,
s/p ___ fundoplication
-Hypothyroidism
Social History:
___
Family History:
+CAD--father died of MI in ___, Grandmother with pulmonary
fibrosis
Physical Exam:
Admission Physical Exam:
VITALS: 98.2 106 143/91 39 98% BiPap ___ FiO2
GENERAL: Alert, oriented, in moderate distress
HEENT: unable to assess as has Bipap on
NECK: supple, JVP not elevated, no LAD
LUNGS: wheeze at upper lung fields, moving air, no rales, no
rhonchi
CV: tachycardic normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rash
NEURO: moving all extremities
Discharge Physical Exam:
Vital Signs: T 97.6 BP 140/90 HR 105 RR ___ O2 93% on RA
General: Alert, oriented Caucasian female, laying in bed and
appearing somewhat dyspneic.
HEENT: Sclerae anicteric
Lungs: Wheezing throughout the lung fields bilaterally, with
diminished breath sounds on the L
CV: Borderline tachycardic with regular rhythm, normal S1 + S2,
no murmurs, rubs, gallops
Abdomen: Abdomen is obese and soft, non-tender, non-distended,
bowel sounds present, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Moves all four extremities spontaneously.
Pertinent Results:
Admission Labs:
--------------
___ 06:29PM ___ PO2-53* PCO2-32* PH-7.40 TOTAL
CO2-21 BASE XS--3
___ 06:29PM O2 SAT-87
___ 05:40PM K+-3.5
___ 02:50PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 01:50PM GLUCOSE-101* UREA N-17 CREAT-0.9 SODIUM-136
POTASSIUM-5.6* CHLORIDE-101 TOTAL CO2-20* ANION GAP-21*
___ 01:50PM estGFR-Using this
___ 01:50PM HCG-<5
___ 01:50PM WBC-11.7* RBC-4.72 HGB-13.6 HCT-42.3 MCV-90
MCH-28.8 MCHC-32.2 RDW-13.4 RDWSD-43.9
___ 01:50PM NEUTS-75* BANDS-0 ___ MONOS-6 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-8.78* AbsLymp-2.22
AbsMono-0.70 AbsEos-0.00* AbsBaso-0.00*
___ 01:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
___ 01:50PM PLT SMR-NORMAL PLT COUNT-257
MICRO:
-------
Respiratory viral screen: Negative
IMAGING:
------------
CXR ___
No acute cardiopulmonary abnormality.
DISCHARGE LABS:
---------------
___ 10:30AM BLOOD WBC-20.8* RBC-5.16 Hgb-15.0 Hct-44.9
MCV-87 MCH-29.1 MCHC-33.4 RDW-13.2 RDWSD-41.7 Plt ___
___ 07:40AM BLOOD Glucose-89 UreaN-20 Creat-0.8 Na-131*
K-4.5 Cl-91* HCO3-20* AnGap-25*
___ 07:40AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.4
___ 07:57AM BLOOD Lactate-2.6*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO EVERY OTHER DAY
2. Tiotropium Bromide 1 CAP IH DAILY
3. Norethindrone-Estradiol 1 TAB PO DAILY
4. albuterol sulfate 0.63 mg/3 mL inhalation PRN
5. albuterol sulfate 90 mcg/actuation inhalation 2 puffs PRN
6. FLUoxetine 20 mg PO BID
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Levothyroxine Sodium 150 mcg PO DAILY
10. Montelukast 10 mg PO DAILY
Discharge Medications:
1. Calcium Carbonate 1000 mg PO DAILY
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
2. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
4. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
5. PredniSONE 60 mg PO DAILY Duration: 14 Doses
This is dose # 1 of 7 tapered doses
RX *prednisone 10 mg 6 tablet(s) by mouth daily Disp #*294
Tablet Refills:*0
6. PredniSONE 50 mg PO DAILY Duration: 14 Doses
This is dose # 2 of 7 tapered doses
7. PredniSONE 30 mg PO DAILY Duration: 14 Doses
This is dose # 4 of 7 tapered doses
8. PredniSONE 20 mg PO DAILY Duration: 14 Doses
This is dose # 5 of 7 tapered doses
9. PredniSONE 10 mg PO DAILY Duration: 14 Doses
This is dose # 6 of 7 tapered doses
10. PredniSONE 5 mg PO DAILY Duration: 14 Doses
This is dose # 7 of 7 tapered doses
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
11. PredniSONE 40 mg PO DAILY Duration: 14 Doses
This is dose # 3 of 7 tapered doses
12. albuterol sulfate 0.63 mg/3 mL inhalation PRN
13. albuterol sulfate 90 mcg/actuation inhalation 2 PUFFS PRN
dyspnea
14. FLUoxetine 20 mg PO BID
15. Fluticasone Propionate 110mcg 2 PUFF IH BID
16. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
17. Levothyroxine Sodium 150 mcg PO DAILY
18. Montelukast 10 mg PO DAILY
19. Norethindrone-Estradiol 1 TAB PO DAILY
20. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Asthma
Secondary: Anxiety, vocal cord dysfunction, tracheobronchial
malacia
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 shortness of breath// eval for pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Unspecified asthma with (acute) exacerbation
temperature: 98.0
heartrate: 113.0
resprate: 19.0
o2sat: 100.0
sbp: 137.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ yo woman ___ asthma, anxiety, TBM s/p Y stent
placed at ___ ___ (removed ___, ___ s/p ablation who
presented with dyspnea and SOB. On admission, the patient was
treated with steroids and nebulizers. She was placed on BiPAP
for comfort, however, she never became hypoxemic. Her course was
complicated by lactic acidosis likely in the setting of over-use
of albuterol inhalers, which was improving at time of discharge.
Bedside peak flow initially 390 which improved to 410 by time of
discharge. The patient's respiratory status improved and she was
transitioned to her home inhalers with plans to follow-up with
IP and Pulmonology for further management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year-old gentleman with a PMH of non-ischemic cardiomyopathy
with EF 20%, COPD, CKD (bl Cr 1.4-1.6), IDDM, atrial
fibrillation on warfarin, s/p AAA repair in ___, now presenting
with back pain, found to have acute on chronic kidney disease.
Patient has been having low back pain, worse with ambulation,
for the past month. He did not do any recent lifting, or have
any trauma to his back. Pain is dull, not relieve by Tylenol as
needed at home; he is unable to take NSAIDs due to CKD. He was
referred by his PCP to Dr. ___ evaluation of his
pain, and was scheduled for CT thorax on ___. Due to
worsening pain that has become intolerable, he presented today.
He denies any fevers, weakness, sensory or motor defecit,
incontinence of urine or stool, or trauma history. He denies
radiating pain or pain in his legs. He has never had back pain
like this before. He did not try ice or heat at home.
Additionally, he notes having dyspnea with exertion and with
lying flat in bed. He sleeps with two pillows and the head of
the bed elevated at nighttime. His abdomen has been more
swollen, which he attributes to his CHF. His has gained about a
pound recently. He does not get lower extremity edema.
On arrival to the ___ ED, initial vital signs were: 97.2 78
114/75 18 95%. Exam revealed left paraspinal tenderness to
palpation, with no sensory or neuro deficits. Labs were
remarkable for Cr 2.5 with BUN 56 (from baseline 1.4-1.6 and
___, INR 3.5, lactate 2.1, differential with 5 atypicals. UA
showed no evidence of infection. CTA abd/pelvis showed no aortic
injury or extravasation of contrast. Vascular surgery was
consulted, and believed that pain was not vascular in etiology.
Patient was not given anything in the ED. They recommended
admission to medicine for ___. Prior to transfer, vital signs
were: 97.7 68 121/73 18 96% RA.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- Non-ischemic cardiomyopathy - moderate dilation of left
ventricular cavity with global LV hypokinesis (LVEF = 20%) w
prior LV thrombus;
- NSVT (___) and syncope s/p single-chamber ICD ___
Virtuoso)
- Hypertension.
3. OTHER PAST MEDICAL HISTORY:
- Atrial fibrillation
- Restrictive lung disease (PFT ___
- AAA repair in ___ with 18 mm tube graft
- Peripheral vascular disease
- Mild CKD creat 1.2-1.3.
- Hiatal hernia.
- Esophageal dysmotility/dysphagia.
- Depression.
- s/p cataract removal.
Social History:
___
Family History:
- Father had high cholesterol and Heart disease and died at the
age of ___
- Mother died from heart disease
- Brother also died of heart problems at young age
Physical Exam:
Admission exam:
Vitals- 97.6 139/84 72 22 94%RA
General- Alert, oriented, no acute distress, very pleasant.
HEENT- Sclera anicteric, MMM, oropharynx clear.
Neck- supple, no appreciable JVD at 45 degress, no LAD
Lungs- Diffusely wheezing. Good air movement.
CV- Very distant heart sounds. Irregularly irregular, no
appreciable murmurs.
Abdomen- soft, non-tender, slightly distended, bowel sounds
present, no rebound tenderness or guarding
Back- TTP over left paraspinal muscles.
GU- no foley
Ext- warm, well perfused, 1+ DP pulses, no clubbing, cyanosis or
edema
Neuro- Alert, awake and oriented x3. Fluent speech. CNs2-12
intact. Distal sensation intact and symmetric. Strength in ___
___ bilaterally.
Discharge exam:
Vitals- 98.0 139/82 66 18 97/RA
General- Alert, oriented, no acute distress, very pleasant.
HEENT- Sclera anicteric, MMM, oropharynx clear.
Neck- supple, no appreciable JVD at 45 degress, no LAD
Lungs- Inspiratory and expiratory wheezes throughout lung
fields. Mild inspiratory crackles most prominent at the bases
R>L. Increased I:E ratio. Decreased air movement throughout.
CV- Very distant heart sounds. Irregularly irregular, no
appreciable murmurs.
Abdomen- soft, non-tender, slightly distended, bowel sounds
present, no rebound tenderness or guarding
Back- TTP over left paraspinal muscles.
GU- no foley
Ext- warm, well perfused, 1+ DP pulses, no clubbing, cyanosis or
edema
Neuro- Alert, awake and oriented x3. Fluent speech. CNs2-12
intact. Distal sensation intact and symmetric. Strengh in ___
___ bilaterally.
Pertinent Results:
Admission labs:
___ 04:27PM BLOOD WBC-8.0 RBC-5.46 Hgb-14.0 Hct-42.1
MCV-77* MCH-25.6* MCHC-33.2 RDW-17.7* Plt ___
___ 01:30PM BLOOD ___ PTT-36.1 ___
___ 04:27PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL
___ 04:27PM BLOOD ___ PTT-44.3* ___
___ 04:27PM BLOOD Glucose-287* UreaN-56* Creat-2.5* Na-136
K-4.8 Cl-96 HCO3-28 AnGap-17
___ 04:27PM BLOOD proBNP-429*
___ 07:47AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.2
___ 04:37PM BLOOD Lactate-2.1*
Discharge labs:
CXR ___
FINDINGS: In comparison with the study of ___, there are lower
lung volumes
that accentuate the transverse diameter of the heart. There is
mild elevation
of pulmonary venous pressure or a manifestation of the patient's
known chronic
lung disease.
An area of increased opacification at the right base would be
worrisome for
developing consolidation in the appropriate clinical setting.
Pacer lead again extends to the region of the apex of the right
ventricle.
CT Abdomen and Pelvis ___
IMPRESSION:
1. No evidence of aortic injury or extravasation of contrast to
suggest leak.
2. Cholelithiasis without evidence of acute cholecystitis.
3. Stable right basilar pulmonary nodules.
4. Possible underlying chronic lung disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mirtazapine 15 mg PO HS
2. Metoprolol Succinate XL 75 mg PO DAILY
3. Senna 1 TAB PO DAILY:PRN constipation
4. Docusate Sodium 200 mg PO DAILY:PRN constipation
5. Amiodarone 200 mg PO DAILY
6. Warfarin 5 mg PO DAILY16
7. Atorvastatin 10 mg PO DAILY
8. insulin lispro protam & lispro [Humalog Mix 50-50 KwikPen] 62
Units Breakfast
insulin lispro protam & lispro [Humalog Mix 50-50 KwikPen] 42
Units Dinner
9. Torsemide 40 mg PO DAILY
10. Spironolactone 12.5 mg PO DAILY
11. Multi-Vite 50 & Over (multivitamin-minerals-lutein) 1
capsule Oral daily
12. Perphenazine 6 mg PO HS
13. Omeprazole 40 mg PO BID
14. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral daily
15. Aspirin 325 mg PO DAILY
16. Imipramine 50 mg PO HS
17. Thiamine 100 mg PO DAILY
18. Ascorbic Acid ___ mg PO DAILY
19. Vitamin D 800 UNIT PO DAILY
20. Vitamin D 50,000 UNIT PO ONCE PER MONTH ON THE ___
21. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. Outpatient Physical Therapy
Diagnosis: Back Pain
Please evaluate and treat
2. Amiodarone 200 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 10 mg PO DAILY
6. Docusate Sodium 200 mg PO DAILY:PRN constipation
7. Imipramine 50 mg PO HS
8. Metoprolol Succinate XL 75 mg PO DAILY
9. Mirtazapine 15 mg PO HS
10. Omeprazole 40 mg PO BID
11. Perphenazine 6 mg PO HS
12. Senna 1 TAB PO DAILY:PRN constipation
13. Thiamine 100 mg PO DAILY
14. Vitamin D 800 UNIT PO DAILY
15. Vitamin E 400 UNIT PO DAILY
16. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral daily
17. Multi-Vite 50 & Over (multivitamin-minerals-lutein) 1
capsule Oral daily
18. Spironolactone 12.5 mg PO DAILY
19. Vitamin D 50,000 UNIT PO ONCE PER MONTH ON THE ___
20. Warfarin 5 mg PO DAILY16
21. Outpatient Lab Work
Please have INR and BMP checked and results faxed to Dr ___
at ___ and to Dr. ___ at ___
ICD 9 584.9, 427
22. 70/30 75 Units Breakfast
70/30 50 Units Dinner
RX *insulin NPH & regular human [Humulin 70/30 Pen] 100 unit/mL
(70-30) 100 Units mL 75 Units before BKFT; 50 Units before DINR;
Disp #*14 Unit Refills:*0
23. Torsemide 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
___
IDDM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Left back pain. Rule out AAA Leak. AAA in ___.
COMPARISON: Prior abdominal/pelvic CT from ___ and ___.
TECHNIQUE: Contiguous axial CT images were obtained through the abdomen and
pelvis with and without IV contrast. 130 cc of Omnipaque intravenous contrast
was provided. Sagittal, coronal reconstructions were generated.
FINDINGS:
CTA: The aortic graft is widely patent with no evidence of free air in or
around the aorta and and no extravasation of contrast to suggest leak or
features to suggest infection. The vessels arising from the abdominal aorta
are widely patent. Celiac axis, SMA, bilateral renal arteries and ___ are
patent. Note is made of duplicated right renal arteries. The left gastric
artery comes directly off the aorta and is also notable for a replaced left
hepatic.
CT OF THE ABDOMEN: There is bibasilar ground glass opacity and intralobular
septal thickening raising possibilty of undering intersitial lung abnormality.
Right lower lobe 7 mm nodule (3:8) has been stable for over ___ years, as has
the imaged portion of the pleural based nodular opacity in the right middle
lobe (3:1). Lingular atelectasis vs scarring noted. Image portions of the
heart and pericardium are within normal limits.
The liver enhances homogeneously with no focal hepatic lesions. The
gallbladder demonstrates dependent partially hyperdense gallstones. There is
no signs of acute cholecystitis. The adrenal glands, pancreas and spleen are
within normal limits. Multiple hypodensities are seen within the kidneys
bilaterally likely represent renal cysts. The kidneys otherwise enhance
symmetrically and excrete contrast without evidence of hydronephrosis or
masses.
Stomach is collapsed. There is no evidence of bowel obstruction. There is
moderate fecal loading in the colon. Per history, patient is status post
appendectomy. There is no retroperitoneal mesenteric lymph node enlargement
by CT size criteria.
CT OF THE PELVIS: Urinary bladder and terminal ureters are within normal
limits. Phleboliths are seen within the pelvis. The prostate is within
normal limits. The rectum is within normal limits. There is no pelvic or
inguinal lymph node enlargement by CT size criteria.
OSSESOUS STRUCTURES: Degenerative changes are noted along the lower spine.
There is no blastic or lytic lesions concerning for malignancy.
IMPRESSION:
1. No evidence of aortic injury or extravasation of contrast to suggest leak.
2. Cholelithiasis without evidence of acute cholecystitis.
3. Stable right basilar pulmonary nodules.
4. Possible underlying chronic lung disease.
Radiology Report
HISTORY: COPD with restrictive lung disease and shortness of breath, to
assess for pulmonary edema.
FINDINGS: In comparison with the study of ___, there are lower lung volumes
that accentuate the transverse diameter of the heart. There is mild elevation
of pulmonary venous pressure or a manifestation of the patient's known chronic
lung disease.
An area of increased opacification at the right base would be worrisome for
developing consolidation in the appropriate clinical setting.
Pacer lead again extends to the region of the apex of the right ventricle.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain
Diagnosed with SPRAIN LUMBAR REGION, OVEREXERTION FROM SUDDEN STRENUOUS MOVEMENT, ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPERTENSION NOS
temperature: 97.2
heartrate: 78.0
resprate: 18.0
o2sat: 95.0
sbp: 114.0
dbp: 75.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ year-old gentleman with a PMH of
non-ischemic cardiomyopathy with EF 20%, COPD, CKD (bl Cr
1.4-1.6), IDDM, atrial fibrillation on warfarin, s/p AAA repair
in ___, now presenting with back pain, found to have acute on
chronic kidney disease.
# Back Pain: Patient has had progressive pain recently and was
schedule to have an outpatient CT scan to evaluate for AAA graft
integrity. However due to increasing pain, he presented to
___. In the ED a CTA abdomen and pelvis plan was completed and
evaluated by vascular surgery. There was no aortic leak at the
site of the graft. CT abd also did show degenerative spinal
changes that may be contributing to his pain. He has no
radicular symptoms or neurologic deficit on exam that would be
suggestive of nerve root compression or cord compression. Likely
musculoskeletal sprain, with musclar tenderness on exam. His
pain was controlled on Tylenol and hot packs. He was discharged
with a referral to outpatient ___.
# Acute on chronic kidney disease: Cr upon presentation was 2.5
from baseline of 1.6. Although patient has gained ~ 20 pounds
since previous admission several months ago, on exam patient did
not have any signs of volume overload. Creatinine improved with
gentle fluids. Acute kidney failure likely secondary to osmotic
diuresis (pre-renal) from uncontrolled diabetes mellitus (last
HgbA1c of 10). Patient may also have progression of CKD
(diabetic glomerularnephropathy) on top of this ___.
# Systolic CHF: Non-ischemic cardiomyopathy with ED 20%, s/p
ICD. Reporting DOE and orthopnea. No gross signs of volume
overload on exam but objectively has gained ~20 pounds in the
last few months - nutrition (diet) vs. fluid. Patient's
torsemide held initially in the setting of pre-renal kidney
injury and resumed prior to discharge.
# Diabetes: Recently started on insulin, and reported to have
FSBS ranging in the 300s-400s. HbA1c at ___ on ___ was
10.1%. Patient has poor diet control at home- copious white
breads and soda. In house patient was counseled regarding the
importance of diet control in disease process and the
consequences of diabetes including kidney, heart, and brain
disease. ___ was consulted in house and increased the
patient's insulin regimen. He was discharged with 70/30 75 units
in the AM and 50 units in the ___.
# Supratherapeutic INR: On warfarin for atrial fibrillation.
Patient's warfarin initially held and then resumed upon
discharge. No signs or symptoms of bleeding in house.
# Atrial fibrillation: continued home metoprolol succinate and
amiodarone
# Depression: continued home imipramine and mirtazapine
# Vitamins: continue home ascorbic acid, calcium, vitamin D,
multivitamin thiamine, vitamin D, vitamin E |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest/back pain
Major Surgical or Invasive Procedure:
___ Emergency repair of type A aortic dissection with a
Bentall procedure using a 25 mm ___ freestyle aortic root
valve and ascending aortic and a hemi arch resection and
replacement using a 28 mm Gelweave graft
___ Mediastinal washout and chest closure
History of Present Illness:
Gentleman in his ___, developed ___ chest pain radiating to
back this am while standing up from watching TV on couch. He
also notes numbness of his lower extremities which resolved. He
waited approximately 20 minutes for pain to ease. He then
proceded to make tea in hopes that pain would further resolve.
It did not, and he drove himself to an OSH. CT at outside
hospital reportedly revealed "aortic arch" dissection. He is
transferred to ___ for further management. On wet-read with
radiology- dissection extends from Aortic root through iliacs.
The patient is stable on an Esmolol drip with 2+ peripheral
pulses. He will head to the OR for repair shortly.
Past Medical History:
Hypertension
Depression
Alcohol Dependence
Seizure disorder (on withdrawal from EtOH)
Osteoarthritis
Carpal Tunnel
Rib fracture with "punctured lung"- remotely
s/p Appendectomy
s/p Tonsillectomy
Social History:
___
Family History:
No premature coronary artery disease
Physical Exam:
Admission exam:
Pulse: 90SR Resp: 20 O2 sat: 92%RA
B/P Right: Left: 143/50
Height: ___ Weight: 140lb
General: NAD, slightly disheveled
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [] Murmur [] grade __2/6 syst.__
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _none__
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
___ Right: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit: no bruits
Discahrge exam:
VS: T 97.8 HR 86 SR BP 110/78 RR 18 O2sat 94%-RA
Wt 60.9kg
Gen: NAD, sitting comfortably in chair
Neuro: A&O x3, MAE, nonfocal exam
CV: RRR, No murmur. sternum stable, incision CDI
Pulm: CTA-bilat, no rales
Abdm: soft, NT/ND/+BS
Ext: warm, well perfused. no edema. Left groin cutdown site
CDI-no eryhtema
Pertinent Results:
Admission labs:
___ 11:55AM URINE RBC->182* WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 11:55AM URINE BLOOD-MOD NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 11:55AM ___ PTT-34.6 ___
___ 11:55AM PLT COUNT-128*
___ 11:55AM WBC-8.9 RBC-4.33* HGB-12.4* HCT-39.7* MCV-92
MCH-28.6 MCHC-31.2 RDW-23.5*
___ 11:55AM ALBUMIN-3.7
___ 11:55AM cTropnT-<0.01
___ 11:55AM ALT(SGPT)-37 AST(SGOT)-108* ALK PHOS-81 TOT
BILI-0.4
___ 11:55AM GLUCOSE-102* UREA N-10 CREAT-0.6 SODIUM-145
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-28 ANION GAP-17
___ 12:21PM LACTATE-1.7
___ 11:55AM GLUCOSE-102* UREA N-10 CREAT-0.6 SODIUM-145
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-28 ANION GAP-17
Discahrge Labs:
___ 05:30AM BLOOD WBC-10.3 RBC-3.00* Hgb-9.1* Hct-29.0*
MCV-97 MCH-30.2 MCHC-31.2 RDW-17.6* Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:44AM BLOOD ___ PTT-31.7 ___
___ 05:30AM BLOOD Glucose-114* UreaN-16 Creat-0.7 Na-137
K-3.8 Cl-101 HCO3-27 AnGap-13
___ 02:59AM BLOOD ALT-66* AST-84* LD(LDH)-269* AlkPhos-209*
Amylase-283* TotBili-2.3*
___ 02:53AM BLOOD ALT-80* AST-208* AlkPhos-81 Amylase-48
TotBili-5.0* DirBili-4.1* IndBili-0.9
___ 02:59AM BLOOD Lipase-409*
___ 05:44AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.1
___ Echo: Pre Bypass: The left atrium is mildly dilated. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Right ventricular chamber size and free
wall motion are normal. The aortic root is severely dilated at
the sinus level. The sinuses of Valsalva are dilated. The
ascending aorta is severely dilated. The aortic arch is mildly
dilated. The descending thoracic aorta is mildly dilated. A
mobile density is seen in the ascending aorta consistent with an
intimal flap/aortic dissection that reaches into the aortic root
and terminates in the sinus of valsalva. This dissection extends
down through the arch and is visible in the descending aorta as
far as can be visualized. There are three aortic valve leaflets.
There is no aortic valve stenosis. Moderate to severe (3+)
aortic regurgitation is seen. The aortic regurgitation jet is
eccentric. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.
Post Bypass: There is a well positioned valve in the aortic
position with a peak gradient of 8 mmHg and a mean gradient of 3
mmHg. There is no evidence of aortic insufficiency. There is a
tube graft in the ascending aorta. Left ventricular function
remains unchanged from prebypass. There is a persistent
dissection flap in the descending aorta.
Radiology Report CHEST (PORTABLE AP) Study Date of ___ 8:44
AM
Final Report: Postoperative appearance of the mediastinum is
unchanged.
Bibasilar streaks of atelectasis are noted. Lungs are otherwise
clear. There has been interval placement of a Dobbhoff tube
which terminates in the mid gastric body although the tip of the
tube is excluded on imaging. A right internal jugular catheter
is unchanged in position with the tip projecting over the
cavoatrial junction.
___. ___
___. ___
Radiology Report ART DUP EXT UP BILAT COMP PORT Study ___
2:05 ___
Final Report: Duplex was performed of bilateral upper extremity
arterial systems.
On the left, the dissection is seen in the subclavian artery and
extends into the axillary and brachial artery. Flow was seen in
both lumens and there is bi/tri-phasic flow in the brachial,
radial and ulnar arteries.
On the right, there is a dissection seen in the subclavian with
flow in both lumens and a biphasic waveform distally. There is
no flow seen in one of the lumens and a very blunted waveform is
seen in the axillary and a small flow lumen. Arterial waveform
becomes monophasic in the axillary, brachial, radial and ulnar
arteries. Brachial, radial and ulnar arteries are patent with
no evidence of dissection.
IMPRESSION: Bilateral upper extremity arterial dissection with
relatively normal flow on the left and narrowed flow lumen on
the right at the axillary and subclavian.
Medications on Admission:
Trazodone 50mg hs prn
Omeprazole 20mg daily
FeSO4 325mg TID
Metoprolol 50mg daily
Clonazepam prn
Centrum Silver
Discharge Medications:
1. traZODONE 50 mg PO HS:PRN insomnia
2. Acetaminophen 650 mg PO Q4H:PRN pain, fever
3. Aspirin EC 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
continue while taking narcotics
5. FoLIC Acid 1 mg PO DAILY
6. Haloperidol 1 mg PO HS
7. Heparin 5000 UNIT SC TID
8. Lorazepam 0.5 mg PO BID:PRN anxiety
9. MetRONIDAZOLE (FLagyl) 500 mg PO TID
continue through ___
10. Milk of Magnesia 30 ml PO PRN constipation
11. Multivitamins 1 TAB PO DAILY
12. Thiamine 100 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 1 Days
Take ___ and then stop
15. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aortic Dissection s/p Asc Aorta replacement
PMH:
Hypertension
Depression
Alcohol Dependence
Seizure disorder (on withdrawal from EtOH)
Osteoarthritis
Carpal Tunnel
Rib fracture with "punctured lung"- remotely
s/p Appendectomy
s/p Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram/Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Right groin- healing well, no erythema or drainage.
Edema- none
Followup Instructions:
___
Radiology Report
STUDY: Bilateral upper extremity arterial duplex.
REASON: Status post repair of type A dissection.
FINDINGS: Duplex was performed of bilateral upper extremity arterial systems.
On the left, the dissection is seen in the subclavian artery and extends into
the axillary and brachial artery. Flow was seen in both lumens and there is
bi/tri-phasic flow in the brachial, radial and ulnar arteries.
On the right, there is a dissection seen in the subclavian with flow in both
lumens and a biphasic waveform distally. There is no flow seen in one of the
lumens and a very blunted waveform is seen in the axillary and a small flow
lumen. Arterial waveform becomes monophasic in the axillary, brachial, radial
and ulnar arteries. Brachial, radial and ulnar arteries are patent with no
evidence of dissection.
IMPRESSION: Bilateral upper extremity arterial dissection with relatively
normal flow on the left and narrowed flow lumen on the right at the axillary
and subclavian.
Radiology Report
HISTORY: Chest closure, removal of sponges.
TECHNIQUE: Intraoperative supine AP view of the chest and two views of a
sponge.
COMPARISON: ___ at 1:12.
FINDINGS:
No radiopaque foreign bodies resembling a retained sponge are noted.
Specifically, the 3 previously noted sponges within the mediastinum have been
removed. The endotracheal tube, Swan-Ganz catheter, mediastinal drains, and
nasogastric tube remain in unchanged positions, with the nasogastric tube side
port at the level of the GE junction. Additionally, a catheter is seen with
tip terminating just above the carina, of uncertain function. Six,
transversely oriented metallic wires representing sternotomy wires are
present, attached to partially imaged metallic clamps.
The patient has an open chest. Dense retrocardiac opacification persists,
likely reflecting atelectasis. There is pulmonary vascular congestion. New
linear opacity in the left mid lung field likely also reflects atelectasis.
IMPRESSION:
No radiopaque foreign body resembling a retained sponge identified. Findings
discussed with Dr. ___ at 9:40, ___ by phone.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after washout and sternal
closure surgery.
AP radiograph of the chest was reviewed in comparison to prior study obtained
at 8:15 a.m.
The sternum has been closed with sternal wires that appear to be intact. The
left chest tube has been inserted. There is small amount of left pleural
effusion, but no obvious pneumothorax. There is unchanged appearance of
mediastinal drains. There is no appreciable right pleural effusion. There is
no appreciable right pneumothorax as well.
Swan-Ganz catheter tip is at the level of the right main pulmonary artery.
The ET tube tip is 6.8 cm above the carina.
Radiology Report
PORTABLE CHEST X-RAY, ___
COMPARISON: ___.
FINDINGS: The patient is status post recent median sternotomy and
cardiovascular surgery. Tip of endotracheal tube terminates above the
thoracic inlet, about 10 cm above the carina, and the cuff is markedly
over-distended, measuring about 4.2 cm in transverse dimension overlying the
lower cervical region. Following removal of left-sided chest tube, a small
left apical pneumothorax has developed, with visceral pleural line just below
the third left posterior rib. These findings have been communicated over
telephone to ___ at 5:30 p.m. on ___ at the time of
discovery. Cardiomediastinal contours are stable in appearance. Worsening
left lower lobe collapse and slight increase in patchy right lower lobe
atelectasis, accompanied by slightly increasing small bilateral pleural
effusions.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: Radiograph of earlier the same date.
FINDINGS: Endotracheal tube has been repositioned, with tip now terminating
5.5 cm above the carina. Other indwelling devices remain in standard
position, and cardiomediastinal contours are stable in appearance. Slight
improvement in left retrocardiac atelectasis and adjacent small left pleural
effusion, but a small left apical pneumothorax has slightly decreased in size,
and there is no evidence of right pneumothorax. Small right pleural effusion
and adjacent right basilar atelectasis are unchanged.
Radiology Report
PORTABLE SEMI-UPRIGHT CHEST OF ___
COMPARISON: ___ radiograph.
FINDINGS: Indwelling support and monitoring devices remain in standard
position. Persistent small left apical pneumothorax. Cardiomediastinal
contours are stable in appearance. Improving bibasilar atelectasis which
remains most prominent in the left retrocardiac region, and apparent slight
decrease in size of small pleural effusions, although positional differences
may contribute to this apparent change.
Radiology Report
HISTORY: Worsening hypoxia.
COMPARISON:
FINDINGS:
Axial. History hypoxia.
IMPRESSION:
AP chest at 2:22 compared to ___:
Left lower lobe consolidation, probably atelectasis, has worsened, and
moderate right basal atelectasis though less severe than the left has also
increased. Pulmonary vasculature is now engorged, although the
cardiomediastinal silhouette has a normal postoperative appearance. No
pneumothorax. ET tube, right internal jugular line, and upper enteric
drainage tube are all in standard positions, respectively. The patient
probably has a small hiatus hernia.
Radiology Report
INDICATION: Dobbhoff tube placement.
COMPARISON: ___.
TECHNIQUE: Portable frontal chest radiographs, three views.
FINDINGS: Postoperative appearance of the mediastinum is unchanged.
Bibasilar streaks of atelectasis are noted. Lungs are otherwise clear. There
has been interval placement of a Dobbhoff tube which terminates in the mid
gastric body although the tip of the tube is excluded on imaging. A right
internal jugular catheter is unchanged in position with the tip projecting
over the cavoatrial junction.
IMPRESSION:
Little change compared to ___ with interval placement of a Dobbhoff which
terminates in the mid gastric body.
Radiology Report
INDICATION: ___ man with a history of a Dobbhoff tube, who presents
for evaluation of position.
COMPARISONS: None.
FINDINGS: There is a Dobbhoff tube which terminates in the antrum of the
stomach. The bowel gas pattern is unremarkable. There is no pneumatosis or
free air. The visualized osseous structures are unremarkable.
IMPRESSION:
Tip of the Dobbhoff tube terminates in the antrum of the stomach.
Radiology Report
TYPE OF EXAMINATION: Chest PA and lateral.
INDICATION: ___ male patient with Bentall and complicated with left
costal margin pain. Evaluate for interval change of left lower lobe process.
FINDINGS: PA and lateral chest views were obtained with patient in upright
position. Analysis is performed in direct comparison with the next preceding
portable single view chest examination of ___. Status post
sternotomy unchanged. No separation of circular sternal wires. Unchanged
appearance of post-operative surgical clips in mediastinum (status post
Bentall). No increased widening of mediastinal structures and no pneumothorax
in the apical area. Right hemithorax demonstrates a pulmonary vasculature
without signs of vascular congestion or acute infiltrates. On the left lung
base extensive density in the left lower lobe area is present and obscures the
diaphragmatic contours. The lateral view demonstrates that these densities
extend into the posterior pleural sinus on the left side whereas the
right-sided diaphragm and posterior pleural sinuses are free. Comparison is
extended to a referred chest examination from an outside institution dated
___ and a referred chest CT examination of the same date.
Patient had an aortic root aneurysm with signs of extensive aortic dissection.
Review of the chest CT demonstrated also an independent abnormality in the
left lung in the form of a linear density in vertical orientation connecting
with the diaphragm laterally and posteriorly. It is also observed that this
density had connections with the vascular system of the lung in its more
centrally located portion. The type of the abnormality cannot be identified
with certainty but possibility of a chronic atelectasis, or perhaps an
intra-lobar pulmonary sequestration may be entertained. It is also unclear to
what extent the present post-operative remaining much larger densities may
have their origin related to this abnormality. Dr. ___, the
referring physician was paged at 3:15 p.m. and situation was discussed.
Recommendation for further imaging will have to be based on patient's clinical
history before the acute aortic dissection event. ? history of chronic
pulmonary infections,previous chest x-rays, chest problems in early childhood
etc.
Radiology Report
CT ABDOMEN AND PELVIS WITH CONTRAST
INDICATION: ___ man. Evaluate for pancreatitis.
TECHNIQUE: CT of the abdomen and pelvis was obtained with multiplanar
reformatted images.
FINDINGS:
There are moderate left and small right non-hemorrhagic pleural effusions and
basilar atelectasis noted. A small pericardial effusion with mild thickening
of the pericardium is noted which may be post-surgical in appearance.
The liver demonstrates normal contour without lesions. The spleen is normal.
The pancreas demonstrates a small hypodense area along the anterior portion of
the pancreatic body (2:30) and this may represent a tiny pancreatic cyst or
IPMN. However, there is no evidence of surrounding peripancreatic stranding
or pancreatic ductal dilatation.
The arteries demonstrate intimal dissection with displacement of the intimal
flap into the lumen from the descending thoracic aorta down to the level of
the aortic bifurcation. This is a known type A dissection status post Bentall
procedure on ___. The true lumen provides blood flow to the
major blood vessels. Except, the ostium and proximal celiac axis remain
narrowed with the distal branches of the celiac artery patent. The SMA and
___ are patent. There are multiple renal hypodensities of which many are too
small to characterize. The largest is noted in the left upper pole and does
not measure simple fluid and may represent a hemorrhagic renal cyst or
proteinaceous renal cyst. Ultrasound study performed for further evaluation.
The bowel is normal. Both adrenal glands are normal. No significant
lymphadenopathy.
CT PELVIS: No evidence of significant lymphadenopathy or free fluid in the
pelvis.
BONES: Mild degenerative disc disease.
IMPRESSION:
1. No evidence of pancreatitis with normal-appearing and enhancing pancreas.
However, a subcentimeter hypodense focus is noted in the anterior body of the
pancreas which may represent a small pancreatic cyst or IPMN.
2. Known type A dissection status post Bentall procedure with filling of the
distal celiac branches and patency of the SMA and ___.
3. Moderate left and small right non-hemorrhagic pleural effusions and
basilar atelectasis. Small pericardial effusion is also noted.
4. Small hypodense lesions in the kidneys are too small to characterize with
the largest in the left upper pole demonstrating not quite simple fluid. This
may represent an underlying proteinaceous or hemorrhagic renal cyst.
Radiology Report
CHEST RADIOGRAPH
HISTORY: Chest pain.
COMPARISONS: Recent prior radiographs from earlier on the same day performed
at ___ as scanned into the ___ PACS.
TECHNIQUE: Chest, AP upright portable.
FINDINGS: The heart is mildly enlarged with a left ventricular configuration.
The mediastinal and hilar contours appear within normal limits without change.
Streaky left basilar opacity suggests minor atelectasis or scarring, but
otherwise, the lung fields appear clear. There is no definite pleural
effusion or pneumothorax.
An old healed right posterior ninth rib fracture appears unchanged.
IMPRESSION: No evidence of acute cardiopulmonary disease.
Radiology Report
HISTORY: Cardiac surgery.
FINDINGS: In comparison with the pre-operative study of ___, there is now an
endotracheal tube in place with its tip approximately 7 cm above the carina.
Right IJ Swan-Ganz catheter extends to the right pulmonary artery and
nasogastric tube extends to the upper portion of the stomach, with the side
hole within the lower esophagus. Left chest tube is in place and there is no
evidence of pneumothorax. Increased opacification at the left base most
likely reflects volume loss in the lower lobe with a small pleural effusion.
The right lung is essentially clear and there is no appreciable pulmonary
vascular congestion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: AAA
Diagnosed with DISS AORT ANEURYSM UNSPEC SITE, ALCOHOL WITHDRAWAL, ALCOH DEP NEC/NOS-CONTIN
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ was admitted to the ___ on ___ after he
developed ___ chest pain radiating to his back and he drove
himself to an outside hospital. A CT scan revealed "aortic arch"
dissection. He was thus transferred to the ___ for further
management. On wet-read it was aortic dissection that extends
from Aortic root through the iliacs. He was transferred to ___
and brought emergently to operating room by Dr ___. He
underwent an Emergency repair of a type A aortic dissection with
a Bentall procedure using a 25 mm ___ freestyle aortic
root valve and ascending aortic and a hemi arch replacement
using a 28 mm Gelweave graft. His bypass time was 236 minutes
with a crossclamp time of 202 minutes and a circulatory arrest
time of 17 minutes. He tolerated the procedure well however
continued to bleed post-operatively and was brought to the CVICU
with an esmar dam covering his chest. He returned to the
operating room the following morning for a washout and chest
closure. After this procedure the paralytics were stopped but
the patient was kept on benzodiazepines because he evident signs
of alcohol withdrawal. A vascular surgery consult was obtained
because of the extent of the dissection which included both the
illiacs and the subclavian branches. No flow limiting disease
was noted and a follow-up appointment was scheduled. He had
copious amounts of pulmonary secretions and on postoperative day
4 had a bronchoscopy with bronchial lavage that showed Ecoli. He
was started on the appropriate antibiotics (Zosyn). Over the
next several days he weaned from the sedation and ventilator
support and on postoperative day (POD)6 he was extubated. He was
still quite lethargic and a feeding tube was placed to assist
initially with nutrition. Although he was hemodynamically
stable, Mr. ___ was experiencing periods of delirium,
confusion, and agitation and thus continued treatment for
withdrawal with Ativan and Haldol. He slowly cleared. On POD 10
he began having loose stool which tested positive for C Diff and
he was started on Flagyl with good effect. He is to be on the
Flagyl until ___. On POD 11 he was transferred to the
stepdown floor for continued recovery. His activity level was
advanced with the assistance of both nursing and physical
therapy. He passed a speech and swallow test for soft foods.
The remainder of his hospital course was uneventful. On POD 13,
Mr. ___ was discharged to rehabilitation at ___
in ___. He is to follow up with Dr ___ in 1
month. An appointment with the vascular surgery service has also
been scheduled and he has been advised to schedule appointments
with his cardiologist Dr. ___ his primary care physician as
an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Avelox
Attending: ___.
Chief Complaint:
R long finger flexor tenosynovitis
Major Surgical or Invasive Procedure:
I&D Right long finger ___
History of Present Illness:
HPI: ___ M with chronic right long finger infection s/p initial
debridement in ___ (Dr. ___, s/p recent I&D in hand
clinic
on ___, now presents with worsening swelling and erythema
of
the right long finger for ___ days. He denies fever, chills, or
trauma. Please see previous OMR notes for full history of his
condition. He had recurrence of abscess and underwent I&D of
the
R long in clinic on ___, with no growth on cultures. He
was
last seen on ___ and noted to be improving at that time. He
is
not taking any antibiotics at this time, though he is followed
by
Infectious Disease and was previously treated for presumed
mycobacterium marinum. Over the past 48 hours, he notes
worsening pain, swelling, erythema, and drainage of rice bodies.
Past Medical History:
MEDICAL HISTORY: None.
SURGICAL HISTORY: S/p radical tenosynovectomy by Dr.
___ in ___, status post bedside I&D ___
___ on ___, date unknown), s/p bedside I&D ___.
Social History:
___
Family History:
unremarkable
Physical Exam:
Vitals: 99.8 103 154/89 16 99% RA
General: Well-appearing male in no acute distress.
Right upper extremity:
- Significant swelling and erythema about the right long
proximal
phalanx
- Tender over flexor tendon sheath
- 2mm open wound over dorsal ulnar aspect of P1, with purulent
exudate
- No significant pain with passive extension
- Fires FDS, FDP to long
- SILT radial/median/ulnar nerve distributions
- WWP distally
Pertinent Results:
___ 03:34PM ___ PTT-32.3 ___
___ 03:31PM LACTATE-1.1
___ 03:30PM GLUCOSE-85 UREA N-14 CREAT-1.0 SODIUM-136
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-23 ANION GAP-19
___ 03:30PM estGFR-Using this
___ 03:30PM CRP-36.3*
___ 03:30PM WBC-17.0*# RBC-5.12 HGB-15.4 HCT-44.7 MCV-87
MCH-30.1 MCHC-34.5 RDW-12.6 RDWSD-40.3
___ 03:30PM NEUTS-83.4* LYMPHS-9.1* MONOS-6.6 EOS-0.2*
BASOS-0.2 IM ___ AbsNeut-14.19* AbsLymp-1.54 AbsMono-1.12*
AbsEos-0.03* AbsBaso-0.04
___ 03:30PM PLT COUNT-304
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pramipexole 0.125 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain not
relieved by acetaminophen
4. Clindamycin 450 mg PO Q6H infection Duration: 10 Days
5. Pramipexole 0.125 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right long finger flexor tenosynovitis.
Discharge Condition:
Stable.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with R long finger pain
TECHNIQUE: AP, lateral, oblique views of the right long finger.
COMPARISON: None.
FINDINGS:
There is no fracture or focal osseous abnormality. There is no focal erosion.
Significant soft tissue swelling seen at the proximal aspect of the long
finger laterally. There is no radiopaque foreign body or subcutaneous gas.
IMPRESSION:
Significant soft tissue swelling. No radiographic evidence of osteomyelitis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Local infection of the skin and subcutaneous tissue, unsp, Oth bacterial agents as the cause of diseases classd elswhr
temperature: 99.8
heartrate: 103.0
resprate: 16.0
o2sat: 99.0
sbp: 154.0
dbp: 89.0
level of pain: 7
level of acuity: 3.0 | Pt was admitted for IV abx, started on vancomycin according to
ID. He was taken to OR for I&D and did well postop. His dressing
has been changed and his infection started to resolve. His
cultures came back as group A Strep and he was switched to
Penicillin G IV. On discharge pt was in stable condition, OT
transitioned him to hand based splint and started him on gentle
ROM. He was followed by ID while inpatient and they started him
on antimycobacterial empiric treatment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, lethargy.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a ___ gentleman with a pmhx. significant for
HTN, diabetes, and sinonasal squamous cell carcinoma diagnosed
in ___, who is admitted from the ED with fever and lethergy.
Mr. ___ was recently admitted on ___ for a total right
maxillecomy and right palatectomy. The surgery was
uncomplicated, and the patient was discharged on ___. According
to patient's wife, Mr. ___ had been improving (though
requiring narcotics for pain) over the course of last week and
weekend, but a few days ago developed increasing lethargy and
just wasn't "right." Had low grade fevers for 2 days prior to
admission.
On day of admission, patient went to ENT office for nasal
packing removal. After packing removed, saw attending and had
fever to 102. Was told to go to the emergency room.
In the ED, initial vitals were: 103.4 88 128/60 20 96%.
Patient was seen by ENT who removed prosthesis and looked with
scope. As per ENT report, no evidence of infection, very open
space, no where for infection to be lurking. Blood cultures
taken and patient received vanc and unasyn. Also given tylenol
and tramadol for fever and pain. On admission, vitals were:
101.2 88 122/54 18 99%.
ROS: Patient denies pain or neck stiffness. He is otherwise
quite lethargic and a complete review of systems is unable to
obtain.
Past Medical History:
--DM
--HTN
--Sinonasal squamous cell carcinoma (dx ___
--Gtube placement
Onc history:
-___ presented with sinusitis sx and found to have a rapidly
growing mass
-___ admitted to ___ for induction chemo with 4 day
course of continuous chemotherapy infusion of docetaxel,
cisplatin, and ___ and was started on neulasta
-___ cycle 2 induction chemo taxotere,, cisplatin,
infusional ___
- Pt is noted to continue progression during induction chemo
- ___ - started weekly chemoradiation with ___ and
concurrent XRT, completed ___
- Tumor remains despite chemoradiation
- ___ plan for surgery which includes removal of the
maxilla, subtotal palatectomy, bilateral neck dissection,
removal of the orbital floor and extensive soft tissue loss of
the cheek
- ___ PET scan shows mass is similar size and slightly
decreased FDG avidity of invasive right sinonasal mass.
Social History:
___
Family History:
Significant for high blood pressure, stroke, and diabetes.
Mother has high CHF. Father has diabetes. Uncle has a bone
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.6, 106/74, 88, 16, 100% on RA, BS 113
GENERAL: Sick appearing, lethargic, sleeping during interview
HEENT: Right side of face swollen, stitches well-healed, palate
prosthesis in place, right eye deviates upward, pupils are equal
and reactive bilaterally, mucous membranes moist, patient unable
to fully open mouth
NECK: No cervical, submandibular, or supraclavicular LAD
CHEST: CTA bilaterally, no wheezes, rales, or rhonchi, port in
place wtihout erythema or crepitus
CARDIAC: RRR, no MRG
ABDOMEN: +BS, G-tube in place, non-tender
EXTREMITIES: No edema bilaterally
SKIN: Very warm, dry
DISCHARGE PHYSICAL EXAM:
VS: 98.5, 100/64, 82, 18, 98% on RA
GEN: Sitting in bed, looks well
HEENT: Pupils equal and reactive, no photophobia, sclerae
anicteric, Edema of right side of face is getting better.
Healing sutures without erythema or exudate.
Neck: Supple
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops
RESP: Good air movement bilaterally, no rales, no rhonchi, no
wheezing
ABD: +BS, Soft, non-tender, non-distended, G-tube in place
without HSM.
EXTR: Trace edema bilateraly, extremities warm and dry
DERM: Dry, warm, without rashes or pressure ulcers
Neuro: Fluent speech, does not seem lethargic currently, totally
oriented
SKIN: Warm and dry
PSYCH: Appropriate and calm
Pertinent Results:
___ 04:43PM URINE HOURS-RANDOM
___ 04:43PM URINE GR HOLD-HOLD
___ 04:43PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 03:49PM LACTATE-1.0
___ 03:45PM GLUCOSE-100 UREA N-22* CREAT-1.1 SODIUM-134
POTASSIUM-4.4 CHLORIDE-87* TOTAL CO2-31 ANION GAP-20
___ 03:45PM estGFR-Using this
___ 03:45PM WBC-9.3 RBC-3.27* HGB-9.7* HCT-29.9* MCV-92
MCH-29.6 MCHC-32.3 RDW-14.9
___ 03:45PM NEUTS-82.3* LYMPHS-9.8* MONOS-7.0 EOS-0.9
BASOS-0.1
___ 03:45PM PLT COUNT-254
CXR ___: AP upright and lateral chest radiograph was
obtained. The lungs are well expanded and clear without pleural
effusion or pneumothorax. The heart is normal in size with
normal cardiomediastinal contours aside from mildly tortuous
aorta. Right Port-A-Cath is unchanged in appearance.
IMPRESSION: No acute intrathoracic process.
CT ___: Post-operative changes. No evidence of discrete
fluid collection. Increased opacification of paranasal sinuses,
particularly right frontal and sphenoid; the possibility of
superimposed infection is not excluded although opacification
may reflect hemorrhagic products.
EKG ___: Sinus rhythm. Possible old inferior myocardial
infarction. Poor R wave progression. Compared to the previous
tracing of ___ difference in R wave progression likely
reflects lead placement. Findings are otherwise similar.
CT ___:
1. No acute intra-abdominal process. No retroperitoneal
hematoma.
2. Horseshoe kidney without hydronephrosis or stone.
3. Duplicated infrarenal IVC.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
Please hold for SBP <100 or HR <50.
2. Fentanyl Patch 25 mcg/h TP Q72H
3. Gabapentin 300 mg PO BID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
Please hold for oversedation or RR <10.
5. Lisinopril 20 mg PO DAILY
Please hold for SBP< 100.
6. Lorazepam 0.5-1 mg PO Q4H:PRN Nausea, insomnia
Please hold for oversedation or RR <10.
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Ondansetron 8 mg PO Q8H:PRN Nausea
9. Pravastatin 40 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Senna 1 TAB PO BID:PRN Constipation
12. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Tubefeeding
Isosource 1.5at 65 ml/hour x24 hours per G-tube.
2. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 500 mg 1000 mg(s) IV Q12 Disp #*1 Vial Refills:*0
3. Gabapentin 300 mg PO BID
4. Lisinopril 20 mg PO DAILY
Please hold for SBP< 100.
5. Lorazepam 0.5-1 mg PO Q4H:PRN Nausea, insomnia
Please hold for oversedation or RR <10.
6. Multivitamins 1 TAB PO DAILY
7. Pravastatin 40 mg PO DAILY
8. Senna 1 TAB PO BID:PRN Constipation
9. ertapenem *NF* 1 gram Injection Q24 Reason for Ordering: As
per ID recommendations.
RX *ertapenem [Invanz] 1 gram 1 gram(s) IV Every 24 hours Disp
#*1 Vial Refills:*0
10. Fluconazole 400 mg PO Q24H
RX *fluconazole 200 mg 2 tablet(s) by mouth Once a day Disp #*10
Tablet Refills:*0
11. Morphine SR (MS ___ 60 mg PO Q12H
12. Docusate Sodium 100 mg PO BID
13. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
Please hold for oversedation or RR <10.
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Ondansetron 8 mg PO Q8H:PRN Nausea
16. Outpatient Lab Work
Labs for antibiotics on ___.
CBC, Chem 10, LFTs, vanc trough
Please fax to ___. Attn: Spyros ___.
17. Outpatient Lab Work
CBC
Please check on ___ and fax to PCP ___ ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Fever
Sinus cancer
Diabetes
Pain
Neuropathy
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
SINONASAL CT
HISTORY: Post-operative fever after treatment of right sinonasal mass.
Question abscess.
COMPARISONS: Pre-operative imaging studies; these include a neck CT from
___, a nasopharyngeal MR from ___, and an FDG PET
study from ___.
TECHNIQUE: Multidetector CT images of the facial bones were obtained with
intravenous contrast. Sagittal and coronal reformations were also performed.
FINDINGS: There has been an extensive resection performed of a mass in the
right maxillary sinus with a large associated soft tissue defect. The medial,
lateral and inferior walls of the right maxillary sinus have been resected
including the hard palate to the left of midline. A new fixation plate has
been placed along a small residual remaining part of the upper anterior right
maxillary wall. Parts of the right lateral pterygoid plate remain. The right
orbit appears intact. Visualized intracranial structures are intact.
There is a confluent opacification of right-sided ethmoid air cells with
somewhat expansile appearance, as before. Patchy opacification of left
ethmoid air cells has increased and there is also new confluent right frontal
sinus opacification with only a small residual quantity of aeration. Patchy
new opacification of the left frontoethmoid recess is also present. The
degree of right sphenoid opacification has increased. Contents of the
sphenoid and right frontal sinus are mildly hyperdense which may indicated
hemorrhagic content.
The right frontal sinus contents are hyperdense which may represent
proteinaceous secretions which could sometimes be seen with fungal infection
or hemorrhage in the immediate post-operative course with similar findings
seen within the sphenoid.
However, there is no discrete fluid collection identified. Fat stranding in
the neck is probably inflammatory or post-surgical and includes subcutaneous
soft tissue stranding as well as swelling of the right masseter. Small
cervical lymph nodes at the upper limits of normal size appear unchanged.
IMPRESSION: Post-operative changes after resection of sinonasal mass. No
evidence of discrete fluid collection. Increased opacification of paranasal
sinuses, particularly the right frontal and sphenoid sinuses. Associated
infection cannot be excluded by this study, although the appearance may be
post-operative and partly due to hemorrhage.
Radiology Report
HISTORY: Fever and drooling.
COMPARISON: ___.
FINDINGS: AP upright and lateral chest radiograph was obtained. The lungs are
well expanded and clear without pleural effusion or pneumothorax. The heart
is normal in size with normal cardiomediastinal contours aside from mildly
tortuous aorta. Right Port-A-Cath is unchanged in appearance.
IMPRESSION: No acute intrathoracic process.
Radiology Report
HEAD CT WITHOUT CONTRAST
INDICATION: ___ male with lethargy and sinus malignancy status post
recent surgery. Evaluate for mass effect prior to lumbar puncture.
COMPARISON: Maxillofacial CT from ___ and PET-CT from ___.
TECHNIQUE: Axial contiguous MDCT images were obtained through the brain
without administration of IV contrast.
DLP: 1657.70 mGy-cm.
CTDI: 188.00 mGy.
FINDINGS: There is no hemorrhage, edema, mass, mass effect, or large
territorial infarction. The ventricles and sulci are normal in size and
configuration and age-appropriate. There is preservation of gray-white matter
differentiation and the basal cisterns appear patent. There is no crowding of
the foramen magnum.
No fracture is identified. There is nearly total opacification of the right
ethmoidal sinus with extension of disease into the right sphenoidal and
frontal sinuses, compatible with provided history of sinus malignancy. There
is no facial or cranial soft tissue abnormality.
IMPRESSION: No evidence of acute intracranial process. Particularly, there
is no evidence of increased intracranial pressure or intracranial herniation.
Radiology Report
HISTORY: ___ male with sinonasal carcinoma and 7 point hematocrit
drop.
COMPARISON: ___ CT abdomen pelvis.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis. No IV or oral contrast administered. Axial images were interpreted
in conjunction with coronal and sagittal reformats.
DLP: 926 mGy-cm
FINDINGS:
The visualized heart is normal. Lung bases are clear. No pericardial or
pleural effusion.
ABDOMEN:
Evaluation of the intra-abdominal organs is limited without administration of
IV contrast. The unenhanced appearance of the liver, gallbladder, intra and
extrahepatic bile ducts, pancreas, spleen, and right adrenal gland are normal.
The left adrenal gland is thickened without discrete nodularity, compatible
with adrenal hypertrophy.
The kidneys are joined at their lower poles immediately anterior to the aorta,
consistent with a horseshoe kidney, unchanged since ___. 2.2 cm left
sided renal hypodensity is consistent with a simple cyst. The ureters are
normal in course and caliber.
The patient is status post percutaneous gastrostomy, with the tube and balloon
in appropriate position. The small and large bowel have a normal course and
calibur. The appendix is normal.
No retroperitoneal or mesenteric lymphadenopathy. The infrarenal IVC is
duplicated. The unenhanced appearance of the intra-abdominal systemic
vasculature is otherwise normal. No abdominal wall hernia, pneumoperitoneum,
or free abdominal fluid.
PELVIS: The bladder and terminal ureters are normal. The uterus / prostate
gland is unremarkable. No pelvic side-wall or inguinal lymphadenopathy. No
free pelvic fluid or inguinal hernia.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy. Multilevel thoracolumbar spine degenerative changes are mild.
There is loss of intervertebral disc space height at L5-S1 with end-plate
sclerosis.
IMPRESSION:
1. No acute intra-abdominal process. No retroperitoneal hematoma.
2. Horseshoe kidney without hydronephrosis or stone.
3. Duplicated infrarenal IVC.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with POSTPROCEDURAL FEVER
temperature: 103.4
heartrate: 88.0
resprate: 20.0
o2sat: 96.0
sbp: 128.0
dbp: 60.0
level of pain: 2
level of acuity: 2.0 | This is a ___ gentleman with a pmhx. significant for DM
II, HTN, and sinonasal SCC admitted with fevers about 2 weeks
after right maxillectomy and palatectomy.
# FEVER: Likely source is sinus, ?ethmoidal sinus. Patient
continued to improve on vanc, zosyn, and fluconazole.
Post-surgical area without evidence of exudate or infection;
just fibrinous and granulation tissue. ID was consulted and
patient will continue on vanc, ertapenem (once/day dosing), and
fluconzaole through ___. He will have labs faxed to
infectious disease clinic on ___. He will also have
follow-up in ID and ___ clinic. On discharge, patient was
afebrile and feeling well. Blood and urine cultures remained
negative. Patient dramatically improved from admission to
discharge with above antibiotics and fluids.
# HCT DROP: Patient with fluctuating hematocrit during
admission. Hemodynamically stable, though BPs a little low
(though patient was also febrile and had poor PO intake).
Hemolysis labs were negative. Lab was contacted and no evidence
of clumping on smear. A CT scan of abdomen/pelvis without
evidence of bleed. Patient will need to have hct followed-up as
outpatient by PCP.
# DIABETES II: Patient was continued on an insulin sliding
scale during admission. He will continue on his oral
hypoglycemics upon discharge.
# HTN: Patient was continued on lisinopril. His atenolol was
held in the setting of slightly low blood pressures and desire
to look for tachycardia if patient were in fact bleeding. This
can be restarted by outpatient provider if necessary.
# PAIN: Patient was continued on his home MS ___ and
gabapentin. He was given dilaudid for breakthrough pain. He
does not need a fentanyl patch on discharge as his pain was
controlled.
# HYPERLIPIDEMIA: Pravastatin was continued.
# SINONASAL TUMOR: Patient will follow-up with outpatient
hematologist/oncologist.
# TUBE FEEDS: Nutrition was consulted. Patient was discharged
on isosource 1.5 at 65ml/hour for 12 hours overnight. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
adhesive
Attending: ___.
Chief Complaint:
left ankle fracture
Major Surgical or Invasive Procedure:
left distal tibia external fixator placement, revision
ex-fixator and fibula plating
History of Present Illness:
___ male w/ hx of ___ transferred from OSH s/p 10
foot
fall from scaffolding. Found to have open LLE tib/fib fracture.
No n/t/w of distal extremity. Given 1 dose ancef at OSH.
Past Medical History:
Hyperlipidemia
Social History:
___
Family History:
NC
Physical Exam:
On Admission:
In general, the patient is in pain
Vitals:VSS
Right 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
Left lower extremity:
Open area of skin to medial malleolus
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
On Discharge:
NAD, comfortable
Vitals:VSS
Right 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
Left lower extremity:
Ex-fix in place, dressing c/d/i
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
Pertinent Results:
Imaging: From OSH demonstrate open tib/fib fracture
Medications on Admission:
zetia
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose:
Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg subq once daily Disp #*14
Syringe Refills:*0
3. Cephalexin 500 mg PO Q12H prevent infection Duration: 21 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth twice daily Disp #*28
Capsule Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*100 Tablet Refills:*0
5. Silver Sulfadiazine 1% Cream 1 Appl TP DAILY
RX *silver sulfadiazine [Silvadene] 1 % apply cream to skin
surrounding pin sites ___ times daily twice daily Disp #*1 Tube
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left distal tibia fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: External fixation, left ankle.
TECHNIQUE: Two views obtained in the OR.
RADIATION: 16.5-second fluoroscopy time.
FINDINGS:
AP and lateral projections obtained in the OR demonstrate placement of the
distal component to the external fixation device through the calcaneus. The
proximal component is not visualized. Transverse fractures through the fibula
and tibia with minimal displacement of the tibial fracture and anterior
displacement of the fibular fracture is noted.
IMPRESSION: Intraoperative images from placement of an external fixation
device around the left ankle.
Radiology Report
INDICATION: Status post fall with open left distal tibial fracture. Assess
fracture pattern/articular involvement.
COMPARISON: Comparison is made to intraoperative fluoroscopic spot views
obtained ___.
TECHNIQUE: Non-contrast axial images were obtained through the left ankle.
Coronal and sagittal reformations were provided.
FINDINGS: The patient is status post debridement and external fixation of a
left distal tibiofibular fracture with soft tissue edema and subcutaneous gas
identified as well as external fixation hardware coursing through the left
calcaneus.
There is a transverse oriented fracture through the distal fibula, 7 cm above
the ankle joint. There is a comminuted fracture of the distal tibia with the
dominat fracture line extending obliquely and inferiorly from the syndesmosis
with multiple additional vertically oriented fracture lines extending
inferiorly through the tibial plafond. There is widening of the superior
aspect of the ankle mortise. Multiple bony fragments are identified within
the joint space. However, it is unclear to what degree these represent acute
or old trauma, as many of the larger fragments appear well corticated. In
addition, there is evidence of degenerative change and/or trauma with
subchondral cyst formation along the anterolateral aspect of the talar dome
(402B:66).
Evaluation of the soft tissue structures is limited given CT technique and
degree of edema. Within this limitation, the major flexor and extensor
tendons appear intact. The ankle joint ligament cannot be fully assessed.
IMPRESSION:
1. Distal transverse oriented fibular fracture 7 cm above the ankle joint.
2. Comminuted fracture of the distal tibia with multiple areas of
intra-articular as well as a syndesmotic extension.
3. Widening the ankle mortise.
Radiology Report
HISTORY: ORIF.
FINDINGS: Images from the operating suite show fixation device about the
distal fibula. Further information can be gained from the operative report.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L LEG INJURY
Diagnosed with FX ANKLE NOS-OPEN, FALL-1 LEVEL TO OTH NEC
temperature: 98.6
heartrate: 78.0
resprate: 16.0
o2sat: 96.0
sbp: 116.0
dbp: 63.0
level of pain: 5
level of acuity: 2.0 | On ___ the patient was admitted to the orthopaedic trauma
service for treatment of an open tibia/fibula fracture, and was
neurovascularly intact.
On ___ the patient was taken to the OR with Dr. ___
irrigation and debridement of open left distal tibia fx,
application of external fixator, closed reduction of distal
tib-fib fracture with manipulation, and application of negative
pressure dressing.
The patient recovered well from the procedure, and was taken
back to the OR by Dr. ___ on ___ for adjustment of the
ex-fix with application or additional pins and frames and
fixation of fibular shaft fracture, debridement and irrigation
of distal tibia fracture.
Post-operative the patient again recovered well, with pain
well-controlled.
He was discharged home with clear instructions for home services
to care for pin sites and also to use silvadene for blistered
areas, with clear instructions to follow-up in ___ clinic in 1
week for evaluation of ex-fix and plan for staged procedure and
definitive ORIF for his fracture after soft tissue is more
suitable for closure. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea, Wound Eval
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ male with
hx of pulmonary fibrosis, s/p basal cell resection on R forehead
(___) who presents with dyspnea. Pt gets the majority of
his
care at ___ but was referred in from urgent care today for
concern of osteomyelitis of the skull and SOB. Pt tells a
somewhat inconsistent history however per his report, he has
chronic SOB which he doesn't think is particularly worse than
usual, he is unsure how long it has been present for. Denies
chest pain, cough. He is unable to walk more than 50 feet
without getting short of breath and endorses worsening fatigue.
He does use a walker at home but does not need home O2. He also
endorses dysuria x years He was also noted to have dense right
facial droop including the eye which the patient and his wife
states began after he had his tumor resection. He also tells me
that he had a fall recently, states he hit his head and states
that was what led to the lesion on his head but is unable to
describe any circumstances surrounding the fall
In the ED, initial vitals were: 97.6 92 140/83 18 100% RA. Labs
were notable for glucose of 67, crit 39.7, Pt was given 1L NS.
CXR showed no acute CP process. EKG showed NSR with
non-specific
ST changes in lateral leads. Pt was admitted to medicine for
further ___, FTT, and wound care management.
On the floor, pt has no specific complaints. Tells me that he
has not had follow up for wound care of the scalp lesion, is
applying Vaseline daily. He states he has been eating less
recently but is unsure if he has lost weight.
Past Medical History:
-hypertension
-remote hx of alcohol dependence
-hearing loss
-squamous cell cancer
-basal cell carcinoma
-pulmonary fibrosis
-? prostate ca
-BPH
-diverticulitis
-insomnia
Social History:
___
Family History:
Father with
CAD/PVD/HTN/MI
Physical Exam:
Admission Exam:
Constitutional: Cachectic, unkempt appearing, alert, oriented to
date, not to year (___), thinks he is at the ___
EYES: Sclera anicteric, EOMI, cloudy R lens
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, no CCE
NEURO: aaox1, R-sided facial droop, tongue deviates to the left,
HOH, ___ strength throughout upper and lower extremities
SKIN: approx. 5 cm open wound on caput, with exposed bone and
crusted blood. No drainage or surrounding erythema.
Pertinent Results:
___ 06:05AM BLOOD WBC-7.3 RBC-3.76* Hgb-10.7* Hct-32.2*
MCV-86 MCH-28.5 MCHC-33.2 RDW-13.2 RDWSD-40.7 Plt ___
___ 06:20AM BLOOD WBC-4.3 RBC-3.88* Hgb-11.0* Hct-33.7*
MCV-87 MCH-28.4 MCHC-32.6 RDW-13.2 RDWSD-41.2 Plt ___
___ 06:23AM BLOOD WBC-4.4 RBC-3.70* Hgb-10.5* Hct-32.5*
MCV-88 MCH-28.4 MCHC-32.3 RDW-13.4 RDWSD-43.2 Plt ___
___ 04:00PM BLOOD WBC-6.3 RBC-4.53* Hgb-13.0* Hct-39.7*
MCV-88 MCH-28.7 MCHC-32.7 RDW-13.3 RDWSD-42.6 Plt ___
___ 04:00PM BLOOD ___ PTT-30.3 ___
___ 06:05AM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-142
K-4.0 Cl-103 HCO3-27 AnGap-12
___ 06:20AM BLOOD Glucose-85 UreaN-17 Creat-0.8 Na-142
K-4.0 Cl-105 HCO3-29 AnGap-8*
___ 06:23AM BLOOD Glucose-66* UreaN-20 Creat-0.7 Na-144
K-4.1 Cl-103 HCO3-25 AnGap-16
___ 04:00PM BLOOD Glucose-67* UreaN-21* Creat-0.8 Na-141
K-4.7 Cl-99 HCO3-28 AnGap-14
___ 04:00PM BLOOD ALT-10 AST-17 AlkPhos-83 TotBili-1.3
___ 06:23AM BLOOD cTropnT-<0.01
___ 04:00PM BLOOD cTropnT-<0.01
___ 06:23AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.9
___ 04:00PM BLOOD Albumin-4.1 Calcium-9.8 Phos-3.2 Mg-2.1
___ 06:23AM BLOOD TSH-1.3
___ 04:00PM BLOOD CRP-37.2*
___ 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:50PM BLOOD Lactate-1.8
CXR:
IMPRESSION:
No acute cardiopulmonary process. Stable chronic lung changes.
MRI:
IMPRESSION:
Limited MR imaging due to poor patient compliance which is also
degraded by motion artifact.
Within the marked limitations of the study there is no acute
intracranial
infarct or large mass.
Generalized cerebral atrophy with associated ex vacuo dilatation
of
ventricular system.
Nonspecific well-circumscribed T1 hyperintense right lateral
periorbital
lesion. On limited imaging at the top of my differential
diagnosis consider a periorbital dermoid cyst.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
2. Finasteride 5 mg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
scalp wound s/p SCC excision
malnutrition
dyspnea
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: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with large open wound on head as well as R-sided
facial droop x months// Please eval for 1) osteo of skull2) e/o stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON None.
FINDINGS:
Limited MRI imaging was performed due to poor patient compliance. Imaging is
also degraded by motion artifact at the
Within the limits of the study no acute intracranial infarct or mass.
Generalized cerebral atrophy with ex vacuo dilatation of the ventricular
system. Periventricular hypodense white matter changes are most likely
sequela of microangiopathy. Nonspecific well-circumscribed T1 hyperintense
right lateral periorbital lesion measuring 14 by 18 x 6 (AP by SI by TV). No
restricted diffusion. The pituitary appears normal. The craniocervical
junction appears normal.
IMPRESSION:
Limited MR imaging due to poor patient compliance which is also degraded by
motion artifact.
Within the marked limitations of the study there is no acute intracranial
infarct or large mass.
Generalized cerebral atrophy with associated ex vacuo dilatation of
ventricular system.
Nonspecific well-circumscribed T1 hyperintense right lateral periorbital
lesion. On limited imaging at the top of my differential diagnosis consider a
periorbital dermoid cyst.
Radiology Report
EXAMINATION: Chest radiographs
INDICATION: History: ___ with dyspnea// assess for pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Outside facility chest radiographs of ___.
FINDINGS:
The lungs are hyperinflated. Diffuse interstitial lung markings, more
predominant in the apices are unchanged. Multiple calcified nodular densities
are demonstrated bilaterally, most prominent in the left hilus. Apical
pleural thickening is re-demonstrated. No pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process. Stable chronic lung changes.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Wound eval
Diagnosed with Dyspnea, unspecified
temperature: 97.6
heartrate: 92.0
resprate: 18.0
o2sat: 100.0
sbp: 140.0
dbp: 83.0
level of pain: 0
level of acuity: 3.0 | # R forehead wound: Plastic surgery saw the pt, and determined
that he was not a good surgical candidate. They made wound
dressing recommendations. He indicated that he was not
interested in surgery or any other large procedures, and just
wanted to go home. MRI performed At time of discharge, pt was
planning on follow-up with ___ and his PCP.
# Dyspnea: Pt with hx of pulmonary fibrosis and symptoms do not
seem to be significantly worse than baseline. After being
admitted, pt stated that he felt fine and was not concerned
about his breathing. Pt maintained normal saturations on RA
throughout admission and at time of d/c, will f/u w/ his
outpatient doctors for this as needed. Pt notably refused ___
services while admitted.
# Severe malnutrition/failure to thrive: Per wife, seems that pt
has continued to decline, esp in the recent ___, w/ wt loss
and increasing frailty. Pt not UTD on cancer screening, has
known
elevated PSA, but wife explains that he wouldn't "want any of
that" (referring to work up or procedures) and just wants to be
home. During this admission, based on that, we attempted to
minimize interventions while supporting pt to have quality of
life.
# R-sided facial droop: pt unable to state timeline for this,
however outpt records and wife's report suggest ___ began after
resection of SCC. That said, distribution of deficit does does
not correspond with nerve injury that could have occurred with
surgical excision of lesion on caput, raising concern for
central
pathology. It does not appear that patient has had any imaging
since deficit was noted. MRI performed with cerebral atrophy but
no evidence for stroke.
# Fall: pt unable to provide details regarding his fall although
he does think that he hit his head. Most likely mechanical
given
pts deconditioned state.
#goals of care: Pt was seen by plastic surgery and declined any
surgical intervention. Pt's wife agreed with / endorsed pt's
lack of interest in
aggressive measures, informed us of DNR/DNI status, and said she
merely wanted to get him home as soon as possible. They declined
hospital bed. Initial plan was to go home with hospice but plans
changed to home with ___ and bridge to hospice. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
vertigo, unsteadiness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old right handed woman with history of
HTN, HLD, diabetes on insulin, Hep C and tobacco abuse who
presents with persisent vertigo since yesterday morning. When
patient woke up yesterday and stood up, the room started
spinning
to the right and she felt nauseated but did not vomit. She sat
back down on the bed and noted that closing her eyes helped.
She
endorses blurred vision, but no diplopia. She tried to eat
something to see if that would help, but it did not. Patient
took a nap, but vertigo persisted upon waking up. She states it
is more severe with position changes, especially with walking,
but also present at rest. Ms. ___ reports that her left arm
has been weak "on and off" since yesterday. For example, she
had
difficulty bringing a glass to her mouth. She has been quite
unsteady with walking, no falls, not sure if she is veering to
the left or the right more. She did not have a headache
initially but now she does after being examined in the ED and
"the doctors ___ back and forth." Currently, the
room spinning sensation persists and has not improved since
yesterday. She continues to be nauseated and zofran did not
help. She denies weakness in her legs, numbness, speech
difficulty, recent infectious symptoms, ear pain, changes in
hearing. Does endorse tinnitus lasting seconds in both ears
occasionally for the last 6 months or so.
Ms. ___ had a similar episode of dizziness 6 months or a
year
ago which lasted ___ days. She did not present for evaluation
at
that time. She told her PCP only after the fact and was
prescribed meclezine as needed. She did not have any work up.
On neuro ROS, the pt endorses occasional twitches in her arms
and
legs for months. denies loss of vision, diplopia, dysarthria,
dysphagia, lightheadedness. Denies difficulties producing or
comprehending speech. Denies focal numbness, parasthesiae. No
bowel or bladder incontinence or retention.
On general review of systems, the pt endorses chronic dry cough
and constipation. denies recent fever or chills. No night
sweats
or recent weight loss or gain. Denies shortness of breath.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting, diarrhea, abdominal pain. No recent change in bowel
or bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
DM type 2 on insulin
Hypertension
Hyperlipidemia
Hepatitis C, diagnosed ___, never treated
Alcohol abuse in remission since ___
Anxiety
Depression
??(per records) CKD per patient from ___ (?MPGN) though Cr is
0.9
GERD
Tobacco abuse
Past surgical history: 2 c-sections
Social History:
___
Family History:
Mother - alive DM2, DM in others. Brother died of colon cancer
at age ___.
No strokes, seizures
Physical Exam:
ADMISSION EXAM:
Vitals: T 99.1 HR 92 BP 139/72 RR 18 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 to self, date, place. Able to
relate history without difficulty. Attentive, able to name ___
backward with mild difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Speech was not dysarthric. Able to follow
both midline and appendicular commands. Pt. was able to register
3 objects and recall ___ at 5 minutes, ___ when given options.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI, left beating sustained nystagmus on left gaze
and right beating sustained nystagmus on right gaze. On upgaze,
there is left beating rotatory nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, proprioception
throughout. No extinction to DSS. Decreased sensation to pin
prick distally in lower extremities to just above the ankles.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 3+ 2
R 2+ 2+ 2+ 3+ 2
Plantar response was flexor bilaterally.
-Coordination: Mild dysmetria on FNF on left. Ataxia with
finger tapping on crease and overshoot with mirroring on left.
No dysmetria on HKS bilaterally.
-Gait: Good initiation. Mildly wide based and unsteady, tends to
fall towards the left perhaps. Romberg absent.
___ SLEEPINESS SCALE: 15
- sitting and reading: 1
- watching tv: 3
- sitting inactive in a public place: 1
- as a passenger in a car for an hour without a break: 3
- lying down to rest in the afternoon when circumstances permit:
3
- sitting and talking to someone: 2
- sitting quietly after lunch without alcohol: 2
- in a car, while stopped for a few minutes in traffic: 0
+ Endorsed snoring hx
+ Patient described having no difficulty falling asleep with her
current sleep medications, but wakes up 3x per night coughing
and choking for breath. She takes cough syrup each evening
before bed for the cough.
DISCHARGE EXAM:
EOMI with non-extinguishing leftward-beating nystagmus on
leftward gaze as well as rightward-beating nystagmus on
rightward gaze which extiguishes after five beats. There is no
upward-beating nystagmus.
Pertinent Results:
ADMISSION EXAM: ___
WBC-11.4*# RBC-3.88* Hgb-12.4# Hct-34.0* MCV-88# MCH-32.0
MCHC-36.5*# RDW-12.7 Plt ___
Neuts-63.8 ___ Monos-3.2 Eos-0.8 Baso-0.3
Glucose-177* UreaN-13 Creat-0.9 Na-138 K-3.6 Cl-103 HCO3-25
AnGap-14
Calcium-9.5 Phos-2.7 Mg-1.5*
ALT-28 AST-26 AlkPhos-101 TotBili-0.1
Calcium-8.9 Phos-3.0 Mg-1.9
UA bland
UTox negative
STROKE WORKUP:
Cholest-130 Triglyc-334* HDL-18 CHOL/HD-7.2 LDLcalc-45
%HbA1c-13.6* eAG-344*
IMAGING:
CTA Neck ___
IMPRESSION:
1. Chronic left lamina lacune without evidence of acute
intracranial hemorrhage. - Common origin of LCCA and innominate
2. Mildly narrowed right cavernous and supraclinoid ICA from
calcified &
non-callc plaque, w/out stenosis.
3. 1.5mm Infundibulum at origin of L ophthalmic artery. No
aneurysm greater than 3 mm in size.
4. Patchy airspace disease in the left upper lung with enlarged
mediastinal lymph node. Dedicated chest CT is recommended for
further evaluation. This report is provided without 3D and
curved reformats. When these images are available, and if
additional information is obtained, then an addendum may be
given to this report.
RECOMMENDATION(S):
1. Patchy airspace disease in the left upper lung with enlarged
mediastinal lymph node. Dedicated chest CT is recommended for
further evaluation.
MRI ___
IMPRESSION:
No evidence of acute ischemia.
No evidence of other acute intracranial process.
Multiple scattered foci of high signal intensity identified in
the subcortical and periventricular white matter, are
nonspecific and may reflect changes due to small vessel disease.
ECHO ___
Conclusions
The left atrium and right atrium are normal in cavity size. No
left atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. 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
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: No cardiac source of embolism seen. Normal global
and regional biventricular systolic function. Moderate mitral
regurgitation. Negative bubble study.
CT Chest ___
IMPRESSION:
Multifocal mediastinal lymphadenopathy accompanied by diffuse
lung disease with predominantly ground-glass features.
Differential diagnosis includes acute processes such as atypical
infection, subacute processes such as hypersensitivity
pneumonitis, and more chronic abnormalities including
sarcoidosis. A neoplastic abnormality such as lymphoma or
multicentric lung adenocarcinoma is considered less likely.
RECOMMENDATION:
___ MONTH FOLLOWUP CT WITH INTERVAL ANTIBIOTIC THERAPY IF
PULMONARY INFECTIOUS SYMPTOMS ARE PRESENT.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. CloniDINE 0.1 mg PO BID
3. Cyclobenzaprine 10 mg PO HS:PRN back pain
4. Fluoxetine 40 mg PO DAILY
5. Lorazepam 0.5 mg PO DAILY:PRN anxiety
6. Omeprazole 20 mg PO BID
7. QUEtiapine Fumarate 50 mg PO QAM
8. QUEtiapine Fumarate 800 mg PO QHS
9. TraZODone 300 mg PO QHS:PRN insomnia
10. Venlafaxine 100 mg PO DAILY
11. DiCYCLOmine 10 mg PO QID:PRN abd pain
12. Glargine 80 Units Breakfast
Discharge Medications:
1. Lorazepam 0.5 mg PO DAILY:PRN anxiety
2. Omeprazole 20 mg PO BID
3. Aspirin 81 mg PO DAILY
4. CloniDINE 0.1 mg PO BID
5. Cyclobenzaprine 10 mg PO HS:PRN back pain
6. DiCYCLOmine 10 mg PO QID:PRN abd pain
7. Fluoxetine 40 mg PO DAILY
8. QUEtiapine Fumarate 50 mg PO QAM
9. QUEtiapine Fumarate 800 mg PO QHS
10. TraZODone 300 mg PO QHS:PRN insomnia
11. Venlafaxine 100 mg PO DAILY
12. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
13. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin [Glucophage] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*3
14. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour one patch daily Disp #*14 Patch
Refills:*0
RX *nicotine 7 mg/24 hour one patch daily Disp #*14 Patch
Refills:*0
15. NovoLOG Mix 70-30 (insulin asp prt-insulin aspart) 100
unit/mL (70-30) subcutaneous 60 Units before BKFT; 40 Units
before DINR;
RX *insulin asp prt-insulin aspart [Novolog Mix ___ FlexPen]
100 unit/mL (70-30) AS INSTRUCTED AS INSTRUCTED Disp #*10
Syringe Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
peripheral vertigo
diabetes mellitus (A1c 13.4%)
hypertension
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: ___ female presenting for evaluation of dizziness,
evaluate for intracranial bleed
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. This report is based on
interpretation of all of these images.
DOSE: This study involved 5 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
4) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 38.1 mGy (Head) DLP =
19.1 mGy-cm.
5) Spiral Acquisition 4.9 s, 38.7 cm; CTDIvol = 35.4 mGy (Head) DLP =
1,371.3 mGy-cm.
Total DLP (Head) = 2,288 mGy-cm.
COMPARISON: None available
FINDINGS:
Head CT: There is no evidence of hemorrhage, edema, masses, mass effect, or
infarction. The ventricles and sulci are normal in caliber and configuration.
No fractures are identified. Chronic left per terminal lacune and identified.
Head CTA: There is an incidental 1.5 mm infundibulum at the origin of left
ophthalmic artery. There is mild narrowing of the right cavernous and supra
clinoid internal carotid artery with calcification. The right A1 is
hypoplastic, a normal variation. Intracranial vascular evaluation otherwise
demonstrates no evidence of stenosis or occlusion or aneurysm greater than 3
mm in size.
Neck CTA: Mild atherosclerotic disease is seen at the origin of right
internal carotid artery. Otherwise, The carotid and vertebral arteries and
their major branches are patent with no evidence of stenoses. There is no
evidence of internal carotid stenosis by NASCET criteria.
Evaluation of the visualized upper chest demonstrate air patchy airspace
disease in the left upper lung. In addition, there is an enlarged mediastinal
lymph node visualized adjacent to the aortic arch (5:21).
IMPRESSION:
1. Chronic left lamina lacune without evidence of acute intracranial
hemorrhage. - Common origin of LCCA and innominate
2. Mildly narrowed right cavernous and supraclinoid ICA from calcified &
non-callc plaque, w/out stenosis.
3. 1.5mm Infundibulum at origin of L ophthalmic artery. No aneurysm greater
than 3 mm in size.
4. Patchy airspace disease in the left upper lung with enlarged mediastinal
lymph node. Dedicated chest CT is recommended for further evaluation.
This report is provided without 3D and curved reformats. When these images
are available, and if additional information is obtained, then an addendum may
be given to this report.
RECOMMENDATION(S):
1. Patchy airspace disease in the left upper lung with enlarged mediastinal
lymph node. Dedicated chest CT is recommended for further evaluation.
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Elevated leukocytosis.
TECHNIQUE: Chest, PA and lateral.
COMPARISON: ___.
FINDINGS:
The cardiac, mediastinal and hilar contours appearance change. There is no
pleural effusion or pneumothorax. Only slightly more prominent than before is
bilateral widespread mild airway thickening suggesting inflammatory process
involving lower airways.
IMPRESSION:
Findings suggesting airway inflammation, although infection is not excluded.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRASTMRI of the brain without contrast MR HEAD
W/O CONTRAST
INDICATION: ___ year old woman with multiple stroke risk factors and vertigo
// ?ischemic 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.
COMPARISON: CTA head and neck ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass, mass effect or
shifting of the normally midline structures. The ventricles and sulci are
prominent, likely age related and involutional in nature. Multiple scattered
foci of high signal intensity are detected in the subcortical and
periventricular white matter, which are nonspecific and may reflect changes
due to small vessel disease. No diffusion abnormalities are detected to
indicate acute or subacute ischemic changes. The major vascular flow voids
are present and demonstrate normal distribution. The orbits are unremarkable,
the paranasal sinuses and the mastoid air cells are clear.
IMPRESSION:
No evidence of acute ischemia.
No evidence of other acute intracranial process.
Multiple scattered foci of high signal intensity identified in the subcortical
and periventricular white matter, are nonspecific and may reflect changes due
to small vessel disease.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with uncontrolled diabetes who presented with
vertigo, CTA neck had incidental finding of mediastinal lymph node. // please
evaluate parenchymal abnormalities and mediastinal lymph node
TECHNIQUE: Multi detector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images.
DOSAGE: TOTAL DLP 289mGy-cm
COMPARISON: NECK CTA ___
FINDINGS:
As is again demonstrated are several mildly enlarged mediastinal lymph nodes
including a dominant 8 mm by 19 mm lymph node lateral to the aortic arch in
the left prevascular space (17, 3). Additional lymph nodes include of 11 mm
short axis of lower right paratracheal node, a 12 mm short axis sub- carinal
node, and additional subcentimeter mediastinal nodes in the peritracheal,
prevascular, paraesophageal, and hilar nodal stations. Heart size is normal,
and additional clustered nodes are present in the right pericardial space.
There is no pericardial or pleural effusion.
Exam was not tailored to evaluate the subdiaphragmatic region, but adrenal
glands are well visualized and normal in appearance.
Skeletal structures of the thorax demonstrate no suspicious lytic or blastic
lesions.
Within the lungs, multifocal regions of ground-glass opacification are again
demonstrated with upper and mid lung predominance. Diffuse bronchial wall
thickening is also present, along with several areas of localized mucoid
impaction. Mild emphysema is also demonstrated as well as minimal reticular
interstitial opacities particularly in the upper lobes.
Although many of the ground-glass opacities appear diffuse, some appear more
patchy and nodular.
IMPRESSION:
Multifocal mediastinal lymphadenopathy accompanied by diffuse lung disease
with predominantly ground-glass features. Differential diagnosis includes
acute processes such as atypical infection, subacute processes such as
hypersensitivity pneumonitis, and more chronic abnormalities including
sarcoidosis. A neoplastic abnormality such as lymphoma or multicentric lung
adenocarcinoma is considered less likely.
RECOMMENDATION:
___ MONTH FOLLOWUP CT WITH INTERVAL ANTIBIOTIC THERAPY IF PULMONARY INFECTIOUS
SYMPTOMS ARE PRESENT.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dizziness
Diagnosed with VERTIGO/DIZZINESS
temperature: 97.8
heartrate: 111.0
resprate: 18.0
o2sat: 99.0
sbp: 144.0
dbp: 94.0
level of pain: 5
level of acuity: 3.0 | ___ is a ___ old right-handed woman with a history
of uncontrolled diabetes, hypertension, hepatitis C and tobacco
abuse who presented with persistent vertigo and unsteadiness. On
examination she had direction changing nystagmus and subtle
left-sided dysmetria. Her MRI was negative for acute stroke
although there was evidence of small vessel disease. Her
presenting symptoms were felt to be secondary to peripheral
vertigo. However, she was noted to have multiple poorly
controlled stroke risk factors, most notably her uncontrolled
diabetes and smoking.
# Neurologic:
Her vertigo was attributed to peripheral vertigo; her presenting
symptoms of direction-changing nystagmus was thought to be
related to her multiple psychoactive medications and there was
no evidence of stroke on MRI. CTA showed mild plaque in the
right ICA, LDL was 45 and HDL was 15. A1c was elevated at 13.6%.
Echocardiogram showed no intracardiac thrombus. She worked with
physical therapy; rehab was recommended but she elected to go
home with home physical therapy.
# Cardiovascular:
She was hypertensive to the 150s and she was started on
lisinopril 5 mg which she has taken in the past.
# Endocrine:
Her A1c was markedly elevated and her blood sugars were in the
200-300s at the onset of her hospitalization. At home she is
only partially compliant with her lantus regimen and she has
frequent overnight snacking which is exacerbated by increaed
appetite secondary to seroquel. ___ was consulted and
recommended restarting her metformin (which had been stopped
last year in the context of an ___ and changing to a 70/30
regimen for improved control. This was discussed with the
patient and her primary care physician and both were in
approval. She should follow up with an endocrinologist if
possible. She was discharged with a ___ to help with blood sugar
monitoring and medication compliance.
# Psychiatric:
Ms. ___ has significant depression and anxiety with
additional psychosocial stressors. This has resulted in
significant polypharmacy with large doses of seroquel and
trazodone at bedtime which are contributing to her metabolic
abnormalities as well as morning somnolence. Her depression is
exacerbating medication non-compliance. We spoke with her
outpatient psychiatric nurse practitioner about management of
her psychatric and medical comorbidities. No changes were made
to her psychoactive medications.
# Respiratory:
She had had diffuse airway thickening on her chest X-ray and
lung parenchyma abnormalities on her CT neck which prompted a CT
chest. THis showed diffuse parenchymal abnormalities and
lymphadenopathy, broad differential, recommend follow up imaging
in ___ months.
# Sleep:
She was quite somnolent in the mornings. Her trazodone and
seroquel was decreased from her home dose. Given her habitus we
were concerned for sleep apnea. An ___ Sleepiness Scale was
15 (as documented above) and was concering for sleep apnea. She
should follow up in sleep clinic. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
___
Attending: ___
Chief Complaint:
Left Facial Droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old right-handed man with h/o A fib on
warfarin, s/p pacemaker, DM, h/o stroke (with residual speech
difficulty) who presented after a 15 minute episode of left face
weakness.
Last night, he went to get a cup of milk and drank it.
Suddenly,
he notice that the milk was dripping down the left side of his
mouth. He called his wife for help and noticed that his speech
did not come out right. He knew what he wanted to say but it
came out slurred. He understood what his wife was saying. When
his wife saw him, she noticed that his left face was droopy. He
checked his BP and it was 160's over 90's. His HR was 120's.
He
got up and walked to the bathroom so he can look in the mirror.
He was able to walk without difficulty. His arms were strong
also. By the time he saw his face in the mirror, he face droop
already resolved (approx 15 minutes after onset).
He did not seek medical attention last night because of his fast
recovery but on second thought today, he thinks it's a good idea
to seek medical attention. He called his cardiologist who sent
him to ___ ED.
On neuro ROS, the pt endorses "head fullness" but denies
headache. Endorses some lightheadedness when he was on
metoprolol. Reports baseline bilateral hearing difficulty. Has
some baseline difficulty producing speech since his stroke ___
years ago. Denies loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, vertigo, tinnitus. Denies difficulties
comprehending speech. Denies focal numbness, parasthesiae
though
has "neuropathy" in the feet. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain
or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain.
Past Medical History:
Stroke ___ years ago happened in the setting of holding warfarin
for colonoscopy. Had right face/arm/leg weakness now resolved.
Only has residual slurred speech and paraphasic error and
word-finding difficulty at baseline.
Asthma vs multifactorial dyspnea secondary to obesity and mild
CHF.
AFib on anticoagulations with a pacer placed.
Diabetes type 2.
Mitral stenosis secondary to rheumatic heart disease.
ASD with left-to-right shunt.
Pneumonia hospitalization in past.
History of MVA at ___ years old.
Phlebitis in ___.
Social History:
___
Family History:
Mother died of a MI at age of ___.
Physical Exam:
Physical Exam:
Vitals: 98.4, 94, 149/91, 21, 99%
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA
Cardiac: RRR, nl.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Mildly inattentive, named ___ till ___,
skipping ___ and ___. Language is fluent with intact
repetition and comprehension. Normal prosody. There are rare
phonatic paraphasic errors. Pt was able to name both high
frequency objects but unable to name low ___ objects such as
stethoscope and bracelet. Able to read without difficulty.
Speech was mildly dysarthric. Able to follow both midline and
appendicular commands. The pt had good knowledge of current
events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing decreased 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. Orbiting symmetric.
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: Length dependent decreased in PP and temp in bilateral
arms (mid forearm) and legs (mid shin on right and knee on left
though there is skin graft on left leg confounding exam). No
deficits to light touch, proprioception throughout.
Graphesthesia
intact in b/l hands.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Coordination:No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Unsteady when attempting to walk in tandem. Romberg
absent.
===========================================
Discharge Physical Examination:
no significant changes from admission exam
Pertinent Results:
___ 09:25PM URINE HOURS-RANDOM
___ 09:25PM URINE HOURS-RANDOM
___ 09:25PM URINE GR HOLD-HOLD
___ 09:25PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 09:25PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-70 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 09:25PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:25PM URINE HYALINE-3*
___ 09:25PM URINE MUCOUS-RARE
___ 06:35PM WBC-10.8# RBC-5.44 HGB-16.5 HCT-50.0 MCV-92
MCH-30.3 MCHC-33.0 RDW-14.7
___ 06:35PM NEUTS-42.3* LYMPHS-43.2* MONOS-11.2* EOS-2.4
BASOS-0.9
___ 06:35PM PLT COUNT-143*
___ 06:22PM ___ PTT-47.9* ___
___ 03:20PM LACTATE-1.6
___ 03:15PM GLUCOSE-275* UREA N-38* CREAT-1.9* SODIUM-138
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-29 ANION GAP-13
___ 03:15PM estGFR-Using this
___ 03:15PM ALT(SGPT)-26 AST(SGOT)-27 ALK PHOS-56 TOT
BILI-0.7
___ 03:15PM cTropnT-<0.01
___ 03:15PM ALBUMIN-4.0 CALCIUM-9.4 PHOSPHATE-2.8
MAGNESIUM-2.0
___ 03:15PM DIGOXIN-0.8*
___ 03:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:11AM BLOOD %HbA1c-7.6* eAG-171*
___ 08:11AM BLOOD Triglyc-200* HDL-27 CHOL/HD-8.8
LDLcalc-171*
___ 08:11AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9 Cholest-238*
Non-Contrast Head CT (___) :
Preliminary Report FINDINGS:
There is no acute intracranial hemorrhage,acute infarction, mass
or midline shift. There is no hydrocephalus. The ventricles and
sulci are enlarged consistent with atrophy. There are
periventricular white matter hypodensities most consistent with
sequelae of chronic small vessel ischemic disease. In the left
frontal lobe, along the convexity is an extraaxial soft tissue
density lesion adjacent to the calvarium which is remodeled.
Visualized paranasal sinuses and mastoid air cells are clear.
There is no fracture.
Preliminary Report IMPRESSION:
No acute intracranial process.
Head Neck CTA (___):
There is no large vessel occlusion, dissection, or aneurysm > 3
mm.
Multifocal atherosclerotic calcifications are seen predominantly
within the bilateral common carotid arteries at the bifurcation
and within the bilateral carotid siphons. The carotid and
vertebral arteries and their major branches are patent with no
evidence of stenoses. The left vertebral artery is noted to be
dominant.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Digoxin 0.125 mg PO DAILY
2. Diltiazem Extended-Release 240 mg PO DAILY
3. glimepiride 2 mg oral unknown
4. saxagliptin 5 mg oral daily
5. Warfarin 4 mg PO EVERY OTHER DAY
6. Warfarin 5 mg PO EVERY OTHER DAY
7. Acetaminophen 325 mg PO Q6H:PRN pain
8. Vitamin D 1000 UNIT PO BID
9. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Digoxin 0.125 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Warfarin 4 mg PO EVERY OTHER DAY
5. Warfarin 5 mg PO EVERY OTHER DAY
6. Diltiazem Extended-Release 240 mg PO DAILY
7. glimepiride 2 mg oral unknown
8. saxagliptin 5 mg oral daily
9. Vitamin D 1000 UNIT PO BID
10. Pravastatin 20 mg PO DAILY
RX *pravastatin 20 mg 1 tablet(s) by mouth once a day at bedtime
Disp #*30 Tablet Refills:*2
11. Fish Oil (Omega 3) 1000 mg PO BID
RX *docosahexanoic acid-epa [Fish Oil] 120 mg-180 mg 1
capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: transient ischemic attack, hyperlipidemia
Secondary Diagnosis: atrial fibrillation on anticoagulation,
pacemaker placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Facial droop. History of stroke.
COMPARISON: ___ and ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS:
There is a dual-lead pacemaker/ICD device which appears unchanged. The
cardiac, mediastinal and hilar contours appear stable. There is no pleural
effusion or pneumothorax. The lungs appear clear. The chest is hyperinflated
somewhat.
IMPRESSION:
No evidence of acute disease.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with slurred speech on coumadin // eval for ICH
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 891 mGy-cm
CTDI: 53 mGy
COMPARISON: None available.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, acute territorial
infarction, mass or midline shift. There is no hydrocephalus. The ventricles
and sulci are enlarged consistent with atrophy. There are areas of cerebral
white matter hypodensity most consistent with sequelae of chronic small vessel
ischemic disease. The left vertebral artery is ectatic. The mastoid air cells
are clear. There is slight mucosal thickening along each maxillary sinus.
IMPRESSION:
No evidence of acute intracranial process.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: ___ year old man with left face weakness // eval vasculature
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 intravenous administration of 70 cc
Omnipaque 350. Images were processed on a separate workstation with display
of curved reformats, 3D volume rendered images, and maximum intensity
projection images.
DOSE: DLP: 254 0.95 mGy-cm
COMPARISON: Noncontrast CT head ___.
FINDINGS:
CT Head: There is generalized atrophy with prominence of the ventricles,
sulci, and cisterns. There is no mass-effect, midline shift, or
space-occupying lesion. There is no hemorrhage or extra-axial fluid
collection. There is no acute territorial infarct. There is patchy
hypoattenuation of the periventricular white matter, most suggestive of
chronic small vessel ischemic disease. There are focal calcifications in the
right pons.
The visualized paranasal sinuses are clear. The mastoid air cells are clear.
The orbits and soft tissues are unremarkable. There is no displaced calvarial
fracture.
CTA Head: The intracranial internal carotid arteries are normal in
configuration. The anterior and middle cerebral arteries are patent with
normal contrast enhancement and branching pattern. There is a normal anterior
communicating artery complex.
The left vertebral artery is dominant and the right vertebral artery is
developmentally small. The vertebral and basilar arteries demonstrate normal
enhancement without stenosis or occlusion. The posterior cerebral arteries
have a normal branching pattern. The posterior communicating arteries are
visualized.
There is no evidence of stenosis, occlusion, aneurysm or arteriovenous
malformation.
The major cerebral veins are patent.
CTA Neck: The visualized aortic arch is unremarkable. The origins of the major
head and neck vessels off the arch are normal.
The right common, internal and external carotid arteries demonstrate no
evidence of stenosis by NASCET criteria.
The left common, internal and external carotid arteries demonstrate no
evidence of a significant stenosis by NASCET criteria or a dissection. There
is mild soft atheromatous disease of the left proximal internal carotid artery
but no stenosis by NASCET .
There may be narrowing of the origin of the left vertebral artery. The left
vertebral artery is dominant with normal opacification distal to possible
origin narrowing. The cervical right vertebral artery unremarkable except for
a developmentally small caliber. There is no evidence of a dissection.
IMPRESSION:
1. No stenosis dissection, or aneurysm of the major intracranial arterial
vasculature.
2. No dissection of the major cervical arterial vasculature. Possible
narrowing of the origin of the left vertebral artery with normal contrast
opacification throughout the remainder of the vessel.
3. No evidence of hemorrhage or infarction .
Radiology Report
EXAMINATION: CHEST (PA AND LAT)CHEST (PA AND LAT)i
INDICATION: ___ year old man admitted for facial droop, new leukocytosis //
eval for pneumonia
COMPARISON: Chest radiographs since ___ most recently ___.
IMPRESSION:
Moderate cardiomegaly is chronic. Pulmonary vasculature is unremarkable and
there is no edema or pleural effusion. Lungs are clear. Transvenous right
atrial right ventricular pacer leads follow their expected courses.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Slurred speech, Weakness
Diagnosed with TRANS CEREB ISCHEMIA NOS
temperature: 98.4
heartrate: 94.0
resprate: 21.0
o2sat: 99.0
sbp: 149.0
dbp: 91.0
level of pain: 0
level of acuity: 2.0 | - Transient left facial weakness, thought to be TIA, though
unable to obtain MRI due to pacemaker. CTA did not show
significant atherosclerosis, but stroke work up labs showed
significant hyperlipidemia with LDL of 170.
- Pt developed leukocytosis while in the hospital, but afebrile
and clinically appearing well, no evidence of UA or pneumonia.
Should be repeated as outpatient within 1 week.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
171) - () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - () No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
() Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
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 [if no, reason not
discharge on anticoagulation: ____ ] - () N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tylenol / Motrin
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
Induced sputum x3
History of Present Illness:
___ man with history of HIV on
HAART, benign lung nodule s/p surgical excision, prior DVT
presenting with hemoptysis.
The patient reports that he was in his usual state of health
until 3 days ago. She reports that he felt like he was getting a
cold with congestion/rhinorrhea, malaise, and cough. The cough
was initially productive of yellow sputum but 2 days ago it
became blood tinged and he reports coughing up one larger blood
clot. He reports that he has felt more short of breath,
particularly with exertion. He endorses chills and night sweats
but denies fevers. Reports nausea but no vomiting. He has
intermittent abdominal pain, and has constipation alternating
with loose stools. He denies any recent travel or sick contacts.
He states that he has not seen his doctor in some time, and has
missed doses of his HAART.
In the ED, vitals: 96.3 ___ 18 100% RA
Exam: Pulm: Course crackles throughout
Labs notable for: CBC, BMP wnl; Flu negative
Imaging: CXR, CTA chest
Patient given: 1L LR, oxycodone 5 mg, gabapentin 800 mg
Past Medical History:
PAST MEDICAL HISTORY:
PCP: Dr. ___
-AIDS (diagnosed ___, last CD4 count 580 ___,
nadir 40)
-peripheral neuropathy
PAST PSYCHIATRIC HISTORY: per OMR including psych evaluation
dated ___, confirmed with patient
-Diagnoses: depression and PTSD
-Prior Hospitalizations: two remote hospitalizations in ___
___ and ___, both for depression with SI,
s/p
aborted SAs), last admitted to Deac 4 for depression with SI
(___)
-History of assaultive behaviors: endorses previous charges of
A&B (details unknown)
-History of suicide attempts or self-injurious behavior: reports
two prior attempts in ___ leading to hospitalization, once by
attempting to run in front of ___ bus (stopped by police), once
by OD on drugs
-Prior med trials: unknown
-Therapist: previously saw Dr. ___, last seen in
___
-Psychiatrist: none
-Case worker: ___
Social History:
___
Family History:
PSA (heroin, cocaine, EtOH), colon cancer later in life
Physical Exam:
___
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Breathing is non-labored. Faint expiratory wheezing.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Labs:
___ 03:50PM BLOOD WBC: 7.8 RBC: 4.20* Hgb: 14.4 Hct: 44.0
MCV: 105* MCH: 34.3* MCHC: 32.7 RDW: 13.8 RDWSD: 53.2* Plt Ct:
206
___:50PM BLOOD Neuts: 63.0 Lymphs: ___ Monos: 7.8 Eos:
1.5 Baso: 0.6 Im ___: 0.4 AbsNeut: 4.89 AbsLymp: 2.08 AbsMono:
0.61 AbsEos: 0.12 AbsBaso: 0.05
___ 03:50PM BLOOD Glucose: 82 UreaN: 19 Creat: 1.5* Na: 141
K: 4.2 Cl: 104 HCO3: 25 AnGap: 12
___ 03:50PM BLOOD ALT: 21 AST: 22 LD(LDH): 221 AlkPhos: 94
TotBili: 0.6
___ 03:50PM BLOOD Calcium: 9.8 Phos: 2.7 Mg: 2.1
___ 08:26PM BLOOD Lactate: 1.5
Micro:
- Blood cultures (___): pending
- Flu PCR (___): negative
Imaging:
- CXR (___): IMPRESSION: No acute cardiopulmonary abnormality.
- CTA (___):
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. No evidence of cavitary mass or lymphadenopathy.
3. Interval postsurgical changes are seen at the right lower
lobe.
4. Mild central lobar emphysema.
Discharge Labs:
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO TID
2. Atazanavir 300 mg PO DAILY
3. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
4. RITONAvir 100 mg PO DAILY
5. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate
Discharge Medications:
1. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
2. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat
RX *dextromethorphan-benzocaine [Cepacol Sorethroat-Cough] 5
mg-7.5 mg 1 lozenge by mouth every six (6) hours Disp #*60
Lozenge Refills:*0
3. GuaiFENesin-Dextromethorphan 5 mL PO Q6H:PRN Cough
RX *dextromethorphan-guaifenesin [Adult Cough Formula DM Max]
200 mg-10 mg/5 mL 5 ml by mouth every six (6) hours Disp #*1
Bottle Refills:*0
4. Nicotine Patch 14 mg/day TD DAILY
RX *nicotine [Nicoderm CQ] 14 mg/24 hour Apply one patch daily
once daily Disp #*30 Patch Refills:*0
5. Nystatin Oral Suspension 5 mL PO QID
RX *nystatin 100,000 unit/mL 5 ml by mouth four times a day
Refills:*0
6. Atazanavir 300 mg PO DAILY
7. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
8. Gabapentin 800 mg PO TID
9. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
10. RITONAvir 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hemoptysis due to viral bronchitis
Discharge Condition:
Stable
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with productive cough, chest pain, and blood tinged
sputum x 3 days. reports night sweats and swollen lymph nodes. c/o nausea.
denies vomiting// Signs of pneumonia or TB?
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___, CT chest ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Chain sutures are noted in the right lower
lobe. There is associated atelectasis in the right lung base. No focal
consolidation. No pleural effusion or pneumothorax is seen. There are no
acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ Year old male Patient with PMH HIV on HAART (undetectable
viral load since ___, benign lung nodule s/p surgical removal one year ago,
prior DVT in leg, presenting with 3 days of cough w/ blood tinged sputum,
night sweats, pleuritic chest pain, headaches, nausea, and dizziness.//
Concerned for PE and tuberculosis.
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 = 18.2 mGy (Body) DLP =
9.1 mGy-cm.
2) Spiral Acquisition 4.0 s, 31.6 cm; CTDIvol = 9.0 mGy (Body) DLP = 283.3
mGy-cm.
Total DLP (Body) = 292 mGy-cm.
COMPARISON: CTA chest from ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
pulmonary artery is normal in caliber. 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: Mild central lobar emphysema. Patient is status post interval
resection of previously noted right lower lobe pulmonary nodule. Stable
calcified right lower lobe granuloma is noted. Lungs are clear without masses
or areas of parenchymal opacification. The airways are patent to the level of
the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. No evidence of cavitary mass or lymphadenopathy.
3. Interval postsurgical changes are seen at the right lower lobe.
4. Mild central lobar emphysema.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Cough
Diagnosed with Hemoptysis, Chest pain, unspecified
temperature: 96.3
heartrate: 108.0
resprate: 18.0
o2sat: 100.0
sbp: 147.0
dbp: 116.0
level of pain: 9
level of acuity: 3.0 | Mr. ___ is a ___ man with history
of HIV on HAART, benign lung nodule s/p surgical excision, prior
DVT presenting with hemoptysis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
right ankle fracture
Major Surgical or Invasive Procedure:
___: right ankle ORIF
History of Present Illness:
___ is a ___ year old female who presented to the ED
after slipping on seaweed in ___ on ___. She initially
presented to an OSH and subsequently left for further follow up
at ___. Imaging demonstrated R trimalleolar equivalent
ankle fracture.
Past Medical History:
Depression
Social History:
___
Family History:
Noncontributory
Physical Exam:
Exam on discharge:
O:
AVSS
Breathing comfortably
R ankle elevated on pillows, in cast. Wiggles toes. Sensation
intact in visible toes. Toes WWP.
Pertinent Results:
___ 06:12AM BLOOD WBC-6.7 RBC-3.48* Hgb-11.4 Hct-33.5*
MCV-96 MCH-32.8* MCHC-34.0 RDW-12.2 RDWSD-43.2 Plt ___
___ 06:12AM BLOOD Glucose-110* UreaN-5* Creat-0.6 Na-145
K-3.6 Cl-103 HCO3-30 AnGap-12
___ 06:12AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.0
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: ___ year old woman with ankle fracture// s/p reduction in splint
s/p reduction in splint
TECHNIQUE: AP lateral and oblique views of the right ankle were performed.
COMPARISON: Right ankle radiographs ___, performed 3 hours
earlier.
FINDINGS:
Overlying cast obscures bony details. Re-demonstration of acute fracture
through the medial malleolus and the posterior malleolus. There are no
significant degenerative changes. The medial clear space measures to 4 mm.
IMPRESSION:
Re-demonstration of acute fracture through the medial and posterior malleolus
status post splinting. Previously noted proximal fibular fracture not
included in field of view. Medial clear space measures up to 4 mm.
Radiology Report
EXAMINATION: ANKLE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ORIF right ankle.
TECHNIQUE: Screening was provided knee operating room without a radiologist
present. Total fluoroscopy time 38.3 seconds.
COMPARISON: Radiographs same day.
FINDINGS:
Images demonstrate placement of fixation screws at the medial malleolus. For
details of the procedure please consult the procedure report.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Ankle injury
Diagnosed with Displaced trimalleolar fracture of right lower leg, init, Fall same lev from slip/trip w/o strike against object, init
temperature: 97.7
heartrate: 64.0
resprate: 18.0
o2sat: 99.0
sbp: 131.0
dbp: 71.0
level of pain: 7
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 right ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for right ankle ORIF, which the patient tolerated well. For
full details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given anticoagulation per routine. The patient's
home medications were continued throughout this hospitalization,
with the exception of naltrexone. 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 and the patient was voiding/moving bowels
spontaneously. The patient is NWB in the RLE extremity, and will
be discharged on ASA 325mg daily for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Shortness of breath, L-sided chest pain
Major Surgical or Invasive Procedure:
Thoracentesis w/chest tube placement (___)
History of Present Illness:
___ yo F w hx of recently dx a-fib (rivaroxaban on hold since
last admission earlier this month), CAD, HLD, osteoarthritis s/p
hip replacement (___), recent admission for myopericarditis
(d/c 3d ago on colchicine, naproxen) presenting for evaluation
of shoulder /L flank pain.
She was discharged ___ on naproxen / colchicine following a
hospitalization for myopericarditis.
Was doing well for the 3 days between admission and presently.
___, after dinner on ___, developed severe left flank and
shoulder pain, and presented to ___ for
evaluation.
At ___, labs relatively benign. CTA torso - no PE to
segmental level. small pericardial effusion. moderate left
pleural effusion with associated atelectasis. Transferred ___
for further eval.
In the ED, had persistent L flank and shoulder pain, no other
sx, was hypotensive to ___ (pulsus < 10) despite 3 L IVF,
started on levophed (0.04), no CVL. Labs notable for WBC 7.2,
hgb 8.3 (from 9.5 ___, nl BMP, VBG 7.39/43, lactate 0.9, UA
unremarkable. Pleural fluid was drained by IP, serosanginous.
- also given CTX 1g at 1149, Azithro 500 at 1150, Vanc IV at
1309, Morhpine 2 IV x1, colchicine, naproxen, ASA, Zofran,
On arrival to the MICU, her L flank and shoulder pain had
improved. Some difficulty taking deep breath iso pain. Reports
persistent mild dry cough that has been present x1 month. Has
had low grade temps to 99.6 x1month. Chest pain has largely
resolved. No dizziness / lightheadedness.
Past Medical History:
1. CARDIAC RISK FACTORS
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- Myopericarditis ___
3. OTHER PAST MEDICAL HISTORY
- atrial fibrillation
- hip replacement ___
Social History:
___
Family History:
Brother Alive ___ polyps
Father ___
Mother ___ at age ___ CAD
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: Reviewed in Metavision
Constitutional: Sitting in bed, eating dinner, non-toxic
appearance, only cautiously moving L arm, but overall NAD
HEENT: NCAT, PERRL, EOMI, MMM, OP clear
Neck: supple, JVP not elevated
Chest: Diminished BS at left base up to mid lung.
Cardiovascular: RRR, Normal S1/S2, +pericardial friction rub at
LUSB
Abdomen: Soft, nondistended. Nontender.
Extr: Warm. No clubbing, cyanosis, or edema.
Skin: No rash.
Neuro: Speech fluent.
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 1530)
Temp: 97.9 (Tm 98.3), BP: 100/63 (100-126/63-76), HR: 66
(66-78),
RR: 18 (___), O2 sat: 91% (91-95), O2 delivery: Ra, Wt: 156.08
lb/70.8 kg
Gen: sitting comfortably in bed in NAD
HEENT: PERRL, EOMI, OP clear
CV: RRR, nl S1, S2, no m/r/g, JVP flat, no pericardial knock or
friction rub appreciated
Chest: decreased BS L base, faint crackles R base, no L-sided
chest wall TTP
Abd: + BS, soft, NT, ND, no HSM
MSK: lower ext warm without edema
Neuro: AOx3, CN II-XII intact, ___ strength all extremities,
sensation grossly intact, gait not tested
Pertinent Results:
ADMISSION LABS
___ 10:37AM BLOOD WBC-7.2 RBC-2.84* Hgb-8.3* Hct-26.3*
MCV-93 MCH-29.2 MCHC-31.6* RDW-12.7 RDWSD-42.5 Plt ___
___ 10:37AM BLOOD Neuts-74.8* Lymphs-14.3* Monos-9.0
Eos-1.4 Baso-0.1 Im ___ AbsNeut-5.39 AbsLymp-1.03*
AbsMono-0.65 AbsEos-0.10 AbsBaso-0.01
___ 10:37AM BLOOD Glucose-94 UreaN-10 Creat-0.5 Na-140
K-4.2 Cl-108 HCO3-21* AnGap-11
___ 05:34PM BLOOD ALT-26 AST-34 LD(LDH)-569* AlkPhos-108*
TotBili-0.4
___ 10:37AM BLOOD Calcium-7.6* Phos-2.4* Mg-1.7
___ 10:37AM BLOOD TSH-2.1
___ 10:37AM BLOOD Cortsol-7.6
___ 05:34PM BLOOD CRP-86.7*
___ 05:34PM BLOOD IgG-671*
___ 10:42AM BLOOD ___ pO2-26* pCO2-43 pH-7.39
calTCO2-27 Base XS-0
___ 10:42AM BLOOD Lactate-0.9
PERTINENT/DISCHARGE LABS
___ 07:40AM BLOOD WBC-5.6 RBC-3.89* Hgb-11.0* Hct-34.7
MCV-89 MCH-28.3 MCHC-31.7* RDW-13.1 RDWSD-42.2 Plt ___
___ 07:40AM BLOOD Glucose-140* UreaN-11 Creat-0.5 Na-138
K-4.6 Cl-101 HCO3-26 AnGap-11
___ 06:57AM BLOOD ALT-25 AST-16 LD(LDH)-190 AlkPhos-91
TotBili-0.2
___ 07:56AM BLOOD proBNP-1059*
___ 05:34PM BLOOD cTropnT-<0.01
___ 06:57AM BLOOD Cortsol-17.7
___ 08:02AM BLOOD Cortsol-26.5*
___ 08:44AM BLOOD Cortsol-30.2*
___ 12:20PM BLOOD ANCA-NEGATIVE B
___ 07:40AM BLOOD CRP-7.6*
WBC 5.6, Hgb 11.0 (from 10.4), Plt 332
BMP WNL (glu 140)
Ca/Mg/Phos WNL
CRP 7.6 from 91 (___) and 139 (___)
Quant-GOLD: pending
Prior:
TSH 2.1
AM Cortisol 26.5
Trop neg x 2
RF neg
___ neg
Anti-CCP neg
ANCA neg
Pleural fluid (___): TNC ___, RBC ___, 50% polys, 17%
lymphs, Tprot 3.4, LDH 313, pH 7.37
Pleural fluid (___): NGTD
Pleural fluid enterovirus cx (___): negative
Pleural fluid (___): 3+ PMNs, no organisms, Cx negative, AFB
neg, AFB cx pending
BCx (___): negative x 2
UCx (___): mixed flora
Cytology pleural fluid (___): negative
Flow cytometry pleural fluid (___): negative
IMAGING/STUDIES
CXR (___):
In comparison with the study of ___, there is little
overall change in the moderate left pleural effusion with volume
loss in the left lower lobe. No evidence of vascular congestion
or acute focal pneumonia. Cardiomediastinal silhouette is
stable.
CXR (___):
Cardiomediastinal silhouette is within normal limits. There is
a
left retrocardiac opacity and a moderate left-sided pleural
effusion which is slightly larger compared to previous study.
There are no pneumothoraces. Right lung is clear.
TTE (___):
The left ventricle has a normal cavity size. There is normal
regional left ventricular systolic function. Overall
left ventricular systolic function is normal. Normal right
ventricular cavity size with normal free wall motion.
There is a very small pericardial effusion. The effusion is echo
dense, c/w blood, inflammation or other cellular
elements. There is increased respiratory variation in
transmitral/transtricuspid inflowand brief interventricular
septal "shudder", c/w (likely transient) effusive-constrictive
physiology.
IMPRESSION: Very small echodense pericardial effusion with
evidence of effusive-constrictive physiology. No tamponade.
Compared with the prior TTE (images reviewed) of ___, the
percardial effusion is now smaller.
CTA chest ___, ___:
1. No evidence for pulmonary embolism or acute aortic syndrome.
2. Small pericardial effusion, unchanged compared to ___ but slightly increased compared to ___.
3. Moderate left pleural effusion with compressive left lower
lobe atelectasis, unchanged compared to ___ but new
compared to ___.
4. No evidence for free fluid or other acute abnormalities in
the
abdomen or pelvis.
5. 2 x 1.5 cm left adrenal nodule, stable in size compared to
the
recent exam from ___, is not fully characterized on
single phase CT in the absence of a precontrast scan.
Statistically, it most likely represents an adenoma.
6. Other stable findings include multiple hepatic hemangiomas,
mild diverticulosis without acute diverticulitis, and an
enlarged
uterus with multiple large calcified fibroids.
RECOMMENDATION(S):
Adrenal protocol MRI with and without contrast, to be performed
non urgently at the patient's convenience, within approximately
3
months.
Cardiac CT (___):
1. Diffuse smooth enhancement of the pericardium with small
amount of non loculated nonhemorrhagic pericardial effusion
measuring up to 1.4 cm in maximal thickness in the base above
the
diaphragm, most likely representing ongoing pericarditis. No
pericardial calcifications or CT evidence of constrictive
physiology.
2. Otherwise no acute process within the chest.
3. 3 mm right upper lobe nodule abutting the minor fissure.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Colchicine 0.6 mg PO BID
5. Guaifenesin-CODEINE Phosphate 5 mL PO TID:PRN cough
6. Naproxen 500 mg PO Q12H
7. Pantoprazole 40 mg PO Q24H
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Metoprolol Tartrate 25 mg PO ONCE MR1:PRN atrial fibrillation
10. Multivitamins 1 TAB PO DAILY
11. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN Nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
2. PredniSONE 30 mg PO DAILY Duration: 5 Days
Take 30 mg daily until ___. On ___, start taking 25 mg daily
Tapered dose - DOWN
RX *prednisone 5 mg 6 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. PredniSONE 25 mg PO DAILY Duration: 7 Days
Take 25 mg daily ___. On ___, start taking 20 mg daily.
Tapered dose - DOWN
RX *prednisone 5 mg 5 tablet(s) by mouth once a day Disp #*35
Tablet Refills:*0
4. PredniSONE 20 mg PO DAILY
On ___ start taking 20 mg daily until further instructions
Tapered dose - DOWN
RX *prednisone 5 mg 4 tablet(s) by mouth once a day Disp #*120
Tablet Refills:*0
5. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Colchicine 0.6 mg PO BID
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Guaifenesin-CODEINE Phosphate 5 mL PO TID:PRN cough
11. Metoprolol Tartrate 25 mg PO ONCE MR1:PRN atrial
fibrillation
12. Multivitamins 1 TAB PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Pericarditis, idiopathic
Left pleural effusion, idiopathic
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 dyspnea, cp// eval for interval worsening,
new acute process
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray and chest CT from earlier the same day ___.
FINDINGS:
Left basilar opacity is compatible with a moderate left-sided pleural effusion
with adjacent atelectasis. Unchanged since prior. Elsewhere, lungs are
clear. Cardiac silhouette is not well assessed though grossly stable.
Pericardial effusion was better seen on prior CT. No acute osseous
abnormalities.
IMPRESSION:
No significant interval change of moderate left-sided pleural effusion with
adjacent atelectasis.
Radiology Report
INDICATION: ___ year old woman with pleural effusion// left ___ r/o PTX
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Left pleural effusion has decreased in volume. No pneumothorax is seen.
There is subsegmental atelectasis in the right lung base. Cardiomediastinal
silhouette is stable. No new consolidations
Radiology Report
INDICATION: ___ year old woman with pericardial effusion, now admitted w/ new
L pleural effusion s/p drainage ___// size of L pleural effusion?
COMPARISON: Radiographs from ___
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. There is a left
retrocardiac opacity and a moderate left-sided pleural effusion which is
slightly larger compared to previous study. There are no pneumothoraces.
Right lung is clear.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with left pleural effusion// interval
assessment
IMPRESSION:
In comparison with the study of ___, there is little overall change in
the moderate left pleural effusion with volume loss in the left lower lobe.
No evidence of vascular congestion or acute focal pneumonia. Cardiomediastinal
silhouette is stable.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Shoulder pain
Diagnosed with Pleural effusion, not elsewhere classified
temperature: 97.7
heartrate: 74.0
resprate: 16.0
o2sat: 95.0
sbp: 99.0
dbp: 63.0
level of pain: 7
level of acuity: 3.0 | ___ w hx of recently dx a-fib (rivaroxaban on hold since last
admission earlier this month), CAD, HLD, osteoarthritis s/p hip
replacement (___), recent admissions for idiopathic
pericarditis ___ ___ and ___ ___, discharged on
colchicine and naproxen) presenting as transfer from ___
with L-sided chest pain and SOB, pleural effusion, and
hypotension likely due to transient constrictive physiology for
which she briefly required pressors, improved with fluids and
thoracentesis. Prednisone initiated for refractory pericarditis
and discharged with close outpatient f/u.
# Hypotension:
Patient presented as transfer from ___ and was
hypotensive
on arrival, for which she received 3L IVFs and briefly required
levophed in the ICU. Etiology thought secondary to volume
depletion in setting of transient constrictive physiology from
refractory pericarditis. Pulsus negative in the ED, and TTE ___
showed showed decrease in size of pericardial
effusion without e/o tamponade, as well as changes c/w likely
transient effusive-constrictive physiology. CTA chest at ___
without PE. Low suspicion for sepsis in absence of localizing
signs/symptoms of infection. No e/o adrenal insufficiency. She
was seen by ___ cardiology (Dr. ___, who agreed with
hypovolemia in setting of transient constrictive physiology as
the most likely explanation for her hypotension. In discussion
with cardiology and rheumatology, see below, prednisone was
initiated for refractory pericarditis/serositis. HD stable at
the
time of discharge.
# L-sided chest pain:
# Idiopathic, refractory pericarditis with small pericardial
effusion:
# L-sided pleural effusion:
Patient diagnosed with idiopathic pericarditis ___, with
recent admission ___ for ongoing pericarditis, for which
she was discharged on colchicine/naproxen. She presented as
transfer from ___ this admission with ongoing L-sided
chest pain, SOB, and new L pleural effusion, concerning for
refractory pericarditis now with associated pleural effusion. No
evidence for ACS, and CTA chest at ___ was negative for PE.
TTE ___ showed small pericardial effusion (decreased from
prior)
with evidence of (likely transient) effusive constrictive
physiology but no e/o tamponade. IP was consulted, and she
underwent thoracentesis ___, with 700cc drained. Effusion was
exudative by Light's criteria. Low suspicion for parapneumonic
effusion in absence of PNA (pleural fluid culture negative at
time of discharge, AFB negative, culture pending). Cytology and
flow cytometry from pleural fluid were negative as well.
Rheumatology was consulted and found no evidence for an
underlying auto-immune disorder (RF, ___, anti-CCP, and ANCA all
negative). In discussion with cardiology and rheumatology, the
decision was made to initiate prednisone for refractory and
HD-significant pericarditis/serositis. Prednisone 30mg daily was
initiated on ___ with significant improvement in her symptoms,
with plan to taper by 5mg weekly initially, with slower tapering
once dose <15mg per day (final taper to be determined by
outpatient cardiologist Dr. ___ based on clinical response
and CRP). Quant-GOLD sent, pending at discharge. Colchicine was
continued, and naproxen d/c'd. CRP had declined from ___ on
admission to 7 at discharge. CXR at the time of discharge showed
a stable, moderate L pleural effusion, thought too small to tap
after evaluation by IP. Ms. ___ will f/u with her outpatient
cardiologist, Dr. ___, on ___ f/u with IP pending at
discharge. Ms. ___ will require close monitoring of CRP and
likely repeat CXR and TTE as outpatient. Should she require
prednisone at doses greater than 20mg for >4 weeks, would
consider initiation of PCP ___.
# Normocytic anemia:
Hgb 9.7 on admission, stable from discharge on prior admission.
Improved without transfusion to 11.0 at discharge. Low suspicion
for active bleeding, and previously guaiac negative. Rivaroxaban
had been discontinued on prior admission and was not resumed as
below.
# Afib:
Previously noted to have a-fib during prior admissions ___
and
___, for which Xarelto was initiated and then discontinued
given concern for possible hemorrhagic pleural effusion and
CHADs2=1. Patient was in NSR this admission with well-controlled
rates. Xarelto was not resumed. She was discharged on home ASA.
# L adrenal nodule:
2 x 1.5 cm left adrenal nodule incidentally seen. Will require
adrenal protocol CT in 3 months
** TRANSITIONAL **
[ ] f/u Quantiferon-Gold (sent given prednisone initiation)
[ ] trend CRP
[ ] f/u pending pleural fluid cultures
[ ] consider repeat TTE in ~8 weeks
[ ] consider short-interval repeat CXR to monitor L-pleural
effusion
[ ] prednisone taper (tentative plan for 5mg taper every week,
with slower tapering once dose <15mg); consider PCP/bone ppx if
plan for dosing >20mg for >4 weeks
[ ] consider re-initiation of Xarelto once pericardial effusion
has completed resolved
[ ] adrenal protocol CT in 3 months |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Avandia / lisinopril
Attending: ___.
Chief Complaint:
R foot infection
Major Surgical or Invasive Procedure:
___ line placement
History of Present Illness:
___ y/o M with DM with recurrent R foot infection. Patient was
admitted and treated with IV antibiotics in ___ for similar
infection. At that time patient had polymicrobial infection
including pseudomonas that was pan sensitive. Patient has been
on ciprofloxacin, cephalexin since ___ without improvement of
foot infection. Patient was referred to the ED by PCP for
further evaluation and IV antibiotics. Patient denies right foot
pain, fevers, chills, but does note drainage from the wound. He
denies sweats, chest pain, SOB, nausea, vomiting, dysuria,
hematuria. Patient reports intermittent diarrhea from his recent
antibiotics.
In the ED, initial VS: 98.8 104 119/87 16 100%. Podiatry was
called and agreed to see the patient in the AM. Patient was
given IV vancomycin and zosyn and admitted to medicine for
further management. VS on xfer were 98.8 °F (37.1 °C), Pulse:
90, RR: 16, BP: 122/76, O2Sat: 100.
On arrival to the medical floor, patient appeared comfortable
and denied any complaints. Vitals were T: 98.5 P: 80 BP: 165/77
RR: 20 SaO2: 100% on Room air
Past Medical History:
IDDM
gout
HTN
A-fib
hypercholesterolemia
GERD
Venous statis ulcers
COPD
obesity
Pulm HTN
CKD stage III
Social History:
___
Family History:
Mother: died of PNA ___ yrs. Father: died of MI ___ years. No
siblings.
Physical Exam:
admission exam
VS - T: 98.5 P: 80 BP: 165/77 RR: 20 SaO2: 100% RA Wt 113.4 kg
GENERAL - Alert, interactive, well-appearing morbidly obese man
in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, large, no LAD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no wheezes/rales/ronchi, good air movement, resp
unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - R great toe w/ white tip and green-ish immediately
surrounding tissue w/ erythema extending up dorsum of foot into
calves; skin breakdown and maceration between the toes, no
obvious exudates b/l calves wrapped in ACE bandages, 3+ edema
NEURO - awake, A&Ox3, CNs III-XII grossly intact, motor and
sensation grossly intact
.
discharge exam
VS: 98.2 134/61-155/80 ___ 20 99% RA
GENERAL - Alert, interactive, well-appearing morbidly obese man
in NAD
HEENT - sclerae anicteric, MMM, OP clear
NECK - Supple, large, no LAD
HEART - irregular, nl S1-S2, no MRG
LUNGS - CTAB, no wheezes/rales/ronchi, good air movement, resp
unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - R great toe w/ white discoloration over the tip
improved from prior exam. dorsal aspect of R foot erythematous
and warm with skin breakdown. No open lesions or ulcerations.
Webspaces are macerated. venous stasis skin changes in bilateral
lower extremities. 2+ pitting edema
NEURO - awake, A&Ox3, CNs III-XII grossly intact, strength ___.
decreased sensation over R foot
Pertinent Results:
___ 09:00PM BLOOD WBC-11.2* RBC-4.41* Hgb-14.2 Hct-42.3
MCV-96 MCH-32.1* MCHC-33.4 RDW-14.0 Plt ___
___ 09:00PM BLOOD Neuts-82.5* Lymphs-8.3* Monos-5.5 Eos-3.0
Baso-0.6
___ 07:10AM BLOOD WBC-8.7 RBC-4.34* Hgb-13.7* Hct-42.4
MCV-98 MCH-31.5 MCHC-32.2 RDW-13.9 Plt ___
___ 04:35PM BLOOD ___ PTT-34.9 ___
___ 07:10AM BLOOD ___ PTT-34.5 ___
___ 10:45AM BLOOD ESR-28*
___ 09:00PM BLOOD Glucose-186* UreaN-28* Creat-1.4* Na-137
K-4.8 Cl-102 HCO3-25 AnGap-15
___ 04:35PM BLOOD Glucose-205* UreaN-25* Creat-1.4* Na-139
K-3.8 Cl-102 HCO3-29 AnGap-12
___ 07:10AM BLOOD Glucose-162* UreaN-23* Creat-1.3* Na-141
K-3.9 Cl-104 HCO3-28 AnGap-13
___ 07:10AM BLOOD ALT-24 AST-34 AlkPhos-94 TotBili-0.7
___ 04:35PM BLOOD Calcium-8.3* Phos-2.3* Mg-2.1
___ 07:10AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.3
___ 09:00PM BLOOD CRP-38.0*
___ 04:35PM BLOOD Digoxin-0.8*
.
micro
- blood cultures pending
- ___ skin scrapings negative
.
studies
Right Lower Extremity Arterial study
FINDINGS: Monophasic Doppler waveforms were seen bilaterally at
the femoral, popliteal, posterior tibial and dorsalis pedis
arteries.
The right ABI was 0.71 and the left ABI was 0.91.
Pulse volume recordings showed fairly symmetric amplitudes
bilaterally at all levels.
COMPARISON: Compared to the non-invasive arterial study
obtained on ___, there has been mild progression of
disease in the right lower extremity.
IMPRESSION:
1. Mild inflow arterial disease to the lower extremities, with
aortoiliac location.
2. Mild associated outflow arterial disease in the bilateral
lower
extremities, likely located at the popliteal/tibial level.
.
Right Foot Xray - prelim read - could not rule out
osteomyelitis. correlate clinically.
.
CXR (prelim report)
FINDINGS: A new left-sided PICC line terminates in the low SVC.
The lungs
remain hyperinflated with blunting of the bilateral costophrenic
angles. No focal consolidation or pneumothorax is present.
IMPRESSION: New left-sided PICC line tip in the low SVC.
Medications on Admission:
1. insulin glargine 100 unit/mL Solution Sig: ___ (64)
units Subcutaneous once a day.
2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO once a day.
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAYS
(___).
4. calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAYS
(___).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAYS
(___).
8. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAYS
(___).
9. Klor-Con M20 20 mEq Tablet, ER Particles/Crystals Sig: One
(1) Tablet, ER Particles/Crystals PO once a day.
10. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
11. warfarin 4 mg daily
12. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day.
15. metoprolol succinate 100 mg daily
16. multivitamin 1 tab PO DAILY
17. torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAYS
(___).
18. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAYS
(___).
19. ipratropium-albuterol ___ mcg/actuation Aerosol Sig: ___
puffs Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
20. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Medications:
1. insulin glargine 100 unit/mL Solution Sig: ___ (64)
units Subcutaneous once a day.
2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAYS
(___).
4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAYS
(___).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. digoxin 250 mcg Tablet Sig: One (1) Tablet PO QMOWEFR ___
-___.
8. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAYS
(___).
9. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
10. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
11. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
12. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. torsemide 20 mg Tablet Sig: Three (3) Tablet PO QTUTHSA
(___).
15. torsemide 20 mg Tablet Sig: Two (2) Tablet PO QMoWeFriSun
___.
16. torsemide 20 mg Tablet Sig: Two (2) Tablet PO QSUN (every
___.
17. ipratropium-albuterol ___ mcg/actuation Aerosol Sig: ___
puffs Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
18. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
19. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours) for 4 weeks: day ___.
20. ketoconazole 2 % Cream Sig: One (1) Appl Topical BID (2
times a day) for 4 weeks: ketaconazole cream applied to
interdigital areas and all of R foot .
21. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
___.
22. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
primary diagnosis: osteomyelitis
secondary diagnosis: diabetes, atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ gentleman with history of recurrent right lower
extremity cellulitis.
TECHNIQUE: Non-invasive evaluation of the arterial system in the bilateral
lower extremities was performed with Doppler signal, pulse volume recordings
and segmental limb pressure measurements.
FINDINGS: Monophasic Doppler waveforms were seen bilaterally at the femoral,
popliteal, posterior tibial and dorsalis pedis arteries.
The right ABI was 0.71 and the left ABI was 0.91.
Pulse volume recordings showed fairly symmetric amplitudes bilaterally at all
levels.
COMPARISON: Compared to the non-invasive arterial study obtained on ___, there has been mild progression of disease in the right lower
extremity.
IMPRESSION:
1. Mild inflow arterial disease to the lower extremities, with aortoiliac
location.
2. Mild associated outflow arterial disease in the bilateral lower
extremities, likely located at the popliteal/tibial level.
Radiology Report
HISTORY: ___ man, with history of recurrent right lower extremity
infection. Assess for osteomyelitis.
COMPARISON: Right foot radiograph on ___ and MR foot on ___.
RIGHT FOOT RADIOGRAPH, THREE VIEWS: There is severe diffuse osteopenia,
limiting detection of subtle fractures. There is no fracture or dislocation.
There is no definite evidence of bone destruction to suggest osteomyelitis. No
soft tissue gas or foreign body.
Degenerative changes are overall mild-to-moderate, with a prominent plantar
calcaneus spur. There is no large ankle joint effusion.
IMPRESSION: No definite sign of osteomyelitis.
Radiology Report
INDICATION: ___ man with new left-sided PICC.
FINDINGS: A new left-sided PICC line terminates in the low SVC. The lungs
remain hyperinflated with blunting of the bilateral costophrenic angles. No
focal consolidation or pneumothorax is present.
IMPRESSION: New left-sided PICC line tip in the low SVC. Discussed with
___ on the IV team via telephone at ___ on ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RIGHT FOOT INFECTION
Diagnosed with IDDM W SPEC MANIFESTATION, CELLULITIS OF FOOT
temperature: 98.8
heartrate: 104.0
resprate: 16.0
o2sat: 100.0
sbp: 119.0
dbp: 87.0
level of pain: 0
level of acuity: 3.0 | ___ year old man with DMII, CHF, AFib, EtOH abuse and chronic ___
edema and recurrent cellulitis who presents to the ED from
clinic for worsening RLE cellulitis.
# R Foot Infection/Onychomycosis: Patient w/ h/o significant
cellulitis s/p initial mgmt w/ IV abx in ___ for polymicrobial
infection then transitioned to po cipro and keflex. Plain films
were conerning for osteo at that time so MRI was pursued which
was negative. His symptoms progressed despite multiple abx
courses and close follow up by his outpatient providers. Recent
outpatient culture showed resistant pseudomonas. He was
initially started on vancomycin and zosyn. ID was consulted to
help with further antibiotic managmement of his infection. Given
so many treatment failures, it was felt that current infection
likely represents a deeper infection especially since
pseudomonas was isolated. ESR and CRP continued to be elevated
and a foot xray could not rule out osteomyelitis. Antibiotics
were switched to cefepime 2 g IV q12 hours with plans to
complete a ___ week course. (day 1 was ___. A PICC line was
placed successfully. He was discharged to rehab with plans to
have weekly lab draws and follow up in infectious disease
clinic.
.
# DMII: Patient continued on home regimen of lantus 64 units
daily with insulin sliding scale. Glyburide was held during
admission but restarted upon discharge. Blood sugars remained
well controlled.
.
# AFib on coumadin: Patient was continued on home doses of
metoprolol and digoxin. He was also continued on warfarin 4 mg
daily. His INR should be rechecked on ___.
.
# chronic dCHF: Continued home torsemide, losartan, and
metoprolol.
.
# HTN, benign: continued home losartan and metoprolol
.
# HLD: Continued home simvastatin 40
.
# Gout: Continued home allopurinol
.
# COPD: Stable, at baseline. continue home regimen of
albuterol/ipratropium prn.
.
Transitional Issues:
-weekly labs: CBCw/diff, CMP, ESR/CRP and fax to ___ clinic at
___
-f/u with ID as scheduled
-continue compression and elevation of R foot
-check INR on ___ and coumadin dosing may need
further adjustment
-patient full code during admission |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lithium
Attending: ___
Chief Complaint:
Dizziness, N/V, Pre-syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of alcoholic cirrhosis c/b alcoholic hepatitis and
decompensated portal hypertension w/ ascites, jaundice, and
malnutrition, and bipolar disorder who presents to the ED for
nausea and lightheadedness. She states that while standing in
line to check in at her doctor's office for a regular check-up
she felt like she was going to pass out. She sat down, and
denies LOC or hitting her head. She admits to having these
episodes in the past at home, but she is able to lay down and
she feels better. She denies having any CP, SOB, palpitations
prior to this episode.
Of note, she has been drinking on and off for the past 2 wks,
___ bottle vodka every other day, last drink last night before
midnight. She felt nauseous and vomited multiple times on ___,
nonbilious, nonbloody. Assoc with some loose stools. Denies any
abd pain, fever, chills, urinary sx. She denies any prior
history of alcohol withdrawal or withdrawal seizures. She admits
to some
nausea, but denies tremor, headache, anxiety, formication.
Also of note, pt states that her diuretics (lasix,
spironolactone) were recently decreased given her kidney
function has been worsening.
Regarding her cirrhosis:
MELD: ___
Child Class: A
Last EGD: ___ - no varices
Past Medical History:
Diverticulitis ___
hypertension
EtOH Cirrhosis
GERD
Social History:
___
Family History:
Father: HTN, diverticulitis (1 episode)
Mother: good health
FH of colon cancer, cholecystitis
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 98.1, P 87, BP 102/61, RR 18, SpO2 100% RA
GENERAL: Alert and interactive. In no acute distress. Cachectic.
HEENT: NCAT. PERRL, EOMI. Sclera icteric and without injection.
MMM. No notable sublingual icterus.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, minimally tender
in
epigastrium, no guarding or rebound. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. Occasional spider angiomata on chest
and legs.
NEUROLOGIC: CN grossly intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
DISCHARGE PHYSICAL EXAM
=======================
VS: 24 HR Data (last updated ___ @ 1115)
Temp: 98.2 (Tm 98.4), BP: 102/63 (100-126/62-85), HR: 102
(90-111), RR: 18 (___), O2 sat: 97% (97-100), O2 delivery: Ra
GENERAL: Frail appearing. In no acute distress.
CARDIAC: Regular rate and rhythm. Normal S1 and S2. No murmurs,
rubs, or gallops
LUNG: Clear to auscultation bilaterally. No crackles, wheezes,
or
rhonchi.
ABD: Soft, nontender, nondistended. Normal bowel sounds
throughout.
EXT: Warm, well perfused. No lower extremity edema. Mild palmar
erythema.
NEURO: AAOx3. No asterixis on exam.
SKIN: Occasional spider angiomata present on chest.
Pertinent Results:
ADMISSION LABS:
===============
___ 12:45PM URINE HOURS-RANDOM CREAT-238 SODIUM-<20
POTASSIUM-39 TOT PROT-50 PHOSPHATE-32.3 MAGNESIUM-5.6
PROT/CREA-0.2
___ 12:45PM URINE UCG-NEGATIVE OSMOLAL-354
___ 12:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 12:45PM URINE COLOR-Orange* APPEAR-Hazy* SP ___
___ 12:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM* UROBILNGN-4* PH-5.0
LEUK-NEG
___ 12:45PM URINE RBC-3* WBC-3 BACTERIA-FEW* YEAST-NONE
EPI-1 TRANS EPI-<1
___ 12:45PM URINE HYALINE-111*
___ 12:45PM URINE CA OXAL-OCC*
___ 12:45PM URINE MUCOUS-RARE*
___ 10:30AM GLUCOSE-120* UREA N-36* CREAT-1.6*
SODIUM-127* POTASSIUM-4.8 CHLORIDE-86* TOTAL CO2-18* ANION
GAP-23*
___ 10:30AM ALT(SGPT)-16 AST(SGOT)-56* ALK PHOS-144* TOT
BILI-2.5*
___ 10:30AM LIPASE-99*
___ 10:30AM ALBUMIN-4.9 CALCIUM-10.8* PHOSPHATE-4.5
MAGNESIUM-1.4*
___ 10:30AM OSMOLAL-283
___ 10:30AM ASA-NEG ACETMNPHN-NEG tricyclic-NEG
___ 10:30AM WBC-5.5 RBC-3.82* HGB-12.4 HCT-34.7 MCV-91
MCH-32.5* MCHC-35.7 RDW-15.9* RDWSD-51.8*
___ 10:30AM NEUTS-75.8* LYMPHS-13.8* MONOS-9.1 EOS-0.4*
BASOS-0.4 NUC RBCS-0.5* IM ___ AbsNeut-4.16 AbsLymp-0.76*
AbsMono-0.50 AbsEos-0.02* AbsBaso-0.02
___ 10:30AM ___ PTT-34.8 ___
___ 09:15AM UREA N-32* CREAT-1.4* SODIUM-131*
POTASSIUM-3.9 CHLORIDE-87* TOTAL CO2-22 ANION GAP-22*
___ 09:15AM ALT(SGPT)-14 AST(SGOT)-43* ALK PHOS-145* TOT
BILI-2.4*
___ 09:15AM ALBUMIN-5.1
___ 09:15AM WBC-5.6 RBC-3.88* HGB-12.6 HCT-36.0 MCV-93
MCH-32.5* MCHC-35.0 RDW-15.9* RDWSD-54.4*
___ 09:15AM ___ PTT-33.7 ___
PERTINENT LABS:
===============
___ 05:25AM BLOOD ALT-10 AST-30 AlkPhos-118* TotBili-3.7*
DirBili-1.3* IndBili-2.4
___ 10:30AM BLOOD Glucose-120* UreaN-36* Creat-1.6* Na-127*
K-4.8 Cl-86* HCO3-18* AnGap-23*
___ 05:41AM BLOOD ___ pO2-161* pCO2-31* pH-7.48*
calTCO2-24 Base XS-1 Comment-GREEN TOP
DISCHARGE LABS:
===============
___ 05:12AM BLOOD WBC-3.2* RBC-3.10* Hgb-10.0* Hct-29.7*
MCV-96 MCH-32.3* MCHC-33.7 RDW-16.2* RDWSD-56.6* Plt Ct-43*
___ 05:12AM BLOOD ___ PTT-32.2 ___
___ 05:12AM BLOOD Glucose-99 UreaN-31* Creat-0.8 Na-134*
K-4.9 Cl-93* HCO3-26 AnGap-15
___ 05:12AM BLOOD ALT-10 AST-27 AlkPhos-101 TotBili-2.5*
___ 05:12AM BLOOD Albumin-4.9 Calcium-10.8* Phos-3.2 Mg-2.4
MICRO:
======
___ 12:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH
IMAGING:
========
EXAMINATION: Chest radiograph ___
IMPRESSION:
No signs of pneumonia. Subtle wedge deformity of a lower
thoracic vertebral body, apparently new from prior. Please
correlate for focal pain.
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) ___
IMPRESSION:
1. Cirrhotic liver with splenomegaly and trace ascites. Patent
hepatopetal flow in the portal vein.
2. CBD is mildly prominent at 8 mm in comparison with prior,
without signs of intrahepatic biliary dilation, please correlate
clinically.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Thiamine 100 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Spironolactone 50 mg PO DAILY
7. Lactulose 15 mL PO DAILY:PRN constipation
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Lactulose 15 mL PO DAILY:PRN constipation
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Spironolactone 50 mg PO DAILY
7. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
-Presyncope
-acute kidney injury
-Severe protein calorie malnutrition
SECONDARY DIAGNOSES:
-Alcohol use disorder
-Cirrhosis
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 presyncope// CXR- please eval for PNA or effusion
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___ and ___
FINDINGS:
PA and lateral views the chest were provided. The lungs are clear
bilaterally. No focal consolidation, large effusion, or pneumothorax is seen.
No signs of congestion or edema. Heart size and mediastinal contours are
normal. Bony a subtle anterior wedge compression deformity in the lower
thoracic spine was not clearly seen on prior and clinical correlation for
associated pain is advised.. No free air below the right hemidiaphragm.
IMPRESSION:
No signs of pneumonia. Subtle wedge deformity of a lower thoracic vertebral
body, apparently new from prior. Please correlate for focal pain.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with presyncope, liver disease// Please
evaluate for peritoneal fluid, PVT
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound ___
FINDINGS:
LIVER: The liver is diffusely echogenic large in size. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is
patent with hepatopetal flow. There is trace of ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 8 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening,
however there is minimal sludge.
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 15 cm.
KIDNEYS: The limited view of the kidneys show that the right kidney measures
10 cm, the left kidney measures 10 cm. Normal cortical echogenicity and
corticomedullary differentiation is seen bilaterally. There is no evidence of
masses, stones, or hydronephrosis in the kidneys.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver with splenomegaly and trace ascites. Patent hepatopetal
flow in the portal vein.
2. CBD is mildly prominent at 8 mm in comparison with prior, without signs of
intrahepatic biliary dilation, please correlate clinically.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness, N/V, Presyncope
Diagnosed with Alcohol dependence with withdrawal, unspecified
temperature: 97.5
heartrate: 116.0
resprate: 20.0
o2sat: 100.0
sbp: 100.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ yo woman with history of alcoholic
cirrhosis, MELD-Na 24(now ___ A, complicated by
alcoholic hepatitis and decompensated
portal hypertension with ascites, jaundice, and malnutrition,
admitted for pre-renal ___ ___ dehydration, poor PO intake, and
recent binge-drinking (last drink ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abd Pain, Lower Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with past medical history of sickle cell
trait, hypothyroidism who presents with general malaise
abdominal
pain and nausea.
Patient was initially seen in urgent care for left sided low
back
pain on ___. Given prescription for Flexeril. Took a single
pill without significant somatic improvement. Since that time,
the patient states that she has had some continued pain in her
lower back, however, she has had persistent worsening of her
nausea and vomiting. She has not been able to hold anything down
in the last 2 days. She called her PCPs office and requested
they
do blood work. She had an appointment but did not go to it. She
came in today because she is having ongoing pain in her back as
well as persistent nausea and vomiting. She denies any chest
pain, shortness of breath. She denies any fevers or chills.
Denies any urinary symptoms. Denies any hematuria or
hematemesis.
She denies any Tylenol or alcohol use. She denies any history of
sickle cell crises and only has sickle cell trait. Her brother
has full sickle cell. She denies taking any other medicines.
Initial vital signs were notable for: 98.5 69 153/102 16 100% RA
Exam notable for: Gen: Scleral icterus, no acute distress, Abd:
Initially TTP in RUQ, Neuro: AAOx3. Gross sensorimotor intact
Labs were notable for:
-serum tox neg for ___, TCAs
-UA with trace protein, small bilirubin, few bacteria, rare
mucous
-Lactate neg
-Coags wnl
-BMP wnl
-CBC: Hgb 9.5
-ALT ___->1374
-AST 1823->908
-Tbili/Dbili 5.4/4.2 -> 4.1
-Alk phos 463->332
-Lipase 75
-H/H 11.4/38.1 -___
-HBsAg: negative
-HBc-Ab: negative
-HBs-Ab: positive
-HCV-Ab: negative
Studies performed include:
-RUQUS: Cholelithiasis, with mild gallbladder wall thickening
and
trace pericholecystic fluid, in the setting of mild intrahepatic
biliary dilatation, raises concern for choledocholithiasis.
-MRCP:
1. Diffuse mildly heterogeneous hepatic parenchymal enhancement
suggesting acute hepatitis.
2. Minimally dilated gallbladder with substantial wall edema but
no
pericholecystic inflammatory change most likely attributable to
underlying hepatocellular disease. No convincing evidence for
acute cholecystitis.
3. No evidence for cholangitis or choledocholithiasis.
4. Trace perihepatic ascites and small bilateral pleural
effusions.
Patient was given: 2L NS, Zosyn x2, Zofranx3, morphine 4mg IV
x1,
oxycodone 5mg x1
Consults:
Surgery: picture not consistent with cholecystitis, recommended
GI for degree of transaminitis
GI: Patient to be admitted to Medicine ___ given severe
hepatitis and potential progression to liver failure (INR
normal,
not encephalopathic per report). Cholangitis is unlikely, would
not continue pip-tazo.
-In terms of w/u: add HCV VL, HBV VL, HSV IgG/IgM and PCR, VZV
IgG/IgM and PCR, EBV Abs and PCR, CMV Abs and VL. Add ___,
anti-smooth, immunoglobulins, AMA, Fe/Ferritin/TIBC
- Add: full urine and serum tox
-HOLD cyclobenzaprine (only new drug as far as we know_
Vitals on transfer: T 98.2, BP 113/73, HR 68, RR 18, 96% RA
Upon arrival to the floor, patient says she feels fine. She
states that her back pain for which she saw urgent care on
___
for started last ___. It is on the lower left side of her
back
and moves around to the front. She tried a
massage/ice/Tylenol/ibuprofen for it last week, which all did
not
help. She took cyclobenzaprine for it ___ night (what she was
given to her by urgent care). ___ she started feeling dizzy,
lightheaded, and had some nausea/vomiting. ___ afternoon,
she states she started feeling weird, had some more
nausea/vomiting, and her urine got really dark. She did not take
cyclobenzaprine other than ___ night. She denies taking any
other medications other than her levothyroxine occasionally
(does
not take it regularly), and she denies taking any herbal
supplements, dietary supplements, or other over the counter
medications. She states she eats healthy and exercises, and she
rarely drinks alcohol. She denies fevers/chills or any other
sign
of infection. She has had no difficulty breathing, no weight
loss, no malaise, no recent travel (went to ___ over the summer), no muscle pain or weakness.
Of note, she states she has never had a sickle cell crisis
before; however, she does endorse scleral icterus that lasts a
few days when she gets dehydrated.
Past Medical History:
Sickle cell trait
Hypothyroidism
Social History:
___
Family History:
-Brother: sickle cell disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 98.2, BP 113/73, HR 68, RR 18, 96% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Scleral icterus b/l. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Bibasilar rales. No wheezes, rhonchi. No increased work
of
breathing.
BACK: No spinous process tenderness. No CVA tenderness. Left
lower back slightly tender to palpation.
ABDOMEN: Normal bowels sounds, non distended, RUQ TTP.
Hepatomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEURO: A+O x3.
DISCHARGE PHYSICAL EXAM:
98.3 ___ 18 95% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Very mild scleral icterus b/l. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: CTA b/l No wheezes, rhonchi. No increased work of
breathing.
BACK: No spinous process tenderness. No CVA tenderness. Left
lower back slightly tender to palpation.
ABDOMEN: Normal bowels sounds, non distended, RUQ TTP.
Hepatomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEURO: A+O x3. No asterixis. DOWB intact. MAEE.
Pertinent Results:
ADMISSION LABS:
___ 11:32PM BLOOD WBC-8.4 RBC-5.37* Hgb-11.4 Hct-38.1
MCV-71* MCH-21.2* MCHC-29.9* RDW-19.8* RDWSD-48.9* Plt ___
___ 03:52AM BLOOD ___ PTT-27.3 ___
___ 11:32PM BLOOD Glucose-118* UreaN-8 Creat-0.7 Na-136
K-4.4 Cl-96 HCO3-25 AnGap-15
___ 11:32PM BLOOD ALT-2077* AST-1823* AlkPhos-463*
TotBili-5.4* DirBili-4.2* IndBili-1.2
___ 11:32PM BLOOD Lipase-75*
___ 11:32PM BLOOD calTIBC-562* Hapto-218* Ferritn-42
TRF-432*
___ 07:20AM BLOOD TSH-7.7*
___ 07:20AM BLOOD Free T4-0.9*
___ 11:32PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG
___ 11:32PM BLOOD HCG-<5
___ 11:32PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 11:32PM BLOOD ___
___ 10:50AM BLOOD HIV Ab-NEG
___ 11:32PM BLOOD ___ Acetmnp-NEG Tricycl-NEG
___ 11:32PM BLOOD HCV Ab-NEG
DISCHARGE LABS
___ 07:20AM BLOOD WBC-5.7 RBC-4.34 Hgb-9.5* Hct-31.2*
MCV-72* MCH-21.9* MCHC-30.4* RDW-19.8* RDWSD-49.3* Plt ___
___ 07:20AM BLOOD ___ PTT-29.5 ___
___ 07:20AM BLOOD Glucose-78 UreaN-8 Creat-0.8 Na-139 K-4.3
Cl-102 HCO3-25 AnGap-12
MICRO:
BLOOD CX ___: No growth to date
Urine Culture ___: Negative
IMAGING:
RUQ U/S ___
Cholelithiasis, with mild gallbladder wall thickening and trace
pericholecystic fluid, may represent acute calculous
cholecystitis, however the gallbladder itself is not markedly
distended, and sonographic ___ sign was negative. Lack of
gallbladder distension may be secondary to an element of
underlying chronic cholecystitis. Presence of mild central
intrahepatic biliary ductal dilation also noted, for which an
MRCP is recommended for further evaluation.
MRCP ___. Diffuse mildly heterogeneous hepatic parenchymal enhancement
suggesting
hepatocellular disease or acute hepatitis in the appropriate
clinical setting.
2. Moderate gallbladder wall edema but no pericholecystic
inflammatory change most likely attributable to underlying
hepatocellular disease rather than acute cholecystitis.
Additionally, the gallbladder is only minimally distended. No
choledocholithiasis.
3. Trace perihepatic ascites and small bilateral pleural
effusions could be due to third spacing.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QPM Back pain
RX *lidocaine [Lidocaine Pain Relief] 4 % apply to back daily
Disp #*30 Patch Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
3. Levothyroxine Sodium 100 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Acute hepatitis, unspecified
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 pain and jaundice// cbd dilation? mass?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites. There is mild intrahepatic
biliary dilatation.
BILE DUCTS: There is no intrahepatic biliary dilation. The common bile duct
is not well evaluated.
GALLBLADDER: Cholelithiasis, with mild gallbladder wall thickening and trace
pericholecystic fluid. The gallbladder is not significantly distended.
Sonographic ___ test is equivocal.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 10.3 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Cholelithiasis, with mild gallbladder wall thickening and trace
pericholecystic fluid, may represent acute calculous cholecystitis, however
the gallbladder itself is not markedly distended, and sonographic ___ sign
was negative. Lack of gallbladder distension may be secondary to an element
of underlying chronic cholecystitis. Presence of mild central intrahepatic
biliary ductal dilation also noted, for which an MRCP is recommended for
further evaluation.
RECOMMENDATION(S): MRCP.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:55 am, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with new severe transaminitis, direct
hyperbilirubinemia w/ normal CBD on US, evaluate for cholangitis, evaluate for
obstructive common bile duct.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 7 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Liver gallbladder ultrasound dated ___.
FINDINGS:
Lower Thorax: There is trace pleural fluid bilaterally. There is bibasilar
atelectasis.
Liver: The liver is normal in signal intensity and morphology. There is
heterogeneous hepatic parenchymal enhancement on the early arterial phase,
normalized on subsequent post-contrast sequences. There is no suspicious
lesion. Scattered nonenhancing T2 hyperintensities are consistent with simple
cysts or biliary hamartomas. The portal and hepatic veins are patent. There
is trace perihepatic ascites.
Biliary: Gallbladder is only mildly distended and contains numerous
intraluminal stones. There is moderate gallbladder wall edema. There is no
biliary ductal dilatation and no choledocholithiasis.
Pancreas: Unremarkable.
Spleen: Unremarkable.
Adrenal Glands: Unremarkable.
Kidneys: There is no hydronephrosis. There are 2 small adjacent cysts in the
right upper pole or a single cyst with a thin septation (05:29). There is an
additional simple cyst in the right lower pole. There is no suspicious renal
lesion.
Gastrointestinal Tract: No bowel obstruction or ascites.
Lymph Nodes: No lymphadenopathy.
Vasculature: The hepatic vasculature is patent.
Osseous and Soft Tissue Structures: No suspicious osseous lesion. No focal
abnormality.
IMPRESSION:
1. Diffuse mildly heterogeneous hepatic parenchymal enhancement suggesting
hepatocellular disease or acute hepatitis in the appropriate clinical setting.
2. Moderate gallbladder wall edema but no pericholecystic inflammatory change
most likely attributable to underlying hepatocellular disease rather than
acute cholecystitis. Additionally, the gallbladder is only minimally
distended. No choledocholithiasis.
3. Trace perihepatic ascites and small bilateral pleural effusions could be
due to third spacing.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:36 am, 5 minutes after
discovery of the findings.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: Abd pain, Lower back pain
Diagnosed with Other cholangitis
temperature: 98.5
heartrate: 69.0
resprate: 16.0
o2sat: 100.0
sbp: 153.0
dbp: 102.0
level of pain: 7
level of acuity: 3.0 | ___ yo F with hx of sickle cell trait, hypothyroidism presenting
with general malaise, abdominal pain, and nausea, found to have
acute hepatitis of unclear etiology, but improving without any
targeted intervention. Patient will follow up in ___
and will have labs drawn at PCP appointment next week. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
___
Attending: ___.
Chief Complaint:
increased seizure frequency
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ woman with mild static
encephalopathy
and ___ syndrome who presents with an increased
frequency of typical events in the context of malodorous urine.
Patient's staff, ___, from the residence called to report
that patient had 3 seizures in a row yesterday, possible
"convulsive", but different than her usual seizures, with limb
jerking, repetitive speech, confusion, one of which was
prolonged, lasting 30 minutes for which she was given ativan per
seizure protocol.
Today she remains confused today with staring spells, and a foul
odor was noted with urination.
Dr. ___ to bring ___ to the ER for
continuous EEG and admission to epilepsy monitoring unit given
prolonged and possibly convulsive seizures, for seizure
evaluation and infectious, toxic/metabolic evaluation.
Briefly, ___ has a history of atypical absence seizures in
childhood with staring and unresponsiveness. She then developed
generalized tonic-clonic seizures at age ___. Her EEG showed
1.5-2.5 slow spike wave activity characteristic of
___
syndrome. Her seizure types include: 1. Drop seizures during
which she has quick head drops with rapid recovery of mental
status. 2. Staring spells with unresponsiveness. 3. Eyes
rolling followup. 4. Oral and hand automatisms with
unresponsiveness. 5. Focal facial twitching involving the right
side. 6. Generalized tonic-clonic seizure.
On ROS, patient denies headache, nausea, GI distress, vertigo,
visual changes, pain.
Past Medical History:
-___ Syndrome: Per Dr. ___, seizures
include:
1. Drop seizures during which she has head drops and these
correlated with frontal spikes.
2. Staring spells and unresponsiveness.
3. Eyes rolling up.
4. Oral and hand automatism with unresponsiveness.
5. Focal facial twitching involving the right side.
-Mental retardation: No known underlying dx per sister. She was
delayed in her walking and her speech. She is thought to
function at the level of an ___ grader. Her
neuropsychological testing in the past showed a verbal IQ of 66,
performance IQ 73, and full scale IQ of 68. She attended several
special education programs.
-COPD
-Scoliosis
-Ankle fracture s/p fixation
-Tubal ligation
-Osteoporosis
Social History:
___
Family History:
Per prior notes, little is known about the family history. There
is no information about her father. ___ is apparently one of
six children, three boys and three girls. There is a cousin with
learning disability and an uncle with behavioral problems.
According to prior notes, sister reports no family history of
seizures.
Physical Exam:
Physical Exam on Admission:
Vitals: 99.6 82 102/60 97%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was flexor bilaterally.
-Coordination: moderate low amplitude intention tremor
bilaterally, no dysdiadochokinesia noted. No dysmetria on FNF or
HKS bilaterally.
-Gait: does not walk at baseline
Physical Exam on Discharge:
T 97.9 BP 97/53 HR 74 RR 18 O2 96 RA
awake, alert, speech fluent
moves upper and lower extremities symmetrically
no pronator drift
mild postural and action tremor in upper extremities bilaterally
finger to nose intac b/l, mild ataxia on foot tapping
Pertinent Results:
Labs on Admission:
___ 11:00PM WBC-7.2 RBC-4.22 HGB-14.4 HCT-41.4 MCV-98
MCH-34.0* MCHC-34.7 RDW-12.6
___ 11:00PM PLT COUNT-172
___ 11:00PM NEUTS-34.7* LYMPHS-53.5* MONOS-7.9 EOS-2.8
BASOS-1.2
___ 11:00PM GLUCOSE-94 UREA N-18 CREAT-0.5 SODIUM-140
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-28 ANION GAP-12
___ 11:12PM LACTATE-0.6
___ 11:00PM LIPASE-36
___ 11:00PM ALBUMIN-3.9
___ 11:00PM VALPROATE-69
___ 12:33PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:33PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
Microbiology:
Urine culture- neg
Studies:
Chest xray ___ evidence of acute cardiopulmonary process.
EEG ___
This is an abnormal extended routine EEG due to the presence of
bursts of generalized spike and wave or sharp and slow wave
discharges at
___ Hz without any clear clinical correlate. Independent focal
epileptiform discharges are also seen in the frontal and
temporal regions
bilaterally. These findings indicate generalized and focal
cortical
irritability. There are no clear electrographic or clinical
seizures
EEG ___
This is an abnormal extended routine EEG due to the presence of
bursts of generalized spike and wave or sharp and slow wave
discharges at
___ Hz. One of the runs shows brief head drop on video but rest
without any clear clinical correlate. Independent focal
epileptiform discharges are also seen in the frontal and
temporal regions bilaterally. These findings indicate
generalized and focal cortical irritability.
EEG ___
This is an abnormal continuous EEG monitoring study due to the
presence of bursts of generalized spike and wave or sharp and
slow wave
discharges at ___ Hz. Few of the runs show brief head drop on
video but most had no clear clinical correlate. Independent
focal epileptiform discharges are also seen in the frontal and
temporal regions bilaterally. These findings indicate
generalized and focal cortical irritability.
Medications on Admission:
Depakote ER 750/500 mg b.i.d.,
Felbatol 1200 mg t.i.d.,
Lyrica 100/150 mg b.i.d.,
oxcarbazepine 600 mg b.i.d.,
banzel 800 mg b.i.d.,
lorazepam as needed for seizures,
Tylenol with Codeine as needed for back pain,
alendronate 70 mg weekly,
fexofenadine 60 mg b.i.d.,
fluticasone,
Advair Diskus, Combivent,
Singulair,
triple-antibiotic treatment,
calcium, vitamin D,
milk of magnesium and MiraLax.
Discharge Medications:
1. Divalproex (EXTended Release) 750 mg PO QAM
2. Divalproex (EXTended Release) 500 mg PO QPM
3. felbamate *NF* 1200 mg ORAL TID Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
4. Pregabalin 100 mg PO QAM
5. Pregabalin 150 mg PO QPM
6. Rufinamide 400 mg PO BID
RX *rufinamide [Banzel] 400 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
7. Oxcarbazepine 600 mg PO BID
8. Fexofenadine 60 mg PO BID
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Montelukast Sodium 10 mg PO DAILY
12. Lorazepam 2 mg PO AS BELOW
1 tab sz >5 min, or 7+ head drops in 2 hs; or a GTCstaring
spell> 5 min Max 4mg in 12 hours
13. Alendronate Sodium 70 mg PO Q WEEKLY
14. Calcium Carbonate 0 mg PO Frequency is Unknown
15. Vitamin D 0 UNIT PO DAILY
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Clobazam 5 mg PO HS
RX *clobazam [Onfi] 5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
___ Gastaut Syndrome
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: ___ female with ___ syndrome, now presenting
with confusion and more severe seizures for the last two days. Evaluate.
COMPARISON: Multiple prior chest radiographs, most recent on ___.
TECHNIQUE: Frontal upright and lateral chest radiograph.
FINDINGS: A generator is again noted in the left mid hemithorax, with leads
ending in the supraclavicular region in the left side of the neck. Otherwise,
the lungs are well expanded without focal lesions. Cardiomediastinal and
hilar contours are unremarkable. There is no pleural effusion or
pneumothorax.
IMPRESSION: No evidence of acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SZ
Diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY
temperature: 99.6
heartrate: 82.0
resprate: nan
o2sat: 97.0
sbp: 102.0
dbp: 60.0
level of pain: 0
level of acuity: 3.0 | ___ woman with mild static encephalopathy and
___ syndrome who presents with an increased frequency
seizures with slightly different semiology.
# Neuro: Patient was admitted for infectious workup for seizure
trigger and continuous EEG monitoring. She did not have a
leukocytosis, urine analysis and urine culture were neg for
infection, and chest xray did not show a pneumonia. She
remained afebrile. No evidence of Bartholin cyst. Valproic acid
level was therapeutic at 69 on admission. Ms. ___ was
monitored on EEG which showed one electrographic seizure-
appeared to be a drop attack. EEG otherwise showed brief runs of
___ spike and wave discharges, generally during
sleep/drowsiness without a clinical correlate. Decreased
Rufinamide from 800mg bid to ___ bid with plans to continue
taper as outpatient. Started Clobazam 5mg ___ increase to
5mg bid in 1 week, goal dose 20mg bid.
Patient may resume all previous medications with changes noted
in page 1. |