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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
breakthrough seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: (obtained through her daughter on the phone and ___
interpreter)
The pt is a ___ with intractable seizures who presents with a
seizure episode.
She has otherwise been in her usual state of health until a
seizure episode in the late afternoon of which we know about
only
by second hand report. She in fact had spent most of the day
with
her daughter who noted nothing unusual during her visit. Prior
to
leaving the patient did report feeling slightly odd and
expressed
a concern that she might have a seizure. Her daughter left
around
5pm.
Shortly thereafter, the patient was with a friend and was
observed to "zone out" - which is similar to prior descriptions
of her seizure semiology. There were no reports of abnormal
movements but she was slightly confused and somewhat
"post-ictal"
by EMS report. By the time of her arrival in the ED she had
essentially returned to baseline. Then at 5:50pm another event
was witnessed whereby she "stopped responding to voice, had
mouth
movements, put her hand at her forehead and wouldn't put it
down.
When this ended, she was confused for a few minutes, then had
coarse generalized shaking tremor but was mentally alert and
responsive". Seizure broke without rescue medication.
Over the past several months, her seizures have become more
difficult to control and in the past have typically clustered
around her menses but lately have seemed not to be correlated to
her menses. She has had difficulties with medication compliance
in the past but claims good compliance lately.
Of note, she was seen at her PCP's office for ear pain and was
given a Z-pack for possible bacteral URI. She does not remember
taking this medication earlier in the month however.
She has ileostomy (and recently met with surgeon to discuss
takedown) but has had weight loss. She reports good oral intake
and no changes in her ostomy output.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Seizure disorder ___ neurocysticercosis,
Medically refractory UC
Internal hemorrhoids
Laparoscopic TAC/ileostomy ___ ___
Lap converted to open proctectomy with IPAA via stapled
anastomosis (___)
Ileostomy takedown ___ ___
Exploratory laparotomy
Resection of ileostomy takedown site
Cholecystectomy
Ileostomy ___ ___
Social History:
___
Family History:
- No history of seizures.
- No history of IBD.
- Sister has chronic abdominal pain and hemorrhoids.
Physical Exam:
Physical Exam:
Vitals: 97.3 60 126/75 22 100% ra
General: Awake, cooperative, NAD.
HEENT: mild right sided periauricular pain to palpation, no
masses, 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. ilostomy clear and intact
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, 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.
Pertinent Results:
___ 06:16PM GLUCOSE-106* UREA N-7 CREAT-0.7 SODIUM-139
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-30 ANION GAP-14
___ 06:16PM MAGNESIUM-1.9
___ 06:16PM CARBAMZPN-5.2
___ 06:16PM WBC-5.6 RBC-4.97 HGB-11.8* HCT-37.2 MCV-75*
MCH-23.6* MCHC-31.6 RDW-14.7
___ 05:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
Medications on Admission:
BENZONATATE - benzonatate 200 mg capsule. 1 capsule(s) by mouth
twice a day as needed cough
CARBAMAZEPINE - carbamazepine ER 300 mg capsule,extended release
mphase12hr. 5 capsule(s) by mouth once a day take 2 tabs in AM
and 3 tabs in ___
FLUOXETINE - fluoxetine 20 mg capsule. 1 Capsule(s) by mouth
once
a day for depression
LAMOTRIGINE [LAMICTAL ODT] - Lamictal ODT 100 mg disintegrating
tablet. 1 tablet,disintegrating(s) by mouth in am and 2 in pm -
WAS NOT TAKING!
LEVETIRACETAM - levetiracetam 500 mg tablet. 5 tablet(s) by
mouth
once a day
LOPERAMIDE - loperamide 2 mg capsule. ___ Capsule(s) by mouth
twice a day as needed for loose stools
CALCIUM CARBONATE-VITAMIN D3 - calcium carbonate-vitamin D3 500
mg (1,250 mg)-400 unit tablet. 1 Tablet(s) by mouth once a day
FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1
Tablet(s) by mouth twice a day on an empty stomach iron for
blood
MULTIVITAMIN - multivitamin tablet. ___ Tablet(s) by
mouth
once a day
PEG 400-PROPYLENE GLYCOL [LUBRICANT EYE (PEG-PEG 400)] -
Lubricant Eye (PEG-PEG 400) 0.4 %-0.3 % Drops. 1 drop(s) each
eye
three times a day
Discharge Medications:
1. Ferrous Sulfate 325 mg PO BID
2. LeVETiracetam 2500 mg PO DAILY
1000mg qAM and 1500mg qPM
3. Multivitamins 1 TAB PO DAILY
4. Fluoxetine 20 mg PO DAILY
5. Artificial Tears ___ DROP BOTH EYES TID
6. Carbamazepine (Extended-Release) 600 mg PO QAM
7. Carbamazepine (Extended-Release) 900 mg PO QPM
8. LaMOTrigine 25 mg PO BID SEE TAPER SCHEDULE IN OMR
RX *lamotrigine 25 mg ___ tablet(s) by mouth twice daily Disp
#*200 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Breakthrough seizures in the setting of not taking Lamictal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest, AP upright portable view.
CLINICAL INFORMATION: Increased seizure frequency.
___.
TECHNIQUE: Single AP upright portable view of the chest.
FINDINGS: Slight left base opacity is felt to most likely be due to
atelectasis and overlying nipple shadow, however, findings can be better
evaluated on dedicated PA and lateral views. The right lung is clear. No
definite pleural effusion is seen. There is no evidence of pneumothorax. The
cardiac and mediastinal silhouettes are unremarkable. There is no pulmonary
edema.
IMPRESSION: Slight increase in opacity at the lateral left lung base may be
due to atelectasis and overlying nipple shadow. This could be further
evaluated with dedicated PA and lateral views.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY, ABDOMINAL PAIN OTHER SPECIED
temperature: 97.3
heartrate: 60.0
resprate: 22.0
o2sat: 100.0
sbp: 126.0
dbp: 75.0
level of pain: 13
level of acuity: 3.0 | Admitted for breakthrough seizures, infectious workup negative.
Patient then told us on HD#2 that she hadn't been taking
lamictal for 1 month because it was denied by her insurance last
month. This didn't make sense to us because she had been taking
it for 3 months, but we called her pharmacy and it appears that
she was originally given 2 months presciption for genetic
lamotrigine but had it refilled by another provider who wrote
for brand name ___, which was rejected by insurance.
Patient did not inform us of this problem but just stopped
taking it, which is almost certainly why she had breakthrough
seizures. We verified with her pharmacy that her insurance
would cover genetic lamotrigine, so we wrote her a prescription
for this with an increasing taper since she had been off it for
almost a month. Her daughter was explained the taper schedule
and she will help her mother adhere to this. She was discharged
home on HD#2 in good condition with her neurologic exam at
baseline. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tobramycin / Bactrim
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ congenital Bronchopulmonary dysplasia s/p chronic
tracheostomy, laryngeal stenosis and chronic bronchitis p/w 1
weeks of chest pain, thick green secretions w/ blood clots from
trach over past week, nasal congestion, sore throat, general
myalgias. Increased suctioning (5x per day vs normal 1).
+chills, no documented fevers. Intermittent dizziness,
lightheaded. Nephew w/ cough and URI symptoms. Chest congestion.
+nausea, no emesis/diarrhea. No travel. No recent surgeries, no
h/o blood clots. Decreased urination ___ decreased PO intake.
Took nyquil and oxycodone for throat pain at home w/ no
improvement.
States that her symptoms feel similar to prior admission, but
more severe than past tracheitis. Last admitted ___ with
similar symptoms. In the ED, initial vitals were 97.8 102 118/62
18 100% RA initially, but progessed with hypoxia to 70-80s with
? plugging event. got mucomyst, suctioned in ___, was placed on
continuous nebs. On transfer, vitals were: 77 100/51 18 100% RA
On arrival to the MICU, without respiratory distress, able to
talk without desaturation, on 9LPM trach mask.
Past Medical History:
- Tracheabronchomalacia ___ premature birth at 26 weeks, s/p 4
airway reconstructions, last at age ___, tracheostomy at age ___
months
- Bronchopulmonary dysplasia
- Chronic bronchitis and tracheitis
- Laryngeal and tracheal stenosis
- Asthma
- GERD
- s/p lysis of the supraglottic stenosis by ENT, ___
- s/p ___ in trach ___
Social History:
___
Family History:
Father with history of DM. PGF with bone cancer, MGM with breast
cancer at a young age.
Physical Exam:
Admit PHYSICAL EXAM:
Vitals- T: 98.6 BP: 101/45 P:92 R: 18 O2: 100% 9LPM humidified
trach mask
GENERAL: Alert, oriented, no distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD, tracheostomy in place
LUNGS: transmitted sounds 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: intact
NEURO: A&Ox3, MAES, appropriate
DISCHARGE PHYSICAL EXAM
Vitals: afebrile 98.5 114/64 HR 71 100% on TM
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, trach in place
Lungs: breathing comfortably. clear to auscultation bilaterally,
no wheezes, rales, ronchi
CV: mildly tachycardic but regular, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMIT LABS
___ 11:03AM BLOOD WBC-6.7 RBC-4.65 Hgb-11.7* Hct-36.3
MCV-78* MCH-25.1* MCHC-32.1 RDW-18.0* Plt ___
___ 11:03AM BLOOD Neuts-60.2 ___ Monos-6.7 Eos-1.9
Baso-0.1
___ 11:03AM BLOOD Plt ___
___ 11:03AM BLOOD Glucose-73 UreaN-15 Creat-0.7 Na-136
K-4.3 Cl-107 HCO3-22 AnGap-11
___ 03:37AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.9
___ 11:13AM BLOOD Lactate-0.8
DISCHARGE LABS
___ 06:00AM BLOOD WBC-6.0 RBC-4.02* Hgb-10.7* Hct-32.4*
MCV-81* MCH-26.6* MCHC-33.0 RDW-18.2* Plt ___
___ 12:21PM BLOOD Glucose-72 UreaN-8 Creat-0.7 Na-136 K-4.1
Cl-105 HCO3-23 AnGap-12
IMAGING
CXR ___
IMPRESSION:
No acute cardiopulmonary abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH BID:PRN dyspnea
3. Amikacin Inhalation 500 mg IH BID
4. budesonide 0.5 mg/2 mL inhalation bid
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Hyper-Sal (sodium chloride) 3 % inhalation BID
8. Ipratropium Bromide Neb 1 NEB IH Q8H:PRN dyspnea
9. Loratadine 10 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
12. Ranitidine 150 mg PO DAILY
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH BID:PRN dyspnea
3. Amikacin Inhalation 500 mg IH BID
4. budesonide 0.5 mg/2 mL inhalation bid
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Ipratropium Bromide Neb 1 NEB IH Q8H:PRN dyspnea
8. Loratadine 10 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
11. Ranitidine 150 mg PO DAILY
12. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times daily
Disp #*90 Capsule Refills:*5
13. Guaifenesin ER 1200 mg PO Q12H
RX *guaifenesin 600 mg 2 tablet(s) by mouth twice daily Disp
#*56 Tablet Refills:*0
14. Hyper-Sal (sodium chloride) 3 % inhalation BID
15. Naproxen 500 mg PO Q12H:PRN chest pain
take with food; stop taking if belly pain or stool changes
RX *naproxen 500 mg 1 tablet(s) by mouth twice daily Disp #*30
Tablet Refills:*0
16. Acetylcysteine Inhaled For interventional pulmonary use
only 4 mL NEB Q6H
RX *acetylcysteine 100 mg/mL (10 %) three times a day Disp #*2
Vial Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Tracheitis, acute
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with concern for pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Left-sided Port-A-Cath tip terminates in the proximal right atrium. Heart size
is normal. Mediastinal and hilar contours are unremarkable. Tracheostomy tube
tip is in unchanged position. Pulmonary vasculature is normal. Lungs are
clear. No focal consolidation, pleural effusion or pneumothorax is
identified. There is no acute osseous abnormality pattern
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with congenital bronchopulmonary dysplasia,
chronic tracheostomy admitted for ? tracheitis // evaluate for interval
change
TECHNIQUE: Portable AP radiographs of the chest from ___. .
COMPARISON: ___.
FINDINGS:
The tip of an accessed left pectoral MediPort extends into the right atrium.
Lung volumes are low, but the lungs are grossly clear. The trachea is midline
with tracheostomy tube in place. Assessment for tracheitis would be more
appropriate with cross-sectional imaging. There is no pneumothorax. The heart
and mediastinum are within normal limits despite the projection. There is
unchanged interposition of the colon under the diaphragm.
IMPRESSION:
No change from the study of 1 day prior.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Sore throat, Chest pain, Dyspnea
Diagnosed with AC TRACHEITIS NO OBSTRUC
temperature: 97.8
heartrate: 102.0
resprate: 18.0
o2sat: 100.0
sbp: 118.0
dbp: 62.0
level of pain: 2
level of acuity: 2.0 | ___ congenital Bronchopulmonary dysplasia s/p chronic
tracheostomy, laryngeal stenosis and chronic bronchitis p/w 1
weeks of chest pain, thick green secretions from trach
suspicious for recurrent tracheitis with transient hypoxia.
#?Tracheitis, acute- Increased sputum production, blood clots
from trach suggested tracheitis. Mucus plugged in ED causing
transient hyoxia, so was monitored on trach mask in ICU
overnight, quickly transitioned to RA and called out. CXR
negative for pneumonia. Initially started on cefepime/azithro;
however, per review of pulm and ID notes, avoidance of
antibiotics if possible is desireable given her tendency towards
resistant organisms. She looked clinically well. Antibiotics
were stopped. She received mucomyst nebs with improvement in
symptoms and was discharged.
CHRONIC ISSUES
#Bronchopulmonary dysplasia/tracheal stenosis: Continued inhaled
amikacin, budesonide, ipratropium.
#GERD: Continued home PPI.
TRANSITIONAL ISSUES
None. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
heparin (porcine)
Attending: ___.
Chief Complaint:
Thrombosed fistula.
Major Surgical or Invasive Procedure:
___ thrombolysis of femoral fistula ___
History of Present Illness:
___ incarcerated male with PMH of ESRD on HD ___
hypertension and COPD who presented with a clotted right femoral
fistula.
The patient last had HD on ___ (four days prior to
presentation); it was then noted to be clotted with attempt for
repair in the ___ Procedural Center with thrombectomy. However,
this was unsuccessful and he was then referred to the ED for ___
repair on ___. He has been hypertensive throughout the day in
the ___ however he has no other complaints. He
denies headache, vision changes, chest pain, shortness of
breath, abdominal pain, vomiting.
His ED course was complicated by hyperkalemia as high as 7.7 and
he received insulin/dextrose/albuterol/calcium gluconate. There
were not peaked T waves on EKG.
- In the ED, initial vitals were: 97.6 59 188/94 18 99% RA
- Exam was notable for:
General- NAD
HEENT- PERRL, EOMI, normal oropharynx
Lungs- Non-labored breathing, CTAB
CV- RRR, no murmurs, normal S1, S2, no S3/S4, clotted fistula
noted in the right groin
Abd- Soft, nontender, nondistended, no guarding, rebound or
masses
Msk- No spine tenderness, moving all 4 extremities
Neuro-A&O x3, CN ___ intact, normal strength and sensation in
all extremities, normal speech and gait.
Ext- No edema, cyanosis, or clubbing
- Labs were notable for:
K 7.7 --> 6.6 --> 6.9 --> 5.0
6.3< 11.4/35.5 < 79
- Studies were notable for:
CXR:
Mild hilar congestion. Small metallic densities projecting over
the left axilla may be external versus tiny foreign bodies.
- Patient was given:
Dextrose 50% 25 gm
IV Calcium Gluconate
IV Insulin (Regular) for Hyperkalemia 10 units
IV Calcium Gluconate 1 g ___ Stopped (___)
IV Dextrose 50% 25 gm
IV Hydralazine
On arrival to the floor, the patient reports feeling well with
no complaints of chest pain, headache, shortness of breath,
visual changes, abdominal pain.
****Past medical history was through patient and not confirmed
with medical records. He does not know any of his medications.
Prison guards gave me number to prison (___) and ask to
be directed to clinic. They open at 8 AM. His medications were
inserted into OMR but with no dosages***
Past Medical History:
ESRD on HD ___ to hypertension. Has been on HD for ___ years
Emphysema
Surgery for gunshot wound.
Patient has had two AV fistulas that failed. Has right femoral
AV
fistula for access currently
HIT? (according to allergy record)
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION
=========
VITALS: 97.6 PO 193 / 95 R Lying 68 18 98 Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Soft, NT, ND. Has surgical scar
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+ bilaterally. Right femoral fistula with bandage c/d/I over
site. No thrill palpated. Has two failed AV fistulas on his
right and left upper extremity with no thrill.
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE
=========
VITALS:
24 HR Data (last updated ___ @ 710)
Temp: 97.4 (Tm 97.8), BP: 152/66 (125-180/62-87), HR: 81
(70-81), RR: 17 (___), O2 sat: 92% (91-97), O2 delivery: Ra
Not in room, will examine this ___.
GEN: well-appearing, receiving HD
HEENT: MMM
PULM: No increased WOB
EXT: warm
Pertinent Results:
ADMISSION
=========
___ 07:40PM PLT SMR-VERY LOW* PLT COUNT-79*
___ 07:40PM NEUTS-71.8* LYMPHS-16.9* MONOS-7.0 EOS-3.5
BASOS-0.6 IM ___ AbsNeut-4.49 AbsLymp-1.06* AbsMono-0.44
AbsEos-0.22 AbsBaso-0.04
___ 07:40PM WBC-6.3 RBC-3.56* HGB-11.4* HCT-35.5*
MCV-100* MCH-32.0 MCHC-32.1 RDW-14.1 RDWSD-51.9*
___ 07:40PM estGFR-Using this
___ 07:40PM GLUCOSE-76 UREA N-86* CREAT-14.8* SODIUM-136
POTASSIUM-8.3* CHLORIDE-93* TOTAL CO2-24 ANION GAP-19*
___ 07:44PM K+-7.7*
___ 08:17PM ___ PTT-30.0 ___
___ 08:17PM K+-6.6*
___ 10:44PM K+-6.9*
___ 11:23PM K+-5.0
IMAGING
=======
AV fistulogram ___:
Satisfactory restoration of flow following chemical and
mechanical
thrombolysis and deployment of a 9 mm x 60 cm Covera stent graft
at the venous anastomosis with a good angiographic and clinical
result.
DISCHARGE
=========
___ 07:23AM BLOOD WBC-8.6 RBC-3.01* Hgb-9.7* Hct-29.5*
MCV-98 MCH-32.2* MCHC-32.9 RDW-13.4 RDWSD-48.0* Plt Ct-86*
___ 07:23AM BLOOD Plt Ct-86*
___ 07:23AM BLOOD Glucose-83 UreaN-63* Creat-14.1*# Na-136
K-6.1* Cl-95* HCO3-26 AnGap-15
___ 07:23AM BLOOD Calcium-9.0 Phos-5.1* Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Allopurinol ___ mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. CARVedilol 6.25 mg PO BID
6. Doxercalciferol 4 mcg IV 3X/WEEK (___)
7. Epoetin Alfa Dose is Unknown IV Frequency is Unknown
8. Ferric Gluconate 62.5 mg IV 1X/WEEK (TH)
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. mometasone-formoterol 200-5 mcg/actuation inhalation DAILY
12. sevelamer CARBONATE 2400 mg PO TID W/MEALS
13. sevelamer CARBONATE 1600 mg PO BID:PRN With snacks
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Allopurinol ___ mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. CARVedilol 6.25 mg PO BID
5. Doxercalciferol 4 mcg IV 3X/WEEK (___)
6. Epoetin Alfa 8000 UNIT IV ASDIR
7. Ferric Gluconate 62.5 mg IV 1X/WEEK (TH)
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. mometasone-formoterol 200-5 mcg/actuation inhalation DAILY
11. sevelamer CARBONATE 2400 mg PO TID W/MEALS
12. sevelamer CARBONATE 1600 mg PO BID:PRN With snacks
13. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
========
clotted arteriovenous fistula
end-stage renal disease
hyperkalemia
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 HTN, missed dialysis, sob// effusion/consolidation?
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided. Tiny metallic densities
projecting over the left axilla and left upper chest could represent imbedded
foreign bodies versus surface debris. The lungs are clear bilaterally. The
hila appear slightly congested though there is no frank edema. The heart is
normal in size. No large pleural effusion or pneumothorax is seen. Bony
structures are intact. Mediastinal contour is normal.
IMPRESSION:
Mild hilar congestion. Small metallic densities projecting over the left
axilla may be external versus tiny foreign bodies.
Radiology Report
INDICATION: ___ year old man with clotted groin AV fistula// clotted fistula.
Requires temporary catheter access for hemodialysis.
COMPARISON: None
TECHNIQUE: OPERATOR: Dr. ___ radiology attending)
performed the procedure.
ANESTHESIA: Procedure was performed with local 1% lidocaine only, 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: 2.9 min, 8 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right neck was prepped and draped in the
usual sterile fashion.
Ultrasound demonstrated multiple soft tissue neck collaterals, and an occluded
right internal jugular vein in it's mid portion. The caudal end of the right
internal jugular vein was visible where it entered the brachiocephalic, and
this was selected as the target. Under continuous ultrasound guidance, the
caudal end of the right internal jugular vein was accessed using a
micropuncture needle. Permanent ultrasound images were obtained before and
after intravenous access, which confirmed vein patency. Subsequently a Nitinol
wire was passed into the right atrium using fluoroscopic guidance. The needle
was exchanged for a micropuncture sheath.
The Nitinol wire was removed and a short Amplatz wire was advanced into the
IVC. Next, given extensive scar tissue, serial dilation of the tract was
required. A 20 cm trialysis triple-lumen catheter was advanced over the wire
into the superior vena cava with the tip in the cavoatrial junction. All 3
access ports were aspirated, flushed and capped. The catheter was secured to
the skin with a 0 silk suture and sterile dressings were applied. Final spot
fluoroscopic image demonstrating good alignment of the catheter and no
kinking. The patient tolerated the procedure well without immediate
complications.
FINDINGS:
1. Initial ultrasound of the right neck demonstrated complete occlusion of
the mid portion of the right internal jugular vein with only a very caudal
patent segment identified which was used for access. Multiple other
collaterals seen. External jugular vein on the right not well appreciated.
2. Initial ultrasound of the left neck demonstrated complete occlusion of the
left internal jugular vein.
IMPRESSION:
Successful placement of a temporary triple lumen trialysis catheter via the
right internal jugular venous approach. The tip of the catheter terminates in
the distal superior vena cava. The catheter is ready for use.
Radiology Report
INDICATION: ___ year old man with clotted right femoral fistula// failed
attempt in AV care
COMPARISON: None available.
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr.
___, Interventional Radiology fellow 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
125mcg of fentanyl and 2.5 mg of midazolam throughout the total intra-service
time of 135 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: 6 mg of tPA.
CONTRAST: 97 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 21.9 minutes, 207 mGy
PROCEDURE:
1. Antegrade access through graft into outflow vein.
2. 6 mg of tPA administered through AV loop graft.
3. 6 ___ Angiojet thrombolysis of AV loop graft.
4. 7 mm and 8 mm balloon plasty of the AV loop graft through antegrade access.
5. Retrograde access through AV loop graft into the inflow artery.
6. 5.5 ___ ___ balloon pull-through from arterial anastomosis into
outflow vein.
7. 6 mm and 7 mm balloon plasty of the AV loop graft through retrograde
access.
8. 5.5 ___ ___ balloon push through from antegrade access into outflow
vein.
9. 8 mm balloon plasty of focal stenoses of AV loop graft through retrograde
access.
10. Placement of a 9 mm x 60 cm Covera stent graft at the venous anastomosis
with subsequent balloon dilatation using a 9 mm balloon.
11. Right groin AV loop graft fistulagram.
PROCEDURE DETAILS:
Written informed consent was obtained from the patient outlining the risks,
benefits and alternatives to the procedure. The patient was then brought to
the angiography suite and placed supine on the image table with the upper
extremity abducted and stabilized.
Clinical examination demonstrated a palpable, but completely thrombosed graft
in the right groin. Further evaluation by targeted ultrasound demonstrated a
completely thrombosed graft extending into the outflow vein. The right groin
was prepped and draped in the usual sterile fashion.
A preprocedure timeout was performed as per ___ protocol.
Using ultrasound and fluoroscopy, the arterial inflow and outflow stent levels
were identified and the skin was marked with a skin marker. Antegrade
(directed towards the venous outflow) access into the thrombosed graft was
obtained under continuous ultrasound guidance using a 21G micropuncture
needle. Permanent ultrasound images were saved. An 0.018 wire was then
advanced easily into the outflow vein under fluoroscopic guidance. A 4.5F
micropuncture sheath was advanced and used to exchange for an 0.035 Glidewire.
A short 6 ___ sheath was placed over the wire. A ___ Kumpe catheter was then
advanced over the wire and slowly withdrawn while injecting dilute contrast to
establish the distal extent of thrombus into the outflow vein. The Kumpe
catheter was advanced to the venous anastomosis. The Glidewire was removed
and 6 mg of tPA diluted to 20 cc was administered through the Kumpe catheter
as it was pulled back to the antegrade access. The Kumpe catheter was
re-advanced into the loop graft and an Amplatz wire was advanced through the
Kumpe catheter into the outflow vein. The Kumpe catheter was removed. A 6
___ Angiojet catheter was advanced over the wire to the venous anastomosis.
The Angiojet catheter was turned on, placed on power pulse mode, as it was
pulled and advanced the entire length of the loop graft three balloons. The
Angiojet catheter was removed over the wire.
Next, a 7 mm Conquest balloon was advanced over the wire through the
retrograde access and balloon plasty of the entire loop graft was performed.
Antegrade (directed towards the venous outflow) access into the thrombosed
graft was obtained under continuous ultrasound guidance using a 21G
micropuncture needle. Permanent ultrasound images were saved. An 0.018 wire
was then advanced easily into the outflow vein under fluoroscopic guidance. A
4.5F micropuncture sheath was advanced and used to exchange for an 0.035
Glidewire. The Glidewire was advanced into the inflow artery. A Kumpe
catheter was advanced over the Glidewire and the Glidewire was exchanged for a
___ wire which was advanced into the inflow artery. A 5.5 ___ ___
balloon was advanced over the ___ wire into the arterial anastomosis.
Pull-through of the dilated fluid balloon was performed into the outflow vein.
Digital subtraction AV graft fistulogram demonstrated restoration of flow but
multiple areas of stenosis in the graft. In addition, there were two areas of
aneurysmal dilation in the graft. Next, a 6 mm Mustang balloon was advanced
over the retrograde axis and angioplasty was performed along the half of the
loop graft closer to the arterial anastomosis. An 8 mm Conquest balloon was
advanced over the wire through the retrograde access and balloon plasty of
more focal areas of persistent stenosis in the loop graft was performed.
Digital subtraction AV graft fistulogram through multiple obliquities
demonstrated persistent stenosis at the venous anastomosis. The 8 mm Conquest
balloon was removed over the wire from the retrograde access. The 6 ___
sheath was exchanged over the wire for a 9 ___ sheath. A 9 mm x 60 cm
Covera stent graft was advanced over the wire and deployed at the venous
anastomosis. A 9 mm Conquest balloon was advanced over the wire to within the
stent and inflated to fully dilate stent. Digital subtraction AV graft
fistulogram demonstrated appropriate risk flow throughout the entire loop
graft and resolution of the area of stenosis of the venous anastomosis.
A completion fistulagram was performed demonstrated brisk flow throughout the
entire graft with no residual stenosis.
Clinical examination revealed a satisfactory thrill along the length of the
graft.
The sheaths were removed and hemostasis was achieved with two 0-silk
pursestring sutures. There were no immediate complications.
FINDINGS:
1. Complete thrombosis of the right groin AV loop graft to the level of the
outflow vein.
2. Restoration of flow but multiple areas stenosis in the loop graft after 6
mg of tPA, 6 ___ Angiojet, 6 mm balloon plasty of the loop graft through
the antegrade access, and 5.5 ___ balloon pull-through the arterial
anastomosis through the retrograde anastomosis.
3. Improvement but persistence of 2 focal areas of narrowing in the loop graft
and narrowing at the venous anastomosis after 7 mm balloon plasty of the loop
graft through the antegrade access in 6 mm balloon plasty of the loop graft
through the retrograde access.
4. Resolution of the 2 focal areas of narrowing the new graft but persistent
stenosis at the venous anastomosis after 8 mm balloon plasty through the
antegrade access.
5. Resolution of the venous outflow stenosis following deployment of a 9 mm x
60 cm Covera stent at the venous anastomosis, dilated to 9 mm with balloon.
6. Completion fistulogram demonstrated brisk flow throughout the entire graft.
IMPRESSION:
Satisfactory restoration of flow following chemical and mechanical
thrombolysis and deployment of a 9 mm x 60 cm Covera stent graft at the venous
anastomosis with a good angiographic and clinical result.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Clotted graft
Diagnosed with Hyperkalemia
temperature: 97.6
heartrate: 59.0
resprate: 18.0
o2sat: 99.0
sbp: 188.0
dbp: 94.0
level of pain: 0
level of acuity: 3.0 | TRANSITIONAL ISSUES:
====================
[] The dressing on his neck from his temporary HD line should
remain in place until ___, after which it should be removed.
[] He should continue intermittent HD on a ___ schedule.
[] Monitor BP and adjust meds as needed. He is being discharged
on his home BP meds, though needed higher doses while in-house
due to missed HD. Please check his BP every few days to make
sure he remains normotensive. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Transvenous biopsy of IVC Mass
History of Present Illness:
Ms. ___ is a ___ year old female with minimal past medical
history who presents for abdominal pain. Patient noticed sudden
onset of right sided flank/abdominal pain 10 days PTA. Denies
any association with food. Initially thought she was
constipated however has had normal bowel movements after using
laxatives with no improvement in pain. pain described as
crampy, no radiation, no positional variation. No dyspnea on
exertion. Denies any recent immobilzation. Has no history of
pain similar to this.
While patient was down in the ED, she had a CT abd/pelvis which
showed large mass arising from IVC near porta hepatis-> IVC
clot vs. mesenchymal tumor. Vascular surgery saw the patient
and recommended admission to medicine as well as an MRV to
further clarify the etiology of the mass. A read on the MRV is
still pending.
Patients labs in the ED were unremarkable, including a normal
lactate, UA. Pelvic exam was wnl.
On the floor, vs were: 97.7 128/72 57 18 100RA. Patient's pain
was controlled with Morphine sulfate IV and patient was made NPO
for possible procedure while MRV was pending.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Ten point review of
systems is otherwise negative.
Past Medical History:
morbid obesity
migraine headaches occasionally
tendinitis in her ankles
Social History:
___
Family History:
no known history of blood clots or cancers
Physical Exam:
ADMISSION:
Vitals: 97.7 128/72 57 18 100RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender to palpation, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: dry, no erythema or rashes
DISCHARGE:
Vitals: 98.1 110/57 62 18 100ra
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender to palpation, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: dry, no erythema or rashes
Pertinent Results:
ADMISSION:
___ 05:05PM BLOOD WBC-7.6 RBC-4.93 Hgb-13.1 Hct-40.7 MCV-83
MCH-26.6* MCHC-32.1 RDW-13.1 Plt ___
___ 05:20AM BLOOD ___ PTT-66.9* ___
___ 05:05PM BLOOD Glucose-94 UreaN-10 Creat-1.0 Na-140
K-4.8 Cl-102 HCO3-27 AnGap-16
___ 05:05PM BLOOD ALT-23 AST-28 AlkPhos-92 TotBili-0.5
___ 05:05PM BLOOD Lipase-17
___ 05:05PM BLOOD Albumin-4.3
___ 05:14PM BLOOD Lactate-1.0
DISCHARGE:
___ 07:35AM BLOOD WBC-5.7 RBC-4.58 Hgb-12.6 Hct-37.9 MCV-83
MCH-27.6 MCHC-33.3 RDW-13.2 Plt ___
___ 07:35AM BLOOD ___ PTT-32.7 ___
___ 07:35AM BLOOD Glucose-171* UreaN-12 Creat-0.9 Na-138
K-4.2 Cl-99 HCO3-28 AnGap-15
REPORTS:
TRANSVAGINAL US:
IMPRESSION:
1. Technically limited by body habitus. IUD appears in
appropriate position.
2. No fibroids, ovarian mass or cyst.
CT ABDOMEN:
IMPRESSION: Hypodense soft tissue mass at the porta hepatis of
unclear
origin, possibly arising from the caudate lobe of liver or IVC.
Differential
diagnosis includes mesenchymal tumors of the inferior vena cava
such as
leiomyosarcoma. Although unusual, a large clot within the IVC
cannot be
completely excluded with this appearance. Further assessment
with MR is
recommended for a more complete characterization.
MRV:
IMPRESSION:
1. 4.5 cm mass centered on the anterior wall of the
infrahepatic suprarenal
inferior vena cava. The anterior component of the lesion
enhances and is
suspicious for an intrinsic tumor of the wall of the inferior
vena cava such as a leiomyosarcoma. The more posterior
component of the lesion occupying the lumen of the inferior vena
cava does not enhance and is consistent with bland
thrombus and likley hemorrhage within the lesion as a portion is
extraluminal.
The inferior vena cava remains patent.
2. Bilateral simple renal cysts.
BIOPSY OF IVC MASS:
IMPRESSION:
Preliminary Report
Successful biopsy of an inferior vena cava mass, with multiple
fragments obtained and sent to pathology.
Radiology Report
CHEST CT WITH CONTRAST
INDICATION: Patient with likely leiomyosarcoma to the IVC. Evaluate for
metastasis.
COMPARISON: None.
TECHNIQUE:
Axial helical MDCT images were obtained from the suprasternal notch to the
upper abdomen with administration of IV contrast. Multiplanar reformatted
images in coronal and sagittal axis were generated.
FINDINGS:
LUNGS AND AIRWAYS:
There is no lung lesion suspicious for metastasis. Increase density of the
lung bases and atelectatic bands are probably due to insufficient inspiration.
The airways are patent until the subsegmental levels.
MEDIASTINUM:
Thyroid is unremarkable. There is no pathologic supraclavicular, mediastinal
or axillary lymph node enlargement by CT size criteria. There is no pleural
or pericardial effusion. Heart and great vessels are not dilated.
UPPER ABDOMEN: This study is not tailored for assessment for intra-abdominal
organs. Please refer to recent MRI and abdominal CT for description of the
IVC mass and kidney cyst.
OSSEOUS STRUCTURES: There is no bone lesion concerning for malignancy.
CONCLUSION:
There is no evidence of metastasis at the thoracic level.
Radiology Report
INDICATION:
___ female with IVC mass, possibly leiomyosarcoma, comes in today for
an IVC biopsy.
OPERATORS:
Dr. ___, ___ fellow and Dr. ___, ___ attending, who was
present and supervising.
ANESTHESIA:
200 mcg of fentanyl and 4 mg of Versed were used to provide conscious sedation
for this total intraservice time of 1 hour and 17 minutes during which
patient's hemodynamic parameters were continuously monitored. Additionally,
1% lidocaine was used for local anesthesia.
PROCEDURE DETAILS:
Written informed consent was obtained from the patient after explaining risks,
benefits and alternatives to the procedure. Patient was brought to the
angiography suite and placed supine on the imaging table. The right groin was
prepped and draped in the usual sterile fashion. A preprocedure timeout was
performed as per ___ protocol.
Using ultrasound and fluoroscopic guidance, the right common femoral vein was
punctured with a micropuncture needle and subsequently a 0.018 nitinol wire
was advanced under fluoroscopy. The needle was exchanged for a micropuncture
sheath and the wire upsized for ___ wire and subsequently a 7 ___
35-cm ___ Tip sheath was advanced over the wire up to the level of the iliac
bifurcation. Following, an Omniflush catheter was navigated into the inferior
part of the inferior vena cava, and a digital subtraction venogram was
obtained. The venogram demonstrated a large round filling defect of the
inferior vena cava at the level of T12, which in conjunction with the prior CT
imaging, most likely represents the mass. Based on these findings, decision
was made to obtain fragments for biopsy.
Following, the sheath was advanced up to the level of the mass and a radial
jaw was used to attempt to biopsy the lesion. However, due to lack of
steerability of the radial jaw, this maneuver was difficult. So following,
the sheath was exchanged for a steerable morph sheath 6 ___ catheter, and
the radial jaw was readvanced to the level of the mass. Multiple fragments
were obtained and sent to pathology. Following, all catheters and wires were
removed, and the 6 ___ morph sheath was also removed. 10 minutes of manual
compression were used to achieve hemostasis. Patient tolerated the procedure
well without immediate complications.
IMPRESSION:
Successful biopsy of an inferior vena cava mass, with multiple fragments
obtained and sent to pathology.
Radiology Report
HISTORY: Mid abdominal pain, CT abdomen pelvis with query mass arising from
the IVC at the porta hepatis. Further characterization.
TECHNIQUE: Multiplanar T1 and T2 weighted imaging was obtained on a 1.5 T
magnet, including dynamic 3D imaging obtained prior to, during and subsequent
to the intravenous administration of 0.1 mmol/kg of Gadavist (14 ml).
Unfortunately the patient developed nausea and vomiting at the end of the
study and was unable to complete the last 2 phases of post contrast imaging.
COMPARISON: CT ___.
FINDINGS:
The liver is of normal signal and morphology on T1 and T2 weighted imaging.
No signal drop-off on out of phase imaging when compared to in phase T1
weighted imaging to indicate significant fatty deposition. No intra or
extrahepatic biliary dilatation. The gallbladder is unremarkable. No
gallstones.
There is a 4.5 cm (anteroposterior) x 3.7 cm (transverse) x 3.6 cm
(craniocaudal) lesion centered within the infrahepatic suprarenal inferior
vena cava. The lesion is centered on the anterior wall of the vessel and
appears separate from the adjacent duodenum, pancreatic head and caudate lobe
of the liver. The lesion appears to have 2 separate components. The anterior
component appears slightly less T2 hyperintense and demonstrates some
enhancement (however this is limited by the lack of delayed phase imaging and
motion artifact). The posterior component which lies within the lumen of the
inferior vena cava does not enhance and is slightly more T2 hyperintense,
either representing adjacent thrombus or hemorrhage/necrosis within the
lesion. The IVC is expanded but remains patent. The lesion extends
superiorly to just below the intrahepatic IVC, lying 4.5 cm below the hepatic
vein/IVC confluence. The hepatic and portal venous systems are patent. It
extends inferiorly to just above the level of the left renal vein. The renal
veins are patent.
The pancreas is of normal signal and morphology. No focal pancreatic lesion
or pancreatic duct dilatation. Normal appearance of the spleen.
No adrenal lesion. The kidneys enhance symmetrically. There are bilateral T2
hyperintense nonenhancing lesions within both kidneys compatible with simple
cysts. No suspicious renal lesion.
Normal appearance of the visualized small and large bowel. No upper abdominal
or retroperitoneal lymphadenopathy. No free fluid.
The visualized lung bases are unremarkable. No abnormal signal within the
visualized skeletal system.
IMPRESSION:
1. 4.5 cm mass centered on the anterior wall of the infrahepatic suprarenal
inferior vena cava. The anterior component of the lesion enhances and is
suspicious for an intrinsic tumor of the wall of the inferior vena cava such
as a leiomyosarcoma. The more posterior component of the lesion occupying the
lumen of the inferior vena cava does not enhance and is consistent with bland
thrombus and likley hemorrhage within the lesion as a portion is extraluminal.
The inferior vena cava remains patent.
2. Bilateral simple renal cysts.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN RLQ
temperature: 97.8
heartrate: 74.0
resprate: 14.0
o2sat: 98.0
sbp: 139.0
dbp: 92.0
level of pain: 8
level of acuity: 3.0 | ___ without sig PMH presents with abdominal pain, found to have
irregular mass of the IVC concerning for leiomyosarcoma.
# Abdominal pain/irregular mass/mesenchymal tumor of the IVC: Pt
presented w/ 10 days of R sided abdominal pain. Seen in ED and
CT scan performed with follow up MRV showing mass of IVC with
partial thrombus in IVC. Vascular surgery and transplant
surgery were consulted, as well as oncology. After speaking
with Dr. ___ was made to pursue biopsy of
presumed leiomyosarcoma given that pre-operative radiation would
be beneficial if it were high grade. Biopsy of IVC mass was
performed on ___ without incident and sent to pathology.
Patient has follow up appointments with Dr. ___ Dr.
___ as an outpatient. Pathology specimens were verified via
telephone to be in the pathology department to be logged.
-f/u with Dr. ___ Dr. ___ as an outpatient
-oxycodone PRN for pain
#IVC Thrombus: likely in setting of hypercoaguable state from
malignancy as well as local endothelial dysfunction from mass.
patient initially maintained on heparin drip IV via weight based
protocol. Patient tolerated this well. After biopsy, she was
watched overnight and switched to enoxoparin in the AM (150mg SC
BID). She should continue this until directed by her surgeon to
discontinue prior to surgery.
-Continue lovenox ___ SC BID |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
b/l leg swelling
Major Surgical or Invasive Procedure:
Paracentesis ___
History of Present Illness:
___ year old man with Hep B/C cirrhosis who p/w worsening leg
swelling. Edema has been worsening over the past several weeks.
His lasix dose was increased to 160mg daily (from 120mg daily)
yesterday per liver clinic NP instruction. Today on awakening,
his edema extended to mid-thigh prompting him to come to the ED.
Denies fevers, chills, chest pain, or SOB. Occasionally coughs
up trace amt blood. Has chronic mild abdominal discomfort which
is unchanged, no N/V. Had watery diarrhea several days ago (up
to 10 BMs/day), but bowels are now back to his baseline, no
melena or hematochezia. Has been experiencing new auditory
hallucinations "it sounds like there's radio static in my head"
but denies confusion. He didn't take his lactulose today.
.
In the ED initial VS were 98.4, 94, 111/61, 18, 100%RA. Exam
notable for pitting edema to thighs. Labs notable for elevated
ALT, AST, AP, TBili. CXR negative. He was given 15mg morphine
and was admitted to medicine for further evaluation. Transfer VS
were 98.4, 88, 188/63, 18, 100% RA.
.
Currently, he is comfortable and hungry, would like to eat.
Past Medical History:
-Hepatitis B/C cirrhosis, last EGD ___ with 1 cord of grade I
varices (h/o grade II varices and portal gastropathy on past
EGD), hepatopulmonary syndrome (pO2 77), known <2cm hepatoma
being monitored closely. HCV VL negative, HepBSAg negative now.
-Pulmonary sarcoid with possible hepatic involvement
-COPD, not on home O2
-OSA, not on cpap
-GERD
-Herniated disc at C6
-Chronic shoulder pain s/p right shoulder surgery for rotator
cuff tears
-s/p bilateral ulnar nerve transpositions
Social History:
___
Family History:
Father died of stroke. Brother died of hemochromatosis and HCC.
Physical Exam:
On Admission:
VITALS: 97.4, 112/62, 93, 18, 96%RA, 182 lbs
GENERAL: Well appearing man in NAD.
SKIN: Jaundiced. Numerous spider angiomas on chest and back.
Erythema over both shins, worse on left, slightly warm. Open
sore on third toe of left foot. Multiple ecchymotic areas on
arms bilaterally.
HEENT: + scleral icterus. PERRLA/EOMI. MMM. OP clear.
NECK: Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or ___. JVP not elevated.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: Distended, +dullness to percussion, non-tender, NABS.
EXTREMITIES: 3+ pitting edema bilaterally to mid-thigh
NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation
throughout. ___ strength throughout. Slight asterixis.
Discharge:
T 98-98.3, 91-124/58-65, 80-101, 94-95%RA
I/O: ___, Wt 166.8 <- 175.2 <- 177.4 <- 178.6 <-
182.7 ___
SKIN: Jaundiced. Numerous spider angiomas on chest and back.
Erythema over legs bilaterally stable.
HEENT: + scleral icterus. PERRLA/EOMI. MMM. OP clear but dry.
NECK: Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. ___
systolic murmur best heard over LLSB, I appreciated radiation to
axilla. JVP 7cm.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: Distended, increased from yesterday, +dullness to
percussion over sides, mildly tender over right side, NABS.
EXTREMITIES: ___ pitting edema bilaterally to mid-thigh. Left
leg non-tender but mildly warm and red. + right shoulder drop
arm test
Pertinent Results:
Admission Labs:
___ 08:25PM GLUCOSE-79 UREA N-19 CREAT-1.1 SODIUM-133
POTASSIUM-3.2* CHLORIDE-93* TOTAL CO2-25 ANION GAP-18
___ 08:25PM ALT(SGPT)-41* AST(SGOT)-98* ALK PHOS-189* TOT
BILI-8.4*
___ 08:25PM ALBUMIN-3.8
___ 08:25PM WBC-6.2 RBC-3.56* HGB-11.1* HCT-34.5* MCV-97
MCH-31.2 MCHC-32.1 RDW-18.2*
___ 08:25PM NEUTS-70.5* LYMPHS-15.7* MONOS-9.3 EOS-4.1*
BASOS-0.5
___ 08:25PM PLT COUNT-129*
___ 08:25PM ___ PTT-39.3* ___
___ 10:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
Relevant Labs:
___ 05:20PM BLOOD ALT-39 AST-90* AlkPhos-185* TotBili-7.6*
DirBili-4.7* IndBili-2.9
___ 01:30PM BLOOD C3-97 C4-22
___ 06:30AM BLOOD WBC-6.4 RBC-3.10* Hgb-10.1* Hct-30.8*
MCV-99* MCH-32.6* MCHC-32.8 RDW-19.2* Plt ___
___ 06:30AM BLOOD ___ PTT-43.2* ___
___ 06:30AM BLOOD Glucose-79 UreaN-15 Creat-1.0 Na-135
K-3.3 Cl-91* HCO3-33* AnGap-14
___ 06:30AM BLOOD ALT-37 AST-85* AlkPhos-138* TotBili-8.7*
___ 06:30AM BLOOD Calcium-9.9 Phos-3.7 Mg-2.1
___ 01:30PM BLOOD Cryoglb-NO CRYOGLO
Ascites:
___ 03:18PM ASCITES WBC-135* RBC-1095* Polys-4* Lymphs-39*
Monos-13* Mesothe-26* Macroph-18*
___ 03:18PM ASCITES TotPro-0.8 Glucose-125 LD(LDH)-68
Albumin-LESS THAN 1
Micro:
___ Urine culture: No Growth
Ascites:
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 (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Imaging:
___ CXRay:
IMPRESSION: Stable area of scarring in the right upper lobe.
Otherwise,
unremarkable study.
___ Liver US with dopplers:
Lobulated contour of the liver, compatible with patient's known
history of
underlying cirrhosis. Ascites and splenomegaly signify
underlying portal
hypertension. Hepatic vasculature is patent.
___: Bilateral lower extremity dopplers:
No evidence of deep venous thrombosis in bilateral lower
extremities.
Medications on Admission:
AMILORIDE - 5 mg Tablet - 2 Tablet(s) by mouth twice a day
CIPROFLOXACIN - 500 mg Tablet - 1 Tablet(s) by mouth once a day
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 40 mg Capsule, Delayed
Release(E.C.) - 1 Capsule(s) by mouth twice a day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inhaled twice a day
FUROSEMIDE - 160 mg daily
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 103 mcg (90 mcg)-18
mcg/Actuation Aerosol - 2 puff inhaled four times a day
LACTULOSE - 10 gram/15 mL Solution - 60 ml(s) by mouth three
times a day decrease to bid if more than 3bmd per day
MIDODRINE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth three times a day
MORPHINE - 15 mg Tablet - 0.5 (One half) Tablet(s) by mouth q 6
hours prn for pain
RANITIDINE HCL - 300 mg Tablet - 1 Tablet(s) by mouth twice a
day
RIFAXIMIN [XIFAXAN] - 550 mg Tablet - 1 Tablet(s) by mouth twice
a day
TADALAFIL [CIALIS] - 10 mg Tablet - one Tablet(s) by mouth as
needed for Erectile dysfunction NOT TO EXCEED ONE DOSE MORE
OFTEN
THAN ONCE IN THREE DAYS.
TESTOSTERONE [ANDRODERM] - 2 mg/24 hour Patch 24 hr - Apply one
patch daily
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaled once a day
TRAZODONE - 50 mg Tablet - ___ Tablet(s) by mouth q hs prn
URSODIOL - 300 mg Capsule - 1 Capsule(s) by mouth three times a
day
CALCIUM CARBONATE-VITAMIN D3 - 500 mg calcium (1,250 mg)-200
unit
Tablet - 1 Tablet(s) by mouth twice a day
MULTIVITAMIN - (Prescribed by Other Provider; ___) - Tablet -
1 Tablet(s) by mouth once a day
Discharge Medications:
1. amiloride 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
4. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
5. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
6. Combivent ___ mcg/actuation Aerosol Sig: Two (2) puff
Inhalation four times a day.
7. lactulose 10 gram/15 mL (15 mL) Solution Sig: Sixty (60) mL
PO three times a day: decrease to bid if more than 3bmd per day.
Disp:*1 bottles* Refills:*0*
8. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. morphine 15 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours)
as needed for pain: this medication may make you sleepy.
Disp:*42 Tablet(s)* Refills:*0*
10. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. testosterone 2 mg/24 hour Patch 24 hr Sig: One (1) patch
Transdermal once a day.
13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. trazodone 50 mg Tablet Sig: ___ Tablet PO at bedtime as
needed for insomnia.
15. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
16. multivitamin Tablet Sig: One (1) Tablet PO once a day.
17. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit
Tablet Sig: One (1) Tablet PO twice a day.
18. multivitamin Tablet Sig: One (1) Tablet PO once a day.
19. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Take 30 minutes prior to first lasix dose.
Disp:*30 Tablet(s)* Refills:*0*
20. tadalafil 10 mg Tablet Sig: One (1) Tablet PO ot to exceed
one dose more often than once in three days as needed for
erctile dysfunction.
21. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Three (3) Tablet, ER Particles/Crystals PO once a day.
Disp:*90 Tablet, ER Particles/Crystals(s)* Refills:*0*
22. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day) for 5 days.
Disp:*22 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary: Volume overload, Acute Liver Injury, Liver cirrhosis
Secondary: Rotator cuff arthropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
Comparison is made with a prior study from ___.
CLINICAL HISTORY: Bilateral lower extremity edema, chronic liver disease,
assess for pulmonary edema or effusions.
FINDINGS: PA and lateral views of the chest were obtained demonstrating
clear, well expanded lungs without focal consolidation, effusion, or
pneumothorax. A stable area of peripheral scarring is noted in the right
upper lobe. No pleural effusion or pneumothorax is seen. The
cardiomediastinal silhouette appears normal. Bony structures appear intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION: Stable area of scarring in the right upper lobe. Otherwise,
unremarkable study.
Radiology Report
INDICATION: Bilateral leg swelling. Assess for DVT.
COMPARISONS: None available.
FINDINGS: Grayscale and color Doppler images of bilateral common femoral,
superficial femoral, deep femoral, popliteal and calf veins were obtained with
normal flow, compressibility and augmentation. Soft tissue edema in bilateral
lower extremities is noted.
IMPRESSION:
No evidence of deep venous thrombosis in bilateral lower extremities.
Radiology Report
INDICATION: Patient with worsening LFTs and massive swelling. Assess for
portal vein thrombosis.
COMPARISONS: MR abdomen of ___ and abdominal ultrasound of ___.
FINDINGS:
The liver is of lobulated contour, compatible with known history of underlying
liver cirrhosis. The liver echotexture is coarse. There is no evidence of
intrahepatic or extrahepatic biliary ductal dilatation. The CBD is of normal
caliber measuring 5 mm. The gallbladder is collapsed as the patient is
postprandial. The spleen is enlarged measuring 13.3 cm. Small-to-moderate
amount of ascites is present.
COLOR DOPPLER AND SPECTRAL ANALYSIS: The main portal vein, left and right
portal veins are patent with hepatopetal flow. The left and right renal
arteries are patent with appropriate arterial waveforms. The hepatic veins
are patent. The IVC is patent.
IMPRESSION:
Lobulated contour of the liver, compatible with patient's known history of
underlying cirrhosis. Ascites and splenomegaly signify underlying portal
hypertension. Hepatic vasculature is patent.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: NEEDS A NEW LIVER
Diagnosed with SWELLING OF LIMB, EDEMA, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA
temperature: 98.4
heartrate: 94.0
resprate: 18.0
o2sat: 100.0
sbp: 111.0
dbp: 61.0
level of pain: 10
level of acuity: 3.0 | ASSESSMENT & PLAN: ___ with Hep B/C cirrhosis who p/w worsening
leg swelling, and worsening LFTS and cholestatic labs.
# ___ edema: Likely from worsening liver failure and upregulation
of RAS. Ruled out clot in IVC or portal vein. Pt breathing
comfortably and JVP non elevated. No h/o CHF and recent echo
WNL with exception of mild PA HTN. DVT ruled out. There is
erythema/warmth over left shin that appears more consistent with
stasis dermatitis from the fluid accumulation. Pt was diuresed
with 80 IV lasix BID with good effect: weight down to 166 at
discharge, from 182.7 on admission ___. Patient was also
started on metolazone 2.5mg daily and 12.5mg albumin. The
patient was continued on home medications and discharged on 80mg
PO lasix and metolazone.
# Acute liver failure/Mild abdominal pain: ___ MELD 24. 90 day
mortality 0.39. SAAG 3.0, likely portal HTN related. ALT, AST,
AP, and TBili all elevated from baseline. LFTs were trended
throughout admission and were stable. Cryo and C3/C4 were
negative/ normal.
# Auditory Hallucinations: Patient reports hearing radio static
in his head. Didn't take lactulose on admission and though
denies confusion, does seem mildly confused with slight
asterixis overnight, suggesting hepatic encephalopathy.
Asterixis resolved and patient was continued on lactulose and
rifaximin. No evidence of SBP on tap. Was resolved at
discharge.
# Hep B/C cirrhosis: C/b grade I varices, hepatopulmonary
syndrome, and known <2cm hepatoma. Recently denied for
transplant due to lack of social supports. We continued
lactulose, rifaximin, and cipro for SBP ppx.
# Shoulder pain: Known right rotator cuff arthropathy. The pain
is severe. Per the patient, he needs shoulder replacement
surgery, but this will not occur unless he gets liver transplant
first. The patient's morphine was increased to 22.5mg q6h PRN
at discharge.
# COPD: No wheezes on exam.
- Continue Advair, Combivent, Spiriva
# OSA: Patient does not wear CPAP.
# GERD: Unclear why pt is on both an H2 blocker and PPI but will
continue both for now.
# Hypokalemia: likely ___ diuresis and recent diarrhea. We
started and continued 60meq K daily at discharge
# Transitional:
- Discharge weight was recorded at 166.8, although day prior had
been 175.2. Admission weight 182.7 on ___
- Adjust standing potassium (60meq daily) pending lab results at
next clinic appointment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Tegretol / Dilantin Kapseal / Penicillins / Sulfa (Sulfonamide
Antibiotics) / Bactrim
Attending: ___
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ is a ___ year-old man with longstanding seizure
disorder (also static encephalopathy since head injury ___ ago,
HTN/HL/CAD s/p CABG, bilateral ulnar neuropathies) who was BIBA
to our ED this morning around 10am after a GTC seizure at home.
It was apparently witnessed by his wife, who is unavailable for
comment at the moment. Reportedly, he fell out of bed with the
seizure. Shortly after arrival in our ED, another seizure was
witnessed.
Regarding his seizure history, detailed info regarding onset is
unavailable at the ___, but it apparently started ___ ago
after some sort of TBI. He has also suffered a reported static
encephalopathy with mild difficulties in attention and judgement
ever since that time. He was treated with phenobarbital for many
years, and then started on lamotragine about a decade ago;
Keppra
was used also, then stopped, and then started again just last
year. Most of these AED changes have occurred in the setting of
inpatient admission for breakthrough wake-up seizures similar to
the one today. AED complainace has been a problem with some of
these presentations -- for example, his LTG level on admission
last ___ was 2.3, and quickly rebounded to 12 after
observed med administration. I do not have any information at
this time regarding the patient's AED complaince recently.
Prior MRI (several years ago) and CT did not shown any focal
anatomic abnormality to explain the patient's seizure risk (only
chronic microvascular ischemic white matter disease, Left BG
lacunar disease). Several prior EEGs over the past ___ years have
shown a variety of non-focal findings, ranging from normal to
generalized mild slowing to bitemporal theta slowing. Dr.
___
has suggested that early-morning hypoglycemia may be to blame;
to
explain the fact that his blood sugar has been normal or high
when measured after morning seizures in the past, he and the
patient's ___ physicians have invoked the Simogyi phenomenon
(of note, however, the patient takes just 10U of detemir, and
this is given in the morning, not the night before, so the
probability of this explanation is questionable, especially
given
the poor empiric support for the existence of this phenomenon in
general). Past presentations like this one have led to multiple
additional GTC seizures and prolonged time for recovery to
baseline mental status, so it has been recommended (on discharge
last year) that the patient be started empirically on standing
IV
Ativan when he presents like this. 1mg of IV Ativan was given by
the ED as today's second seizure was resolving there.
Past Medical History:
1. longstanding seizure disorder, as above (followed in clinic
here by Dr. ___ s/p muliple admissions for break-through
wake-up seizures in the past 10+ years
2. "static encephalopathy" with frontal deficits
(attn/judgement/planning -- see Dr. ___ assessment
from 200x in OMR)
3. CAD s/p 2v angioplasty in ___, RCA stenting ___, 3vCABG
___, fixed inferolateral defect on echo since ___ (incl recent
stress-echo ___ with stable inf TWF on ECGs.
4. HTN on ACEI
5. HL on statin
6. IDDM (A1cs historically 7-8% on AM 10U Levemir + SSI) c/b
retinopathy and neuropathy
7. erectile dysfunction
8. chronic bilateral ulnar neuropathies & R median neuropathy
s/p several EMG studies here at ___
9. progressive macrocytic anemia and thrombocytosis under
clinic
investigation by Heme-Onc (last ___, Dx unclear).
10. actinic keratosis on skin cream
11. "NMSC" listed in OMR (?non-melanoma skin cancer)
Social History:
___
Family History:
Father and sister with MIs at young age (___).
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
General: Lying in bed in NAD, eyes closed, no spont movements,
non-sensical responses to questions, briefly opens eyes,
intermittently tracks.
HEENT: Atraumatic, bald, pale. Anicteric. Mucous membranes are
moist. No lesions noted in oropharynx.
Neck: Supple, full passive range of motion (no nuchal rigidity).
No bruits. No lymphadenopathy. No goiter.
Pulmonary: Lungs CTA bilaterally (anterior/lateral; did not
listen posteriorly at this time). Breathing is non-labored.
Chest: old CABG scar over sternum. Small round/flaky yellowish
skin placques in region of scar, with prominent superficial
arterioles.
Cardiac: RRR, normal S1/S2, no M/R/G heard in loud ED.
Abdomen: Soft, non-tender, and non-distended, minimal bowel
sounds.
Extremities: Cool, but well-perfused, no cyanosis or significant
edema. Intact radial, DP pulses bilaterally.
*****************
Neurologic examination:
Mental Status: Opens eyes for a few seconds maximum. Tracks and
blinks to threat intermittently. Confused -- non-sensical and
placating answers ___, ok, etc.) to simple/orientation
questions, including "what is your name?". Does follow some very
simple commands, hold up arms/legs (after I position them for
him). Limited speech is not slurred; cannot test language or
cognition in any relevant level of detail at this time. Does not
seem to neglect either side of visual space.
-Cranial Nerves:
II: PERRL, 3.5 to 2mm and brisk. Visual fields are grossly full
bilaterally by intermittent blink-to-threat.
III, IV, VI: EOMs full and conjugate. Rare, Spontantous,
intermittent horizontal nystagmus appeared at random in any
direction of gaze, seemed to beat left (only ___ beats, only
seen
3x, with pt closing eyes; may be saccadic intrusions.
V: Facial sensation intact by grimace & corneals.
VII: Symmetric grimace and eye closure. ___ have mild ptosis on
R
(inconsistently less elevated than L with brief eye-opening).
VIII: Hearing grossly intact.
IX, X: Will not open mouth enough to eval palate elevation.
XI: unable to test.
XII: Will not protrude tongue.
Motor:
- Assymetric postural tremor in LUE>LLE (not in R-sided limbs),
continuous, ___ Hz, present only when holding against gravity
or
squeezing hand. No adventitious movements at rest. Pt has
paratonia/gigenhalten-type tone x4 extr and neck.
- Holds arms and legs anti-gravity without drift. Briskly
withdraws (&grimaces) to miniaml noxious stimulation x4.
Squeezes
hands on command.
-Sensory: grimaces to minimal nailbed pressure x4.
-Reflexes (left; right):
Biceps (++;++) brisk bilat
Triceps (+;+)
Brachioradialis (++;++)
Quadriceps / patellar (++;++) brisk bilat
Gastroc-soleus / achilles (0;0)
Plantar response was extensor bilaterally (more brisk on the
Right).
-Coordination & Gait: unable to test
Pertinent Results:
Admission Labs:
___ 11:10AM WBC-10.8 RBC-3.64* HGB-12.8* HCT-39.9*
MCV-110* MCH-35.3* MCHC-32.2 RDW-14.7
___ 11:10AM NEUTS-76.1* ___ MONOS-2.8 EOS-1.9
BASOS-0.8
___ 11:10AM ___ PTT-32.7 ___
___ 11:10AM GLUCOSE-417* UREA N-14 CREAT-0.8 SODIUM-135
POTASSIUM-5.7* CHLORIDE-99 TOTAL CO2-20* ANION GAP-22*
___ 11:10AM CALCIUM-8.8 PHOSPHATE-2.7 MAGNESIUM-1.9
___ 11:10AM ACETONE-NEG OSMOLAL-304
___ 11:10AM ALT(SGPT)-15 AST(SGOT)-22 CK(CPK)-50 ALK
PHOS-74 TOT BILI-0.6
___ 11:10AM CK-MB-2 cTropnT-<0.01
___ 05:10PM GLUCOSE-323* UREA N-14 CREAT-0.8 SODIUM-138
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
___ 03:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 03:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Discharge Labs:
___ 06:30AM BLOOD WBC-8.6 RBC-3.25* Hgb-11.1* Hct-34.7*
MCV-107* MCH-34.0* MCHC-31.8 RDW-14.7 Plt ___
___ 06:30AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8
Key Studies:
CXR ___
FINDINGS: Single portable view of the chest was compared to
previous exam
from ___. The lungs remain grossly clear.
Cardiomediastinal
silhouette is within normal limits. Osseous and soft tissue
structures are unremarkable.
IMPRESSION: No definite acute cardiopulmonary process based on
a portable
film slightly limited by respiratory motion.
CT Head Non-contrast ___
FINDINGS: The exam is limited by severe streak and motion
artifact. Despite these limitations, there is no hemorrhage or
major vascular territorial infarction, edema, mass, or shift of
normally midline structures. Prominence of ventricles and sulci
compatible with cortical atrophy. Gray-white differentiation is
preserved. The basilar cisterns are patent. The visualized
paranasal sinuses are well aerated. There is no calvarial
fracture or soft tissue hematoma.
IMPRESSION: No acute intracranial process.
MRI Head ___ PRELIMINARY REPORT
IMPRESSION: Chronic findings unchanged from most recent MR ___
with several foci of old ischemic infarcts; seizures could be
related to one of these especially at the right frontal vertex.
There is no evidence of acute process or anatomic substrate for
seizure or evidence of infection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LaMOTrigine 200 mg PO BID
2. LeVETiracetam 750 mg PO BID
3. Aspirin 325 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
6. Enalapril Maleate 5 mg PO DAILY
7. Levemir *NF* (insulin detemir) 10 units Subcutaneous qam
8. HumaLOG *NF* (insulin lispro) sliding scale untis
Subcutaneous as directed
9. Atorvastatin 40 mg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Enalapril Maleate 5 mg PO DAILY
6. LaMOTrigine 200 mg PO BID
7. LeVETiracetam 750 mg PO BID
8. Metoprolol Tartrate 12.5 mg PO BID
9. HumaLOG *NF* (insulin lispro) 0 untis SUBCUTANEOUS AS
DIRECTED
10. Levemir *NF* (insulin detemir) 10 units Subcutaneous qam
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
afebrile for >24 hours. awake and alert. oriented x3, able to do
DOWB. Able to answer questions appropriately. Strength nl. mild
bilateral psotural tremor. Reflexes symmetric and stable from
prior. Toes up on L, equivocal on R.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST: ___
HISTORY: ___ male with seizures.
FINDINGS: Single portable view of the chest was compared to previous exam
from ___. The lungs remain grossly clear. Cardiomediastinal
silhouette is within normal limits. Osseous and soft tissue structures are
unremarkable.
IMPRESSION: No definite acute cardiopulmonary process based on a portable
film slightly limited by respiratory motion.
Radiology Report
INDICATION: Seizures, vomiting.
COMPARISON: ___.
TECHNIQUE: Axial MDCT data were acquired through the head. Images were
reconstructed using bone and soft tissue algorithms and displayed in multiple
planes.
FINDINGS: The exam is limited by severe streak and motion artifact. Despite
these limitations, there is no hemorrhage or major vascular territorial
infarction, edema, mass, or shift of normally midline structures. Prominence
of ventricles and sulci compatible with cortical atrophy. Gray-white
differentiation is preserved. The basilar cisterns are patent. The
visualized paranasal sinuses are well aerated. There is no calvarial fracture
or soft tissue hematoma.
IMPRESSION: No acute intracranial process.
Radiology Report
INDICATION: "Breakthrough seizures," head turns to the left, also fever;
seizure protocol, evaluate for infection.
COMPARISON: Multiple prior CTs of the head and multiple prior MRs ___ the
head, including the most recent NECT head of ___, and the most recent
MR head ___.
TECHNIQUE: Multiplanar multisequence MRI of the brain, before and after the
intravenous administration of 6ml Gadovist, as per the ___ "acute seizure"
protocol.
FINDINGS: There is no acute infarct or intra-axial hemorrhage. No
extra-axial blood or fluid collection is present. The ventricles and sulci
are prominent, suggesting age-related global atrophy, including atrophy of the
medial temporal lobes; slight asymmetric prominence of all components of the
right lateral ventricle is unchanged and likely congenital or developmental.
Multiple chronic lacunes, presumably hypertensive, are seen throughout the
brain, e.g. in the brainstem and the right lentiform nucleus. Low
signal-intensity focus on the gradient echo is seen in the right frontovertex
representing prior hemorrhagic focus. Dystrophic calcifications are seen in
the globi pallidi, bilaterally. No intracranial mass is identified. The
major intracranial vessel flow voids are preserved.
The brainstem, posterior fossa, and cervicomedullary junction are
unremarkable. The orbits, periorbital and paracavernous spaces are normal.
No abnormality of the skull base or calvaria is identified.
IMPRESSION: Chronic findings, unchanged from most recent MR study, with
several foci of old ischemic infarction; seizures could be related to one of
these, particularly the lesion at the right frontal vertex. There is no
evidence of acute ischemia, other anatomic substrate for seizure, or finding
to suggest intracranial infection.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with seizures.
PA and lateral upright chest radiographs were reviewed with comparison to
___ and ___.
The patient is after partial sternotomy. Heart size and mediastinum are
stable. There is interval resolution of pulmonary edema. Minimal linear
opacity in the right lower lung might potentially reflect area of atelectasis
or infectious process (less likely). Left apical opacity is unchanged and
most likely reflects post-radiation changes related to the upper thorax.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SEIZURE
Diagnosed with OTHER CONVULSIONS
temperature: 98.0
heartrate: 72.0
resprate: 16.0
o2sat: 100.0
sbp: 153.0
dbp: 63.0
level of pain: 0
level of acuity: 3.0 | ***Transitional Issues: AED levels, blood sugar control. PCP,
___ follow up.
___ M with IDDM, HL, CAD/CABG, and seizure disorder with prior
admissions for breakthrough GTCs. p/w 1 gen sz at home (___
300s), another in ED, febrile to 103 with prolonged confusional
state after seizure.
# Generalized tonic-clonic seizures: The patient presented after
a GTC at home. He had another GTC lasting 1 minute in the ___
ED and was given ativan 1mg IV. After the seizure, he was
confused, disoriented, and somnolent. He was loaded with keppra
and continued on his home AED regimen of lamictal 200mg BID and
keppra 750mg BID. During his past admissions, he has had
repeated GTCs in the hospital. To prevent this, he was given
ativan 1mg q8h overnight. He did not have any additional
seizures during his hospitalization. His mental status cleared
slowly (after discontinuing standing ativan in the morning) and
he returned to his baseline mental status on the day after
admission.He was oriented, responded appropriately to questions,
and had normal strength and sensation. An MRI on ___ did not
show any new cause for his seizures. He was discharged without
any change to his home AED regimen. His AED levels are still
pending at this time.
# Fever and leukocytosis: The patient was febrile to 103.2 in
the ___ ED following his seizure. A urinalysis/urine culture
and CXR did not show any evidence of infection. An LP was
attempted on the evening of admission (___) but was
unsuccessful. Given concern for possible CNS infection,
vancomycin 1g q12h, meropenem 1g q8h, and acyclovir 650mg q8h
were started empirically. An LP was arranged with interventional
radiology but delayed due to an emergent case. He had no further
fevers and had an only mildly elevated WBC count. On ___ our
suspicion for infection was very low for a number of reasons; He
had had an almost immediate decrease in temperature after
starting antibiotics, which is quite unusual. He also reported
no current or preceding headache, neck stiffness of fevers. He
also rapidly improved to his baseline once ativan was stopped.
Because of the low suspicion his antibiotics were stopped.The LP
was also canceled given this low suspicion. He was observed 24
hours off of antibiotics and did very well, without any fevers.
# Hyperglycemia: The patient presented with a blood glucose of
417, a bicarb of 20, and an anion gab of 17, concerning for DKA.
The patient had no acetone or acetoacetate in his blood, though
he did have ketonuria. He was given insulin 10U SC in the ED and
a repeat set of electrolytes showed a glucose of 323 with a
normal bicarb and anion gap. He was placed on an insulin sliding
scale, though his blood sugar was 260-280 during the day. He was
discharged on his home diabetes regimen with instructions to
follow up with his PCP.
# CAD s/p CABG: The patient's ECG on admission did not show any
significant change from prior studies. His cardiac enzymes were
not suggestive of cardiac ischemia. He was continued on his home
ASA, plavix, and atorvastatin.
# HTN: The patient was continued on his home metoprolol and
enalapril.
# hematologic abnormalities: The patient presented with a
thrombocytosis to 721 and a macrocytic anemia. This is present
in labs dating back at least a year and the patient is followed
by heme/onc for this. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L hand pain / Cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH of IV Heroin Use (w/ prior leg cellulitis as a result),
who presents as transfer from ___ with complaint of hand
pain, was admitted for cellulitis
Pt notes that he has been using IV heroin on and off but most
recently over the last month. Does not lick needles, but injects
primarily into arms. Had cellulitis of leg last year, treated
with PO Abx and no bloodstream spread. Notes that he feels that
he is withdrawing since being admitted. 2 days ago, noted
swelling of his left hand where he had been injecting. At high
point detox he was given PO Bactrim + Keflex, then brought to
___ for evaluation. There was unable to obtain IV access so
had right femoral CVL placed. Pt was reportedly yelling at staff
there, was given Vancomycin and dilaudid and transferred to
___.
In our ED, initial VS were 98.6 85 115/80 16 96% RA. Labs were
notable for: WBC 12.0, H/H 13.5/39.2, CHEM wnl, lactate 0.8.
Hand XR showed soft tissue swelling in the dorsal aspect of the
L hand. No radiopaque foreign body seen. Pt was given CTX,
ibuprofen, and oxycodone and was admitted to medicine for
further care.
On arrival to floor, pt is comfortable resting in bed, but noted
that he was beginning to withdraw. He noted that the swelling in
his hand had decreased overnight.
Review of systems:
(+) Per HPI
(-) Denied fever, chills, joint pain, nausea, vomiting,
diarrhea, abd pain, SOB, chest pain, dysuria, swelling in other
areas of body.
Past Medical History:
IV heroin Use
Tobacco User
Cellulitis
ADHD
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.6, 130/55, 63, 18, 98RA
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
Groin: Right CVL in place in femoral vein, has adhesive tape
dressing, no oozing from site
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no splinter hemorrhages, ___ lesions
Left hand: unable to fully make a fist, diffuse edema of dorsum
of hand and fingers, no fluctuance noted, has pain with ROM of
wrist, +erythema to wrist, unable to locate inoculation site
Neuro: AOx3 pleasant, moving all extremities appropriately
DISCHARGE PHYSICAL EXAM:
VS: 98.5 ___ 119-128 20 96% RA
General: Alert, oriented, no acute distress
HEENT: NCAT, sclerae anicteric, conjunctivae noninjected
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no splinter hemorrhages, ___ lesions
Left hand: edema of dorsum of hand and fingers improved from
prior, no fluctuance noted, has decreased pain with ROM of
wrist, +erythema to wrist and dorsum of hand
Neuro: AOx3 ___
Pertinent Results:
ADMISSION LABS:
___ 04:40AM PLT COUNT-180
___ 04:40AM NEUTS-71.7* LYMPHS-16.3* MONOS-9.7 EOS-1.7
BASOS-0.2 IM ___ AbsNeut-8.61* AbsLymp-1.96 AbsMono-1.17*
AbsEos-0.20 AbsBaso-0.03
___ 04:40AM WBC-12.0* RBC-4.52* HGB-13.5* HCT-39.2*
MCV-87 MCH-29.9 MCHC-34.4 RDW-11.7 RDWSD-37.0
___ 04:40AM GLUCOSE-99 UREA N-11 CREAT-0.8 SODIUM-138
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14
___ 04:57AM LACTATE-0.8
DISCHARGE LABS:
___ 07:23AM BLOOD WBC-8.8 RBC-4.95 Hgb-14.9 Hct-43.3 MCV-88
MCH-30.1 MCHC-34.4 RDW-12.2 RDWSD-38.9 Plt ___
___ 07:23AM BLOOD Glucose-123* UreaN-12 Creat-0.9 Na-141
K-4.4 Cl-102 HCO3-26 AnGap-17
___ 07:23AM BLOOD Calcium-9.8 Phos-4.7* Mg-2.1
PERTINENT MICRO:
___ BLOOD CULTURE - No growth to date
___ BLOOD CULTURE - No growth to date
___ BLOOD CULTURE - No growth to date
TTE ___:
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
L Hand Xray ___:
Soft tissue swelling in the dorsal aspect of the hand and wrist.
No
radiopaque foreign body seen. No displaced fracture.
Radiology Report
EXAMINATION: HAND (PA,LAT AND OBLIQUE) LEFT
INDICATION: ___ year old man with IV drug use and L hand cellulitis, rule out
foreign body or obvious fracture of the metacarpals.
TECHNIQUE: Left hand, three views.
COMPARISON: None available.
FINDINGS:
No acute fracture, dislocation, or degenerative change is seen. There is
marked soft tissue swelling about the dorsal aspect of the left hand and
wrist. No radiopaque foreign body is identified. No lytic or sclerotic
lesion is seen.
IMPRESSION:
Soft tissue swelling in the dorsal aspect of the hand and wrist. No
radiopaque foreign body seen. No displaced fracture.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Cellulitis, Transfer
Diagnosed with Cellulitis of left upper limb, Opioid abuse, uncomplicated
temperature: 98.6
heartrate: 85.0
resprate: 16.0
o2sat: 96.0
sbp: 115.0
dbp: 80.0
level of pain: 10
level of acuity: 3.0 | ___ PMH of IV Heroin Use (w/ prior leg cellulitis as a result),
who presented as a transfer from ___ with complaint of
hand pain, was admitted for cellulitis
Investigations/Interventions
1. Cellulitis Left Hand - Pt presented with
edematous/erythematous left hand and forearm ___ inoculation
from injection drug use into dorsum of left hand, with Xray not
showing any e/o foreign body. Pt received IV vancomycin at OSH
via right femoral CVL before cultures were drawn, and subsequent
cultures were negative at time of discharge. Pt had a systolic
murmur at ___ on exam, which is unclear if existed prior to
this admission, so had TTE which was negative for vegetations or
valvular abnormalities. No e/o endocarditis on exam.
Accordingly, was likely a flow murmur. EKG without e/o
conduction abnormalities. Given decreased edema/erythema in left
forewarm/dorsum of hand, was switched from IV to PO antibiotics
w/ doxycycline and Keflex on ___, as had prior MRSA
cellulitis which was resistant to Bactrim. He was instructed to
take ___nding ___. Pt was instructed not to
inject, and clean needle technique was discussed.
2. Heroin Withdrawal - Pt recently relapsed after ___ years of
sobriety, was acutely withdrawing and required 1 dose of PO
methadone 20mg, as well as clonidine. Pt was improved at time of
discharge. Femoral line was removed prior to discharge. Pt
discharged back to ___ to continue detox and to be
transitioned to ___. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
acute neck pain
Major Surgical or Invasive Procedure:
REVISION POSTERIOR LAMI FUSION C3-T6, T3 CORPECTOMY on ___
History of Present Illness:
___ is a ___ female with multiple myeloma currently
treated with velcade and cytoxan, known to ___ spine since
___ with back pain due to extensive lesions
throughout the spine. On ___ for C4 intraspinal lesion and C4
fractures she underwent C4 corpectomy, anterior fusion with
discectomy of C3-C4 and C4-C5, anterior plate of C3-C5, as well
as biopsy of C4; on ___ she underwent poasterior arthrodesis
of C3-C4 an C4-C5, laminectomy and biopsy of intraspinal lesion
C3-C4 and C4-C5, posterior instrumentation of C3-C5. Since that
time that patient has done relatively well, with chronic back
pain however, no neurological symptoms. While putting on a shirt
recently, the patient felt a crunch in her neck and had
immediate cervical pain. As the pain progressed she also
developed tingling in the left fifth digit.Patient presented to
___ ED as a result of the pain and new tingling and was found
to have a C7 compression fracture on CT c-spine. Patient denied
any other numbness/tingling/new weakness, fevers, chills, saddle
anesthesia, urinary retention, bowel incontinence. Orthopaedic
Spine was consulted for recommendations given the new findings
of a C7 compression fracture.
Past Medical History:
AUTOLOGOUS STEM CELL COLLECTION
END STAGE RENAL DISEASE
HYPERTENSION
MULTIPLE MYELOMA
PAST ONCOLOGIC HISTORY: (from OMR note)
initially diagnosed in ___ with kappa multiple
myeloma. She is currently ___ months from her autologous stem
cell transplant for her disease diagnosis.
She initially received 6 cycles of Velcade and dexamethasone
from
___, through ___.
From ___ through ___, she received 5
cycles of Velcade, dexamethasone, and Revlimid in renal dosing(5
mg).
She received Cytoxan mobilization therapy in ___
followed by her autologous stem cell transplant with melphalan
as
her conditioning regimen. On ___, she received a
total of 5.11 x 10^6 CD34/KG.
From ___ through ___, received 2 cycles of
Velcade, dexamethasone, and Revlimid.
___, she started Velcade 1.3 mg per m2 subcu days 1
and 15 and had received 26 cycles of maintenance but was found
to
have disease progression in early ___. With her
fluctuating myeloma labs her dosing schedule has changed to
various dosing of Velcade, adding Revlimid and Decadron.Cytoxan
was added day 8 of cycle 6 ___ of Cytoxan was in
___ after 8 cycles.with the most recent stopping Revlimid and
adding Pomalidomide and Decadron day of and day after Velcade on
___.
On ___ she presented to clinic with worsening neck pain and
inability to raise hands above her shoulders. She was found on
MRI imaging to have new and worsening compression fractures
raising concern for cord compression.
On ___ she had
1. C4 corpectomy, intraspinal lesion, extradural.
2. Anterior interbody fusion with diskectomy C3-C4, C4-C5.
3. Interbody reconstruction with biomechanical device.
4. Anterior plate instrumentation C3 through C5.
5. Open biopsy, C4 vertebrae.
And on ___ she had additional surgery
1. Open treatment fracture, posterior, C4.
2. Posterior arthrodesis C3-C4, C4-C5.
3. Laminectomy and biopsy intraspinal lesion C3-C4, C4-C5.
4. Posterior instrumentation C3, C4, C5.
5. Autograft, skin incision.
6. Allograft, morselized.
She was discharged home on ___.
XRT to her C spine and left shoulder (completed ___, Lumbar
spine (completed ___.
She resumed Pomalidomide on ___.
She then was unable to take her medication due to esophagitis
from radiation on ___ and has not resumed to date.
She was hospitalized for esophagitis, back pain and nausea and
vomiting from ___ and again ___.
She had persistent cytopenias and bone marrow biopsy done on
___ revealed:
MARKEDLY HYPOCELLULAR BONE MARROW (OVERALL CELLULARITY LESS THAN
5%)WITH SCATTERED INTERSTITIAL PLASMA CELLS. SEE NOTE.
NOTE: The aspirate and core biopsy are markedly hypocellular
with
abundant hemosiderin deposits and scant hematopoiesis, however,
focal clusters of cytologically atypical plasma
cells are seen on the core biopsy which are CD138
immunoreactive.
CYTOGENETIC DIAGNOSIS: 46,XX[20] Normal female karyotype.
Her myeloma labs started to increase once again and due to the
above bone marrow findings, concern was that her underlying
cytopenias are due to burden of disease therefore her therapy
was
changed to Carfilzomib while awaiting arrival of newer novel
agent of Daratumumab.
She initiated Carfilzomib on ___. Which was stopped on
___ due to rising creatinine.
She stated Velcade and Cytoxan ___. C1D8 was held due to
cold symptoms.
She was admitted to the hospital for severe back pain ___
and discharged ___. She had a spinal Xray and an MRI of her
cervical and thoracic spine which showed many known myeloma
lesions and compression fractures but nothing that appeared
unstable or anything that would require immediate surgical
intervention. While she was in the hospital she received
Velcade/Cyclophosphamide/Dexamethasone, C1D15 (___).
She completed Velcade/Cyclophosphamide/Dexamethasone cycle 1
___
Cycle 2 Day 1 Velcade/Cyclophosphamide/Dexamethasone ___
cyclophosphamide dose reduced to 300mg/m2 for low plt count
this
cycle. Day 8 cyclophosphamide held due to low platelet counts.
Cycle 1 dose 1 Daratumumab given ___ had some sinus
congestion with infusion was given 10mg cetirizine PO and was
able to complete dose without other incident.
Dose 2 of Daratumumab given ___ without incident.
Dose 3 of Daratumumab given ___ without incident.
Dose 4 of Daratumumab given ___ without incident.
Dose 5 of Daratumumab given ___ without incident.
Dose 6 of Daratumumab given ___ without incident.
Dose 7 of Daratumumab given ___ without incident.
Dose 8 of Daratumumab given ___ without incident.
Dose 9 of Daratumumab given ___ without incident.
Dose 10 of Daratumumab given ___ without incident.
Social History:
___
Family History:
Father has HTN and a history of a thrombotic event in setting of
chain-saw accident, on lifetime warfarin. Mother has type ___
diabetes. Brother and sister have type I DM. Sister also has a
sickle cell trait. Maternal and paternal aunts with history of
breast cancer. Paternal uncle with renal cancer.
Physical Exam:
ADMISSION EXAM:
VITAL SIGNS: 96/58 20 96% RA
General: NAD, Resting in bed comfortably, husband at bedside
___: MMM, unable to palpate her neck as she has the cervical
collar on
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Neuro exam:
Moter strength out of 5:
- shoulder abd: 5 b/l
- shoulder add: 5 b/l
- elbow flex: 5 b/l
- elbow ext: 5 b/l
- wrist flex: 5 b/l
- wrist ext: 5 b/l
- finger flex: 5 b/l
- finger ext: 5 b/l
- finger abd: 5 b/l
- thumb abd: 5 b/l
DISCHARGE EXAM:
Vitals:99.1 118/65 108 18 99 RA
General: NAD, Resting in bed comfortably
___: MMM.
CV: Tachycardic to ~100s on auscultation, systolic ejection
murmur. Normal S1, S2.
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, slightly distended but non-tender on exam.
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: A&Ox 3. Neuro exam:
Motor strength out of 5:
- shoulder abd: 5 b/l
- shoulder add: 5 b/l
- elbow flex: 5 b/l
- elbow ext: 5 b/l
- wrist flex: 5 b/l
- wrist ext: 5 b/l
- finger flex: 5 b/l
- finger ext: 5 b/l
- finger abd: 5 b/l
- thumb abd: 5 b/l
Sensation intact to light touch throughout.
Reflexes: 2+ and symmetric in biceps, brachioradialis, knees,
ankles
Pertinent Results:
ADMISSION LABS:
___ 03:45PM BLOOD WBC-1.2* RBC-2.79* Hgb-8.4* Hct-24.5*
MCV-88 MCH-30.1 MCHC-34.3 RDW-16.3* RDWSD-49.5* Plt Ct-36*
___ 03:45PM BLOOD Neuts-52.5 ___ Monos-10.8 Eos-1.7
Baso-0.0 Im ___ AbsNeut-0.63* AbsLymp-0.40* AbsMono-0.13*
AbsEos-0.02* AbsBaso-0.00*
___ 03:45PM BLOOD ___ PTT-26.4 ___
___ 03:45PM BLOOD Plt Ct-36*
___ 03:45PM BLOOD Glucose-87 UreaN-31* Creat-2.1* Na-138
K-4.1 Cl-106 HCO3-22 AnGap-14
DISCHARGE LABS:
___ 12:11AM BLOOD WBC-1.0* RBC-2.45* Hgb-7.2* Hct-21.9*
MCV-89 MCH-29.4 MCHC-32.9 RDW-14.0 RDWSD-45.2 Plt Ct-20*
___ 12:00AM BLOOD Neuts-61 Bands-1 ___ Monos-5 Eos-1
Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-0.74* AbsLymp-0.38*
AbsMono-0.06* AbsEos-0.01* AbsBaso-0.00*
___ 12:00AM BLOOD Plt Smr-VERY LOW Plt Ct-28*
___ 12:11AM BLOOD Plt Ct-20*
___ 12:11AM BLOOD Glucose-102* UreaN-21* Creat-2.1* Na-139
K-4.7 Cl-104 HCO3-26 AnGap-14
___ 12:00AM BLOOD ALT-<5 AST-22 LD(LDH)-428* AlkPhos-126*
TotBili-0.5
___ 12:11AM BLOOD Albumin-3.1* Calcium-10.7* Phos-3.9
Mg-1.6
___ 05:00PM BLOOD PEP-HYPOGAMMAG FreeKap-3400* FreeLam-2.8*
Fr K/L-GREATER TH IgG-341* IgA-28* IgM-18* IFE-TRACE MONO
IMAGING:
ECHO ___:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF=75%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. with normal free
wall contractility. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is an anterior space which
most likely represents a prominent fat pad.
IMPRESSION: Vigorous biventricular systolic function may explain
a benign flow murmur. No pathologic valvular disease seen. Image
quality limited by cervical spine stabilizer covering sternum.
LUNG SCAN ___:
FINDINGS: Ventilation and perfusion images demonstrate the
subtle matched area
of relative decreased counts centrally on the posterior views.
Chest x-ray shows no pulmonary consolidation.
IMPRESSION: Very low likelihood for acute pulmonary embolism.
MR CERVICAL ___:
1. Diffuse bone marrow replacement throughout the visualized
osseous
structures compatible with diffuse myelomatous involvement,
progressed since
___. Note that with near complete involvement of
numerous vertebral
bodies, the patient is at risk of additional fractures or
worsening collapse.
2. Severe pathologic compression deformity of the C7 vertebral
body, new since
___, with 3 mm posterior extra cortical soft tissue
extension into
the epidural space with encasement of the left C8 nerve root.
3. Progression of a moderate pathologic compression deformity of
the T3
vertebral body since ___ with a 6 mm soft tissue extension
into the
epidural space producing severe spinal canal and bilateral
neural foraminal
narrowing with spinal cord compression. Note that with diffuse
involvement of
the vertebral body, the patient is at risk for abrupt collapse
with worsening
compression of the spinal cord, and close clinical followup for
worsening
symptomology is advised.
4. Unchanged mild pathologic compression deformity of the T11
vertebral body,
now with 4 mm extra cortical soft tissue extension into the
epidural space
along the left pedicle.
5. Unchanged pathologic compression fractures of T8, T9, T10 and
L1 as
described in detail above.
6. Large expansile lesion of the right posterior eighth rib with
extra
cortical soft tissue extension, roughly similar to the ___
examination.
7. Normal spinal cord signal.
8. Degenerative changes, as detailed above, with multilevel
spinal canal and
neural foraminal narrowing.
9. Postsurgical changes from anterior and posterior fusion of C3
through C5
with C4 corpectomy and intervertebral spacers.
CT T-SPINE ___:
1. Numerous lytic lesions throughout the visualized bones with
multiple
pathologic fractures, as detailed above.
2. Compared to ___, there is increased loss of height at
C7 and T3,
with new retropulsion and anterior epidural masses at these
levels, as seen on
the ___ MRI.
3. T5 vertebral body demonstrates unchanged moderate loss of
height compared
to ___, but pathologic fracture of the posterior
superior corner with
a minimally retropulsed cortical fragment is new.
4. Large pleural mass contiguous with the right seventh
posterior rib lytic
lesion is again partially visualized.
5. Several small, faintly hyperdense foci, up to 2.5 mm, in the
medullary
region of the partially visualized kidneys, not clearly seen on
the
noncontrast abdominal CT from ___, which may represent
mild medullary
nephrocalcinosis versus milk of calcium in tiny cysts or
calyces.
CT L-SPINE ___:
1. 4 lumbar-type vertebrae are present. There is no
transitional anatomy in
the upper sacrum.
2. Lytic lesions are again seen throughout the visualized bones.
3. Complete compression of L2 vertebral body, and mild superior
endplate
deformities of L3 and L4 vertebral bodies, are unchanged
compared to ___.
4. Largest visualized lytic lesion in the right ilium, which is
slightly
expansile, and the largest visualized lytic lesion in the left
ilium, which is
slightly expansile with dehiscence of the lateral cortex, are
also not
significantly changed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q24H
2. Albuterol Sulfate (Extended Release) 4 mg PO QID:PRN
SOB/wheeze
3. Allopurinol ___ mg PO DAILY
4. Atovaquone Suspension 1500 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID:PRN
wheezing
7. FoLIC Acid 1 mg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Omeprazole 20 mg PO DAILY
10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
11. Senna 8.6 mg PO BID:PRN constipation
12. Sodium Bicarbonate 650 mg PO QID
13. Temazepam 15 mg PO QHS:PRN insomnia
14. Vitamin D ___ UNIT PO 1X/WEEK (TH)
15. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Medications:
1. Dexamethasone 10 mg PO DAILY Duration: 4 Doses
RX *dexamethasone 2 mg 5 tablet(s) by mouth once a day Disp #*15
Tablet Refills:*0
2. Morphine Sulfate ___ ___ mg PO Q4H:PRN Pain - Moderate
RX *morphine 15 mg ___ tablet(s) by mouth every four (4) hours
Disp #*90 Tablet Refills:*0
3. Acyclovir 400 mg PO Q24H
RX *acyclovir 400 mg 1 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
4. Albuterol Sulfate (Extended Release) 4 mg PO QID:PRN
SOB/wheeze
5. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
6. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 mL by mouth once a day Refills:*0
7. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*12 Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID:PRN
wheezing
10. FoLIC Acid 1 mg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Omeprazole 20 mg PO DAILY
13. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
14. Senna 8.6 mg PO BID:PRN constipation
15. Sodium Bicarbonate 650 mg PO QID
16. Temazepam 15 mg PO QHS:PRN insomnia
17. Vitamin D ___ UNIT PO 1X/WEEK (TH)
18.Outpatient Lab Work
Please draw CHEM-7, Calcium and Albumin.
ICD10 Code: ___
Fax Results to Dr. ___: ___
Please draw on ___ or ___.
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Acute compression fracture of C7
Soft tissue mass at T3 extending into spinal canal
Progressive multiple myeloma
Secondary Diagnosis:
CKD Stage IV
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Followup Instructions:
___
Radiology Report
EXAMINATION: DX CERVICAL AND THORACIC SPINES
INDICATION: ___ woman with with multiple myeloma and C-spine fracture
heard crack and increased pain.
TECHNIQUE: 6 views of the cervical and thoracic spine.
COMPARISON: Same-day cervical spine CT, Chest CT ___, Chest
Radiograph ___, Cervical Spine CT ___, and Cervical
Spine radiograph ___ CT torso from ___.
FINDINGS:
Thoracic spine: Again seen, are multiple compression fractures. Compression
fractures of the lower thoracic spine and upper lumbar spine are unchanged
from prior. Known worsening of the T3 fracture seen on same-day CT scan, not
visualized radiographically.
Cervical spine: Patient is status post anterior and posterior spinal fusion
of C3 through C5 with C4 corpectomy and C3-C4 and C4-C5 intervertebral disc
spacers with anterior fixation hardware. Overall hardware has not
significantly changed. Known new C7 fracture not seen radiographically.
Right chest wall port is noted. Known pleural-based soft tissue lesions are
partially visualized, particularly on the right.
IMPRESSION:
1. New C7 and worsening of T3 compression fractures not seen radiographically.
2. Multiple compression fractures of the lower thoracic spine overall
unchanged.
3. Cervical spine hardware. No evidence of hardware fracture or loosening.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ woman with multiple myeloma and C-spine fracture
heard crack and increased pain.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 927 mGy-cm.
COMPARISON: Cervical spine radiographs ___, chest CT ___
cervical spine CT ___.
FINDINGS:
There is a severe compression deformity of the C7 vertebral body, which is new
compared to ___. The C7 vertebral body appears almost completely
replaced by a soft tissue lesion with suggestion of soft tissue extending
posteriorly by a approximately 3 mm. Since prior, there has also been
increased loss of height in the T3 vertebral body without significant bony
retropulsion. There is associated prevertebral soft tissue swelling. The
bones are diffusely demineralized with extensive lytic lesions, consistent
with known history of multiple myeloma. The patient is status post anterior
and posterior spinal fusion of C3 through C5 with C4 corpectomy and C3-C4 and
C4-C5 intervertebral disc spacers. Overall hardware is without evidence of
fracture or loosening.
There is left apical scarring. The thyroid is unremarkable. Right-sided
internal jugular central venous catheter is partially visualized. Right
cervical lymph node has enlarged, currently measuring 2.3 by 1.2 cm (3:64),
previously 1.7 x 0.8 cm.
IMPRESSION:
1. Severe compression deformity of the C7 vertebral body which is new when
compared to chest CT from ___. This vertebral body appears almost
completely replaced by a soft tissue with a suggestion of 3 mm of soft tissue
extension posteriorly.
2. Worsening T3 compression fracture compared to ___.
3. Anterior and posterior spinal fusion hardware is intact.
4. Multiple lytic bony lesions, consistent with known history of multiple
myeloma.
5. Interval enlargement of right cervical lymph node since ___.
Radiology Report
EXAMINATION: MRI CERVICAL AND THORACIC PT21 MR SPINE
INDICATION: History of multiple myeloma with cervical spine fracture with
increased neck pain.
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.
COMPARISON: Cervical spine CT ___. MR cervical and thoracic spine
___. MR thoracic and lumbar spine ___. Cervical
spine CT ___. Numerous cervical spine radiographs dating from ___ through ___. MR cervical spine ___. CT
chest, abdomen and pelvis ___.
FINDINGS:
CERVICAL:
There is susceptibility artifact from anterior and posterior fusion of C3
through C5 with C4 corpectomy with vertebral and intervertebral spacers.
Alignment is maintained. There is diffuse bone marrow replacement throughout
the cervical spine.
There is severe pathologic compression deformity of the C7 vertebral body with
a cortical defect seen posteriorly (2:9) with extra cortical soft tissue
extension posteriorly on the left with 3 mm encroachment on the epidural space
(2:9). This is new compared to ___. There appears to involvement
of the left C7-T1 neural foramen with encasement of the exiting nerve root
(06:24). This also produces mild spinal canal narrowing, though there is no
contact of the ventral cord.
There is a small midline disc protrusion at C5-C6 with focal remodeling of the
ventral spinal cord without underlying signal abnormality. The remainder of
the neural foramina are grossly patent.
Spinal cord is otherwise normal in signal and morphology.
THORACIC:
Alignment is maintained. There is diffuse bone marrow placement throughout
the thoracic spine.
There is moderate pathologic compression deformity of the T3 vertebral body
with posterior cortical defect with 6 mm extra cortical soft tissue extension
posteriorly into the epidural space (2:7), progressed since ___. Soft
tissue compresses the ventral cord with extension to the bilateral neural
foramina, producing severe spinal canal and bilateral neural foraminal
narrowing. There is compression of the spinal cord, with displacement
posteriorly, without underlying cord signal abnormality.
Mild pathologic compression of the T8 vertebral body, severe compression of
the T9 vertebral body, mild superior endplate compression the T10 vertebral
body and mild compression of the T11 vertebral body given difference in
technique appear unchanged from the CT examination from ___. There is
unchanged severe compression deformity of the L1 vertebral body with unchanged
6 mm of bony retropulsion on the left in conjunction with ligamentum flavum
hypertrophy producing unchanged moderate spinal canal narrowing.
There is a posterior cortical defect of the T11 vertebral body with roughly 4
mm of extra cortical soft tissue extension posteriorly, encroaching into the
epidural space, extending along the pedicle, though not appearing to involve
the neural foramen (14:7).
Mild pathologic compression deformity of the L3 vertebral body and moderate
superior endplate compression of the L4 vertebral body appear unchanged from
___.
Fatty replacement of the T12 and L2 vertebral bodies unchanged, with the
exception of a new 7 mm marrow replacing lesion in the superior aspect of the
T12 vertebral body (10:9).
Overall marrow replacing lesions have progressed since ___.
There are posterior disc bulges at T5-T6, T6-T7, T7-T8, T8-T9, T9-T10, T10-T11
and T11-T12 levels which in conjunction with ligamentum flavum hypertrophy
produce mild spinal canal narrowing at the T7-T8, T8-T9 and T9-T10 levels.
There is moderate bilateral neural foraminal narrowing bilaterally at a T8-T9
and T9-T10 levels. The remainder of the neural foramina appear patent without
moderate or severe narrowing.
Spinal cord is normal in signal. Conus medullaris terminates of the T12
level.
OTHER: There is a large expansile lesion of the right posterior eighth rib
with extra cortical soft tissue extension, partially visualized measuring at
least 8.1 x 4.4 cm (13:25), roughly similar to the ___ examination.
Other marrow replacing rib lesions with some areas of expansion and extra
cortical soft tissue are partially imaged and better characterized on the ___ CT examination. The visualized retroperitoneum is grossly unremarkable.
IMPRESSION:
1. Diffuse bone marrow replacement throughout the visualized osseous
structures compatible with diffuse myelomatous involvement, progressed since
___. Note that with near complete involvement of numerous vertebral
bodies, the patient is at risk of additional fractures or worsening collapse.
2. Severe pathologic compression deformity of the C7 vertebral body, new since
___, with 3 mm posterior extra cortical soft tissue extension into
the epidural space with encasement of the left C8 nerve root.
3. Progression of a moderate pathologic compression deformity of the T3
vertebral body since ___ with a 6 mm soft tissue extension into the
epidural space producing severe spinal canal and bilateral neural foraminal
narrowing with spinal cord compression. Note that with diffuse involvement of
the vertebral body, the patient is at risk for abrupt collapse with worsening
compression of the spinal cord, and close clinical followup for worsening
symptomology is advised.
4. Unchanged mild pathologic compression deformity of the T11 vertebral body,
now with 4 mm extra cortical soft tissue extension into the epidural space
along the left pedicle.
5. Unchanged pathologic compression fractures of T8, T9, T10 and L1 as
described in detail above.
6. Large expansile lesion of the right posterior eighth rib with extra
cortical soft tissue extension, roughly similar to the ___ examination.
7. Normal spinal cord signal.
8. Degenerative changes, as detailed above, with multilevel spinal canal and
neural foraminal narrowing.
9. Postsurgical changes from anterior and posterior fusion of C3 through C5
with C4 corpectomy and intervertebral spacers.
RECOMMENDATION(S): The T3 vertebral body compression fracture with soft
tissue extension produces adjacent spinal cord compression, and is at risk for
further collapse and increasing compression of the spinal cord. Close
clinical attention to worsening symptomatology is advised.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 11:31 AM, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT T-SPINE W/O CONTRAST
INDICATION: ___ year old woman with refractory multiple myeloma, known C7
fracture, bony pain throughout body. Please eval for fractures/lytic lesions.
TECHNIQUE: Non-contrast helical multidetector CT the thoracic spine was
performed. Soft tissue and bone algorithm images were generated. Coronal and
sagittal reformations were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.1 s, 32.9 cm; CTDIvol = 40.2 mGy (Body) DLP =
1,292.3 mGy-cm.
Total DLP (Body) = 1,292 mGy-cm.
COMPARISON: MRI cervical and thoracic spine of ___.
CT chest of ___.
FINDINGS:
There are 12 rib-bearing vertebrae.
Lytic lesions are present diffusely throughout the thoracic spine and imaged
ribs, corresponding to the diffuse bone marrow infiltration on the preceding
MRI.
ACDF is partially visualized at C5; it is demonstrated to extend from C3
through C5 on the preceding cervical spine MRI.
There is a pathologic fracture of C7 vertebral body with moderate loss of
height and retropulsion, as seen on the recent MRI, progressed since the ___ CT. There is associated erosion of the posterior cortex with an anterior
epidural mass.
Moderate compression deformity of the T3 vertebral body due to an associated
large lytic lesion (7:25) has progressed since ___. There is
associated erosion of the right lateral and posterior endplates, and new
retropulsion with an anterior epidural mass, as seen on the preceding MRI.
T4 vertebral body demonstrates mild unchanged loss of height. There is an
expansile lytic lesion of the right T4 transverse process.
The moderate T5 vertebral body loss of height has not significantly changed
since ___. However, pathologic fracture of the superior posterior
corner of T5 with minimal retropulsion of a cortical fragment, image 7:27, is
new compared to ___. There is also erosion of the right and left
lateral endplates. There is a non expansile lytic lesion of the right T5
transverse process, 3:32.
Moderate anterior compression deformity of T6 is similar to ___.
Expansile lytic lesion in the T6 spinous process is similar to ___.
There is a pathologic fracture through the non expansile lytic lesion of the
right T6 transverse process, 3:38.
Mild to moderate compression deformity of the T8 is unchanged compared to ___. There is erosion of the anterior, right lateral, and left lateral
endplates.
Severe compression deformity of T9 with retropulsion appear unchanged compared
to the ___ CT. There is erosion of the superior, inferior, and
anterior endplates.
T10 vertebral body demonstrates mild loss of height with a right superior
endplate defect and mild retropulsion of the right superior corner, unchanged.
In combination with T10-T11 facet arthropathy and ligamentum flavum
thickening, this results an moderate spinal canal narrowing.
T11 vertebral body demonstrates mild to moderate loss of height, similar to
the prior chest CT, with erosion of the anterior and left lateral endplates.
Lytic lesions are seen in multiple included posterior ribs. The large right
pleural mass contiguous with the right seventh posterior rib lytic lesion is
again partially visualized. There is a chronic healed fracture of the right
posterior tenth rib.
Concurrent lumbar spine MRI is reported separately.
Linear fibrosis is again seen in the partially visualized upper lobe of the
left lung, extending from the apex to the mediastinum. Linear scarring is
again seen in the partially visualize basal left lower lobe.
There are several small, faintly hyperdense foci, up to 2.5 mm, in the
medullary region of the partially visualized kidneys, not clearly seen on the
noncontrast abdominal CT from ___. It is not clear whether these
represent mild medullary nephrocalcinosis versus milk of calcium in tiny cysts
or calyces.
IMPRESSION:
1. Numerous lytic lesions throughout the visualized bones with multiple
pathologic fractures, as detailed above.
2. Compared to ___, there is increased loss of height at C7 and T3,
with new retropulsion and anterior epidural masses at these levels, as seen on
the ___ MRI.
3. T5 vertebral body demonstrates unchanged moderate loss of height compared
to ___, but pathologic fracture of the posterior superior corner with
a minimally retropulsed cortical fragment is new.
4. Large pleural mass contiguous with the right seventh posterior rib lytic
lesion is again partially visualized.
5. Several small, faintly hyperdense foci, up to 2.5 mm, in the medullary
region of the partially visualized kidneys, not clearly seen on the
noncontrast abdominal CT from ___, which may represent mild medullary
nephrocalcinosis versus milk of calcium in tiny cysts or calyces.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST
INDICATION: ___ year old woman with refractory multiple myeloma and known C7
fracture, bony pain throughout body. Please evaluate for fractures/lytic
lesions.
TECHNIQUE: Non-contrast helical multidetector CT of the lumbar spine was
performed. Soft tissue and bone algorithm images were generated. Coronal and
sagittal reformations were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.1 s, 29.6 cm; CTDIvol = 40.2 mGy (Body) DLP =
1,159.8 mGy-cm.
Total DLP (Body) = 1,160 mGy-cm.
COMPARISON: Cervical and thoracic spine MRI, ___.
CT abdomen pelvis of ___.
FINDINGS:
There are 4 lumbar-type vertebrae. There is no transitional anatomy in the
upper sacrum.
Lytic lesions are again seen throughout the visualized bones, including the
lower thoracic spine, lumbar spine, upper sacrum, and medial iliac bones.
Concurrent thoracic spine MRI is reported separately.
There is complete compression of the L2 vertebral body with vertebra plana
deformity and left paracentral retropulsion resulting in mild spinal canal
narrowing, similar to the prior abdominal/ pelvic CT allowing for differences
in technique.
Mild superior endplate deformity of the L3 vertebral body with a pathologic
fracture of the anterior superior corner are similar to the prior
abdominal/pelvic CT allowing for differences in technique.
L4 vertebral body superior endplate deformity with mild to moderate loss of
height appears unchanged.
The largest visualized lytic lesion in the right ilium is slightly expansile
without evidence for pathologic fracture, 3:62, similar to the prior
abdominal/ pelvic CT. The largest visualized lytic lesion in the left ilium
is slightly expansile with a dehiscence of the lateral cortex, also similar to
the prior CT, 03:59.
Sacroiliac joints maintain normal width with small osteophytes, indicating
mild osteoarthritis.
Sigmoid diverticula are noted without evidence for acute diverticulitis.
IMPRESSION:
1. 4 lumbar-type vertebrae are present. There is no transitional anatomy in
the upper sacrum.
2. Lytic lesions are again seen throughout the visualized bones.
3. Complete compression of L2 vertebral body, and mild superior endplate
deformities of L3 and L4 vertebral bodies, are unchanged compared to ___.
4. Largest visualized lytic lesion in the right ilium, which is slightly
expansile, and the largest visualized lytic lesion in the left ilium, which is
slightly expansile with dehiscence of the lateral cortex, are also not
significantly changed.
Radiology Report
INDICATION: C3/T6 fusion
TECHNIQUE: Three views of the thoracic spine
COMPARISON: ___
FINDINGS:
There is prior anterior and posterior fusion at the C3 through C5 levels with
C4 corpectomy. Intraoperative radiographs demonstrate placement of additional
rods and pedicle screws to the mid thoracic vertebral body level. The lungs
are opacified. There is a right-sided port. For further details please see
the intraoperative note.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: increawe pressure airway intraoperatively // r/o pntx
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___ on chest x-ray and CT ___.
IMPRESSION:
There is no evident pneumothorax. ET tube is in standard position. Port a
cath tip is obscured by new spinal hardware. Skin staples in the midline are
noted. There are low lung volumes. Cardiomegaly is stable. Ill-defined
bilateral opacities right greater than left are more conspicuous than before,
consistent with pleural lesions, better evaluated on prior CT. Osseous
lesions due to myelomatous involvement was also better evaluated on prior CT
Radiology Report
INDICATION: ___ year old woman with component separation and VHR, intubated
// assess interval change
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Extensive cervicothoracic spinal fusion with pedicular screws and rods in
situ. Right-sided Port-A-Cath in situ with the tip in the mid SVC. ECG leads
on the chest. The heart size appears increased, but similar compared to
prior. No pneumothorax. Mild atelectatic changes seen in the bibasal areas
(left more than right). The pleural based mass in the mid aspect of the right
lung as well as extensive bony lesions were better appreciated on CT.
IMPRESSION:
No significant interval change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with multiple myeloma s/p spinal stabilization
surgery w/ persistent tachycardia // Please eval for pneumonia vs. pulmonary
embolism
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiographs from ___, ___
FINDINGS:
Again seen is spinal fusion hardware, right-sided Port-A-Cath with tip
terminating in the mid to distal SVC, and postsurgical staples overlying the
mediastinum. The mediastinum is largely obscured by hardware. Partially
visualized heart appears unchanged in size. Lung volumes are low. Pleural
based mass at the level of the right mid lung as well as extensive bony
lesions better appreciated on most recent CT of the chest. There is no
pneumothorax or pleural effusion.
IMPRESSION:
The mediastinum and lungs are largely obscured by hardware. Within these
limitations, there is little change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with multiple myeloma s/p spine surgery w/
persistent tachycardia, ambulatory hypoxemia to 91% // Please eval for
pneumonia vs. pulmonary embolism
IMPRESSION:
In comparison to ___ chest radiograph, lung volumes are slightly
larger with improved aeration at the lung bases and apparent decrease in size
of bilateral pleural effusions. No other relevant change in the appearance of
the lungs. Right chest wall mass and multiple skeletal lesions associated
with myeloma have been more fully evaluated by CT.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with multiple myeloma s/p spinal surgery w/
persistent tachycardia, ambulatory hypoxemia, evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Neck pain
Diagnosed with Pathological fracture in neoplastic disease, oth site, init, Secondary malignant neoplasm of bone
temperature: 98.2
heartrate: 110.0
resprate: 18.0
o2sat: 99.0
sbp: 113.0
dbp: 54.0
level of pain: 5
level of acuity: 3.0 | ___ year old woman w/ HTN, CKD, and refractory kappa multiple
myeloma s/p auto HSCT ___ w/ relapse w/ C4 cord compression
from soft tissue mass and path frx (recently treated w/
daratumumab, now on Bortezomib and cyclophosphamide (___),
currently held) w/known extensive spinal lesions requiring
multiple cervical spine surgeries who p/w acute neck pain, found
to have almost complete replacement of C7 by a soft tissue
lesion causing moderate spinal canal stenosis. During this
admission , she had posterior fusion of ___ with removal
of prior hardware.
During her hospital course, she was noted to be slightly more
tachycardic (baseline HR ___, in house up to 120s), with
intermittent low O2 saturations and desaturation with activity.
Given that PE was on the differential, she had ___ U/S and V/Q
scan done showing no DVT and low probability of PE (given CTA
relatively contraindicated with her ESRD). No obvious acute
cause of tachycardia was identified and TTE revealed no
significant changes.
She was also constipated in the perioperative period, improved
with lactulose.
Additionally, she had an elevated calcium and was given IVF and
furosemide. Her ___ count remained low and she got a dose of
neupogen just prior to discharge. She additionally got a unit of
platelets just prior to discharge.
# Spinal cord compression: s/p surgical decompression and fusion
#Tachycardia: Chronic but has been more elevated to 110s-120s in
post-op period. Concern for DVT vs. atelectasis vs. pna. All
studies negative w/ unchanged EKG, ECHO, negative V/Q scan.
# Refractory Myeloma: She is C1D20 Cytoxan/Velcade/Dex. She has
pancytopenia from disease and ___ chemo. She is profoundly
neutropenic with worsening thrombocytopenia. Further tx to be
determined as an outpatient.
# ESRD: Cr stable, baseline 2.1-2.4
# Constipation: perioperative reported constipation, pt w/o
discomfort, passing gas; calcium w/in normal currently. Had BM
w/ lactulose.
# Hypercalcemia: chronically elevated, monitored throughout
admission and got IVF, lasix prior to discharge as well as 10mg
dexamethasone with course of 3 more days dexamethasone.
Pamidronate was not given because of proximity to surgery and
last dose few weeks ago. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / niacin
Attending: ___.
Chief Complaint:
Primary: s/p unwitnessed fall
Secondary: UTI, Bradycardia, Right humerus fractures, Multiple
Nasal Fractures, hypoxia-possible pneumonia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ year-old female with a history of
hypertension, hyperlipidemia, diabetes, hypothyroidism,
depression, and restless leg syndrome who has been admitted
several times over the last ___nd altered
mental status and presents as a transfer from ___ after
being found down in her SNF on ___. The fall was unwitnessed,
but head strike is presumed from a large facial hematoma
surrounding her left eye. She was taken to ___ where she
was ruled out for C-spine injury but found to have a right
humerus fracture and multiple nasal bone fractures and
transferred to ___. In the ED she was given IV pain medication
and found to be bradycardic to the ___ with preserved blood
pressure of 110s/30s-40s.
She has been admitted several times over the last six months. In
___ she was admitted to ___ after a fall and found
to be in acute renal failure with Cr 6.5 w/ radiologic evidence
of right hydronephrosis secondary to a right ureteral narrowing.
She was brought to the OR for placement of a ureteral stent when
she developed atrial fibrillation with both rapid ventricular
rate and pauses of up to 8 seconds. She was treated with
dopamine for bradycardia and ultimately transferred to ___
where she was diagnosed with and treated for E. coli urosepsis
and had an EP consult that diagnosed her with sick sinus
syndrome and tachy-brady syndrome in the setting of active
infection. At that time PPM was deferred due to concern for
hardware infection.
She was admitted to ___ again in ___ with a fall and
altered mental status and was again found to have acute kidney
injury and atrial fibrillation with rapid ventricular rate in
the setting of Klebsiella urosepsis. Her cardiac and renal
disease improved with treatment of her infection and she was
discharged on ___ monitor that recorded normal
sinus rhythm with rates 60-64 over the next week.
In ___ she returned to ___ for ureteroscopy, biopsy,
and stent placement and post-operatively developed VRE
urosepsis, AF w/ RVR, and ___ treated with daptomycin. Her AF
was unresponsive to metoprolol, so she was loaded with
amiodarone and discharged on 200mg PO QD.
The patient does not recall the fall. She denies any chest
pain, shortness of breath, nausea, vomiting, fever, chills,
abdominal pain, or diarrhea at this time.
Past Medical History:
1. Ulcerative colitis, status post proctectomy and ileostomy in
___ on B12 replacement.
2. Hypertension.
3. Hyperlipidemia.
4. Hypothyroidism.
5. Depression.
6. Anxiety.
7. Gastroesophageal reflux disease.
8. Restless legs syndrome.
9. Urinary frequency.
10. Diabetes mellitus, not on any medication.
11. Hyperparathyroidism.
12. Personality disorder.
13. Anemia.
14. Atrophic dermatitis.
15. Hearing loss.
Social History:
___
Family History:
Not contributory
Physical Exam:
Exam on admission
PHYSICAL EXAM:
GENERAL: lying in bed, somewhat somnolent, intermittently
responsive, oriented to place and person
HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no
LAD. Ecchymosis noted periorbitally L>R with minimal tenderness
to palpation
CARDIAC: Bradycardic in the ___, regular rhythm, S1 and S2
normal
PULMONARY: Clear to auscultation, no wheezing crackles or
rhonchi
ABDOMEN: Soft, non-tender, non-distended, bowel sounds present
EXTREMITIES: Painful right upper extremity with posterior
splint. Able to wiggle right fingers. No pain at left upper
extremity and b/l lower extremities. No pain to legs b/l or left
arm.
NEUROLOGIC: Reflexes, strength, and sensation grossly intact.
Cranial nerves II-XII intact.
SKIN: No lacerations or open wounds noted, skin is intact, no
rash
Exam on discharge
Vitals: T97.2 HR61 BP 146/65 RR 18 SpO2 96% on 2L NC
GENERAL: lying in bed, intermittently responsive to commands,
orientated to person, place and time
HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no
LAD. Ecchymosis noted periorbitally L>R with minimal tenderness
to palpation. Ecchymosis noted to forehead. Abrasion noted to
the Left forehead. Tongue appears dark and discolored.
CARDIAC: Regular rate and rhythm, S1 and S2 normal
PULMONARY: Lung sounds difficult to hear due to patient
position
ABDOMEN: Soft, non-tender, non-distended, bowel sounds present
EXTREMITIES: Painful right upper extremity with posterior
splint. Able to wiggle right fingers. Right fingers appear
edematous. Capillary refill time <5 seconds to the digits.
Radial pulse palpable. Ecchymosis noted to the left upper
extremity. No pain at left upper extremity and b/l lower
extremities. No pain to legs b/l or left arm.
NEUROLOGIC: Unable to fully assess due to patient not able to
follow instructions. Cranial nerves II-XII intact.
SKIN: No lacerations or open wounds noted, skin is intact, no
rash
Pertinent Results:
LABS AT ADMISSION
___ 11:50PM BLOOD WBC-10.0 RBC-3.90 Hgb-9.9* Hct-36.1
MCV-93# MCH-25.4* MCHC-27.4* RDW-22.5* RDWSD-75.4* Plt ___
___ 11:50PM ___ PTT-33.1 ___
___ 11:50PM NEUTS-77.3* LYMPHS-15.7* MONOS-5.8 EOS-0.2*
BASOS-0.2 IM ___ AbsNeut-7.72*# AbsLymp-1.57 AbsMono-0.58
AbsEos-0.02* AbsBaso-0.02
___ 11:50PM WBC-10.0 RBC-3.90 HGB-9.9* HCT-36.1 MCV-93#
MCH-25.4* MCHC-27.4* RDW-22.5* RDWSD-75.4*
___ 11:50PM ALBUMIN-3.1* CALCIUM-10.3 PHOSPHATE-4.3
___ 11:50PM cTropnT-0.02*
___ 11:50PM ALT(SGPT)-17 AST(SGOT)-38 ALK PHOS-57 TOT
BILI-<0.2
___ 11:50PM GLUCOSE-132* UREA N-30* CREAT-2.3*#
SODIUM-136 POTASSIUM-5.5* CHLORIDE-107 TOTAL CO2-18* ANION
GAP-17
___ 11:59PM LACTATE-1.7
___ 11:50PM GLUCOSE-132* UREA N-30* CREAT-2.3*#
SODIUM-136 POTASSIUM-5.5* CHLORIDE-107 TOTAL CO2-18* ANION
GAP-17
___ 10:40AM URINE WBCCLUMP-MANY MUCOUS-OCC
___ 10:40AM URINE RBC-178* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-0
LABS AT DISCHARGE
___ 01:05PM BLOOD WBC-9.9 RBC-3.70* Hgb-9.5* Hct-34.1
MCV-92 MCH-25.7* MCHC-27.9* RDW-21.8* RDWSD-72.8* Plt ___
___ 11:50PM BLOOD Neuts-77.3* Lymphs-15.7* Monos-5.8
Eos-0.2* Baso-0.2 Im ___ AbsNeut-7.72*# AbsLymp-1.57
AbsMono-0.58 AbsEos-0.02* AbsBaso-0.02
___ 01:05PM BLOOD Plt ___
___ 04:05AM BLOOD ___ PTT-30.8 ___
___ 01:05PM BLOOD Glucose-118* UreaN-23* Creat-1.3* Na-139
K-4.6 Cl-108 HCO3-22 AnGap-14
___ 04:42AM BLOOD cTropnT-<0.01
___ 01:05PM BLOOD Calcium-10.6* Phos-2.4* Mg-1.9
MICROBIOLOGY LABS
Stool: -C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay. (Reference Range-Negative).
Urine: NO ___
IMAGING
___ RUE film:
IMPRESSION:
Comminuted fracture through the distal right humerus without
intra-articular extension with near full width posterior
displacement of the distal fracture fragment as described above.
Two longitudinally oriented free bony fragments are present
along the fracture line.
Per OSH report (___):
CXR ___: No e/o PTX. Pulmonary edema. Right humerus fx seen but
not completely visualized
CT cspine ___: no fractures and collar cleared @ ___
CT torso ___: CT torso without evidence of acute injury. There
was some stranding noted around the right renal hilum where she
has a stent in place.
CT face ___: nasal bone fxs and extensive facial hematomas.
___ Chest Radiograph
IMPRESSION:
Patient is rotated and there is S-shaped scoliosis. Allowing
the limitations of the study there are lower lung volumes with
increasing bibasilar opacities right greater than left could be
atelectasis or pneumonia. There is no pneumothorax. New right
upper lobe opacities could represent aspiration. Cardiac size
cannot be evaluated. Mediastinal silhouette is unchanged
___ Abdominal Radiograph
IMPRESSION:
1. Grossly unchanged positioning of the right double-J ureteral
stent.
2. Severe multilevel degenerative changes of the lumbar spine,
similar to the recent prior CT.
___ Renal US
FINDINGS:
Note is made that the examination is somewhat limited due to
body habitus and lack of cooperation from the patient. The
right kidney measures 8.7 cm. The left kidney measures 9.7 cm.
There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally. A renal cyst with a thin
septation is seen arising from the interpolar region of the left
kidney measuring 2.2 cm. The ureteral stent is not well
visualized.
The bladder is empty and cannot be evaluated.
IMPRESSION: Technically limited ultrasound as described above.
No hydronephrosis bilaterally
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Pravastatin 80 mg PO QPM
4. rOPINIRole 1 mg PO QPM
5. Sertraline 200 mg PO DAILY
6. TraZODone 200 mg PO DAILY
7. Ipratropium Bromide Neb 1 NEB IH Q6H
8. LORazepam 0.5 mg PO QHS:PRN insomnia
9. Pregabalin 75 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 (One)
tablet(s) by mouth every eight (8) hours Disp #*30 Tablet
Refills:*0
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % Rinse 15 ml twice daily
Refills:*0
4. TraMADol 25 mg PO Q6H:PRN pain Duration: 3 Days
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*6 Tablet Refills:*0
5. Amiodarone 200 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Ipratropium Bromide Neb 1 NEB IH Q6H
8. Levothyroxine Sodium 112 mcg PO DAILY
9. LORazepam 0.5 mg PO QHS:PRN insomnia
10. Omeprazole 20 mg PO DAILY
11. Pravastatin 80 mg PO QPM
12. Pregabalin 75 mg PO BID
13. rOPINIRole 1 mg PO QPM
14. Sertraline 200 mg PO DAILY
15. TraZODone 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Right humerus fracture
2. nasal bone fracture
3. periorbital hematomas
4. Bradycardia
5. UTI
6. Pneumonia
7. Acute heart failure
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: HUMERUS (AP AND LAT) RIGHT
INDICATION: History: ___ with fall, known right humerus fracture // humerus
eval for ortho? humerus eval for ortho?
TECHNIQUE: Frontal and lateral radiographs of the right humerus.
COMPARISON: Radiographs of the right humerus dated ___.
FINDINGS:
There is a comminuted, angulated fracture of the distal humerus, without
definite intra-articular extension. Distal dominant fragment appears
posteriorly angulated. Severe degenerative changes are seen involving the
right glenohumeral joint. There is narrowing of the right acromiohumeral
interval likely reflecting background rotator cuff tear.
IMPRESSION:
1. Comminuted, angulated fracture of the distal humerus.
2. Severe degenerative changes involving the right glenohumeral joint and
probable rotator cuff tear.
Radiology Report
INDICATION: ___ year old woman with fall and right humeral fracture with
?intra-articular extension into elbow. Preoperative planning.
TECHNIQUE: ___ MD CT images were obtained through the right distal humerus
and the elbow without the administration of IV contrast. Coronal and sagittal
reformatted images were also generated.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.3 s, 21.9 cm; CTDIvol = 16.1 mGy (Body) DLP =
352.2 mGy-cm.
Total DLP (Body) = 352 mGy-cm.
COMPARISON: Right elbow radiograph from ___ at 06:43
FINDINGS:
The study moderately limited due to streak artifact from overlying splint
material and technique. Allowing for this, there is a comminuted fracture
through the distal right humerus without intra-articular extension. There is
near full width posterior displacement of the distal fracture fragment with
respect to the proximal humeral shaft. There is likely a longitudinally
oriented free fracture fragment measuring 6 cm along the ulnar aspect of the
fracture (401b:27, 02:12), although the superior portion of this fragment is
not included in the field of view. There is second, smaller free bony
fragment in the posterior and radial aspect of the fracture measuring 2 cm in
craniocaudal ___ (401b:15). No additional fracture is identified. The
radial capitellar and ulnar trochlear joints are well aligned. No large joint
effusion is present. The soft tissues about the elbow are grossly
unremarkable. There is no large bony fragment seen within the cubital tunnel.
IMPRESSION:
Comminuted fracture through the distal right humerus without intra-articular
extension with near full width posterior displacement of the distal fracture
fragment as described above. Two longitudinally oriented free bony fragments
are present along the fracture line.
Detail limited by streak artifact from splint.
s
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new oxygen requirement. // eval for
pneumonia vs. aspiration pneumonitis.
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___.
IMPRESSION:
Patient is rotated and there is S-shaped scoliosis. Allowing the limitations
of the study there are lower lung volumes with increasing bibasilar opacities
right greater than left could be atelectasis or pneumonia. There is no
pneumothorax. New right upper lobe opacities could represent aspiration.
Cardiac size cannot be evaluated. Mediastinal silhouette is unchanged
Radiology Report
INDICATION: ___ year old woman with UTI, s/p fall, evaluate uretal stent
placement
TECHNIQUE: Single supine frontal view radiograph of the abdomen.
COMPARISON: Prior abdominal radiographs dated ___ and CT of the
torso dated ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are notable for severe multilevel degenerative changes,
multilevel compression fractures, lumbar spinal fusion hardware, and partially
imaged intra medullary rods and the proximal femora bilaterally. A right
ureteral double-J stent projects in unchanged location compared with the prior
CT.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. Grossly unchanged positioning of the right double-J ureteral stent.
2. Severe multilevel degenerative changes of the lumbar spine, similar to the
recent prior CT.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman s/p fall with UTI // eval uretal stent
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Renal ultrasound ___.
FINDINGS:
Note is made that the examination is somewhat limited due to body habitus and
lack of cooperation from the patient. The right kidney measures 8.7 cm. The
left kidney measures 9.7 cm. There is no hydronephrosis, stones, or masses
bilaterally. Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally. A renal cyst with a thin septation is
seen arising from the interpolar region of the left kidney measuring 2.2 cm.
The ureteral stent is not well visualized.
The bladder is empty and cannot be evaluated.
IMPRESSION:
Technically limited ultrasound as described above. No hydronephrosis
bilaterally.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: PNA, consolidation, volume overload
TECHNIQUE: AP chest x-ray
COMPARISON: ___
FINDINGS:
There are increasing bilateral pulmonary opacities with relative sparing of
the left apex, which is partially obscured by an overlying tube. There is no
pneumothorax. There is widening of the pleural space bilaterally and blunting
of the costophrenic sulci most likely representing pleural fluid. The heart
appears enlarged. The aorta is tortuous and calcified.
IMPRESSION:
Increasing bilateral pulmonary opacities most likely due to edema. Evidence
of small pleural effusions. Underlying pneumonia is also possible and
clinical correlation is recommended.
Radiology Report
INDICATION: ___ year old woman s/p fall with UTI, probable pneumonia, and
tachycardia // eval for fluid overload
TECHNIQUE: Portable chest radiograph.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The lung volume is small. Pulmonary edema has improved. Bilateral mid to
lower lung opacities are unchanged. Bilateral atelectasis with pleural
effusion are unchanged. Severe cardiomegaly and the mediastinum are
unchanged. No pneumothorax. The spinal hardware is seen with no evidence of
dated dehiscence.
IMPRESSION:
Improved pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with nasal fracture, increasing RR //
aspiration, pulm edema? aspiration, pulm edema?
IMPRESSION:
Comparison to ___. No relevant change is noted. Moderate
cardiomegaly with bilateral pleural effusions of mild to moderate extent as
well as multiple known bony changes. Mild to moderate pulmonary edema
persists.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Unsp superficial injury of unsp part of head, init encntr, Fall on same level, unspecified, initial encounter
temperature: nan
heartrate: 40.0
resprate: 14.0
o2sat: 98.0
sbp: 119.0
dbp: 51.0
level of pain: c
level of acuity: 2.0 | The patient was admitted to the ___ service as a
transfer from ___ after being found down in her nursing
home after an unwitnessed fall. In the trauma bay, she was found
to have symptomatic bradycardia to the mid ___ and hypotensive
to SBPs ___. She received a fluid bolus and atropine 0.5,
then recovered and maintained a HR >40 and SBP>100 for the
remainder of the day. Her imaging demonstrated the following
traumatic injuries: 1) non-operative comminuted, angulated
fracture of distal humerus 2) nasal bone fractures, and
3)extensive facial hematomas. Her tertiary trauma exam revealed
no other traumatic injuries. Per the orthopedic surgery team,
the humeral fracture did not require operation and was treated
with an orthoplast splint with elbow at 90 degrees, including
wrist. She will follow up in ___ clinic in 2 weeks. She
will be non-weight-bearing on the right arm with finger range of
motion as tolerated until then. For the nasal bone fracture,
plastic surgery recommended follow up in their clinic in 2
weeks. The patient was then transferred to the medicine service
for further management of the cause of her fall and her
symptomatic bradycardia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo right handed man with a h/o DM,
CAD/CABG, EtOH abuse, and HTN who presents as an OSH transfer
with left sided weakness. He was last normal last night (___)
when going to sleep. This morning (___) he awoke at 4am to use
the bathroom. He had a fall, described as sliding down the wall
with possible lightheadedness. His wife was unable to help him
up
and called their son-in-law (who lives across the street) to
help
him back to bed. He then went back to sleep. Around 3 hours
later, he awoke for the day. He felt off balance and while
walking to the kitchen and needed to hold onto the wall, but did
not fall. He was able to make toast and coffee. His wife then
awoke and was concerned he had a left facial droop and slurred
speech. The patient also endorsed left facial numbness. She
called her daughter to come over, who agreed about the facial
droop and called ___.
EMS arrived and his blood glucose was 58. He was brought to
___ where exam was concerning for mild left leg
weakness as well. It was initially felt this left sided weakness
and facial droop were from his hypoglycemia but they persisted
despite correction of his blood sugar. He was transferred to
___ for stroke/TIA workup.
For the past ___ wks, he has been feeling tired and lethargic
with barely with enough energy to walk out to car and back. He
saw his PCP 2 wks ago (at the ___ who found elevated LFTs.
Because of this, Mr. ___ stopped drinking alcohol. He denies
withdrawal sx, but has been having lower blood sugars since
stopping drinking.
Over the course of the day, his left leg weakness and facial
droop have improved. His face is currently at baseline. He
continues to have mild decreased sensation on his left face,
though this has improved.
Review of Systems:
Endorses recent sore throat, treated with steroid gargle.
The pt denies headache, loss of vision, blurred vision,
diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness. No bowel or
bladder
incontinence or retention. The pt denies recent fever or chills.
No recent weight loss. Denies cough, shortness of breath.
Denies
chest pain or palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies rash.
Past Medical History:
- Insulin dependent DM c/b neuropathy and proteinuria
- CAD s/p CABG
- CKD with baseline Cr of 1.5
- GERD
- HTN
- gout
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 74 121/61 18 95%
FSBG: 102
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple.
Pulmonary: clear to auscultation bilaterally
Cardiac: RRR, no murmurs
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: decreased hair on legs below knees bilaterally
NEUROLOGIC EXAMINATION
-Mental Status: Alert, oriented. Able to relate history without
difficulty. Language is fluent with normal prosody. There were
no paraphasic errors. Pt. was able to name both high and low
frequency objects on the stroke card except hammock. Able to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3mm bilaterally and sluggish (appears to have
cataracts). VFF to confrontation with finger counting.
Funduscopic exam revealed no papilledema.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch and pin in all
distributions
VII: No NLFF. With smile, bottom lip is asymmetric (lower on
right) but upper lip is symmetric and activates well
bilaterally.
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: full strength in trapezii bilaterally.
XII: Tongue protrudes in midline with full ROM right and left
-Motor: Normal bulk, tone throughout. Mild left action tremor
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
- reflexes: 1+ at right knee, otherwise difficult to elicit
throughout
- Toes were downgoing bilaterally.
-Sensory: No deficits to light touch, pinprick, throughout.
Absent vibration in the toes and ankles bilaterally, present in
knees and hands. Decreased position sense in toes bilaterally.
Temperature gradient in legs bilat.
-Coordination: No dysmetria on FNF or HKS bilaterally.
-Gait: Gait mildly wide based. Able to walk independently but
appears somewhat unsteady.
=========================================
DISCHARGE PHYSICAL EXAM:
T 98.1 BP 145/56 HR 74 RR 18 O2 98% RA
Alert, oriented, interactive, speech fluent, no dysarthria
CN: Pupils 5->3, EOMI, V1-V3 sensation intact to light touch,
strong masseter, Right nasolabial fold flattening, smile
asymmetric with decreased activation on the right. Cheek puff
symmetric. Hearing intact. Palate elevates symmetrically. SCMs
strong. Tongue midline.
Motor: ___ in upper and lower extremities.
Reflexes: 2+ in upper extremities. 1+ in quads, 0 in Achilles.
Toes down.
Sensory: Light touch intact and symmetric in upper and lower
extremities. Pinprick: V1-V3 same, upper extremities same.
Decreased pinprick from feet to halfway up the calves
bilaterally. Decreased pinprick sensation in C2 distribution
over the left side.
Coordination: Bilateral intention tremors. Bilateral decreased
rapid alternating movements. Romberg with slight sway.
Gait: Wide based gait, veers to side with quick turning.
Pertinent Results:
ADMISSION LABS:
___ 09:51PM BLOOD WBC-9.1 RBC-3.34* Hgb-9.8* Hct-29.4*
MCV-88 MCH-29.3 MCHC-33.3 RDW-15.8* RDWSD-50.2* Plt ___
___ 09:51PM BLOOD Neuts-73.5* Lymphs-14.8* Monos-9.6
Eos-1.2 Baso-0.2 Im ___ AbsNeut-6.65* AbsLymp-1.34
AbsMono-0.87* AbsEos-0.11 AbsBaso-0.02
___ 09:51PM BLOOD Glucose-102* UreaN-41* Creat-1.7* Na-136
K-4.1 Cl-99 HCO3-24 AnGap-17
___ 09:51PM BLOOD ALT-54* AST-61* CK(CPK)-422* AlkPhos-281*
TotBili-0.6
___ 09:51PM BLOOD CK-MB-5 cTropnT-0.04*
___ 07:03AM BLOOD Calcium-8.6 Phos-2.4* Mg-1.7 Cholest-124
___ 09:51PM BLOOD Albumin-3.3*
___ 07:03AM BLOOD Triglyc-199* HDL-19 CHOL/HD-6.5
LDLcalc-65
___ 09:51PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
IMAGING:
MRI/A BRAIN ___:
No acute infarct. Normal cerebral and cervical vasculature.
MRI C-SPINE ___:
1. No evidence of C2 vertebral body lesion. Mild, asymmetric
fluid in the
right C1-2 articulation may be contributing to the patient's
symptoms.
2. Advanced degenerative changes of the cervical spine,
superimposed on a
small spinal canal.
DISCHARGE LABS:
___ 07:03AM BLOOD WBC-7.8 RBC-3.35* Hgb-9.5* Hct-30.0*
MCV-90 MCH-28.4 MCHC-31.7* RDW-15.9* RDWSD-52.3* Plt ___
___ 07:03AM BLOOD Glucose-271* UreaN-35* Creat-1.5* Na-135
K-4.6 Cl-98 HCO3-24 AnGap-18
___ 07:03AM BLOOD ALT-56* AST-56* CK(CPK)-333* AlkPhos-268*
___ 07:03AM BLOOD %HbA1c-PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Pregabalin 150 mg PO BID
3. Glargine 70 Units Breakfast
Glargine 80 Units Bedtime
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
4. Terazosin 15 mg PO QHS
5. Allopurinol ___ mg PO DAILY
6. Aspirin 162 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Nortriptyline 75 mg PO QHS
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Amlodipine 10 mg PO DAILY
11. Atorvastatin 80 mg PO QPM
12. Omeprazole 20 mg PO DAILY
13. Docusate Sodium 100 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 162 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Docusate Sodium 100 mg PO DAILY
5. Glargine 70 Units Breakfast
Glargine 80 Units Bedtime
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Pregabalin 150 mg PO BID
9. Allopurinol ___ mg PO DAILY
10. Furosemide 20 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Nortriptyline 75 mg PO QHS
13. Terazosin 15 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Occipital neuralgia
Gait ataxia
Elevated creatinine kinase
Secondary diagnosis:
Diabetes
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: MRI AND MRA BRAIN AND MRA NECK
INDICATION: Evaluate for acute infarct in a patient with left facial droop
and numbness which resolved.
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of 19 mL of
MultiHance intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: None.
FINDINGS:
MRI Brain:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. Prominent ventricles and sulci are age appropriate. There is
no abnormal enhancement after contrast administration. Major intracranial
flow voids are preserved.
MRA brain: The intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm formation. There is a prominent right posterior communicating
artery. The left is either hypoplastic or absent.
MRA neck: The common, internal and external carotid arteries appear normal.
There is no evidence of internal carotid artery stenosis by NASCET criteria.
The origins of the great vessels, subclavian and vertebral arteries appear
normal bilaterally. A 2 vessel arch is noted. The right vertebral artery is
mildly dominant.
Artifact from prior median sternotomy is noted.
IMPRESSION:
No acute infarct. Normal cerebral and cervical vasculature.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST
INDICATION: Evaluate for C2 lesion in a patient with numbness over the C2
distribution.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were then performed.
COMPARISON: None.
FINDINGS:
There is normal alignment. Multilevel degenerative changes are superimposed
on a congenitally small spinal canal. At each level, a disc osteophyte
complex contributes to mild spinal canal stenosis and uncovertebral spurring
produces significant, moderate to severe bilateral neural foraminal narrowing.
No individual level is better or worse than the others. Asymmetric fluid
within the right C1-2 reticulation appears degenerative, but may be
contributing to the patient's pain.
IMPRESSION:
1. No evidence of C2 vertebral body lesion. Mild, asymmetric fluid in the
right C1-2 articulation may be contributing to the patient's symptoms.
2. Advanced degenerative changes of the cervical spine, superimposed on a
small spinal canal.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Weakness, Hypoglycemia, Transfer
Diagnosed with OTHER MALAISE AND FATIGUE
temperature: 98.1
heartrate: 74.0
resprate: 18.0
o2sat: 95.0
sbp: 121.0
dbp: 61.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old right-handed man with a h/o DM,
CAD/CABG, EtOH abuse, and HTN who presented as described in the
HPI with acute onset gait ataxia, reported left facial droop and
L facial numbness in the setting of hypoglycemia.
#NEUROLOGY
On the morning of admission, exam was notable for decreased
sensation in the C2 region on the left scalp, in addition to a
peripheral neuropathy with loss of pinprick to mid shin and
impaired proprioception. Face was assymetric (with subtle R NLF
flattening), but there was no left facial droop. He had a mild
bilateral upper and lower extremity ataxia, he ambulated with a
wide based gait. MRI revealed small vessel disease but no
evidence of acute stroke. Based on history, exam as above, and
that patient himself did not think that he had left weakness at
any point, TIA was thought to be possible, but less likely. More
likely was worsening of chronic deficits due to small vessel
disease, neuropathy ___ diabetes) and chronic mild bilateral
ataxia (alcohol related). Telemetry monitoring was unremarkable.
HbA1c was 8.6%, LDL 65. He was continued on ASA 162mg daily.
Regarding left C2 vs occipital nerve distribution sensory loss -
MRI of the cervical spine was performed showing extensive
arthritis with multilevel foraminal stenosis. In the setting of
diabetes (which predisposes to compressive neuropathies)external
compression due to sleeping position or with fall prior to
admission was thought to be the etiology of his symptoms. This
will likely slowly resolve with no intervention.
#CV, history of CAD - As above, home ASA continued, as well as
half-dose MTP and atorvastatin. Troponin was mildly elevated to
0.04 on admission but downtrended. He was asymptomatic with no
CP or SOB, troponinemia likely ___ CAD in the setting of CKD.
#HTN: Half-dose MTP and home dose amlodipine contined on
admission for permissive HTN, continued on home dose of both at
time of discharge.
#DM on insulin at home. Complicated by DM neuropathy.
- halved dose of insulin given hypoglycemia on admission. Given
subsequent hyperglycemia, home dose of insulin was resumed. He
was discharged on his home dose of insulin. Metformin was held
given CKD and contrast load, was resumed upon discharge. He was
also continued on Pregabalin 150 mg PO/NG BID per home dose.
#CKD: baseline Cr 1.6. Admission Cr 1.5.
#Elevated CPK: Up to 422 on admission, thought to be related to
patient's fall though no history of prolonged down time. This
downtrended, PCP was informed.
#Transaminitis: likely related to alcohol abuse, stable from
outpatient labs.
#Alcohol abuse: No withdrawal symptoms during admission.
Counseled on refraining from alcohol which patient confirmed he
had been doing for the past two weeks. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers, Diarrhea, abdominal pain
Major Surgical or Invasive Procedure:
-Flex Sigmoidoscopy with biopsies
-___ guided drainage of intraabdominal fluid collection
History of Present Illness:
___ h/o UC who presents from ___ for possible pelvic
abscess, fever. Patient initially presented last week to ___
with complaints of fever. Patient has had persistent fever since
discharge from ___ and represented to the ___.
Patient had CT abdomen/pelvis which showed a possible abscess
and portal vein thrombosis. Patient w/ poor apetite. + nausea, 1
episode of vomiting. Non-bloody/non-bilious. Pt is reporting
fevers up to 102 over the past week. He is also reporting "chest
pain", but points to his abdominal RUQ. He states that they are
sharp pains that come and go throughout the day. He has been
having 2 episodes of diarrhea daily which are sometimes bloody.
1 episode of emesis over the past week. He denies oral ulcers,
skin changes, joint pain, visual changes
Pt recently seen in ___ for 11 days of subjective
fevers,
fatigue and poor appetite. Some rhinorrhea and has developed a
cough with some associated left sternal chest pain. He underwent
a CTA chest which was unremarkable for a PE and only showed a
small pleural effusion. He was discharged with presumptive viral
URI with PCP follow up. ___ recently underwent colonoscopy in
___ for continued diarrhea which showed severe inflammation.
Biopsies were taken to rule out dysplasia and CMV, and C.Diff
was also tested for. This finding was taken as a failure of
Remicaid and patient was then switched to humira
In regards to his UC history, patient was diagnosed ___ years
prior and was started on mesalamine with no effect. He failed
remicaide treatments as well and was put on ___. His GI
physician recently stopped his ___ a few days prior due to his
abdominal pain. He has been on a month long steroid taper,
currrently pred 5 mg daily which he is supposed to finish
___.
In the ___, initial VS were 101.4 96 118/76 20 98% . Received
ciprofloxacin, tylenol, and morphine. Labs showed a WBC of 19.9
and Hct of 30, mild transaminitis and AP of 400. INR was noted
to be 1.5 and lactate was normal. Blood cultures were taken
REVIEW OF SYSTEMS:
Denies headache, vision changes, rhinorrhea, congestion, sore
throat, cough, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
All other 10-system review negative in detail.
Past Medical History:
Ulcerative colitis
Social History:
___
___ History:
Daughter with type 1 diabetes, no hx of GI disorders
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 99.2 150/82 119 16 96% RA
GEN - Alert, oriented, no acute distress
HEENT - NCAT, MMM, EOMI, sclera anicteric, OP with mild
ulceration in left buccal mucosa
NECK - supple, no JVD, no LAD
PULM - CTAB, no w/r/r
CV - RRR, S1/S2, no m/r/g
ABD - somewhat distended, mildly tender in LUQ
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally
NEURO - CN II-XII intact, motor function grossly normal
SKIN - no ulcers or lesions
Pertinent Results:
Admission Labs
___ 02:32PM ___ PTT-33.1 ___
___ 02:32PM PLT COUNT-493*
___ 02:32PM WBC-19.9* RBC-3.41* HGB-9.6* HCT-30.0* MCV-88
MCH-28.2 MCHC-32.0 RDW-16.5
___ 02:32PM NEUTS-90.3* LYMPHS-6.1* MONOS-3.3 EOS-0.1
BASOS-0.1
___ 02:32PM ALBUMIN-3.0*
___ 02:32PM ALBUMIN-3.0*
___ 02:32PM estGFR-Using this
___ 02:32PM GLUCOSE-91 UREA N-10 CREAT-0.7 SODIUM-134
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-24 ANION GAP-17
___ 02:49PM LACTATE-1.2
___ 02:49PM LACTATE-1.2
___ 11:34PM ALT(SGPT)-74* AST(SGOT)-47* ALK PHOS-346* TOT
BILI-1.3
Discharge Labs
Reports
MRI
Medications on Admission:
1. Furosemide 20 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Zolpidem Tartrate 10 mg PO HS
4. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC BID
RX *enoxaparin 80 mg/0.8 mL 0.8 mL SQ twice a day Disp #*14
Syringe Refills:*0
2. Outpatient Lab Work
Please check CBC, Chem 7 and LFT's on ___ and fax
results to ___.
3. ertapenem *NF* 1 gm IV ONCE Duration: 1 Doses Reason for
Ordering: first dose inhouse will dc with ertapenem
You should take this medication daily until you see the ID
doctors who ___ direct the course.
RX *ertapenem [Invanz] 1 gram 1 gm IV daily Disp #*30 Gram
Refills:*0
4. Citalopram 20 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Zolpidem Tartrate 10 mg PO HS
7. Outpatient Lab Work
Please have your INR drawn on ___ and have results faxed to
your primary care doctor Dr. ___. His fax # is ___.
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
9. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
-Diverticular abscess with liver microabscesses
-Portal Vein Thrombosis
Secondary
-Ulcerative colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
AP CHEST, 8:09 A.M. ON ___
HISTORY: ___ man with severe left upper quadrant pain. Known portal
venous thrombosis and ulcerative colitis, retroperitoneal mass. Rule out air
under the diaphragm.
IMPRESSION: AP semi-erect chest compared to ___:
No free subdiaphragmatic gas. Moderate cardiomegaly, pulmonary and
mediastinal vasculature all increased indicating biventricular cardiac
decompensation on the verge of pulmonary edema. Small bilateral pleural
effusions are presumed. No pneumothorax.
Radiology Report
HISTORY: ___ man with left upper quadrant abdominal pain, known
portal vein thrombosis and ulcerative colitis who presents for evaluation of
perforation or obstruction.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
Upright and supine images of the abdomen demonstrate nonspecific gas in
throughout the small and large bowel. There is no evidence of bowel
distention. There is no free air or pneumatosis. There is a compression
deformity at T12 which appears to be stable compared to the chest CTA from ___. There are no soft tissue calcifications.
IMPRESSION:
No definite evidence of perforation or obstruction.
Radiology Report
INDICATION: History of ulcerative colitis, now with thrombosis of the left
portal vein complicated by liver ischemia, here to evaluate for liver abscess.
COMPARISON: CT of the abdomen and pelvis with contrast performed at ___
___ on ___.
TECHNIQUE: Limited abdominal ultrasound.
FINDINGS: There is a large geographic area of heterogeneously hypoechoic
liver parenchyma involving the majority of the enlarged left lobe of the liver
consistent with an area of ischemic liver. No focal fluid collections are
identified within this geographic area, which is grossly unchanged from the CT
of ___, allowing for differences in technique. Thrombosis of the left
portal vein is redemonstrated on color Doppler analysis. The main portal vein
is patent with normal hepatopetal flow.
In segment V of the liver, there is a hyperechoic lesion abutting the
gallbladder fossa measuring 1.6 x 1.5 x 1.1 cm, which is most compatible with
a benign hemangioma. Adjacent to this is a slightly tubular focal fluid
collection in segment V measuring 1.7 x 1.7 x 0.6 cm, which appears to
correspond to a focal hypodensity on the CT, seen on series 2, image 42. An
ill-defined slightly hypoechoic lesion in segment V/VIII of the liver measures
6 x 1.5 x 1.1 cm and may correspond to a hypodensity seen on series 2, image
25 of the most recent CT. A coarsely calcified hypoechoic region at the
diaphragm is also seen on the CT and corresponds to an old calcified hematoma.
No intrahepatic biliary dilation is seen. The common bile duct is slightly
patulous, measuring 7 mm in diameter. The gallbladder is distended with
numerous shadowing stones, some of which appear adherent to the non-dependent
wall of the gallbladder on image 13. Where seen, the gallbladder wall
interspaced with the liver does not appear thickened or edematous. The spleen
is borderline enlarged, measuring 12.6 cm. The visualized head of the pancreas
is unremarkable. The neck, body and tail of the pancreas are obscured by
overlying bowel gas and cannot be evaluated.
A small left pleural effusion is noted.
IMPRESSION:
1. Minimal 1.6-cm focus of fluid pocket in segment V.
2. Large geographic area of heterogeneous parenchyma in the left hepatic lobe
suggesting an area of ischemic liver. Superinfection is not excluded, but no
focal or drainable fluid collection is identified. The appearance is not
significantly changed from the preceding CT allowing for differences in
technique. Further imaging with MR may be helpful.
3. Persistent thrombosis of the left portal vein.
4. 1.6-cm hemangioma in segment V and probable old calcified hematoma at the
right hepatic dome.
5. Indeterminate hypoechoic lesion in segment V/VIII. Attention on followup
imaging is recommended with MRCP.
6. Small left pleural effusion.
Radiology Report
HISTORY: Ulcerative colitis, fevers and leukocytosis with retroperitoneal
collection seen on CT scan. Portal vein thrombosis. Evaluate for
retroperitoneal mass versus abscess.
COMPARISON: CT dated ___ and MRI dated ___.
TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 Tesla
magnet including dynamic 3D imaging obtained prior to, during and after the
uneventful intravenous administration of 7 mL of Gadavist.
FINDINGS:
ABDOMEN:
There are extensive filling defects within the segmental branches of the left
portal vein in segments II and III, consistent with extensive portal vein
thrombosis (sequence ___ image 61). There are also filling defects within
subsegmental portal vein branches within segments V/VIII (sequence ___ image
70) and inferiorly in segment V (sequence ___ image 107). However, the area
of thrombosis within the inferior aspect of segment V is much less evident
than on the previous CT. Distal to the portal vein thrombus within segments
II and III of the liver, there are multiple bulbous areas of non-enhancement
peripherally within the liver (for example, sequence ___ image 42) which
possibly represent small microabscesses. An area of linear non-enhancement is
identified inferiorly in segment V (sequence ___ image 115) and has decreased
in size since the previous CT. There is also a rounded area of peripheral
hypoenhancement in segment V measuring 1.6 cm (sequence ___ image 110) which
appears similar to the previous CT.
There is high signal on T2 within the parenchyma surrounding the areas of
portal vein thrombosis in segments II and III (sequence 14 image 18), in
segment V/VIII (sequence 14 image 25 and inferiorly in segment V (sequence 16
image 14). These areas demonstrate arterial phase enhancement post-contrast
(for example, sequence ___ image 42) and also demonstrate restricted
diffusion (sequence 16 image 24, 27, 33). There are also multiple peripheral
areas of arterial phase enhancement throughout the right lobe which have no T2
correlate and do not washout.
There is a 4.1 x 3 cm area of T2 hypointensity within segment VIII of the
liver (sequence 14 image 19). This does not enhance post contrast (sequence
___ image 52) and is unchanged since the previous MRI, likely representing
old hematoma.
The main portal vein, superior mesenteric vein and splenic vein are patent.
No overt air in the portal system. The hepatic arteries are patent. There is
conventional hepatic arterial anatomy. The hepatic veins are patent. No
intra or extrahepatic duct dilatation. Multiple gallstones are identified
within the gallbladder. The gallbladder is otherwise unremarkable.
There is a subcentimeter cyst within the upper pole of the right kidney
(sequence 13 and image 31). There is an accessory right renal artery. The
kidneys are otherwise unremarkable. Adrenals and pancreas are within normal
limits. Normal caliber pancreatic duct. The spleen is within normal limits.
The visualized small and large bowel is unremarkable. No retroperitoneal or
mesenteric adenopathy. There are small bilateral pleural effusions with
bibasal atelectasis.
Note is made of a chronic anterior wedge compression fracture at T12 with
approximately 50% loss of vertebral body height anteriorly (series 10 image
9). Bone marrow signal is normal. No destructive osseous lesions.
PELVIS:
There is a 3.1 x 2.7 cm rounded collection which appears to be arising from
the posterior wall of the sigmoid colon (sequence 3 image 24). This is of
mixed intermediate and high signal on T2 and of mixed intermediate and low
signal on T1. There are foci of blooming within it on the in-phase sequence,
consistent with gas. It demonstrates diffusion restriction (sequence 8 image
54) and demonstrates peripheral rim enhancement post-contrast (sequence 22
image 73) but is centrally nonenhancing. It has decreased slightly in size
since the previous CT at which time it measured 3.6 x 2.9 cm.
The sigmoid colon appears mildly thickened and there is prominence of the
vessels within the sigmoid mesentery. However, the mucosa does not
demonstrate hyperenhancement. There is mild fat stranding surrounding the
upper rectum, which also appears mildly thickened. The rectum is otherwise
unremarkable. A small amount of free fluid is noted within the pelvis.
The bladder and prostate are within normal limits. No pelvic adenopathy.
Severe degenerative disc disease is identified at L5-S1. Bone marrow signal
is normal. No destructive osseous lesions.
IMPRESSION:
1. Extensive portal vein thrombus involving segmental branches of the left
portal vein in segments II and III and subsegmental branches in segments
V/VIII and inferiorly in segment V. These findings have developed since the
previous MRI in ___. They are relatively unchanged since the
previous CT dated ___, although the area inferiorly within
segment V has improved slightly since the previous CT.
2. Innumerable peripheral areas of bulbous nonenhancement within segments II
and III of the liver, many appearing contiguous with distal portal vein
branches, which are a very unusual appearance but suggestive of small
microabscesses or infectious foci (septic thrombophlebitis).
3. High T2 signal and diffusion restriction with arterial phase enhancement
within the parenchyma surrounding the portal vein thrombosis in segments II,
III, V/VIII and V. Multiple peripheral areas of arterial phase
hyperenhancement in the right lobe without T2 correlate. All of these
findings are likely perfusion-related or reactive.
4. 3.1 x 2.7 cm rounded complex lesion arising from the posterior wall of
sigmoid colon which likely represents a small collection and has decreased
slightly in size since the previous CT. This may represent a diverticular
abscess. Similar to the recent CT, there is thickening of the sigmoid colon
and upper rectum with mild surrounding fat stranding, suggestive of colitis.
5. 4.1 x 3 cm T2 hypointense, non-enhancing lesion in segment VIII of the
liver which likely represents an old hematoma and is unchanged since the MRI
in ___.
6. Small bilateral pleural effusions.
7. Small amount of free fluid in the pelvis.
8. Cholelithiasis.
9. Chronic anterior wedge compression fracture at T12.
The above findings were discussed by telephone with Dr. ___
___ (attending hospitalist) at the time of discovery at 17.45, ___. Dr ___
___, cross-sectional interventions fellow on call.
Given the unusual hepatic findings, recommend close followup of hepatic
findings to ensure appropriate stability or response to therapy.
Radiology Report
INDICATION: ___ male with a new PICC line placement.
___.
FINDINGS: Single frontal view of the chest demonstrates interval placement of
a right PICC with tip in the lower SVC. There is stable prominence to the
cardiac silhouette and mild tortuosity to the thoracic aorta. Lung aeration
is significantly improved, as is mild interstial pulmonary edema. There is no
consolidation or large pleural effusion. The extreme right costophrenic angle
is excluded.
IMPRESSION:
1. Right PICC with tip in the lower SVC.
2. Improved mild interstitial pulmonary edema.
Gender: M
Race: AMERICAN INDIAN/ALASKA NATIVE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with PERITONEAL ABSCESS
temperature: 101.4
heartrate: 96.0
resprate: 20.0
o2sat: 98.0
sbp: 118.0
dbp: 76.0
level of pain: 5
level of acuity: 2.0 | ASSESSMENT AND PLAN: This patient is a ___ y/o M with severe
ulcerative colitis s/p failed remicaid treatment who presented
as transfer from ___ for possible intra-abdominal
abscess, portal vein thrombosis, abdominal pain and bloody
diarrhea.
#Fevers/Abdominal pain/diarrhea- Ultimately the patient was
found on MRI to have a diverticular abscess with associated
microabscesses in his liver. UC flare did not fit this picture
with abscess formation and only 2 bowel movements a day. He
underwent a flexible sigmoidoscopy which showed ulcerations,
pseudopolps, and possible fistulous tract. He was placed on
Vanc/Cefepime/Flagyl with GI and ID following. His white count
and fever curve normalized, and he was discharged with a PICC
for an extended course of ertapenem. He will have GI and ID
outpatient followup.
#Portal Vein Thrombosis- He was found on MRI to have an
extensive portal vein thrombosis with hypoperfusion of several
liver segments. Likely from hypercoagulable state from chronic
UC but he will also have outpatient workup for a hypercoagulable
state with hematology. Per GI recs, he was started
anticoagulation with heparin gtt and was discharged with a
lovenox bridge to coumadin.
#Liver function test abnormalities- Patient had mild
transaminitis with elevated alk phos suggesting biliary injury
or dysfunction. U/S had heterogeneous parenchyma in the left
hepatic lobe suggesting an area of ischemic liver which could be
contributing. ___ have had a component of portal vein thombosis
causing liver injury. On discharge, transaminases trended to
normal while alk phos trended to near normal.
# Hypoxia: Initially had O2 sats in the low ___ with CXR showing
evidence of edema on CXR. It was thought to be likely ___ fluids
and drips. Resolved after IV lasix on ___
# Ulcerative colitis: He was followed by GI in house and it was
decided that his UC treatment would commence again after this
acute infection has resolved. His diarrhea and bloody stools
resolved during his hospital stay. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / gabapentin
Attending: ___.
Chief Complaint:
back pain, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ year old man with CAD, A-fib, AAA s/p EVAR
(___), PAD s/p bypass/angioplasties, HTN, HLD, RA on chronic
steroids, prostate cancer s/p XRT, multilevel lumbar stenosis
and compression fractures s/p L1-2 discectomy and L2 ___
presents with 1 day of abdominal pain and continued soft stools,
as well as chronic back pain.
He's had 5 recent admissions to ___ since ___, detailed
below:
-___ to ___: Cellulitis of the left leg in setting of
neuropathic and aterial lower extremity ulcers and chronic
osteomyelitis of the left ___ toe. Amputation was deferred to
his outpatient podiatrist Dr. ___. Hospitalization was
complicated by urinary retention (discharged with foley in
place) and brief delirium.
-___ to ___: Presented with leg swelling and malaise,
found to have NSTEMI. Cath showed total occlusion of the RCA,
supplied by collaterals; unable to engage LMCA. No intervention
performed. Developed hematuria on heparin gtt, with Hct drop to
19 requiring 3 units PRBCs (which provoke cardiogenic pulmonary
edema); discharged off Plavix.
-___ to ___:
Presented with hematuria in setting of radiation cystitis,
requiring bladder irrigation, complicated again by urinary
retention and A-fib with RVR necessitating ICU transfer. Once
patient was stabilized and transferred out of ICU, he underwent
a cystoscopy, channel TURP, clot evacuation, and fulgeration of
small erythematous areas by urology on ___. After the
procedure, his bleeding was markedly reduced. He was also
treated with ceftriaxone for urosepsis with a course of
ceftriaxone. Had diarrhea this admission but C diff testing was
negative.
-___ to ___ after presenting with 3 weeks of diarrhea,
with fever and leukocytosis on presentation. C diff was positive
and he was treated with 2 week course of oral Vancomycin.
-___ admitted with self-limited episode of bilateral
___ numbness and weakness. Noted to have continued diarrhea, C
diff neg ___.
Since discharge on ___, he continued to have ___ loose
("pudding-like") bowel movements per day but was otherwise doing
raseonably well. He went to pain clinic ___ where he complained
of worsening b/l leg pain, hip pain, and leg weakness (but was
still able to walk with his walker with some pain). On the day
prior to admission, he developed abdominal pain, not worse with
eating. He continued to have soft stools. He did not have any
nausea/vomiting, dark or bloody stools. His sister called his
concierge physician who requested that he present for evaluation
for ischemic colitis.
In the ED, initial vitals were: Temp: 99.1 HR: 89 BP: 111/64
Resp: 18 O(2)Sat: 95 Normal
Labs were notable for: Na 131 (previously nl), WBC 12.2 from 6
on discharge, positive UA (pt with chronic indwelling foley). CT
abd/pelvis showed proctocolitis involving the proximal
descending colon to the level of the rectum appear similar to
___, patent SMA, chronically thrombosed ___. He had no
further episodes of diarrhea while in the ED.
Patient was given: Percoset x2.
Consults: none
On the floor, he is comfortable. He denies any active abdominal
or leg pain. Does continue to have chronic low back pain.
Past Medical History:
- Coronary artery disease, recent NSTEMI ___ managed medically
- Recent transurethral resection of a 3cm bladder tumor
(___),
- Recurrent cellulitis
- Foot ulcers (17 wounds, 2 probe to bone - followed by Dr
___
- Atrial fibrillation (s/p DCCV ___, not currently on
anticoagulation because of thrombocytopenia - only on ASA 325mg)
- AAA s/p EVAR ___
-PAD s/p L fem-AT bypass (___), R profunda-BK pop bypass
(___), L pop and L AT angioplasties (___)
- Hypertension
- Hyperlipidemia
- Rheumatoid arthritis (on chronic steroids)
- Prostate cancer s/p XRT in ___ now in complete remission,
complicated by radiation cystitis
- Lumbar spinal stenosis
- DJD with L2 vertebral compression fracture s/p L1/L2
discectomy and laminectomy with ___ in ___
- Hx of ocular migraines (none for years)
-neuropathy
-rosacea
-Cholelithiasis
-Chronic Thrombocytopenia due to possible myelodysplastic sx vs
ITP
Social History:
___
Family History:
Mother passed away at age ___ of lung cancer.
Father died at ___ of lung cancer.
Uncle died of bladder CA
One sister is ___ - with bladder CA, former smoker,
One daughter ___ and one son ___; healthy.
He denies any neurological conditions running in his family. No
family history of recurrent skin infections, premature CAD, SCD,
recurrent blood clots or strokes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.8 129/60s 75 20 100 RA
General: Alert, oriented, no acute distress, somewhat tangential
at times when recounting recent events. Chronically ill
appearing.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: RRR, S1/S2, III/VI holosystolic murmur at left USB with
radiation to axilla but not carotids; no gallops, or rubs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds
present,mild guarding.
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Multiple bandages in place over bilateral feet.
Neuro: CNII-XII grossly intact, ___ strength upper/lower
extremities, grossly normal sensation, 2+ reflexes bilaterally,
gait deferred.
DISCHARGE PHYSICAL EXAM:
Vitals: 97.9 100-130/60 ___ 16 100 RA
General: Alert, oriented, no acute distress. Chronically ill
appearing.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: RRR, S1/S2, III/VI holosystolic murmur at left USB with
radiation to axilla; no gallops, or rubs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non tender, no guarding.
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Multiple bandages in place over bilateral feet.
Neuro: CNII-XII grossly intact, moving all extremities in bed,
gait deferred.
Pertinent Results:
LABS:
===============
ADMISSION LABS:
___ 01:35PM ___ PTT-27.7 ___
___ 01:35PM PLT COUNT-83*
___ 01:35PM NEUTS-87.3* LYMPHS-3.0* MONOS-6.2 EOS-1.4
BASOS-0.3 IM ___ AbsNeut-10.64* AbsLymp-0.37* AbsMono-0.75
AbsEos-0.17 AbsBaso-0.04
___ 01:35PM WBC-12.2*# RBC-3.23* HGB-8.9* HCT-29.1*
MCV-90 MCH-27.6 MCHC-30.6* RDW-18.2* RDWSD-59.5*
___ 01:35PM estGFR-Using this
___ 01:35PM GLUCOSE-96 UREA N-19 CREAT-0.9 SODIUM-131*
POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-24 ANION GAP-15
___ 01:48PM LACTATE-1.4
___ 06:28PM URINE WBCCLUMP-RARE MUCOUS-RARE
___ 06:28PM URINE RBC-8* WBC-34* BACTERIA-MOD YEAST-NONE
EPI-<1
___ 06:28PM URINE RBC-8* WBC-34* BACTERIA-MOD YEAST-NONE
EPI-<1
___ 06:28PM URINE BLOOD-TR NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
___ 06:28PM URINE COLOR-Yellow APPEAR-Clear SP
___
DISCHARGE LABS:
___ 06:34AM BLOOD WBC-13.9* RBC-3.30* Hgb-9.0* Hct-30.6*
MCV-93 MCH-27.3 MCHC-29.4* RDW-18.1* RDWSD-61.0* Plt ___
___ 06:34AM BLOOD Glucose-78 UreaN-17 Creat-0.8 Na-139
K-4.3 Cl-105 HCO3-22 AnGap-16
___ 06:34AM BLOOD Calcium-8.1* Phos-3.9 Mg-2.0
MICRO:
===============
___ 8:40 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool MORE THAN 12 HRS OLD.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ 2:05PM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
FECAL CULTURE (Final ___: 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.
___ 5:40 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 1:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
===============
___ CXR IMPRESSION:
No evidence of pneumonia or pulmonary edema.
___ CTA
1. Proctocolitis involving the proximal descending colon to the
level of the
rectum appear similar to ___. The etiology of this is
uncertain,
but may represent a chronic infectious, inflammatory, or less
likely ischemic
process. The superior mesenteric artery remains patent. The
inferior
mesenteric artery is chronically thrombosed.
2. Compression deformity of L3 and anterior wedge compression
deformity of L1
are new from ___.
3. Stable appearance of abdominal aortic aneurysm and juxtarenal
bifurcated
aortoiliac stent graft with extensive atherosclerotic vascular
disease, as
described above.
4. Chronic splenic infarcts.
5. Cholelithiasis.
___ L SPINE X RAY FLEXION/EXTENSION
Multiple abnormalities similar to recent CT including
compression fractures at multiple levels of the lumbar spine,
sequela of vertebroplasty, and sacral fracture. Dense material
in the pelvis may be within the GI tract, possibly ingested
material or dental amalgam.
___ KUB
There is a radiopaque foreign body likely within the sigmoid
colon or small
bowel loops.
___ PELVIC X RAYS
No acute fracture. Radiodensity overlying the right iliac bone
is of
uncertain significance and may reflect an ingested substance.
Repeat
radiographs of the abdomen are recommended.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcium Carbonate 500 mg PO QID:PRN heart burn
4. Finasteride 5 mg PO DAILY
5. Furosemide 80 mg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Methylprednisolone 4 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. LOPERamide 2 mg PO QID:PRN diarrhea
12. Potassium Chloride 80 mEq PO DAILY
13. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
14. Torsemide 2.5 mg PO DAILY
15. Digoxin 0.125 mg PO DAILY
16. Florastor (Saccharomyces boulardii) 250 mg oral BID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcium Carbonate 500 mg PO QID:PRN heart burn
4. Finasteride 5 mg PO DAILY
5. Furosemide 80 mg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Potassium Chloride 80 mEq PO DAILY
Hold for K >
8. Tamsulosin 0.4 mg PO QHS
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. LOPERamide 2 mg PO QID:PRN diarrhea
12. Methylprednisolone 4 mg PO DAILY
13. Digoxin 0.125 mg PO DAILY
14. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 11 Days
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*52 Capsule Refills:*0
15. Florastor (Saccharomyces boulardii) 250 mg oral BID
16. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every eight (8) hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
lumbar spinal stenosis
Colitis
L3 Compression fracture
SECONDARY DIAGNOSES:
coronary artery disease
peripheral arterial 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
INDICATION: ___ with abdominal pain, history of CHF, any evidence of
consolidation or edema?
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Cardiomediastinal silhouette including possible mild cardiomegaly is
unchanged. Lungs are clear. Pulmonary vascular engorgement is unchanged.
There is no pleural effusion or pneumothorax.
IMPRESSION:
No evidence of pneumonia or pulmonary edema.
Radiology Report
EXAMINATION: CTA ABD/PEL WANDW/O C W/REONS
INDICATION: ___ year old man with extensive vascular history, presents with
abd pain. Was told by PCP he might have ischemic colitis. // any evidence of
ischemic colitis?
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 4.8 s, 53.0 cm; CTDIvol = 4.0 mGy (Body) DLP = 212.1
mGy-cm.
4) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP =
10.8 mGy-cm.
5) Spiral Acquisition 6.5 s, 51.1 cm; CTDIvol = 16.9 mGy (Body) DLP = 863.2
mGy-cm.
6) Spiral Acquisition 6.5 s, 51.1 cm; CTDIvol = 16.9 mGy (Body) DLP = 863.5
mGy-cm.
Total DLP (Body) = 1,950 mGy-cm.
COMPARISON: CTA abdomen pelvis dated ___, and CT abdomen pelvis
dated ___.
FINDINGS:
VASCULAR:
Again seen is a juxtarenal aortic bi-iliac stent graft of an abdominal aortic
aneurysm. The aneurysm sac appears thrombosed, and measures up to 5 cm in
diameter, unchanged. No endoleak is appreciated. A thrombosed aneurysm of
the left internal iliac artery is also unchanged in appearance. A partially
thrombosed aneurysm of the right common iliac artery appears unchanged. The
origin of the celiac trunk appears widely patent. The bilateral single renal
arteries are patent. Calcified and noncalcified plaque is seen at the origin
of the superior mesenteric artery, as well as throughout the course of the
superior mesenteric artery, which remains patent. There is aneurysmal
dilatation the origin of the inferior mesenteric artery, which is chronically
thrombosed.
There is persistent complete thrombosis of the bilateral superficial femoral
arteries.
LOWER CHEST: A 2 cm nodule in the right lower lobe with associated adjacent
bronchiectasis is unchanged from least ___. No new pulmonary nodules are
identified. The heart does not appear enlarged. There is no pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A
subcentimeter hypodensity adjacent to the gallbladder fossa is too small to
fully characterize, but may represent a cyst, biliary hematoma, or area of
focal fat. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder contains stones, without evidence of gallbladder
wall thickening or pericholecystic fluid.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is enlarged, measuring 14.8 cm. Wedge-shaped areas of
hypodensity within the spleen appear similar to ___, and are
consistent with infarcts. As before, the splenic artery demonstrates
extensive calcified atherosclerotic disease. Trace perisplenic fluid has
decreased in volume over the interval. Several punctate hypodensities within
the spleen appear unchanged, and may represent cysts.
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.
Several simple renal cysts are identified. There is no evidence of stones,
solid renal lesions, or hydronephrosis. There are no urothelial lesions in the
kidneys or ureters. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is under distended, but grossly normal. Small
bowel loops demonstrate normal caliber, wall thickness and enhancement
throughout. There is diffuse wall thickening, mucosal hyperenhancement, and
mild fat stranding involving the proximal descending colon to the level of the
rectum, similar in extent compared to prior. Appendix is resected.
RETROPERITONEUM: Scattered prominent retroperitoneal lymph nodes appear
similar to prior
PELVIS: The bladder is decompressed by a Foley catheter. The bladder wall
appears thickened and trabeculated, which may be in part due to
underdistention. There is no evidence of pelvic or inguinal lymphadenopathy.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: A penile prosthesis with reservoir is in place. The
prostate is not visualized. Seminal vesicles appear grossly unremarkable.
BONES: The bones appear diffusely demineralized. Interval development of a
compression deformity with significant loss of height of the L3 vertebral body
is new from ___. An additional anterior wedge compression deformity
of L1 is also new from ___. Patient is status post kyphoplasty of
L2. Severe degenerative changes are seen within the lumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Proctocolitis involving the proximal descending colon to the level of the
rectum appear similar to ___. The etiology of this is uncertain,
but may represent a chronic infectious, inflammatory, or less likely ischemic
process. The superior mesenteric artery remains patent. The inferior
mesenteric artery is chronically thrombosed.
2. Compression deformity of L3 and anterior wedge compression deformity of L1
are new from ___.
3. Stable appearance of abdominal aortic aneurysm and juxtarenal bifurcated
aortoiliac stent graft with extensive atherosclerotic vascular disease, as
described above.
4. Chronic splenic infarcts.
5. Cholelithiasis.
Radiology Report
EXAMINATION: L-SPINE (WITH FLEX, EXT AND OBL)
INDICATION: Frontal, lateral and flexion extension views of the lumbar spine
appear
TECHNIQUE: Frontal, lateral and flexion extension views.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
There is reversal of normal upper lumbar spine lordosis. There has been
vertebroplasty of L2. Wedge compression deformity of L2 appears slightly
progressed from previous CT were a recent fracture was demonstrated.
Compression deformity also present at L3, similar to prior CT. Mild
anterolisthesis of L5 with respect to S1. Severe L4-5 and L5-S1 degenerative
changes involving degenerative discogenic change and facet joint arthropathy.
There is a aortoiliac stent in-situ. There is vascular calcification. He L3
vertebral body demonstrates mild retropulsion similar to prior CT. There is
no significant dynamic instability identified on flexion extension views.
Fracture along the anterior cortex of the sacrum is seen.
Density projecting over the pelvis may be ingested material, with
considerations including ingested tablet or given the density of this, dental
amalgam.
IMPRESSION:
Multiple abnormalities similar to recent CT including compression fractures at
multiple levels of the lumbar spine, sequela of vertebroplasty, and sacral
fracture.
Dense material in the pelvis may be within the GI tract, possibly ingested
material or dental amalgam.
RECOMMENDATION(S): The impression and recommendation above was entered by Dr.
___ on ___ at 15:38 into the Department of Radiology critical
communications system for direct communication to the referring provider.
Radiology Report
EXAMINATION: BILAT HIPS (AP,LAT AND AP PELVIS) BILATERAL
INDICATION: ___ year old man with right hip and anterior thigh pain // any
fracture any fracture
TECHNIQUE: One view pelvis and two views of each hip
COMPARISON: CT dated ___ of the abdomen and pelvis.
FINDINGS:
There are mild femoral acetabular joint degenerative changes bilaterally
greater trochanteric enthesopathy. No acute fractures noted. There are heavy
vascular calcifications. Incidental note is made of an aortal bi-iliac stent
graft as well as penile prosthesis. A radiodensity overlying the right iliac
bone is of uncertain significance.
IMPRESSION:
No acute fracture. Radiodensity overlying the right iliac bone is of
uncertain significance and may reflect an ingested substance. Repeat
radiographs of the abdomen are recommended.
NOTIFICATION: Findings discussed with Dr. ___ on ___ by
telephone at 16:30, 5 min after discovery of the findings.
Radiology Report
INDICATION: ___ year old man with radiodensity seen on pelvic x rays over
right iliac // characterize radiodensity over right iliac
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
An approximately 11 cm radiopacity projects over the region of the lower mid
abdomen which appears to be within the bowel loops (cecum) on most recent CT
from ___. There are no abnormally dilated loops of large or small
bowel.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable. An aortic stent is noted.
IMPRESSION:
There is a radiopaque foreign body likely within the sigmoid colon or small
bowel loops.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Back pain
Diagnosed with Unspecified abdominal pain, Diarrhea, unspecified
temperature: 99.1
heartrate: 89.0
resprate: 18.0
o2sat: 95.0
sbp: 111.0
dbp: 64.0
level of pain: 7
level of acuity: 2.0 | ASSESSMENT AND PLAN: ___ year old man with A-fib, AAA s/p EVAR
(___), PAD s/p bypass/angioplasties, HTN, HLD, RA on chronic
steroids, prostate cancer s/p XRT, multilevel lumbar stenosis
and compression fractures s/p L1-2 discectomy and L2 ___
presenting with one day of abdominal pain, now improved, and
several days of ___ soft stools per day.
#Lumbar Radiculopathy in setting of L3 Compression Fracture:
Recent imaging confirmed significant L spine disease (MRI),
including new L3 compression fracture, bilateral pedicle
fractures, with retropulsion as well as spinal cord narrowing.
He had hip x rays which showed no fracture and lumbar AP/LAT
flexion/extension XR to assess for dynamic instability which
showed multiple abnormalities similar to recent CT including
compression fractures at multiple levels of the lumbar spine,
sequela of vertebroplasty, and sacral fracture. He was seen by
ortho spine (Dr. ___ who recommended outpatient evaluation
with Dr. ___ possible ___, ___, and wearing TLSO
brace with activity. He continued on his home pain regimen.
#C diff: He had one day of abdominal pain and ___ loose stools
per day prior to admission. C diff returned positive, and he was
started on a 14 day course of PO vanco for recurrent c. diff.
Course to be conclude on ___.
# Pyuria: He had WBC in his UA. Pyuria is expect in the setting
of chronic indwelling foley. He was not started on antibiotics
for his positive UA, and culture grew mixed flora. Foley was
changed per outpatient urologist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetracycline Analogues
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with history of asthma, HTN, CAD, GERD who is
presenting with shortness of breath.
He has not had episodes of shortness of breath like this
before. His symptoms have been ongoing since late ___, when
he developed dyspnea that progressed throughout the day (he
feels relatively good in the morning and is very short of breath
by nighttime), and affected his ability to climb stairs and walk
longer distances. His dyspnea feels like "I can't get enough
air" and "throat tightness."
Of note, he was recently hospitalized here in ___ for
similar symptoms. He was found to have PNA and treated with
antibiotics. Per his outpatient pulmonologist's note (Dr.
___:
"A CXR demonstrated PNA and he was started on
levaquin and prednisone 50 mg. However, his symptoms persisted,
and after two days he was admitted to ___ from ___ for an
asthma exacerbation where he received ceftriaxone and
azithromycin in addition to IV steroids. He was ultimately
discharged home to complete a 10-day prednisone taper and 5
more
days of levaquin. He was then evaluated by his PCP, ___.
___, on ___, at which time he was reporting a general
improvement in his symptoms but ongoing wheezing. The decision
was made at that time to increase his prednisone dose to 20 mg
with an extended taper. One week later, on ___, his
prednisone was decreased further to 10 mg in the setting of
symptom improvement, though after several days he increased the
dose back up to 30 mg given that he continued to wheeze and
have
intermittent episodes of dyspnea."
Since he has been discharged, he has had minimal relief in
symptoms. There was concern that he could not complete an
exercise stress test due to his symptoms. However, his PCP was
concerned that at this point he needs further workup for his
shortness of breath, including for pulmonary and cardiac
etiologies.
He went to ___ at the end of ___ and called his
pulmonologist, on ___ to report worsening shortness of breath.
It was recommended he increase his daily prednisone dose from 10
mg to 20 mg, so he has been continuing on 20 mg ___.
In the ED, initial vitals were: 97.4 F, BP 140/90s, HR ___, RR
20, 99% RA
- Exam notable for: n/a
- Labs notable for: 10.3, Hgb 14.2, plts 256, neg trop, Cr 1.1,
lactate 1.1
- Imaging was notable for: clear chest x-ray
Upon arrival to the floor, patient reports that he has noticed
every time his prednisone is decreased from 20 mg to 10 mg, he
becomes more symptomatic. He was recently diagnosed with asthma,
although he has had some exercise-induced symptoms since he was
a child. There is no family history of lung disease or asthma.
He does have seasonal allergies and irregularly takes Claritin D
for symptoms. He also reports going to an allergiest at one
point "and I was allergic to everything she tested me for." He
has not had anaphylaxis in the past, no lip swelling. He has
been traveling frequently, and most recently was in ___, but
has also been in ___ and ___ and was in ___ ___ years
ago (has gone 36 times in total). Denies exposure to animals
including birds.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Hyperlipidemia
Borderline hypertension
Osteoarthritis
Mild intermittent asthma
s/p knee meniscectomy in ___
s/p lower lumbar surgery in ___.
Social History:
___
Family History:
Father, grandfather and brother with coronary artery disease
with MIs before age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
====================================
General: Alert, oriented, walking around the room with street
clothes on
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD or thyromegaly
appreciated on exam, although ?asymmetry of the left neck.
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: mild wheezes in the anterior lung fields b/l, no
crackles, 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: 98.3 140-160s/80-90s ___ 18 95-96% RA
General: Alert, oriented, walking around the room in no acute
distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD or thyromegaly
appreciated on exam.
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Unlabored breathing. Good air movement. CTA b/l.
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, gait
deferred.
Pertinent Results:
ADMISSION LABS
==========================
___ 08:30PM WBC-10.3* RBC-4.54* HGB-14.2 HCT-43.6 MCV-96
MCH-31.3 MCHC-32.6 RDW-13.4 RDWSD-47.7*
___ 08:30PM NEUTS-71.5* LYMPHS-18.7* MONOS-7.4 EOS-0.8*
BASOS-0.6 IM ___ AbsNeut-7.39* AbsLymp-1.93 AbsMono-0.76
AbsEos-0.08 AbsBaso-0.06
___ 08:30PM PLT COUNT-256
___ 08:30PM CRP-0.9
___ 08:30PM T4-6.2
___ 08:30PM TSH-2.9
___ 08:30PM proBNP-81
___ 08:30PM cTropnT-<0.01
___ 08:30PM estGFR-Using this
___ 08:30PM GLUCOSE-99 UREA N-26* CREAT-1.1 SODIUM-138
POTASSIUM-5.4* CHLORIDE-101 TOTAL CO2-23 ANION GAP-19
___ 08:38PM LACTATE-1.1 K+-4.0
DISCHARGE LABS
====================
___ 04:23AM BLOOD WBC-7.3 RBC-4.29* Hgb-13.2* Hct-41.2
MCV-96 MCH-30.8 MCHC-32.0 RDW-13.2 RDWSD-47.3* Plt ___
___ 04:23AM BLOOD Plt ___
___ 04:23AM BLOOD Glucose-89 UreaN-25* Creat-1.0 Na-140
K-3.8 Cl-105 HCO3-24 AnGap-15
___ 04:23AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.2
CT TRACHEA ___
-No evidence of substantial tracheobronchial malacia.
-Interval resolution of right middle lobe pneumonia. No
suspicious lung
nodules that require follow-up.
STRESS ECHO ___
This ___ year old man with h/o HL and family history
of pre-mature CAD was referred to the lab for evaluation of SOB.
He
exercised for 15.5 minutes on modified ___ protocol and
stopped for
fatigue. The peak estimated MET capacity is 13.3, which
represents an
excellent exercise tolerance for his age. No chest, arm, neck,
back
discomfort or abnormal SOB reported throughout the test. No
significant
ST segment changes noticed throughout the test. Rhythm was sinus
with
rare isolated APBs and two isolated VPBs. Baseline HTN with
appropriate
hemodynamic response to exercise and recovery.
IMPRESSION : No anginal symptoms or ischemic EKG changes to the
achieved
workload. Excellent functional capacity. Baseline HTN. Echo
report sent
separately.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Pravastatin 20 mg PO QPM
3. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
5. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Claritin-D 12 Hour (loratadine-pseudoephedrine) ___ mg oral
DAILY:PRN
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Claritin-D 12 Hour (loratadine-pseudoephedrine) ___ mg
oral DAILY:PRN
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Pravastatin 20 mg PO QPM
6. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
7. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Airway hyper-reactivity
SECONDARY:
Asthma
Pre-hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with CP and SOB// r/o PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION:
No evidence of pneumonia.
Radiology Report
EXAMINATION: CT TRACHEA W AND W/O CONTRAST
INDICATION: ___ year old male with h/o asthma, CAD, GERD, HTN presenting with
shortness of breath 1 month after hospitalization for PNA. // Requesting
dynamic CT of trachea to evaluate for tracheomalacia and other causes for
persistent dyspnea
TECHNIQUE: Multi detector helical scanning of the chest was performed at end
inspiration, reconstructed as contiguous 5.0 and 1.25 mm thick axial and 2.5
mm thick coronal images of the full chest. Multi detector helical scanning of
the chest was repeated during forced expiration, and reconstructed as
contiguous 5.0 and 1.25 mm thick axial images. Endoscopic navigation and
localization images were reconstructed from both end inspiration and dynamic
expiration scanning, and 3D volume renderings were reconstructed from the
expiration scans. Intravenous contrast agent was not employed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.8 s, 43.7 cm; CTDIvol = 14.2 mGy (Body) DLP = 618.5
mGy-cm.
2) Spiral Acquisition 2.6 s, 40.7 cm; CTDIvol = 4.1 mGy (Body) DLP = 165.9
mGy-cm.
3) Spiral Acquisition 2.5 s, 40.2 cm; CTDIvol = 4.1 mGy (Body) DLP = 163.9
mGy-cm.
Total DLP (Body) = 948 mGy-cm.
COMPARISON: CT chest from ___
FINDINGS:
DYNAMIC TRACHEAL IMAGING REPORT
NOW = current study; MRP = most recent prior CT Dynamic Trachea
I. INSPIRATORY TRACHEA
LENGTH from vocal cords/arytenoids to carina: 13.1cm
SHAPE: Horseshoe Roundx Lenticular Sabre-sheath Crescent
Other:_________
Wall thickening: Nx Y : unifocal multifocal max thickness: mm
Abn calcification: Nx Y : unifocal multifocal max thickness: mm
Abn peritrachea: Nx Y : unifocal multifocal
FOCAL NARROWING (STRICTURE)
1. N x Y
II. DYNAMIC TRACHEA
1. At sternal notch
NOW Cor x Sag
INSP: 29 x 22mm 487mm2
EXP: 27 x 22mm 451mm2 I-E/I = 7% decrease
SHAPE during EXP
Horseshoex Round Lenticular Sabre-sheath Crescent Other:_________
2. 2cm above carina
NOW Cor x Sag
INSP: 23 x 21mm 391mm2
EXP: 22 x 19mm 377mm2 I-E/I = 19% decrease
SHAPE during EXP
Horseshoex Round Lenticular Sabre-sheath Crescent Other:_________
III. DYNAMIC BRONCHI
R Main - smallest true diameter
NOW INSP 13mm EXP 13mm
L Main - smallest true diameter
NOW INSP 13mm EXP 10mm
BrI - smallest true diameter
NOW INSP 9mm EXP 5mm
Bronchi: Exp diameter < 3mm
RUL Nx Y
RBT Nx Y
LUL Nx Y
LBT Nx Y
?Air trapping?
Mildx Moderate Severe
CHEST CT
The thyroid gland is homogeneous in attenuation without focal nodularity.
There is no supraclavicular or axillary lymphadenopathy by CT size criteria.
The imaged chest wall is unremarkable.
The imaged upper abdomen demonstrate surgical clips at the gallbladder fossa,
likely from prior cholecystectomy. There is mild circumferential thickening
of the esophagus, possibly from esophagitis. Otherwise, the upper abdomen is
unremarkable. There is no mediastinal or hilar lymphadenopathy by CT size
criteria.
The heart size is within normal limits. Trace pericardial effusion is likely
physiologic. Moderate coronary calcifications in the LAD distribution is
overall unchanged from prior exam. No significant valvular calcifications are
seen.
The ascending and descending aorta are normal in caliber. The main pulmonary
artery is normal in caliber.
There has been interval resolution of ground glass opacities in the right
middle lobe. There are no suspicious lung nodules that require follow-up.
The airways are patent to the subsegmental levels. There is no substantial
collapse of the central airways. There is physiologic degree of air-trapping
for this age group.
There is no suspicious osseous lesion concerning for malignancy or infection.
IMPRESSION:
-No evidence of substantial tracheobronchial malacia.
-Interval resolution of right middle lobe pneumonia. No suspicious lung
nodules that require follow-up.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified
temperature: 97.4
heartrate: 80.0
resprate: 20.0
o2sat: 95.0
sbp: 144.0
dbp: 97.0
level of pain: 0
level of acuity: 3.0 | ___ year old male with h/o asthma, GERD, who presented with
shortness of breath for the past 1 month following a
hospitalization for pneumonia and asthma exacerbation. His
respiratory status was otherwise stable on admission, and he was
admitted for expedited workup for his persistent dyspnea. CT
trachea showed no evidence of substantial tracheobronchial
malacia and interval resolution of right middle lobe pneumonia.
Stress echo was within normal limits. His shortness of breath
was likely related to airway hyper-reactivity following recent
infection, with a prolonged recovery. He was stable for
discharge with close follow up.
#Dyspnea: Patient most likely had a prolonged asthma flare in
the setting of a recent PNA given his symptoms and response to
albuterol and prednisone. However, he seems to be steroid
dependent right now due to difficulty tapering off steroid.
Given prolonged dyspnea that is worse on exertion, we performed
stress testing and TTE ECHO to evaluate for possibility of a
cardiac etiology but both were negative. After discussing with
his outpatient pulmonologist, we decided to proceed with CT
trachea which was negative for tracheobronchial malacia and
revealed interval resolution of right middle lobe pneumonia. His
respiratory status was otherwise stable with good air movement
and w/o wheezing or hypoxia. Symptoms improved during the
admission. Patient will continue on 10mg prednisone, albuterol
nebs, and advair BID, and will follow-up closely with outpatient
providers.
#HTN:
SBPs intermittently elevated during admission, 130s-160s. ___
benefit from outpatient HTN treatment, although unclear if these
are representative of baseline BPs.
CHRONIC ISSUES:
#Primary prevention
Patient continued with aspirin and pravastatin.
#Allergies
Takes Claritin D at home, reports loratidine monotherapy not
effective. Patient was offered trial of fexofenadine 60mg BID.
***TRANSITIONAL ISSUES:***
- Follow up with PCP and pulmonologist
- Further prednisone to be determined by outpatient providers
- ___ monitor blood pressure and consider starting
antihypertensive medications if appropriate
# CONTACT: ___ (wife) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
erythromycin / Tetracycline / Macrolide Antibiotics / lidocaine
Attending: ___.
Chief Complaint:
altered mental status, fever
Major Surgical or Invasive Procedure:
incision and drainage of left thigh hematoma on ___
History of Present Illness:
___ with h/o dementia, HTN who presents with AMS, elevated WBC,
temp to 100.7 from NH, abd distention. FSG elevated (not
diabetic). Pt fell 4 weeks ago, had left thigh hematoma. Not
initially drained, then went to ___ where it was drained. 2
weeks ago developed fever, hyperglycemia, seizures, went to
___ and was admitted to ICU for 4 days. Had thigh re-drained
by ortho at that time. Has indwelling foley. Pt is full code per
paperwork.
Per report, pt had an unwitnessed fall ~6 weeks ago while in her
assisted living home. She developed a large hematoma over her L
flank and L thigh, which was initially left untreated upon her
initial evaluation at ___. However, while she
was at her rehab facility, she developed fevers, hyperglycemia
(BG in the 400s despite no prior hx of diabetes), and seizures.
She was admitted to the ICU at ___ for these
problems, and her thigh hematoma was eventually surgically
drained by an orthopedic surgeon while she was at ___. A
lateral and medial incision were made, a large amount of
hematoma was evacuated, and the skin was stapled closed. A foley
catheter was placed during that admission in
order avoid soilage of her medial incision. Reportedly, the
patient underwent an extensive neurology and cardiac workup at
___, including head CT and EEG, but no etiology of her
seizure was ever identified. She also developed a new RLE DVT
and her coumadin was resumed with a lovenox bridge. She was
eventually discharged to a skilled nursing facility but she may
have never fully returned to her baseline mental status.
According to rehab paperwork: Pt with new change in mental
status and new difficulty with swallowing. Pt with episodes of
loss of congition. T 100.7 down to 99.7. FSG 441, 435, 397 from
___. HR 116.
Pt transferred from BIN. At BIN:
- Labs notable for: lactate 3.8
- UA positive
- Pt given vanc/zosyn + IVF (2L NS) + tylenol ___ PR x1,
morphine 2mg IV
- CT Abd/pelvis including L leg showed abdominal fluid
collection and thigh fluid collection
- CXR:
In the ED initial vitals were: 98 122 133/61 17 99% ra
- Labs were significant for: INR 4.2, PTT 34, lactate 2.7, VBG
7.45/30; no other labs done
- Patient was given: 10mg IV vit K, morphine 5mg IV x1, 1L NS
- Surgery was consulted, recs: Admit to medicine, trend hcts.
Will take to OR ___ for I&D, possible VAC placement. Please
give Vit K, have FFP on call to OR, NPO after midnight.
- Vitals prior to transfer were: 98.2, 108, 136/46, 19, 96% RA
On the floor, pt is lying with eyes clothes and only answer
yes/no questions. She denies pain, SOB.
Past Medical History:
dementia
depression
HTN
spinal stenosis
DJD
seizures
falls
DVT on coumadin
Social History:
___
Family History:
noncontributory to this admission
Physical Exam:
ADMISSION PHYSICAL EXAM:
=====================
Vitals - 98.2, 121/50, 100, 16, 99% RA
GENERAL: elderly woman, lying in bed, eyes closed, in NAD
HEENT: mildly diaphoretic, PERRL, dry MM
NECK: easy flexion for limited range given pt resistance when
attempting to get chian all the way to chest
CARDIAC: regular, rate approx 100, brief systolic murmur at RUSB
LUNG: CTAB anteriorly and posteriorly on the L, shallow
breathing, no accessory muscle use
ABDOMEN: soft, NT, ND, +BS
BACK: no CVAT
EXTREMITIES: longitudinal scar along L lateral thigh without
erythema or fluctuance, superior to scar is small 2cm area of
skin erosion; no significant ___ edema; no fluctuance or erythema
along medial thighs
NEURO: noncompliant with exam, cogwheel rigidity in UE, moves
all extremities spontaneously
DISCHARGE PHYSICAL EXAM:
========================
VS - 97.8 156/60 (122-175/52-78) 85-101 BG 197-257
General: lethargic but arouseable, follows simple commands
HEENT: PERRL, EOMI, anicteric sclera
Neck: no adenopathy or JVD
CV: RRR, no m/r/g appreciated
Lungs: Limited exam. CTAB anteriorly without respiratory
distress
Abdomen: NT/ND, +BS
GU: foley draining clear yellow urine
Ext: warm, well perfused, left medial and lateral incisions
appear healed without evidence of infection (minimal area of
open wound that appears more like a decubitus ulcer), woundvac
in place draining serousanguinous fluid, +bilateral pedal
pitting edema
Neuro: mild right facial droop
Pertinent Results:
ADMISSION LABS:
==============
___ 03:30AM BLOOD WBC-12.3*# RBC-3.38* Hgb-10.3*# Hct-31.8*
MCV-94 MCH-30.5 MCHC-32.5 RDW-15.6* Plt ___
___ 07:30PM BLOOD ___ PTT-34.2 ___
___ 03:30AM BLOOD Glucose-276* UreaN-26* Creat-0.7 Na-146*
K-3.6 Cl-111* HCO3-24 AnGap-15
___ 07:30PM BLOOD CK(CPK)-10*
___ 03:30AM BLOOD ALT-15 AST-12 AlkPhos-45 TotBili-0.3
___ 07:30PM BLOOD cTropnT-<0.01
___ 07:30PM BLOOD CK-MB-1
___ 03:30AM BLOOD Albumin-2.7* Calcium-9.6 Phos-3.1 Mg-2.0
___ 08:05PM BLOOD ___ pO2-70* pCO2-30* pH-7.45
calTCO2-21 Base XS--1
___ 07:46PM BLOOD Lactate-2.7*
PERTINENT LABS:
==============
___ 04:03AM BLOOD WBC-8.4 RBC-3.15* Hgb-9.5* Hct-29.7*
MCV-94 MCH-30.2 MCHC-32.1 RDW-15.6* Plt ___
___ 07:15PM BLOOD ___ PTT-68.9* ___
___ 07:46PM BLOOD Lactate-1.3
DISCHARGE LABS:
==============
___ 07:10AM BLOOD WBC-7.8 RBC-3.25* Hgb-10.1* Hct-29.6*
MCV-91 MCH-31.1 MCHC-34.1 RDW-16.6* Plt ___
___ 07:10AM BLOOD ___ PTT-29.5 ___
___ 07:10AM BLOOD Glucose-203* UreaN-12 Creat-0.6 Na-140
K-3.7 Cl-104 HCO3-27 AnGap-13
MICROBIOLOGY:
==============
___:
URINE CULTURE Final
___
>100,000 org/ml ESCHERICHIA COLI
50-100,000 org/ml KLEBSIELLA PNEUMONIAE
E COLI K PNEUMO
M.I.C. RX M.I.C. RX
------- ------ ------- ------
AMPICILLIN >=32 R >=32 R
AMP/SULBAM 8 S
AMOX/CLAV 8 S <=2 S
CEFAZOLIN <=4 S <=4 S
CEFEPIME <=1 S
CEFTAZIDIME <=1 S <=1 S
CEFTRIAXONE <=1 S <=1 S
CIPROFLOXACIN 0.5 S <=0.25 S
ERTAPENEM <=0.5 S <=0.5 S
ESBL NEG S
GENTAMICIN <=1 S <=1 S
IMIPENEM <=0.25 S <=0.25 S
LEVOFLOXACIN 1 S <=0.12 S
NITROFURANTOIN 32 S 64 I
PIP/TAZ <=4 S <=4 S
TOBRAMYCIN <=1 S <=1 S
TRIM/SULFA >=320 R <=20 S
LEFT THIGH CULTURE
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
IMAGING:
==============
___ ___
FINDINGS: There is no evidence of acute intracranial
hemorrhage, mass, masseffect or large territorial infarction.
Prominent ventricles and sulci are likely related to age-related
global atrophy. Periventricular and subcortical white matter
hypodensities are likely secondary to chronic small vessel
ischemic disease.
No acute fracture is identified. The visualized paranasal
sinuses, mastoid air cells and middle ear cavities are clear.
The globes are unremarkable.
IMPRESSION: No intracranial hemorrhage or other acute
abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Milk of Magnesia 30 mL PO QHS:PRN constipation
2. Bisacodyl 10 mg PR HS:PRN constipation
3. Multivitamins 1 TAB PO DAILY
4. Amlodipine 5 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. OxycoDONE (Immediate Release) 2.5 mg PO TID
8. Senna 8.6 mg PO HS
9. RISperidone 0.25 mg PO HS
10. Artificial Tears Preserv. Free ___ DROP BOTH EYES QHS
11. Gabapentin 100 mg PO TID
12. Polyethylene Glycol 17 g PO BID
13. Psyllium 1 PKT PO DAILY
14. Losartan Potassium 50 mg PO DAILY
15. Acetaminophen 500 mg PO Q8H:PRN pain
16. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral Daily
17. Ferrous Sulfate 325 mg PO DAILY
18. Ampicillin 250 mg PO Q8H
19. Florastor (saccharomyces boulardii) 250 mg oral BID
20. Warfarin Dose is Unknown PO DAILY16
21. Divalproex Sod. Sprinkles 125 mg PO DAILY
22. Docusate Sodium 200 mg PO DAILY
23. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
24. Venlafaxine 75 mg PO BID
25. Exelon (rivastigmine) 9.5 mg/24 hour transdermal Daily
26. Flector (diclofenac epolamine) 1.3 % transdermal Q12H
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Artificial Tears Preserv. Free ___ DROP BOTH EYES QHS
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Gabapentin 100 mg PO TID
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO BID
8. Venlafaxine 75 mg PO BID
9. Warfarin 3 mg PO DAILY16
10. Ciprofloxacin HCl 500 mg PO Q12H Duration: 8 Days
- take through ___
11. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
12. Metoprolol Succinate XL 100 mg PO DAILY
13. Miconazole Powder 2% 1 Appl TP TID:PRN rash area
14. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
15. Exelon (rivastigmine) 9.5 mg/24 hour TRANSDERMAL DAILY
16. Docusate Sodium 200 mg PO DAILY
hold for loose stools
17. Milk of Magnesia 30 mL PO QHS:PRN constipation
18. Psyllium 1 PKT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
=========
1. e. coli bactermia
2. klebsiella and e. coli urinary tract infection
3. delirium
4. Recurrent left thigh hematoma
5. Stress hyperglycemia
6. hypercalcemia
7. pre-diabetes
8. deep vein thrombosis
SECONDARY:
==========
8. vascular dementia
9. hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: History of altered mental status and supratherapeutic INR.
Please evaluate for bleed.
COMPARISONS: None.
TECHNIQUE: ___ images were obtained through the brain without the
administration of IV contrast. Multiplanar reformatted images in coronal and
sagittal axis were generated and reviewed.
DLP: 1028 mGy-cm.
FINDINGS: There is no evidence of acute intracranial hemorrhage, mass, mass
effect or large territorial infarction. Prominent ventricles and sulci are
likely related to age-related global atrophy. Periventricular and subcortical
white matter hypodensities are likely secondary to chronic small vessel
ischemic disease.
No acute fracture is identified. The visualized paranasal sinuses, mastoid
air cells and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION: No intracranial hemorrhage or other acute abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Hyperglycemia
Diagnosed with ALTERED MENTAL STATUS , DEHYDRATION
temperature: 98.0
heartrate: 122.0
resprate: 17.0
o2sat: 99.0
sbp: 133.0
dbp: 61.0
level of pain: nan
level of acuity: 2.0 | ___ with h/o dementia, HTN who presents with AMS, found to have
a thigh fluid collection, E. Coli UTI/bacteremia and
hyperglycemia.
# Goals of care: On the day of discharge there was discussion
with HCP ___ and ___ sister ___. Palliative care and
medical team were also involved. It was discussed with the
family that it was likely that patient was nearing the end of
her life given her worsening mental status, decreased po intake
and recurrent infections. ___ decided that the patient should
become DNR/DNI and have palliative care and hospice involved
once she returned to the nursing facility. She was unsure about
whether the patient should return to the hospital if she were to
have another infection/acute medical issue.
# Dementia and Delirium: Multifactorial including sepsis from
E. coli bacteremia, E. coli and klebsiella UTI c/b
pyelonephritis, and metabolic derangements. She also has a known
dementia and could not compensate in the setting of acute
illness and prolonged hospitalizations with recent discharges to
and from rehabilitation centers. NCHCT was negative for acute
intracranial process. She was treated with broad spectrum
antibiotics, vancomycin and zosyn, until sensitivities from ___
returned. Anti-delerium measurements were taken including
avoiding narcotic pain medications and sedating medications,
ensuring adequate hydration and bowel movements, and encouraging
appropriate sleep/wake cycle.
# Sepsis: Met SIRS criteria on admission. Due to urosepsis from
E. Coli and klebsiella. She was originally started on vancomycin
and zosyn to broadly cover urinary sources and potential
infection of her hematoma. Fluid collections in her thigh were
drained but did not look infected so vancomycin was stopped.
Upon sensitivities from ___, she was narrowed to oral
ciprofloxacin. After transition to oral cipro, she remained
afebrile and did not develop a white blood cell count. She will
continue ciprofloxacin and complete a 14 day course on ___.
# Hyperglycemia and pre-diabetes: Likely stress response to
sepsis. A1c was 6.3%, indicating pre-diabetes. She was continued
on a low dose ISS and diabetic diet. Can transition to oral
hypoglycemic if indicated. She should continue insulin sliding
scale as ordered to maintain post-meal glucose <200 mg/dL and
fasting glucose <180 mg/dL.
# HTN: Her metoprolol and amlodipine were re-started. She
remained normotensive on this regimen so her triameterene-HCTZ
and losartan were discontinued. Consider re-starting if SBP
>180mmHg for 24hrs.
# Recent DVT: Her INR was reversed for I&D of hematoma. She was
then bridged with heparin gtt while being transitioned to oral
warfarin. Her INR was 2.0 at the time of discharge on a 3mg PO
dose of coumadin. This will change and next INR should be drawn
on ___ with notification of MD for adjustment of dose.
# Dementia: Risperidone and depakote were held as these
medications were believed to be contributing to her delerium and
altered sensorium. She was continued on venlafaxine and
rivastigmine.
TRANSITIONAL ISSUES:
* f/u blood sugars qACHS, consider starting metformin if fasting
blood sugars >180 or post-meal glucoses are >200 if insulin
sliding scale is not being used.
* continue ciprofloxacin for 14 days, end date ___.
* wound vac changes every 3 days, follow up surgery clinic
___.
* re-start home anti-hypertensives if SBP >180mmHg for 24hrs.
* needs close follow up of INR given conconimant use of
ciprofloxacin. Please re-check ___ and notify MD of result. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Benzoate Analogues
Attending: ___
Chief Complaint:
Sinus Arrest
Major Surgical or Invasive Procedure:
Central line ___
Intubation/mechanical ventilation (___)
History of Present Illness:
Ms. ___ is an ___ yo F with a history of CAD s/p NSTEMI ___,
___, HTN, HLD presenting with sudden dyspnea, transferred from
___ for bradycardia. She reports that today at 6 pm she started
to feel ill--nasuea and vomiting x 1, diarrhea x 5, pain at the
base of her neck in the back, SOB. She had otherwise been
feeling well. She went to the hospital and they had an EKG with
rate 39. Her blood pressure was ___ so peripheral dopa was
started and also recieved atropine x 1. Transferred to ___
because her cardiologist was here.
On arrival, remained in junctional rhythm with rate 60-70s, no P
waves. She is still feeling nauseous but denies chest pain or
neck pain anymore. She took her am meds including metoprolol and
took ASA 325 mg this evening when she started to feel bad. She
is still reporting SOB, with saturations difficult to assess
because of poor pleth reading but when it is good, saturations
are 100% on 10 L NC.
.
0200: dropped heart rate again and blood pressure --> dopa
increased to 10 with improvement. Still nausea, got ativan 0.25
IV x 1 for this because everything else prolongs QTc. Patient
was started on dopamine at 10mcg/kg/hr, given atropine x 1.
Patient was then found to have hyperkalemia (7.1) ___ (4.2 from
1.6-1.8) and troponin 0.78 at which time she was given calcium
gluconate, insulin, dextrose and IV furosemide 20mg. Patient
was vomiting so decision was made to intubate for airway
protection. She became hypotensive so a RIJ central line was
placed, dopamine was increased to 20 and she was started on
norepinephrine.
.
In the ED, initial vitals were 98.5 62 96/70 24 87%.
vitals prior to transfer were 97.8 71 108/56 26 94%
.
Unable to obtain ROS as patient intubated and sedated.
.
On arrival to floor patient is currently on fentanyl, versed,
dopamine 20 (now down to 12), and norepinephrine (now off)
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: -
- PERCUTANEOUS CORONARY INTERVENTIONS: ___ angio revealed
distal LAD disease, not amenable to PCI
- PACING/ICD: -
3. OTHER PAST MEDICAL HISTORY:
Hypothyroidism
Right kidney stone (known)
Stress incontinence
Gout
Neuropathy
Anemia
Social History:
___
Family History:
Son has MVP and PVCs.
.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION:
VS: 98.1 130/25 51 20 96 on CMV 500 RR 18 PEEP 10 FIO2 70% RR
General: intubated, sedated, intermittently moving extremities
HEENT: NCAT, pupils non reactive
Neck: JVD not appreciable
CV: systolic murmur at LSB, regular rate and rhythm
Lungs: crackles present at mid axillary line, unable to hear
posteriorly
Abdomen: soft, nt, nd, +BS
GU: foley in place
Ext: 2+ pitting edema to knee bilaterally, prominent cyanosis in
fingerbeds
Neuro: intermittently purposeful
Skin: no rashes or excoriations
PULSES: DP 2+ bilaterally, radial 2+ bilaterally
.
DISCHARGE:
Weight: 98.7k (99.7k) Admit weight 108.6k
VS: 98.1 HR 65-72, BP 151-155/67-70, RR 18 97% sat RA.
General: Lethargic, difficult to arouse responding only to loud
verbal cues.
Neck: JVD not appreciable
CV: systolic murmur at LSB, regular rate and rhythm
Lungs: faint bibasilar crackles, otherwise CTA
Abdomen: S/NT/ND + BS.
GU: OOB to commode voiding CYU.
Ext: No appreciable edema, skin warm and dry.
Neuro: lethargic, arousable to voice, following commands.
Oriented to self intermittently to place and time.
Skin: no rashes or excoriations
PULSES: DP 2+ bilaterally, radial 2+ bilaterally
Tele: sinus, no ecotpy overnight.
Pertinent Results:
ADMISSION:
___ 01:40AM ___ PTT-30.4 ___
___ 01:40AM PLT COUNT-247
___ 01:40AM NEUTS-88.6* LYMPHS-7.5* MONOS-3.4 EOS-0.2
BASOS-0.3
___ 01:40AM WBC-17.5*# RBC-3.79* HGB-12.0 HCT-37.5
MCV-99* MCH-31.8 MCHC-32.1 RDW-14.0
___ 01:40AM ALBUMIN-3.9 CALCIUM-8.9 PHOSPHATE-5.0*#
MAGNESIUM-2.1
___ 01:40AM CK-MB-8 cTropnT-0.78* proBNP-2869*
___ 01:40AM LIPASE-105*
___ 01:40AM ALT(SGPT)-43* AST(SGOT)-46* CK(CPK)-280* ALK
PHOS-109* TOT BILI-0.2
___ 01:40AM GLUCOSE-191* UREA N-72* CREAT-4.2*#
SODIUM-131* POTASSIUM-7.1* CHLORIDE-100 TOTAL CO2-15* ANION
GAP-23*
___ 03:30AM URINE EOS-NEGATIVE
___ 03:30AM URINE MUCOUS-RARE
___ 03:30AM URINE GRANULAR-23*
___ 03:30AM URINE RBC-2 WBC-11* BACTERIA-FEW YEAST-NONE
EPI-2
___ 03:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
___ 03:30AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 03:57AM URINE HOURS-RANDOM UREA N-225 CREAT-134
SODIUM-29 POTASSIUM-73 CHLORIDE-10
___ 04:22AM LACTATE-1.6
.
DISCHARGE:
___ 08:45AM BLOOD WBC-10.8 RBC-3.59* Hgb-11.0* Hct-34.7*
MCV-97 MCH-30.5 MCHC-31.6 RDW-13.7 Plt ___
___ 08:45AM BLOOD Glucose-171* UreaN-59* Creat-2.3* Na-143
K-4.3 Cl-108 HCO3-23 AnGap-16
___ 08:45AM BLOOD Calcium-9.6 Phos-4.2 Mg-2.0
.
MICRO:
___ STOOL C. difficile DNA amplification
assay-FINAL; FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ URINE URINE CULTURE-FINAL {YEAST, YEAST}
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL
.
IMAGING:
EKG: rate 69, junctional rhythm, normal axis, no STE, STD, TWI.
.
CARDIAC CATH ___:
1. Selective coronary angiography of this right dominant
system
demonstrated single vessel coronary artery disease. The ___
had mild diffuse disease. The LAD had mild diffuse disease with
a total
occlusion of the very distal, small caliber LAD with mild
antegrade
collaterals. The territory supplied by this region was very
small. The LCx had mild diffuse disease. The RCA had mild
diffuse disease.
.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease with total occlusion of
the distal LAD, not amenable for PCI.
.
___ Cardiovascular ECHO
Conclusions
The left atrium is normal in size. There is symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular systolic
function is hyperdynamic (EF>75%). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened (?#). The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
.
IMPRESSION: Hyperdynamic left ventricular systolic function. No
regional wall motion abnormality appreciated. Mild aortic
regurgitation.
.
___ Imaging CHEST (PORTABLE AP)
FINDINGS: Since prior exam, there are new interstitial
opacities and vascular congestion, most consistent with moderate
pulmonary edema. There is no focal airspace opacity, pleural
effusion, or pneumothorax. The mediastinal contours are normal.
The heart size is mildly enlarged.
IMPRESSION: New moderate pulmonary edema.
.
___ Cardiovascular ECHO
The left atrium is mildly dilated. 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) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Tricuspid regurgitation is
present but cannot be quantified. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
.
Compared with the prior study (images reviewed) of ___, no
clear change.
.
CT HEAD W/O CONTRAST Study Date of ___ 12:12 ___
IMPRESSION:
.
No acute intracranial process. Note that MRI is more sensitive
for acute
ischemia.
.
___ CXR:
There is substantial interval improvement of pulmonary edema,
minimal
currently. The NG tube tip is in the stomach. Heart size and
mediastinum are stable. There is interval extubation of the
patient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Cyanocobalamin 50 mcg PO DAILY
5. Ferrous Sulfate 325 mg PO BID
6. Gabapentin 600 mg PO QAM
7. Gabapentin 1200 mg PO QPM
8. Levothyroxine Sodium 125 mcg PO DAILY
9. Lisinopril 40 mg PO DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Vitamin B Complex 1 CAP PO DAILY
12. Vitamin D 400 UNIT PO DAILY
13. Atorvastatin 80 mg PO DAILY
14. Hydrochlorothiazide 12.5 mg PO DAILY
15. Metoprolol Succinate XL 50 mg PO DAILY
16. Sulfameth/Trimethoprim DS 1 TAB PO BID
17. Pantoprazole 40 mg PO Q24H
18. Glargine 46 Units Breakfast
Glargine 35 Units Bedtime
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Bengay 1 Appl TP TID:PRN foot pain
7. Senna 1 TAB PO BID:PRN constipation
8. Metoprolol Tartrate 12.5 mg PO BID
9. Pantoprazole 40 mg PO Q24H
10. Vitamin B Complex 1 CAP PO DAILY
11. Vitamin D 400 UNIT PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Cyanocobalamin 50 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Type II DM
DLD
HTN
___
CAD: ___ angio revealed distal LAD disease, not amenable to PCI
Hypothyroidism
Right kidney stone (known)
Stress incontinence
Gout
Neuropathy
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Volume overload, evaluate changes in pulmonary edema.
COMPARISON: ___.
TECHNIQUE: Portable frontal chest radiograph.
FINDINGS: In comparison to study from ___, there appears to have been
slight interval increase in moderate pulmonary edema with increasing layering
right greater than left pleural effusions. The appearance of volume status is
similar to that of ___. There is otherwise no significant interval change
with redemonstration of left IJ, right IJ central venous catheters in
unchanged position as well endotracheal tube and NG tube in appropriate
position. There is no new focal consolidation, and there is no pneumothorax.
IMPRESSION: Interval increase in moderate pulmonary edema with layering right
greater than left pleural effusions, worse compared to yesterday's
examination, very similar in appearance to that of ___.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with fluid overload and
respiratory failure.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The ET tube tip is 3.8 cm above the carina. The right internal jugular line
tip is at the level of low SVC. Heart size and mediastinum are stable.
Vascular congestion is bilateral, associated with bilateral pleural effusion.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with pulmonary edema,
intubated with OG tube that potentially changes position.
Portable AP radiograph of the chest was reviewed in comparison to prior study
obtained the same day earlier.
The NG tube tip is in the proximal stomach, potentially slightly more proximal
than on the prior study but still with the sidehole being distal to the
gastroesophageal junction.
The ET tube tip is 4.6 cm above the carina. The right internal jugular line
tip is at the cavoatrial junction. The left internal jugular line tip is at
the junction of left brachiocephalic vein and SVC. Heart size and mediastinum
are stable. Pulmonary edema appears to be progressed since the prior study
associated with bilateral pleural effusions and bibasal atelectasis.
Radiology Report
HISTORY: Respiratory failure secondary to fluid overload.
COMPARISON: ___.
TECHNIQUE: Portable chest radiograph, single view.
FINDINGS: There is no significant change compared to prior examination with
redemonstration of moderate bilateral right greater than left layering pleural
effusions as well as moderate pulmonary edema. Positioning of the
endotracheal tube and left internal jugular central venous catheter and NG
tube are unchanged. There has been interval removal of a right internal
jugular central venous catheter. There is no pneumothorax.
IMPRESSION: Interval removal of right internal jugular central venous
catheter, otherwise no significant change.
Radiology Report
HISTORY: Acute renal failure, altered mental status, status post NG tube
placement.
Evaluate NG placement.
ABDOMEN, SINGLE VIEW, WITH MULTIPLE ATTEMPTS. Edge enhancement
post-processing.
On one view, the tip of an NG tube is seen overlying the upper abdomen.
Interestingly, it does not follow the usual leftward course as it passes into
the fundus, though the significance of this is uncertain. Limited assessment
of the chest shows slight improvement compared with ___ in the CHF
findings and bibasilar opacities.
Radiology Report
HISTORY: Unarousable after arrest.
TECHNIQUE: MDCT data were acquired through the head without intravenous
contrast. Images were displayed in multiple planes.
COMPARISON: No prior neuroimaging at this institution.
FINDINGS:
There is no hemorrhage, major vascular territory infarction, edema, mass, or
shift of the normally midline structures. Mild enlargement of the ventricles
and sulci is compatible with atrophy. The basal cisterns are patent.
Gray-white matter differentiation is preserved. The visualized paranasal
sinuses and mastoid air cells are normally pneumatized and clear. The skull
and extracranial soft tissues are unremarkable.
IMPRESSION:
No acute intracranial process. Note that MRI is more sensitive for acute
ischemia.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with acute renal failure
and fluid overload.
Portable AP radiograph of the chest was reviewed with comparison to ___.
There is substantial interval improvement of pulmonary edema, minimal
currently. The NG tube tip is in the stomach. Heart size and mediastinum are
stable. There is interval extubation of the patient.
Radiology Report
INDICATION: Chest pain and bradycardia. Evaluate for pneumonia.
COMPARISONS: Chest radiograph from ___.
TECHNIQUE: A single AP upright view of the chest was obtained.
FINDINGS: Since prior exam, there are new interstitial opacities and vascular
congestion, most consistent with moderate pulmonary edema. There is no focal
airspace opacity, pleural effusion, or pneumothorax. The mediastinal contours
are normal. The heart size is mildly enlarged.
IMPRESSION: New moderate pulmonary edema.
Radiology Report
INDICATION: Evaluate endotracheal tube placement.
COMPARISONS: Chest radiograph from ___ at 01:34. Chest radiograph
from ___.
FINDINGS: A new endotracheal tube is in satisfactory position approximately
4.5 cm from the carina. The nasogastric tube courses below the diaphragm with
the tip out of fields of view.
Since the prior exam, the lung volumes are lower. There is moderate pulmonary
edema, which is somewhat accentuated by the lower lung volumes, though likely
worsened. Small pleural effusions are difficult to exclude. There is no
pneumothorax. Mediastinal contours appears wider, which may be due to
technique. The heart size remains mildly enlarged.
IMPRESSION:
1. Slight interval worsening of the moderate pulmonary edema.
2. Minimally widened mediastinum, likely accounted for by supine technique.
There is high clinical concern for dissection, could consider a CT.
3. Satisfactory position of the endotracheal and nasogastric tubes.
Radiology Report
HISTORY: Hypotension, new central line.
COMPARISON: ___.
FINDINGS:
There is new right IJ line with tip in the SVC. Heart size is mildly enlarged
and there is increased vascular plethora and alveolar infiltrate compatible
with worsening pulmonary edema.
Radiology Report
HISTORY: Pulmonary edema, line placement.
FINDINGS: There is a new double lumen left IJ catheter with tip in the upper
SVC. Right IJ line tip is in the mid SVC. ET tube tip is in similar location
compared to prior, 3 cm above the carina. There continues to be mild
cardiomegaly, vascular redistribution, and patchy areas of alveolar infiltrate
most marked in the right lower lobe.
Radiology Report
HISTORY: New IJ line unchanged.
___.
FINDINGS:
The appearance of a right IJ, left IJ, ET tube, and NG tube are similar
compared to the study from earlier the same day. The bilateral pleural
effusions, bilateral lower lobe volume loss, pulmonary vascular redistribution
common ill-defined vasculature compatible with CHF.
Impression: increased CHF.
Radiology Report
HISTORY: Check lines and pulmonary edema.
___.
FINDINGS:
Compared to the prior study there is no significant interval change.
Radiology Report
HISTORY: Volume overload with pneumonia.
FINDINGS: In comparison with study of ___, the monitoring and support
devices remain in place. The indistinctness of pulmonary vessels is less
prominent, consistent with some improvement in pulmonary vascular status. The
hazy opacification at the right base with poor definition of the hemidiaphragm
is not seen. In view of the apparent supine position of the patient, this
would suggest improvement in the degree of right pleural effusion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: HEART BLOCK
Diagnosed with ATRIOVENT BLOCK COMPLETE, HYPERKALEMIA, ACUTE KIDNEY FAILURE, UNSPECIFIED, SYSTOLIC HEART FAIL, UNSPEC, ACIDOSIS, LEUKOCYTOSIS, UNSPECIFIED , HYPOTENSION NOS, SHOCK NOS
temperature: 98.5
heartrate: 62.0
resprate: 24.0
o2sat: 87.0
sbp: 96.0
dbp: 70.0
level of pain: 13
level of acuity: 1.0 | Ms. ___ is an ___ yo F with a history of CAD s/p NSTEMI ___,
___, HTN, HLD presenting with sudden dyspnea in setting of
volume overload and hyperkalemia after a recent dye load.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Meropenem / Penicillins / Carbapenem
Attending: ___.
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is ___ year old ESRD on hemodialysis, CAD s/p MI, afib and
CVA, presented with hypotension prior to beginning dialysis on
___ (did not receive dialysis). His last dialysis was ___
___. He was sent to the ED complaining of weakness for 1
week and generally feeling unwell. He appeared pale. Denied
pain. He was admitted for a similar episode of hypotension in
___ that responded to IVF w/o infectious source found and
he was discharged on midodrine and his metoprolol was stopped.
.
In the ED yesterday he was afebrile. BP 82/49. ROS for infection
was negative. He received 1 Liter bolus. Labs showed baseline
anemia, and baseline electrolyte abnormalitis. Notably K 4.7 and
troponin 0.05. A UA was significant for UA >182WBC lg leuk sm
bld mod bact 0 epi. Urine and blood cultures - pending,
Lactate 1.6.
At that point his vitals were stable 112/58 68 96% home oxygen.
He underwent a CTA of his torso which showed a stable aortic
aneurysm/dissection. Then started on vancomycin, levofloxacin,
and Flagyl for possible infection and transferred to the FICU.
.
In the FICU he was found to have pyuria and started on abx w/
urine cx pending. He was started on linezolid and tobramycin due
to past resistance to antibiotics. D/ced given low suspicion of
infx. He tolerated hemodialysis on the morning of ___ w/out
fluid bolus. He felt well and had 6 hours of obs w/ stable BPs
(SBP 97-121).
.
Transfer vitals were 112/58 68 96% on 2l (home oxygen).
.
Upon arrival to the floor on ___ 7 Mr. ___ was feeling well.
States that he has felt much better since dialysis this morning.
No weakness, dizzyness, SOB, or N/V. He does endorse decreased
food intake over the past week.
.
.
Imaging:
- bedside u/s: lg infrarenal aorta/iliacs c/f aneurysm vs
dissection
- CT torso: stable aneurysm
Ekg: 62 LAD, RBBB w/ Left anterior fascicular block, twi III,
avF
consult: FYI'd renal
.
.
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.
Primary Care Physician: ___
.
Past Medical History:
- ESRD on HD (___)
- CAD s/p MI
- Afib, not anticoagulated
- CVAs x2, residual R sided weakness, from ___ ___ then ___ ___ ago
- Hx of GI Bleed
- Nephrolithiasis
- OSA, not using CPAP
- Iron Deficiency Anemia
- Depression
- Hx of C.diff
- Restrictive Ventalatory Pulmonary Defect
- Pelvic and wrist fractures ___
- Recurrent UTIs, including VRE and klebsiella
- Multiple episodes of line related bacteremia:
- MRSA in ___ treated for 6 weeks of vanc given possible
clot in fistula. Line removed. TTE negative for vegetation. TEE
not performed.
- ESBL E.coli bacteremia in ___ thought to be line related.
- ESBL E.coli bacteremia in ___. Thought to be line
related. s/p total 4-week course of meropenem/ertapenem.
(___) for likely endovascular infection in setting of R
IJ clot.
- ESBL E.coli x 2 types, E. faecium BSI unclear source despite
extensive work-up (___). s/p 4 weeks of Vancomycin and
Meropenem.
- ESBL E. coli and E. faecium BSI (___) thought to be line
related s/p 2 weeks Vancomycin/Meropenem.
- Pansusceptible Klebsiella pneumoniae BSI thought ___ CBD
stone. s/p ERCP and stenting. Due for repeat ERCP
Past Surgical History
- ___ C2 fracture dislocation with progressive collapse s/p
ORIF C2 and posterior instrumentation C1-C5 and left iliac crest
bone graft placement, complicated by osteomyelitis.
- ___ Right popliteal thrombosis s/p popliteal and tibial
embolectomy and R below the knee popliteal and tibial vein path
angioplasty
- R AVF placement ___
- L UE fistulogram/angioplasty ___
- LUE fistulagram ___
- LUE fistulogram and angioplasty of central venous stenosis
___
- L AV brachiocephalic fistula ___
- cataract surgery ___
- R ureteral stent placement ___
- I&D R wrist ___
- R shoulder surgery ___
- L cataract surgery ___
- L knee surgery
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Admission to Medicine:
Vitals: T:95.9 BP: 142/82 P: 70 R: 18 O2: 99% 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, neck collar in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, no CVA
tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, CN II-XII w/out decrement, PERRL, ___ RLE strength,
___ RUE strength
Discharge:
Vitals: T:95.6 BP: 110/70 P: 74 R: 20 O2: 100% 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, neck collar in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, no CVA
tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, CN II-XII w/out decrement, PERRL, ___ RLE strength,
___ RUE strength
Pertinent Results:
Admission:
___ 12:05PM BLOOD WBC-8.6 RBC-3.51* Hgb-10.8* Hct-33.0*
MCV-94 MCH-30.9 MCHC-32.9 RDW-15.7* Plt ___
___ 12:05PM BLOOD Neuts-75.8* Lymphs-17.3* Monos-5.0
Eos-1.6 Baso-0.3
___ 12:05PM BLOOD ___ PTT-28.1 ___
___ 12:05PM BLOOD Glucose-98 UreaN-59* Creat-5.6*# Na-138
K-4.5 Cl-100 HCO3-25 AnGap-18
___ 12:05PM BLOOD ALT-10 AST-11 AlkPhos-112 TotBili-0.2
___ 12:05PM BLOOD Lipase-18
___ 12:05PM BLOOD cTropnT-0.05*
___ 12:05PM BLOOD Albumin-3.5 Calcium-8.6 Phos-4.1 Mg-1.9
___ 12:19PM BLOOD Lactate-1.6
___ 05:20PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 05:20PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 05:20PM URINE RBC-10* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
___ 05:20PM URINE WBC Clm-MANY
Blood cultures pending x2
Urine culture pending
CTA ABD & PELVIS Study Date of ___ 2:39 ___ \
Pending
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___
2:39 ___
Pending
Medications on Admission:
(per last discharge):
1. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO at bedtime.
8. midodrine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO once a
day.
11. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
13. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
14. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Discharge Medications:
1. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO three
times a day.
2. fluoxetine 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. midodrine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO once a
day.
11. docusate sodium 50 mg Capsule Sig: One (1) Capsule PO once a
day.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six
(6) hours.
14. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO once a day.
15. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Hypotension
2. Pre-existing End stage renal disease on hemodialysis,
pulmonary artery hypertension, A-fib, coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Hypotension in patient with known chronic aortic aneurysm and
dissection.
COMPARISON: CT abdomen and pelvis from ___ and CT torso from ___.
TECHNIQUE: MDCT-acquired axial images from the thoracic inlet through the
pubic symphysis were performed after intravenous contrast injection, with
image acquisition timed for the arterial phase. The scan was repeated due to
accidental disconnection of the patient's intravenous line. Multiplanar
reformation was performed to generate sagittal and coronal image series.
CTA CHEST: There is no mediastinal, axillary, or hilar lymphadenopathy. The
main airways are patent bilaterally. The lungs are clear with no nodules or
diffuse opacities. The heart chambers are normal in size. There are
scattered atherosclerotic calcifications within the thoracic aorta and
coronary vessels as well as a hemodialysis catheter terminating at the
cavoatrial junction. The intrathoracic aorta is not aneurysmal and there is
no evidence of dissection. There is no pericardial or pleural effusion.
CTA ABDOMEN: There is marked pneumobilia with air partially filling the
gallbladder and intrahepatic bile ducts. There has been interval increase in
the amount of pneumobilia since the prior examination. The liver and
gallbladder otherwise appear normal without focal or diffuse abnormality. The
pancreas, adrenals, and spleen are normal. The bilateral kidneys are atrophic
and cystic, consistent with history of hemodialysis. The stomach, duodenum,
and intra-abdominal loops of bowel are normal, without dilation or
wall-thickening.
The aneurysmal dilation of the celiac axis is stable (6:85). A 1 cm partially
thrombosed aneurysm of the left gastric artery is also stable (6:77). There
is stable, severe atherosclerotic stenosis of the bilateral renal arterial
origins (6:100, 102). The superior and inferior mesenteric arteries are
patent. There is no retroperitoneal or abdominal hematoma or extravasation of
contrast.
The focal dissection involving distal abdominal aorta extending into the left
common iliac artery is unchanged in size and extent. The left common iliac
arterial aneurysm measures 3.9 cm which is stable within measurement error
(6:153). The extent of dissection in the proximal right common iliac artery
as well as the focal dissection of the proximal left external iliac artery is
also stable. There is a stable arteriovenous fistula between the common right
femoral artery and vein (6:207).
CTA PELVIS:
There is eccentric urinary bladder wall thickening, new from the prior study
on ___. The prostate is enlarged. The rectum and pelvic loops of
large and small bowel appear normal. There is no pelvic or inguinal
lymphadenopathy. There is no pelvic free fluid or hematoma.
BONE WINDOWS:
There is a subacute to chronic fracture of the right inferior pubic ramus with
surrounding callus formation. This fracture is new from ___ (6:218).
There are extensive degenerative changes of the imaged spine, but no acute
fracture or malalignment is noted. There are no lesions concerning for
malignancy.
IMPRESSION:
1. Stable appearance of multiple focal arterial aneurysms and dissection,
without evidence of rupture to explain patient's hypotension.
2. Extensive pneumobilia which may be explained by prior sphincterotomy, if
this is the case. However, enterobiliary fistula cannot be entirely ruled
out.
3. Eccentric bladder wall thickening, which is new from ___.
Correlation with urinalysis and urine cytology recommended. Recommend
non-urgent ultrasound and depending on findings of above, possible urology
consultation.
4. Subacute-to-chronic fracture of the right inferior pubic ramus, new since
___.
5. Chronic renal disease associated with hemodialysis.
Radiology Report
HISTORY: Hypotension and possible pneumonia.
FINDINGS: In comparison with the study of ___, there are lower lung
volumes. Indistinctness of pulmonary vessels suggests some elevated pulmonary
venous pressure in a patient with cardiac enlargement and tortuosity of the
aorta and brachiocephalic vessels. Atelectatic changes are seen at the bases.
Tip of the dialysis catheter appears to extend to the lower right atrium or
possibly the inferior vena cava.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: HYPOTENSIVE
Diagnosed with HYPOTENSION NOS, END STAGE RENAL DISEASE
temperature: 97.6
heartrate: 64.0
resprate: 14.0
o2sat: 94.0
sbp: 82.0
dbp: 49.0
level of pain: 0
level of acuity: 1.0 | Brief Hospital Course
___ M w/ hx of ESRD on HD, CAD, afib, CVA w/ residual R sided
weakness who presented from dialysis with hypotension. The cause
of which is likely multifactorial including: Decreased PO
intake, possibly worsening pulmonary hypertension, and changing
dialysis requirements.
.
Hypotension: He initially presented with hypotension of 82/49.
The BP normalized in ED with one liter of IVF, which was
reassuring. Of note the patient had a similar episode of
hypotension several months ago that resolved with IVF. Blood
cultures and urine cultures were sent with consideration of his
prior infections (hx of ESBL e.coli, VRE, multiple episodes of
sepsis). Although the patient was initially started on
vanc/levofloxacin/flagyl in ED and later transitioned to more
narrow coverage (linezolid and tobramycin), antibiotics were
ultimately discontinued as no infectious cause could be found.
His WBC has remained normal and he has had no fevers. CXR did
not show signs of pneumonia. Blood pressure remained above 110
throughout the admission. Pyuria was present on UA and likely
reflects ESRD on HD. Bedside U/s in the ED demonstrated a large
aortic aneurysm, which appears stable on CT scan, and unlikely
to be cause of hypotension. No signs of bleeding. Cultures need
to be followed up as an outpatient. He was continued on
mitodrine without uptitation per renal recommendation. A TTE was
performed to assess for cardiogenic cause of hypotension. The
patient and his wife expressed a strong desire for discharge
prior to formal interpretation of his TTE. This will need to be
followed up by his outpatient providers. His dry weight in HD
was increased in an effort to prevent further ___
hypotension.
.
ESRD on HD: Patient has a MWF schedule. The last HD was on
___ prior to admission. He missed his ___ HD because of
hypotension. While in the hospital he received HD on ___
and ___ and ___ which was well tolerated. Renal
saw the patient while in the hospital and was involved in his
care. All meds were renally dosed. On ___ his dialysis was
optimized to leave him with a slightly higher dry weight. Follow
up was arranged with his primary physician and the ___
clinic.
.
Hx of CAD: The patient does not have signs of active ischemia.
There were no EKG changes from a recent comparison. The trop was
0.05 in this renal patient. Considering bifascicular block and
risk for total heart block, should discuss with PCP. His statin
and ASA were continued. Beta blockade continued to be held in
setting of hypotension.
.
Pulmonary Hypertension: This was noted on TTE from ___
___. He does not have signs of heart failure on exam; however,
the concern was raised for the possibility of it being a factor
in his episodes of hypotension.
.
INCIDENTAL FINDINGS
1. Eccentric bladder wall thickening, new from ___ that
needs to be correlated with U/A and cytology. A bladder
ultrasound considered. He should follow up with his primary care
physician.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Painful hardware right lower extremity, prominent screw
Major Surgical or Invasive Procedure:
___ Dr. ___ of hardwareprominent distal
interlock screw
History of Present Illness:
HPI: ___ female who is status post right ORIF femur with
Synthes femoral nail for periprosthetic femur fracture ___.
Since ___, patient has noticed increasing swelling along the
medial aspect of her right knee. She does not note any hardware
protruding from her skin.
She otherwise has good range of motion in her right knee. She
has no complaints of nausea, vomiting, fever, or chills.
Past Medical History:
- Seizure disorder
- Stroke at age ___ and resultant right-sided deficits at baseline
- Fibromyalgia
- Migraines
- Asthma/COPD
PSH:
- TKA ___ years ago
- Right ankle arthrodesis at age ___
Social History:
___
Family History:
None on file.
Physical Exam:
Vitals: AVSS
Right Lower Extremity Exam:
Surgical dressing c/d. Changed POD 3.
SILT sp/dp/s/s/t
Motor exam complicated by prior ankle fusion, grossly intact
WWP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea
2. Baclofen 10 mg PO TID
3. DULoxetine ___ 60 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. LevETIRAcetam 500 mg PO BID
6. Verapamil SR 180 mg PO Q12H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneously qpm Disp #*28
Syringe Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
5. Senna 8.6 mg PO QHS
RX *sennosides [senna] 8.6 mg 8.6 mg by mouth at bedtime Disp
#*30 Tablet Refills:*0
6. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 capsule(s) by mouth
once a day Disp #*60 Tablet Refills:*0
7. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea
8. DULoxetine ___ 60 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Gabapentin 200 mg PO TID
11. LevETIRAcetam 500 mg PO BID
12. Verapamil SR 180 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
prominent distal interlock s/p right retrograde femoral nail on
___ with Dr. ___
___ Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane or crutches).
Followup Instructions:
___
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ___ with R bulge R knee c/f hardware displacement// Eval
hardware displacement
TECHNIQUE: Frontal, lateral, and sunrise view radiographs of the right knee.
COMPARISON: Prior radiograph dated ___
FINDINGS:
A fracture is again noted within the distal right femur stabilized with an
intramedullary rod. There are 3 distal interlocking screws in place
stabilizing the IM rod. The middle screw appears intervally retracted with
bulging of the overlying skin. The proximal tibia and fibula are patent.
Knee arthroplasty components appear unchanged in position. Trace joint
effusion.
IMPRESSION:
Recent operative fixation of a distal femur fracture with IM rod. Interval
retraction of the middle interlocking screw at the level of the medial femoral
condyle with bulging of the overlying skin.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with previous right femur fracture, pre-operative study.//
Pneumonia? Mass?
COMPARISON: Prior exam is dated ___
FINDINGS:
AP upright and lateral views of the chest provided. Lungs are clear. There is
no focal consolidation, effusion, or pneumothorax. There are no signs of
congestion or edema. The cardiomediastinal silhouette is normal. Imaged
osseous structures are intact. No free air below the right hemidiaphragm is
seen.
IMPRESSION:
No acute intrathoracic process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Knee pain, Wound eval
Diagnosed with Displacement of int fix of right femur, init, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause
temperature: 97.1
heartrate: 89.0
resprate: 17.0
o2sat: 97.0
sbp: 132.0
dbp: 68.0
level of pain: 5
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a prominent right distal interlock screw and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for removal of
painful/prominent hardware, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
___ weightbearing right lower extremity with bilateral upper
extremity assist in the right lower extremity, and will be
discharged on Lovenox per primary surgery for DVT prophylaxis.
The patient will follow up with Dr. ___ in 1 week. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right leg pain
dyspnea
Major Surgical or Invasive Procedure:
Cardiac catheterization, ___
Trans-esophageal Echo, ___
History of Present Illness:
As per HPI by admitting MD:
___ year old female with a history of JAK2(+) polycythemia ___
myelofibrosis (on ruxolitinib), R lower extremity DVT (dx
___, on edoxaban for 3 months ending in ___, HTN, CKD
stage III, cryptogenic organizing pneumonia (on prednisone),
presenting with right unilateral leg pain and persistent
dyspnea.
Of note, the patient was recently admitted to ___ from ___
to ___ for COP. She initially presented to ___
in
___ for cough and SOB, for which she was initially treated
for pneumonia. At this time, she was also having hemoptysis and
epistaxis. An outpatient CT chest showed bilateral central
ground
glass opacities c/f COP (no bx performed), so she was started on
steroids with transient initial improvement in symptoms. After
her symptoms worsened (started having productive cough), she
presented to ___ ED and was noted to be mildly hypoxic,
possibly due to pulmonary microhemorrhage vs. aspiration of
epistaxis I/s/o edoxaban for DVT (dx'ed ___, on edoxaban for
3+ months ending in ___. Bronchoscopy on ___ showed only
scant bloody secretions and otherwise normal examination. ___,
ANCA, and anti-GBM all negative. Negative infectious workup
(including viral culture, CMV, legionella, PCP) and low
suspicion
for infection given lack of infectious symptoms, no suggestive
findings on imaging, and more probable association with the
epistaxis. Her hypoxia improved with discontinuation of edoxaban
(due to completion of 3 month course for provoked DVT) and was
able to saturate well on RA with ambulation upon discharge. She
was discharged with atovaquone for PCP prophylaxis and
prednisone
40 mg daily to be continued for 1 month.
During her hospitalization, she was also noted to have
moderate-severe mitral regurgitation and mild LV systolic
dysfunction c/w CAD. She also had intermittent, scant epistaxis
most likely ___ edoxaban use and relative thrombocytopenia.
After the patient was discharged from ___ on ___, the
patient continued to have episodes of dyspnea associated with
some dizziness, chest pressure, and fast heart rate. Episodes
lasted about 5 minutes each and happen ___ times per day. The
episodes are not activity related and not clearly relieved with
rest. There was no clear positional component either. The
episodes continued for the next week or so until yesterday when
the dyspnea became more constant with associated feeling of
chest
pressure. Last night, the patient also developed moderate pain
in
the right calf and right medial thigh that was worse with
palpation.
The patient continues to have baseline orthopnea (sleeping on 2
pillows at night) that started in ___ with the "pneumonia"
and has not worsened since then (but also not improved). She
also
continues to have epistaxis about 10 times in the day with light
red fluid leaking from her nose (resolved with packing with
tissue). No hemoptysis or hematemesis.
Past Medical History:
- JAK2(+) polycythemia ___ myelofibrosis on ruxolitinib
- Right lower extremity DVT (dx ___, on edoxaban for 3+
months ending in ___
- HTN
- CKD III
- Cryptogenic organizing pneumonia on prednisone
Social History:
___
Family History:
- History of "blood clots" in the family (unspecified family
members). No diagnosed coagulopathy
- Mother: afib, myelofibrosis, and "leaky valves"
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: HR 82, BP 145/78, RR 17, 97% on RA, weight 71.08 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
appreciable murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing. Normal tympany to
percussion.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended. Tenderness to
palpation over the left half of the abdomen where splenomegaly
is
also noted. No peritoneal signs.
EXTREMITIES: No clubbing or cyanosis. Pulses DP/Radial 2+
bilaterally. 1+ pitting edema on the right leg up to the
mid-calf, no pitting edema on the left leg. Tenderness to
palpation over the right calf and right medial thigh and right
popliteal fossa. Negative ___ sign bilaterally. No erythema on
the lower extremities bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3.
DISCHARGE PHYSICAL EXAM:
========================
VS: 24 HR Data (last updated ___ @ 730)
Temp: 97.5 (Tm 98.4), BP: 192/84 (113-192/59-84), HR: 72
(69-92), RR: 16 (___), O2 sat: 99% (97-100)
GEN: In NAD, resting comfortably in bed
HEENT: NCAT. EOMI. MMM.
CARDIAC: RRR, III/VI holosystolic murmur over the apex.
PULMONARY: CTAB, no crackles/wheezing/rhonchi.
ABDOMEN: Soft, non-tender, non-distended, + bowel sounds
EXTREMITIES: Warm, well perfused. Trace ___ edema bilaterally.
SKIN: No significant rashes. Warm and dry.
NEURO: AAOx3. Motor and sensation grossly intact.
Pertinent Results:
ADMISSION LABS:
================
___ 12:50PM BLOOD WBC-62.4* RBC-3.51* Hgb-8.4* Hct-30.9*
MCV-88 MCH-23.9* MCHC-27.2* RDW-19.2* RDWSD-61.3* Plt ___
___ 12:50PM BLOOD Neuts-95* Bands-2 Lymphs-0* Monos-0*
Eos-3 Baso-0 AbsNeut-60.53* AbsLymp-0.00* AbsMono-0.00*
AbsEos-1.87* AbsBaso-0.00*
___ 12:50PM BLOOD Anisocy-1+* Poiklo-2+* Polychr-1+*
Ovalocy-1+* Schisto-1+* Tear Dr-1+* RBC Mor-SLIDE REVI
___ 12:50PM BLOOD ___ PTT-27.3 ___
___ 12:50PM BLOOD Glucose-121* UreaN-38* Creat-1.6* Na-138
K-4.9 Cl-107 HCO3-19* AnGap-12
___ 12:50PM BLOOD proBNP-907*
___ 12:50PM BLOOD cTropnT-<0.01
DISCHARGE LABS:
================
___ 06:40AM BLOOD WBC-70.4* RBC-3.76* Hgb-8.7* Hct-33.2*
MCV-88 MCH-23.1* MCHC-26.2* RDW-20.8* RDWSD-65.7* Plt ___
___ 06:40AM BLOOD Glucose-58* UreaN-73* Creat-1.8* Na-136
K-5.1 Cl-104 HCO3-16* AnGap-16
___ 06:40AM BLOOD Calcium-9.5 Phos-5.6* Mg-2.2
PERTINENT LABS:
================
___ 03:56PM OTHER BODY FLUID FluAPCR-POSITIVE*
FluBPCR-NEGATIVE
IMAGING:
========
___: V/Q Lung Scan:
IMPRESSION:
1. Overall unusual pattern of ventilation/perfusion, which is
indeterminate but not suggestive of pulmonary embolism.
2. Decreased perfusion in the right middle lobe with normal
perfusion could be secondary to parenchymal opacity noted in
recent chest radiograph.
___: ___ venous U/S:
Impression:
No evidence of deep venous thrombosis in the right lower
extremity veins.
Superficial thrombophlebitis of the right greater saphenous vein
___: CXR:
Persistent right base opacity. Pulmonary opacities better
assessed on prior CT from ___, at which point
differential diagnosis included organizing pneumonia and
alveolar proteinosis.
___: EKG
Sinus rhythm. Ventricular premature complex. Probable left
atrial enlargement. Left ventricular hypertrophy
___: Cardiac Catheterization:
Normal left and right heart filling pressures.
No angiographically apparent coronary artery disease.
Maximize medical therapy
Consider TEE for evaluation of MR
___: CT chest w/o contrast
New pneumonia, left lower lobe, more likely infectious than
cryptogenic. No good evidence for cardiac decompensation.
Improvement since ___ of previous cryptogenic alveolitis
in the middle lobe and upper lobes, slight worsening right lower
lobe.
Suggest clinical investigation regarding possible thoracic
spinal stenosis.
Mild cardiomegaly, mild dilatation pulmonary artery, and aortic
valvular
calcification, best evaluated by echocardiography.
___: Renal ultrasound
1. Atrophic and slightly echogenic right kidney.
2. Normal appearance of the left kidney.
Splenomegaly, 21.7 cm
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atovaquone Suspension 1500 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Jakafi (ruxolitinib) 15 mg oral DAILY
5. Lisinopril 40 mg PO DAILY
6. Pantoprazole 40 mg PO DAILY
7. PredniSONE 40 mg PO DAILY
8. Verapamil 40 mg PO DAILY
9. Calcium Carbonate 500 mg PO BID
10. Vitamin D 800 UNIT PO DAILY
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC DAILY
RX *enoxaparin [Lovenox] 80 mg/0.8 mL 80 mg SQ once a day Disp
#*30 Syringe Refills:*0
2. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tab-cap by mouth once a day Disp
#*30 Capsule Refills:*0
4. Sodium Bicarbonate ___ mg PO BID
RX *sodium bicarbonate 650 mg 3 tablet(s) by mouth twice a day
Disp #*180 Tablet Refills:*0
5. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. PredniSONE 30 mg PO DAILY
RX *prednisone 10 mg 3 tablet(s) by mouth once a day Disp #*24
Tablet Refills:*0
7. Allopurinol ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atovaquone Suspension 1500 mg PO DAILY
10. Calcium Carbonate 500 mg PO BID
11. Citalopram 20 mg PO DAILY
12. Jakafi (ruxolitinib) 15 mg oral DAILY
13. Pantoprazole 40 mg PO DAILY
14. Vitamin D 800 UNIT PO DAILY
15. HELD- Lisinopril 40 mg PO DAILY This medication was held.
Do not restart Lisinopril until your kidney doctor says it is ok
16. HELD- Verapamil 40 mg PO DAILY This medication was held. Do
not restart Verapamil until your renal doctor says it is ok
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=====================
Mitral valve posterior leaflet vegetation
Severe Mitral Regurgitation
Acute diastolic heart failure
Cryptogenic Organizing Pneumonia
Acute on chronic kidney disease
SECONDARY DIAGNOSES
=====================
Thrombocytopenia
Chronic anemia
JAK2 polycythemia ___ myelofibrosis
Influenza
Metabolic acidosis
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 SOB// r/o acute process
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Right base opacity is re-demonstrated more subtle left base opacity such as
seen on CT from ___ were better assessed on CT. Again, findings
may be due to organizing pneumonia or alveolar proteinosis. No pleural
effusion or pneumothorax is seen. Cardiac and mediastinal silhouettes are
stable.
IMPRESSION:
Persistent right base opacity. Pulmonary opacities better assessed on prior
CT from ___, at which point differential diagnosis included
organizing pneumonia and alveolar proteinosis.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: History: ___ with recent DVT, off anticoagulation, now with
worsening swelling and pain// eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the right
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
There is an occlusive thrombus and tenderness to examination throughout the
course of the right greater saphenous vein.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Superficial thrombophlebitis of the right greater saphenous vein.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ w/ JAK2(+) polycythemia ___ myelofibrosis (on ruxolitinib),
CKD-3, likely cryptogenic organizing pneumonia (on prednisone) admitted for
acutely worsening dyspnea most likely due to 4+ MR, diastolic heart failure.//
?interval change in cryptogenic organizing pneumonia on prednisone treatment
TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. Contrast agent was not administered. All images were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.4 s, 37.7 cm; CTDIvol = 7.9 mGy (Body) DLP = 297.8
mGy-cm.
Total DLP (Body) = 298 mGy-cm.
COMPARISON: Compared to chest CTs ___ and G ___ both at ___
___
FINDINGS:
CHEST PERIMETER: No findings in the imaged portion of the thyroid need any
further imaging evaluation. Supraclavicular and axillary lymph nodes are not
enlarged. Breast evaluation is reserved exclusively for mammography. No soft
tissue abnormalities elsewhere in the chest wall.
This study is not appropriate for subdiaphragmatic diagnosis though it shows
continued severe splenomegaly.
CARDIO-MEDIASTINUM:Esophagus is unremarkable. Atherosclerotic calcification
is mild in head and neck vessels, but not in coronary arteries. Aorta is
normal size, valvular calcifications are mild. Evaluation of cardiac chambers
and function and mildly enlarged pulmonary artery would require
echocardiography, if not recently performed.
THORACIC LYMPH NODES: Mediastinal lymph nodes are not pathologically enlarged
or growing. Hilar contours on this noncontrast study do not suggest
adenopathy.
LUNGS, AIRWAYS, PLEURAE: There are 2 types of pulmonary abnormality.
Multi lobar ground-glass opacification which improved substantially between
___ and ___ is slightly more extensive in the right lower lobe
today than before, but has otherwise continued to improve, with a small, but
improving residual in middle lobe and lingula.
New more consolidative abnormality at the base of the left lower lobe is
substantially more radiodense any preceding pulmonary infiltration in ___.
It is accompanied by mild bronchial occlusion suggesting infectious rather
than cryptogenic pneumonia. There are no lung lesions concerning for
malignancy.
Aside from minimal pleural thickening contiguous with the left lower lobe
consolidation, pleural surfaces are normal.
CHEST CAGE: Although there are no bone lesions in the imaged chest cage
suspicious for malignancy or infection, it should be noted that radionuclide
bone and FDG PET scanning are more sensitive in detecting early osseous
pathology than chest CT scanning.
Osteophytes narrowing the midthoracic vertebral canal to between 8 and 11 mm,
302:126, and 602:59 could cause symptoms of spinal stenosis. Clinical
correlation advised.
IMPRESSION:
New pneumonia, left lower lobe, more likely infectious than cryptogenic. No
good evidence for cardiac decompensation.
Improvement since ___ of previous cryptogenic alveolitis in the middle
lobe and upper lobes, slight worsening right lower lobe.
Suggest clinical investigation regarding possible thoracic spinal stenosis.
Mild cardiomegaly, mild dilatation pulmonary artery, and aortic valvular
calcification, best evaluated by echocardiography.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ w/ JAK2(+) polycythemia ___ myelofibrosis (on ruxolitinib),
CKD-3, likely cryptogenic organizing pneumonia (on prednisone) admitted for
acutely worsening dyspnea most likely due to 4+ MR ___ MV vegetation, course
complicated by acute on chronic kidney disease. Acute drop in bicarb from 17
to 11 from this morning to afternoon, concern for obstruction.// ?obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
Relative atrophy of the right kidney which measures up to 9 cm though appears
slightly echogenic with cortical thinning is noted. No worrisome renal
lesion. No hydronephrosis. Left kidney measures 9.8 cm, with normal
echotexture and no concerning lesions or hydronephrosis. Incidental note is
made of splenomegaly up to 21.7 cm in length. The urinary bladder is normal
with bilateral ureteral jets seen.
IMPRESSION:
1. Atrophic and slightly echogenic right kidney.
2. Normal appearance of the left kidney.
Splenomegaly, 21.7 cm
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea on exertion, R Leg swelling
Diagnosed with Ac emblsm and thombos unsp deep veins of r prox low extrm, Dyspnea, unspecified
temperature: 97.4
heartrate: 94.0
resprate: 18.0
o2sat: 100.0
sbp: 147.0
dbp: 69.0
level of pain: 10
level of acuity: 2.0 | ___ year old female with a history of JAK2(+) polycythemia ___
myelofibrosis (on ruxolitinib), R lower extremity DVT (dx
___, edoxaban for 3 months ending in ___, HTN, CKD
stage III, likely cryptogenic organizing pneumonia (on
prednisone) re-admitted for persistent dyspnea most likely
related to severe MR due to posterior leaflet vegetation.
Hospital course c/b ___ on CKD.
# Mitral valve posterior leaflet vegetation
TEE from ___ indicates vegetation on posterior leaflet of
mitral valve. Cardiac surgery and ID are on board. No sign of
conduction abnormality on EKG. Serum cultures with no growth x6,
final. At this time there is increasing suspicion for possible
nonbacterial thrombotic endocarditis. Repeat BCx drawn ___ no
growth at time of discharge and final blood cultures returned
negative. Started on heparin gtt ___, transitioned to lovenox
on day of discharge. Discharged with plan to continue lovenox.
She has cardiology follow up scheduled to help determine course
of anticoagulation and surgical plan. A TEE will be scheduled in
the next ___ weeks to re-evaluate her valve.
# AoCKD
# Metabolic acidosis
History of CKD III, baseline Cr 1.4-1.6. Elevated to 1.8 after
contrast load on ___, suggestive of mild ___, resolved. Cr bump
to 2.2 on ___. Per Renal, no evidence of ATN on spun urine, ___
most likely ___ furosemide and lisinopril. Cr improved after
holding those medications, discharge Cr 1.8. Started on sodium
bicarbonate per Renal, uptitrated during admission. Restarted
diuretic (Torsemide 10) on discharge, but held Lisinopril. She
also had a borderline / mildly elevated K at around 5.0 and was
counseled on adherence to a low K diet and avoidance of
lisinopril additionally for this reason.
# Acute diastolic heart failure
# Severe MR
___ regurgitation discovered on recent TTE. Cath ___ ruled
out ischemic component. Patient has severe mitral regurg with
preserved LVEF 50%. Holding home verapamil in order to improve
contractility and effective cardiac output given regurg. Patient
will benefit from afterload reduction to limit retrograde flow.
She was started on torsemide 10 mg prior to discharge. Her
lisinopril was held on discharge given resolving ___.
# Likely Cryptogenic Organizing Pneumonia
Diagnosed based on radiographic evidence from CT chest, improved
on repeat scan with high-dose steroids. Given known MR as above
unclear to what extent COP is contributing to her symptoms. Of
note, patient may require endocrine follow-up given risk of
adrenal insufficiency with chronic steroid use. Awaiting
surgical intervention for MV vegetation after prednisone taper,
per Cardiac Surgery prednisone dose closer to 10mg QD would be
ideal to reduce risk of post op sternal wound complications. ___
CT chest showing improvement from prior. Baseline PFTs obtained
on ___, consistent with restrictive lung disease (FEV1 2.07 (65%
predicted) with FEV1/FVC 75 (96% predicted). Prednisone taper
per Pulm - started 30mg QD ___ for 1 week, then 20mg QD for 1
week, then 10mg QD for 1 week. Continued Atovaquone ppx,
calcium, VitD.
# Thrombocytopenia
# Anemia
Patient had a steadily decreasing platelet count since prior
hospitalization ___ (150 at the time), low 100s on admission.
Outpatient ___ hematologist notified and inpatient heme-onc
consulted. Appears to be related to marrow suppression in
setting of known PV myelofibrosis and high dose steroids.
Unlikely consumptive process or splenic sequestration. Labs
reassuring for no hemolytic or consumptive process. Evidence of
iron deficiency anemia given calculated transferrin saturation
of 3%. Started on ferrous sulfate PO after discussion with outpt
hematologist. Platelets trended up and normalized by discharge.
CHRONIC ISSUES
==============================
# Influenza A (resolved)
Confirmed positive shortly after arrival. Suspect this, in
combination with MR, exacerbated underlying dyspnea. Patient has
subjectively improved and no back to baseline. Remained afebrile
throughout admission. Completed 5 day course of Tamiflu with
renal dosing (___).
# Saphenous vein thrombophlebitis
Superficial thrombophlebitis of the right great saphenous vein
as seen on ___. Patient reports that leg pain has resolved.
# Recent unprovoked DVT
Given age, known myeloproliferative disorder, and recent
unprovoked DVT, at risk for repeat thrombo-embolic event.
# JAK2 Polycythemia
# Leukocytosis
# Anemia
Baseline WBC in 50-60s, baseline hgb in ___, platelets
downtrending to <100, noted above. Continued home ruxolitinib.
# Hypertension
Her home verapamil and lisinopril were held as outlined above.
She was started on torsemide 10mg with a BP in the 150's
systolic. Discussed with her to have her BP re-evaluated going
forward with PCP and if still elevated consider resuming
lisinopril if renal function allows, or consider alternate
agent. As torsemide was started at the time of discharge,
unclear how much it would affect her BP therefore an additional
agent was not initiated.
TRANSITIONAL ISSUES
==============================
[ ] Holding home lisinopril, verapamil on discharge given new
diagnosis of heart failure and ___
[ ] She will need follow up BMP on the day after discharge (at
PCP ___ to monitor her Cr, bicarb; please recheck one
week later.
[ ] based on BMP results, may need to reconsider Lovenox and/or
Torsemide dosing
[ ] Patient at risk for osteoporosis and will likely benefit
from bisphosphonate as outpatient
[ ] Continue atovaquone, Vitamin D, & calcium prophylaxis while
on chronic steroids. Will remain on prednisone daily until
pulmonary follow up.
[ ] Prednisone taper: After 1 week of 30mg daily (last day
___, decrease to 20mg daily for 1 week, then 10mg daily for 1
week
[ ] Patient requires medical leave form for work to be filled
out by PCP
[ ] Has Cardiology and Cardiac Surgery follow-up to discuss
mitral valve replacement
[ ] Repeat TEE around ___ to monitor for LV thrombus, to be
scheduled by cardiology division
[ ] Hematology follow up of JAK2 polycythemia ___: uptrending
WBC this admission, discharge WBC 70.4
[] Additionally has follow up with Pulmonology to discuss COP
treatment and steroid timing if planned Cardiac surgery occurs
[] Needs renal follow up for new ___ and acidosis, to be
scheduled after discharge by nephrology division
Time spent coordinating discharge: 60 minutes
PCP notified via telephone call of discharge with warm handoff
given. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Iodinated Contrast- Oral and IV Dye
Attending: ___.
Chief Complaint:
Nausea, vomiting, headache
Major Surgical or Invasive Procedure:
None this admission.
___: left craniotomy for clipping of ACOMM aneurysm
History of Present Illness:
Mr. ___ is a ___ year old male POD4 from left craniotomy
for aneurysm clipping. His post-operative course was significant
for severe pain and the chronic pain service was consulted. He
was discharged to home yesterday and was feeling generally well
and states his pain was tolerable. He ate spaghetti for dinner
and around ___ he was having uncontrolled pain which he
describes as in the left temporal/frontal region. He woke this
morning and took his medications however he had multiple
episodes
of nausea and vomiting and was unable to keep his medications or
food down. He went to an OSH and was transferred here for
neurosurgical evaluation. Head CT showed post-op changes without
acute hemorrhage.
He reports ___ headache with some dizziness. He currently
denies visual changes. Denies diarrhea, fevers, seizures,
incontinence of bowel and bladder, or recent trauma. He states
he
has been taking his medications as prescribed including bowel
meds but has not had a bowel movement since before surgery. He
reports he has 11 doses of methadone remaining at home.
Past Medical History:
HTN
HLD
narcotic dependence
Past surgical history
left craniotomy for ACOMM aneurysm clipping ___
multiple hernia repairs
cervical spine fusion
Social History:
___
Family History:
Mr. ___ has no family history of aneurysm or ruptured
aneurysms.
Physical Exam:
ON ADMISSION:
************
PHYSICAL EXAM:
O: T: 99.3 BP: 192/87 HR: 49 R: 16 O2Sats: 96% RA
Gen: WD/WN, complaining of severe pain, NAD.
HEENT: Pupils: PERRL EOMs: intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect- although frequently complaining of pain
Orientation: Oriented to person, place, and date- self corrected
for date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria. Some paraphasic errors when
answering date, self corrected.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5 to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. Mild BUE tremors.
Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
ON DISCHARGE:
************
Opens eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: Right 2.5-2mm Left 2.5-2mm
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [ ]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
IPQuadHamATEHLGast
[x]Sensation intact to light touch
Wound:
[x]Sutures in place
[x]Well-approximated, no erythema or active drainage
Pertinent Results:
See OMR for pertinent lab results/imaging.
Medications on Admission:
Discharge Medications from ___:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Dexamethasone 2 mg IV Q12H Duration: 2 Doses
This is dose # 2 of 2 tapered doses
RX *dexamethasone 2 mg 1 tablet(s) by mouth once, at bedtime
Disp #*1 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second Line
6. Naloxone Nasal Spray 4 mg IH ONCE MR1 severe respiratory
depression, altered mental status, associated with opiate use
Duration: 1 Dose
RX *naloxone [Narcan] 4 mg/actuation 1 actuation intranasally
Once MR1 Disp #*2 Spray Refills:*0
7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth q6hrs Disp #*28 Tablet
Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 17.2 mg PO QHS
10. Atorvastatin 20 mg PO QPM
11. BuPROPion XL (Once Daily) 150 mg PO DAILY
12. Lisinopril 20 mg PO DAILY
13. Methadone (Concentrated Oral Solution) 10 mg/1 mL 170 mg PO
DAILY
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every 8 hrs prn Disp #*24 Tablet Refills:*0
2. Dexamethasone 2 mg PO Q12H Duration: 6 Doses
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
This is dose # 1 of 3 tapered doses
RX *dexamethasone 1 mg 2 tablet(s) by mouth twice a day Disp
#*24 Tablet Refills:*0
3. Dexamethasone 2 mg PO DAILY Duration: 4 Doses
Start: After 2 mg Q12H tapered dose
This is dose # 2 of 3 tapered doses
4. Dexamethasone 1 mg PO DAILY Duration: 4 Doses
This is dose # 3 of 3 tapered doses
5. Famotidine 20 mg PO BID Duration: 14 Days
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*0
6. Relistor (methylnaltrexone) 150 mg oral DAILY
Please follow-up with your PCP for additional refills of this
medication
RX *methylnaltrexone [Relistor] 150 mg 1 tablet(s) by mouth once
a day Disp #*30 Tablet Refills:*0
7. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Moderate
8. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
9. Atorvastatin 20 mg PO QPM
10. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
11. BuPROPion XL (Once Daily) 150 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Lisinopril 20 mg PO DAILY
14. Methadone 170 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY
16. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
ACOMM aneurysm
Chronic pain
Opioid-induced constipation
Post-operative nausea and vomiting
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 HTN, bradycardia, new// recent acomm aneurysm,
head ache severely worsening
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Reference CTA head ___.
FINDINGS:
The patient is status post left frontotemporal craniotomy. Postsurgical
changes including pneumocephalus are present. Additionally, there is
bilateral extra-axial low-density fluid overlying both cerebral convexities,
probably reflecting hygroma. An A-comm aneurysm clip is demonstrated, with
associated streak artifact. No acute intracranial hemorrhage or evidence of a
large territorial infarct. No midline shift.
There is a 5.5 x 1.2 cm fluid collection overlying the left craniotomy site,
possibly reflecting a seroma. Paranasal sinus disease includes thickening and
partial opacification of the left greater than right anterior ethmoid air
cells and a mucous retention cyst in the left frontal sinus. Mastoid air
cells and middle ear cavities are clear. The visualized portion of the orbits
are unremarkable.
IMPRESSION:
1. Postsurgical changes following left frontotemporal craniotomy, including
small volume pneumocephalus and a subcutaneous fluid collection at the
surgical site which could reflect a seroma.
2. No hemorrhage or large areas of loss of gray-white matter differentiation.
Radiology Report
INDICATION: History: ___ with post op constipation// constipation?
TECHNIQUE: Supine and upright AP views of the abdomen
COMPARISON: None.
FINDINGS:
A large amount of fecal loading is seen throughout the colon and rectum. No
dilated loops of small bowel, differential air-fluid levels, or free
intraperitoneal air identified. Tiny coil like radiopaque density projects
over the right iliac bone. No acute osseous abnormality. No concerning soft
tissue calcifications.
IMPRESSION:
Large fecal loading throughout the colon and rectum. No small bowel
obstruction or free intraperitoneal air.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache
Diagnosed with Primary thunderclap headache, Essential (primary) hypertension, Bradycardia, unspecified
temperature: 99.3
heartrate: 50.0
resprate: 16.0
o2sat: 98.0
sbp: 167.0
dbp: 90.0
level of pain: 10
level of acuity: 2.0 | ___ male s/p left craniotomy for aneurysm clipping and
discharged home on ___, returned as transfer to ___ ED on ___
for post-operative headache, nausea, vomiting and constipation.
#Constipation
Upon his arrival back in the ED, the patient had severe nausea
and reported that he had not had a BM since before his surgery.
A KUB was done that revealed a large stool burden, but no
evidence of ileus. He was given a fleet enema and resumed on an
aggressive bowel regimen, including standing Docusate sodium,
Senna, Miralax and Bisacodyl as well as prn Milk of Magnesia. On
___, he was initiated on daily Relistor for opioid-induced
constipation. He had multiple BMs on ___.
#Nausea and vomiting
EKGs were performed that revealed the patient's QTc to be 419
and 440. He vomited x 1 on the morning of ___, and was given
Compazine. He continued to be nauseous and vomited two more
times. His diet was limited to clear liquids and he was given
Zofran x 1 as a second line agent. His nausea improved, and his
diet was advanced back to regular on ___.
#Chronic pain
The patient was resumed on his daily Methadone and put on prn
Oxycodone, APAP and Fioricet for pain control. His pain was
adequately controlled at time of discharge.
#S/P left craniotomy for aneurysm clipping.
Patient was neurologically intact on his return to the hospital.
No repeat imaging or LP was indicated. He was monitored with
neuro checks every 4 hours. He remained neurologically stable
until his discharge on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
progressive confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with cirrhosis, hep C, ETOH use disorder, HTN, seizures,
prior ___ s/p evacuation (___), depression, and bipolar who
presents with progressive confusion.
He initially presented to ED 1 day prior on ___ for confusion
and placement, brought in by ___. He also reported right
paraspinal pain, but denied bowel or bladder symptoms, no
weakness. At that point labs were unremarkable, CT head stable
(see below), and plan was for him to await placement in
coordination with case management with plan for outpt
neuropsychiatric evaluation. However, he eloped. Subsequent to
patient eloping, patient's daughter reported she received a call
from patient stating he was on a park bench in ___ and
that
he was confused saying that was where he lived. Patient was
placed on a ___.
Of note, he was removed from rest home due to alcohol use on
___. He has been living alone in apartment since then but
feeling unsafe. Daughter concerned he is not caring for himself,
including not washing himself, etc. Has had slowly progressive
confusion, "finding himself somewhere without memory of how he
got there" for the past year, but no sudden change in mental
status. Last ETOH use per patient on ___. Per daughter, he has
had unstable gait and falls most recently in ___, which were
evaluated at OSH ED with CTH reportedly normal.
Past Medical History:
cirrhosis
hep C
ETOH use
HTN
seizures
depression
Right subdural hematoma status post surgical evacuation (___)
after a fall
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: 97.3PO, 133 / 74R Sitting, 66, 16, 95 Ra
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. Sclera anicteric and without injection.
ENT: supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
MSK: No spinous process tenderness. No CVA tenderness. R low
back
musculature moderately TTP.
SKIN: Warm. No rash.
NEUROLOGIC: AAOX2 (to self, "hospital" but not to ___, not to
year ___. Could not state reason for admission. Motor ___
and
SILT in bilateral ___.
DISCHARGE PHYSICAL EXAM
=======================
24 HR Data (last updated ___ @ 1139)
Temp: 97.3 (Tm 98.1), BP: 155/76 (135-155/67-76), HR: 65
(65-68), RR: 18, O2 sat: 94%, O2 delivery: RA
GENERAL: Alert and interactive, laying comfortably in bed. In no
acute distress.
EYES: NCAT. Sclera anicteric and without injection.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing. No hepatomegaly.
ABDOMEN: Normal bowels sounds, mildly distended, non-tender to
deep palpation in all four quadrants.
MSK: No spinous process tenderness. No CVA tenderness. R low
back
paraspinous tenderness
SKIN: Warm. No rash.
NEUROLOGIC: AAOX2 (to self, "my room, nut house" but not to
___, ___ but not month or season) Could not state reason
for
admission. Motor ___ and SILT in bilateral ___. No dysmetria or
asterixsis. Mild tremor with hand outstretched.
Pertinent Results:
ADMISSION LABS
================
___ 02:29PM BLOOD WBC-8.0 RBC-4.58* Hgb-14.2 Hct-43.2
MCV-94 MCH-31.0 MCHC-32.9 RDW-13.3 RDWSD-45.9 Plt ___
___ 05:53PM BLOOD WBC-9.4 RBC-4.57* Hgb-13.9 Hct-42.2
MCV-92 MCH-30.4 MCHC-32.9 RDW-13.3 RDWSD-45.2 Plt ___
___ 02:29PM BLOOD Neuts-72.8* Lymphs-15.9* Monos-8.6
Eos-1.4 Baso-0.9 Im ___ AbsNeut-5.81 AbsLymp-1.27
AbsMono-0.69 AbsEos-0.11 AbsBaso-0.07
___ 02:29PM BLOOD Plt ___
___ 02:43PM BLOOD ___ PTT-31.4 ___
___ 02:29PM BLOOD Glucose-91 UreaN-7 Creat-0.9 Na-145 K-4.5
Cl-106 HCO3-25 AnGap-14
___ 05:53PM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-145
K-4.4 Cl-104 HCO3-25 AnGap-16
___ 02:29PM BLOOD ALT-11 AST-16 AlkPhos-103 TotBili-0.4
___ 02:29PM BLOOD Albumin-4.2 Calcium-9.4 Phos-3.0 Mg-1.9
___ 10:50AM BLOOD Trep Ab-NEG
___ 06:25AM BLOOD HIV Ab-NEG
___ 05:53PM BLOOD TSH-0.43
___ 05:53PM BLOOD calTIBC-313 VitB12-464 TRF-241
___ 02:29PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 06:25AM BLOOD HCV VL-6.6*
DISCHARGE LABS
===============
___ 07:02AM BLOOD WBC-5.4 RBC-4.19* Hgb-12.9* Hct-39.0*
MCV-93 MCH-30.8 MCHC-33.1 RDW-13.2 RDWSD-44.9 Plt ___
___ 07:02AM BLOOD WBC-5.4 RBC-4.19* Hgb-12.9* Hct-39.0*
MCV-93 MCH-30.8 MCHC-33.1 RDW-13.2 RDWSD-44.9 Plt ___
___ 05:53PM BLOOD Neuts-77.1* Lymphs-14.2* Monos-6.8
Eos-1.0 Baso-0.5 Im ___ AbsNeut-7.28* AbsLymp-1.34
AbsMono-0.64 AbsEos-0.09 AbsBaso-0.05
___ 07:02AM BLOOD Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD ___ PTT-30.7 ___
___ 07:02AM BLOOD Glucose-85 UreaN-11 Creat-0.7 Na-137
K-4.0 Cl-99 HCO3-24 AnGap-14
___ 06:25AM BLOOD Glucose-91 UreaN-13 Creat-0.8 Na-141
K-4.1 Cl-106 HCO3-24 AnGap-11
___ 07:02AM BLOOD Mg-1.8
___ 07:02AM BLOOD Mg-1.8
___ 06:25AM BLOOD Albumin-3.8 Calcium-8.7 Phos-3.5 Mg-1.9
IMAGING:
==========
CT HEAD ___
Final Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with confusion// eval 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: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy
(Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
Encephalomalacia in the right posterior temporal and occipital
lobes with ex
vacuo dilatation of the temporal and occipital horns of the
right lateral
ventricle is compatible with prior infarct.
Patient is status post right frontal parietal craniotomy. Thin
extra-axial 3
mm wide hyperdensity along the right frontoparietal convexity at
the site of
prior craniotomy may reflect chronic dural thickening, and less
likely
unlikely to reflect an acute subdural hematoma (02:15).
There is no evidence of acute territorial infarction,intra-axial
hemorrhage,edema,or mass. There is prominence of the ventricles
and sulci
suggestive of involutional changes. Periventricular and
subcortical white
matter hypodensities are nonspecific, but likely reflect the
sequela of
chronic microvascular infarction.
There is no evidence of fracture. The visualized portion of
the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. Thin extra-axial hyperdensity along the right frontoparietal
convexity at
the site of prior craniotomy defect most likely reflects chronic
dural
thickening with an acute subdural hematoma considered less
likely. Comparison
with more recent prior imaging would be helpful, or
alternatively a follow-up
CT head can be obtained for further assessment.
2. Chronic right posterior cerebral artery territorial infarct.
3. No acute intracranial abnormality otherwise demonstrated.
___ electronically signed on ___ ___ 8:20
___
Imaging Lab
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Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with ? ___ call; please acquire at midnight// eval
___
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.1 cm; CTDIvol = 49.7 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
Status post right frontoparietal craniotomy. The previously seen thin
extra-axial 3 mm wide hyperdensity in the right frontoparietal convexity at
site of prior craniotomy is unchanged from 4 hours prior. Encephalomalacia in
the posterior right temporal and occipital lobes with ex vacuo dilation of the
right lateral ventricle temporal and occipital horns is compatible with prior
infarct. There is no evidence of acute infarction,hemorrhage,edema,or mass.
There is no evidence of acute fracture. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Thin extra-axial hyperdensity along the right frontoparietal convexity at
site of prior craniotomy defect is unchanged from 4 hours.
2. Chronic right PCA territory infarct.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Psych eval
Diagnosed with Altered mental status, unspecified
temperature: 98.1
heartrate: 65.0
resprate: 16.0
o2sat: 95.0
sbp: 152.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | BRIEF HOSPITAL COURSE:
====================
___ with cirrhosis, hep C, ETOH use disorder, HTN, seizures,
prior ___ s/p ___, possible depression vs bipolar
who was brought in by his daughter with progressive confusion
and failure to thrive at home. Per his daughter, there was
concern of progressive confusion, disorientation, and
impulsiveness over the past year, with concern that he was
unable to appropriately care for himself at home. He was
evaluated with a head CT unremarkable for acute changes,
dementia work up included a normal TSH/B12, and neg HIV/trep Ab.
His presentation was most concerning for progressive process of
dementia, with cognitive abilities worsened by chronic EtOH use.
Per psychiatry evaluation, depression or other underlying mood
disorder was unlikely contributor to dementia.
TRANSITIONAL ISSUES:
====================
[] f/u need to continue antidepressant, assess depressive
symptoms, and confirm accurate diagnosis (reported depression vs
bipolar, evaluated by psychiatry here without concern for
significant mood disorder)
[] f/u BP, was normotensive while in hospital and home
amlodipine/metoprolol were held at discharge
[] f/u in liver clinic for Hepatitis C treatment evaluation
[] f/u status of cirrhosis, determine timing for repeat
screening EGD |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male, s/p high speed rollover MVC
___, who initially went to ___, eloped, and was
brought into police custody. He was then brought to ___
with complainsts of right upper quadrant abdominal pain and
found to have a grade 2 liver laceration with HCT of 37. Head
CT/cervical spine CT negative.
Past Medical History:
Asthma
ETOH
?suboxone program
Social History:
___
Family History:
NC
Physical Exam:
Admission PE: ___:
Temp: 98.6 HR: 55 BP: 123/69 Resp: 18 O(2)Sat: 98
Constitutional: NAD, alert, GCS 15
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: diffuse tenderness to palpation
Extr/Back: No cyanosis, clubbing or edema
Neuro: Speech fluent, neuro intact
Discharge PE: ___:
Temp: 98.6 HR: 53 BP: 122/62 Resp: 20 O(2)Sat: 99 (RA)
Constitutional: NAD, alert, GCS 15
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: soft, nontender, BS active
Extr/Back: No cyanosis, clubbing or edema
Neuro: Speech fluent, neuro intact
Pertinent Results:
___ 12:40AM ___ PTT-31.6 ___
___ 12:40AM PLT COUNT-196
___ 12:40AM NEUTS-68.4 ___ MONOS-6.7 EOS-0.7
BASOS-0.6
___ 12:40AM WBC-6.9 RBC-4.85 HGB-14.1 HCT-41.9 MCV-87
MCH-29.1 MCHC-33.7 RDW-12.8
___ 12:40AM LIPASE-11
___ 12:40AM ALT(SGPT)-47* AST(SGOT)-37 ALK PHOS-69 TOT
BILI-2.1*
___ 12:40AM estGFR-Using this
___ 12:40AM GLUCOSE-89 UREA N-14 CREAT-0.9 SODIUM-139
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16
___ 05:45AM PLT COUNT-172
___ 05:45AM WBC-6.0 RBC-4.28* HGB-12.7* HCT-37.2* MCV-87
MCH-29.7 MCHC-34.1 RDW-12.9
___ 05:45AM LIPASE-9
___ 05:45AM ALT(SGPT)-40 AST(SGOT)-30 ALK PHOS-59
AMYLASE-11 TOT BILI-1.9*
MRI Cervical Spine
No cord signal abnormality. No paraspinal edema or evidence of
ligamentous injury.
Medications on Admission:
1. Suboxone 8mg PO TID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain Duration: 14 Days
2. Docusate Sodium 100 mg PO BID Duration: 14 Days
Discharge Disposition:
Home
Discharge Diagnosis:
polytrauma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
No cord signal abnormality. No paraspinal edema or evidence of ligamentous
injury. These findings were communicated via phone call to Dr. ___
by Dr. ___ ___ at 15:10 hrs.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Transfer
Diagnosed with LIVER INJURY NOS, TRAFFIC ACC NOS-DRIVER
temperature: 98.6
heartrate: 55.0
resprate: 18.0
o2sat: 98.0
sbp: 123.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man who was admitted for
___ on ___ s/p high speed rollover single car MVC 24
hours prior to admission. Per report, patient was driving under
influence at the time of the accident, was taken from the scene
of the accident to an OSH from where he eloped to his home. He
was found at home by the police, briefly incarcerated but when
he began to complain of RUQ pain he was taken to the OSH where
CT Abd Pelvis revealed grade II liver laceration. Subsequently
he was transferred to ___ for further management.
Once at ___ he was seen by the ___ service and admitted for
for further evaluation. His LFT's inititally bumped at the OSH
ED but have since trended down. His hematocrit has trended
between37.9-41 and the patient has remained hemodynamically
stable. Tertiary survey initially revealed ongoing cervical
spinal tenderness and a C-Collar was placed. CT C-spine was
normal and MRI of the C-Spine revealed no cord signal
abnormality, paraspinal edema or evidence of ligamentous injury.
OT evaluated patient due to his questionable loss of
conciousness and post concussive symptoms and recommended
Cognitive Neurology follow-up.
At the time of his discharge on ___ the patient was
tolerating a regular diet without nausea or vomitting, afebrile
with a normal white blood cell count, ambulating independently
and voiding adequately. Of note the patient was kept off
Suboxone that he has reportedly taking for the past 10 months.
He did not show any signs of withdrawal and his pain was well
controlled on PO Tylenol and Ultram. Prior to his discharge to
the county jail we discussed the patient's case with the doctor
on call at the ___ Jail who asked us discharge the patient
without Suboxone because he will undergo appropriate
detoxification at the jail facility under supervision of the
medical team there. He will follow up in our clinic as well as
at the Cognitive Neurology clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vicodin / Dilaudid
Attending: ___
___ Complaint:
chest pain
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
___ w/pmh CAD s/p CABG and multiple PCI last ___ in ___,
HTN, borderline DM presents with acute chest pain, neg trop x2
and admitted for possible stress test.
Patient developed pain around 1 ___ in his subxiphoid area while
standing at work. Not worse with exertion or deep breaths. No
diaphoresis or pain in his arms or back. The pain resolved on
its
own within 15 minutes. He called his cardiologist who
recommended
coming to the ED for evaluation.
In the ED, initial VS were: 97.1 56 166/67 18 99% RA
Labs showed: Trop negative x2
Imaging showed:
EKG shows STE in III and aVF and TWI and STD anteriorly, stable
Received:
___ 15:56 PO/NG Atorvastatin 80 mg
___ 15:56 PO Aspirin 324 mg
Cardiology was consulted
Transfer VS were: 55 138/61 16 95% RA
On arrival to the floor, patient reports continued feeling well.
He states it is hard to tell if this is prior to previous pain
episodes as he has pain with his hiatal hernia. No shortness of
breath. He exercises almost everyday with a treadmill, bike and
weights without any chest pain normally.
Past Medical History:
- Hypertension.
- Type 2 diabetes mellitus - diet-controlled.
- Dyslipidemia.
- Coronary artery disease status post CABG ___ (SVG to LAD,
SVG to RCA, SVG to OM-1, LIMA to diagonal).
- S/p PCTA with stent placement ___ at ___
- Status post PTCA ___ with two stents placed in
SVG to OM-1.
- Status post PTCA in ___ with one stent placed to the
SVG to OM-1.
- Status post two myocardial infarctions.
- Anal fistula.
- LV gram ___ showing an ejection fraction of 68% and
no wall motion abnormalities.
- Hiatal hernia.
Social History:
___
Family History:
F - CAD s/p CABG x4, died ___
M - CHF, HTN, MI, died at ___
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM:
=========================
VS: 97.9 159/70 64 18 96 RA
GENERAL: Adult male in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
=========================
DISCHARGE PHYSICAL EXAM:
=========================
VITALS: Tm 97.8 HR 60 BP 174/72 RR 18 SPO2 95% RA
GENERAL: Elderly man sitting up in bed in NAD
HEENT: MMM
CV: RRR. Soft s1/s2. No m/r/g. JVD ___ ___+ radial pulses
RESP: CTAB. No w/r/r
GI: Soft. NT. ND. +BS
EXT: No ___ edema, cyanosis, or clubbing. No calf tenderness.
SKIN: Warm and well-perfused. No rashes.
NEURO: AAOx3. Moving all 4 extremities. CN II-XII grossly intact
Pertinent Results:
===============
Admission labs
===============
___ 03:15PM BLOOD WBC-6.3 RBC-4.72 Hgb-13.7 Hct-40.1 MCV-85
MCH-29.0 MCHC-34.2 RDW-12.0 RDWSD-36.9 Plt ___
___ 03:15PM BLOOD Neuts-63.3 ___ Monos-10.0 Eos-2.1
Baso-0.5 Im ___ AbsNeut-4.00 AbsLymp-1.51 AbsMono-0.63
AbsEos-0.13 AbsBaso-0.03
___ 04:32PM BLOOD ___ PTT-34.2 ___
___ 03:15PM BLOOD Glucose-127* UreaN-24* Creat-1.2 Na-142
K-4.5 Cl-104 HCO3-20* AnGap-18*
___ 03:15PM BLOOD ALT-31 AST-33 AlkPhos-65 TotBili-0.6
___ 03:15PM BLOOD Lipase-49
___ 03:15PM BLOOD cTropnT-<0.01
___ 07:22PM BLOOD cTropnT-<0.01
___ 03:15PM BLOOD Albumin-4.4
===============
Pertinent labs
===============
___ 06:30AM BLOOD %HbA1c-6.5* eAG-140*
===============
Discharge labs
===============
___ 08:20AM BLOOD WBC-5.6 RBC-4.77 Hgb-13.8 Hct-40.6 MCV-85
MCH-28.9 MCHC-34.0 RDW-11.9 RDWSD-36.6 Plt ___
___ 08:20AM BLOOD Glucose-126* UreaN-19 Creat-1.1 Na-142
K-3.9 Cl-101 HCO3-25 AnGap-16
===============
Studies
===============
Cardiac perfusion test (___): IMPRESSION: 1. Moderate fixed
perfusion defect involving the inferior and inferolateral walls,
similar to ___ 2. Mild interval decrease in ejection
fraction from 48% to 40%.
Exercise stress test (___): IMPRESSION: No anginal symptoms.
EKG with repolarization abnormalities that normalized with
exertion and returned to baseline during recovery. Nuclear
report sent separately.
CXR (___): IMPRESSION: No acute cardiopulmonary process. No
significant change from the prior study
===============
Microbiology
===============
Urine culture (___): contaminated specimen
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Esomeprazole 40 mg Other DAILY
5. Finasteride 5 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. irbesartan 75 mg oral DAILY
8. Metoprolol Tartrate 50 mg PO BID
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Potassium Chloride 20 mEq PO DAILY
11. Aspirin 325 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Psyllium Wafer 1 WAF PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Esomeprazole 40 mg Other DAILY
6. Finasteride 5 mg PO DAILY
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. irbesartan 75 mg oral DAILY
9. Metoprolol Tartrate 50 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. Potassium Chloride 20 mEq PO DAILY
13. Psyllium Wafer 1 WAF PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
==================
#Non-cardiac chest pain
#HTN
SECONDARY DIAGNOSES
===================
# NIDDM
# GERD
# Hiatial hernia
# BPH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with chest pain// evaluate for intra-thoracic
process
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Patient is status post median sternotomy and CABG. The cardiac and
mediastinal silhouettes are stable. No focal consolidation, pleural effusion,
evidence of pneumothorax is seen. There is no pulmonary edema.
IMPRESSION:
No acute cardiopulmonary process. No significant change from the prior study.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 97.1
heartrate: 56.0
resprate: 18.0
o2sat: 99.0
sbp: 166.0
dbp: 67.0
level of pain: 2
level of acuity: 2.0 | SUMMARY: Mr. ___ is an ___ year old male with CAD s/p CABG and
multiple PCI last ___, HTN, NIDDM, who presented with acute
chest pain admitted for workup. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
PICC removal
PICC insertion
History of Present Illness:
___ PMH of Metastatic jejunal NET (s/p mult abdominal resections
for malignant bowel obstruction now w/ end jejunostomy c/b
severe
short bowel syndrome, now on depot octreotide, everolimus, TPN
and daily mIVF (1L LR)) with recent admission for dehydration,
hyperkalemia, ___ from high ostomy output & short gut syndrome
who presents as a transfer from ___ for fever.
She presented to ___ for rigors and some mild abdominal pain. CT
a/p showed complex fluid collections c/f abscess. She received
cefepime, vancomycin, and Flagyl prior to transfer.
ED initial vitals were 100.4 98 106/67 16 100% RA
Exam in the ED showed : non-tender abdominal, but bilateral CVA
tenderness
ED work-up significant for:
-CBC: WBC: 5.1. HGB: 7.9*. Plt Count: 110*. Neuts%: 81.3*.
-Chemistry: Na: 141 (New reference range as of ___. K:
3.3* (New reference range as of ___. Cl: 105. CO2: 22.
BUN: 21*. Creat: 1.0. Ca: 8.5. Mg: 2.0. PO4: 3.1.
-Coags: INR: 1.2*. PTT: 28.0.
-LFTs: ALT: 26. AST: 38. Alk Phos: 123*. Total Bili: 1.4.
ED management significant for surgical consult, who recommended
RUQUS, broad spectrum IV ABx. She also received 40 mg IV
potassium.
On arrival to the floor, patient reiterates that up until 3 days
ago she was in USOH after her most recent discharge and doing
well. Then 2 days ago felt cold and ___ AM develop shaking
rigors, felt generally unwell and non-specific RLQ ab pain which
brought her to the ed.
Patient denies night sweats, headache, vision changes, neck
pain, photophobia. No dynophagia or dental pain.
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, cough, hemoptysis, chest pain, palpitations,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes. She denies pain at injection
site of octreotide from ___ and no pain at ___ site. No leg
swelling.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per last clinic note by Dr ___:
"- ___: abdominal pain, fever, and chills. CT shows
a
mass in the small bowel. Other testing not entirely documented
(in ___
- ___: s/p resection. Path showed T4N1 well-differentiated
NET of the jejunum. Her chromogranin A was elevated to 117
prior
to resection.
- ___: Imaging showed ___, but
chromogranin
remained elevated
- ___: negative octreotide scan (NV)
- ___: CT Torso showed multiple small mesenteric lymph
nodes
(largest 14mm) and two subcentimeter nodules along the liver
capsule, concerning for recurrent metastatic disease.
- ___: chromogranin 207, serotonin 2379
- ___: Initiated octreotide 20mg IM monthly
- ___: Liver Bx showed metastatic NET, well-differentiated,
Ki67 16.6%
- ___: octreotide 20mg IM
- ___: admitted with nausea, vomiting, discovered to have
sigmoid bowel obstruction.
- ___ ex-lap, SBR, bladder repair
- ___ washout, TAC, SBR, L salpingectomy
- ___: Dotatate scan shows widespread disease in the
abdomen
- ___: octreotide 20mg IM (no dose since ___
PAST MEDICAL HISTORY:
Sarcoidosis (Dx early ___)
HTN
Thyroid nodule
SBO s/p resection (___)
Type II DM
Social History:
___
Family History:
Sister with colon polyps
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
___ 0029 Temp: 99.1 PO BP: 116/62 HR: 74 RR: 18 O2 sat: 96%
O2 delivery: RA
GENERAL: Well- appearing woman in no distress lying in bed
comfortably.
HEENT: Anicteric, PERLL, Mucous membranes dry, oropharynx
clear.
Poor dentition but no dental pain to palpation. No tongue or
palatal lesions. No lesions of posterior oropharynx or uvula.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly. Jejunostomy site
is c/d/I w/no slouging or erythema. ostomy with bilious thin
liquid c/w prior admissions from my experience w/her
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness. Foot exam bilaterally is without abnl.
MSK: glut site of IM injection w/o fluctuance or erythema
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. Strength full throughout.
SKIN: No significant rashes. Left PICC site clean without
erythema, secretion, tenderness. No palpable cord
DISCHARGE PHYSICAL EXAM
========================
VS: 24 HR Data (last updated ___ @ 1203)
Temp: 97.9 (Tm 98.4), BP: 123/78 (117-146/62-86), HR: 77
(76-80), RR: 18, O2 sat: 99% (97-99), O2 delivery: Ra, Wt: 156.8
lb/71.12 kg
GENERAL: Well-appearing lady, in no distress sitting in bed
comfortably.
HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx
clear.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, ostomy bag full of liquid jejunal content,
normal bowel sounds, soft, non-tender, no guarding, no palpable
masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention and linear thought
process. CN II-XII intact. Strength full throughout. Sensation
to light touch intact.
SKIN: No significant rashes. Right PICC without drainage,
tenderness, erythema.
Pertinent Results:
___ 08:07PM BLOOD WBC-5.1 RBC-2.76* Hgb-7.9* Hct-25.1*
MCV-91 MCH-28.6 MCHC-31.5* RDW-13.9 RDWSD-45.7 Plt ___
___ 08:07PM BLOOD Neuts-81.3* Lymphs-14.4* Monos-3.7*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-4.12 AbsLymp-0.73*
AbsMono-0.19* AbsEos-0.00* AbsBaso-0.01
___ 08:57AM BLOOD Neuts-59.3 ___ Monos-14.1*
Eos-4.1 Baso-0.3 NRBC-0.3* Im ___ AbsNeut-3.66
AbsLymp-1.27 AbsMono-0.87* AbsEos-0.25 AbsBaso-0.02
___ 08:07PM BLOOD Glucose-120* UreaN-21* Creat-1.0 Na-141
K-3.3* Cl-105 HCO3-22 AnGap-14
___ 08:57AM BLOOD Glucose-115* UreaN-11 Creat-0.9 Na-142
K-4.2 Cl-100 HCO3-32 AnGap-10
___ 06:05AM BLOOD ALT-24 AST-38 LD(LDH)-264* AlkPhos-113*
TotBili-1.8* DirBili-1.4* IndBili-0.4
___ 08:57AM BLOOD ALT-26 AST-44* LD(LDH)-262* AlkPhos-180*
TotBili-0.7
___ 06:05AM BLOOD Calcium-8.4 Phos-1.9* Mg-1.9
___ 08:57AM BLOOD Albumin-3.3* Calcium-9.4 Phos-4.1 Mg-2.2
___ 05:17AM BLOOD Triglyc-187*
___ 05:17AM BLOOD 25VitD-8*
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| NON-FERMENTER, NOT
PSEUDOMONAS AERUGIN
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S 8 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
LEVOFLOXACIN---------- 1 S
MEROPENEM-------------<=0.25 S 1 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S 8 R
Right-sided PICC line has been placed with its tip projecting
over the
cavoatrial junction. Left-sided PICC line has been removed.
Lungs are clear. Cardiomediastinal silhouette is stable. There
is no pleural effusion. No pneumothorax is seen
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron ODT 8 mg PO Q8H
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Simethicone 120 mg PO QID
4. Everolimus 10 mg PO Q24H
5. Psyllium Wafer ___ WAF PO BID
6. Vitamin D ___ UNIT PO 1X/WEEK (TH)
7. amLODIPine 5 mg PO DAILY
8. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety
9. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
11. Metoprolol Tartrate 25 mg PO Q6H
12. Pantoprazole 40 mg PO Q24H
13. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H Duration: 10 Days
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV every
24 hours Disp #*8 Intravenous Bag Refills:*0
2. LOPERamide 4 mg PO Q6H
RX *loperamide 2 mg 2 tablets by mouth every six (6) hours Disp
#*100 Tablet Refills:*0
3. sodium chloride 0.9 % 1 liter intravenous DAILY
RX *sodium chloride 0.9 % 0.9 % 1 liter IV daily Refills:*3
4. Thiamine 100 mg PO DAILY Duration: 5 Days
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*5 Tablet Refills:*0
5. Psyllium Wafer 2 WAF PO TID
RX *psyllium 2 wafers by mouth three times a day Disp #*84 Each
Refills:*0
6. Vitamin D 5000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) [Ergocal] 2,500 unit 2
capsule(s) by mouth once a day Disp #*60 Capsule Refills:*0
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Ascorbic Acid ___ mg PO DAILY
9. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
11. Pantoprazole 40 mg PO Q24H
12. HELD- Everolimus 10 mg PO Q24H This medication was held. Do
not restart Everolimus until Dr. ___ recommends to resume
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Klebsiella pneumonia blood stream infection / sepsis
Intestinal insufficiency, high ostomy output
Pelvic ascites NOS
Severe vitamin D Deficiency
Pancytopenia
Metastatic jejunal neuroendocrine tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent, requires assistance
intermittently
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with abdominal pain fever// assess for cholecystitis/abscess
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Earlier same-day CT abdomen pelvis ___ from outside
facility.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There are several echogenic solid masses in the left hepatic
lobe measuring up to 18 mm. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is minimal intrahepatic biliary ductal dilation. The CBD
measures 7 mm.
GALLBLADDER: The gallbladder is not distended. There is minimal gallbladder
wall thickening and trace pericholecystic fluid. There is masslike,
hypoechoic, avascular material layering relatively dependently within the
gallbladder lumen, possibly a sludge ball. There is trace pericholecystic
fluid. Gallbladder wall is intact.
PANCREAS: The head and body of the pancreas are within normal limits. The tail
of the pancreas is not visualized due to the presence of gas.
SPLEEN: Normal echogenicity, measuring 10.8 cm.
KIDNEYS: The right kidney measures 11.0 cm. The left kidney measures 11.0 cm.
Limited sagittal views of the kidneys demonstrate no evidence of
hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Focal echogenic intraluminal material layering dependently in the
gallbladder lumen without vascularity or shadowing, likely representing a
sludge ball/congealed sludge. No stones. While there is slight gallbladder
wall thickening and trace pericholecystic fluid, the gallbladder is not
distended. Findings not consistent with acute cholecystitis.
2. Minimal intrahepatic biliary ductal prominence. CBD within normal limits,
measuring 7 mm.
3. Multiple echogenic solid liver masses consistent known history of
metastatic neuroendocrine tumor.
4. No ascites. Patent portal vein.
Radiology Report
EXAMINATION: Portable chest x-ray
INDICATION: ___ year old woman with picc// picc positioning
TECHNIQUE: Portable chest x-ray
COMPARISON: Chest x-ray ___
FINDINGS:
The tip of the left PICC appears, within the right atrium. There are no large
pleural effusions. Atelectatic changes are seen at the right lung base. A
developing pneumonia cannot be excluded. There are somewhat low lung volumes
causing crowding of the bronchovascular markings and exaggeration of heart
size. The trachea is midline. Degenerative changes are seen in the spine.
IMPRESSION:
The tip of the left PICC overlies the right atrium.
Atelectatic changes right lung base, developing pneumonia cannot be excluded.
RECOMMENDATION(S): Recommend pulling back the PICC 1-2 cm if the desired
location is the cavoatrial junction.
Radiology Report
EXAMINATION: CT scan of the abdomen pelvis with intravenous contrast
INDICATION: ___ year old woman with SB neuroendocrine tumor s/p multiple
surgeries. Presented with abdominal pain, fever, rigors, found to have GNR
BSI.// "abdominal collection" seen in OSH report, unclear whether collection
has appearance to be infected (source) or not
TECHNIQUE: Axial CT images of the abdomen pelvis with intravenous contrast.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total study DLP 1300.84 mGy cm.
COMPARISON: CT cystogram dated ___. CT scan of the abdomen
pelvis dated ___. Dotatate scan dated ___.
FINDINGS:
LOWER THORAX: Linear atelectasis at the lung bases, right greater than left.
HEPATOBILIARY: Multiple hypodense rim enhancing liver lesions appear increased
in size and number from the prior examinations, for instance measuring 18 mm
in segment 3, previously 15 mm (axial series 2, image 89) and 28 mm in segment
2, previously 15 mm (axial series 2, image 82). No biliary ductal dilatation.
Unremarkable gallbladder.
PANCREAS: Unremarkable.
SPLEEN: Unremarkable. No splenomegaly.
ADRENALS: The adrenal glands are normal in size and morphology.
URINARY: Bilateral renal cortical cysts, the largest measuring 21 mm in the
lower pole of the left kidney. Unremarkable bladder.
GASTROINTESTINAL: Patient is status post total colectomy and jejunal resection
with end ileostomy and rectal stump. The residual small bowel is normal in
caliber. The stomach is unremarkable.
REPRODUCTIVE ORGANS: Interval increase in size in soft tissue mass within the
posterior cul-de-sac measuring 25 x 21 x 25 mm (axial series 2, image 124),
previously 23 x 20 x 20 mm in ___. Additional adjacent soft tissue
nodule measuring 15 mm. Patient is status post left salpingo-oophorectomy and
right salpingectomy.
LYMPH NODES: Multiple enlarged retroperitoneal lymph nodes appear increased in
size in comparison to prior examinations, measuring up to 13 mm aortocaval
(axial series 2, image 90) and 12 mm para-aortic (axial series 2, image 90).
Multiple enlarged mesenteric lymph nodes are also noted measuring up to 12 mm
(axial series 2, image 104). No pelvic or inguinal adenopathy.
PERITONEUM, RETROPERITONEUM, MESENTERY: Several soft tissue nodules are noted
within the right hemipelvis, which appears slightly increased in size in
comparison to previous, measuring up to 14 mm (axial series 2, image 111),
previously 7 mm. There is a small volume pelvic ascites and extending up the
right midabdomen with some associated peritoneal enhancement but no defined
fluid collection.
VASCULAR: No abdominal aortic aneurysm. Mild atherosclerotic calcification.
BONES: Stable sclerotic lesion within the left innominate and right pubic
bones. No new or suspicious osseous lesion.
SOFT TISSUES: Nonspecific nodule within the subcutaneous tissues of the right
gluteal region appears minimally increased in size, measuring 18 mm,
previously 14 mm. Postsurgical changes of the anterior abdominal wall.
Single residual skin staple along the lower abdominal wall.
IMPRESSION:
1. Small volume pelvic ascites tracking up the right mid abdomen with mild
peritoneal enhancement but no defined fluid collection.
2. Interval progression of disease with increasing size and number of hepatic
metastases, retroperitoneal and mesenteric adenopathy, peritoneal nodularity,
and pelvic soft tissue masses.
3. Nonspecific subcutaneous nodule within the right gluteal region, likely
injection granuloma or hematoma.
4. Single residual skin staple along the anterior lower abdominal wall.
Radiology Report
INDICATION: ___ year old woman with picc// r dl picc 46cm iv ping ___
Contact name: ping, ___: ___
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Right-sided PICC line has been placed with its tip projecting over the
cavoatrial junction. Left-sided PICC line has been removed. Lungs are clear.
Cardiomediastinal silhouette is stable. There is no pleural effusion. No
pneumothorax is seen
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ w/ metastatic NET, Klebsiella bacteremia, pelvic fluid with
peritoneal enhancement at OSH.// Assess for interval change in peritoneal
enhancement/ pelvic fluid. Would like to rule out ongoing organizing
collection.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 22.7 s, 0.2 cm; CTDIvol = 386.4 mGy (Body) DLP =
77.3 mGy-cm.
3) Spiral Acquisition 7.1 s, 45.9 cm; CTDIvol = 9.0 mGy (Body) DLP = 408.4
mGy-cm.
Total DLP (Body) = 488 mGy-cm.
COMPARISON: Multiple prior examinations, most recent exam is CT abdomen
pelvis from outside hospital on ___
FINDINGS:
LOWER CHEST: There is linear density at the by lateral lung bases, right
greater than left, likely representing atelectasis. No large focal
consolidation or concerning pulmonary nodules identified. There is no pleural
or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Multiple hypodense, rim enhancing liver lesions are unchanged compared to
prior, measuring up to 2.7 cm in the left lobe (series 5; image 20). Biliary
system appears unchanged without definite intra or extrahepatic biliary
dilatation. The gallbladder shows evidence of layering intraluminal sludge
with prominence of the gallbladder wall without edema or definite adjacent
stranding.
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 hydronephrosis. There are multiple renal hypodensities in the
left kidney, largest in the lower pole measuring 2.0 cm consistent with simple
cysts. There is no perinephric abnormality.
GASTROINTESTINAL: Patient is status post total colectomy in jejunal resection
with end ileostomy and rectal stump. Residual small bowel remains normal in
caliber. Stomach is unremarkable.
PELVIS: 2.5 x 2.1 cm soft tissue mass within the posterior cul-de-sac is
unchanged compared to prior. Adjacent soft tissue nodule continues to measure
1.5 cm in short axis. Patient is status post left salpingo-oophorectomy and
right salpingectomy. There remains small volume, serous appearing free fluid
in the pelvis, with adjacent mild peritoneal enhancement, similar compared to
prior. No organizing collection is identified.
LYMPH NODES: Multiple enlarged retroperitoneal lymph nodes appear similar
compared to prior examination, measuring up to 1.2 cm in the aortocaval region
(series 5; image 32) and 1.0 cm in the left periaortic region (series 5; image
28). Multiple enlarged mesenteric lymph nodes are also noted measuring up to
1.0 cm (series 5; image 42). No pelvic or inguinal adenopathy. Several soft
tissue nodules are noted within the right hemipelvis, similar in size compared
to prior, measuring up to 9 mm in size in the right hemipelvis (series 5;
image 49).
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: Nonspecific soft tissue nodule in the right gluteal region is
again seen (series 5; image 58), measuring 1.9 x 1.1 cm, similar to prior.
Post-surgical changes are again noted along the anterior abdominal wall with
single skin staple noted, unchanged.
IMPRESSION:
1. Small volume pelvic ascites persists with mild peritoneal enhancement but
no defined fluid collection.
2. Unchanged hepatic metastases, retroperitoneal and mesenteric adenopathy,
peritoneal nodularity, and pelvic soft tissue masses.
3. Nonspecific subcutaneous nodule within the right gluteal region is
unchanged, likely injection granuloma or hematoma.
4. Single residual skin stable along the lower anterior abdominal wall is
unchanged.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Fever, Transfer
Diagnosed with Unspecified abdominal pain
temperature: 100.4
heartrate: 98.0
resprate: 16.0
o2sat: 100.0
sbp: 106.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | Mrs. ___ is a ___ year-old lady with metastatic jejunal NET
on everolimus s/p multiple SB resections c/b short bowel
syndrome now TPN/IVF-dependent who presented with fever and
rigors, found to havesepsis with K.pneumonia BSI and pelvic
fluid of uncertain significant who improved with broad
antibiotic coverage and PICC removal. Now stable on CTX with new
PICC in place, TPN restarted and monitored >___ for refeeding
syndrome.
#K.pneumonia Sepsis/BSI
Met sepsis criteria via fever, tachycardia, leukopenia,
positiveblood culture. Source remains unclear at this time and
may have included urinary (no OSH urine cx), CLABSI (PICC
pulled, tip cultured but negative cx), gut translocation. SIRS
resolved with broad antibiotic coverage. Narrowed to CTX based
on cultures, surveillance cultures are negative to date. Will
need to complete 14 day course of CTX 2g q24h on ___.
#Pelvic fluid: Found on OSH CT. Fluid is serous on CT
appearance, had mild peritoneal enhancement which was stable on
interval imaging at ___ suggesting more likely
malignancy-related enhancement. Colorectal surgery consulted who
recommended against fluid drainage as appears sterile and would
risk infection. Initially covered with metronidazole for this
possibility but discontinued on ___ given stable CT.
#Small Bowel Insufficiency
#High Jejunostomy output
#High risk for malnutrition
Small bowel insufficiency and TPN/IVF dependent secondary to
multiple SB resections. Jejunostomy output oscillated during
admission but was grossly similar to previous generating daily
-1500cc TBW (including TPN). Resumed 1L NS daily upon discharge.
Patient was started on loperamide 4mg q6h and uptitrated
psyllium 2WAF tid to minimize output. New PICC was placed and
patient started on TPN and monitored >___ for refeeding
syndrome.
#Hypokalemia
#Hypophosphatemia
Secondary to GI losses
Oncology repletion scales
#Pancytopenia
Multifactorial including everolimus and sepsis. Improved during
admission. Hb<7 at multiple times during admission but patient
declined transfusion.
#Metastatic jejunal NET
Metastatic to liver, s/p multiple bowel resections. Everolimus
held in setting of sepsis due to immunosuppresion (discussed
with primary oncologist Dr. ___. CT A/P with some evidence
of progression of disease. Treatment plan to be re-addressed in
the outpatient setting.
#HTN
#CAD
Held metoprolol and amlodipine in setting of hypovolemia.
Patient normotensive at all times, metoprolol and amlodipine
discontinued upon discharge.
#Type 2 DM
Patient without need for sliding scale for >48h on TPN. Insulin
discontinued.
#Vitamin D Deficiency: Extremely low in spite of supplementation
with 50,000U weekly
likely ___ rapid intestinal transit and absence of terminal
ileum. Discussed with nutrition, no IV formulation available.
Will attempt daily supplementation with 5000U.
TRANSITIONAL ISSUES
====================
1. Oncology follow-up: Patient to get dotatate scan on ___ and
f/u with Dr. ___ on ___.
2. Antibiotic course: Will need to complete a 14-day antibiotic
course of ceftriaxone 2g q24h through (and including) ___
3. Ostomy output / IVF: Ostomy output is on average 2500cc/day,
have been uptitrating loperamide and psyllium while in house.
Please monitor ostomy output ___ times/week. For now will need
to remain in 1L NS daily in addition to her TPN.
4. Vitamin D: Switched from 50,000 weekly to 5000 daily due to
profound deficiency. Please repeat in 1 month and adjust dose as
necessary.
5.Pending labs: Vitamins A, E, K pending upon discharge. Please
follow-up and supplement as needed
This patient's complex discharge plan was formulated and
coordinated over 90 minutes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Productive Cough
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old with a history of COPD, chronic
atrial fibrillation (on warfarin) and non-ischemic
cardiomyopathy (EF 35% ___, bronchiectasis presenting with
dyspnea and a chest x-ray showing a left upper lobe opacity
consistent with community-acquired pneumonia.
He was seen ___ an ___ clinic & treated w/
doxycycline for a presumed sinusitis, with partial improvement.
Within ___ days of stopping antibiotics, he noted worsening
cough/fatigue and dyspnea with minimal exertion. He reports
cough, productive of clear phlegm and worse at night. He reports
mild inspiratory pain. He denies any fever/chills; he denies
chest pain/dyspnea at rest. He denies paroxysmal nocturnal
dyspnea/orthopnea/or lower extremity edema. He denied travel
history and has no pets. Patient has lost ___ lbs ___ the past 2
weeks, ___ the setting of decreased appetite.
___ the ED, his vitals were: T 98.9; BP 109/84; HR 90; 97% O2 on
RA.
Labs: wbc 9.6, INR of 7.0 - UA w/ 9 RBC
Medications: Ceftriaxone, azithromycin, 1 L NS.
Past Medical History:
Atrial fibrillation
Cardiomyopathy (EF 25%), last CHF hospitalization ___
Bronchiectasis
COPD
Emphysema
Hypertension
Left acetabulum fracture
Right mid shaft femur fracture
Cervical spine spondylosis with vertebrobasilar insufficiency
Low back pain
Left eye blindness
Glaucoma
Cataracts
Social History:
___
Family History:
No family history of early cardiac disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 122 / 72
R Lying 56 18 96 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV:irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: rhonchi ___ RUL, bilateral bibasilar crackles.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused,
DISCHARGE PHYSICAL EXAM:
=========================
Vital signs: T 98.0 BP 116/68 HR 98 RR 18 SpO2 95 RA
General: alert, oriented, engaged, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: L upper lobe with rales, crackles at lung bases
bilaterally
CV: irregular irregular, S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Skin: diffuse ichthyosis on extremities
Pertinent Results:
ADMISSION LABS:
======================
___ 09:10AM BLOOD WBC-9.6 RBC-4.25* Hgb-12.5* Hct-38.1*
MCV-90 MCH-29.4 MCHC-32.8 RDW-13.2 RDWSD-43.9 Plt ___
___ 09:10AM BLOOD ___
___ 09:10AM BLOOD UreaN-9 Creat-0.7 Na-132* K-4.9 Cl-92*
HCO3-29 AnGap-16
___ 09:10AM BLOOD AST-25
___ 09:10AM BLOOD Albumin-3.2*
___ 05:54AM BLOOD Calcium-7.9* Phos-3.4 Mg-1.8
PERTINENT LABS:
=====================
___ 05:56AM BLOOD WBC-8.4 RBC-3.98* Hgb-11.9* Hct-35.3*
MCV-89 MCH-29.9 MCHC-33.7 RDW-13.4 RDWSD-43.6 Plt ___
___ 05:54AM BLOOD WBC-8.9 RBC-4.02* Hgb-12.0* Hct-36.2*
MCV-90 MCH-29.9 MCHC-33.1 RDW-13.2 RDWSD-43.4 Plt ___
___ 05:56AM BLOOD ___ PTT-72.6* ___
___ 05:54AM BLOOD ___ PTT-64.6* ___
___ 06:44AM BLOOD ___ PTT-44.7* ___
___ 05:56AM BLOOD Glucose-88 UreaN-8 Creat-0.6 Na-130*
K-3.8 Cl-94* HCO3-24 AnGap-16
___ 05:54AM BLOOD Glucose-88 UreaN-8 Creat-0.4* Na-130*
K-3.9 Cl-90* HCO3-27 AnGap-17
___ 06:44AM BLOOD Glucose-106* UreaN-9 Creat-0.5 Na-130*
K-3.8 Cl-90* HCO3-28 AnGap-16
___ 06:44AM BLOOD Calcium-8.1* Phos-3.9 Mg-1.9
___ 06:44AM BLOOD WBC-9.8 RBC-3.90* Hgb-11.6* Hct-34.1*
MCV-87 MCH-29.7 MCHC-34.0 RDW-13.4 RDWSD-42.5 Plt ___
___ 05:56AM BLOOD Osmolal-269*
___ 09:10AM BLOOD TSH-0.91
___ 01:54PM BLOOD Lactate-1.8
___ 04:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:00PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 04:00PM URINE RBC-9* WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 01:59PM URINE Hours-RANDOM Creat-52 Na-133
___ 01:59PM URINE Osmolal-529
IMAGING:
====================
#CXR ___:
PA and lateral views of the chest provided.There is left lung
volume loss with increased left upper lung opacityconcerning for
pneumonia. Scarring ___ the right apex is noted. The heart
ismildly enlarged. No large effusion is seen. No pneumothorax.
Mediastinalcontour is within normal limits. Aortic
calcification is present. Bonystructures are intact.
IMPRESSION: COPD with left upper lobe opacity concerning for
pneumonia. Please note,follow-up to resolution is strongly
recommended to exclude underlyingmalignant process.
#CXR ___
Large airspace opacity ___ the left upper lung is grossly
unchanged. Patchy
opacities ___ the right lung are stable as well. No pleural
effusions or
pneumothorax. The hila and cardial mediastinal silhouette are
otherwise
unchanged.
IMPRESSION:
Persistent severe left lung opacity. No new consolidation.
MICROBIOLOGY:
=====================
___ 1:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Time Taken Not Noted ___ Date/Time: ___ 1:53 pm
BLOOD CULTURE
Blood Culture, Routine (Pending):
Back
Time Taken Not Noted ___ Date/Time: ___ 7:40 am
URINE CHEM # ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, ___
infected patients the excretion of antigen ___ urine may
vary.
___ 2:55 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Warfarin 5 mg PO QOD
3. Warfarin 7.5 mg PO QOD
4. Metoprolol Succinate XL 100 mg PO DAILY
5. magnesium 250 mg oral DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. brimonidine 0.2 % ophthalmic BID
8. bimatoprost 0.01 % Other QHS
9. Potassium Chloride 20 mEq PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. benazepril-hydrochlorothiazide ___ mg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Please take this until ___. Please finish your entire course
of antibiotics.
2. Azithromycin 250 mg PO Q24H Duration: 3 Doses
Last day ___.
3. benazepril 10 mg ORAL DAILY
4. Cefpodoxime Proxetil 200 mg PO Q12H
final day ___
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Warfarin 5 mg PO DAILY16
7. Warfarin 5 mg PO DAILY16
8. Amlodipine 5 mg PO DAILY
9. bimatoprost 0.01 % Other QHS
10. brimonidine 0.2 % ophthalmic BID
11. Fish Oil (Omega 3) 1000 mg PO DAILY
12. magnesium 250 mg oral DAILY
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Potassium Chloride 20 mEq PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
-Community Acquired Pneumonia
-Coagulopathy
Secondary Diagnosis:
-Hyponatremia due to SIADH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with Hx COPD and c/o increased weakness
COMPARISON: ___ and ___
FINDINGS:
PA and lateral views of the chest provided.
There is left lung volume loss with increased left upper lung opacity
concerning for pneumonia. Scarring in the right apex is noted. The heart is
mildly enlarged. No large effusion is seen. No pneumothorax. Mediastinal
contour is within normal limits. Aortic calcification is present. Bony
structures are intact.
IMPRESSION:
COPD with left upper lobe opacity concerning for pneumonia. Please note,
follow-up to resolution is strongly recommended to exclude underlying
malignant process.
Radiology Report
INDICATION: ___ year old man with CHF (EF 25%), HTN, COPD treated for PNA. //
Worsening cough, evaluating any interval changes with antibiotic treatment
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Large airspace opacity in the left upper lung is grossly unchanged. Patchy
opacities in the right lung are stable as well. No pleural effusions or
pneumothorax. The hila and cardial mediastinal silhouette are otherwise
unchanged.
IMPRESSION:
Persistent severe left lung opacity. No new consolidation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Weakness, Failure to thrive, Cough
Diagnosed with Pneumonia, unspecified organism
temperature: 98.9
heartrate: 90.0
resprate: 18.0
o2sat: 97.0
sbp: 109.0
dbp: 84.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is an ___ year old male with a history of atrial
fibrillation, cardiomyopathy / congestive heart failure (CHF)
with an ejection fraction of 25%, hypertension, COPD, who was
admitted to the ___ on ___ for worsening cough and left
upper lobe opacity on chest x-ray most concerning for pneumonia.
#COMMUNITY ACQUIRED PNEUMONIA:
Prior to his admission, he had been seen by his ENT for presumed
worsening sinusitis and given a course of doxycycline prior to
admission. His symptoms had transiently improved, but then
worsened when he discontinued his medications. The day of his
admission, he was seen by his PCP, where he was noted to have
had a 7 pound weight loss.
During his stay at ___, he was afebrile and remained on room
air. He was treated initially with 1 gm IM ceftriaxone and
azithromycin 250 mg. He was tested for legionella, which was
negative. His sputum culture grew scant commensal respiratory
flora and sparse gram negative rods. A repeat chest x-ray on
___ was largely unchanged from his prior on ___. It was
found that he had a left upper lobe pneumonia and a small
right-sided pleural effusion.
His antibiotics were narrowed to cefpodoxime 200 mg twice a day
and continued on his azithromycin 250 mg twice a day for a total
course of 7 days (expected end date: ___.
#HYPONATREMIA
He was noted to be hyponatremic upon admission, with an elevated
urine osms and a decreased serum osms, while clinically
appearing euvolemic. We temporarily discontinued his thiazide
diuretic while he was ___ patient. Although HCTZ and low solute
intake due to reduce appetite may also have contributed, we
presumed he had SIADH due to elevate urine osmolarity, with a
pulmonary cause related to his pneumonia and a question of
underlying malignancy. We restricted his fluid intake to 1.5
liters / day and trended his hyponatremia, which was stable. He
was never symptomatic.
#ELEVATED INR
While he was admitted, his initial INR was 7.0, likely secondary
to his decreased oral intake and the known drug interaction
between doxycycline and warfarin. He did not have signs of
hemolysis / active bleeding and we did not elect to reverse his
Coumadin with vitamin K during his admission.
When his INR became 2.8, his warfarin was resumed at a reduced
dose (3 mg PO). His home dose alternates between 5 and 7 mg PO.
As he was still taking azithromycin, we reduced his dose.
#DECONDITIONING:
He was seen by physical therapy and nutrition during his stay.
Physical therapy recommended discharge to a rehabilitation
facility.
Nutrition recommends oral dietary supplements (eg: Ensure three
times a daily as tolerated) and multivitamins.
#ATRIAL FIBRILLATION:
He was rate controlled on metoprolol XL 100 mg daily and
anti-coagulated with warfarin. No complaints of chest pain /
palpitations. Resuming warfarin on ___ and holding on
admission due to elevated INR
#CHRONIC SYSTOLIC CHF:
Due to non-ischemic cardiomyopathy, EF of 35% NYHA class I-II.
He was euvolemic on exam. No on home furosemide. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
pravastatin
Attending: ___.
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
.
___
.
Time: 223
_
________________________________________________________________
PCP:
Name: ___.
Location: ___
Address: ___
Phone: ___
Fax: ___
.
_
________________________________________________________________
HPI:
___ woman with HTN, DN2, CAD, CKD, HF with preserved EF,
and PAD s/p abdominal aortic angioplasty (___) bilateral renal
artery stenosis presents to 2 weeks of exertional dyspnea and
positive d-dimer. The patient states she's been feeling unwell
for about 4 weeks. She went to her doctor today where she had
blood tests performed including a d-dimer which was positive
therefore she was told to come to the emergency department. Her
Lasix was increased to 40 mg bid but she had difficulty being
compliant with this increased dose. She denies dyspnea at rest,
she denies chest pain, she denies history of blood clot or
additional complaints at this time. + dry cough x 6 months. +
chills. + leg swelling. No PND. She sleeps with 5 pillows every
night x 6 months. No fevers. + 2lb weight loss. No nausea. No
chest pressure or tightness. + sleepiness. No easy bleeding or
bruising. No hematochezia. + dark stool x a couple weeks. +
Decreased appetite. She had abdominal pain after eating over the
weekend which resolved. It was associated with diarrhea which
might have consisted of dark stool. But she denies overt black
stool. She thinks that she has had a colonoscopy twice but she
can't remember when the last one was.
Rectal exam per ___ MD demonstrated small amount of brown guiac
positive. HCT found to be 24 down from baseline of 37.0 in ___
.
In ER: (Triage Vitals:|20:49 |0 |97.8 |64 |123/44 |16 |99% RA )
Meds Given: None
Fluids given: 250 cc
Radiology Studies: None
consults called: None
.
PAIN SCALE: ___
+ restless leg
.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI
HEENT: [X] All normal
RESPIRATORY: [+] Per HPI
CARDIAC: [+] Per HPI but denies CP
GI: As per HPI
GU: [X] All normal
SKIN: [X] All normal
MUSCULOSKELETAL: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
PVD
-___
LLE: ___ CFA disease. The IIA was occluded.
- Heart failure with preserved EF admitted in ___
RLE: Proximal 50% eccentric stenosis in the CIA with 80%
stenosis in
the distal CIA to origin IIA. The IIA had diffuse disease.
PTA and stenting of the right CIA with a 8x60mm Protege
stent and a 9.0x27mm Visipro stent.
Patent CFA, diffuse disease of the SFA involving the origin with
long segment total cocclusion in the proximal segment with
reconstitution in ___ canal. There is 80% stenosis in the
mid popliteal artery. The TPT, AT, Peroneal and ___ were free of
disease and filled the foot robustly.
-___ PTCA/stent left common iliac artery with a 7.0 x
57mm
visi pro stent. PTCA/stent distal left CIA and EIA with a 8 x
40mm protégé stent. The right SFA has diffuse disease
proximally and a 100% mid vessel stenosis with reconstitution
proximal to the ___ as well as significant
collaterals
from the PFA to the ___.
- h/o leukocytosis
- GERD, Hiatal hernia, Schatzkis ring
- Bursitis right elbow
- ___ broken right fibula
- Hysterectomy
- Tonsillectomy as a child
Social History:
___
Family History:
Her mother died of ovarian cancer in her ___.
Her grandmother died of an MI at age ___. Father died of
complication of diabetes. Brother also died of complications of
diabetes. No
other family members with cancer.
Brother with T2DM
Father with T2DM
Mother with T2DM, ovarian cancer
Maternal Grandmother CAD/PVD, stroke
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7 PO 164 / 71 R Lying 86 20 91 RA
157.8 down from 166 previously
71.6
BS = 131
CONS: NAD, comfortable appearing
HEENT: pin point pupils b/l
CV: Nml s1s2 RRR no m/r/g but her heart
RESP: b/l ae no w/c/r
GI: +bs, soft, NT, ND, no guarding or rebound
back: No spinal tenderness
GU: No CVAT
RECTAL: Vault empty of stool
MSK: feet appear well perfused but DPP pulses could not be
detected
SKIN: no rash
NEURO: face symmetric speech fluent but she is vague about the
dates her sx started but knew her medications
PSYCH: calm, cooperative
LAD: No cervical LAD
DISCHARGE PHYSICAL EXAM:
Vitals: 98.0 56 163/78->134/54 18 94%RA
Weight 70.9kg->70.9kg I/O 24hr yesterday -1.1L (admit weight
71.6kg)
General: Sitting up in bed, appears comfortable in NAD
HEENT: PERRL, EOMI, sclera anicteric
CV: S1S2 WNL, no m/r/g; right sided carotid thrill and bruit
RESP: Good air movement bilaterally, no crackles
GI: +BS, soft, NT, ND, no guarding or rebound
EXT: warm and well perfused, 1+ ___ edema in ankles/feet, wrapped
with ace wraps
SKIN: no rash
NEURO: AAOx3, conversational, motor and sensory exam grossly
intact
Pertinent Results:
IMAGING:
Renal Ultrasound
IMPRESSION:
1. Patent main renal vasculature.
2. No evidence of right renal artery stenosis. Assessment of
left renal
artery stenosis is limited although appears stenosed on prior
CTA.
3. No hydronephrosis.
___:
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CT Chest: ___:
IMPRESSION:
Mild pulmonary edema. Tiny pleural effusions. Cardiac
enlargement.
Suggestion of pulmonary artery hypertension.
Diffuse bronchial wall thickening, likely related to edema.
Bronchial wall
thickening is severe in the right lower lobe, possibly from
edema, component
of inflammatory/ infectious process cannot be excluded. No
infiltrates or
consolidations in the lungs
There is central mediastinal adenopathy, largest lymph node
measures 1.7 cm,
indeterminate, possibly reactive.
___. CT Abdomen/Pelvis:
IMPRESSION:
1. No specific CT findings of malignancy in the abdomen or
pelvis.
2. Severe atherosclerosis.
___ TTE
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF=55-60%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
is normal with borderline normal free wall function. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___
mild pulmonary hypertension is seen and right ventricular
systolic function is minimally reduced. Other findings are
similar.
___ CXR
IMPRESSION:
In comparison to ___ chest radiograph, cardiomegaly
and pulmonary
vascular congestion are accompanied by development of mild
pulmonary edema
with associated small bilateral pleural effusions.
___ Carotid series
IMPRESSION:
60-69% stenosis in the right internal carotid artery with
moderate calcified
plaque. Less than 40% stenosis in the left internal carotid
artery with
calcified plaque in the common carotid artery.
___ CT Chest
IMPRESSION:
No evidence of infection, malignancy, or structural lung
disease.
Findings - severe coronary atherosclerosis, and improved
bronchial cuffing and
resolved septal thickening- point to improved cardiogenic
pulmonary edema,
also responsible for mild enlargement of central low-attenuation
lymph nodes.
ADMISSION LABS:
___ 07:00PM URINE HOURS-RANDOM CREAT-33 SODIUM-95 TOT
PROT-7 PROT/CREA-0.2
___ 07:00PM URINE U-PEP-NO PROTEIN
___ 07:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:15AM GLUCOSE-113* UREA N-61* CREAT-3.9*
SODIUM-131* POTASSIUM-4.7 CHLORIDE-93* TOTAL CO2-23 ANION GAP-20
___ 06:15AM CK(CPK)-84
___ 06:15AM CK-MB-2 cTropnT-<0.01
___ 06:15AM TOT PROT-6.7 CALCIUM-8.9 PHOSPHATE-4.2
___ 06:15AM C3-99 C4-21
___ 06:15AM WBC-9.4 RBC-2.70* HGB-7.1* HCT-22.1* MCV-82
MCH-26.3 MCHC-32.1 RDW-16.8* RDWSD-50.3*
___ 11:30PM ___ PTT-32.1 ___
___ 10:50PM GLUCOSE-165* UREA N-59* CREAT-3.9*#
SODIUM-132* POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-21* ANION
GAP-21*
___ 10:50PM LD(LDH)-174 CK(CPK)-78 TOT BILI-0.3
___ 10:50PM cTropnT-<0.01
___ 10:50PM CK-MB-1 proBNP-2042*
___ 10:50PM IRON-42
___ 10:50PM calTIBC-345 HAPTOGLOB-312* FERRITIN-24
TRF-265
___ 10:50PM WBC-9.0 RBC-2.80*# HGB-7.4*# HCT-24.0*#
MCV-86 MCH-26.4 MCHC-30.8* RDW-17.1* RDWSD-53.3*
___ 10:50PM NEUTS-60.0 ___ MONOS-11.7 EOS-3.6
BASOS-0.8 IM ___ AbsNeut-5.40 AbsLymp-2.08 AbsMono-1.05*
AbsEos-0.32 AbsBaso-0.07
___ 10:50PM RET AUT-3.0* ABS RET-0.08
INTERVAL/DISCHARGE LABS:
___ 07:15AM BLOOD WBC-10.3* RBC-2.77* Hgb-7.3* Hct-23.2*
MCV-84 MCH-26.4 MCHC-31.5* RDW-17.1* RDWSD-52.6* Plt ___
___ 07:05AM BLOOD WBC-8.1 RBC-2.87* Hgb-7.6* Hct-23.6*
MCV-82 MCH-26.5 MCHC-32.2 RDW-16.4* RDWSD-49.6* Plt ___
___ 07:05AM BLOOD WBC-8.0 RBC-2.77* Hgb-7.4* Hct-22.6*
MCV-82 MCH-26.7 MCHC-32.7 RDW-16.5* RDWSD-49.5* Plt ___
___ 07:10AM BLOOD Glucose-92 UreaN-67* Creat-3.0* Na-129*
K-4.5 Cl-89* HCO3-28 AnGap-17
___ 10:55PM BLOOD Glucose-202* UreaN-74* Creat-3.0* Na-127*
K-4.7 Cl-88* HCO3-28 AnGap-16
___ 07:25AM BLOOD Glucose-106* UreaN-73* Creat-2.7* Na-131*
K-4.9 Cl-90* HCO3-29 AnGap-17
___ 03:00PM BLOOD Glucose-108* UreaN-73* Creat-3.0* Na-129*
K-5.1 Cl-89* HCO3-28 AnGap-17
___ 06:55AM BLOOD Glucose-75 UreaN-76* Creat-2.8* Na-131*
K-4.6 Cl-90* HCO3-31 AnGap-15
___ 04:55PM BLOOD Glucose-103* UreaN-75* Creat-2.9* Na-129*
K-4.6 Cl-89* HCO3-29 AnGap-16
___ 06:55AM BLOOD Glucose-91 UreaN-75* Creat-2.4* Na-126*
K-4.3 Cl-87* HCO3-30 AnGap-13
___ 06:50PM BLOOD Glucose-234* UreaN-76* Creat-2.6* Na-127*
K-4.4 Cl-89* HCO3-27 AnGap-15
___ 07:05AM BLOOD Glucose-82 UreaN-74* Creat-2.5* Na-131*
K-4.7 Cl-92* HCO3-30 AnGap-14
___ 03:00PM BLOOD Glucose-83 UreaN-80* Creat-2.8* Na-129*
K-4.8 Cl-89* HCO3-29 AnGap-16
___ 07:30AM BLOOD Glucose-65* UreaN-73* Creat-2.3* Na-134
K-4.4 Cl-90* HCO3-34* AnGap-14
___ 07:05AM BLOOD Glucose-50* UreaN-74* Creat-2.2* Na-130*
K-4.1 Cl-87* HCO3-31 AnGap-16
___ 07:05AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.0
___ 07:15AM BLOOD ALT-11 AST-14 AlkPhos-68 TotBili-0.3
___ 09:00AM BLOOD calTIBC-337 VitB12-1032* Hapto-300*
Ferritn-28 TRF-259
___ 09:00AM BLOOD TSH-1.9
MICRO: ___ Ucx negative
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with + d-dimer and sob. // Please evaluate for
DVTs
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
without intravenous contrast. Reformatted coronal, sagittal, thin slice axial
images images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.1 s, 65.9 cm; CTDIvol = 8.2 mGy (Body) DLP = 537.5
mGy-cm.
Total DLP (Body) = 538 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: CT chest ___
FINDINGS:
Lungs:
Parenchyma and Airways: There is bilateral moderate to severe bronchial wall
thickening, most prominent in the right lower lobe, new since ___.
There is tiny area of peripheral mucus plugging in the right upper lobe. Few
linear bands of subpleural atelectasis or fibrosis. There are no nodular
infiltrates or consolidations. . Few tiny benign calcified lung granulomas
are seen. There is mild atelectasis in the left lower lobe medially. There
are areas of interlobular septal thickening, best seen in the lung apices and
lung bases, consistent with edema.
Vessels: Mildly prominent main pulmonary artery measuring 3.3 cm, has enlarged
compared with 2.7 cm previously, suggesting pulmonary artery hypertension.
Normal caliber aorta, with atherosclerotic calcifications. There are
three-vessel coronary artery calcifications.
Mediastinum and Hila: Enlarged peritracheal lymph nodes, largest measures 1.7
cm short axis more prominent compared with 0.8 cm previously 1.2 cm subcarinal
lymph node. No hilar adenopathy.
Heart and Pericardium: Heart is mildly enlarged. No pericardial effusion.
Three-vessel coronary artery calcifications are seen.
Pleura: There is trace bilateral pleural effusion.
Neck, Thoracic Inlet, Axillae, Chest Wall: Normal thyroid gland. There is no
adenopathy.
Upper Abdomen: Please see separate CT abdomen pelvis report for abdominal
findings. Small volume perihepatic ascites is seen.
Chest Cage: Degenerative changes spine. No worrisome lesions.
IMPRESSION:
Mild pulmonary edema. Tiny pleural effusions. Cardiac enlargement.
Suggestion of pulmonary artery hypertension.
Diffuse bronchial wall thickening, likely related to edema. Bronchial wall
thickening is severe in the right lower lobe, possibly from edema, component
of inflammatory/ infectious process cannot be excluded. No infiltrates or
consolidations in the lungs
There is central mediastinal adenopathy, largest lymph node measures 1.7 cm,
indeterminate, possibly reactive.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old woman with history of renal artery stenosis here with
acute renal failure // ?renal artery stenosis? hydronephrosis
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: CTA of the abdomen pelvis from ___.
FINDINGS:
The right kidney measures 11.9 cm. The left kidney measures 9.3 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
In the lower pole the left kidney, a round hypoechoic exophytic simple cyst
measures 1.9 x 1.6 x 1.7 cm, overall stable from CT examination in ___ an
ultrasound in ___ and given differences in measurement. Previously described
7 mm hypoechoic lower pole lesion on ultrasound and ___ is not seen.
Renal Doppler: Intrarenal arteries show delayed upstroke without plateau and
and continuous antegrade diastolic flow. The resistive indices of the right
intra renal arteries range from 0.59 to 0.68. The resistive indices on the
left are not well assessed. Bilaterally, the main renal arteries are patent
with slightly delayed upstroke without plateau and continuous antegrade
diastolic flow. Main renal veins are patent bilaterally.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
1. Patent main renal vasculature.
2. No evidence of right renal artery stenosis. Assessment of left renal
artery stenosis is limited although appears stenosed on prior CTA.
3. No hydronephrosis.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ year old female with fatigue and anorexia. Evaluate for
malignancy.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Spiral Acquisition 10.1 s, 65.9 cm; CTDIvol =
8.2 mGy (Body) DLP = 537.5 mGy-cm. Total DLP (Body) = 538 mGy-cm.
COMPARISON: ___
FINDINGS:
The examination is slightly motion degraded.
LOWER CHEST: Please see report from dedicated CT of the chest for
supradiaphragmatic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation.
The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The left kidney is atrophic. A hyperdense cyst in the lower pole of
the left kidney is grossly unchanged since the prior examination. There is no
hydronephrosis. There is no nephrolithiasis. There is symmetric, nonspecific
bilateral perinephric stranding.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. Innumerable colonic diverticula
are seen.
PELVIS: The urinary bladder and distal ureters are unremarkable. A small
amount of pelvic free fluid is noted, and is of doubtful clinical
significance.
REPRODUCTIVE ORGANS: The uterus is not visualized. There are no adnexal
masses
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There are extensive vascular calcifications. Stents are seen in the
bilateral common iliac arteries, extending from the aortic bifurcation to the
bifurcation of the common iliac arteries.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No specific CT findings of malignancy in the abdomen or pelvis.
2. Severe atherosclerosis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CKD, dCHF p/w CHF exacerbation //
Evidence of worsening pulm edema or effusions?
IMPRESSION:
In comparison to ___ chest radiograph, cardiomegaly and pulmonary
vascular congestion are accompanied by development of mild pulmonary edema
with associated small bilateral pleural effusions.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old woman with vasculopathy, CCK, CHF p/w CHF
exacerbation, found to have right carotid bruit and thrill // Evidence of
carotid stenosis?
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None
FINDINGS:
RIGHT:
The right carotid vasculature has moderate calcified plaque atherosclerotic
plaque.
The peak systolic velocity in the right common carotid artery is 48 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 165, 149, and 55 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 43 cm/sec.
The ICA/CCA ratio is 3.4.
The external carotid artery has peak systolic velocity of 202 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has moderate calcified atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is 75 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 81, 53, and 49 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 20 cm/sec.
The ICA/CCA ratio is 1.1.
The external carotid artery has peak systolic velocity of 78 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
60-69% stenosis in the right internal carotid artery with moderate calcified
plaque. Less than 40% stenosis in the left internal carotid artery with
calcified plaque in the common carotid artery.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old female with history of DMII, HTN, CAD, PVD, CKD,
HFpEF presents with SOB and hypoxia found to have anemia, volume overload, and
___. // Evidence of improvement in volume overload? Evidence of underlying
structural lung disease?
TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. Contrast agent was not administered. All images were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.5 s, 35.9 cm; CTDIvol = 6.8 mGy (Body) DLP = 239.3
mGy-cm.
Total DLP (Body) = 239 mGy-cm.
COMPARISON: Compared to chest CT scans ___, most recently ___.
FINDINGS:
Supraclavicular and axillary lymph nodes are not enlarged. Specifically
excluding the breasts which require mammography for evaluation, there are no
soft tissue abnormalities in the chest wall suspicious for malignancy. This
study is not appropriate for subdiaphragmatic diagnosis but shows no mass in
either adrenal gland.
There are no thyroid lesions warranting further imaging evaluation.
Atherosclerotic calcification is moderate to severe in the head and neck
arteries and in the coronaries. Aorta and pulmonary arteries are normal size.
Evaluation of cardiomegaly would require echocardiography. There is no
pericardial or pleural effusion.
Mediastinal adenopathy is moderate, relatively unchanged in size, for example
18 x 27 mm in the right lower paratracheal station, 02:20, previously 22 x 25
mm and right lower paraesophageal, 20 mm, 02:27, previously 21 mm,
prevascular, 10 mm, 4:92, previously 12 mm. Relative low attenuation of the
lymph node, 22 ___, suggests that the adenopathy may be due to congestive heart
failure.
There is no pericardial left pleural effusion. Small right pleural effusion
is unchanged, and layers posteriorly.
Previous mild peribronchial cuffing and septal thickening have improved.
Linear atelectasis at the base the left lung is stable. There is no
consolidation. There is no consolidation or lung nodules.
There are no bone lesions in the chest cage suspicious for malignancy or
infection.
IMPRESSION:
No evidence of infection, malignancy, or structural lung disease.
Findings - severe coronary atherosclerosis, and improved bronchial cuffing and
resolved septal thickening- point to improved cardiogenic pulmonary edema,
also responsible for mild enlargement of central low-attenuation lymph nodes.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea, Abnormal labs
Diagnosed with Anemia, unspecified
temperature: 97.8
heartrate: 64.0
resprate: 16.0
o2sat: 99.0
sbp: 123.0
dbp: 44.0
level of pain: 0
level of acuity: 2.0 | ___ year old female with history of DMII, HTN, CAD, PVD, CKD,
HFpEF presents with SOB and hypoxia
found to have anemia, volume overload, and ___.
# Acute on chronic diastolic CHF: Patient presented with
subacute development of SOB, hypoxia and fatigue. Imaging showed
no evidence of DVT/PE, CT showing volume overload. Effective
diuresis was challenging challenging due to renal artery
stenosis and resulting poorly controlled blood pressure. An
important option that has been considered is stenting of her
renal artery to improve blood pressure, renal function, and
ability to diurese; however, stenting of the renal artery
carries with it the risk of further renal injury and the patient
has been unwilling to risk undergoing dialysis. Given these
factors, achieving a true dry weight while optimizing renal
function will be
challenging. She was started on clonidine 0.2mg TID in order to
better control BP and maximize renal perfusion/diuresis. She
initially responded minimally to 80 IV Lasix though urine output
slightly picked up with 120IV Lasix. After several days of
diuresis, had not made progress on bolus dosing of Lasix. CXR
___ showed pulm edema and pleural effusions bilaterally. Lasix
gtt started and patient's weight went down, UOP increased
dramatically, and Cr improved with improvement in respiratory
status. Exam improved with patient intermittently requiring O2
only when not using IS and when curled in bed as O2 sat improves
with IS and ambulation. Cr improved then started to rise so
lasix gtt switched to 100mg torsemide with continued improvement
in Cr and improvement in Na. UOP remained high and patient
appeared euvolemic with improvement in volume overload on CT
Chest so discharged on 80mg torsemide to avoid overdiuresis. She
was followed by renal and cardiology during admission.
#Shortness of breath/Hypoxia: Primarily due to heart failure
exacerbation as above, but intermittent dyspnea and hypoxic
continued even after achievement of euvolemia and improvement in
clinical exam, CT Chest findings, and overall respiratory
status. Of note, patient had intermittent O2 sat to ___ when
sleeping. Repeat CT prior to discharge showed no evidence of
structural lung disease with minimal edema/effusions. Patient
had improved oxygenation with increased ambulation and worsened
why lying in bed. She did not used IS as frequently as
recommended. It appears that much of her hypoxia and dyspnea was
due to atelectasis and deconditioning. Her respiratory status
and oxygenation improved dramatically in the day prior to
discharge with increased ambulation after achieving euvolemia.
Patient discharged with encouragement to remain active, use IS
at home, and monitor weights. She would also benefit from
outpatient sleep study given likely undiagnosed sleep apnea
based on nocturnal desaturations, resistant hypertension, and
daytime fatigue.
# ___: Patient with baseline CKD with one functioning kidney due
to complete left sided renal artery stenosis and at risk for
loss of right kidney due to 90% stenosis. As noted above,
achieving effective diuresis is quite challenging in the setting
of renal artery stenosis. She has a very narrow window where her
kidney function is optimized. In addition, optimizing her blood
pressure control is key aspect in addressing her overall volume
status so was started on clonidine as above. On admission, Cr
rose as high as 3.9 but with diuresis gradually improved. Cr
fluctuated during admission depending on improvement in renal
perfusion/congestion versus overdiuresis, but once started on
lasix gtt and true diuresis was initiated, patient improved
dramatically with discharge Cr 2.2. Per renal, this is likely
her new baseline. ACE held during admission, and after
discussion with renal and cardiologyy was discontinued as at
this point as no clear indication that outweighs risk.
Discussion of right renal stenting as an outpatient is ongoing,
but patient will almost definitely need dialysis eventually.
Patient and daughter were advised that she will need to followup
with her outpatient nephrologist after discharge. It will be
important to discuss dialysis as an option in the near future.
Currently her functional status has been severely limited by her
dyspnea/fatigue as daughter states that because of this she
spends most of the day sleeping. Family was counseled that,
while dialysis does carry with it physical limitations, it may
be worth considering if it can offer her at improved quality of
life at least 4 days during the week.
# Anemia, subacute: Patient with evidence of new anemia since
___ when her H/H was ___. She remained hemodynamically
stable without active bleeding or evidence of hemolysis. SPEP
and UPEP negative. Iron studies suggest iron deficiency anemia
and she was started on PO iron replection. Labs otherwise
notable for ineffective reticulocytosis secondary to
myelosuppression. Smear reviewed by hematology team and notable
for spur cells (LFTs WNL). No teardrops or hypolobulated
neutrophils to suggest marrow infiltration. She received 1 unit
pRBCs on ___ with appropriate response and was stable
since that time. GI evaluated patient and recommended
further workup with EGD/Colonoscopy as outpatient. Discharged
with iron supplementation.
# Anorexia: Patient with a 1 month history of poor PO intake.
Differential is broad and includes CHF, PUD, malignancy,
infection. No evidence of malignancy on CT A/P, no infectious
signs or symptoms. Can certainly be related to
poorly controlled CHF, particularly as she spends most of the
day
sleeping when she is at home due to dyspnea. As noted above,
requires further evaluation with EGD/Colonoscopy in the setting
of anemia. During this admission her PO intake has been
monitored. She has no difficulty with regular meals. Poor
nutrition appears to be due to lack of interest thought patient
states she doesn't like the food. She is willing to try more
Ensure if she is not eating a meal. Social work is working on
helping to arrange Ensure supplementation coverage as
outpatient. Patient should be monitored for mood disorder as may
also be playing a role.
#Hyponatremia: Complicated balance between hypervolemic
hyponatremia and overdiuresis. Na fluctuated between 127 and
134. Discharge Na 130, which may be new baseline.
#Thrush: Clinical exam c/w thrush of unclear etiology,
especially given recent complaint of sore throat. Treated with
Nystatin swish and swallow.
#Carotid bruit: Noticeable carotid bruit and thrill on exam.
Carotid u/s shows 60-69% right sided carotid stenosis.
Stable compared to prior outpatient study. Will need outpatient
f/u.
# DMII: Last Hgb A1C 6.1 in ___. Stable on home lantus
and HISS
# HTN: BPs to 170s-180s early in admission. Medcations titrated,
with final regimen including carvedilol 50mg BID, clonidine
0.2mg TID, hydralazine 100mg TID, amlodipine 10mg daily,
isosorbide mononitrate 120mg daily. SBPs at discharge largely in
130-150 range, which was acceptable per cardiology.
# PAD/CAD: Stable on beta blocker, aspirin, fish oil and
statin. Restarted cilostazol on discharge. Given atherosclerosis
seen on CT chest, atorvastatin dose increased to 80mg, though
given hx of myalgias with pravastatin should be monitored for
leg pains.
#GERD: Stable on PPI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
HYPOXIA
Major Surgical or Invasive Procedure:
RIGHT KNEE ARTHROCENTESIS
.
SURGICAL PROCEDURES (ORTHOPEDICS):
1. Arthrotomy right knee. Evacuation of infection,
debridement, and irrigation and complete synovectomy.
2. Deep biopsy proximal tibia bone.
3. Evacuation of deep osteomyelitic abscess.
4. Placement of antibiotic cement.
History of Present Illness:
___ with hx peripheral neuropathy, non-operative L pelvic
fracture ___ & recent MVC with non-displaced lateral tibial
plateau fracture who presents from rehab with new-onset hypoxia;
ED imaging notable for pulmonary edema and RLL atalectasis vs
PNA.
.
Patient recently admitted ___ following MVC. After
multiple return visits to ED, MRI R knee showed a non-displaced
lateral tibial plateau fracture, felt to be non-operable. She
has been fairly immobile at rehab. Was started on lovenox ___
prior to admission (___). On the day prior to admission, noted
to have O2 sat 89%/RA with conversational dyspnea which worsened
to 89%/2L NC on the day of admission. Also reported vague
pleuritic left chest pain. Rehab medical staff noted decreased
bibasilar breath sounds.
.
___ the ED, exam was significant for R basilar crackles. Labs
revealed for elevated D-dimer and elevated BNP. CTA chest
negative for PE and suggestive of pulmonary edema plus stomach
and transverse colon distension. Received 1 dose levofloxacin
and admitted for further evaluation.
.
This morning on the floor she is uncomfortable, complaining of R
knee pain and abdominal pain. Still feels short of breath
especially when talking. Feels grossly deconditioned relative to
her baseline of regular gym exercise with a physical trainer. No
fever or chills, some diaphoresis. She perseverates on knee
pain, and has trouble answering specific questions.
.
Regarding her abdominal pain, she denies associated
nausea/vomiting. Thinks her last bowel movement was probably 1
week ago. Passing flatus. Minimal appetite. No urinary symptoms.
.
REVIEW OF SYSTEMS: As per HPI. Reports constipation with
increasing abdominal distension and discomfort. No headache,
lightheadedness, rhinorrhea, cough, nausea, vomiting, diarrhea,
BRBPR, melena, or dysuria.
Past Medical History:
Peripheral neuropathy
Osteoporosis
Non-operative left pelvic fracture ___
Motor Vehicle Crash ___
Social History:
___
Family History:
Sister has history of alcoholism
Physical Exam:
ADMISSION
VS: 98.3 96.8 150/80 75 20 95% on 3L NC
GENERAL: thin elderly female, lying flat ___ bed, appears
uncomfortable
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, slightly dry MM
NECK: supple, no LAD, no JVD
LUNGS: decreased BS at bases, no wheezing or rhonchi, slightly
labored respirations
HEART: RRR, II/VI systolic murmur loudest at RUSB
ABDOMEN: bowel sounds present, soft but distended and
tympanitic, mild tenderness throughout though no guarding or
rebound
EXTREMITIES: RLE ___ immobilizer, No edema, 2+ DP pulses
SKIN: diaphoretic, no jaundice
NEURO: oriented x3, CNs II-XII grossly intact, moving all four
extremities
PSYCH: tearful/anxious, not listening or answering all questions
appropriately
Pertinent Results:
ADMISSION LABS
___ 06:25PM WBC-11.0# RBC-4.09* HGB-12.4 HCT-37.2 MCV-91
MCH-30.4 MCHC-33.4 RDW-13.5
___ 06:25PM NEUTS-87* BANDS-0 LYMPHS-5* MONOS-8 EOS-0
BASOS-0 ___ MYELOS-0
___ 06:25PM GLUCOSE-107* UREA N-28* CREAT-0.7 SODIUM-131*
POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-26 ANION GAP-16
___ 06:30PM LACTATE-1.3
___ 06:25PM proBNP-2248*
___ 06:25PM D-DIMER-2237*
.
OTHER PERTINENT LABS
___ 07:01AM BLOOD CRP-172.4*
___ 06:30PM BLOOD Lactate-1.3
___ 07:01AM BLOOD ESR-72*
___ 10:50PM JOINT FLUID ___ Polys-96*
___ Monos-0
.
DISCHARGE LABS
___ 05:49AM BLOOD WBC-10.7 RBC-3.30* Hgb-9.8* Hct-30.1*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.6 Plt ___
___ 05:49AM BLOOD Neuts-82.3* Lymphs-11.9* Monos-5.2
Eos-0.4 Baso-0.2
___ 05:49AM BLOOD Glucose-97 UreaN-10 Creat-0.7 Na-134
K-2.9* Cl-96 HCO3-31 AnGap-10
___ 01:40PM BLOOD Na-132* K-3.7 Cl-97
.
MICRO
___ 10:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CLUSTERS.
Reported to and read back by ___ (___)
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CLUSTERS.
.
___ 10:50 pm JOINT FLUID Source: Knee.
**FINAL REPORT ___
GRAM STAIN (Final ___:
Reported to and read back by ___ @ 0032 ON
___.
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
___ 11:10 am TISSUE RIGHT TIBIAL PLATCAO DEEP BONE
CULTURE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
Reported to and read back by TO ___ ___
@1500.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___-___ ___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
.
___ BLOOD CULTURE - NEGATIVE (FINAL)
___ - BLOOD CULTURES PENDING
___ 10:50PM JOINT FLUID Crystal-NONE
.
IMAGING
.
___ CT CHEST
CONCLUSION:
Pulmonary edema. Evidence of likely prior ischemic heart disease
and some
right-sided heart failure also.
No PE as clinically questioned. Incidentally noted, and best
appreciated on
the scout radiographs is significant colonic and gastric
distention.
.
___ ECHO
Conclusions
The left atrium is normal ___ size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). There is a focal outpouching of inferior left
ventricular apex c/w a very small aneurysm. This was visualized
only after contrast administration. Doppler parameters are most
consistent with Grade I (mild) left ventricular diastolic
dysfunction. The right ventricular cavity is mildly dilated with
borderline normal free wall function. The diameters of aorta at
the sinus, ascending and arch levels are normal. The number of
aortic valve leaflets cannot be determined. There was no aortic
stenosis or regurgitation. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Very small aneurysm of the left ventricular apex
with preserved global systolic function. Mild diastolic
dysfunction. No significant [SIC]
.
___ KUB
FRONTAL SUPINE RADIOGRAPHS OF THE ABDOMEN: Note is made of
diffuse gaseous
distention of the colon as well as scattered air-filled loops of
small bowel.
This is a finding which is new since the comparison CT. There is
no definite pneumoperitoneum or pneumatosis on this limited
evaluation (patient refused decubitis positioning). Dense
material ___ the urinary bladder is likely from prior intravenous
injection of iodinated contrast.
IMPRESSION: Diffuse gaseous distention of the bowel, most likely
related to
ileus.
.
___ KUB
INDINGS: Stool is seen throughout the colon which is not
dilated. There is
gas ___ non-dilated loops of small bowel. This is a supine view
and therefore
cannot assess for free air, however, this is a nonobstructive
pattern.
Compared to the prior study, the amount of stool is increased,
but the amount of distention of the colon has decreased.
.
___ R KNEE FILMS (3 VIEWS)
THREE VIEWS RIGHT KNEE: There is increased lucency and sclerosis
within the
lateral tibial plateau consistent with the known fracture at
this location.
There is a moderate-sized joint effusion. No new fracture is
identified.
IMPRESSION: Lateral tibial plateau fracture.
.
___ PATHOLOGY
Right tibial plateau bone, biopsy: Acute osteomyelitis.
.
___ PELVIS MR +CONTRAST
FINDINGS: The images are not tailored for evaluation of
paraspinal abscesses, however there is good visualization of the
psoas muscles and the paravertebral muscles along the lumbar
spine. There is no evidence of osteomyelitis involving the
lumbosacral spine. There is no evidence of paraspinal abscesses.
No edema is seen within the lumbar vertebral bone marrow.
Degenerative changes are seen ___ the spine, most pronounced at
L4-L5 level and ___ the hip joints bilaterally.
There is a linear slightly irregular region of high signal
intensity involving the left sacral ala on STIR imaging with
some enhancement post-contrast administration representing an
acute or subacute insufficiency fracture. The previously
identified fracture involving the anterior left acetabulum is
not as well depicted on the current T2 sequences, likely related
to interval
healing.
The visualized bowel appears within normal limits.
There is no pelvic lymphadenopathy. There is a small
diverticulum of the
anterolateral aspect of the urinary bladder on the right (3,
26). The
visualized uterus is unremarkable. The rectosigmoid appears
within normal
limits.
Limited views of the kidneys demonstrate no gross abnormalities.
A small Tarlov cyst is seen ___ the sacrum (5, 30).
IMPRESSION:
1. No evidence of lumbosacral vertebral or sacral osteomyelitis,
or
paraspinal abscesses.
2. No evidence of psoas abscess.
3. Acute to subacute sacral insufficiency fracture involving the
left sacral ala.
4. Degenerative changes involving the spine and hip joints.
.
___ RUQ US
RIGHT UPPER QUADRANT ULTRASOUND: The liver echotexture is normal
without
focal lesion. There is no intra- or extra-hepatic bile duct
dilation and the common bile duct measures 4. The main portal
vein is patent with hepatopetal flow. The gallbladder is
distended with sludge, but there is no wall thickening. There is
a trace intra-abdominal ascites. The spleen is 7.5 cm with
multiple echogenic foci suggestive of calcified granulomata
related to prior infection. The IVC and hepatic veins are
enlarged.
IMPRESSION:
1. Patent portal vein with normal waveforms.
2. Trace ascites.
3. Right pleural effusion.
4. Enlargement of the IVC and hepatic veins suggests right
ventricular
failure or fluid overload.
.
___ CXR
IMPRESSION: AP chest compared to ___ and ___:
Mild interstitial edema has improved, heart size remains top
normal. Small
right pleural effusion is unchanged, no left pleural effusion.
No pulmonary
consolidation. Heterogeneous opacification at the base of the
left lung is
almost certainly atelectasis. Left PIC line ends ___ the low
third of the SVC. No pneumothorax.
Medications on Admission:
1. calcium carbonate 500mg BID
2. senna 8.6 mg Tablet, 2 tabs HS
3. docusate sodium 100 mg BID
4. polyethylene glycol 3350 17 gram/dose daily
5. cholecalciferol (vitamin D3) 1,000 unit BID
6. acetaminophen 650mg QID
7. ducolax suppository PR daily
8. lovenox 40mg SC daily
9. ultram 50mg QID prn moderate-severe pain
Discharge Medications:
1. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*0*
2. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PACKET PO DAILY (Daily).
Disp:*30 * Refills:*2*
4. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. acetaminophen 650 mg/20.3 mL Solution Sig: 1.5 CUPS (975 MG)
PO Q6H (every 6 hours).
Disp:*180 CUPS (975 MG)* Refills:*2*
6. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) SYRINGE
Subcutaneous HS (at bedtime).
Disp:*30 syringes* Refills:*2*
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
9. morphine 10 mg/5 mL Solution Sig: One (1) ML (2 MG) PO Q4H
(every 4 hours) as needed for pain.
Disp:*1 BOTTLE (200 CC OR CLOSEST EQUIVALENT - 1 MONTH SUPPLY)*
Refills:*0*
10. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating/gas pain.
Disp:*120 Tablet, Chewable(s)* Refills:*0*
11. nafcillin ___ D2.4W 2 gram/100 mL Piggyback Sig: One (1)
PIGGYBACK Intravenous every four (4) hours.
Disp:*180 PIGGYBACKS* Refills:*2*
12. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1)
SYRINGE Intravenous PRN (as needed) as needed for line flush.
Disp:*30 SYRINGES* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
MSSA bacteremia
Deep tibial plateau osteomyelitis
.
SECONDARY DIAGNOSES
Recurrent Ileus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Patient with hypoxia after MVC.
TECHNIQUE: Frontal and lateral radiographs of the chest were obtained.
COMPARISON: Chest radiograph from ___ and ___.
FINDINGS:
Slight prominence of the interstitial markings in general may represent a
degree of failure.There are new right greater than left basilar opacity, not
seen on ___ with a history of trauma, likely representing
atelectasis or pneumonia. The cardiomediastinal silhouette and hila are
normal. There is no pneumothorax. There is mild elevation of the left
hemidiaphragm, unchanged from the prior study.
IMPRESSION:
Right greater than left basilar opacities, likely representing atelectasis or
pneumonia.
Radiology Report
STUDY: CT chest.
INDICATION: Patient with recent immobilization, elevated D-dimer and hypoxia.
For evaluation.
TECHNIQUE: Multislice CT imaging acquisition of the chest was acquired
according to a CT pulmonary angiogram protocol. Non-contrast and
contrast-enhanced images were acquired.
COMPARISON: Recent imaging, including a CT torso from ___.
REPORT:
Non-contrast imaging does not reveal findings suggestive of an acute aortic
pathology. Good quality CT pulmonary angiogram protocol study was acquired.
CT pulmonary angiogram is negative for pulmonary embolism.
There are bilateral effusions which appear simple (as opposed to representing
hemothoraces). There is significant associated bibasal relaxation
atelectasis. This is consistent with the patient's recent chest radiograph.
There are no findings suggestive of significant mediastinal lymphadenopathy.
No findings suggestive of an acute aortic pathology.
The major airways are patent to the subsegmental level. There is, however,
evidence of significant bronchial wall thickening particularly in the lower
lobes bilaterally.
The lung parenchyma demonstrates areas of ground-glass opacity and the overall
appearances suggests pulmonary edema. No definitive associated pneumonia. A
dilated right atrium and right ventricle are noticed. Concentric left
ventricular hypertrophy is noted. There is a focal aneurysmal outpouching of
the apical left ventricle (series 3, image 80), suggesting a prior apical
infarct with a small amount of pseudoaneurysm formation. Correlation with
echo or EKG may be useful.
Below the diaphragm, a significantly distended gastric bubble is again noted.
Some air in the transverse colon is also seen. The very tip of the liver and
spleen are seen which appear grossly normal. The remainder of the abdomen has
not been adequately visualized, however.
Mild pectus excavatum deformity. The osseous structures are otherwise grossly
normal.
There is apparent sternal irregularity but this represents respiratory
artifact, as it is not seen on the non-contrast study.
CONCLUSION:
Pulmonary edema. Evidence of likely prior ischemic heart disease and some
right-sided heart failure also.
No PE as clinically questioned. Incidentally noted, and best appreciated on
the scout radiographs is significant colonic and gastric distention. Findings
were discussed with Dr. ___ at the time of interpretation.
Radiology Report
INDICATION: Abdominal pain and distention.
COMPARISON: ___.
FRONTAL SUPINE RADIOGRAPHS OF THE ABDOMEN: Note is made of diffuse gaseous
distention of the colon as well as scattered air-filled loops of small bowel.
This is a finding which is new since the comparison CT. There is no definite
pneumoperitoneum or pneumatosis on this limited evaluation (patient refused
decubitis positioning). Dense material in the urinary bladder is likely from
prior intravenous injection of iodinated contrast.
IMPRESSION: Diffuse gaseous distention of the bowel, most likely related to
ileus.
Radiology Report
REASON FOR EXAMINATION: Chronic lower extremity pain, persistent oxygen
requirement despite diuresis and increased white blood cell count.
Portable AP radiograph of the chest was reviewed in comparison to ___.
Heart size is enlarged, stable. Mediastinum is stable. The patient continues
to be in interstitial pulmonary edema which appears to be improved since the
prior study. There is a right lower lobe asymmetric opacity that might
reflect infectious process in this area, appears to be slightly more prominent
than on the prior examination. Small amount of pleural effusion is better
appreciated on the CT chest from ___.
Radiology Report
INDICATION: Worsening tenderness of the right knee.
COMPARISON: MRI dated ___ and Radiograph dated ___
THREE VIEWS RIGHT KNEE: There is increased lucency and sclerosis within the
lateral tibial plateau consistent with the known fracture at this location.
There is a moderate-sized joint effusion. No new fracture is identified.
IMPRESSION: Lateral tibial plateau fracture.
Radiology Report
HISTORY: Bone graft insertion.
FINDINGS: Multiple images from the operating suite show bone graft insertion.
Further information can be gathered from the operative report.
Radiology Report
ABDOMEN ON ___
HISTORY: Question narcotic-induced ileus.
REFERENCE EXAM: ___.
FINDINGS: Stool is seen throughout the colon which is not dilated. There is
gas in non-dilated loops of small bowel. This is a supine view and therefore
cannot assess for free air, however, this is a nonobstructive pattern.
Compared to the prior study, the amount of stool is increased, but the amount
of distention of the colon has decreased.
Radiology Report
STUDY: MRI of the pelvis without and with contrast.
INDICATION: ___ female with MSSA bacteremia with right knee
osteomyelitis presenting with new right paraspinal and flank pain. Suspect
psoas abscess or vertebral or pelvic osteomyelitis.
COMPARISON: CT of the pelvis dated ___.
TECHNIQUE: Multiplanar T1- and T2-weighted images of the pelvis were acquired
on a 1.5 Tesla magnet, including dynamic 3D imaging, obtained prior to, during
and after the uneventful intravenous administration of 7.5 mL of Gadovist.
FINDINGS: The images are not tailored for evaluation of paraspinal abscesses,
however there is good visualization of the psoas muscles and the paravertebral
muscles along the lumbar spine. There is no evidence of osteomyelitis
involving the lumbosacral spine. There is no evidence of paraspinal
abscesses. No edema is seen within the lumbar vertebral bone marrow.
Degenerative changes are seen in the spine, most pronounced at L4-L5 level and
in the hip joints bilaterally.
There is a linear slightly irregular region of high signal intensity involving
the left sacral ala on STIR imaging with some enhancement post-contrast
administration representing an acute or subacute insufficiency fracture. The
previously identified fracture involving the anterior left acetabulum is not
as well depicted on the current T2 sequences, likely related to interval
healing.
The visualized bowel appears within normal limits.
There is no pelvic lymphadenopathy. There is a small diverticulum of the
anterolateral aspect of the urinary bladder on the right (3, 26). The
visualized uterus is unremarkable. The rectosigmoid appears within normal
limits.
Limited views of the kidneys demonstrate no gross abnormalities.
A small Tarlov cyst is seen in the sacrum (5, 30).
IMPRESSION:
1. No evidence of lumbosacral vertebral or sacral osteomyelitis, or
paraspinal abscesses.
2. No evidence of psoas abscess.
3. Acute to subacute sacral insufficiency fracture involving the left sacral
ala.
4. Degenerative changes involving the spine and hip joints.
Findings were discussed with Dr. ___ telephone on ___ at
9:45 a.m.
Radiology Report
INDICATION: ___ female with right tibial osteomyelitis and septic
knee, found to have obstructive LFTs with an elevated total bilirubin.
Evaluate for obstruction or inflammation.
COMPARISON: CT ___.
RIGHT UPPER QUADRANT ULTRASOUND: The liver echotexture is normal without
focal lesion. There is no intra- or extra-hepatic bile duct dilation and the
common bile duct measures 4. The main portal vein is patent with hepatopetal
flow. The gallbladder is distended with sludge, but there is no wall
thickening. There is a trace intra-abdominal ascites. The spleen is 7.5 cm
with multiple echogenic foci suggestive of calcified granulomata related to
prior infection. The IVC and hepatic veins are enlarged.
IMPRESSION:
1. Patent portal vein with normal waveforms.
2. Trace ascites.
3. Right pleural effusion.
4. Enlargement of the IVC and hepatic veins suggests right ventricular
failure or fluid overload.
Radiology Report
AP CHEST 8:09 A.M. ON ___
HISTORY: Portal vein congestion. Question pleural effusions.
IMPRESSION: AP chest compared to ___ and ___:
Mild interstitial edema has improved, heart size remains top normal. Small
right pleural effusion is unchanged, no left pleural effusion. No pulmonary
consolidation. Heterogeneous opacification at the base of the left lung is
almost certainly atelectasis. Left PIC line ends in the low third of the SVC.
No pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HYPOXIA
Diagnosed with HYPOXEMIA, HYPERTENSION NOS
temperature: 98.0
heartrate: 81.0
resprate: 16.0
o2sat: 96.0
sbp: 130.0
dbp: 69.0
level of pain: 5
level of acuity: 3.0 | ___ with history of colonic ileus, osteoporosis, peripheral
neuropathy & traumatic left pelvic fracture now admitted from
rehab where she was placed following MVC ___ which she sustained
a non-displaced lateral tibial plateau fracture, found to have
MSSA bacteria, septic R knee and proximal tibial osteomyelitis.
.
#. Septic R knee and osteomyelitis
Patient found to have MSSA bacteremia. Arthrocentesis ___
showed >100K WBCs 96% poly, 10K RBCs. Went to OR ___ for R
knee washout and was found to have proximal tibial osteomyelitis
which was cleaned out and reconstructed with antibiotic-laden
cement (see ortho operative note for full details). Blood
cultures and intra-operative joint fluid/tissue cultures all
grew MSSA. She was treated with IV nafcillin. Never febrile. WBC
transiently elevated but back to baseline by discharge. TTE
negative for endocardiac vegetations. Work with physical therapy
was limited by pain, which was attempted to be controlled with
PO liquid tylenol standing + morphine sulfate low-dose PRN.
Geriatrics consult assisted with pain control regimen. Continue
on pre-admission lovenox for DVT prophylaxis. Discharge plan is
for long-term nafcillin via PICC and ID OPAT follow-up.
.
#. Hypoxia
Chest imaging wnl on admission. No evidence of pneumonia,
effusions or PE. Some pulmonary congestion and new O2
requirement was thought to be ___ systemic bacterial infection.
O2 requirement and hypoxia improved spontaneously after ___ days
IV antibiotics for MSSA bacteremia/osteomyelitis.
.
#. Colonic Ileus:
Patient's abdomen was distended and tender but soft. CTA chest
noted incidental finding of colonic and gastric distension.
Patient reports constipation x1 week on admission. KUB x2
consistent with colonic ileus (which she had during a prior
admission too, requiring rectal tube placement). She continued
to pass flatus. Repeat KUB obtained for question of SBO when she
developed N/V and was unable to tolerate POs. Methylnaltrexone
promoted one BM; she had a second large BM 4 days later with
only home bowel regimen (senna/colace/miralax) plus IV
hydration. Expect ileus to be an ongoing problem requiring
aggressive bowel regimen +/- enemas/supposities PRN + physical
activity/increased PO intake. We note that multiple abdominal
films showed no evidence of bowel obstruction, only gas.
.
# Positive UA.
Positive UA on admission. Notably afebrile without dysuria,
frequency or urgency. Received levo ___ ED ___, then 3 days
vanc/zosyn/cipro before being started on nafcillin ___ for MSSA
bacteremia/osteomyelitis as above. Ucx ulimately negative.
.
# Hyponatremia:
On admission, Na 131 down from 139 on ___. However, Na 131
similar to levels ___ ___. At that time,
hyponatremia was felt to be secondary to SIADH ___ setting of
pain from hip fracture. Differential this time again includes
SIADH, possibly secondary to pain or pulmonary process, vs new
CHF, vs. hypovolemic hyponatremia. Urine osm, lytes consistent
with hypovolemia. FeNa <1. Improved with IVF during this
admission.
.
# Hypokalemia
Labs prior to discharge showed hypokalemia w/K 2.9; likely ___
very large BM 12h prior. K was repleted. ___ require chemistry
lab check +/- K repletion ___ the future if/when she has other
large BMs.
.
# Hx Osteoporosis:
Continued calcium, vitamin D.
.
TRANSITIONAL ISSUES
1. ID CLINIC FOLLOW-UP - SEE OPAT NOTE ___ OMR
2. Can eventually stop lovenox, timing TBD by ortho ___ follow-up
appt.
3. Continue ___ as-needed; adjust pain medication PRN with eye
towards minimizing opiates given history of recurrent ileus.
4. Needs cognitive/occupational therapy evaluation prior to
leaving ___ to assess whether she is safe to drive,
___ light of recent T-bone MVC. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
increased seizure frequency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with history of ___
syndrome who presents with increased seizure frequency as well
as
lethargy in setting of clobazam initiation several months ago.
The patient is well known to me from admission to the epilepsy
service in ___ for increased seizure frequency. At that time,
his clobazam dose was increased which he initially tolerated
well. Gradually, he started to have increased seizure frequency
from baseline, including clusters of tonic and tonic clonic
seizures. He has also become more lethargic sleeping often
during the day. In fact, for the last week, he has not been
able
to attend his day program as he is too sleepy. Patient was
taking
clobazam ___ which was changed to ___ in hopes of decreasing
lethargy during the day. Per mom, this was not effective.
Patient was last seen in our ED on ___ for a cluster of
seizures.
There was no clear trigger--negative infectious work up, no
missed AEDs, no sleep deprivation. He remained seizure free for
quite some time and was discharged home from the ED.
___ has had a dry cough for the last week or so. Mom denies
recent fevers, chills, rhinorrhea, abdominal pain, diarrhea,
dysuria/urinary frequency. ___ has not missed any AED doses
and has not been sleep deprived. He is currently on clobazam,
keppra, lamictal, and zonegran. Patient has a vagal nerve
stimulator, but per mom, it has not been used for many years as
it was not effective. For the last several weeks to months, he
has had an increase in seizure frequency and requiring ativan
more frequently. He last received 4mg of ativan on ___, and,
prior to that, on ___. Patient's most recent seizure was
last night. He was shaving in the bathroom at around 8pm when
his mom heard him fall. She found him in the bathtub, unclear
if
there was a head strike. However, he has definitely had
multiple
head strikes recently with his increased seizure frequency.
In terms of prior seizure history: Mr. ___ was first
diagnosed
with ___ when he was ___ years old. His seizure types
include staring spells with automatisms, drop attacks,
tonic/clonic episodes. In ___, the patient had a left vagal
stimulator placed due to seizures refractory to medication. The
patient has had multiple injuries throughout his life secondary
to his seizure condition including but not limited to head and
face lacerations requiring stitches, falls from standing height,
and closed head injuries.
On neuro ROS, the pt denies headache, loss of vision, vertigo.
Denies difficulties producing or comprehending speech. Denies
focal weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
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:
___ syndrome - diagnosed at age ___
Left vagal nerve stimulator placement - ___
Left vagal nerve stimulator revision (battery replacement) -
___
Social History:
___
Family History:
Aunt has ?seizure history. General family history of HTN and DM.
No strokes or dementia.
Physical Exam:
Admission Exam:
Vitals: T 98.0 HR 88 BP 130/81 RR 20 O2 100% ra
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: 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: Somnolent, eyes closed, arouses easily to voice,
oriented to self, ___, ___. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI with end gaze sustained nystagmus on right and
left gaze, direction changing. 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. Patient is
full strength in all muscle groups of the upper and lower
extremities b/l.
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
--------------------
Discharge Exam:
MS - Awake, alert, oriented to BI, MDY, follows commands, good
comprehension
CN - visual fields intact, EOMI, eyes conjugate, face symmetric
Motor - strength full
Coordination - normal FNF
Gait - independent ambulation
Pertinent Results:
___ EEG
This is an abnormal video EEG monitoring session because of
frequent runs of generalized beta frequency activity that likely
represent electrographic seizures occurring up to multiple times
an hour. Clinically, these often appear to involve behavioral
arrest followed by non-specific movements. In addition,
multifocal isolated epileptiform discharges, including those of
bifrontal, right frontal, and independent bitemporal origin, are
present. Independent bilateral focal slowing in the temporal
regions suggests subcortical dysfunction in those locations. The
degree of background slowing is consistent with a mild
encephalopathy of non-specific etiology.
___ EEG: reads pending
___ EEG
This 24 hour monitoring session captured five electrographic
seizures, the last of which was prolonged. Other pushbutton
activations were
decreased responsiveness may have corresponded to an excessively
drowsy
state, as demonstrated by the propensity for the patient to have
slow wave sleep intrusions into the daytime hours. A poorly
organized encephalopathic background persists.
___ EEG
This continuous EEG recording captured brief and more prolonged
bursts of high amplitude generalized polyspike and wave
discharges
superimposed upon a slow and disorganized background. One
electrographic
seizure was seen; the clinical correlate was an atonic seizure.
Overall,
this represents an improvement over the previous day's
recording.
___ EEG: reads pending
___ CT Head
1. No acute intracranial process.
2. Left occipital scalp hematoma without calvarial fracture.
___ 11:00AM BLOOD WBC-7.2 RBC-4.95 Hgb-15.6 Hct-43.3 MCV-87
MCH-31.5 MCHC-36.1* RDW-13.3 Plt ___
___ 11:00AM BLOOD Glucose-183* UreaN-11 Creat-0.8 Na-140
K-4.5 Cl-108 HCO3-18* AnGap-19
___ 11:00AM BLOOD ALT-34 AST-38 AlkPhos-126 TotBili-0.3
___ 11:00AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clobazam 10 mg PO QAM
2. Clobazam 30 mg PO QPM
3. LaMICtal XR (lamoTRIgine) 1500 mg oral QPM
4. Keppra XR (levETIRAcetam) 3000 mg oral QPM
5. Zonisamide 200 mg PO QAM
6. Zonisamide 500 mg PO QPM
7. Lorazepam Dose is Unknown PO PRN seizure
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Keppra XR (levETIRAcetam) 3000 mg oral QPM
2. LaMICtal XR (lamoTRIgine) 1500 mg oral QPM
3. Multivitamins 1 TAB PO DAILY
4. Zonisamide 200 mg PO QAM
5. Zonisamide 500 mg PO QPM
6. Rufinamide 800 mg PO BID
RX *rufinamide [Banzel] 400 mg 2 tablet(s) by mouth twice daily
Disp #*120 Tablet Refills:*11
7. Lorazepam 2 mg PO DAILY:PRN seizure. ___ repeat once in 30
min if needed
Discharge Disposition:
Home
Discharge Diagnosis:
___ Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with cough // eval for pna
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
As on prior, extremely low lung volumes are noted. Left chest wall vagal
nerve stimulator is again seen. The lungs are grossly clear. There is no
effusion or obvious consolidation. Cardiomediastinal silhouette is within
normal limits. No acute osseous abnormalities.
IMPRESSION:
Low lung volumes without acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with seizures with head trauma, 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: Total DLP (Head) = 1,226 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
A left occipital scalp hematoma is noted (3a:58) without underlying calvarial
fracture. No osseous abnormalities seen. Trace mucosal thickening of
bilateral maxillary sinuses and a mucous retention cyst in the sphenoid sinus
are noted. The paranasal sinuses, mastoid air cells, and middle ear cavities
are otherwise clear. The orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Left occipital scalp hematoma without calvarial fracture.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: Seizure
Diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY
temperature: 98.0
heartrate: 88.0
resprate: 20.0
o2sat: 100.0
sbp: 130.0
dbp: 81.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man with history of ___
syndrome who presented with lethargy in setting of clobazam
initiation and multiple dose adjustments. He was admitted for
clobazam wean while on EEG monitoring. His seizure frequency
increased as the clobazam was weaning off, so he was started on
rufinamide per his outpatient Epileptologist's plan.
On EEG initially he was having ___ subclinical seizures per
hour, each lasting ___ sec, consistent with prior EEG
recordings. Once the clobazam started weaning down, he increased
to having ___ seizures lasing ___ sec every 10 minutes.
However, prior to the first dose of rufinamide, he decreased to
___ events per hour lasting <10 sec each. The day of discharge,
he had gone the previous 24 hours without any seizures for
several hours, then with a few seizures in an hour; this was an
overall improvement since admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Latex / Ativan / Penicillins / Paxil / amiodarone
Attending: ___.
Chief Complaint:
increasing dyspnea in the setting of known MR
Major Surgical or Invasive Procedure:
___ - 1. Mitral valve repair with a P2 resection and ___
___ annuloplasty ring, 38 mm, model number is ___, serial
number is ___. 2. Closure of patent foramen ovale. 3.
Pulmonary vein isolation with left atrial appendage resection.
___ - Simple extraction of teeth 5, 18, and 20.
___ - Cardiac Catheterization
History of Present Illness:
This ___ man with history of mod-severe mitral valve
prolapse with mod-severe mitral regurgitation and recurrent
episodes of polymorphic ventricular tachycardia/VF. He is status
post ICD implantation in ___ and generator change in ___. Earlier in ___, he developed AF in the setting of
thyrotoxicosis. Methimazole was initiated and he underwent a
successful cardioversion. He has had no further episodes of afib
and is on coumadin.
Since we saw him on ___ of this year he has become
progressively more dyspneic from his mitral regurg. He was
supposed to have a diagnostic cath in the interim and was
supposed to have dental work completed in anticipation of MV
replacement/repair. He has completed part of the dental
procedures but requires an addtional dental extraction as of
this
time.
Past Medical History:
- question migraine - 2 headaches only about ___ years ago
bifrontal in location with possible scintillating scotoma
- idiopathic VF/PMVT s/p ICD
- MVP with mod-severe MR, diagnosed age ___
- atrial fibrillation: recently started on coumadin, amiodarone
- syncope
- multiple traumatic fx
- prior cocaine
- s/p appendectomy
- s/p inguinal hernia repair
Social History:
___
Family History:
No family history of stroke in the young or sudden death.
Physical Exam:
Physical Exam
Pulse:58 Resp:18 O2 sat:98%
B/P ___: 128/67 Left:
Height: 6ft Weight:94.3 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]. Pacer site with well healed
scar
Heart: RRR [x] Irregular [] Murmur [x] grade IV/VI at apex
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 ___: +2 Left:+2
DP ___ Left:+2
___ ___: +2 Left:+2
Radial ___ Left:+2
Carotid Bruit ___: none Left:none
Pertinent Results:
___ 06:05AM BLOOD WBC-4.8 RBC-3.05* Hgb-8.9* Hct-25.9*
MCV-85 MCH-29.1 MCHC-34.3 RDW-14.5 Plt ___
___ 06:20AM BLOOD Hct-27.2*
___ 06:00AM BLOOD ___
___ 06:20AM BLOOD ___
___ 06:05AM BLOOD UreaN-8 Creat-0.9 Na-136 K-4.1 Cl-101
___ 06:20AM BLOOD UreaN-8 Creat-0.9 Na-136 K-4.0 Cl-102
___ 06:20AM BLOOD Mg-2.1
___ TEE
Prebypass:
The study was limited by poor gastric windows.
No mass/thrombus is seen in the left atrium or left atrial
appendage.
The width of the PFO is 4 mm. A ___ shunt across the
interatrial septum is seen at rest.
Poor visualization of deep epigastric windows.
Overall left ventricular systolic function appears to be
moderately depressed globally, especially given MR.
___ ventricular chamber size and free wall motion are normal.
The aortic root is moderately dilated at the sinus level,. The
width of the ascending aorta and aortic arch is normal.There are
simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are severely thickened/deformed. The
mitral valve leaflets are myxomatous. Severe (4+) mitral
regurgitation is seen.
There is no pericardial effusion.
Postbypass:
Again the gastric views were limited.
Initial attempt to wean from CPB failed because of severe LV
dysfunction even though on an epinephrine infusion.
The second attempt was successful on higher doses of inotrope.
A well seated mitral annuplasty ring is seen. No mitral
regurgitation is present.
Peak gradient across mitral valve is 4 mm Hg.
LV sytolic function remains moderately globally depressed.
No PFO is seen at the IAS.
No left atrial appendage is seen as it was ligated by the
surgeon during bypass.
Rest of the exam is unchanged from before.
Surgeon was notified about the findings.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO BID
3. Warfarin 6 mg PO DAILY16
4. Methimazole 15 mg PO BID
5. Lisinopril 5 mg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Methimazole 15 mg PO BID
3. Warfarin 6 mg PO DAILY16 Atrial Fibrillation
___ MD to order daily dose PO DAILY16
5. Acetaminophen ___ mg PO Q6H:PRN pain
6. Docusate Sodium 100 mg PO BID
7. Ranitidine 150 mg PO BID
8. Metoprolol Tartrate 25 mg PO TID
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*10
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Severe mitral regurgitation.
2. Patent foramen ovale.
3. Paroxysmal atrial fibrillation.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema trace
Followup Instructions:
___
Radiology Report
INDICATION: ___ with near syncope // Pulm edema, pna, cardiomeg
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are clear of consolidation. Calcific density again projects over the
anterior right second rib. Left chest wall single lead pacing device is again
noted. Moderate cardiomegaly is unchanged.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: TEETH (PANOREX FOR DENTAL)
INDICATION: ___ year old man with severe mitral regurge // pre op eval for
cardiac surgery
COMPARISON: No comparison
IMPRESSION:
Multiple missing teeth and fillings. No convincing evidence of periradicular
osteolysis. Cortical discontinuation at the right mandibular ankle,
consistent with old fracture. Correlation with clinical history should be
obtained.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with s/p MVR, MAze // cardiac surgical fast
track. eval for ptx, effusions. please ___ in the CVICU if
there is any concern with findings Contact name: ___: ___
cardiac surgical fast track. eval for ptx, effusions. please
IMPRESSION:
In comparison with the study of ___, there has been a cardiac surgical
procedure with intact midline sternal wires. Endotracheal tube tip lies
approximately 4.2 cm above the carina. Right IJ catheter extends to the
carina. Single lead pacer device extends to the apex of the right ventricle.
Increased opacification of the left base is consistent with some combination
of volume loss the left lower lobe and pleural effusion. No evidence of
vascular congestion or pneumothorax.
Radiology Report
INDICATION: Mitral valve replacement now status post chest tube removal.
TECHNIQUE: Bedside frontal chest radiograph.
COMPARISON: Chest radiographs ___ and ___.
FINDINGS:
The patient has been extubated in the interim, which has resulted in lower
lung volumes and increased atelectasis in the right lower lobe. Opacity at
the left lung base is likely atelectasis , unchanged. Mediastinal and pleural
drains have been removed. Small bilateral pleural effusions are presumed. No
pneumothorax. The heart remains mildly enlarged, however, there is no
pulmonary edema.
Emphysema predominantly upper lobes. Cervical ribs are noted. Left pectoral
pacemaker, sternotomy wires and a mitral valve prosthesis are constant. The
right internal jugular catheter courses into the mid SVC.
IMPRESSION:
Lower lung volumes after extubation with worsened atelectasis. No
pneumothorax.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with mvr // r/o inf, eff
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the right internal jugular vein
catheter has been removed. Moderate cardiomegaly persists. Improvement of the
pre-existing right basal atelectasis and minimal left pleural effusion.
Left pectoral pacemaker and alignment of the sternal wires is constant.
Hypotrophic first right rib.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness, Weakness
Diagnosed with SYNCOPE AND COLLAPSE, MITRAL VALVE DISORDER
temperature: 98.3
heartrate: 53.0
resprate: 18.0
o2sat: 100.0
sbp: 121.0
dbp: 66.0
level of pain: nan
level of acuity: 2.0 | ___ yo M with history of severe MR from MVP, Idiopathic VF/PMVT
s/p ICD, hyperthryoidism from Graves and amiodarone, who
presents with worsening symptoms of MR and for evaluation of
MVR. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ female with history of
refractory AML c/b myeloid sarcoma having completed 10 cycles of
decitabine who presents with neutropenic fever.
Patient recently admitted ___ to ___ for febrile
neutropenic likely from facial cellulitis. She was discharged on
Doxycycline and Keflex. She was seen on 7 ___ on ___ with
R
> L bilateral lower extremity edema. Exam during that visit
documented as "RLE with 2+ pitting edema with mild-moderate
erythema up ___ of calf and swelling involving foot as well with
hemosiderosis-type skin discoloration. LLE ___ edema (< right
side) with similar but less marked skin color changes. Both legs
warm to touch." She was broadened to Augmentin + doxycycline.
Bilateral lower extremity ___ was negative on ___ for DVT, but
notable for soft tissue edema in R calf.
Ms. ___ developed a fever on ___ and called her clinic to
report a temperature of 102. Her last ANC prior to presentation
was 200. She also reported chronic left hip pain and R leg
swelling as well as an expanding red and hot patch on the R
shin.
Given fever and symptoms with underlying neutropenia, she was
referred to the ED.
On arrival to the ED, initial vitals were Temperature:101.5,
heart rate 139, blood pressure 128/66, respiratory rate 15 O2:
98% RA. Exam was notable for tachycardia, RLE swelling and
pitting edema and non-blanching brawny erythema over left distal
calf, and non-infected appearing port site. Rectal exam was not
done. Labs were notable for:
- Hemoglobin 4.6, hematocrit 13.5
- Platelets 20
- WBC 6.8, ANC 410, Blasts 21%
- Na 129, Cl 89
- Lactate 1.2
- Flu negative
- INR 1.4
- blood and urine cultures drawn
She was given:
- 3u pRBC
- Acetaminophen 650mg
- Isoniazid ___
- Entecavir 0.5 mg
- Cefepime 2g x 3
- Vancomycin 1000mg x 1 and 1500 mg x 1
- Pyridoxine 50mg
- Hydroxyurea 500mg
- Diphenhydramine 50mg
- fluconazole 400 mg
- NS
Imaging revealed:
- CXR with R port-a-cath in place, no pneumonia or other acute
pathology
Labs prior to transfer were significantly improved with
hematocrit of 32.2. Prior to transfer vitals were 100.1 93
126/53
16 96% RA
On arrival to the floor, the patient and her daughter report
that
she has noticed progressive redness of the RLE for the past week
associated with swelling, though the swelling seems better over
the past day since she had been elevating her legs in the ED.
She
also endorses tolerable L hip pain, for which MRI was recently
done confirming likely leukemic infiltration of this area.
Past Medical History:
======================
PAST ONCOLOGIC HISTORY
======================
- ___: Presents with severe anemia, WBC 12.5, Hgb 7.2, Plt
184, 3% peripheral blasts.
- ___: Bone marrow biopsy reveals myelodysplastic syndrome
with excess blasts-2 with ringed sideroblasts. Blasts ___ in
marrow. Complex abnormal karyotype with trisomy 8 and 5q-. TP53
A276D point mutation present on Rapid Heme Panel. Very high risk
by R-IPSS score.
- ___: C1D1 decitabine 20 mg/m2 x 5 days.
- ___: C2D1 decitabine 20 mg/m2 x 5 days.
- ___: C3D1 decitabine 20 mg/m2 x 5 days.
- ___: C4D1 decitabine 20 mg/m2 x 5 days.
- ___: C5D1 decitabine 20 mg/m2 x 5 days.
- ___: C6D1 decitabine 20 mg/m2 x 5 days.
- ___: C7D1 decitabine 20 mg/m2 x 5 days.
- ___: C8D1 decitabine 20 mg/m2 x 5 days.
- ___: C9D1 decitabine 20 mg/m2 x 5 days. 10% peripheral
blasts noted.
- ___: Admitted in the context of new right leg pain. LENIs
show no evidence of DVT or focal fluid collection in the area of
pain. CT of the right thigh shows no correlate in the area of
reported pain. MRI of the right femur demonstrates an
aggressive-appearing marrow replacement process of the
mid-to-distal right femoral diaphysis with surrounding
periosteal reaction and muscle edema and enhancement. She is
seen
by Dr. ___ Radiation ___ on ___, who recommends
XRT to
the lesion because of risk of recurrent pain in this area and
even fracture. Orthopedic Surgery is consulted, and recommends a
plain film of the femur, which is negative for fracture. They
recommend no surgical intervention.
- ___: Discharged to home
- ___: Undergoes XRT simulation.
- ___: CBC with improving but persistent neutropenia (ANC
140), stable anemia (hemoglobin 8.0 g/dL), and improving
thrombocytopenia (platelet count 46,000/uL), with decreasing
peripheral blasts (2%).
- ___ - ___: Admitted for fever and facial edema and
treated
for facial cellulitis.
=============================
PAST MEDICAL/SURGICAL HISTORY
=============================
Very high risk MDS, as above
Latent Hepatitis B virus infection
Latent Tuberculosis infection
Osteoarthritis
Possible lacunar infarct
Social History:
___
Family History:
- One younger brother deceased, liver cancer
- Second younger brother deceased, either liver or kidney
cancer(unsure which)
- Mother deceased, stroke
- Father deceased, typhoid fever
Physical Exam:
==============================
ADMISSION PHYSICAL EXAMINATION
==============================
Vitals: 97.6 107/63 82 18 93% RA
Gen: pleasant woman in no acute distress, smiling
HEENT: oropharynx with petechiae but no wet purpura, no
mucositis, EOMI, anicteric sclerae
NECK: supple
LYMPH: no palpable adenopathy in neck
CV: RRR, no obvious m/r/g
LUNGS: CTAB posteriorly
ABD: NT/ND, +BS
EXT: warm. bilateral lower extremity pitting edema, R>L, with
dark red erythema extending about halfway up shins with
associated petechiae, warm to touch relative to left
SKIN: see above
NEURO: grossly intact, moving all four extremities
LINES: R Port without surrounding erythema, warmth or tenderness
==============================
DISCHARGE PHYSICAL EXAMINATION
==============================
T:97.4 BP:135/64 HR:78 RR:18 O2:98 ra
Gen: Exhausted woman lying in bed, continues to be very pleasant
HEENT: Blood blister noted on anterior lip, improving. New blood
blister on L interior cheek has drained. No new oropharyngeal
lesions.
LYMPH: One palpable lymph node on L anterior neck
CV: S1/S2 regular with no murmurs, rubs or S3/S4
LUNGS: Clear to auscultation bilaterally
ABD: Soft, non-tender, non-distended
EXT: Warm. Trace bilateral lower extremity edema. Significant
discoloration of the lower shin and foot bilaterally.
NEURO: Grossly intact, moving all four extremities
LINES: R Port without surrounding erythema, warmth or tenderness
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 08:54PM PLT SMR-RARE* PLT COUNT-20*
___ 08:54PM HYPOCHROM-2+* ANISOCYT-1+*
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-2+*
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 08:54PM NEUTS-4* BANDS-2 LYMPHS-60* MONOS-10 EOS-0
BASOS-0 ___ METAS-3* MYELOS-0 BLASTS-21* AbsNeut-0.41*
AbsLymp-4.08* AbsMono-0.68 AbsEos-0.00* AbsBaso-0.00*
___ 08:54PM WBC-6.8 RBC-1.51* HGB-4.6* HCT-13.5* MCV-89
MCH-30.5 MCHC-34.1 RDW-13.6 RDWSD-43.9
___ 08:54PM ALBUMIN-3.5 CALCIUM-8.4 PHOSPHATE-3.5
MAGNESIUM-1.6
___ 08:54PM cTropnT-<0.01
___ 08:54PM ALT(SGPT)-12 AST(SGOT)-21 ALK PHOS-79 TOT
BILI-0.7
___ 08:54PM GLUCOSE-154* UREA N-11 CREAT-0.6 SODIUM-129*
POTASSIUM-4.3 CHLORIDE-89* TOTAL CO2-22 ANION GAP-18
___ 09:02PM LACTATE-1.2
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
___ 06:00AM BLOOD WBC-34.7* RBC-2.67* Hgb-7.9* Hct-23.9*
MCV-90 MCH-29.6 MCHC-33.1 RDW-14.3 RDWSD-46.5* Plt Ct-18*
___ 06:15AM BLOOD Neuts-7* Bands-2 ___ Monos-9 Eos-0
Baso-6* ___ Metas-1* Myelos-2* Blasts-51* AbsNeut-2.66
AbsLymp-6.49* AbsMono-2.66* AbsEos-0.00* AbsBaso-1.77*
___ 06:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Schisto-OCCASIONAL
___ 06:00AM BLOOD Plt Ct-18*
___ 11:33AM BLOOD Plt Ct-50*
___ 06:00AM BLOOD ___ PTT-29.4 ___
___ 06:00AM BLOOD Glucose-178* UreaN-15 Creat-0.5 Na-134*
K-4.4 Cl-91* HCO3-29 AnGap-14
___ 06:00AM BLOOD ___
___ 06:00AM BLOOD ___
___ 06:00AM BLOOD ALT-80* AST-64* LD(LDH)-324* AlkPhos-102
TotBili-0.5
___:00AM BLOOD Albumin-2.9* Calcium-8.0* Phos-3.6 Mg-2.1
===========================
REPORTS AND IMAGING STUDIES
===========================
___ CT ABD/Pelvis: Unremarkable
___ CXR
IMPRESSION:
Compared the prior examination, there has been slight worsening
of borderline vascular congestion with perhaps trace
interstitial
edema. There is no consolidation to suggest pneumonia. There
is
no effusion pneumothorax. The cardiomediastinal silhouette and
hilar contours are unchanged. The right Port-A-Cath is
unchanged
___ CTA CHEST
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. No consolidations to suggest acute infection.
3. Unchanged chronic compression deformity of T12.
4. Diffuse idiopathic skeletal hyperostosis is noted.
___ Doppler Ultrasound L Leg
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity
veins.
___ CXR PA and LAT
FINDINGS:
AP upright and lateral views of the chest provided.
Port-A-Cath noted in the right chest wall with catheter tip in
the region of the low SVC. The lungs appear clear bilaterally
without evidence of pneumonia or edema. No large effusion or
pneumothorax. Cardiomediastinal silhouette is stable with aortic
knob calcifications again noted. Imaged bony structures are
intact. No free air below the right hemidiaphragm is seen. Dish
related changes of the T-spine noted.
============
MICROBIOLOGY
============
- ___ Blood Cultures: NGTD
- ___ Urine Cultures: No growth, final
- ___ UA: Few Bacteria; Trace Protein
- ___ Blood Culture #1 = No growth, final
- ___ Blood Culture #2 = No growth, final
- ___ Urine Culture = No growth
- ___ Blood Culture = No growth, final
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Entecavir 0.5 mg PO DAILY
2. Fluconazole 400 mg PO Q24H
3. Isoniazid ___ mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. Pyridoxine 50 mg PO DAILY
7. Cephalexin 500 mg PO Q6H
8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
9. Furosemide 20 mg PO DAILY
10. Hydroxyurea 500 mg PO DAILY
11. Potassium Chloride 40 mEq PO BID
Discharge Medications:
1. Dexamethasone 2 mg PO DAILY
RX *dexamethasone 2 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
2. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % Every evening Disp #*30 Patch Refills:*0
4. lidocaine 4 % topical ONCE
RX *lidocaine [Lidocare] 4 % Apply to leg Every evening Disp #*6
Patch Refills:*0
5. LORazepam 0.5 mg PO Q8H:PRN nausea, anxiety, insomnia
RX *lorazepam 0.5 mg 1 tablet by mouth every 8 hours Disp #*30
Tablet Refills:*0
6. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Never take more then prescribed amount.
RX *tramadol 50 mg 1 tablet(s) by mouth Every 4 hours Disp #*60
Tablet Refills:*0
7. Hydroxyurea 1000 mg PO DAILY
RX *hydroxyurea 500 mg 2 capsule(s) by mouth daily Disp #*60
Capsule Refills:*0
8. Entecavir 0.5 mg PO DAILY
9. Fluconazole 400 mg PO Q24H
10. Isoniazid ___ mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. Pyridoxine 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
Febrile Neutropenia
===================
SECONDARY DIAGNOSES
===================
Right lower extremity cellulitis
Refractory AML
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: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old woman with AML with swelling in L calf. Evaluate for
DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: DVT ultrasound of ___.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow 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: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with refractory AML and new chest pain// eval
chest pain eval chest pain
IMPRESSION:
Comparison to ___. No relevant change is seen. Stable lung
volumes. Stable moderate cardiomegaly. No evidence of pneumothorax. Mild
retrocardiac atelectasis. Stable position of the right pectoral Port-A-Cath.
No pneumonia. No free subdiaphragmatic air.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old woman with refractory AML with new onset chest pain
and tachycardia, evaluate for PE.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.2 mGy (Body) DLP = 1.4
mGy-cm.
2) Stationary Acquisition 0.8 s, 0.2 cm; CTDIvol = 7.0 mGy (Body) DLP = 1.4
mGy-cm.
3) Spiral Acquisition 4.6 s, 29.9 cm; CTDIvol = 5.7 mGy (Body) DLP = 167.4
mGy-cm.
Total DLP (Body) = 170 mGy-cm.
COMPARISON: Prior chest CT dated ___.
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. There is calcification of the mitral annulus. The
heart, pericardium, and great vessels are otherwise 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. There is dependent atelectasis bilaterally. Scattered small
granulomas suggest prior granulomatous disease. 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.
A chronic compression deformity of T12 with approximately 5 mm retropulsion is
grossly similar to the prior study. There is diffuse bridging osteophyte
formation along the right aspect of the vertebral bodies.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. No consolidations to suggest acute infection.
3. Unchanged chronic compression deformity of T12.
4. Diffuse idiopathic skeletal hyperostosis is noted.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with refractory AML on vanc/cefepime with new
fever// Eval for pneumonia
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: Chest radiograph and CT ___
IMPRESSION:
Compared the prior examination, there has been slight worsening of borderline
vascular congestion with perhaps trace interstitial edema. There is no
consolidation to suggest pneumonia. There is no effusion pneumothorax. The
cardiomediastinal silhouette and hilar contours are unchanged. The right
Port-A-Cath is unchanged
Radiology Report
EXAMINATION: CT scan of the abdomen pelvis with intravenous contrast
INDICATION: ___ year old woman with advanced AML and new fever and vomiting on
broad antibiotics.// Please eval for intra-abdominal infection or evidence of
obstruction
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.4 cm; CTDIvol = 4.8 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 0.9 s, 0.2 cm; CTDIvol = 11.4 mGy (Body) DLP =
2.3 mGy-cm.
3) Spiral Acquisition 8.6 s, 45.4 cm; CTDIvol = 10.7 mGy (Body) DLP = 491.0
mGy-cm.
Total DLP (Body) = 495 mGy-cm.
COMPARISON: Abdominal ultrasound dated ___.
FINDINGS:
LOWER CHEST: The lung bases are clear. No pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver is unremarkable. Focal fatty infiltration adjacent
to the falciform ligament. No suspicious liver mass. The common bile duct is
prominent measuring up to 7 mm. The gallbladder is unremarkable.
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. 9 mm accessory splenic tissue adjacent to the
splenic hilum.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are unremarkable. Subcentimeter renal cortical
hypodensities are too small to characterize but likely represent small cysts.
No hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: Small sliding-type hiatus hernia. The small and large bowel
are normal in caliber. Small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. The appendix is normal.
PELVIS: The bladder is only partially filled but appears grossly unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and adnexae 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: Moderate compression deformity of the T12 vertebral body is stable
dating back to ___.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Unremarkable study. No explanation for the patient's symptoms is identified.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Weakness
Diagnosed with Anemia, unspecified, Tachycardia, unspecified, Fever, unspecified, Weakness
temperature: 101.5
heartrate: 139.0
resprate: 15.0
o2sat: 98.0
sbp: 128.0
dbp: 66.0
level of pain: 0
level of acuity: 1.0 | =================
SUMMARY STATEMENT
=================
Mr. ___ is an ___ female with history of
refractory AML c/b myeloid sarcoma having completed 10 cycles of
decitabine who presents with neutropenic fever. Right lower
extremity cellulitis was a presumed source, though blood
cultures were negative. She was treated with a prolonged course
of broad spectrum antibiotics due to recurrent fevers. She also
developed worsening nausea and bony pain though to be related to
progressing refractory AML, which was supported by a rising
white count and blast percentage. A family meeting was held and
the decision was made to transition the patient to oral
antibiotics and discharge home in order for her to have some
comfortable time out of the hospital. The family plans on
bringing her into the hospital for any new or concerning
symptoms and they do not wish to pursue home or inpatient
hospice.
====================
ACUTE MEDICAL ISSUES
====================
# Febrile Neutropenia
# Asymmetric lower extremity edema
# Lower extremity erythema
Presented with fever, presumed source could be right lower
extremity cellulitis. Completed 7d of vanc/cefepime. Cellulitic
appearance of R leg greatly improved. Transitioned back to
levaquin, then developed high 99 temperature and broadened to
vanc/cefepime again. A day later developed high T99 temperature
and broadened to
posaconazole. The following day (___) developed T of 101, still
no source on blood cultures or CXR. Patient started vomiting and
had hypotension to 90's. Broadened to meropenem. CT
abdomen/pelvis unremarkable. These fevers may represent
infection but more likely represent worsening disease process.
Given goals of care transitioned to oral levaquin on ___ and
she did not have further fevers or worsening in erythema of the
right leg, so she was discharged home.
#Refractory AML
#Transfusion dependence
#Nausea
S/p 10 cycles of decitabine. ANC 650 and blasts notably 37% on
presentation and significantly rising throughout
hospitalization. Had allergic reaction to platelets on ___,
resolved with 50mg IV hydrocortisone, 50mg IV Benadryl and 20mg
IV famotidine. No reaction to platelets on ___. Blasts >70% on
___. Worsening pain in her left hip thought to be related to
disease due to findings on ___ MRI of the pelvis. This was well
controlled with tramadol. She also developed nausea that was not
responsive to ondansetron. A CT abdomen/pelvis was negative. She
was given three days of 4mg IV dexamethasone with resolution of
her nausea. She also had one episode of chest pain and
tachycardia that resolved spontaneously, and a CTA was negative
for PE.
#Patient Values and Goals of Current Hospitalization
On ___ her primary oncologist, Dr. ___ a goals of
care conversation. Notably in this discussion: "She clearly
stated priorities for her goals of care from this point onward,
including:
1) Avoidance of pain.
2) The desire to pass away peacefully.
3) Not to have advanced interventions with "tubes and lines."
I asked her to clarify the latter point, and she stated that she
would not want a breathing tube or chest compressions.
Accordingly, her Code Status has been changed to DNR/DNI."
The patient's daughter confirmed DNR/DNI status. A second family
meeting was held after the patient's son flew in from ___ in
which a plan was devised to transition to only oral medication
and discharge home as long as the patient could remain
comfortable. If she could not do well at home, she will return
to the hospital and at that point we will re-address which
interventions are within the patient's goals of care. The family
clearly stated the patient is not interested in an ___
___ facility or in home hospice.
#Acute Anemia
Hemoglobin 7.2 to 4.6 in about 36 hours on presentation. Guaiac
negative in the ED. She received 3u pRBC. Of note, it is likely
the value of 4.6 was an erroneous lab value, because her
hemoglobin responded to the 10's. She did not require another
transfusion after being admitted to the hospital.
======================
CHRONIC MEDICAL ISSUES
======================
#Latent Tuberculosis
Continued isoniazid and pyridoxine.
# Chronic hepatitis B infection
Continued entecavir 0.5mg tablet daily.
===================
TRANSITIONAL ISSUES
===================
Discharge WBC: 34.7
Discharge PLT: 50
Discharge HGB/HCT: 7.9/23.9
[ ] Consider increasing strength of analgesic regimen, as bony
pain related to disease is expected to worsen
- New Meds: Tramadol 50mg PO Q4hr PRN; Lorazepam 0.5mg q8hrs PRN
nausesa; lidocaine 5% patch; levofrloxacin 500mg q24 hrs,
dexamethasone 2mg daily;
- Stopped/Held Meds: Augmentin, Furosemide, Keflex,
Multivitamins, Potassium Chloride,
Changed Med: Hydrea increased to 1g daily
- Code Status: DNR/DNI, do not transfer to an ICU, confirmed
- Contact Information: ___ (daughter) primary contact
person: cp# ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
Fall.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ h/o osteoporosis and paroxysmal atrial flutter s/p
unwitnessed fall yesterday. At baseline, pt uses a walker for
ambulation. She was alone in her living room yesterday at 6pm
yesterday when she stood up to go to the bathroom and
immediately fell to the floor. She is unsure of LOC. She used
her alert button to call the ambulance. She had had her daily
alcohol intake of 6 cans of beer. She denies symptoms of
lightheadedness, diaphoresis, or palpitations prior to the fall.
She currently has no pain. Pt reports this episode is similar to
one in ___.
In ED, the patient had very inconsistent history and changes
minute to minute what she thinks happened to her. The ED
believed that she was found down by EMS, but unclear how long
she was down. The patient was not felt to be overly intoxicated
on alcohol, but was unable to be consistent with her story on
how many drinks she drank today.
In the ED, initial vitals: 96.9 94 117/65 16 96%
No evidence of trauma on exam in ED. Neurological exam is
normal. C-spine cleared. She was initially observed overnight,
but this AM was felt to be withdrawing from EtOH and in need for
___ and likely rehab. She got a total of 20mg po Valium in the
ED. She has been unable to ambulate in the ED. The ED reports
urinary incontinence (baseline per pt) and multiple stools.
Vitals prior to transfer from ED to floor: 98.3 120 ___
94%RA
Past Medical History:
Osteoporosis
Back pain
Foot and Hip fx
GI bleed with hematemasis
Social History:
___
Family History:
Two daughters in ___ who are generally healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.9F, BP 102/68, HR 115, R 18, O2-sat 95%RA
GENERAL - NAD, comfortable, cachectic
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, tachycardic, regular rate, nl S1-S2,
no MRG
LUNGS - CTAB, expiratory wheezes, no crackles, good air
movement, resp unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - No asterixis, WWP, 1+ peripheral pulses (radials,
DPs)
SKIN - Small ecchymosies left elbow and shoulder
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs absent
in lower extremities b/l
GAIT: unsteady, pt unable to ambulate w/o b/l upper extremity
support
DISCHARGE PHYSICAL EXAM: same as above
Pertinent Results:
___ 04:05PM CALCIUM-8.2* PHOSPHATE-3.1 MAGNESIUM-1.3*
___ 04:05PM CK-MB-3 cTropnT-<0.01
___ 04:05PM CK(CPK)-78
___ 10:10PM GLUCOSE-96 UREA N-2* CREAT-0.4 SODIUM-127*
POTASSIUM-4.2 CHLORIDE-90* TOTAL CO2-26 ANION GAP-15
___ 10:10PM ___
___ 10:10PM WBC-12.2*# RBC-4.76 HGB-14.8 HCT-43.7 MCV-92
MCH-31.1 MCHC-33.9 RDW-12.4
___ 10:10PM NEUTS-85.3* LYMPHS-10.3* MONOS-3.7 EOS-0.2
BASOS-0.5
___ 10:10PM ___ PTT-30.1 ___
___ 07:00AM BLOOD WBC-7.4 RBC-4.10* Hgb-12.7 Hct-37.2
MCV-91 MCH-30.9 MCHC-34.1 RDW-12.7 Plt ___
___ 07:00AM BLOOD Glucose-99 UreaN-5* Creat-0.4 Na-132*
K-3.4 Cl-94* HCO3-29 AnGap-12
___ 08:07AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.5*
___ CXR: FINDINGS: In comparison to prior radiograph and CT,
there is no relevant change. The lungs are clear but
hyperinflated. Cardiomediastinal silhouette and hilar contours
are unremarkable. Multiple wedge-shaped compression deformities
of the thoracic spine are unchanged.
IMPRESSION: Hyperinflation without evidence of pneumonia.
CT Chest: Severe centrilobular emphysema and chronic central
compression
fractures of mid thoracic vertebral bodies. Otherwise,
unremarkable chest CT.
CT C-spine: 1. No evidence of fracture or malalignment.
2. Pocket of gas tracking along the inferior portion of the
right jugular
vein is likely consequence of venous accses.
3. Centrilobular emphysema and subtle opacity on the right
upper lobe(imnage
#58, series # 3).
CT head: No evidence of acute intracranial process. Chronic
maxillar
sinusitis.
Medications on Admission:
1. Alendronate Sodium 70 mg PO QSUN
2. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Alendronate Sodium 70 mg PO QSUN
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Doses
4. Calcium Carbonate 500 mg PO BID
5. Vitamin D 800 UNIT PO DAILY
6. Nicotine Patch 14 mg TD DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypovolemia
Urinary tract infection
Alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with appearance of pneumomediastinum in
cervical spine CT. Evaluate.
COMPARISON: None available.
TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal
notch to the upper abdomen after the administration of IV contrast. Coronal,
sagittal, and axial MIP reformats were generated.
FINDINGS: There is severe bilateral centrilobular emphysema, with an
apico-basal gradient. A large emphysematous bulla is seen in the right apex.
Otherwise, there are no focal opacities. Incidentally noted azygos fissure.
Assessment of the previously seen pocket of air tracking along the right
jugular vein is impossible due to extensive beam hardening artifact from
contrast bolus. No evidence of gas in the soft tissues elsewhere in the
thorax.
The thyroid is unremarkable and there is no supraclavicular lymph node
enlargement. The airways are patent to the subsegmental level. There is no
central or axillary lymphadenopathy. The heart, pericardium, and great
vessels are within normal limits. No hiatal hernia or any other esophageal
abnormality is present.
OSSEOUS STRUCTURES: No focal osseous lesion concerning for malignancy. Loss
of height of the central portion of the vertebral bodies of multiple thoracic
vertebrae are consistent with central compression fractures.
Although this study is not tailored for the assessment of subdiaphragmatic
structures, the visualized liver, spleen, and pancreas are unremarkable.
IMPRESSION: Severe centrilobular emphysema and chronic central compression
fractures of mid thoracic vertebral bodies. Otherwise, unremarkable chest CT.
Radiology Report
HISTORY: ___ woman with fever and increased sputum production,
question pneumonia.
COMPARISON: ___ CT.
TECHNIQUE: PA and lateral views of the chest.
FINDINGS: In comparison to prior radiograph and CT, there is no relevant
change. The lungs are clear but hyperinflated. Cardiomediastinal silhouette
and hilar contours are unremarkable. Multiple wedge-shaped compression
deformities of the thoracic spine are unchanged.
IMPRESSION: Hyperinflation without evidence of pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL +ETOH
Diagnosed with INTERSTITIAL EMPHYSEMA
temperature: 96.9
heartrate: 94.0
resprate: 16.0
o2sat: 96.0
sbp: 117.0
dbp: 65.0
level of pain: 8
level of acuity: 3.0 | ___ h/o osteoporosis, possible paroxysmal atrial flutter, and
alcohol abuse s/p unwitnessed fall and found to have UTI and
orthostatic hypotension.
#Syncope work-up: The patient had an unwitnessed fall at her
home with possible loss of consciousness and was worked up for
cardiac causes of syncope. She was on telemetry for 24 hours
that showed tachycardia with no rhythm abnormalities. EKG showed
sinus tachycardia without rhythm abnormalities or ischemic
changes. Cardiac troponins were negative. B12 pending at time of
discharge. No evidence of seizure.
#UTI: On HOD1, the patient's U/A came back positive for
infection, and she was empirically put on ciprofloxacin 500mg
BID. Urine cultures showed pan-sensitive Klebsiella pneumoniae.
Her WBC count was 12.2 on admission and downtrended to 7.4 on
the day of discharge. She received 6 days of ciprofloxacin 500mg
BID in the hospital and will complete her 7 day course on
___ ___.
#Orthostatic hypotension and tachycardia: On transfer to the
floor from the ED, her vitals were notable for tachycardia to
the 120s at rest. Orthostatic vital signs were notable for
systolic blood pressure drop of 20 going to from supine to
standing, and an increase in heart rate >20 bpm. Her tachycardia
responded to IV fluids, eventually getting to the ___ at rest
with tachycardia to the 110s-120s with ambulation. In addition
to the volume depletion, there is likely a degree of physical
deconditioning causing her tachycardia with ambulation. The
physical therapists worked with her extensively and strongly
recommended that she go for a course at a rehab facility prior
to being discharged home.
#Alcohol abuse: The patient reported that she drinks 6 cans of
beer per day. We consulted the social worker. The patient
indicated that she is ready to stop drinking. There was a family
meeting with the patient, her daughters, the social worker, the
care coordinator, the physical therapist, and the medicine team.
The patient's alcohol abuse was discussed. The patient indicated
again that she is ready to stop drinking and that there is a
certain priest that she would like to help her with this. The
daughter knows the priest and was going to arrange to have him
visit with the patient.
#Cachexia: The patient reports poor nutritional intake and is
very thin. Her poor mobility and alcohol abuse have contributed
to her poor nutritional status. We consulted the nutrition team
who recommended that she supplement her diet with ___
nutritional supplements per day, such as Scandi Shakes or Magic
Cup.
#Physical deconditioning: The patient has very poor mobility and
balance. She was evaluated by the physical therapists who
strongly recommended that she go to an ___ rehab prior to
being discharged home.
#Emphysema: The patient underwent CT scan of the chest while
being initially worked up in the ED. It showed severe apical
emphysema. The patient does not carry a history of COPD, but she
has had an intermittent, productive cough during this
hospitalization. She has also had inspiratory wheezes and
expiratory rhonchi on exam. She has had no shortness of breath
or episodes of oxygen desaturation during this hospitalization.
She was not started on a longterm COPD regimen. She should
follow-up with her PCP for pulmonary function testing and
possible emphysema management as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / quinine
Attending: ___.
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F with MDS on ___ (C3D1 on ___ here w
hypotension, recurrent falls, and anemia.
She is currently on cycle 3 azacitidine, first dose was ___.
Cycle ___, Cycle 2 ___. On her way to the
oncologist office ___ morning she fell approximately 3 times,
witnessed by her daughter. No ___ at that time. Patient
felt that legs gave out from underneath her as well as had
dizziness/lightheadedness. At oncologist office, she was
hypotensive in the ___. Oncologist gave 1L of fluids and sent
her to the ED. No symptoms prior to this. No recent sick
contacts
or travel. Denying any fevers, chills, chest pain, or shortness
of breath. Earlier this week patient endorses diarrhea.
Also of note, she had a recent negative cardiac cath at ___
___. She also has a history of C. diff colitis.
Cr on ___ was 1.3. Baseline Hgb is 9.
In the ED,
- Initial Vitals:
T97.4, HR83, BP 99/74, RR17, 94% RA
- Exam: Elderly female resting comfortably in no acute
distress,
___ systolic murmur radiating to the carotids
- Labs:
WBC 2.4, absolute neutrophile count of 0.61. INR 1.3, Cr 2.5,
BUN
152, HCO3- of 20, CP of 543, lactate 1.2
- Imaging:
CXR: 1. No acute cardiopulmonary abnormality.
2. Probable emphysema.
CT Head w/o contrast: Limited, no acute findings.
- Consults:
- Interventions:
3L LR, doxycycline, vancomycin, cefepime, diphenhydramine,
norepinephrine gtt
Past Medical History:
Hypercholesterolemia
RBBB (right bundle branch block with left anterior fascicular
block)
Essential hypertension
Angina pectoris syndrome
Angina pectoris
Bifascicular block
Aortic valve stenosis
Deep venous thrombosis
DM (diabetes mellitus), type 2 with neurological complications
Obesity
Cataract, nuclear sclerotic senile
Pseudoexfoliation syndrome
Glaucoma suspect of both eyes
Diverticulosis
Adenomatous colon polyp
UTI (urinary tract infection)
E. coli UTI
CKD (chronic kidney disease) stage 3, GFR ___ ml/min
Meningioma
Breast fibroadenoma
Neutropenia
Myelodysplastic syndrome
Osteoarthritis
De Quervain's tenosynovitis, left
Osteoarthritis
Neurogenic claudication
Carpal tunnel syndrome, bilateral
S/P carpal tunnel release, right, ___
Carpal tunnel syndrome
Pulmonary nodules/lesions, multiple
Incidental lung nodule, > 3mm and < 8mm
Sleep apnea
Insomnia
Social History:
___
Family History:
family history includes Alzheimer's in her mother; Cancer in her
father; heart disorder in her brother; ___ in her brother.
father had prostate cancer; son died of colon cancer in his ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: BP 93/60 (66 MAP), HR 98, 18RR 96% O2 sat
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. EOMI. Sclera anicteric and without injection.
NECK: No JVD
CARDIAC: Regular rhythm, normal rate. LUNGS: Clear to
auscultation bilaterally. No wheezes, rhonchi or rales. No
increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
DISCHARGE PHYSICAL EXAM
========================
VS: 97.8 PO 151/66 HR84 RR18 100%RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. EOMI. Sclera anicteric and without injection.
NECK: No JVD
CARDIAC: Regular rhythm, normal rate.
LUNGS: Clear toauscultation bilaterally. No wheezes, rhonchi or
rales. No
increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender. No
organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. brisk cap refill. No rash.
Pertinent Results:
ADMISSION LABS:
___ 05:00PM WBC-2.5* RBC-2.29* HGB-6.8* HCT-22.9*
MCV-100* MCH-29.7 MCHC-29.7* RDW-17.1* RDWSD-60.5*
___ 05:00PM NEUTS-24.3* LYMPHS-64.5* MONOS-5.2 EOS-1.6
BASOS-0.0 IM ___ AbsNeut-0.61* AbsLymp-1.62 AbsMono-0.13*
AbsEos-0.04 AbsBaso-0.00*
___ 05:00PM ___ PTT-28.9 ___
___ 05:00PM GLUCOSE-152* UREA N-25* CREAT-2.4* SODIUM-136
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-20* ANION GAP-11
___ 08:01PM ___ PTT-29.2 ___
___ 08:01PM CK(___)-543*
___ 08:03PM LACTATE-1.2
___ 10:29PM STOOL CDIFPCR-NEG
DISCHARGE LABS:
___ 06:01AM BLOOD WBC-1.9* RBC-2.62* Hgb-7.9* Hct-24.8*
MCV-95 MCH-30.2 MCHC-31.9* RDW-18.3* RDWSD-61.7* Plt Ct-UNABLE
TO
___ 06:01AM BLOOD ___ PTT-28.8 ___
___ 06:01AM BLOOD Glucose-120* UreaN-13 Creat-1.3* Na-139
K-4.4 Cl-107 HCO3-22 AnGap-10
___ 06:01AM BLOOD Albumin-3.2* Calcium-8.3* Phos-2.6*
Mg-2.0
___ 04:38AM BLOOD calTIBC-142* ___ Ferritn-858*
TRF-109*
TTE Report ___ ___
Mildly dilated left atrium. Normal right atrial size. Normal
inter-atrial septum. There is mild symmetric left ventricular
hypertrophy. Normal left ventricular size and systolic function
with estimated ejection fraction 60-65%. Transmitral and tissue
Doppler indices are indeterminate to assess diastolic function.
Normal right ventricular size and systolic function.
The aortic root is normal in size, the ascending aorta is normal
at 3.2 cm. There is no evidence of coarctation of the aortic
arch. Mildly thickened mitral valve with moderate mitral annular
calcification. There is mild calcific mitral stenosis with a
mean
gradient of 5 mm Hg. There is mild to moderate mitral
regurgitation. No mitral valve prolapse. The aortic valve is
trileaflet with mild to moderate thickening and calcification.
There is mild aortic stenosis with a peak pressure gradient 39
mmHg, mean pressure gradient 22 mmHg. Moderate aortic
regurgitation. There is mild pulmonic regurgitation. Mild
tricuspid regurgitation. Estimated pulmonary artery pressure is
normal at 19 mmHg plus CVP. There is a trivial/physiologic
pericardial effusion.
Cardiac Catheterization ___ ___
DOMINANCE:
Dominance: Right
LAD:
Angiographically Minimal Disease in LAD
CIRCUMFLEX:
Angiographically Minimal Disease in LCX
RCA:
Angiographically Minimal Disease in RCA
AIR REST
ECG 10:17:43
AO 144/48 (83) SA 10:36:56
LV 146/4, 28 10:40:10
LV 140/4, 27 10:40:17
LVp 140/4, 27 10:40:21
AOp 135/46 (80) 10:40:29
CONCLUSIONS:
Angiographically Minimal Coronary Disease
Severely Elevated Filling Pressures
Aortic Valve Stenosis - minimal
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine Viscous 2% 5 mL PO TID:PRN effected area
2. Mupirocin Ointment 2% 1 Appl TP BID
3. Omeprazole 40 mg PO BID
4. Losartan Potassium 25 mg PO DAILY
5. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
6. Gabapentin 600 mg PO BID
7. Cyanocobalamin 5000 mcg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Aspirin 81 mg PO DAILY
10. Fluticasone Propionate 110mcg 2 PUFF IH DAILY:PRN congestion
11. Metoprolol Tartrate 25 mg PO BID
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. Vitamin D 5000 UNIT PO DAILY
14. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Cyanocobalamin 5000 mcg PO DAILY
2. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
3. Fluticasone Propionate 110mcg 2 PUFF IH DAILY:PRN congestion
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 600 mg PO BID
6. Lidocaine Viscous 2% 5 mL PO TID:PRN effected area
7. Losartan Potassium 25 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. Mupirocin Ointment 2% 1 Appl TP BID
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Omeprazole 40 mg PO BID
12. Simvastatin 20 mg PO QPM
13. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hypovolemic shock
Nausea/Vomiting
Diarrhea
Myelodysplastic syndrome
___
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 MDS, pancytopenia, immunosupresion, falls, evaluate for
PNA // evalaute for PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: No relevant prior studies available for comparison.
FINDINGS:
The heart is top-normal in size. The mediastinal and hilar contours are
unremarkable. The lungs are slightly hyperinflated, and the lung markings are
mildly coarsened. Mild right basilar atelectasis. Otherwise, no focal
consolidations. No pleural effusions or pneumothorax. Surgical clips project
over the right upper abdomen.
IMPRESSION:
1. No acute cardiopulmonary abnormality.
2. Probable emphysema.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall, thrombocytopenia // eval for IC bleeding
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) = 1,204 mGy-cm.
COMPARISON: No relevant prior studies available for comparison.
FINDINGS:
Artifact limits evaluation of the middle cranial fossa and posterior fossa.
Within these confines:
There is no evidence of acute, large territory infarction,
fracture,hemorrhage,edema,or large mass. Prominence of the extra-axial spaces
is likely due to age-related cerebral atrophy. The ventricles appear within
normal limits for age. Periventricular and subcortical white matter
hypodensities are nonspecific, likely sequela of chronic ischemic small vessel
disease.
The patient is status post remote right parietal craniotomy. The visualized
portion of the paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. Aside from right lens replacement and scleral calcifications, the
visualized orbits are unremarkable.
IMPRESSION:
Limited, no acute findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypotension, s/p Fall
Diagnosed with Anemia, unspecified
temperature: 97.4
heartrate: 83.0
resprate: 17.0
o2sat: 94.0
sbp: 99.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ h/o MDS on ___ (C3D1 on
___, moderate aortic regurgitation/mild aortic stenosis, DM2,
HLD, HTN, CKD, recent hosp for C diff colitis and MRSA
vestibulitis admitted to the ICU with hypovolemic shock and
recurrent falls in the setting of several days of diarrhea,
vomiting, and decreased PO intake, improved with fluid
resuscitation and blood transfusion. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Flonase / contact metal agent
Attending: ___
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
___ - Coronary artery bypass grafts x3 (LIMA-LAD,
SVG-PDA, SVG-OM); Endovascular saphenous vein harvest LLE.
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of coronary
artery disease, hepatitis C, hyperlipidemia, hypertension, and
rheumatoid arthritis. She presented to ___ with complaints of
bilateral arm heaviness, shortness of breath, and rest chest
pressure. She rule in for NSTEMI. She was Plavix
loaded, started nitroglycerin and heparin drips and was
transferred to ___
for further evaluation. A cardiac catheterization that revealed
three vessel disease. Cardiac surgery consulted for surgical
revascularization.
Past Medical History:
Coronary Artery Disease
Hepatitis C
Hyperlipidemia
Hypertension
Hypothyroidism
Rheumatoid Arthritis
Social History:
___
Family History:
Father - CABG at ___, and died at ___.
Mother - died at ___ of an aneurysm.
Physical Exam:
HR: 76 BP: 103/68 RR: 18 O2 sat: 95% RA
Height: 60" Weight:87.9 kg
General: comfortable
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur []
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema []
Varicosities: None []
Neuro: Grossly intact []
Pulses:
Femoral Right: p Left: p
AT Right: p Left: p
Radial Right: p Left: p
Carotid Bruit: Right: absent Left:absent
Discharge Physical exam
Tmax:98.4 Tcurrent: 98.4 B/P: 115/71 HR/Rhythm:87/SR
RR: 16
SaO2: 91% RA FSBG: 102-158
Date wt 90.2(kg)
In 920
Out 2350
Physical Examination:
General/Neuro: NAD [x] A/O x3 [x] non-focal [x]
Cardiac: RRR [x] Irregular [] Nl S1 S2 [X]
Lungs: CTA [x] No resp distress [x] Diminished at bases
Abd: NBS [x]Soft [x] ND [x] NT [x]
Extremities: Pulses doppler [] palpable [X] trace ___ edema
bilaterally
Wounds: Sternal: CDI [] no erythema or drainage [x]
Sternum stable [] Prevena [x]
Leg: Right [] Left[X] CDI [] no erythema or drainage [x]
Other:
Pertinent Results:
PERTINENT HOSPITAL RESULTS AND TRENDS:
Troponin-T 0.18 --> 0.51 --> 0.84 --> 0.81--> 0.29
CK 273 --> 615 --> 495
MB 33 --> 89 --> ___
MBI 12.1 --> 14.5 --> 12.1
Leukocytosis 13.4, Mg 1.8
Therapeutic PTT, elevated ___ 12.8, INR 1.2
BLOOD HCG-<5
%HbA1c-5.8 eAG-120
ALT-15 AST-20 LD(LDH)-311* AlkPhos-77 TotBili-0.4
ADMISSION RESULTS:
___ 11:54PM BLOOD WBC-13.4* RBC-4.80 Hgb-13.9 Hct-42.4
MCV-88 MCH-29.0 MCHC-32.8 RDW-13.8 RDWSD-44.7 Plt ___
___ 11:54PM BLOOD Neuts-66.3 ___ Monos-6.6 Eos-0.0*
Baso-0.2 Im ___ AbsNeut-8.89* AbsLymp-3.56 AbsMono-0.88*
AbsEos-0.00* AbsBaso-0.03
___ 11:54PM BLOOD ___ PTT-150* ___
___ 11:54PM BLOOD Glucose-119* UreaN-27* Creat-0.8 Na-140
K-3.8 Cl-103 HCO3-20* AnGap-17*
___ 11:54PM BLOOD CK(CPK)-273*
___ 11:54PM BLOOD Calcium-9.5 Phos-4.1 Mg-1.8
IMAGING AND PROCEDURES:
CATH ___:
LMCA: without signficant disease.
LAD: diffuse mid to 50%. ___ Diagonal is without significant
disease.
___ Diagonal is with 90% origin.
LCX: 90% proximal.
RCA: long diffuse mid up to 90% focal distally. Right PDA is
without significant disease.
Transthoracic Echocardiogram ___:
The left atrial volume index is normal. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Findings are suggestive of a small apical
pseudoaneurysm. No flow is seen entering the pericardial space
or the right ventricle from the psudoaneurysm. Overall left
ventricular systolic function is moderately depressed (LVEF= 39
%) secondary to apical hypokinesis with focal akinesis and a
dyssynchronous mechanical activation sequence (LBBB). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). 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.
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.
Tranesophageal Echocardiogram ___
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is top normal/borderline dilated. There is moderate
to severe regional left ventricular systolic dysfunction with
thinning and akinesis of the ___ and ___ septal walls. The
distal anterior wall and apex are also akinetic. . There is an
apical left ventricular aneurysm.(True vs psuedo-it has a narrow
neck but overall is small. Overall left ventricular systolic
function is moderately depressed (LVEF= 30 %). Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen.
POSTBYPASS
There is slight improvement of LV function. Distal anterior wall
is improved. RV systolic function remains normal. The study is
otherwise unchanged from prebypass
Discharge Labs
___ 05:15AM BLOOD WBC-5.6 RBC-2.90* Hgb-8.6* Hct-26.4*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.6 RDWSD-47.7* Plt ___
___ 09:15AM BLOOD WBC-5.5 RBC-2.75* Hgb-8.1* Hct-24.6*
MCV-90 MCH-29.5 MCHC-32.9 RDW-14.5 RDWSD-46.5* Plt ___
___ 05:00AM BLOOD WBC-3.9*# RBC-2.65* Hgb-7.8* Hct-24.2*
MCV-91 MCH-29.4 MCHC-32.2 RDW-14.6 RDWSD-48.4* Plt ___
___ 05:15AM BLOOD Glucose-141* UreaN-15 Creat-0.8 Na-133
K-3.6 Cl-93* HCO3-27 AnGap-13
___ 09:15AM BLOOD Glucose-133* UreaN-19 Creat-0.8 Na-134
K-4.0 Cl-94* HCO3-24 AnGap-16
___ 05:00AM BLOOD Glucose-121* UreaN-29* Creat-1.1 Na-131*
K-4.3 Cl-92* HCO3-21* AnGap-18*
___ 06:02AM BLOOD Glucose-116* UreaN-25* Creat-1.4* Na-132*
K-4.7 Cl-94* HCO3-22 AnGap-16
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 175 mcg PO DAILY
2. PredniSONE 5 mg PO PRN RA FLARE RA flare
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Hydroxychloroquine Sulfate 400 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Lisinopril 20 mg PO DAILY
7. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0
2. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*100 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Furosemide 40 mg PO DAILY Duration: 7 Days
RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
5. Metoprolol Tartrate 50 mg PO TID
RX *metoprolol tartrate [Lopressor] 50 mg 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*1
6. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp
#*7 Tablet Refills:*0
7. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl [Acid Control (ranitidine)] 150 mg 1
tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0
8. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth Q 6 hours Disp
#*60 Tablet Refills:*0
9. Atorvastatin 40 mg PO QPM
10. Levothyroxine Sodium 175 mcg PO DAILY
11. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until directed by
cardiologist
12. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until directed by cardiologist
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Coronary Artery Disease
Hepatitis C
Hyperlipidemia
Hypertension
Hypothyroidism
Rheumatoid Arthritis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - Prevena in place - see above for instructions
Followup Instructions:
___
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old woman with s/p CABG on the cardiac surgery fast
track. Evaluate for ptx, effusions.
TECHNIQUE: Frontal view of the chest.
COMPARISON: Chest xrays ___.
FINDINGS:
The Swan-Ganz catheter tip is located in the right pulmonary artery.
Sternotomy wires are intact and aligned. The ET tube is located in the right
mainstem bronchus. An enteric tube extends below the level of the diaphragm
and the tip terminates in the stomach.
The heart size is mildly enlarged. Small round densities most prominent in
the right lung most likely correspond to calcified granulomas and are similar
in appearance to the most recent prior study. No pneumothorax or pleural
effusion. No focal consolidations.
IMPRESSION:
1. No pneumothorax or pleural effusion.
2. ET tube located in the right mainstem bronchus.
3. Redemonstrated calcified granulomas most prominent in the right lung.
NOTIFICATION: The findings were discussed with ___ by ___,
M.D. on the telephone on ___ at 4:25 pm, 20 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with s/p CABG, CTs d/c'd// evaluate for
pneumothorax evaluate for pneumothorax
IMPRESSION:
Monitoring and support devices, with the exception of the right internal
jugular vein catheter, have been removed. Lung volumes have substantially
decreased and moderate cardiomegaly is present. Bilateral areas of extensive
atelectasis are visualized. No pulmonary edema. Moderate over distension of
the stomach.
Radiology Report
INDICATION: ___ year old woman s/p CABG// eval for pleural effusions
TECHNIQUE: AP and lateral chest radiographs
COMPARISON: ___
IMPRESSION:
The patient is post median sternotomy. There are small bilateral pleural
effusions and new mild pulmonary edema. No pneumothorax is identified. The
size of the cardiomediastinal silhouette is enlarged but unchanged. The right
internal jugular sheath has been removed.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old woman with 3v disease awaiting CABG.// pre-op Surg:
___ (CABG) CHEST PAIN
IMPRESSION:
Comparison to ___. No relevant change is noted. Several
calcified granulomas in the lung parenchyma. No pneumonia, no pulmonary
edema, no pleural effusions. Normal size of the heart.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction, Dyspnea, unspecified
temperature: 97.3
heartrate: 88.0
resprate: 16.0
o2sat: 98.0
sbp: 138.0
dbp: 88.0
level of pain: 0
level of acuity: 2.0 | Mrs. ___ underwent routine preoperative testing and
evaluation. Plavix was held and allowed to washout. She remained
stable and was taken to the operating room on ___. She
underwent coronary artery bypass grafting x 3(LIMA-LAD, SVG-PDA,
SVG-OM); Endovascular saphenous vein harvest LLE with Dr. ___.
Please see operative note for further surgical details. She
tolerated the procedure well and was transferred to the CVICU in
stable condition for recovery and invasive monitoring.
She weaned from sedation, awoke neurologically intact and was
extubated on POD 1. She was weaned from inotropic and
vasopressor support. Beta blocker was initiated and she was
diuresed toward her preoperative weight. Chest tubes and pacing
wires were discontinued per protocol without incident. Her QtC
was 750 and Plaquenil, Reglan and Zofran was stopped (QtC 500 on
admission.) Rhematologist called and informed that this was
stopped She remained hemodynamically stable and was transferred
to the telemetry floor for further recovery. She was evaluated
by the physical therapy service for assistance with strength and
mobility. She was kept an additional day due to desatting to 85%
with working with Physical therapy. She was given additional
Lasix and the following day, she was oxygen saturations were
91-93% when working with ___. By the time of discharge on POD 5
she was ambulating freely, the wound was healing, and pain was
controlled with oral analgesics. She was discharged home with
___ services in good condition with appropriate follow up
instructions. Prevena dressing to be removed on POD 7 ___
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PSYCHIATRY
Allergies:
Erythromycin Base / Iodine / Iodine-Iodine Containing / Darvon /
Lexapro / Ceclor / Ampicillin / Novocain / Xylocaine / Percodan
/ Effexor / Trazodone / Lamictal / Epinephrine / Zosyn / Fish
Product Derivatives / Ciprofloxacin
Attending: ___.
Chief Complaint:
S/p recent overdose on pills, ongoing hopelessness, and
suicidality
Major Surgical or Invasive Procedure:
ECT
History of Present Illness:
this is a ___ yo women with hx of multiple myeloma,
bipolar disorder, and cognitive impairment who was referred to
the ED by her psychiatry NP for worsening depression, suicidal
ideation wiht plan to overdose. This occurs in the setting of a
recent psychiatric hospitalization at ___ ___ weeks
ago and having taken 2 days of medication at once on ___
with
unclear intent at self injury (confusion about her pills, pills
being mixed up, and worsening depressive symptoms and
hopelessness). Per collateral so far the patient had been doing
very well after her admission in ___, receiving continuation
ECT (last treatment ___. However, ___ weeks ago she reports
increasing depressed and anxious mood, 3 hours sleep/night, poor
appetite, anhedonia, and poor concentration/memory, increasing
hopelessness and suicidality. These symptoms have been triggered
by her husbands declining health (he has had multiple falls),
her
home services having been cut back from 7 days a week to 5 days
a
week, no longer having a ___ dispense her medication, her
Geriatric case manager being let go, her ___ NP (whom she
was emotionally connected to) leaving, feeling more physically
ill with this course of chemotherapy, worsening hip pain,
feeling
overly sedated on higher dose of seroquel (increased at
___,
feeling overwhelemed by multiple medical appointments and long
drive in and out of ___, and stress over her daughter's
pending unemployment.
Past Medical History:
Past Psychiatric History: history of depression and periods of
irritabilty and anxiety since the late ___ at least. ___
hospitalization ___ for suicidal ideation at ___, ___
___ for suicide attempt with ___ for
___, ___ 4 for anxiety ___ and ___ for
paranoid ideation; and ___ for severe depression where she
received ECT, ___ where she received ECT again. Patient is
followed by therapist ___ (p. ___ at
___ Ctr and ___ for psychopharm in
___.
PAST MEDICAL HISTORY:
-IgG lambda MM s/p 6 cycles of velcade/decadron, currently on
revlimid, and treated with Zometa
-COPD
-Fibromyalgia
-Juvenille RA
-HLD
-HTN
-Hepatitis A
-Depression, suicide attempt ___ requiring hospitalization
-hx of L4-L5 laminectomy d/t DJD ___ had brain abscess treated with IV antibiotics
-residual left sided weakness ___ "minor stroke" in setting of
brain abscess
- osteoarthritis
- rheumatoid arthritis
- ___ spinal surgery involving posterior spinal fusion T1-L3,
- application of interbody biomechanical device T6-T9, interbody
fusion T6-T9.
- h/o positive C.diff treated with flagyl
Social History:
___
Family History:
Daughter has bipolar disorder
Father has depression
Husband with ___ disorder
- Patient denies any SAs in family
Physical Exam:
PHYSICAL EXAMINATION:
VS: BP: 133/79 HR: 68 temp:98.6 resp: 16 O2 sat: 98%
height: weight:
MENTAL STATUS EXAM:
--appearance: good grooming with fair eye contact
--behavior/attitude: cooperative, calm; exhibited PMR
--speech: normal rate, tone, volume, talkative
--mood (in patient's words): "scared"
--affect: blunted
--thought content (describe): ruminative and perseverative of
husbands medical problems, her medical problems, appointments
--thought process: linear but perseverative
--perception: without AVH
--___: Denies ___ at this time
--insight: limited
--judgment: limited
COGNITIVE EXAM:
--orientation: alert to person, place, time, situation
--attention/concentration: able to recite DOWB
--memory (ball, chair, purple): immediate intact ___ and remote
intact ___
--calculations: quarters in $2.25 = 10 (incorrect)
--language: grossly intact
--fund of knowledge: able to recall the president on ___
--proverbs: provided accurate interpretations of "look before
leap," = "Be careful before you plunge, that's what I do, I
plunge"
--similarities/analogies: understood analogy of "apples to
oranges"= "fruit"
PE:
General: Well-nourished, in no distress.
HEENT: Normocephalic. PERRL, EOMI. Oropharynx clear.
Neck: Supple, trachea midline.
Back: No significant deformity, no focal tenderness.
Lungs: Clear to auscultation; no crackles or wheezes.
CV: Regular rate and rhythm
Abdomen: Soft, nontender, nondistended; no masses or
organomegaly.
Extremities: No clubbing, cyanosis, or edema. Tenderness to
palpation of left shoulder and left arm
Skin: Warm and dry, no rash or significant lesions.
Neurological:
*Cranial Nerves-
I: Not tested
II: Pupils equally round and reactive to light
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- Normal bulk and tone bilaterally. No abnormal
movements, tremors. Strength full power ___ on right upper and
lower extremities, ___ in left upper and lower extremities
*Sensation- Increased light touch on right upper and lower
extremity compared to left upper and lower extremity
*Coordination- Normal on finger-nose-finger
Gait- walks with walker
Pertinent Results:
___ 03:10PM GLUCOSE-74 UREA N-9 CREAT-0.6 SODIUM-141
POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
___ 03:10PM CALCIUM-9.2 PHOSPHATE-3.0 MAGNESIUM-1.9
___ 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:10PM WBC-3.4* RBC-4.37 HGB-13.8 HCT-41.5 MCV-95
MCH-31.6 MCHC-33.3 RDW-15.1
___ 03:10PM NEUTS-51.9 ___ MONOS-7.5 EOS-6.7*
BASOS-0.8
___ 03:10PM PLT COUNT-215
MRI and MRA of head and neck: IMPRESSION:
1. Innumerable enhancing lesions in the calvarium and skull
base, compatible
with the diagnosis of multiple myeloma.
2. Age-appropriate MRI of the head, specifically without
evidence of acute
infarct or mass.
3. Mild atherosclerotic disease at the level of the bilateral
cervical ICA
bifurcations, but no evidence of significant stenosis involving
the intra- and extra-cranial vasculature.
Head CT: IMPRESSION:
1. No acute intracranial abnormality. If clinical concern for
a stroke
persists, MRI is a more sensitive exam.
2. Stable chronic small vessel ischemic disease and evidence of
a small prior
infarction in the left frontal lobe.
3. Stable innumerable lytic lesions in the calvarium are
compatible with the
patient's known history of multiple myeloma.
EKG: Sinus, QTC WNL: Sinus rhythm at the lower limits of normal
rate. Low limb lead voltage. RSR' pattern in lead V2. Since the
previous tracing of ___ ventricular premature beats are no
longer seen
Medications on Admission:
ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth every eight (8)
hours
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth
each
evening
DILTIAZEM HCL - 120 mg Capsule, Extended Release - 1 (One)
Capsule(s) by mouth once a day
FOLIC ACID - 1 mg Tablet - 1 (One) Tablet(s) by mouth DAILY
(Daily)
LENALIDOMIDE [REVLIMID] - (dispensed by CarePlus) - 10 mg
Capsule - 2 (Two) Capsule(s) by mouth once a day x 21 days
(states she is supposed to take tonight, tomorrow and day after
to finish this cycle)
MIRTAZAPINE - (Prescribed by Other Provider) - 15 mg Tablet -
0.5 (One half) Tablet(s) by mouth at bedtime
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth daily
QUETIAPINE - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 50 mg Tablet - 1 (One) Tablet(s) by mouth q8PM
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet
-
2 Tablet(s) by mouth every four (4) hours as needed for pain
ASCORBIC ACID - (Prescribed by Other Provider; Dose adjustment
-
no new Rx) - 500 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
ASPIRIN - (OTC; Dose adjustment - no new Rx) - 81 mg Tablet,
Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day
B COMPLEX VITAMINS - (Prescribed by Other Provider) - Tablet
-
1 (One) Tablet(s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit Capsule - 1 Capsule(s) by mouth DAILY (Daily)
MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth DAILY
(Daily)
SENNOSIDES [SENNA] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 8.6 mg Tablet - 1 Tablet(s) by mouth
once a day
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO Q4H:PRN
heartburn
3. Ascorbic Acid ___ mg PO DAILY
4. Atorvastatin 20 mg PO HS
5. Diltiazem Extended-Release 120 mg PO DAILY
Pls give prior to ECT. Pls hold for systolic blood pressure
<100.
6. Divalproex (DELayed Release) 500 mg PO HS
Take with food (with crackers or snack); Pleas hold the night
before ECT
7. FoLIC Acid 1 mg PO DAILY
8. Mirtazapine 7.5 mg PO HS
9. Omeprazole 20 mg PO DAILY
10. Quetiapine Fumarate 25 mg PO HS
11. REVLIMID *NF* (lenalidomide) 20 mg Oral at bedtime
Patient takes 21 days out of 28 cycle * Patient Taking Own Meds
*
12. Vitamin D 1000 UNIT PO DAILY
13. Aspirin 325 mg PO DAILY
14. Senna 1 TAB PO DAILY:PRN constipation
15. Milk of Magnesia 30 ml PO Q8H:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
I. Bipolar disorder with mixed episode; Cognitive Disorder NOS
II. Defer
III.Strong family history of Alzheimers Disease; Multiple
Myeloma, dx ___, with bone involvement, s/p multiplespinal
surgical procedures and tx with chemo;Multiple episodes of
delirium with PNA and UTI; hx of sarcoidosis, Rheumatoid
arthritis; COPD; HTN; HLD
IV. Financial stress, illness in husband, limited supports,
decline in physical health
Discharge Condition:
Stable
MSE:
Appearance: thin, older F with short white hair, wearing
pajamas,
lying in bed
Behavior: cooperative, fair eye contact
Psychomotor: no abnormal movements, no PMR/PMA
Speech: spontaneous, fluent, verbose, normal rate, volume, no
dysarthria
Mood: 'okay.'
Affect: stable, mood-congruent
TP: tangential -goes off on many tangents (talks about her
husband, the ___, her discontent with outpt prescriber)
TC: ruminative about d/c planning to ___
Insight: fair
Juddgment: fair
Followup Instructions:
___
Radiology Report
INDICATION: Evaluate for stroke. History of multiple myeloma.
COMPARISONS: CT head, ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
new large vascular territory infarction. In the left frontal white matter,
there is a region of hypodensity, unchanged from prior exam, and likely the
sequelae of a prior small infarction. Periventricular confluent white matter
hypodensities are consistent with chronic small vessel ischemic disease.
These are unchanged from the prior exam. There is preservation of gray-white
matter differentiation. The ventricles and sulci are normal in size and
configuration for the patient's age. The basal cisterns are patent.
Atherosclerotic calcifications are noted within the internal carotid and
vertebral arteries.
No fracture is identified. Innumerable lytic lesions within the skull are not
significantly changed from the prior exam. The largest is in the right
frontal bone and measures 23 mm in diameter. This lesion has an associated
soft tissue component. There is a small amount of aerosolized secretions
within the right sphenoid sinus. The remainder of the visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
1. No acute intracranial abnormality. If clinical concern for a stroke
persists, MRI is a more sensitive exam.
2. Stable chronic small vessel ischemic disease and evidence of a small prior
infarction in the left frontal lobe.
3. Stable innumerable lytic lesions in the calvarium are compatible with the
patient's known history of multiple myeloma.
Radiology Report
INDICATION: ___ woman with left-sided weakness and history of brain
abscess and multiple myeloma. Assess for intracranial abnormality.
COMPARISON: CT head dated ___.
TECHNIQUE: Sagittal T1 and axial T1, T2, gradient echo, diffusion and
time-of-flight were obtained without contrast. Following IV administration of
gadolinium, MRA of the neck as well as sagittal MP-RAGE and axial T1 spin echo
sequences were acquired.
FINDINGS:
MR HEAD: Again seen innumerable enhancing lesions in the calvarium and skull
base, compatible with the diagnosis of multiple myeloma. There is no evidence
of soft tissue extension with mass effect of the brainstem or cerebral
hemispheres.
The cerebral sulci, ventricles and extra-axial CSF-containing spaces have
age-appropriate size and configuration. There is no shift of the midline
structures. The gray-white matter differentiation is well preserved.
Confluent and scattered periventricular and deep white matter FLAIR/T2 signal
abnormality is in keeping with sequela of chronic small vessel ischemic
disease. There is no evidence of acute ischemic infarct, intracranial
hemorrhage, mass effect or space-occupying lesion. The flow voids of the
major and vessels are preserved. The visualized paranasal sinuses and mastoid
air cells are clear.
MRA HEAD: The intracranial internal carotid, vertebrobasilar and anterior,
middle and posterior cerebral arteries are patent with normal flow-related
enhancement and branching pattern. There is no evidence of stenosis,
occlusion, aneurysm or arteriovenous malformation.
MRA OF THE NECK: The origins of the common carotid and vertebral arteries are
patent without significant stenosis. While there is plaque with minimal
narrowing at the level of the bilateral common carotid artery bifurcation,
there is no evidence of significant stenosis in the anterior circulation. The
cervical portions of the vertebral arteries likewise demonstrate normal
flow-related enhancement.
IMPRESSION:
1. Innumerable enhancing lesions in the calvarium and skull base, compatible
with the diagnosis of multiple myeloma.
2. Age-appropriate MRI of the head, specifically without evidence of acute
infarct or mass.
3. Mild atherosclerotic disease at the level of the bilateral cervical ICA
bifurcations, but no evidence of significant stenosis involving the intra- and
extra-cranial vasculature.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SI
Diagnosed with DEPRESSIVE DISORDER, SUICIDAL IDEATION, ATRIAL FIBRILLATION, CHRONIC AIRWAY OBSTRUCTION
temperature: 98.4
heartrate: 74.0
resprate: 18.0
o2sat: 95.0
sbp: 110.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | 1. Legal: ___
2. Medical:
- Multiple myeloma care was coordinated with oncology. Held
pentamidine and revelmid per their recommendations. Dr
___ will f/u with the patient upon discharge from the
hospital. NP, ___ also confirmed with me that the pt
could restart Revlimid but she should not receive her other
chemotherapeutic agent inhouse due to the need for a negative
pressure room for delivery (i.e the pentamidine). They will
administer such at her next oncology f/u visit which is
scheduled.
-cardiac - No acute concerns during her hospitalization. She was
continued on ASA, diltiazem ER 120mg po daily and atorvastatin
as per her home regimine
-Gerd - was continued on omeprazole 40 mg daily
-Worsening left sided weakness - After her second ECT, the
patient struggled with numbness and tingling in her face and
worse weakness in the left side of her body. Neurology was
consulted. Head CT and MRI were obtained which did not show
evidence of stroke. Therefore, her prolonged left weakness with
dysaesthesia are most consistent with a post-ECT ___
phenomenon. This resolved by the evening of the treatment. It
was recommened that the patient be continued on aspirin and
continue to follow up with her cardiologist. If she has any
further episodes of A.Fib further anticoagulation can be
considered in the future. There was no contraindication to
continuing ECT, but hydration and monitoring fall risk are
important.
Left hip pain and weakness: Over the course of her admission it
was noted that the patient's walk was much slower and more
unsteady. She had been evaluated by orhtopedics and it was felt
that this was not due to her multiple myeloma but likely
arthtritis. She will benefit from additional rehab for
strengthening and balance.
3. Psychiatric:
Mixed manic episode: Upon presentation to inpatient unit, the
patient was pressured, anxious, ruminative on her financial and
social stressors at home, especially her husbands health, She
was sleeping poorly. Her concerntration was also poor. She had
suicidal thoughts with urges to overdose on pills. In fact,
prior to her admission, she had taken extra pills several days
before her presentation. Her husband and her son had intervened
and sought help. Her relapse had occured in the context of her
husbands declining health (he has had multiple falls), her
home services having been cut back from 7 days a week to 5 days
a week, no longer having a ___ dispense her medication, her
Geriatric case manager being let go, her ___ NP (whom she
was emotionally connected to) leaving, feeling more physically
ill with this course of chemotherapy, worsening hip pain,
feeling overly sedated on higher dose of seroquel (increased at
___- hospitalized there briefly psychiatrically), feeling
overwhelemed by multiple medical appointments and long
drive in and out of ___, and stress over her daughter's
pending unemployment. In addition, her ECT had been tapered to
once a month. Upon admission, her ECT was restarted. Given the
increased difficulty in tolerability physically(see below)
(although continues to help her significnatly in terms of mood)
it was continued at a 1x a week interval with plans to continue
to taper and work to discontinue.
In order to assist with the reduction of relapse the importance
of a therapeutic mood stabilizer was again discussed. The
patient has struggled with significant side effects from
medications. However, has never had trial of depakote and has an
uncelar trial with lithium. The risks and benefits of depakote
were disussed and it was started at 250mg and increased to 500mg
QHS. She tolerated this dose well with no adverse effects.
A family meeting was held which included social work at ___
___ and her therapist discussing the importance of increased
supporst at home and that the paitent would actually benefit the
most from living in an assisted living or more supported
environment. As the patient thrives with the strucutre and
support in the hospital, without this, the paitent will continue
to have reccurent relapses given her cogntive dysfunction and
low frustration toleraance. All agreed about the fact that the
Mrs ___ can not be managing her own medications and requires a
case manager to assist with coordination of all of their
appointments and affairs at home. In addition it was suggested
that they begin to look at assisted livings or more supproted
environments. I have also discussed the hospital course and
concerns about Mr. ___ health and needs with ___ brother
who will remain a support and again in detail with their
daughter and health care proxy, ___.
.
Over the course of hospitalization patient's mood significantly
improved. By the time of discharge she had expereicned
signifiant improvement in her depression, anxiety, irrtiability,
ruminative qualities, pressured speech, hopelessness and ___. She
was pleasant, calm, coooperative and reasonable in her thinking.
She was concentrating well. She verbalized understanding of her
discharge instructions and follow up. She no longer presented as
an acute risk to herself. She remains at risk of relapse into
mood symptoms and overdose when overwhelemed again. She and her
family clearly understand this and the importance of seeking
help and limiting access to her medications.
4. Milieu: Initially pt remained in bed most of the time. She
was not
able to participate in groups due to high anxiety and
irritablity, however as course of hospitalization progressed,
patient became more visible on the unit and participated in
groups well. She mainained good hygiene, attended to her ADLs,
interacted with peers and staff appropriately. There were no
behavioral concerns during this hospitalization. She is pleasant
and appreciative of care.
5. Risk Assessment:
Ms. ___ represents a low current risk of harming herself. Her
biggest risk factors are her advancing age, race and poor
physical health. She has not been suicidal during this
admission, but due to her mental illness, she is at risk of
becoming so at some point.
Protecting her, are her medication compliance, engagement with
staff and peers as well as her many family supports. She is
engagedin her own future and d/c planning which is a good sign.
Ms. ___ consistently denied any thoughts of self-harming and
although with advancing age and declining health, her risk will
increase, at this time the least restrictive setting for care is
outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p fall from standing, witnessed although unknown LOC as
patient is unable to report. Initially went to ___
where she was found to have a left humerus fracture, left pubic
ramus fracture, and a T11 and L5 fracture of unknown chronicity.
She was transferred here for further management. At ___ they
obtained a CXR, CT Cspine, CT A/P, CT chest, and CT head. While
here, she has been progressively altered, now only AAOx0,
baseline is AAOx1 but communicative. She had a Hct drop from 38
to 32 and became hypotensive to systolics in the ___. Scans were
repeated at this time. Of note, patient is DNR/DNI. Records are
being obtained from her assisted living home and ___ (where she
normally follows).
Past Medical History:
PMH: Alzheimers, chronic rhinitis, amnesia (psychotic episode in
___, unknown GI cancer (s/p Gleevec), CVA (right cerebellar),
vit D deficiency, removal of ovarian cyst, dementia,
osteoporosis, HTN, depression, diferticulosis
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: 98.0 83 136/62 16 99%
GEN: A&Ox0, only vocalizes to pain, not forming any words
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, slightly distended, diffusely tender to palpation, no
masses or bruising
Ext: No ___ edema, ___ warm and well perfused. Tender to palpation
in Left shoulder, no c-cpine tenderness, tender in Left pelvis,
pelvis stable.
Discharge Physical Exam:
VS: 97.6 79 132/50 16 98%RA
Gen: Somnolent but arousable, NAD, AO
CV: RRR no MRG
Pulm: CTAB, scant expiratory rales
Abd: soft, NT, ND
Ext: LUE in sling, extremities warm and well perfused, 2+ pulses
Pertinent Results:
___ 12:45PM BLOOD WBC-5.2 RBC-2.51* Hgb-7.8* Hct-23.3*
MCV-93 MCH-31.1 MCHC-33.5 RDW-12.9 RDWSD-43.8 Plt ___
___ 04:35AM BLOOD Hct-23.0*
___ 04:15AM BLOOD WBC-7.4 RBC-2.65* Hgb-8.2* Hct-24.4*
MCV-92 MCH-30.9 MCHC-33.6 RDW-13.1 RDWSD-43.8 Plt ___
___ 03:33PM BLOOD WBC-8.5 RBC-2.95* Hgb-9.1* Hct-27.4*
MCV-93 MCH-30.8 MCHC-33.2 RDW-13.0 RDWSD-44.3 Plt ___
___ 12:45PM BLOOD Hct-25.7*
___ 04:33AM BLOOD WBC-7.7 RBC-2.89* Hgb-8.9* Hct-27.0*
MCV-93 MCH-30.8 MCHC-33.0 RDW-13.0 RDWSD-44.2 Plt ___
___ 11:52PM BLOOD Hct-28.2*
___ 06:10PM BLOOD WBC-10.0 RBC-3.33* Hgb-10.4* Hct-31.1*
MCV-93 MCH-31.2 MCHC-33.4 RDW-12.7 RDWSD-43.6 Plt ___
___ 11:00AM BLOOD WBC-12.2* RBC-3.57* Hgb-10.9* Hct-32.9*
MCV-92 MCH-30.5 MCHC-33.1 RDW-12.6 RDWSD-42.5 Plt ___
___ 05:00AM BLOOD WBC-16.1* RBC-4.05 Hgb-12.6 Hct-38.5
MCV-95 MCH-31.1 MCHC-32.7 RDW-12.6 RDWSD-43.6 Plt ___
___ 11:00AM BLOOD Neuts-87.4* Lymphs-6.1* Monos-5.8
Eos-0.0* Baso-0.2 Im ___ AbsNeut-10.66* AbsLymp-0.74*
AbsMono-0.71 AbsEos-0.00* AbsBaso-0.03
___ 04:35AM BLOOD Glucose-109* UreaN-18 Creat-0.6 Na-134
K-3.9 Cl-103 HCO3-23 AnGap-12
___ 04:15AM BLOOD Glucose-106* UreaN-15 Creat-0.6 Na-129*
K-4.2 Cl-98 HCO3-25 AnGap-10
___ 04:33AM BLOOD Glucose-102* UreaN-14 Creat-0.6 Na-130*
K-3.8 Cl-
101 HCO3-19* AnGap-14
___ 12:09AM BLOOD Na-128* K-4.1 Cl-97
___ 11:25AM BLOOD Glucose-247* UreaN-17 Creat-0.9 Na-127*
K-4.9 Cl-93* HCO3-17* AnGap-22*
___ 05:00AM BLOOD Glucose-135* UreaN-15 Creat-0.8 Na-128*
K-4.9 Cl-95* HCO3-17* AnGap-21*
___ 11:25AM BLOOD ALT-13 AST-18 AlkPhos-48 TotBili-0.4
___ 04:35AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.9
___ 04:15AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.0
___ 04:33AM BLOOD Calcium-7.2* Phos-2.9 Mg-1.6
___ 11:25AM BLOOD Albumin-3.8 Calcium-8.5 Phos-3.3 Mg-1.8
___ 06:20PM BLOOD Type-ART pO2-180* pCO2-23* pH-7.51*
calTCO2-19* Base XS--2
___ 01:20PM BLOOD Osmolal-267*
___ 06:20PM BLOOD Lactate-1.5
___ 11:02AM BLOOD Lactate-4.8*
___ ECG:
Baseline artifact. Sinus rhythm. Consider inferior wall
myocardial infarction of indeterminate age. RSR' pattern in lead
V1 with early R wave progression, possible posterior
involvement. Mild Q-T interval prolongation. No previous tracing
available for comparison. Clinical correlation is suggested.
___ CXR:
Bibasilar opacities which are likely atelectasis. Comminuted
proximal left humerus fracture, with suggestion of callus
formation suggesting this is not acute but clinical correlation
is suggested.
___ CT ab/pelvis:
1. No acute for intraperitoneal or retroperitoneal hematoma.
2. A large simple cyst in the left kidney measuring up to 10.9
cm.
3. Known left inferior pubic ramus fracture. No associated
hematoma.
4. Chronic degenerative changes of the spine as noted above.
___ CT Head:
No acute intracranial abnormalities.
___ Left Wrist Xray:
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID
2. Docusate Sodium 100 mg PO DAILY
3. Vitamin D 5000 UNIT PO 1X/WEEK (___)
4. rivastigmine tartrate 6 mg oral BID
5. Lactulose 15 mL PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Escitalopram Oxalate 20 mg PO DAILY
8. Memantine 10 mg PO BID
9. Senna 8.6 mg PO BID
10. OLANZapine 5 mg PO BID
Discharge Medications:
1. Escitalopram Oxalate 20 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. rivastigmine tartrate 6 mg oral BID
4. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*30 Tablet Refills:*0
5. Docusate Sodium 100 mg PO QHS
6. Memantine 10 mg PO BID
7. OLANZapine 5 mg PO BID
8. Acetaminophen 650 mg PO BID
9. Vitamin D 5000 UNIT PO 1X/WEEK (___)
10. Senna 8.6 mg PO BID
11. Lactulose 15 mL PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
T11 and L5 fracture
left proximal humerus fracture
acute left pubic rami fracture
A large simple cyst in the left kidney measuring up to 10.9 cm
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with shortness of breath // ?pneumonia
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___.
FINDINGS:
Lung volumes are relatively low with left greater than right bibasilar
opacities which are likely secondary to atelectasis. Superiorly, the lungs
are clear. The cardiomediastinal silhouette is within normal limits. There
is a comminuted proximal left humerus fracture with suggestion of callus
formation.
IMPRESSION:
Bibasilar opacities which are likely atelectasis.
Comminuted proximal left humerus fracture, with suggestion of callus formation
suggesting this is not acute but clinical correlation is suggested.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall. fx/s hypotension. Evaluate for intraparenchymal
hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT from ___ at 01:28.
FINDINGS:
There is no evidence of acute infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
There is hypodensity in the left lentiform nucleus, likely a prominent
perivascular space. Periventricular and subcortical white matter
hypodensities are consistent with chronic small vessel ischemic disease.
Dense atherosclerotic calcifications noted within the intracranial vertebral
arteries and ICAs.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable. There is evidence of bilateral lens
replacements.
IMPRESSION:
No acute intracranial abnormalities.
Radiology Report
EXAMINATION: CT abdomen pelvis without contrast.
INDICATION: ___ with fall. Evaluate for fractures.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
without intravenous contrast administration, which limits evaluation of solid
organs.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 699 mGy-cm.
COMPARISON: CT abdomen pelvis from ___ at 01:40.
FINDINGS:
LOWER CHEST: There is bibasilar atelectasis. Otherwise, visualized lungs are
within normal limits. There is no evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is a 4 mm punctate calcification in the right lobe of the liver, likely
a sequela of prior granulomatous disease. Focal hypodensity in the
subcapsular region of segment 2 is incompletely characterized but likely a
cyst. 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 within the limits of noncontrast
study. 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 a simple fluid density collection in the midpole of the left kidney
measuring 10.2 (AP) x 10.9 (TV) x 9.8 (SI) mm, compatible with a large cyst.
An exophytic hypodensity is seen in the upper pole of the right kidney,
measuring up to 1.7 x 2.4 cm. 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 seen but there are no
inflammatory changes identified.
PELVIS: The urinary bladder contains a Foley and is decompressed. The distal
ureters are unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Patient is status post hysterectomy.
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.
There is a left inferior pubic ramus fracture and there is no hematoma in the
surrounding subcutaneous tissue. There is grade 1, 7 mm anterolisthesis of L4
over L5, likely degenerative changes given associated facet joint disease.
There is chronic appearance of vertebral body height loss at T11 and L5.
There is chronic appearing deformity of the left femoral greater trochanter.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute for intraperitoneal or retroperitoneal hematoma.
2. A large simple cyst in the left kidney measuring up to 10.9 cm.
3. Known left inferior pubic ramus fracture. No associated hematoma.
4. Chronic degenerative changes of the spine as noted above.
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) LEFT
INDICATION: ___ year old woman s/p fall // e/o fracture
COMPARISON: None.
FINDINGS:
There is diffuse osteopenia as well as diffuse soft tissue swelling about the
wrist. There is a well corticated bony fragment adjacent to the ulnar styloid
which could represent either an ossicle or sequela of a remote ununited ulnar
styloid fracture.
Allowing for this, no lucent lucent or sclerotic fracture line or displaced
fracture fragment is detected involving the distal radius or elsewhere about
the wrist. Linear lucency traversing the scaphoid bone is seen only on one
view and is more suggestive of a bony ridge than an acute fracture.
There is moderate degenerative narrowing of the first CMC joint, with minimal
spurring, mild narrowing of the triscaphe and radiocarpal joints.
Faint calcification in the region of the TFC, consistent with trace
chondrocalcinosis.
IMPRESSION:
1. Osteopenia and diffuse soft tissue swelling.
2. No acute fracture is detected. If the patient at ongoing symptoms about
the left wrist, then followup radiographs in ___ days could help to assess
for changes about a radiographically occult fracture.
3. Moderate first CMC and mild triscaphe and radiocarpal joint osteoarthritis.
4. Ulnar styloid ossicle versus old ununited ulnar styloid fracture noted.
5. Suspect chondrocalcinosis.
6. Correlation with any specific site of symptoms could help for further
assessment.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Altered mental status, unspecified
temperature: 98.0
heartrate: 82.0
resprate: 22.0
o2sat: 97.0
sbp: 124.0
dbp: 72.0
level of pain: UTA
level of acuity: 2.0 | Ms. ___ is a ___ yo F who was admitted to the Acute Care
Trauma Surgery service from an outside hospital after a
witnessed fall from standing. Images reveal comminuted proximal
left humerus fracture, a left pubic rami fracture, T11 and L5
fractures and an incidental finding of a left kidney simple
cyst. Orthopedic surgery was consulted for the humerous and
pubic rami fracture and recommended non-weight bearing to left
upper extremity, weight bearing as tolerated to bilateral lower
extremities and no surgical intervention at this time.
Orthopedic spine surgery was consulted for the thoracic and
lumbar fractures and recommended a TLSO brace with ambulation
and no surgical intervention. She had an acute episode of
hypotension and unresponsiveness. A repeat head CT was done and
showed no change from prior, her blood glucose was 182, an EKG
was preformed and showed normal sinus rhythm. She was noted to
have a decrease in hematocrit and her FAST was negative and a
repeat CT scan of the abdomen and pelvis did not show any new
bleed. She was admitted to the floor for hemodynamic monitoring,
neurologic monitoring, serial hematocrits, and hyponatremia.
An incidental finding of a large simple cyst in the left kidney
measuring up to 10.9 cm was noted.
She arrived hemodyanmically stable on the floor and her
remaining hospital course is as follows:
Medicine was consulted for hyponatremia and recommended a 500 mL
bolus normal saline which was done with little effect. She was
then placed on a 1.5 mL fluid restriction. Repeat sodium was
improved.
Geriatrics was consulted to assist with dementia and pain
management.
Neuro: The patient was alert and oriented x1 throughout this
hospitalization which is her baseline. Pain was managed with PO
Tylenol and oxycodone with good effect.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. On HD2, she was
started on a regular diet, which was well tolerated. Patient's
intake and output were closely monitored. She was incontinent of
urine and stool which is her baseline.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding. Her hematocrit initially trended down then
stabilized.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate with TLSO bace as early as possible. Physical
therapy evaluated the patient and recommended discharge to an
acute rehab facility.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
transferring from bed to chair with assist, incontinent of urine
and stool, and pain was well controlled. The patient received
discharge teaching to an acute rehab facility and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. Her son was notified of her hospitalization
and updated on the plan and agrees. Follow up appointments were
scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
anemia; GI bleed
Major Surgical or Invasive Procedure:
Capsule endoscopy
Endoscopy
Colonoscopy
History of Present Illness:
This is a ___ with history of eating disorder, hypothalamic
amenorrhea on HRT and chronic GI bleeding (overt obscure)
presumably ___ small bowel AVMs who presents with GI Bleeding
and lighthteadedness. Patient reports that she has had a ___ year
history of chronic GI bleeding with extensive work-up including
several endoscopies, colonoscopies, VCEs, CTs and MRIs without a
clearly identified source. Most recently she bled in ___ and
underwent a CT and MRI which did not show any cause for
bleeding. She was given 1u pRBCs and iron infusion at that time.
Since then she returned to her normal bowel habits which are 1
brown BM every other day to every day. On ___, while
travelling to the ___ from ___, she began having multiple
"beet" colored stool with increased gas. Additionally she felt
fatigued and had DOE and palpitations on exertion. She felt
faint while standing however denied LOC. Denies GERD, dysphagia,
NSAID use, abdominal pain, fevers, chills, NS, change in weight,
melena, nausea or hematemesis. Given her symptoms she presented
to the ED for evaluation where she was noted to have a Hb of
7.0. She was given 2 units of blood and was admitted for further
management.
On arrival to the floor, patient reports that her symptoms of
dyspnea and LH have since resolved. She reports that she
admittedly would like to "go home" as she has a "plan with [her]
home gastroenterologist." Moreover she does not want further
testing including endoscopy here while on vacation. She states
that she has several periods where she does not have bleeding
however her last bleed was in ___. SHe has received a total
of 10 units in her lifetime. She has not noticed a change in
bleeding episodes since starting HRT.
ROS: A 10 point ROS was reviewed and otherwise negative.
Past Medical History:
small bowel AVMs resulting in chronic anemia requiring multiple
transfusions
h/o Eating disorder
Hypothalamic Amen
Social History:
___
Family History:
NO family history of bleeding, CAD or DM
Physical Exam:
VS: 98.4 113/69 61 18 100% RA
Gen: pale appearing, NAD
HEENT: EOMI PERRL, sclerae anicteric
Neck: supple
CV: nls1s2 faint flow murmur noted
Pulm: CTAB
Abd: soft NT ND +BS
Ext: wwp no edema
Neuro: grossly intact
Discharge exam:
VSS, orthostatics negative
Unchanged exam
Pertinent Results:
___ 01:10PM BLOOD WBC-4.1 RBC-2.18* Hgb-7.0* Hct-20.4*
MCV-94 MCH-32.1* MCHC-34.3 RDW-13.3 RDWSD-45.8 Plt ___
___ 01:10PM BLOOD Neuts-61.7 ___ Monos-8.9 Eos-0.7*
Baso-1.4* Im ___ AbsNeut-2.55 AbsLymp-1.11* AbsMono-0.37
AbsEos-0.03* AbsBaso-0.06
___ 01:10PM BLOOD Plt ___
___ 01:10PM BLOOD Glucose-74 UreaN-19 Creat-0.5 Na-130*
K-3.5 Cl-94* HCO3-30 AnGap-10
___ 01:10PM BLOOD ALT-26 AST-37 AlkPhos-40 TotBili-0.1
___ 01:10PM BLOOD Albumin-4.4
___ 01:12PM BLOOD Hgb-7.4* calcHCT-22
Discharge labs:
___ 03:30PM BLOOD Hct-28.2*
___ 08:09AM BLOOD WBC-5.1# RBC-3.50* Hgb-10.9* Hct-32.5*
MCV-93 MCH-31.1 MCHC-33.5 RDW-15.0 RDWSD-50.3* Plt ___
___ 12:00AM BLOOD Hgb-10.5* Hct-30.8*
___ 05:05PM BLOOD Hgb-8.8* Hct-25.4*
___ 07:40AM BLOOD WBC-3.2* RBC-3.28* Hgb-10.1* Hct-30.2*
MCV-92 MCH-30.8 MCHC-33.4 RDW-15.2 RDWSD-50.4* Plt ___
___ 08:09AM BLOOD Glucose-68* UreaN-17 Creat-0.5 Na-137
K-3.8 Cl-101 HCO3-24 AnGap-16
Studies:
___ Colonoscopy:
No evidence of diverticulosis.
Old blood was seen throughout the colon and into the distal
terminal ileum, though no source of bleeding was identified.
Otherwise normal colonoscopy to cecum and terminal ileum
___ Push Enteroscopy:
Erythema in the stomach compatible with gastritis
Otherwise normal EGD to proximal jejunum
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO TID
2. Calcium Carbonate 1500 mg PO DAILY
3. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Calcium Carbonate 1500 mg PO DAILY
2. Ferrous Sulfate 325 mg PO TID
3. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal hemorrhage
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old woman with significant ongoing GI bleeding and acute
blood loss anemia, with no source identified on colonoscopy and push
enteroscopy. Old blood seen on colonoscopy. // assess for AVMs, vascular
malformations that could possibly explain source of bleeding
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.1 s, 56.1 cm; CTDIvol = 1.9 mGy (Body) DLP = 103.2
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
3) Stationary Acquisition 9.6 s, 0.2 cm; CTDIvol = 128.4 mGy (Body) DLP =
25.7 mGy-cm.
4) Spiral Acquisition 7.5 s, 48.7 cm; CTDIvol = 5.3 mGy (Body) DLP = 255.1
mGy-cm.
5) Spiral Acquisition 7.5 s, 48.7 cm; CTDIvol = 5.3 mGy (Body) DLP = 255.1
mGy-cm.
Total DLP (Body) = 641 mGy-cm.
COMPARISON: None.
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is no calcium burden in the
abdominal aorta or great abdominal arteries. There is conventional hepatic
arterial anatomy. There is no evidence of active arterial extravasation or
noted vascular malformation.
LOWER CHEST: Minimal atelectasis is noted in the left lung base. There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Two sub cm hypodensities are too small to further characterize
(series 10, image 17 and 19). There is an 11 mm arterially enhancing lesion
within the right hepatic lobe which is not present on the portal venous phase
(series 6, image 29) and might reflect an FNH. The liver otherwise
demonstrates homogenous attenuation throughout. 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, focal renal lesions, or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Colon and rectum are within normal limits.
Appendix is not visualized. There is no evidence of mesenteric
lymphadenopathy. An endoscopy capsule is probably located in the distal
descending colon, however localization is limited secondary to surrounding
streak artifact from the camera.
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: Reproductive organs are within normal limits.
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. Unremarkable CTA examination with no evidence of active arterial
extravasation or noted vascular malformations.
2. Endoscopy capsule probably located in the distal descending colon,
evaluation limited however due to surrounding streak artifact from the camera.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the ___ ___ at 5:17 ___, 20 minutes after discovery of
the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with Angiodysplasia of colon with hemorrhage
temperature: 98.4
heartrate: 80.0
resprate: 14.0
o2sat: nan
sbp: 97.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | ___ y/o woman with hx bowel AVMs with multiple episodes of GI
bleeding requiring transfusions over the last year, who
currently lives in ___ and followed by GI there, who is
in ___ on vacation who has had increasing melena and BRBPR
since ___.
# Acute Blood Loss Anemia: normocytic though may be from
transfusions and iron supplementation. Per patient has a history
of bowel AVMs however have not yet clearly identified the cause.
Other considerations include: dieulafoys, ulcerations, polyps,
masses, arterioenteric fistulas. Per patient she has had several
endoscopies/colonoscopies/enteroscopies in the past and is
interested in pursuing further work-up back in ___. She
required 4U PRBCs to stabilize blood counts while she continued
to have active bleeding. She underwent a capsule endoscopy which
was PENDING upon discharge. The capsule was noted to be
PROBABLY in the colon prior to discharge, but she was instructed
to undergo a KUB either here or in ___ in ___ days to
ensure passage of the capsule. She also had an EGD/colonoscopy
which showed old blood in the colon, no active bleeding. A CTA
of the abdomen demonstrated no obvious AVMs, vascular
malformations, active bleeding. It showed, as noted above, the
capsule was PROBABLY in the colon, but not definite. Per her
request, she was discharged home to followup with her physicians
in ___ and instructed to undergo a KUB in ___ days. She
was also advised not to travel back home if any symptoms of
bleeding.
# Hyponatremia: presumed hypovolemic, improved with IVF
# Osteoporosis: continued vitamin D and calcium |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Dilaudid / erythromycin base
Attending: ___
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
___ - T7-T9 laminectomy, T6-T10 fusion
History of Present Illness:
___ with w/ recently diagnosed hepatocelluar carcinoma, who is
admitted from the ___ with progressive back pain found to have
concern for T8 metastatic disease.
Pt reports progresive back pain for the last two months, which
has become unbearable for the last few days. The pain is located
in his mid-back and radiates up to his neck up to ___ with
pain. He denies recent trauma and notes associated right rib
cage pain. He has been taking oxycodone at home without relief.
Because of his symptoms, he presented to ___, where CT
of the abdomen revealed a lesion at T7, T8 and T9 with canal
impingement. OSH labs were notable for ___ at 2am): WBC 6.1,
12.9/39.7, plts 250, Na 143, K 3.9, Cl 102, CO2 28, ___, gluc
117, LFTs WNL (all labs in chart). Pt was sent to ___ for MRI
and further management.
In the ___, initial VS were pain 10, T 98.4, HR 58, BP 109/66, RR
16, O2 97%RA. MRI of C/T spine showed multilevel cervical spine
spondylosis with disc protrusions and cord compression at C3-C4,
C4-C5, and C5-C6. Thoracic spine was notable for possible T8
metastatic disease with breakthrough of the posterior cortex of
T8 with resultant cord compression and possible high cord
signal. Neurosurgery was consulted who deferred surgical
intervention. Patient recieved IV morphine x3, 6mg IV
dexamethasone, 5mg diazepam, and 1000mg tylenol. Patient was
admitted to ___ for further management.
On arrival to the floor, patient reports persistent ___ back
pain. He reports weakness in his right leg which he attributes
to pain and right hip replacement in ___. He has
chronic consitpation and baseline difficulty urinating due to
BPH. He denies recent fevers or chills. No new headache or
visual complaints. He has some mild SOB due to right rib cage
pain. No N/V/D. No lower extremity edema or new rashes.
Remainder of ROS is unremarkable.
Past Medical History:
PAST ONCOLOGIC HISTORY
-- ___: Presented to the hospital with worsening hip pain
and had a right sided hip replacement. He did not have any
abdominal pain at that time, but his hip pain continued to get
worse despite the surgery. and thus he presented to the ER on
-- ___: Presented to the ___ after falling down
at home. He presented to ___ and at
that time workup to evaluate his hip pain involved imaging
studies that demonstrated an incidental finding of a liver mass
that was concerning for cancer. The patient did not have any
evidence of cirrhosis on imaging and his alpha-fetoprotein level
per MD note was negative per hospital records. The patient
reports that a CT scan done in ___ for a different reason
had
demonstrated a 2.8 x 2.1 lesion in the right lobe of the liver
that is presumed to be the same liver lesion that is now evident
on imaging- but nothing was done about that lesion. Per the
patient, he was told recently that may have been a lesion on the
liver noted on some imaging test ___ years ago, but he was
never informed of that at that time. He was tested for hepatitis
B and was negative. The patient
underwent a liver biopsy on
-- ___: Liver biopsy demonstrated hepatocellular
carcinoma, well differentiated.
--___: Initial clinic visit at ___
PAST MEDICAL HISTORY:
1. Severe anxiety.
2. Depression.
3. Osteoarthritis.
4. Hyperlipidemia.
5. Gout.
6. Abdominal surgery.
7. Hernia repair, inguinal.
8. Laparoscopic repair of hernia.
9. Degenerative disc disease.
10. Diabetes.
11. The patient reports a small MI in his ___ and has also had
prior history of mild heart attacks.
Social History:
___
Family History:
The patient has an older brother who passed away secondary to
liver cancer, he was a heavy drinker. He also had older brother
who died recently in ___ from unknown etiology. His father
was a heavy drinker and alcoholic. Mother passed away secondary
to stroke. The patient also has two daughters, one daughter who
lives in ___ and one daughter who lives in ___
and is suffering from heroin addiction. His family is not
involved in his care.
Physical Exam:
ADMISSION:
VS: BP 100/60 T 98.4 HR 69, RR 18, O2 99%RA
GENERAL: Chronically ill appearing man lying on his left side.
HEENT: NC/AT, EOMI, PERRL, OP clear, JVD not elevated
CARDIAC: RRR, nl S1 and S2, ___ SEM
LUNG: Nonlabored on RA; CTAB no w/r/rh
ABD: +BS, soft, NT/ND, no r/g, no stigmata of chronic liver
disease
EXT: No lower extermity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact. Equal and symetric 4+/5 strength in his
upper extremities, strength limited moderately by pain. ___
strength in right toe extension, flexion, and knee flexion. Also
moderately limited by pain. Full strength LLE. Mute ankle jerk
reflexes bilaterally. FTN intact b/l.
SKIN: Warm and dry
LABS: See attached
DISCHARGE:
AAO x 3
Delt Bi Tri Grip IP Q Ham AT ___ ___
R 4- 5 4 5 ___ 2 4 4
L 4- 5 4+ 5 4+ 5 4 5 5 5
*Bends knee on L when asked to lift leg consistently.
Incision closed with staples. 1 drain stitch, c/d/i
Pertinent Results:
ADMISSION:
___ 10:00PM BLOOD WBC-5.3 RBC-4.01* Hgb-12.5* Hct-36.3*
MCV-91 MCH-31.0 MCHC-34.3 RDW-12.9 Plt ___
___ 10:00PM BLOOD ___ PTT-33.6 ___
___ 10:00PM BLOOD Plt ___
___ 10:00PM BLOOD Glucose-187* UreaN-24* Creat-0.8 Na-140
K-3.9 Cl-104 HCO3-27 AnGap-13
DISCHARGE:
MICRO:
___ 10:25PM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:25PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:25PM URINE RBC-1 WBC-1 Bacteri-MOD Yeast-NONE Epi-<1
___ 10:25PM URINE Mucous-OCC
___ 07:02AM URINE Hours-RANDOM TotProt-6
IMAGING:
___ CT HEAD w/ CONTRAST IMPRESSION:
1. No acute intracranial abnormality.
2. Please note that MRI of the brain is more sensitive for the
evaluation of intracranial metastatic disease or acute infarct.
___ MR ___ spine IMPRESSION:
1. Large osseous metastasis of the T8 vertebral body with new
pathological fracture with epidural extension causing increased
spinal cord compression at T8. There is abnormal T2 cord signal
extending from T7 to T8-9, new from
recent prior MRI on ___ (series 5 image 8). No post
biopsy
hematoma.
2. Scattered osseous metastases without epidural tumor in the
thoracic and lumbar spine. No evidence of metastatic disease in
the cervical spine.
3. Degenerative disc and joint disease in the lumbar spine
resulting in severe spinal canal stenosis at L4-5.
4. Spondylosis in the cervical spine deforming the spinal cord
at C3-4 through C5-6, but no cord signal abnormality.
___ intraoperative fluoroscopy
Intraoperative images from posterior fusion extending from
T6-T10. Please see
the operative report for further details.
___ CXR
As compared to ___ chest radiograph, the patient has
undergone spinal
surgery and has been intubated with an endotracheal tube in
standard position.
Right subclavian vascular catheter terminates in the lower
superior vena cava,
with no visible pneumothorax. Lungs are clear except for linear
atelectasis at
the left lung base.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Magnesium Oxide Dose is Unknown PO Frequency is Unknown
2. Simvastatin 20 mg PO QPM
3. Allopurinol ___ mg PO DAILY
4. Cyclobenzaprine 5 mg PO TID:PRN pain
5. Potassium Chloride 10 mEq PO DAILY
6. Furosemide 20 mg PO DAILY
7. Citalopram 20 mg PO DAILY
8. Diazepam 5 mg PO Q12H:PRN anxiety
9. Ibuprofen 800 mg PO BID:PRN pain
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Diazepam 5 mg PO Q12H:PRN anxiety
RX *diazepam 5 mg 1 tablet by mouth Every 12 hours as needed
Disp #*30 Tablet Refills:*0
4. Acetaminophen 325-650 mg PO Q6H:PRN pain
5. Bisacodyl 10 mg PO DAILY constipation
6. Gabapentin 900 mg PO TID
7. Ketorolac 15 mg IV Q8H Duration: 5 Doses
8. Lidocaine 5% Patch 1 PTCH TD QPM
9. Morphine Sulfate ___ 15 mg PO Q4H:PRN pain
RX *morphine 15 mg 1 tablet(s) by mouth Every 4 hours as needed
Disp #*60 Tablet Refills:*0
10. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
RX *oxyCODONE 1 tablet by mouth Every 8 hours Disp #*30 Tablet
Refills:*0
11. Polyethylene Glycol 17 g PO BID constipation
12. Sarna Lotion 1 Appl TP QID:PRN itching
13. Tizanidine 4 mg PO Q12H:PRN Spasm
14. Furosemide 20 mg PO DAILY
15. Simvastatin 20 mg PO QPM
16. Potassium Chloride 10 mEq PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Acute spinal cord compression
2. Compression from T8 Hepatocellular metastasis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT INTERVENTIONAL PROCEDURE
INDICATION: ___ with w/ recently diagnosed hepatocelluar carcinoma, who is
admitted from the ED with progressive back pain found to have concern for T8
metastatic disease. // ?metastatic HCC to spine
COMPARISON: CT ___, MRI ___.
PROCEDURE: CT-guided T8 vertebral body mass biopsy.
OPERATORS: Dr. ___, radiology fellow and Dr. ___,
attending radiologist. Dr. ___ supervised the trainee during the
entire procedure and reviewed and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a prone position on the CT scan table. Limited
preprocedure CTscan of the intended biopsy area was performed. Based on the
CT findings, an appropriate position for the biopsy was chosen. The site was
marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
was administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, an 11 gauge ___ coaxial needle was introduced
into the lesion. An 14 gauge ___ core biopsy device was used to obtain 3
core biopsy specimens, which were sent for pathology. Aspirated blood was sent
to cytology..
During the procedure, the patient had a small amount of bleeding from the
biopsy needle (approximately 25 cc). The tract was embolized with Gel-Foam
pledgets with cessation of the bleeding. The patient remained asymptomatic
throughout.
DOSE: DLP: 1716.00 mGy-cm
SEDATION: Moderate sedation was provided by administering divided doses of
1.5 mg Versed and 75 mcg fentanyl throughout the total intra-service time of
60 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse. The patient was noted to
have several episodes of asymptomatic bradycardia to as low as 35 bpm during
the procedure. The bradycardia did not correspond to medication
administration. His blood pressure remained stable throughout the procedure.
FINDINGS:
1. Preprocedure CT scan again demonstrates a soft tissue mass at the T8
vertebral body extending into the T7 and T9 vertebral bodies, targeted for
biopsy. The ascending thoracic aorta is mildly enlarged to 4.1 cm. A
calcified granuloma is seen in the right lower lobe. Linear atelectasis is
noted in the left lung. Coronary artery calcifications are of unknown
hemodynamic significance. There is no pleural or pericardial effusion. A 7.0
cm mass is seen in segment VIIof the liver, better evaluated on prior studies.
Calcifications in the liver and spleen suggests prior exposure to
granulomatous disease.
2. Postprocedure CT scan demonstrates air within the T8 vertebral body mass
from the Gel-Foam pledgets. A small amount of air in the epidural space at the
T7-T8 vertebral levels is likely post procedural and may be within veins.
Small subcutaneous air is identified. No paraspinal or extrapleural hematoma
or pneumothorax is seen.
IMPRESSION:
1. CT-guided biopsy of the T8 vertebral body mass. Pathology on cytology are
pending.
2. Small amount of bleeding with the procedure, with Gel-Foam embolization of
the biopsy tract with cessation of bleeding. The patient remained asymptomatic
throughout. No paraspinal or extrapleural hematoma on the postprocedure CT
scan.
3. Patient was noted to have asymptomatic bradycardia on hemodynamic
monitoring during the procedure.
NOTIFICATION: Impressions #1 through #3 were discussed by Dr. ___
with Dr. ___ on the telephone on ___ at 16:45, upon procedure
completion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ male with metastatic hepatocellular carcinoma now
with acute change in mental status. Evaluate for acute intracranial hemorrhage
or mass.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 1341 mGy-cm; CTDI: 50 mGy
COMPARISON: None.
FINDINGS:
There is no acute intracranial hemorrhage,acute infarction or midline shift.
There is no hydrocephalus. There is no edema. There is no fracture.
Visualized paranasal sinuses are clear. There is suggestion of postsurgical
changes related to prior right mastoidectomy. The left mastoid air cells are
underpneumatized.
IMPRESSION:
1. No acute intracranial abnormality.
2. Please note that MRI of the brain is more sensitive for the evaluation of
intracranial metastatic disease or acute infarct.
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR
INDICATION: ___ year old man with metastatic HCC and known T8 cord compression
c/o numbness // ?interval changes Status post recent CT-guided biopsy
of T8.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 weighted imaging was performed. 8 cc of Gadavist was administered
intravenously. Sagittal and axial T1 post-contrast sequences were obtained.
COMPARISON: MRI cervical and thoracic spine ___
FINDINGS:
CERVICAL SPINE:
Alignment is normal. Vertebrae are normal in stature. There is no suspicious
marrow signal abnormality. Intervertebral discs are diffusely desiccated and
mildly decreased in height at C5-6 and C6-7. There are disc osteophyte
complexes and ligamentum flavum thickening at C3-4 through C5-6 that deform
the spinal cord. The worst level of degenerative disease is at C5-6, where
there is at least moderate spinal canal stenosis and deformity of the spinal
cord. There is no cord signal abnormality. There is no pathologic enhancement.
THORACIC SPINE:
There is a large T1 hypointense, T2 heterogeneously hyperintense, STIR
hyperintense, enhancing, destructive lesion consistent with a metastasis
involving the T8 vertebrae. This lesion involves the vertebral body and
bilateral pedicles of T8 with epidural extension of tumor. There is loss of
height of T8 vertebra indicating pathological fracture. Tumor surrounds the
anterior aspect of the spinal cord and extends into both T8-9 neural foramina.
There is resultant compression of the spinal cord with and increased T2 cord
signal extending from T7 to T8-9. There is no pathologic enhancement within
the spinal cord itself. There is no post biopsy hematoma. The osseous
metastasis also extends superiorly into the T7 vertebral body and inferiorly
into the T9 vertebral body.
There is a round lesion at the superior endplate of T11 that demonstrates STIR
hyperintensity and mild enhancement (series 9, image 8). Comparison was made
with CT from ___, which did not demonstrate a Schmorl's node at this
location. This small lesion is likely an osseous metastasis.
There are hemangiomas in the T2, T9, T10, and T12 vertebral bodies.
LUMBAR SPINE:
Vertebrae are normal in stature and alignment. There are scattered osseous
metastases in the L3 and L4 vertebral bodies. There is no pathologic fracture.
The conus terminates at the L2-3 level. There is diffuse desiccation and
narrowing of the intervertebral discs. There is multilevel cervical
spondylosis, worst at L4-5 where there is severe spinal canal stenosis.
There is a hemangioma in the L2 vertebral body.
There are multiple metastases in the iliac bones, the largest a 3.2 cm
metastasis in the left ischium (series 19, image 27). A liver mass is also
partially seen.
IMPRESSION:
1. Large osseous metastasis of the T8 vertebral body with new pathological
fracture with epidural extension causing increased spinal cord compression at
T8. There is abnormal T2 cord signal extending from T7 to T8-9, new from
recent prior MRI on ___ (series 5 image 8). No post biopsy
hematoma.
2. Scattered osseous metastases without epidural tumor in the thoracic and
lumbar spine. No evidence of metastatic disease in the cervical spine.
3. Degenerative disc and joint disease in the lumbar spine resulting in severe
spinal canal stenosis at L4-5.
4. Spondylosis in the cervical spine deforming the spinal cord at C3-4 through
C5-6, but no cord signal abnormality.
NOTIFICATION: Preliminary findings were discussed by Dr. ___ of
radiology with Dr. ___ at 10:20 ___.
Radiology Report
EXAMINATION: T-SPINE
INDICATION: T7-T9 LAMINECTOMY, T6-T10 FUSION
TECHNIQUE: 6 intraoperative frontal and lateral spot projections of the
thoracic spine were obtained without the radiologist present. Total
fluoroscopy time is 238.4 seconds.
COMPARISON: MRI of the thoracic spine ___.
FINDINGS:
The available images show placement of posterior fusion hardware spanning
T6-T10 with bilateral rods and pedicle screws at T6, T7, T9 and T10. There is
no evidence of hardware complication. Bones are osteopenic. The previously
demonstrated mass at T8 is not well visualized on the current exam. Please see
the operative report for further details.
IMPRESSION:
Intraoperative images from posterior fusion extending from T6-T10. Please see
the operative report for further details.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with spine surgery, newly placed central line,
right subclav // ?placement right subclavian line.
IMPRESSION:
As compared to ___ chest radiograph, the patient has undergone spinal
surgery and has been intubated with an endotracheal tube in standard position.
Right subclavian vascular catheter terminates in the lower superior vena cava,
with no visible pneumothorax. Lungs are clear except for linear atelectasis at
the left lung base.
Radiology Report
EXAMINATION: ABDOMEN (SUPINE ONLY)
INDICATION: ___ year old man with abdominal pain // r/o obstruction.
TECHNIQUE: Supine radiographs of the abdomen.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
Gas-filled but nondistended loops of large bowel, nonspecific. No evidence of
free air on this supine radiograph. Stomach is mildly distended with air.
Fixation device is seen in the lower thorax. Staples are seen in a vertical
fashion overlying the fixation device. A right total hip arthroplasty is
visualized.
IMPRESSION:
Nonspecific bowel gas pattern.
Radiology Report
EXAMINATION: Chest CT
INDICATION: ___ year old man with bilateral rib pain // bilateral rib pain,
r/o rib mets
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen. Axial images were reviewed in conjunction with coronal and sagittal
reformats
COMPARISON: ___
FINDINGS:
Aorta and pulmonary arteries are not enhance but dilatation of the ascending
aorta is demonstrated up to 4.3 cm. Pulmonary arteries are normal in diameter.
Extensive Coronary calcifications are present. No pericardial effusion is
seen.
No mediastinal, hilar or axillary lymphadenopathy is present.
Image portion of the upper abdomen re- demonstrate liver hypodensity,
partially imaged, approaching 8 cm. Small amount of right pleural effusion is
demonstrated. A adjacent area of atelectasis present. Airways are patent to
the subsegmental level bilaterally.
3.7 x 2.9 cm soft tissue mass centered at the T8 vertebral body extending into
the T7 and T9 vertebral bodies, similar to ___. Spinal hardware
appears to be unchanged in unremarkable. Subtle heterogeneous lucencies
throughout the osseous structures likely reflects diffuse osteopenia, though
there are a few small focal lucencies in the ribs, including along the left
posterior tenth rib (05:240). If there is concern for bony metastasis, bone
scan may be obtained for further evaluation. No new rib fractures
demonstrated.
Airways are patent to the subsegmental level bilaterally. Calcified pulmonary
nodules are consistent with prior granulomatous exposure and are unchanged as
well as right middle lobe nodule, series 5, image 195 no new nodules masses
are consolidations demonstrated.
IMPRESSION:
Known involvement of the spine the metastatic disease centering at T8 level.
Would be lytic areas in the bones, potentially representing metastatic disease
and should be correlated with bone scan. No new rib fractures noted.
Mild dilatation of ascending aorta. Coronary calcifications.
___ right pleural effusion and right basal atelectasis potentially related
to recent spine surgery.
Lytic lesion in the sternum, series 5, image 263, also should be reassessed
with bone scan.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST
INDICATION: ___ with newly discovered HCC w/ possible new mets to spine now
impinging cords. Evaluate for cervical and thoracic spine impingement.
TECHNIQUE: Sagittal imaging of the cervical and thoracic spine was performed
with T2, T1, and STIR technique. Axial T2 and gradient echo imaging were
performed.
COMPARISON: Outside cervical and thoracic spine CT from ___.
FINDINGS:
Cervical spine: Vertebral body heights and alignment are maintained. No acute
fracture or ligamentous injury is identified. There is no prevertebral soft
tissue swelling. There is multilevel cervical spine spondylosis with disc
protrusions and ligamentum flavum thickening causing cord compression at the
C3-C4, C4-C5, and C5-C6 levels. Cord signal is normal. There is also severe
bilateral neural foraminal narrowing at C2-C3, C3-C4, C4-C5, C5-C6, and left
C6-C7 levels secondary to uncovertebral and facet hypertrophy.
Thoracic spine: Vertebral body heights and disc spaces are maintained. There
is no acute fracture or subluxation. There is replacement of normal fatty
marrow at multiple thoracic levels by soft tissue mass. The largest is
centered at the T8 level and crosses both the superior and inferior disc
spaces into the T7 and T9 vertebral bodies. There is also breakthrough of the
posterior cortex of T8 with soft tissue encroaching upon the spinal canal
causing cord compression with possible high signal within the cord at the T8
level. There are also similar abnormalities at the T2, superior endplate of
T7, T10, as well as T12 levels without cord compression. Additionally, there
are multiple T1 hyperintense lesions at T5, T7, T9, T10-T12 with varying STIR
signal compatible with hemangiomas and/or focal fat.
A large partially visualized right lobe hepatic mass is better characterized
on previous cross-sectional imaging.
IMPRESSION:
1. Replacement of normal fatty marrow by multiple soft tissue lesions within
the thoracic spine with the largest centered at T8 crossing both the superior
and inferior disc spaces into T7 and T9 vertebral bodies. While these
findings are highly suggestive of metastatic disease given known HCC, the
crossing of disc spaces is unusual and infection cannot be excluded.
Additional similar appearing abnormalities seen at T2, superior end plate of
T7, T10, and T12 vertebral bodies.
2. T8 cord compression secondary to posterior cortical breakthrough from soft
tissue mass. Suggestion of abnormal cord signal at T8 level.
3. Severe cervical spondylosis with multilevel disc protrusions causing cord
compression at C3-C4, C4-C5, and C5-C6 levels. Normal cord signal.
4. Incidental note of multiple hemangiomas and focal fat in the thoracic
spine vertebral bodies.
NOTIFICATION: Findings discussed with Dr. ___ by ___ at 12:08pm on
___, immediately following attending review.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain
Diagnosed with SECONDARY MALIG NEO BONE, MAL NEO LIVER, PRIMARY, DIABETES UNCOMPL ADULT, HYPERCHOLESTEROLEMIA
temperature: 98.4
heartrate: 58.0
resprate: 16.0
o2sat: 97.0
sbp: 109.0
dbp: 66.0
level of pain: 10
level of acuity: 2.0 | ___ with w/ recently diagnosed hepatocelluar carcinoma, who is
admitted from the ___ with progressive back pain found to have
concern for T8 metastatic disease with concern for cord
compression. Patient admitted with concern for irritractable
back pain. Started with IV morphine, transitioned to PCA, then
to oral regimen with long and short acting morphine. Patient
found to be delirious during later OMED course. Found to have
UTI with acute urinary retention, started on ceftriaxone and
foley placed with improvement of symptoms. Patient found to have
___ on afternoon of ___. Evaluated by neurosurgery
who determined need for acute surgical intervention. Patient and
HCP were consenting to risks/benifits. Patient transferred to
___ service where...
# AMS
Patient started to become increasing altered following his
course of radiation therapy in the setting of uptitrating pain
medicaiton. Patient found to be somnelent and unarrousable to
sternal rub on AM of ___, recovered quickly with narcan 1mg.
Clear drug overdose with a number of potential causes: pt with
acute urinary retention possibly leading to retention of
excreted morphine metabolites. Patient has also recieved a
signficant amount of opiate narcotics during this admission. Pt
also started haldol 1 mg PO QHS last night for the first time.
Patient also recently found to have +UTI on UCx, Started on CTX
___.
-Reduced MS ___ to 30 mg BID, MS ___ with very cautious use
-Continue Ceftriaxone for 7 day course (d1: ___
-Continue foley catheter, monitor I&Os
-Monitor sx
-Continue Haldol 1 mg PO QHS for now as opiates primary suspect
for AMS
# Back pain: ___ to progressive metastatic carcinoma. Initial
MRI showed some concern for cord compression, neurosurgery
deferred surgical management on admission and recommended
continued treatment medically with IV steroids and monitored
neuro exam. Spinal biopsy on ___ revealed metastatic HCC.
Rad onc consulted, ___ radiation therapy sessions completed on
___. Continued to have significant pain especially after
radiation, but no saddle anesthesia, bowel/urine incontinence.
Pain management consulted and following, started and
transitioned off PCA. Now on oral ___ and long acting morphine.
Patient found to have ___ weakness on afternoon of ___. F/u
MR ___ spine read revealed pathological fracture of T8 +
worsened chord compression. Patient transferred to ___ service
where...
- Neuro check q4 hours
- Hold further tapering of dexamethasone for now, re-instate 4mg
BID
- appreciate pain recommendations: MS ___, MS contin, standing
tylenol, gabapentin
- d/c lidocaine patch as patient c/o back pain while placing and
little subjective pain relief reported
- per neurosurg, activity as tolerated
- standing bowel regimen while on narcotics
- IV morphine for breakthrough
- IV toradol prior to radiation
# metastatic HCC: Had been presumed to be limited stage and a
candidate for surgical resection. HW, now with metastatic bony
lesions, confirmed with biopsy. No evidence of liver
dysfunction. Patient to follow-up with Dr. ___ as
outpatient following discharge.
# Severe anxiety/depression.
Increased home celexa from 20 mg to 40 mg PO daily. Intially
given valium PRN anxiety but d/c'd in setting of delirum. Social
work, Pall care, and psychiatry all consulted. Psych diagnosed
adjustment disorder in setting of terminal illness. Wish to
re-eval prior to discharge.
#Constipation: Pt reports lifelong issues with constipation,
reports hesitance given backpain. Will help soften stools for
easier passage.
-Continued standing colace, polyethelene glycol, senna with
laculose PRN
# Hyperlipidemia.
Held simvastatin in setting of acute illness
# Gout.
Con't home allopurinol
# Diabetes: Not on meds at home. ___ worsen in setting of
steroids. Placed on HISS.
# CAD: The patient reports a small MI in his ___ and has also
had
prior history of mild heart attacks. Not on a CAD regimen at
home, aside from simvastatin
- Holding simvastatin
On ___, the Neurosurgery service was re-consulted due to
concerns of an exam change in the patient's lower extremities.
A MRI was completed and showed a new pathologic fracture of T8,
worsening compression, and increased cord edema from T7 to T9.
During the evening, the primary team call and stated the patient
was Team no longer moving his lower extremities. He had
decreased rectal tone as well. Mr. ___ was emergently taken
to the operating suite where he underwent a laminectomy and
fusion from T7-T9 and fusion from T6 to T10. Mr. ___
tolerated the procedure well and there were no intraoperative
complications. Please see the operative report for further
details. He was transferred to the ICU for close neurologic
monitoring and further management.
On ___, Mr. ___ was extubated successfully. A central line
was placed so pressors could be initiated to keep the patient's
mean arterial pressure > 85. A figure-of-eight brace was
ordered for the patient to prevent his thoracic surgical wound
from dehiscence.
On ___, Mr. ___ continued to recover well. He was seen by
Physical Therapy and was mobilizing from bed to chair with
assistance. He was continued on pressors to keep his MAP up.
On ___, the patient's neurologic examination remained stable.
He remains on pressors for a MAP >85. The drain was removed and
he was re-started on SQH.
On ___, the Dexamethasone was stopped. A family meeting was
held with Social Work, Neurosurgery, Palliative Care and
Oncology to determine the plan moving forward.
On ___, the patient's neurologic examination remained stable.
The pressors were stopped today and his MAP requirement was
liberalized. It was determined he would be transferred to the
___ service on ___.
ON ___ Patient was neurologically stable. Awaiting transfer to
OMED. Patient worked ___. He was screened for rehab placement.
___, the patient was neurologically stable. His pain
medications were adjusted as he was still experiencing bilateral
rib pain. He was found to have a pressure ulcer developing
which was evaluated. He was screened for rehab. He was
discharged to rehab with follow up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / clonidine patch / Erythromycin Base / Amoxicillin
/ hydrochlorothiazide / aspirin
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___ debridement, vac placement
___ bedside debridement
History of Present Illness:
___ with complex PMH including recent (___) CVA secondary to
bleed with resulting aphasia, HTN, DM2, AFib, CAD s/p stenting,
COPD, and recent admission for Enterococcus and S. epidermidis
bacteremia presents with fever from rehab after discharge on
___. He was discharge with a course of vancomycin that he
completed on ___.
The patient was unable to provide any history on the floor and
not accompanied by family. Based on report from ED, the patient
had appeared altered with intermittent fevers at rehab for the
past week. He had been having increased somnolence with less
verbalization. Because of the stroke, he had been bed bound
since discharge in ___.
In the ED, initial vitals were: 99.6 68 153/83 15 98% RA. Tmax
was 102.
Exam notable for LUE PICC line without redness or purulence at
the site, large deep sacral ulcer without surrounding cellulitis
but with foul-smell and mild purulence.
Patient had multiple LP attempts but due to body habitus was
unable to obtain.
Patient received: IV Acetaminophen IV 1000 mg, IVF 1000 mL NS
1000 mL, IH Albuterol 0.083% Neb Soln 1 NEB, IV CeftriaXONE 2
gm, IV Vancomycin 1500 mg.
Vitals prior to transfer were: 99.8 70 127/39 18 98% RA.
On arrival to the floor, patient appears alert but does not
respond to well to questioning. He was able to grunt "nah-uh"
when asked if he has any pain. He yells out when attempts were
made to assess his sacral wound.
REVIEW OF SYSTEMS:
Unable to be obtained from patient
Past Medical History:
Type 2 DM
CVA with aphasia in ___
Subdural hematoma
Atrial fibrillation formerly on Coumadin but no longer
CAD s/p RCA DES in ___
COPD
Gout
HLD
Obesity
Spermatocele
OSA
TTE ___: LVH with EF >60%
B/L knee replacements
Social History:
___
Family History:
Brother died of heart failure in ___, sister of cancer (type
unknown) in ___.
Physical Exam:
ADMISSION EXAM
Vitals: T 100.0 BP 120/45 HR 72 RR 18 SAT 97 O2 on RA
GENERAL: Laying down in bed, tracks occasionally, opens eyes,
no apparent distress
HEENT: Sclera anicteric, MM's moist, EOMI grossly intact based
on eye movement, PERRL; known right facial droop
CARDIAC: RRR, S1/S2, ___ systolic murmur
LUNG: Crackles throughout with diminished breath sounds
ABDOMEN: Obese, no obvious tenderness or distension, +BS,
G-tube
site intact without erythema or drainage
GU: Foley in place
EXTREMITIES: Obese, no pitting edema, warm and well perfused,
has L arm PICC in place with no erythema or fluctuance
SKIN: warm and well perfused, no rash; very large sacral ulcer
wound that goes deep into muscle but does not probe to bone with
purulence and very foul smell
NEURO: Patient unable to comply with neuro exam
DISCHARGE EXAM
VS 98.9 146/54 20 100%/CPAP
I/O: 2456+300IV/3200+BM 24H, 782/600 8H
General: NAD, makes eye contact, tracks
HEENT: EOMI, Sclera anicteric without injection
Neck: Supple, no JVD
CV: RRR, no M/R/G
Lungs: breathing comfortably on RA, clear bilaterally
Abdomen: obese, soft, no obvious tenderness, nondistended, +BS,
G tube in place, c/d/no drainage, erythema
GU: Foley in place
Ext: WWP, no pitting edema; PICC in LUE, c/d, non-tender
Neuro: unable to participate in full neuro exam, tracks
Pertinent Results:
ADMISSION LABS
==============
___ 06:37PM BLOOD WBC-8.3 RBC-3.80*# Hgb-10.8*# Hct-34.5*#
MCV-91 MCH-28.4 MCHC-31.3* RDW-15.3 RDWSD-49.7* Plt ___
___ 06:37PM BLOOD Neuts-75.4* Lymphs-11.5* Monos-8.6
Eos-3.3 Baso-0.4 Im ___ AbsNeut-6.23*# AbsLymp-0.95*
AbsMono-0.71 AbsEos-0.27 AbsBaso-0.03
___ 06:37PM BLOOD Ret Aut-3.8* Abs Ret-0.15*
___ 06:37PM BLOOD Glucose-188* UreaN-20 Creat-0.8 Na-135
K-3.9 Cl-99 HCO3-29 AnGap-11
___ 06:37PM BLOOD Iron-17*
___ 06:37PM BLOOD calTIBC-217* Ferritn-210 TRF-167*
___ 06:46PM BLOOD Lactate-1.7
___ 08:20PM URINE Color-Straw Appear-Clear Sp ___
___ 08:20PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 08:20PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 08:20PM URINE CastHy-3*
___ 08:20PM URINE Mucous-RARE
MICROBIOLOGY
============
___ 6:12 pm SWAB Source: sacral ulcer.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
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
in this
culture.
Work-up of organism(s) listed discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
___ 11:51 pm TISSUE Source: sacral decubitus wound.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
TISSUE (Final ___:
MIXED BACTERIAL FLORA.
Due to mixed bacterial types [>=3] an abbreviated
workup is
performed; all organisms will be identified and
reported but only
select isolates will have sensitivities performed.
PROTEUS MIRABILIS. MODERATE GROWTH.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ENTEROCOCCUS SP.. SPARSE GROWTH.
ESCHERICHIA COLI. RARE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| KLEBSIELLA PNEUMONIAE
| | ENTEROCOCCUS
SP.
| | |
ESCHERICHIA COLI
| | | |
AMPICILLIN------------ =>32 R <=2 S =>32 R
AMPICILLIN/SULBACTAM-- 8 S 8 S =>32 R
CEFAZOLIN------------- 16 R <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R 0.5 S
GENTAMICIN------------ <=1 S <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S
PENICILLIN G---------- 1 S
PIPERACILLIN/TAZO----- <=4 S 8 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R <=1 S <=1 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___:
UNABLE TO R/O PATHOGENS DUE TO OVERGROWTH OF SWARMING
PROTEUS SPP..
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___: NO GROWTH.
REPORTS
=======
CXR ___. Linear mid to lower lung opacities likely reflect
atelectasis.
2. Congested hila. Clinical correlation is recommended.
Noncon CT Head ___. No evidence for acute intracranial abnormalities.
2. Previously demonstrated large left
parietal/occipital/posterior temporal hematoma has slightly
decreased in size and density compared to ___, with
decreased mass effect
MRI Brain ___
1. Unchanged left temporo-occipital intraparenchymal hematoma
with local mass effect and no evidence of enhancement.
Follow-up to resolution is
recommended.
2. Chronic subarachnoid hemorrhage in the right frontal lobe.
3. No new hemorrhage.
4. Unchanged 3 mm aneurysm of the proximal basilar artery.
DISCHARGE LABS:
==============
___ 06:04AM BLOOD WBC-8.2 RBC-2.89* Hgb-8.3* Hct-27.2*
MCV-94 MCH-28.7 MCHC-30.5* RDW-18.2* RDWSD-60.7* Plt ___
___ 06:04AM BLOOD Neuts-62.4 Lymphs-15.7* Monos-11.3
Eos-8.8* Baso-0.5 Im ___ AbsNeut-5.09 AbsLymp-1.28
AbsMono-0.92* AbsEos-0.72* AbsBaso-0.04
___ 04:54AM BLOOD Glucose-136* UreaN-33* Creat-0.7 Na-135
K-4.2 Cl-95* HCO3-31 AnGap-13
___ 04:54AM BLOOD Calcium-9.8 Phos-3.0 Mg-2.3
PERTINENT LABS:
==============
___ 04:02AM BLOOD Vanco-15.0
___ 06:37PM BLOOD Ret Aut-3.8* Abs Ret-0.15*
___ 05:38AM BLOOD ALT-15 AST-18 LD(LDH)-135 AlkPhos-135*
TotBili-0.2
___ 06:37PM BLOOD calTIBC-217* Ferritn-210 TRF-167*
___ 04:57AM BLOOD CRP-48.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever
2. Allopurinol ___ mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Bisacodyl ___AILY:PRN constipation
5. Fluoxetine 10 mg PO DAILY
6. Furosemide 60 mg PO BID
7. HydrALAzine 25 mg PO Q6H
8. Labetalol 600 mg PO QID
9. Lactulose 15 mL PO BID
10. LeVETiracetam 750 mg PO BID
11. Milk of Magnesia 30 mL PO Q8H:PRN constipation
12. Senna 17.2 mg PO BID
13. Tamsulosin 0.4 mg PO QHS
14. TraZODone 50 mg PO QHS:PRN insomnia
15. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
16. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q6H:PRN GI
distress
17. Brovana (arformoterol) 15 mcg/2 mL inhalation BID:PRN SOB
18. Fleet Enema ___AILY:PRN constipation
19. MetFORMIN (Glucophage) 500 mg PO BID
20. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
21. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
22. Potassium Chloride 10 mEq PO DAILY
23. Glargine 8 Units Bedtime<br> Regular 6 Units Q6H
Insulin SC Sliding Scale using HUM Insulin
24. Aspirin 81 mg PO DAILY
25. Heparin 5000 UNIT SC BID
26. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
27. Docusate Sodium (Liquid) 100 mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q6H:PRN GI
distress
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Bisacodyl ___AILY:PRN constipation
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Fleet Enema ___AILY:PRN constipation
8. Fluoxetine 10 mg PO DAILY
9. Furosemide 60 mg PO BID
10. Heparin 5000 UNIT SC BID
11. Glargine 8 Units Bedtime<br> Regular 6 Units Q6H
Insulin SC Sliding Scale using HUM Insulin
12. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
13. Labetalol 200 mg PO BID
hold for HR<50, BP<100
14. LeVETiracetam 750 mg PO BID
15. Milk of Magnesia 30 mL PO Q8H:PRN constipation
16. Senna 17.2 mg PO BID
17. TraZODone 50 mg PO QHS:PRN insomnia
18. Acetaminophen 650 mg PO Q4H:PRN pain, fever
19. Brovana (arformoterol) 15 mcg/2 mL inhalation BID:PRN SOB
20. Lisinopril 10 mg PO DAILY
hold for BP<100
21. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
22. Tamsulosin 0.4 mg PO QHS
23. MetFORMIN (Glucophage) 500 mg PO BID
24. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
25. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
26. Collagenase Ointment 1 Appl TP Q8H:PRN debridement
27. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
last day ___
28. Vancomycin 1250 mg IV Q 24H
last day ___
29. Famotidine 20 mg PO Q12H Duration: 6 Weeks
30. CeftriaXONE 2 gm IV Q24H
last day ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
#Sepsis secondary to infected sacral decubitus ulcer
#Sacral osteomyelitis
#Toxic-metabolic encephalopathy
Secondary:
#Aphasia and incomplete hemiplegia
#History of intraparenchymal Hemorrhage ___
#Traumatic right SAH/SDH ___
#PEG and chronic urinary catheter
#Coronary artery disease s/p RCA DES ___
#Atrial fibrillation
#Chronic diastolic heart failure
#Diabetes mellitus type II
#COPD
#Gout
#Obesity
#OSA
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - always.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with fever // eval for acute process
TECHNIQUE: Portable chest x-ray.
COMPARISON: Chest radiographs dated ___
FINDINGS:
Portable semi-upright radiograph of the chest demonstrates low lung volumes
and stable linear opacities bilaterally radiating from the hila, which are
consistent with atelectasis. The hila appear congested. The cardiac
silhouette is mildly enlarged, stable since prior examination. No definite
consolidation is identified. There may be a small left pleural effusion. No
pneumothorax is identified. Right PICC is in place with tip in SVC.
IMPRESSION:
1. Linear mid to lower lung opacities likely reflect atelectasis.
2. Congested hila. Clinical correlation is recommended.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ man with altered mental status. Evaluate for
intracranial hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) CT Localizer Radiograph
4) CT Localizer Radiograph
5) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT dated ___.
FINDINGS:
The study is mildly limited by motion artifact through the posterior fossa and
inferior temporal lobes.
The previously seen large intraparenchymal hemorrhage involving the left
parietal, occipital, and posterior temporal lobes demonstrates decreased size
and decreased density of blood products since ___. Mild edema persists
surrounding the hemorrhage. The occipital horn and atrium of the left lateral
ventricle remain effaced, but the body and frontal horn have re-expanded. The
third ventricle has also re-expanded. Rightward shift of midline structures
has decreased. Left perimesencephalic cistern has re-expanded.
There is no new hemorrhage.
Aside from the local mass effect related to the above described parenchymal
hematoma, the ventricles and sulci are prominent due to age-related
parenchymal volume loss. Diffuse supratentorial white matter hypodensities
are grossly unchanged, nonspecific but likely sequelae of chronic small vessel
ischemic disease.
No evidence of an acute fracture. There is mild mucosal thickening of the
left maxillary, bilateral ethmoid, and bilateral sphenoid sinuses. Mastoid
air cells are clear. Visualized orbits are grossly unremarkable.
IMPRESSION:
1. No evidence for acute intracranial abnormalities.
2. Previously demonstrated large left parietal/occipital/posterior temporal
hematoma has slightly decreased in size and density compared to ___, with decreased mass effect.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ with a h/o recent admission for Enterococcus and Staph Epi
bacteremia, CVA ___ with resultant aphasia, HTN, DM, HLD, CAD, who presented
from rehab with fevers and change in mental status // Eval for interval
change
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 15 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CT head ___, and ___ new line CTA head and neck ___
FINDINGS:
The examination is motion degraded, particularly the MPRAGE postcontrast
sequences. Within these confines:
The 7.1 by 3.6 x 4.3 cm left temporo-occipital intraparenchymal hematoma is
unchanged in size from the prior examination. The local mass effect with
effacement of the adjacent sulci and atrium and occipital horn of the left
lateral ventricle is unchanged. This hematoma demonstrates an outer
peripheral rim of T1 and T2 hypointense signal with susceptibility and an
inner peripheral rim of T1 hyperintense signal. This hematoma demonstrates
restricted diffusion. The central portions of this hematoma are T1
hypointense and T2/FLAIR hyperintense. There is no enhancement within or
surrounding the hematoma. Minimal surrounding T2/FLAIR hyperintense signal is
consistent with edema.
Faint, curvilinear T1 hyperintense signal with susceptibility in the sulci of
the right frontal lobe represents chronic subarachnoid hemorrhage, related to
trauma as seen on the CT head ___.
No new hemorrhage is identified. Punctate micro hemorrhages of the right
putamen, posterior right parietal lobe and right cerebellar hemisphere are
noted.
There is no evidence of midline shift or infarction.T2/FLAIR hyperintensities
in the periventricular, subcortical, and deep white matter are nonspecific,
but may represent the sequela of chronic small vessel ischemic disease. There
is no abnormal enhancement after contrast administration.
The paranasal sinuses and mastoid air cells are clear. The orbits are
unremarkable.
The left mid and distal intradural vertebral artery enhances and is patent,
improved from the CTA head ___, where no contrast opacification
was visualized. The 3 mm aneurysm of the proximal basilar artery on 100b:30
is unchanged.
IMPRESSION:
1. Unchanged left temporo-occipital intraparenchymal hematoma with local mass
effect and no evidence of enhancement. Follow-up to resolution is
recommended.
2. Chronic subarachnoid hemorrhage in the right frontal lobe.
3. No new hemorrhage.
4. Unchanged 3 mm aneurysm of the proximal basilar artery.
Gender: M
Race: BLACK/AFRICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status, Fever
Diagnosed with Altered mental status, unspecified
temperature: 99.6
heartrate: 68.0
resprate: 15.0
o2sat: 98.0
sbp: 153.0
dbp: 83.0
level of pain: unable
level of acuity: 2.0 | ___ with a h/o recent admission for Enterococcus and Staph Epi
bacteremia, CVA ___ with resultant aphasia, HTN, DM, HLD, CAD,
who presented from rehab with fevers and change in mental
status.
ACTIVE PROBLEMS
# Sepsis/Sacral Wound Ulcer Infection/Osteomyelitis: Most
obvious source of infection is his sacral decubitus ulcer. CXR
w/o PNA, UA negative, LFT's normal. Other sources to consider
include PICC (nontender, not obviously infected), knee
replacement, and less likely intra-abdominal or meningitis. Had
fevers first several days after admission. WBC initially
uptrended, later downtrending, and of note WBC was lower than
prior hospitalization. Initially started on meningitis dosing of
Cefepime by the ED given concern for meningitis, but this was
changed as meningitis was not felt to be high on DDx. Was then
started on Vanc, Cefepime, Flagyl for broad spectrum coverage.
S/p bedside debridement of sacral wound ___ by ACS. Further
surgical management by ___ on ___ of sacral wound notable for
bone involvement concerning for osteomyelitis. Patient had wound
vac placed by surgery. Patient narrowed to CTX on ___.
Otherwise, patient has been afebrile, no leukocytosis, and
clinically improving. Plan per ID is IV Vanc/Ceftriaxone/Flagyl
x 6 weeks after source control for osteo (last day ___,
with weekly lab monitoring (see transitional issues), and
outpatient ID follow up. Will need wound vac dressing changes
MWF until surgery follow up ___
# Altered Mental Status: Patient had large L territorial
(involving temporal, parietal, and occipital lobe) hemorrhagic
CVA with resulting aphasia. Patient has had waxing and waning
episodes of inattention. Likely hypoactive delirium in the
setting of infection. Admission noncontrast head CT unremarkable
for new infarcts. DDx also includes seizure activity as pt was
on Cefepime which lowers seizure threshold, in addition to
independent effects of Cefepime-induced encephalopathy. Cefepime
was thus changed to Ceftriaxone. Patient had scheduled head MRI
w/o contrast performed while inpatient which revealed no acute
change since prior imaging. His mental status waxed and waned
throughout the admission. Per MRI read follow-up of L
temporo-occipital IPH is recommended on repeat scan (time-frame
undefined).
# Anemia: Stable. Not entirely clear why patient is anemic. MCV
is normal, Ferritin normal (but acutely inflamed), Iron low,
TIBC low, Retic Index <2%. Jehovah's witness, so no blood
transfusions. Tried to minimize lab draws (not every day) once
the patient was clinically stabilized.
# Chronic Diastolic CHF: On Furosemide 60mg BID at rehab, which
was continued here. Became fluid overloaded during a prior
admission when Lasix was held.
CHRONIC PROBLEMS
# Nutrition: nutrition consulted for tube feeds. Per nutrition,
given Zinc 220mg x14 days and Vitamin C 500mg x14 days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of HIV/AIDS, jaw osteomyelitis, resolving vaginal herpes,
reports right leg pain for three days. She woke up one day with
this pain over right knee and ankle. Worse when standing or
walking. Skin overlying these knee and ankle are red. She was
seen in discharge clinic today. MD's there examined her and
referred to ED for evaluation and consideration of joint
effusion. There was thought that this mild erythema, pain and
mild swelling was due to cellulitis but no tappable effusions
were present. She was given a dose of cefazolin and oral
doxycycline. She was given morphine for pain control.
She denies IV drug use. She is unclear how she has this leg
pain/cellulitis, and she appears to be a reliable historian. She
has been compliant with her medications, except for lovenox. She
was recently admitted for febrile neutropenia and restart of
antiretroviral therapy. She also has a resolving maxillary
osteomyelitis and has continued on augmentin for this. She has
an oral surgeon out of ___ who has been following her
osteomyelitis.
ROS: Loose stools. Mild nausea. No vomiting. No dyspnea, chest
pain, abdominal pain, focal weakness, dysuria. Spotting vaginal
bleeding. Slightly irreg periods. Full 10 point review of
systems performed and otherwise neg except above.
Past Medical History:
PAST MEDICAL HISTORY:
- HIV/AIDS (not on treatment, last CD4 of 2 on ___
-> Past PCP ___ (___)
-> Past Zoster
-> Says she was taking Complera (rilpivirine + tenofovir +
emtricitabine) until 2 weeks ago. Says she has been on numerous
HIV regimens prior to that, but cannot remember the names.
- Depression
- Past Nasal Surgery (___)
- Appendectomy ___ or ___
- Past Bowel Obstruction treated surgically ___ or ___
- C section
- Osteomyelitis of the maxilla.
- DVT right arm from ___ ___
Social History:
___
Family History:
No family members with tuberculosis.
Physical Exam:
T. 97.8 BP 116/84 HR 68 RR18 O2 sat 98%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 non-icteric, o/p
clear, MMM.
Neck: Supple, no JVD, no thyromegaly.
Lymph nodes: No cervical, supraclavicular or axillary LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash over torso. Tatoos
Right leg: circled area of erythema over right knee and front of
ankle area. Able to flex knee with mild pain, though feels tight
with full knee flexion. Some pain with rotation of right ankle.
Not remarkably swollen, but tender to palpation.
Neuro: Cranial nerves ___ grossly intact, muscle strength ___
in all major muscle groups, sensation to light touch intact,
non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS:
___ 07:15PM ___ PTT-40.3* ___
___ 07:15PM PLT COUNT-301
___ 07:15PM NEUTS-60.8 ___ MONOS-8.2 EOS-3.8
BASOS-0.8
___ 07:15PM WBC-4.3 RBC-3.56* HGB-10.4* HCT-31.5* MCV-88
MCH-29.4 MCHC-33.2 RDW-17.9*
___ 07:15PM estGFR-Using this
___ 07:15PM GLUCOSE-81 UREA N-9 CREAT-1.0 SODIUM-140
POTASSIUM-3.0* CHLORIDE-103 TOTAL CO2-24 ANION GAP-16
___ 07:28PM LACTATE-0.9
___ 08:30PM URINE UCG-NEGATIVE
___ 08:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:30PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 08:30PM URINE HYALINE-3*
___ 08:30PM URINE MUCOUS-OCC
.
___ Right Knee & Ankle Films:
RIGHT KNEE: Two AP views, oblique, and lateral views of the
right knee were obtained. No evidence of acute fracture or
dislocation is seen. There is no suprapatellar joint effusion.
No concerning osteoblastic or lytic lesion is seen. No cortical
destruction is seen.
RIGHT ANKLE: Three views of the right ankle were obtained. No
acute fracture or dislocation is seen. The ankle mortise and
talar dome are intact. No concerning osteoblastic or lytic
lesion is seen. No radiopaque foreign body is seen.
IMPRESSION: No fracture or dislocation. No cortical
destruction to suggest acute osteomyelitis, however, MRI is more
sensitive
.
DISCHARGE LABS: (day prior to discharge AMA - refused all other
phlebotomy)
___ 08:00AM BLOOD WBC-2.8* RBC-3.37* Hgb-10.0* Hct-29.9*
MCV-89 MCH-29.5 MCHC-33.4 RDW-17.6* Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-77 UreaN-10 Creat-1.0 Na-142
K-3.8 Cl-108 HCO3-28 AnGap-10
___ 08:00AM BLOOD ALT-12 AST-17 AlkPhos-65 TotBili-0.1
___ 08:00AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.0
___ 08:10AM BLOOD Vanco-25.1*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
3. Atovaquone Suspension 1500 mg PO DAILY
4. Azithromycin 1200 mg PO 1X/WEEK (___)
5. Stribild *NF* (elvitegr-cobicist-emtric-tenof)
___ mg Oral daily
6. Enoxaparin Sodium 90 mg SC Q 24H
7. Fluconazole 400 mg PO Q24H
8. FoLIC Acid 1 mg PO DAILY
9. Lorazepam 0.5 mg PO Q4H:PRN nausea
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. Promethazine 25 mg PO Q6H:PRN nausea
12. Ranitidine 150 mg PO DAILY
13. ValACYclovir 1000 mg PO Q12H
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H Duration: 5 Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*10 Capsule Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
4. Atovaquone Suspension 1500 mg PO DAILY
5. Azithromycin 1200 mg PO 1X/WEEK (___)
6. Enoxaparin Sodium 90 mg SC DAILY
7. Fluconazole 400 mg PO Q24H
8. FoLIC Acid 1 mg PO DAILY
9. Lorazepam 0.5 mg PO Q4H:PRN nausea
10. Ranitidine 150 mg PO DAILY
11. Stribild *NF* (elvitegr-cobicist-emtric-tenof)
___ mg Oral daily
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. Promethazine 25 mg PO Q6H:PRN nausea
14. ValACYclovir 1000 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Right leg pain
Cellulitis
HIV
Osteomyelitis
PICC line DVT.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Right knee, four views, right ankle, three views.
CLINICAL INFORMATION: Pain with overlying erythema.
COMPARISON: None.
FINDINGS:
RIGHT KNEE: Two AP views, oblique, and lateral views of the right knee were
obtained. No evidence of acute fracture or dislocation is seen. There is no
suprapatellar joint effusion. No concerning osteoblastic or lytic lesion is
seen. No cortical destruction is seen.
RIGHT ANKLE: Three views of the right ankle were obtained. No acute fracture
or dislocation is seen. The ankle mortise and talar dome are intact. No
concerning osteoblastic or lytic lesion is seen. No radiopaque foreign body
is seen.
IMPRESSION: No fracture or dislocation. No cortical destruction to suggest
acute osteomyelitis, however, MRI is more sensitive.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: RT ANIKLE INFECTION
Diagnosed with CELLULITIS OF LEG
temperature: 98.8
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 119.0
dbp: 88.0
level of pain: 10
level of acuity: 3.0 | ___ with HIV, immunocompromised status, recent treatments for
osteomyelitis and vaginal herpes, presented with new right leg
pain, erythema over the knee and ankle, concerning for
cellulitis and possibly septic arthritis. No tapable joint
effusions were found in the ED or on floor. She was started on
vancomycin with improvement in all of her symptoms - decreased
erythema, decreased pain and resolution of mild right ankle
swelling. She was noncompliant throughout her hospitalization
with blood draws and anticoagulation. She refused to have her IV
replaced ___ and ___ and refused oral
antibiotics. On ___ She stated she was leaving despite
explanation of the consequences of untreated infection in her
immunocompromised state. She was informed that she would be
leaving against medical advice but insisted that she would
leave anyway. She subsequently changed her mind and agreed to IV
replacement and vancomycin, but continued to refuse blood draws
and anticoagulation. Cancelled her ID follow up on ___ stating
she would seek care at ___. Explained again on ___ am that she
needs IV vancomycin for 5 days or faces possibly severe, life
threatening infection. Explained she needs ID follow up for this
reason also. On ___ AM Dr. ___ PCP intern, called
her at bedside and persuaded her to stay in the hospital and
come to an earlier follow appointment with her. On ___ through
___, repeatedly explained again the importance of keeping her
follow up appointments as she is transferring her care. On day
of discharge, the patient refused to have an IV placed (her
current PIV had infiltrated, refused her last doses of
vancomycin and left against medical advice.
.
# Right leg cellulitis: She denies trauma to this area recently.
No findings of joint infection. improved on vancomycin but has
refused her last doses ___ pm [partial dose] and ___ am).
Previously reviewed informally with infectious disease consult
with plan to change to doxycycline and continue augmentin for
her osteomyelitis if she leaves AMA. Otherwise had planned for 5
days IV vancomycin.
Have not been able to complete vancomycin for a 5 day course
since she insisted on leaving against medical advice. As
discussed with ID, will continue doxycycline po x 5 days. Did
not place PICC line in her because of recent PICC line
associated DVT and ongoing noncompliance with enoxaparin even
while she has been hospitalized. ___ decreased vancomycin to
750mg IV Q12H for trough=25 on 1000 mg IV Q12H
.
# Noncompliance with danger to self: Throughout her
hospitalization, she persistently refused blood draws, refused
enoxaparin (in setting of recent RUE DVT just weeks prior to
admission), and intermittantly refused antibiotics, IVs and
physical exam. Intermittantly threatened to leave AMA. Cancelled
her ID follow up on ___ stating she would seek care at ___. She
saw social work ___ who persuaded her to remain in hospital for
her antibiotics and have IV replaced. Ultimately, she refused
her last doses of vancomycin and left against medical advice. It
was explained to her that her infection was not completely
treated and she should take 5 days of Doxycycline and keep her
follow up appointments next week and in ___ with her new PCP.
.
# Headache: Reported ___ for first time (though she stated
she had symptoms for 2 days). Reported that she felt like "the
right half of her face is dizzy" and noted poorly described
visual changes. no meningismus. She reported, right sided pain
facial and temporal head pain and some photophobia that became
worse with dilated optho exam. Symptoms resolved with fioracet
and naproxen.
.
# Visual changes: seen by opthalmology ___ with normal exam,
she is near sighted and requires glasses but has not filled her
prescription recieved from outside.
# Neutropenia: chronic likely HIV related. Her normal WBC on
admission was an elevation of her baseline counts. monitored.
Patient was advised to seek medical attention for fevers > 101.
.
# Right leg pain: resolved with treatment of cellulitis.
initially required IV morphine then oral dilaudid.
.
# HIV: continued ART, prophy meds. Contacted ID and they were
made aware of patient's admission.
.
# Maxillary osteomyelitis: continued Augmentin - ID advises a
six week course from day of surgical debridement and start of
antibiotics ___. Advised patient to continue augmentin Q12H
until ___ and to contact her PCP if she runs out of
medication.
.
# Nausea: anti-emetics prn. monitored closely.
.
# RUE DVT post PICC line: Noted on last admission (___).
Treated with enoxaparin. Patient discontinued her injections
prior to her admission. She was restarted on anticoagulation at
the time of this hospital admission but remained noncompliant
throughout her hospitalization despite numerous warnings about
potentially life threatening complications from pulmonary
embolism.
.
# Vaginal herpes - resolved per pt. continued acyclovir in house
and restarted valacyclovir (her home medication) at ___.
.
# Tobacco use - defers nicotine patch.
.
# DVT Prophy - continued enoxaparin though she refused to take
this medication throughout her hospitalization. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yo M with metastatic renal CA s/p IL-2 and Avastin
and most recently Sunitinib who recent cord compression s/p T8
laminectomy and radiation on ___ and C6 Corpectomy and C5-7
anterior fusion on ___ who presented with ___ days of
worsening back pain. Patient had been doing well since his last
surgery ~2 weeks ago but reports that this pain began earlier
this week when he was walking to the kitchen and felt he "threw
out" his back. The pain continued to escalate this week up to
the point that he was unable to move due to excrutiating pain.
He increased is dilaudid dose to 32 mg Q2H and this brought the
pain down to ___ at most. He denies any urinary or bowel
incontinence but it has been hard to get to the bathroom due to
pain. Also his appetite has been poor and he has not been eating
well.
In the ___, VS: 98.0 116 135/80 16 97% RA. The patient was unable
to tolerate MRI secondary to severe pain. He was given
hydromorphone IV. After discussion with the patient's oncologist
Dr. ___ was decided the patient could have an MRI later this
evening or in the morning once he had better pain control.
Neurosurgery was consulted and deemed no active neurosurgical
issues but recommended re-imaging and pain control. Neurology
was consulted and recommended continue adequate pain control and
MRI of the C/T/L spine to see if extension of disease. Rectal
exam was done and pt had normal tone.
Patient was given 3x 2mg IV dilaudid.
Consulting services were neurology and neurosurgery
Final vitals prior to transfer were 98.8 °F (37.1 °C), Pulse:
100, RR: 16, BP: 103/82, O2Sat: 96, O2Flow: ra
Access 20GA R hand
IVF 3L NS
Review of Systems:
(+) Per HPI. (+) Chills, diplopia (unchanged).
(-) Denies fever, night sweats, blurry vision, loss of vision.
Denies headache. Denies chest pain or tightness, palpitations.
Denies cough, shortness of breath. Denies nausea, vomiting,
diarrhea, constipation. Denies dysuria, stool or urine
incontinence. No new weakness in extremities but limited
movement due to pain. All other systems negative.
Past Medical History:
- presented to ___ in ___ c/o abdominal pain and gross
hematuria. CT scan performed and showed a 14-cm tumor on his
left kidney.
- ___: underwent a radical left nephrectomy which showed a
14 x 14 x 10 cm tumor that was of clear cell type, firm and
nuclear grade ___. There was evidence of tumor thrombus
extending
into a large muscular vein at the hilum of the kidney. His left
adrenal gland was removed and was negative for tumor. ___ hilar
lymph nodes, ___ paraaortic lymph nodes and a small bowel lymph
node obtained was negative for malignancy.
- ___: suffered a traumatic work-related fall (fell 25
feet
off a ladder). Standard trauma x-rays and a nonenhanced CT,
showed the presence of new pulmonary nodules.
- ___ CT TORSO: innumerable pulmonary metastases, bulky
mediastinal lymphadenopathy.
- ___: FNA right upper lobe lung nodules showed malignant
cells consistent with metastatic clear cell carcinoma of the
kidney
___: Started on IL-2; received 10 out of 14 doses, first
week was complicated by encephalopathy and the second week was
complicated by renal failure, transaminitis and Staph
epidermitis
bacteremia s/p Vancomycin
- ___ chest CT, no evidence of progression of metastatic
disease
- ___ CT TORSO: progression of disease
- ___: Started Avastin 10mg/kg q2 weeks; CT ___ showed
stable disease
- ___: Cyberknife to subcarinal mass; 2400 cGy in 3
fractions. Avastin on hold.
- ___: Restarted Avastin every 2 weeks.
- ___: Admitted for severe neck pain, MRI showed
degenerative
disc disease. Avastin on hold.
- ___: CT with disease progression in lytic lesions, slight
progression of chest disease
- ___: Avastin resumed 10mg/kg q2 weeks.
- ___: Admitted to ___ with progressive disease
and worsening pain, started on Sunitinib on ___ at a dose of
37.5 mg daily for 4 weeks on, 2 weeks off.
- ___: started cycle 2 of Sunitinib
- ___: presented with RLE weakness and found to have cord
compression at T8; underwent laminectomy on ___. Admitted
___.
___ MRI: new mass lesion in the right petrous apex
and clivus in close proximity to the right sixth cranial nerve.
- ___: radiation to T5-T9, C2-T3, right clivus.
- ___: C6 Corpectomy and C5-7 anterior fusion
.
PAST MEDICAL HISTORY:
GERD
s/p appendectomy at age ___ 25ft fall; suffered bilateral calcaneal fractures,
bilateral tibial fractures, L2 fracture
s/p IVC filter
Depression
Anxiety
Social History:
___
Family History:
Mother had breast cancer but died of alcohol abuse. His brother
also has alcoholic liver disease.
Physical Exam:
Vitals - 98.9 125/80 109 18 96% RA
GENERAL: Uncomfortable due to pain but NAD. Wearing ___ J
brace.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM, nontender supple neck, no LAD
CARDIAC: Regular tachycardia, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: Limited due to neck brace and pain but no gross
abnormalities noted. Refused rectal exam given that it had been
done in ___.
Pertinent Results:
___ 03:10PM GLUCOSE-97 UREA N-20 CREAT-0.9 SODIUM-140
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
___ 03:10PM WBC-4.2 RBC-3.37* HGB-9.5* HCT-29.8* MCV-88
MCH-28.2 MCHC-32.0 RDW-18.2*
___ 03:10PM NEUTS-76* BANDS-1 LYMPHS-14* MONOS-6 EOS-3
BASOS-0 ___ MYELOS-0
___ 03:10PM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 03:10PM PLT SMR-LOW PLT COUNT-162#
___ 03:10PM ___ PTT-33.8 ___
.
___ MRI of spine (prior to neurosurgery): IMPRESSION:
Marked relatively short-interval progression of the widespread,
extensive osseous metastatic disease, as detailed above. Most
concerning are:
1. Malignant compression fracture of the C6 vertebral body,
with significant collapse, angular kyphosis and retropulsion of
its dorsal cortex. There is marked canal stenosis and cord
compression at this level, without evidence of cytotoxic edema
within the cord substance at this time.
2. Extensive paraosseous soft tissue mass involving the T2
vertebral body and its posterior elements with large epidural
soft tissue component and cord displacement and effacement;
again, there is no definite abnormality of spinal cord signal at
this level.
3. Destruction of the T8 right posterior elements and
associated rib, with large paraosseous soft tissue mass.
4. Involvement of the T11 and L1 vertebrae with retropulsion of
their dorsal cortex, but no significant canal compromise or
thecal compression.
5. Large lesion in the "superior sulcus" of the right
hemithorax; brachial plexus involvement is not fully assessed on
this examination, but is a consideration.
.
___ MRI of Spine: CONCLUSION: Extensive metastatic disease.
No evidence of tumor progression in the interval since the ___ spine MR. ___ post interval cervical decompression with
no evidence of cord compression. Metastases at T2 and T11
encroach on the spinal cord, unchanged since the prior study.
Decrease in the volume of fluid at the thoracic laminectomy
site. This no longer encroaches on the spinal cord or canal.
Medications on Admission:
1. methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*126 Tablet(s)* Refills:*0*
2. sertraline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (___).
Disp:*90 Tablet(s)* Refills:*2*
4. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
Disp:*270 Capsule(s)* Refills:*2*
5. levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*.
8. everolimus 10 mg Tablet Sig: One (1) Tablet PO daily ().
9. Dilaudid 8 mg Tablet Sig: ___ Tablets PO q2h as needed for
pain.
Disp:*90 Tablet(s)* Refills:*2
10.clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for Anxiety/pain.
Discharge Medications:
1. methadone 10 mg Tablet Sig: Four (4) Tablet PO BID (2 times a
day).
Disp:*240 Tablet(s)* Refills:*0*
2. methadone 10 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
Disp:*90 Tablet(s)* Refills:*0*
3. sertraline 50 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO THREE TIMES WEEKLY ON MON WED FRI ().
Disp:*20 Tablet(s)* Refills:*2*
5. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
6. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
9. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for Anxiety/pain.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. everolimus 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO twice a day
for 7 days: Then take one and ___ tablets (3mg) and ask Dr.
___ when to lower the dose again.
Disp:*70 Tablet(s)* Refills:*1*
13. hydromorphone 8 mg Tablet Sig: ___ Tablets PO Q3H: PRN as
needed for pain.
Disp:*200 Tablet(s)* Refills:*0*
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Back pain due to spinal metastases
Metastatic renal cell cancer
Urinary retention
Pancytopenia (low blood counts)
Depression
Hypothyroidism
GERD
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
MR CERVICAL, THORACIC AND LUMBAR SPINE ___
HISTORY: Hepatocellular carcinoma with extensive metastatic disease and
worsening back pain.
Sagittal imaging was performed with long TR, long TE fast spin echo, short TR,
short TE spin echo, and STIR technique. Axial long TR, long TE fast spin echo
imaging was performed. After administration of 7 mL of Gadovist intravenous
contrast, sagittal short TR, short TE spin echo imaging was performed through
the spine with axial short TR, short TE images through selected levels.
Comparison to a cervical and thoracic spine MR of ___.
FINDINGS: In the interval, there has been decompression of the cervical cord
with a C6 corpectomy and anterior fusion from C5-C7. This has relieved the
cord compression present on the prior study. However, extensive metastatic
disease persists, involving nearly every visualized vertebral body. In spite
of this extensive metastatic disease, there is actual cord encroachment due to
tumor only at the T2 level, where it involves the right pedicle and lamina and
encroaches upon the spinal cord from a side, and at T11 where it gross out of
the posterior margin of the vertebral body to encroach on the spinal canal.
There is a tiny midline disc protrusion at T8-9 that indents the spinal canal
and slightly flattens the anterior surface of the spinal cord. There is no
evidence of worsening of metastatic disease since the ___ examination.
Again seen, the patient is status post laminectomy from T6 through T10. There
is a persistent fluid collection at the surgical site, smaller than on the
study of ___. There is now no encroachment on the spinal cord or the
canal by this collection.
The extensive metastases enhance after contrast administration. There is no
evidence of leptomeningeal enhancement.
CONCLUSION: Extensive metastatic disease. No evidence of tumor progression
in the interval since the ___ spine MR.
___ post interval cervical decompression with no evidence of cord
compression.
Metastases at T2 and T11 encroach on the spinal cord, unchanged since the
prior study.
Decrease in the volume of fluid at the thoracic laminectomy site. This no
longer encroaches on the spinal cord or canal.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: BACK PAIN
Diagnosed with BACKACHE NOS, MALIG NEOPL KIDNEY
temperature: 98.0
heartrate: 116.0
resprate: 16.0
o2sat: 97.0
sbp: 135.0
dbp: 80.0
level of pain: 10
level of acuity: 2.0 | Brief Assessment: Admitted with much worse lumbosacral pain
after recent C6 corpectomy and C5-7 anterior Fusion for
malignant compression fracture and rapid progression of spinal
mets from ___ while on therapy. Presentation was worrisome for
progression of known spinal metastases and recurrent cord
compression. Initially the patient required high doses of IV
dilaudid for pain control. Because the patient was unable to
undergo MRI except under anesthesia, he was started on high dose
steroids since this would also be an effective treatment for
pain from bone metastases. MRI under anesthesia subsequently
ruled out cord compression. The patient was seen in consultation
with the palliative care service and his pain medications were
titrated up with much improved pain control.
.
# Back pain due to cancer w/o impending cord compression: No
neurologic deficits on admission exam but presentation had been
concerning for impending cord compression given the tempo of his
disease. The patient was unable to tolerate MRI without
anesthesia due to pain and anxiety. Steroids started empirically
for pain and he ruled out for cord compression on ___ by MRI
under anesthesia. He will continue Decadron 4mg Q12 given his
improved pain even though he has no cord compression. He will
taper the dose gradually with a decrease in 1 week to 3 mg Q12.
Dr. ___ primary oncology fellow) will taper his dose
further as outpatient. Methadone dose was titrated up to
40mg-40mg-30mg which he will continue as an outpatient. He will
continue po dilaudid ___ mg Q3H:PRN as well as scheduled
gabapentin. He was advised by the neurosurgery service that he
must wear an Aspen collar at all times even during meals for
next two to three months until advised otherwise b the
neurosurgical service.
.
# Urinary retention: required a foley catheter at the time of
admission (probably due to increase narcotic dose). Foley was
DC'd without difficulty prior to discharge.
.
# Pancytopenia: etiology unclear. Has received extensive XRT to
spine in the past and has extensive ___ metastases so may be
the result of decreased marrow reserve and marrow infiltration.
Did not require transfusion.
.
# HCC: Currently on afinitor (evirolimus). Discussed with
primary oncologist. The patient was restarted on his therapy as
soon as drug was procured and consent obtained. Glu was
monitored carefully without findings of hyperglycemia since MTOR
inhibitors can alter insulin uptake and cause severe
hyperglycemia in setting of steroids. The patient had no
findings of hyperglycemia on afinitor and decadron.
.
# Depression: Continued on sertraline.
.
# Hypothyroidism: continued on levothyroxine at 150mcg.
.
# GERD: continued on ppi.
.
# Hypophosphatemia: repleted po.
.
# Elevated LFTs: trended daily.
.
# PPx: bowel regimen and SQ heparin (cleared with neurosurgery)
.
# Precautions: Hx of positive MRSA screen. Kept on fall
precautions.
.
# Code status: FULL |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/metastatic renal cell carcinoma s/p radical left
nephrectomy and adrenalectomy presents with hyperkalemia. Pt was
seen in ___ clinic today to enrole in new trial and had
routine blood work drawn which showed hyperkalemia and ___.
In ED pt given 1Lns, insulin and dextrose.
On arrival to the floor pt denies CP, leg cramping. No recent
injuries, bruising or medication changes. Reports good PO
intake, denies N/V/D. +Constipation up until yesterday. No
changes in urination. Denies dysuria. Also w/fatigue and mild
SOB, relived with nebs.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
PAST ONCOLOGIC HISTORY (per ___ discharge summary):
___ - left radical nephrectomy and adrenalectomy for an 8 cm
conventional clear cell carcinoma (grade 3) presenting as
hematuria.
___ - recurrence in the left ilium (biopsy-documented)
presenting as hip pain. This was treated with radiation therapy
by Dr. ___ (Radiation Oncology, ___.
___ - development of mediastinal lymphadenopathy shown by
transbronchial biopsy to be metastatic renal cell carcinoma,
also treated with radiation therapy by Dr. ___.
___ - development of a large right adrenal mass on CT scan.
The patient was also noted to have small subcentimeter lung
nodules as well, presumably metastatic disease.
___ - Consented for protocol ___, Tivozanib
___ - Tivozanib, protocol ___ C1D1. C6, the first week of
treatment was held because of elevated lipase which resolved.
___ - start of Tivozanib extension trial ___. Last dose
was ___ due to progression of disease at nearly every site
including hilar LNs, paraesophagel node, right adrenal mass.
___ - started protocol ___ (BKM120/Avastin)
PAST MEDICAL HISTORY (per ___ discharge summary):
Peptic ulcer disease with h/o remote UGI bleed
Hypertension
Hyperlipidemia
COPD
S/p tonsillectomy
Social History:
___
Family History:
Mother died of renal failure in the setting of congenital single
kidney. Father died of stroke. Son with seizure disorder and
recent stroke. Daughter died of heroin overdose.
Physical Exam:
Admission Exam:
Vitals: T:98.1 BP:118/54 P: R: O2:
PAIN: 0
General: nad
Lungs: scattered expiratory wheezing
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Discharge exam:
AVSS
Weight 147.7
General: no apparent distress
Lungs: clear, sparse expiratory wheeze
Cardiac, rr, nl rate
Abd: soft, nontender, nondistended
Ext: warm, well purfused, 1+ bilateral edema to shin
Skin: no rash
Neuro: alert, oriented, good attention, ambulates with cane
Pertinent Results:
___ 03:10PM BLOOD WBC-9.0 RBC-3.71* Hgb-8.8* Hct-30.8*
MCV-83 MCH-23.6* MCHC-28.4* RDW-16.8* Plt ___
___ 08:15PM BLOOD ___ PTT-32.2 ___
___ 03:10PM BLOOD UreaN-85* Creat-3.4*# Na-132* K-6.6*
Cl-97 HCO3-20* AnGap-22*
___ 07:45AM BLOOD UreaN-71* Creat-2.9* Na-137 K-4.0 Cl-96
HCO3-31 AnGap-14
___ 03:10PM BLOOD ALT-20 AST-25 AlkPhos-156* TotBili-0.3
___ 03:10PM BLOOD Albumin-3.6 Calcium-9.3 Phos-7.0*#
Mg-3.1*
___ 07:40AM BLOOD Calcium-8.8 Phos-5.3* Mg-2.0
CXR: 1. Increased heart size, consistent with cardiomegaly
and/or pericardial effusion. 2. Mild, if any, pulmonary edema.
3. Bilateral small to moderate pleural effusions with associated
bibasilar atelectasis.
TTE: IMPRESSION: Normal biventricular regional/global systolic
function. Mild to moderate mitral regurgitation. Grade II left
ventricular diastolic dysfunction. Moderate pulmonary
hypertension. Moderate to severe tricuspid regurgitation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nausea *Research Pharmacy
Approval Required* Research protocol ___
2. ipratropium-albuterol ___ mcg/actuation inhalation q4 prn
wheezing *Research Pharmacy Approval Required* Research
protocol ___
3. everolimus 10 mg oral daily *Research Pharmacy Approval
Required* Research protocol ___
4. Metoprolol Succinate XL 50 mg PO DAILY *Research Pharmacy
Approval Required* Research protocol ___
5. Docusate Sodium 100 mg PO BID *Research Pharmacy Approval
Required* Research protocol ___
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation *Research
Pharmacy Approval Required* Research protocol ___
7. Senna 8.6 mg PO BID
8. Ranitidine 150 mg PO BID *Research Pharmacy Approval
Required* Research protocol ___
9. Furosemide 40 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
10. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
11. Omeprazole 20 mg PO DAILY
12. Aspirin 325 mg PO DAILY
13. Morphine SR (MS ___ 30 mg PO Q12H *Research Pharmacy
Approval Required* Research protocol ___
Discharge Medications:
1. Aspirin 325 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
2. Docusate Sodium 100 mg PO BID *Research Pharmacy Approval
Required* Research protocol ___
3. Metoprolol Succinate XL 50 mg PO DAILY *Research Pharmacy
Approval Required* Research protocol ___
4. Morphine SR (MS ___ 15 mg PO Q12H *Research Pharmacy
Approval Required* Research protocol ___
RX *morphine [MS ___ 15 mg 1 tablet extended release(s) by
mouth twice per day Disp #*30 Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
6. Ondansetron 4 mg PO Q8H:PRN nausea *Research Pharmacy
Approval Required* Research protocol ___
7. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation *Research
Pharmacy Approval Required* Research protocol ___
9. Ranitidine 150 mg PO BID *Research Pharmacy Approval
Required* Research protocol ___
10. Senna 8.6 mg PO BID
11. Torsemide 80 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
RX *torsemide 20 mg 4 tablet(s) by mouth daily Disp #*120 Tablet
Refills:*0
12. everolimus 10 mg oral daily *Research Pharmacy Approval
Required* Research protocol ___
13. ipratropium-albuterol ___ mcg/actuation inhalation q4 prn
wheezing *Research Pharmacy Approval Required* Research
protocol ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute kidney injury
Chronic kidney disease stage III
Acute on chronic diastolic heart failure
Hyperkalemia
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Acute kidney injury, with a recent diagnosis of diastolic heart
failure. Evaluate for evidence of heart failure.
COMPARISON: Chest radiograph from ___.
FINDINGS:
A portable frontal chest radiograph demonstrates interval increase in the
heart size, which is consistent with cardiomegaly and/or pericardial effusion.
There is mild, if any, pulmonary edema. Bilateral pleural effusions are small
to moderate in size, with associated bibasilar atelectasis. There is no
pneumothorax.
IMPRESSION:
1. Increased heart size, consistent with cardiomegaly and/or pericardial
effusion.
2. Mild, if any, pulmonary edema.
3. Bilateral small to moderate pleural effusions with associated bibasilar
atelectasis.
These findings were communicated via telephone by Dr. ___ to Dr.
___ at 1741 on ___.
Radiology Report
HISTORY: Status post left nephrectomy with worsening renal function and known
mass compressing the right kidney. Evaluate right kidney.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
The patient is status post left nephrectomy. The right kidney is normal in
size, measuring 11.8 cm. There are multiple thin-walled anechoic lesions
throughout the right kidney, compatible with simple cysts, measuring up to 3.7
x 3.4 x 2.8 cm in the upper pole, not significantly changed compared to the
prior CT from ___, allowing for differences in modality. A tiny
hyperdense lesion in the interpolar region seen on the prior CT is not
identified on today's study. No suspicious renal lesions are identified.
There is no hydronephrosis or nephrolithiasis. A large heterogeneous mass
adjacent to the anterior and superior aspect of the right kidney is
incompletely assessed on today's study, measuring up to at least 5.9 cm in the
axial plane, better evaluated on the prior CT from ___. As on
the prior CT this mass appears separate from the right kidney in almost all
planes, with one area of contact along its inferior aspect, and is most likely
centered in the right adrenal. The bladder is grossly unremarkable.
Color and spectral Doppler imaging was performed of the renal vasculature.
The right main renal artery demonstrates a sharp systolic upstroke and forward
flow throughout diastole, with a resistive index of 0.90. The resistive
indices within the intrarenal arteries were measured slightly more centrally
than usual, in the segmental arteries, but are elevated throughout, measuring
0.98, 0.92, and 0.86 in the upper pole, interpolar region, and lower pole,
respectively. The main renal vein is patent, with appropriate directional
flow.
IMPRESSION:
1. Increased resistive indices within the main renal artery and its segmental
branches, non-specific in nature. This can be due to chronic hypertension or
underlying medical renal disease if such conditions exist; it is possible that
increased outflow pressure related to renal vein compression by the known
adjacent mass could contribute. The main renal vein is patent, however.
Further evaluation of the renal vein could be performed with a dedicated MRI.
2. No hydronephrosis.
Findings and recommendations were discussed with Dr. ___ by Dr. ___
at 5:46 p.m. via telephone on the day of the study, 30 minutes after
discovery.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: HYPERKALEMIA
Diagnosed with HYPERKALEMIA
temperature: 98.1
heartrate: 66.0
resprate: 18.0
o2sat: 94.0
sbp: 115.0
dbp: 40.0
level of pain: 0
level of acuity: 2.0 | ___ with metastatic renal cell carcinoma s/p radical left
nephrectomy and adrenalectomy presents with acute renal failure,
hyperkalemia, acute on chronic diastolic heart failure. He was
treated with diuresis with improvement in his ARF, potassium and
heart failure.
# Acute renal failure:
# Chronic kidney disease stage III:
This is likely from compressive effects on the right kidney as
well has acute on chronic heart failure. He was treated with
aggressive diuresis with some improvement of his kidney
function. His creatinine was 2.9 at the time of discharge.
Nephrology was consulted and recommended to continue diuresis.
# Acute on chronic diastolic heart failure:
He presented with fluid overload. He was significantly above his
dry weight which has yet to be determined. According to OMR he
has been as low as ~130 pounds. At the time of discharge he was
147 pounds. He continued to be fluid overloaded at the time of
discharge. We are discharging him with 80mg of torsemide daily.
He was instructed weigh himself daily. If he gains more than 3
pounds he will contact hematology for further recommendations
with his diuretics. He will have labs on ___ to make sure his
electrolytes and BUN/Cr are tolerating diuresis. He will follow
in heart failure clinic next week for further evaluation and
management of his diastolic heart failure. He was educated on a
low sodium diet.
# Hyperkalemia:
This improved with diuresis. At the time of discharge his
potassium was normal.
# Metastatic renal cell carcinoma:
He will follow up with oncology in clinic next week to discuss
treatment options. He was continued on a decreased dose of his
morphine regimen (which he appeared to be tolerating well). With
the change in renal function he may not metabolize this
medication as well.
# Anemia:
Hematocrit was stable. No evidence of bleed.
DNR/DNI: confirmed with pt on admission
CONTACT: HCP ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Syncope/PNA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with CAD, AAA, severe aortic stenosis, squamous NSCLC stage
IIIa and gastric GIST now on C1D23 ___ with XRT
presenting to the ED with pre-syncope and hypotension.
His oncologic hx briefly is as follows: In late ___ and early
___ he was found to have a mass on pre-operative evaluation for
his AAA with a CT Chest showing a 3cm LUL mass with partial
hilar and mediastinal invasion and local lymphadenopathy--bx
showed this to be squamous cell. In subsequent workup also was
found to have a greater curvature stomach mass with moderate FDG
avidity with FNA showing GIST.
In the last 3 days, patient developed a productive cough with
brown sputum at home that kept him awake overnight. He has
thusfar been treated with 3 days of Levaquin.
On ___, he presented to the ED for crampy abdominal pain after
bending during chemo. When he straightened up, the pain
resolved. At that time, he had dizziness when walking, but
resolved spontaneously. Orthostatics were negative that day at
XRT (lying 94/50, sitting 104/64, standing 90/58).
Today, he was in ___ for radiation treatment for
lung cancer when he developed sudden onset dizziness and
lethargy. He was found to have SBP in the 70's. Pt also reports
also having intermittent L eye "flashes" x 30min which have
resolved. Per radiation oncology note: he has not been
eating/drinking for
past few days.
In the ED initial vitals were: 98.3 77 ___ 18 95%.
On ED exam ntoed to have +2 pitting edema.
Lactate 1.5. Chem 7 grossly nl. Tn negative.
WBC 2.7 with ANC of 2300. Plt 141 down from 177 two days ago.
HgB 12.1 down from usual baseline ~14 but consistent with recent
baseline of ~12.4.BCx are pending.
CTA showed unchanged fusiform partially thrombosed infrarenal
7.4 AAA, without evidence of impending rupture. LUL and LLL
opacities concerning for PNA and no PE. Decreased size of the
left upper lobe mass, with area of paramediastinal
consolidation, likely related to radiation effect and unchanged
soft tissue mass at the greater curvature of the stomach
possibly representing previously seen GIST.
He was given 1L NS, Cefepime/Azithromycin.
Past Medical History:
ONCOLOGIC HISTORY:
___: pre-operative evaluation for an aortic aneurysm repair,
the patient was found to have a lung nodule.
___: CT Chest showed a large 3cm plus left upper lobe mass
with signs of partial hilar and mediastinal invasion and local
lymphadenopathy
___: PET showed the left upper lobe mass was FDG avid as was
the FDG avid left hilar and left paratracheal lymph nodes. There
was note of an exophytic mass measuring 2.4 x 3.7 cm which
appears to arise from the greater curvature of the stomach, with
moderate FDG avidity
___: A biopsy of the main lung lesion and level 4L nodal
station were performed by Interventional Pulmonary on ___
and disclosed a squamous cell carcinoma. The cells expressed by
immunohistochemistry p63 and cytokeratin ___, but not TTF-1,
Napsin A, synaptophysin or chromogranin. This is consistent with
nonsmall cell lung cancer
___: MRI head showed no evidence of intracranial metastatic
disease
___: FNA of gastric lesion shows GIST
PAST MEDICAL HISTORY:
1. Nonsmall cell lung cancer as above.
2. GIST (gastric)
3. Prostate cancer, localized, treated with definitive
radiotherapy on ___. By report, undetectable PSA
4. Hypertension
5. Hyperlipidemia
6. Coronary artery disease status post medical/stent management
7. Severe peripheral vascular disease with > 6cm aortic
aneurysm
8. Status post vascular surgery legs
9. Status post right knee replacement
10. Severe aortic stenosis (by echo)
Social History:
___
Family History:
FAMILY HISTORY: The patient's mother died from breast cancer at
early age. No other history of cancer in the family.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.0, 118/80, 80, 18, 98RA
GEN: Pleasant male in NAD
HEENT: EOMI, sclera anicteric, dry mucous membranes
NECK: No LAD, no JVD appreciated
LUNGS: CTA b/l, no w/r/r
CARDIAC: III/VI late peaking SEM heard best at ___. No rubs or
gallops
ABDOMEN: +BS, NTND
EXTREMITIES: B/l edema, worse in left lower leg (reports chronic
___ surgery)
DISCHARGE PHYSICAL EXAM
99.9 122/84 75 18 98RA
GEN: Pleasant male in NAD
HEENT: EOMI, sclera anicteric, dry mucous membranes
NECK: No LAD, no JVD appreciated
LUNGS: CTA b/l, no w/r/r
CARDIAC: III/VI late peaking SEM heard best at RUSB. No rubs or
gallops
ABDOMEN: +BS, NTND
EXTREMITIES: B/l edema, worse in left lower leg (reports chronic
___ surgery)
Pertinent Results:
ADMISSION
___ 01:03PM BLOOD WBC-2.7* RBC-4.34* Hgb-12.1* Hct-36.8*
MCV-85 MCH-27.8 MCHC-32.8 RDW-15.1 Plt ___
___ 01:03PM BLOOD Neuts-85.5* Lymphs-9.4* Monos-3.4 Eos-0.7
Baso-1.1
___ 01:03PM BLOOD Plt ___
___ 01:15PM BLOOD Glucose-126* UreaN-28* Creat-1.2 Na-137
K-4.3 Cl-100 HCO3-26 AnGap-15
___ 06:35AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.6
___ 01:20PM BLOOD Lactate-1.5
IMAGING
ECHO ___: LVEF 50-55%. Severe aortic valve stenosis (valve
area <1.0cm2). Trace aortic regurgitation is seen. Mild
symmetric left ventricular hypertrophy with top normal left
ventricular cavity size and low-normal systolic function. Normal
right ventricular cavity size and systolic function.
___ MR HEAD W/ and W/O CONTRAST:
1. No evidence of intracranial metastatic disease.
2. No acute infarct or hemorrhage.
3. Nonspecific white matter changes, compatible small-vessel
ischemic disease
in a patient of this age.
CTA TORSO: ___
. Unchanged fusiform partially thrombosed infrarenal abdominal
aortic
Preliminary Reportaneurysm, measuring up to 7.4 cm, essentially
unchanged from 2 days prior. No
Preliminary Reportevidence of impending rupture.
Preliminary Report2. Ground-glass opacities in the left upper
and lower lobes are concerning for
Preliminary Reportpneumonia.
Preliminary Report3. No evidence of pulmonary embolism.
Preliminary Report4. Decreased size of the left upper lobe mass,
with area of paramediastinal
Preliminary Reportconsolidation, likely related to radiation
effect.
Preliminary Report5. Unchanged soft tissue mass at the greater
curvature of the stomach,
Preliminary Reportpreviously characterized by PET-CT as FDG
avid, possibly representing a GIST
Preliminary Reporttumor.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Lisinopril 5 mg PO DAILY
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
4. Oxybutynin 15 mg PO DAILY
5. solifenacin 10 mg oral BID
6. Lorazepam 0.5 mg PO Q8H:PRN nausea
7. Carvedilol 12.5 mg PO DAILY
8. NIFEdipine CR 60 mg PO DAILY
9. Pravastatin 80 mg PO QPM
10. Clopidogrel 75 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Aspirin 325 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Ondansetron 8 mg PO Q8H:PRN nausea
3. Oxybutynin 5 mg PO TID
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H
5. Pravastatin 80 mg PO QPM
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Vitamin D ___ UNIT PO DAILY
8. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN pain
9. Levofloxacin 750 mg PO Q24H
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*4 Tablet Refills:*0
10. Aspirin 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Community Acquire Pneumonia
Hypotension from Poor PO intake, Antihypertensives
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA TORSO
INDICATION: History: ___ with known AAA and NSCLC presenting w/ hypotension
and near sycnope. Evaluate for AAA leak and pulmonary embolism.
TECHNIQUE: Chest, Abdomen and Pelvis CTA: Non-contrast and arterial phase
images were acquired through the chest abdomen and pelvis
Oral contrast was not administered
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DLP: 2304 mGy-cm (chest, abdomen and pelvis.
IV Contrast: 130 mL of Omnipaque
COMPARISON: CTA of the abdomen and pelvis from 2 days prior. PET-CT from
___. Chest CT from ___.
FINDINGS:
CHEST: Soft tissue mass in the left upper lobe has decreased in size, since
the CT from ___, now appearing less bulbous, and more elongated,
abutting the upper mediastinum (03:32). These paramediastinal changes may be
secondary to radiation effect. There are scattered ground-glass opacities in
the left upper and lower lobes, concerning for pneumonia. There is no pleural
effusion or pneumothorax. Partially calcified pleural plaques are noted
bilaterally, possibly related to prior asbestos exposure.
The thyroid gland is slightly heterogeneous posteriorly, with no discrete
nodule appreciated. The heart is normal in size with no pericardial effusion.
The aorta and pulmonary arteries enhance uniformly with no evidence of filling
defect, penetrating ulcer, or dissection. Prominent left hilar lymph nodes are
again seen and not significantly changed CT. There is mild thickening of the
mid and distal esophagus, which may represent esophagitis.
ABDOMEN:
The liver again contains at least 3 hypodense lesions, likely representing
cysts. The gallbladder is normal. The pancreas again demonstrates mild fatty
replacement, with no surrounding stranding. There is stable non-specific
haziness in the portocaval space.
The spleen is normal in size and shape. The adrenal glands are slightly
thickened bilaterally, with no discrete mass. The kidneys contain cortical
hypodensities bilaterally, statistically likely representing cysts. There is
no hydronephrosis.
The distal esophagus and stomach are decompressed. Again seen is a soft tissue
mass at the greater curvature of the stomach, measuring approximately 3.6 x
2.1 cm (03:108), previously characterized by PET-CT as FDG avid, possibly
representing a GIST tumor. The small bowel is normal in caliber with no
evidence of inflammation. The appendix and large bowel are unremarkable aside
from scattered sigmoid diverticula, without evidence of diverticulitis. There
is no mesenteric lymphadenopathy, free fluid, or free air.
PELVIS: The bladder is normal appearing. The prostate contains numerous
brachytherapy seeds. There is no free fluid in the pelvis or pelvic sidewall
or inguinal lymphadenopathy. Bilateral fat containing inguinal hernias are
noted.
VESSELS: The visualized descending thoracic aorta is normal in caliber. There
is mild atherosclerotic calcification of the origin of the celiac axis, with
no evidence of high-grade stenosis.
Beginning at the upper abdominal aorta, there is mural thrombus within the
posterior aspect of the aorta (02:48), unchanged from ___. There is a
partially thrombosed fusiform infrarenal abdominal aortic aneurysm,
terminating at the level of the aortic bifurcation, with the maximal
transverse diameter measuring up to 7.4 cm, essentially unchanged from 2 days
prior, accounting for differences in measurement technique.
Morphology of the aneurysm is unchanged with similar narrowing of the lumen
superiorly.
There is no discontinuity of the aortic wall calcifications to suggest rupture
and no indistinctness of the para-aortic soft tissues to suggest impending
rupture. Moderate atherosclerotic calcification involves the iliac vessels
bilaterally, and into the imaged femoral vessels. There is a stable 1.1 cm
aneurysm of the left internal iliac artery.
OSSEOUS STRUCTURES: Multilevel degenerative changes of the thoracolumbar spine
are noted, with loss of disc height and endplate osteophyte formation. No
concerning lytic or sclerotic lesions are identified.
IMPRESSION:
1. Unchanged fusiform partially thrombosed infrarenal abdominal aortic
aneurysm, measuring up to 7.4 cm, essentially unchanged from 2 days prior. No
evidence of impending rupture.
2. Ground-glass opacities in the left upper and lower lobes are concerning for
pneumonia.
3. No evidence of pulmonary embolism.
4. Decreased size of the left upper lobe mass, with area of paramediastinal
consolidation, likely related to radiation effect.
5. Unchanged soft tissue mass at the greater curvature of the stomach,
previously characterized by PET-CT as FDG avid, possibly representing a GIST
tumor.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, Hypotension
Diagnosed with VERTIGO/DIZZINESS
temperature: 98.3
heartrate: 77.0
resprate: 18.0
o2sat: 95.0
sbp: 98.0
dbp: 76.0
level of pain: 0
level of acuity: 2.0 | BRIEF HOSPITAL COURSE
___ with CAD, AAA, severe aortic stenosis, squamous NSCLC stage
IIIa and gastric GIST, C1D23 (Week 4 of 6 weeks ___ with
XRT) had a presyncopal episode during radiation therapy and was
found to have a systolic pressure in the ___ from
combination of poor PO intake and multiple antihypertensives.
Was hydrated initially with bolus and then with maintenance
fluids. Several antihypertensives discontinued including
carvedilol, lisinopril, nifedipine. Home oxybutynin was changed
from 15mg daily to 5mg TID.
Orthostatics negative prior to discharge. No events on
telemetry. Non-focal neurologic exam. Respiratory status
unchanged. Had been on Levofloxacin for outpatient PNA tx--in
house recieved dose of Cefepime/Azithro, transitioned to
CTX/Azithromycin on day of d/c. Shoudl continue Levofloxacin
through ___ to complete a 7 day course of CAP tx.
ACTIVE ISSUES
# HYPOTENSION/PRE-SYNCOPE: Multiple reasons to be orthostatic
including decreased PO intake, current infection with pna, as
well as being preload dependent with severe AS. He is also on
multiple anti-hypertensives which have been decreased recently
due to his requirements decreasing in the setting of chemo and
possibly he is overmedicated currently as well. EKG in ED shows
sinus rhythm with possible P-mitrale. Tellingly, original EKG
taken in context of hypotension did not show tachycardia,
suggesting some level of beta blockade effect. S/p 1L NS in the
ED and by the time patient arrived on floor, appeared near
euvolemia and was placed on gentle maintenance fluids.
Orthostatics negative on day of discharge with pressures in
120s/130s. Nifedipine/Carvedilol/Lisinopril/Solifenacin were
stopped. Oxybutynin was continued at 5mg TID instead of 15mg
daily.
# COMMUNITY ACQUIRE PNA: On review of records, actually does not
meet HCAP criteria. PNA was not controlled with PO Levofloxacin.
Widespread opacities on CTA radiographically interpreted as
pneumonia, could also represent asymmetric pulmonary edema in
setting of possible cardiac event. In ED recieved
Cefepime/Azithro, narrowed to CTX/Azithro on floor. Transitioned
to PO Levofloxacin on discahrge.
# SEVERE AORTIC STENOSIS: As of ___ pt with LVEF 50-55%.
Severe aortic valve stenosis (valve area <1.0cm2). Carvedilol
was held. Consider o/p echo for f/u.
# AAA/PERIPHERAL VASCULAR DZ: Has increased significantly over
the past few months. Per note by Dr. ___ would not be
realistic or ethical to offer him repair even in context of
rupture. However, according to the patients understanding, the
plan is if he tolerates chemotherapy, he would then become a
candidate for AAA repair. Cont ASA/Plavix--should clarify ASA
dosing with vascular surgery as outpatient.
# LEFT EYE FLASHING: Appears to be due to orthostasis. Also
possibly insufficiency related to hypotension in posterior
circulation vs. embolic/Thrombotic TIA. Less likely retinal
detachement. Resolved by arrival on floor.
# NSCLC STAGE IIIA: Squamous cell carcinoma. Now day 25 of
chemotherapy with next scheduled dose to be on day 29 (___).
Cont o/p oncologic treatment plan.
# PANCYTOPENIA: Likely chemo effect.
# GASTRIC GIST: Pt does not appear to be on treatment at this
time. Given slow growing nature of this tumor in conjunction
with other malignancy and multiple cardiac/vascular, there may
not be plans to treat this. Continue with outpatient oncology
plan.
# CAD: Pt denies chest pain at this time. EKG in ED w/o ischemic
changes. Held carvedilol as above. As outpatient, consider
metoprolol instead when pressures stabilize out.
# HX PROSTATE CANCER: Treated with definitive radiotherapy on
___. By report, undetectable PSA.
TRANSITIONAL ISSUES
-- consider outpatient echocardiogram to assess for any
progression of aortic stenosis
-- To continue Levofloxacin through ___ to complete a 7 day
course of treatment for CAP
-- Consider dose reducing ASA from 325mg to 81mg
-- Pt advised to return to hospital immediately in event of
worsening respiratory function
-- For CAD, carvedilolw as held. As outpatient, consider
metoprolol instead when pressures stabilize out. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with a history of breast cancer, NIDDM, DVT (on
Coumadin), osteoporosis who presents with right leg pain and
swelling since ___. Patient states that she noted some
bleeding at the wound site on her right lower leg, and that the
leg has become more painful, red, and swollen since that time.
She states that she presented to her PCP today who recommended
she come to the emergency department for further evaluation. She
denies fevers or chills. She denies cellulitis in the past. She
denies trauma to the leg.
In the ED, initial vitals were: 97.4, HR 105, 156/63, 16, 97%
RA, tachy resolved spontaneously after recheck
Exam: warm, erythematous RLE below knee with ulceration
Labs: lactate 2.1
Imaging:
Right ankle X-ray ___ (wet read):
Soft tissue swelling is seen most prominently over the dorsum of
the right foot and ankle. There is no radiographic evidence of
osteomyelitis. No fracture or dislocations are seen. There are
no significant degenerative changes. The mortise is congruent on
this non stress view. The tibial talar joint space is preserved
and no talar dome osteochondral lesion is identified.
Patient was given 1 g Vanc, lorazepam 0.5 mg, 500 cc IV NS
Had a mild cutaneous eruption with hives on administration with
vancomycin which was treated with Benadryl.
Decision was made to admit given concern for extent of
cellulitis
On the floor, patient is resting comfortably in wheel chair. She
denies fevers, chills, chest pain, shortness of breath.
Past Medical History:
# Right breast cancer (ER positive, HER-2/neu negative) in ___
status post lumpectomy, tamoxifen as well as Arimidex; last
mammogram was neg in ___
# history of left lower extremity thrombophlebitis (in ___, was
on tamoxifen) and stasis dermatitis;
# history of UGIB ___ with blood transfusion, neg
EGD/colonoscopy)
# osteoporosis (bone scan in ___
# OCD with some element of anxiety as well as depression
# L elbow fracture s/p ORIF in ___
# Hyperlipidemia
Social History:
___
Family History:
Father died at ___ of MI. Mother died in ___ of gastric cancer.
No family history of clots/hypercoagulability.
Physical Exam:
==========================
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 133 / 77 84 18 93% RA
Gen: Pleasant, very conversive, NAD. AAOx3
HEENT: Anicteric
CV: RRR, ___ systolic murmur over the precordium (known)
Pulm: No increased WOB. CTAB. No w/r/r
Abd: Soft, NTND.
Ext: WWP. No c/c/e
Skin: Warm, erythematous area on RLE approximately 10 cm in
diameter from ankle to mid leg with 1 cm punctate ulceration. No
purulent drainage, fluctuance, or crepitance. TTP. Venous stasis
changes over anterior shins b/l
Neuro: CNII-XII intact. Moving all extremities spontaneously
Psych: Normal mood/mentation
Access: PIV
==========================
DISCHARGE PHYSICAL EXAM:
Vitals: afebrile 104 / 62, 67 20 97 % on RA
Gen: Pleasant, very conversive, NAD. AAOx3
HEENT: Anicteric
CV: RRR, ___ systolic murmur over the precordium (known)
Pulm: No increased WOB. CTAB. No w/r/r
Abd: Soft, NTND.
Ext: WWP. No c/c/e
Skin: Warm, erythematous area on RLE decreased in size from
yesterday (from ankle to mid leg) with 1 cm punctate ulceration
with purulent drainage. No fluctuance, or crepitance. TTP.
Venous stasis changes over anterior shins b/l
Neuro: CNII-XII intact. Moving all extremities spontaneously
Psych: Normal mood/mentation
Pertinent Results:
ADMISSION LABS:
___ 01:00AM BLOOD WBC-7.9 RBC-4.13 Hgb-12.6 Hct-38.6 MCV-94
MCH-30.5 MCHC-32.6 RDW-13.3 RDWSD-45.8 Plt ___
___ 01:00AM BLOOD Neuts-69.8 Lymphs-14.5* Monos-13.3*
Eos-1.5 Baso-0.6 Im ___ AbsNeut-5.50 AbsLymp-1.14*
AbsMono-1.05* AbsEos-0.12 AbsBaso-0.05
___ 01:00AM BLOOD Glucose-192* UreaN-15 Creat-0.5 Na-137
K-3.8 Cl-98 HCO3-24 AnGap-19
==========================
DISCHARGE LABS:
___ 06:05AM BLOOD WBC-6.5 RBC-4.08 Hgb-12.6 Hct-38.1 MCV-93
MCH-30.9 MCHC-33.1 RDW-13.2 RDWSD-45.7 Plt ___
___ 06:05AM BLOOD Glucose-169* UreaN-16 Creat-0.4 Na-140
K-3.9 Cl-102 HCO3-25 AnGap-17
=========================
IMAGING:
Right Ankle XR ___:
FINDINGS:
Soft tissue swelling is seen most prominently over the dorsum of
the right
ankle. There is no radiographic evidence of osteomyelitis. No
fracture or
dislocations are seen. There are no significant degenerative
changes. The
mortise is congruent on this non stress view. The tibial talar
joint space is
preserved and no talar dome osteochondral lesion is identified.
IMPRESSION:
No radiographic evidence of osteomyelitis.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Ketoconazole 2% 1 Appl TP QHS
3. Warfarin 1 mg PO DAILY16
4. Sertraline 75 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Simvastatin 10 mg PO QPM
7. LORazepam 0.5 mg PO BID:PRN Anxiety
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*40 Capsule Refills:*0
2. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*40 Tablet Refills:*0
3. Warfarin 2.5 mg PO DAILY16
4. Ketoconazole 2% 1 Appl TP QHS
5. Lisinopril 5 mg PO DAILY
6. LORazepam 0.5 mg PO BID:PRN Anxiety
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Sertraline 75 mg PO DAILY
9. Simvastatin 10 mg PO QPM
10.Outpatient Lab Work
Chem 7, INR to be drawn on ___
ICD - 10: I 48.0 (atrial fibrillation), L 03.115 (cellulitis
right leg)
Please fax results to PCP ___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
=============
cellulitis
SECONDARY:
=============
deep vein thrombosis on warfarin
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: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: ___ with diabetes, cellulitis over right ankle. Evaluate for
signs of osteomyelitis
TECHNIQUE: Frontal, oblique, and lateral view radiographs of right ankle
COMPARISON: None
FINDINGS:
Soft tissue swelling is seen most prominently over the dorsum of the right
ankle. There is no radiographic evidence of osteomyelitis. No fracture or
dislocations are seen. There are no significant degenerative changes. The
mortise is congruent on this non stress view. The tibial talar joint space is
preserved and no talar dome osteochondral lesion is identified.
IMPRESSION:
No radiographic evidence of osteomyelitis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Leg pain
Diagnosed with Cellulitis of left lower limb
temperature: 97.4
heartrate: 105.0
resprate: 16.0
o2sat: 97.0
sbp: 156.0
dbp: 63.0
level of pain: 10
level of acuity: 3.0 | ___ yo female with a history of breast cancer, NIDDM, DVT (on
Coumadin), osteoporosis who presented with RLE cellulitis.
# RLE Cellulitis: Large-sized area of cellulitis on RLE with
ulceration, suspect skin flora with ulcer site as portal of
entry. No signs of osteo on x-ray and no signs of abscess
clinically. Area of erythema improving prior to discharge.
Cephalexin plus Bactrim for MRSA coverage given purulent
drainage on admission. Duration should be 10 days (last day
___. Should continue dressing changes QD and PRN. Follow
up with podiatry/wound care clinic is recommended.
# Hx of DVT: Remote hx in setting of malignancy. On Coumadin.
Patient stopped 2 days prior in setting of bleeding from leg
ulcer. Continued warfarin at lower dose 2.5 mg
CHRONIC ISSUES:
==========================
# Diabetes: Well controlled on metformin.
# Hypertension: Continued home lisinopril
# Depression/Anxiety: Continued home sertraline and lorazepam
# Hyperlipidemia: Continued home Simvastatin 10 mg PO QPM |
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, vomiting, eating disorder
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ F with a history of an eating disorder with
recent admission for bulimia, presenting with 4 days of nausea,
vomiting, and diarrhea. The patient reports that she had been
feeling unwell for approximately one week with abdominal pain
nausea and vomiting. She reports an associated decrease in
appetite and that her abdominal pain would resolve with
vomiting. She denied any chest pain, shortness of breath,
fevers, or chills. She feels that these symptoms are similar to
those she had approximately ___ year ago which also resulted in an
ICU admission.
She was admitted to the ICU at ___ on ___ for hypokalemia
related to an eating disorder. During this admission she had her
electrolyte abnormalities corrected and was seen by several
services including social work and psychiatry. Strong
recommendations were made to discharge the patient to an
inpatient psychiatric program at that time, however, the patient
adamantly refused and was deemed to have capacity. The patient's
parents were additionally involved in her care and a plan was
made to have the patient return home to ___ in the care of her
parents.
After being discharged, the patient returned to ___ with her
parents for several months. While there she spoke with a general
practitioner of ___ Medicine" who gave her a ___
medication to help with her kidneys. She is no longer taking
this medicine and does not recall what it was. After returning
to the ___ in ___, the patient reports seeing a
psychiatrist on a weekly basis. This continued until ___
___ when the patient and the psychiatrist mutually agreed that
they no longer needed to have their meetings.
In the ED, initial vitals: 2 96.5 97 120/79 16 100% RA. On
exam, she was alert and oriented. She did not have any stigmata
of bulimia, however, she was noted to have ___ as well as
significant hypokalemia with a potassium of 1.8. There were
corresponding EKG changes including U waves in her anterolateral
leads. She was given potassium repletion orally and parenterally
as well as a GI cocktail before ___ transferred to the MICU
for electrolyte monitoring.
On transfer, vitals were: 0 74 119/88 15 100% RA
On arrival to the MICU, the patient remained hemodynamically
stable with good understanding of her condition and is agreeing
to whatever treament may be necessary.
Past Medical History:
- Bulimia during high school at age ___, which lasted about six
months. She did not see a therapist. Her parents knew about
and helped her with the problem. Pt states her goal body weight
is 45kg and she has recently weighed 48kg.
- Hypokalemia ___ years ago; she was dieting at the time
- She has never been diagnosed with anorexia.
Social History:
___
Family History:
Grandfather with lung cancer. Both parents alive and healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: BP: ___ P: 67 R: 14 O2: 100 RA
GENERAL: Alert, oriented, no acute distress
HEENT: PERRLA, EOMI, NCAT, good dentition
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, no rebound tenderness or
guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no excoriations over the knuckles
SKIN: No rashes
NEURO: CN II-XII grossly intact, speech fluent
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.3 90-110s/50-70s 80-110s 18 100%RA
GENERAL: Alert, oriented, no acute distress, tearful
HEENT: Sclerae anicteric, dry mucous membranes, no tenderness
over parotid glands, dental caries in left mandibular molars
NECK: supple, JVP not elevated, no LAD, no subcutaneous
emphysema
RESP: CTAB no wheezes, rales, rhonchi
CV: Slight tachycardic, regular rhythm, Nl S1, S2, No MRG
ABD: Soft, NT/ND 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: No excoriations or rash.
Pertinent Results:
ADMISSION LABS:
===============
___ 08:35PM BLOOD WBC-11.6*# RBC-4.34# Hgb-13.8# Hct-35.2*
MCV-81*# MCH-31.7 MCHC-39.1*# RDW-12.2 Plt ___
___ 08:35PM BLOOD Neuts-71.2* ___ Monos-6.6 Eos-0.2
Baso-0.4
___ 08:35PM BLOOD Glucose-94 UreaN-73* Creat-3.2*# Na-131*
K-1.8* Cl-72* HCO3-37* AnGap-24*
___ 08:35PM BLOOD ALT-14 AST-20 CK(CPK)-39 AlkPhos-69
TotBili-0.6
___ 08:35PM BLOOD Lipase-83*
___ 08:35PM BLOOD Albumin-5.0 Calcium-11.0* Phos-2.6*#
Mg-2.3
PERTINENT LABS:
===============
___ 12:30AM BLOOD Lactate-1.2
___ 04:53AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:53AM BLOOD TSH-1.8
___ 04:53AM BLOOD Albumin-3.5 Calcium-8.6 Phos-5.2* Mg-2.2
___ 04:53AM BLOOD ALT-30 AST-46* AlkPhos-70 Amylase-407*
TotBili-0.4
___ 06:17AM BLOOD Glucose-86 UreaN-39* Creat-1.4* Na-138
K-3.9 Cl-108 HCO3-21* AnGap-13
___ 12:11PM URINE Color-Yellow Appear-Hazy Sp ___
___ 12:11PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM
___ 12:11PM URINE RBC-34* WBC-22* Bacteri-MANY Yeast-NONE
Epi-14 TransE-<1
___ 10:58AM URINE Hours-RANDOM UreaN-731 Creat-62 Na-67
K-72 Cl-81 Albumin-2.8 Alb/Cre-45.2*
___ 02:00AM URINE Hours-RANDOM UreaN-601 Creat-42 Na-95
K-24 Cl-79
___ 12:11PM URINE UCG-NEGATIVE
___ 12:11PM URINE bnzodzp-NEG barbitr-POS opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
PERTINENT IMAGING:
==================
Renal US ___:
IMPRESSION:
Echogenic kidneys. No evidence of renal stones, masses, or
hydronephrosis. Normal sonographic appearance of the bladder.
ECG ___:
Sinus rhythm. Within normal limits. No significant change
compared with
previous tracing of ___.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
80 160 76 374 409 69 71 80
CXR ___:
IMPRESSION:
No acute intrathoracic process.
DISCHARGE LABS:
===============
___ 06:17AM BLOOD Glucose-86 UreaN-39* Creat-1.4* Na-138
K-3.9 Cl-108 HCO3-21* AnGap-13
___ 06:17AM BLOOD Calcium-9.4 Phos-4.7* Mg-1.6
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES: Severe hypokalemia, bulimia nervosa,
acute-on-chronic renal failure
SECONDARY DIAGNOSES: Bulimia nervosa
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 2D N/V/D now w/ gastritis vs FB sensation after eating
apple // eval ? mediastinal abnormalities
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided. There is no focal consolidation,
effusion, or pneumothorax. The cardiomediastinal silhouette is normal. No
radiopaque foreign body or signs of pneumomediastinum. Imaged osseous
structures are intact. No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with bulimia and presented with hypokalemia of
1.8 with AoCKD // please assess for renal cysts or structural abnormalities
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys and
bladder were obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 10.3 cm. The left kidney measures 10.7 cm. There is
no hydronephrosis, stones, or masses bilaterally. The renal cortex is
echogenic bilaterally.
The bladder is normal in appearance.
IMPRESSION:
Echogenic kidneys. No evidence of renal stones, masses, or hydronephrosis.
Normal sonographic appearance of the bladder.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Epigastric pain, N/V
Diagnosed with HYPOKALEMIA, RENAL & URETERAL DIS NOS
temperature: 96.5
heartrate: 97.0
resprate: 16.0
o2sat: 100.0
sbp: 120.0
dbp: 79.0
level of pain: 2
level of acuity: 3.0 | Ms. ___ is a ___ with a history of bulimia for ___ years who
presented with severe hypokalemia (K of 1.8), metabolic
alkalosis, ___, and elevated amylase in the setting of extreme
diet and purging behavior. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ceclor / Vasotec / Talwin / Vioxx / Allopurinol And Derivatives
/ Lyrica / gluten / naproxen
Attending: ___.
Chief Complaint:
REASON FOR MICU: GI bleed, hypotensive
CHIEF COMPLAINT: maroon stools
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with hx. primary biliary cirrhosis, diastolic
HF, afib on aspirin, celiac's disease, multiple recent
admissions for lower GI bleed presenting with c/o maroon stools.
Patient reports onset of 'burning' RLQ abdominal pain yesterday
morning, rated it ___, waxing and waning throughout the day.
She then noticed feeling weak this AM ___ walking from kitchen
to living room, sat down and felt 'exhausted' and took a nap.
She woke up and had a BM that left the toilet bowl 'maroon'
colored around 11a, continued to feel dizzy/lightheaded and
called her GI doc who advised her to go to the ED. Denies
fevers or chills, no diarrhea, no n/v, has been compliant with
gluten free diet.
Of note, patient was recently hospitalized from ___ with
c/o BRBPR. Hospitalization notable for HCT drop to 16 requiring
massive transfusion protocol. CTA localized bleeding to
jejunum, patient underwent ___ guided coil-embolization ___.
Hemostasis could not be achieved however and px. underwent small
bowel resection ___ with operative findings notable for
multiple SB massess and ulcerations throughout the small
intestine, pathology consistent with ulcerative jejunitis. Px
was noted to have persistent bloody BMs post SB resection but
remained hemodynamically stable. Also dx with LUE basilic vein
thrombosis ___. She was discharged to an extended care
facility where she has done well. She saw GI in followup ___
at which point she was having normal BMs, was advised to
continue to avoid gluten and continue on ursodial for PBC.
In the ED, initial vs were: 98.9 83 99/62 18 98% RA. Labs were
notable for H/H of 8.7/27.0 (stable from last month), WBC 12.2
chem-7 with BUN 33, lactate WNL. CTA abd/pel showed no
convincing evidence for arterial extravasation. Surgery was
consulted who recommended type and cross, making NPO, and
notifying ___ if significant hematocrit drop. GI was also
consulted who recommended CTA to help localize, large bore IVs
for volume resusitation, serial HCTs, ICU admission and they
reported the previous site of bleeding was not easily accessable
by endoscopy and so surgery and ___ should be aware of the
patient. Patient was given pantoprazole 40 IV, 3u pRBCs, 1L
crystalloid and admitted.
On the floor, patient currently feels 'much better' also she
stills feels a little tired. No longer dizzy/lightheaded.
Denies any episodes of chest pain, n/v/diarrhea, last BM was
1130a which has been the only bloody BM.
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, Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- Primary biliary cirrhosis
- GERD
- Celiac disease (last EGD in ___: scalloping of duodenal
folds,
last TTG 58 ___
- Diverticulitis
- B12 deficiency anemia
- Atrial fibrillation
- CAD (multiple stents placed in ___
- Diastolic heart failure (TTE ___: LVEF > 55%, mild mitral
regurgitation)
- HTN
- Prediabetes
- Hyperparathyroidism
- Osteoarthritis
- Degenerative cervical spine disease (cervical spondylotic
myelopathy (surgery by Dr. ___, ___: C5-6,
C6-7 discectomies, anterior C6 corpectomy, anterior cervical
fusion with iliac crest bone graft) with plans for future
surgery
- MGUS
- OSA
- TAH/BSO
Social History:
___
Family History:
CAD on father's side, diabetes on mother's side, maternal uncle
with liver cancer. No family history of colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: as per OMR
General: awake, alert, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, ___ systolic murmur LUSB
Abdomen: soft, non-distended, bowel sounds present, mild
tenderness to deep palpation RLQ and LLQ, midline incisional
scar well healed
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact, strength ___ in UE and ___ b/l
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: 98.2 | 122/68 | 71 | 18 | 100%/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mild conjunctival pallor, MMM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Normal rate and irregular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: non-distended, BS+ ___ quadrants, tympanic, soft,
non-tender on palpation. No masses. No organomegaly.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin:No lesions
Neuro: AOx3. No gross motor or sensory deficits.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:05PM BLOOD WBC-12.1* RBC-3.03* Hgb-8.7* Hct-27.0*
MCV-89 MCH-28.6 MCHC-32.2 RDW-13.8 Plt ___
___ 03:05PM BLOOD Neuts-86.6* Lymphs-8.6* Monos-3.0 Eos-1.6
Baso-0.3
___ 03:05PM BLOOD ___ PTT-29.1 ___
___ 03:05PM BLOOD Glucose-94 UreaN-33* Creat-1.0 Na-142
K-4.4 Cl-103 HCO3-28 AnGap-15
___ 03:05PM BLOOD Calcium-9.1 Phos-3.9 Mg-2.0
___ 03:17PM BLOOD Lactate-1.5
___ 11:08PM BLOOD freeCa-1.12
IMAGING:
========
___ CT ABD & PELVIS:
FINDINGS: Bibasilar atelectasis is present. Mitral annular and
coronary artery calcifications are noted. The visualized heart
and pericardium are otherwise unremarkable.
The liver enhances homogeneously without focal lesions or
intrahepatic biliary ductal dilatation. Cholelithiasis is
present in an otherwise unremarkable gallbladder. The portal
vein is patent. The spleen is homogeneous and normal in size.
Note is made of absence of fatty infiltration of the tail of the
pancreas, but this remains similar in appearance since ___.
Calcification of the left adrenal gland may be a sequela of
prior infection. The right adrenal gland is unremarkable. The
kidneys present symmetric nephrograms excretion of contrast. A
small hypodensity in the lower pole of the right kidney is too
small to characterize. There is no hydronephrosis.
The stomach and small bowel show no evidence of wall thickening
or
obstruction. Anastomosis in the left upper quadrant appears
unremarkable.
The colon is also unremarkable without any evidence of wall
thickening or
obstruction. There is no abdominal free air or free fluid.
There is no
mesenteric or retroperitoneal lymphadenopathy.
The bladder is significantly distended. The patient is status
post
hysterectomy. The adnexa are unremarkable. There is no pelvic
free fluid.
There is no pelvic sidewall or inguinal lymphadenopathy.
Posterior surgical fixation of L5 and S1 is noted and L1-L5
laminectomes.
Severe multilevel degenerative changes are noted with
levoscoliosis centered at L2.
CTA: The abdominal aorta has significant atherosclerotic
disease and is
ectatic without frank aneurysm. The origins of the celiac, SMA,
renal
arteries, and ___ are widely patent without stenosis. There is
no evidence of active arterial extravasation.
IMPRESSION:
1. No evidence of active extravasation.
2. Unremarkable appearance of small bowel anastomosis.
3. Other chronic findings as above.
___ CXR:
FINDINGS: Single portable view of the chest. There is a right
IJ central venous catheter with tip in the mid SVC. There is no
pneumothorax. Previously seen layering effusions and pulmonary
edema have resolved. Cardiac silhouette is mildly enlarged,
stable in configuration. Right shoulder arthroplasty and lower
cervical/upper thoracic vertebral orthopedic hardware is again
seen.
PERTINENT LABS:
===============
Hct:
___: 27.0
___: 32.2
___: 31.1
___: 31.3
___: 32.4
___: 32.3
___: 32.2
___ 11:15AM BLOOD Hct-33.8*
___ 06:48PM BLOOD Hct-33.1*
___ 04:47AM BLOOD Hct-32.2*
___ 12:45PM BLOOD Hct-32.8*
___ 08:40PM BLOOD Hct-34.4*
___ 07:35AM BLOOD WBC-8.3 RBC-3.84* Hgb-10.9* Hct-33.9*
MCV-88 MCH-28.5 MCHC-32.3 RDW-14.6 Plt ___
___ 12:50PM BLOOD Hct-33.9*
DISCHARGE LABS:
===============
___ 07:35AM BLOOD WBC-8.3 RBC-3.84* Hgb-10.9* Hct-33.9*
MCV-88 MCH-28.5 MCHC-32.3 RDW-14.6 Plt ___
___ 07:35AM BLOOD Glucose-101* UreaN-15 Creat-0.8 Na-143
K-3.9 Cl-111* HCO3-21* AnGap-15
___ 07:35AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.1
___ 04:47AM BLOOD PEP-TRACE ABNO FreeKap-PND FreeLam-PND
IgG-694* IgA-53* IgM-259*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Potassium Chloride 20 mEq PO BID
4. Acetaminophen 650 mg PO Q6H:PRN pain
5. Aspirin 325 mg PO DAILY
6. Calcitriol 0.25 mcg PO MWF
7. Calcium Carbonate 1200 mg PO DAILY
8. Fexofenadine 120 mg PO DAILY
9. Fish Oil (Omega 3) ___ mg PO BID
10. Gabapentin 1200 mg PO BID
11. Gabapentin 600 mg PO DAILY
12. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN
hemorrhoids
13. Multivitamins 1 TAB PO DAILY
14. Simvastatin 20 mg PO HS
15. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN
elbow skin itch
16. Ursodiol 900 mg PO QAM
17. Ursodiol 600 mg PO QPM
18. Verapamil SR 120 mg PO Q24H
19. Vitamin D ___ UNIT PO DAILY
20. Torsemide 20 mg PO X2 DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Calcitriol 0.25 mcg PO MWF
3. Calcium Carbonate 1200 mg PO DAILY
4. Fexofenadine 120 mg PO DAILY
5. Gabapentin 1200 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 20 mg PO HS
8. Ursodiol 900 mg PO QAM
9. Ursodiol 600 mg PO QPM (___)
10. Vitamin D ___ UNIT PO DAILY
11. Docusate Sodium 300 mg PO HS
12. Pantoprazole 40 mg PO Q12H GERD
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth twice a day Disp #*60 Tablet Refills:*0
13. Senna 1 TAB PO HS constipation
14. Fish Oil (Omega 3) ___ mg PO BID
15. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN
hemorrhoids
16. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN
elbow skin itch
17. Gabapentin 600 mg PO DAILY
18. Atenolol 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
#Gastrointestinal bleed of unkown site
#Celiac Disease
SECONDARY DIAGNOSIS
#Clonally driven atypical cell proliferation in jejunum
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Multiple GI bleeds status post small bowel resection.
COMPARISON: CTA abdomen and pelvis ___. CT abdomen pelvis ___.
TECHNIQUE: Images through the abdomen and pelvis were taken before and after
the administration of 150 cc of Omnipaque intravenous contrast in a
multiphasic fashion. Coronal and sagittal reformats were also examined.
FINDINGS:
Bibasilar atelectasis is present. Mitral annular and coronary artery
calcifications are noted. The visualized heart and pericardium are otherwise
unremarkable.
The liver enhances homogeneously without focal lesions or intrahepatic biliary
ductal dilatation. Cholelithiasis is present in an otherwise unremarkable
gallbladder. The portal vein is patent. The spleen is homogeneous and normal
in size. Note is made of absence of fatty infiltration of the tail of the
pancreas, but this remains similar in appearance since ___. Calcification of
the left adrenal gland may be a sequela of prior infection. The right adrenal
gland is unremarkable. The kidneys present symmetric nephrograms excretion of
contrast. A small hypodensity in the lower pole of the right kidney is too
small to characterize. There is no hydronephrosis.
The stomach and small bowel show no evidence of wall thickening or
obstruction. Anastomosis in the left upper quadrant appears unremarkable.
The colon is also unremarkable without any evidence of wall thickening or
obstruction. There is no abdominal free air or free fluid. There is no
mesenteric or retroperitoneal lymphadenopathy.
The bladder is significantly distended. The patient is status post
hysterectomy. The adnexa are unremarkable. There is no pelvic free fluid.
There is no pelvic sidewall or inguinal lymphadenopathy.
Posterior surgical fixation of L5 and S1 is noted and L1-L5 laminectomes.
Severe multilevel degenerative changes are noted with levoscoliosis centered
at L2.
CTA: The abdominal aorta has significant atherosclerotic disease and is
ectatic without frank aneurysm. The origins of the celiac, SMA, renal
arteries, and ___ are widely patent without stenosis. There is no evidence of
active arterial extravasation.
IMPRESSION:
1. No evidence of active extravasation.
2. Unremarkable appearance of small bowel anastomosis.
3. Other chronic findings as above.
Radiology Report
HISTORY: ___ female with new central line.
COMPARISON: ___.
FINDINGS:
Single portable view of the chest. There is a right IJ central venous
catheter with tip in the mid SVC. There is no pneumothorax. Previously seen
layering effusions and pulmonary edema have resolved. Cardiac silhouette is
mildly enlarged, stable in configuration. Right shoulder arthroplasty and
lower cervical/upper thoracic vertebral orthopedic hardware is again seen.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with RECTAL & ANAL HEMORRHAGE
temperature: 98.9
heartrate: 83.0
resprate: 18.0
o2sat: 98.0
sbp: 99.0
dbp: 62.0
level of pain: 4
level of acuity: 2.0 | ___ h/o HTN, Afib, OSA, dCHF, MGUS, PBC and longstanding silent
celiac disease for ___ years and on a gluten-free diet for the
last ___ years whose tTGs have rarely normalized despite
presumedly adequate adherence. Presents with dizziness and
maroon colored stools.
#GI bleed of unknown site: Her hematocrit dropped to 27,
required 3 units of PRBCs. Did not require surgery this time.
Source of bleeding could be residual ulcerative jejunitis or
site of previous anastomosis. Hematocrit has been stable around
33 during the last 3 days before discharge.
#Celiac disease: Asymptomatic, with presumed adequate adherence,
though some doubts are raised. Jejunal biopsy does not point to
very significant enteropathy. tTGs only normalized in one
occasion in ___.
#Clonally driven atypical T cell expansion in jejunum: Unclear
whether all the lesion was resected, concern for multiple
residual lesions as per surgical report. Was discussed in tumor
board by heme/onc and was not considered a definitive lymphoma
but a lesion with significant risk for progression to lymphoma. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male on warfarin s/p recent ICD placement, brought
to ED via EMS from home secondary to no bowel movement for five
days and severe rectal pain. Patient attempted enema one hour
before calling EMS without improvement or bowel movement. Of
note, pt was discharged from BI yest (___) following elective
ICD implanation complicated by hyponatremia.
In ED, initial vitals were 97.1 103 130/67 16 100% RA. He was
extremely agitated, asking for an enema. He denies other
symptoms although refused to fully participate in HPI. The
patient received a rectal exam in the ED with mild success,
showing guaiac negative with firm stool in the vault. He then
received two enemas that were met with resistance. The patient
also had urinary retention requiring Foley placement. There is
concern that the patient's impacted stool is compressing the
bladder causing retention. Labs showed WBC count 12.5K,
hemoglobin 9.5, creatinine 1.3, INR 2.6. Viscous lidocaine was
applied to the external anus. Patient's warfarin and amiodarone
was given. He was administered 30 mL lactulose. KUB showed no
evidence of obstruction or free air. Vitals upon transfer were
98.2 88 132/62 16 100% RA.
Upon arrival to the floor the patient had a large bowel movement
with relief of his abdominal discomfort. His only complaint was
of rectal pain, and he requested hemorrhoid cream for chronic
hemorrhoids.
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. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
Systolic heart failure (EF 25%)
Atrial fibrillation with apical thrombus on warfarin
CAD s/p ___ 2 to LAD
Hypertension
Hyperlipidemia
Dyspepsia/gastritis, positive H.Pylori
Glaucoma
BPH
Arthritis
___ Syndrome
H/o hepatatis, not active
s/p ICD implantation
s/p appendectomy
s/p inguinal repair surgery, here for redo today
Social History:
___
Family History:
Father died at ___ of MI.
Physical Exam:
Vitals: T: 97.6 BP: 93/59 P: 76 R: 18 O2: 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: Distant heart sounds, RRR, no audible m/r/g, pacemaker site
c/d/i
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: Diffuse bruising, at baseline per patient
Neuro: Cranial nerves ___ grossly intact, muscle strength ___
in all major muscle groups, sensation to light touch intact,
non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
___ 11:50PM BLOOD WBC-12.5* RBC-3.18* Hgb-9.5* Hct-29.6*
MCV-93 MCH-29.9 MCHC-32.1 RDW-15.9* RDWSD-54.0* Plt ___
___ 09:20AM BLOOD WBC-9.9 RBC-3.04* Hgb-9.0* Hct-27.1*
MCV-89 MCH-29.6 MCHC-33.2 RDW-16.0* RDWSD-51.8* Plt ___
___ 11:50PM BLOOD Glucose-112* UreaN-41* Creat-1.3* Na-134
K-3.9 Cl-92* HCO3-23 AnGap-23*
___ 09:20AM BLOOD Glucose-121* UreaN-31* Creat-1.1 Na-136
K-3.0* Cl-97 HCO3-27 AnGap-15
KUB (___):
1. Normal bowel gas pattern without evidence of obstruction.
2. Small left pleural effusion
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Lisinopril 10 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Warfarin 2 mg PO DAILY16
9. Zolpidem Tartrate 5 mg PO QHS
10. Acetaminophen 650 mg PO Q6H
11. Aspirin 81 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN pain
14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY:PRN itch
16. Cephalexin 500 mg PO Q6H
17. Torsemide 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Lisinopril 10 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN pain
11. Pantoprazole 40 mg PO Q24H
12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY:PRN itch
13. Warfarin 2 mg PO DAILY16
14. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally DAILY:PRN Disp
#*50 Suppository Refills:*3
15. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR QID:PRN
hemorrhoids
RX *hydrocortisone 2.5 % 1 cream(s) rectally twice a day
Refills:*0
16. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
DAILY Refills:*0
17. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Capsule Refills:*3
18. Torsemide 40 mg PO DAILY
19. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Constipation
Acute urinary retention
Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with severe rectal/abdominal pain //
?obstruction versus degree of constipation?
TECHNIQUE: Spine and upright fronto radiographs of the abdomen
COMPARISON: Chest radiograph ___
FINDINGS:
Gas is seen within nondilated loops of small and large bowel. There is stool
in the cecum and ascending colon. There is no subdiaphragmatic free air,
pneumatosis or portal venous gas detected.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies. There is leftward curvature of the lumbar spine. Pacer lead is seen
in the right ventricle. Small left pleural effusion is unchanged blunting the
costophrenic sulcus.
IMPRESSION:
1. Normal bowel gas pattern without evidence of obstruction.
2. Small left pleural effusion
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Constipation, Rectal pain
Diagnosed with UNSPECIFIED CONSTIPATION, RETENTION URINE UNSPECIFIED
temperature: 97.1
heartrate: 103.0
resprate: 16.0
o2sat: 100.0
sbp: 130.0
dbp: 67.0
level of pain: 9
level of acuity: 3.0 | ___ year old male on warfarin s/p recent ICD placement, brought
to ED via EMS from home secondary to constipation and severe
rectal pain.
# Constipation:
Patient presented with severe rectal pain in the setting of
constipation. Attempts were made at manual disimpaction in the
ED, however they were unsuccessful. He received a tap water
enema, lactulose and Miralax, ultimately with a large bowel
movement upon arrival to the floor and relief of his symptoms.
He initially had urinary retention that was felt to be due to
his severe constipation. After resolution of his constipation he
was able to urinate without difficulty. His constipation was
likely a result of his recent oxycodone use after ICD placement.
He was discharged on a more aggressive bowel regimen, with
instructions to decrease the use of the laxatives if he begins
to have loose stools.
# Acute kidney injury:
Creatinine 1.3 from 1.0 on recent discharge. Improved to 1.1 on
repeat, likely related to decreased PO intake versus urinary
retention. Should be monitored at next PCP ___.
# Acute on chronic systolic congestive heart failure:
Patient has EF 25%. Dry weight 145-148 pounds. He did not appear
to be volume overloaded on admission. His home meds were
continued, but one dose of torsemide was held due to his
decreased PO intake for the past 24 hours and mild ___.
- Continued metoprolol XL 25mg daily, lisinopril 10mg daily
- Held torsemide 40mg daily, but resume on discharge
- Spironolactone held on recent admission, will continue to hold
# Atrial fibrillation/apical thrombus: INR 2.6 (___).
- Continued metoprolol XL 25 mg
- Continued amiodarone 200 mg daily
- Continued warfarin, should follow-up with ___
clinic
# CAD
# Hyperlipidemia: STEMI s/p ___ 2 to LAD ___.
- Continued aspirin 81 mg PO daily
- Continued home clopidogrel
- Continued home atorvastatin
# Anemia:
Had acute blood loss during recent admission attributed to
hematoma at ___ site. Hemoglobin stable with level upon
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:
Chest Pain
Major Surgical or Invasive Procedure:
Right Chest Tube
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
Mr. ___ is a ___ male with metastatic
pancreatic cancer receiving palliative AbGn-107 on DF/HCC ___
who presents with chest pain.
On ___ morning patient had routine CT torso for staging. He
then went home and while he was bending over to pick up laundry
he had sudden onset sharp central chest pain and associated
cough
and shortness of breath. His symptoms improve when in upright
position. He called his outpatient Oncology team who recommended
further evaluation.
On arrival to the ED, initial vitals were 97.1 65 122/70 16 97%
RA. Exam was notable for decreased breath sounds at right base.
Labs were notable for WBC 3.0, H/H 10.8/33.4, Plt 140, INR 1.2,
Na 134, K 3.5, BUN/Cr ___, BNP 35, and Trop-T < 0.01. CTA
chest showed worsening of right pleural effusion. IP was
consulted and placed right chest tube with removal of 1700 ml.
Pleural fluid studies were sent. CXR showed decrease in pleural
effusion and no pneumothorax. Patient was given creon, ursodiol,
Tylenol, ibuprofen, and 500cc NS. Prior to transfer vitals were
98.7 69 112/71 16 96% RA.
On arrival to the floor, patient reports his breathing and pain
has improved. He also notes feeling more itchy recently. He
denies fevers/chills, night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbness, hemoptysis,
palpitations, abdominal pain, nausea/vomiting, diarrhea,
hematemesis, hematochezia/melena, dysuria, hematuria, and new
rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST MEDICAL HISTORY:
- Benign tumor (glomangioma) removed from left hand in ___
- Back pain since ___
- Left elbow pain since ___ r/t lifting injury
- Nephrolithiasis ___
- Tinnitus ___
- Pneumonia x3 (once as a child, once in ___, once in ___
- Colon polyps at age ___
- ACL tear in 1990s, occasional left knee pain
Social History:
___
Family History:
Father with lung cancer. Sister with breast
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.0, BP 123/78, HR 61, RR 20, O2 sat 97% RA.
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, decreased breath
sounds at right base, right chest tube in place.
ABD: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 02:00AM BLOOD WBC-3.0* RBC-3.67* Hgb-10.8* Hct-33.4*
MCV-91 MCH-29.4 MCHC-32.3 RDW-14.0 RDWSD-45.5 Plt ___
___ 02:00AM BLOOD Neuts-52.2 ___ Monos-10.1 Eos-5.4
Baso-1.3* AbsNeut-1.55* AbsLymp-0.92* AbsMono-0.30 AbsEos-0.16
AbsBaso-0.04
___ 02:00AM BLOOD ___ PTT-96.3* ___
___ 02:00AM BLOOD Glucose-128* UreaN-17 Creat-0.9 Na-134*
K-9.8* Cl-102 HCO3-25 AnGap-7*
___ 02:00AM BLOOD ALT-27 AST-62* LD(LDH)-912* AlkPhos-146*
TotBili-1.7*
___ 02:00AM BLOOD cTropnT-<0.01
___ 02:00AM BLOOD proBNP-35
___ 02:00AM BLOOD TotProt-7.0 Albumin-3.9 Globuln-3.1
Cholest-121
___ 03:56AM BLOOD K-3.5
___ 03:19PM PLEURAL TNC-335* RBC-669* Polys-4* Lymphs-30*
Monos-46* Macro-19* Other-1*
___ 03:19PM PLEURAL TotProt-1.2 Glucose-121 LD(LDH)-59
Amylase-7 Albumin-0.7 Cholest-15 Triglyc-230 proBNP-46
==================
IMAGING AND STUDIES
==================
___ MRCP
IMPRESSION:
1. Mild intrahepatic biliary ductal dilatation to the level of
the hepaticojejunostomy is unchanged from ___.
2. Redemonstration of soft tissue in the pancreatectomy bed that
includes the SMV and encases and narrows the SMA, which appears
slightly increased compared to MRI from ___, but is
similar compared to more recent CTs.
3. Moderate right pleural effusion, slightly decreased from ___.
4. Probable small left upper pole renal infarct. Continued
attention on follow-up is recommended.
5. Otherwise expected post treatment changes following Whipple
procedure and right hepatic ablation.
___ CXR
IMPRESSION:
In comparison with the study of ___, there has been no
reaccumulation of right pleural effusion with the chest tube in
place. Small pneumothorax is again seen.
The cardiac silhouette is within normal limits and there is no
vascular congestion or acute focal pneumonia.
___ TTE normal without elevated PASP
___ RUQ US with dopplers: Limited study due to acoustic
shadowing from overlying bowel gas demonstrate possible
bidirectional flow of the proximal main portal vein. The
splenic
vein and SMV are not visualized and thrombosis involving these
vessel cannot
be excluded.
CXR ___: New small pleural effusion since ___ with right
basal pigtail in place. Slightly increased right apical
pneumothorax.
Ascites flow study with nuc med ___: Positive study showing flow
of activity from the site of injection in the right lower
quadrant ascites into the right pleural effusion.
==============
DISCHARGE LABS:
==============
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon ___ CAP PO TID W/MEALS
2. Ursodiol 600 mg PO BID
3. Vitamin D ___ UNIT PO 1X/WEEK (___)
4. turmeric 400 mg oral DAILY
5. paricalcitol 1 mcg oral DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Zinc Sulfate 220 mg PO DAILY
Discharge Medications:
1. Furosemide 80 mg PO 8AM AND 2PM
RX *furosemide 80 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
3. Creon ___ CAP PO TID W/MEALS
4. paricalcitol 1 mcg oral DAILY
5. turmeric 400 mg oral DAILY
6. Ursodiol 600 mg PO BID
7. Vitamin D ___ UNIT PO 1X/WEEK (___)
8. Vitamin D ___ UNIT PO DAILY
9. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with dyspnea// PE?
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 412 mGy-cm.
COMPARISON: CT chest performed ___ at 08:44 CT chest ___
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. Dilated main pulmonary artery measuring up to 3.6 cm may
reflect pulmonary arterial hypertension. The heart, pericardium, and great
vessels are within normal limits. No pericardial effusion is seen. Right
internal jugular catheter terminate in the right atrium.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: There is interval increase in size of a now moderate to large
right pleural effusion. This effusion appears of simple density layering
posteriorly with associated compressive atelectasis in the right right lower
lobe. There is no left effusion. No pneumothorax.
LUNGS/AIRWAYS: Compressive atelectasis of the right lower lobe. Previously
described pulmonary nodules are unchanged from recent prior.
BASE OF NECK: 7 mm hypodensity in the left thyroid lobe is unchanged.
ABDOMEN: Again seen is a fiducial marker along the posterior right hepatic
lobe with adjacent hypodensity reflecting site of prior ablation. Small
volume ascites is noted.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Moderate to large volume right pleural effusion increased in the interval
with associated compressive lower lobe atelectasis. Previous CT suggested
discontinuity in the right hemidiaphragm near the RFA site. Consider
thoracentesis with fluid assessment to further assess.
2. Partially visualized ascites.
3. Unchanged pulmonary nodules.
4. Main pulmonary artery is dilated, unchanged, correlate for pulmonary
arterial hypertension.
Radiology Report
INDICATION: ___ year old man with hx of pancreatic cancer with mets to liver
s/p RFA and new right pleural effusion s/p chest tube placement.// eval for
PTX
TECHNIQUE: Single portable view of the chest.
COMPARISON: None.
FINDINGS:
Right chest wall port is noted with catheter tip projecting over the right
atrium. Lung volumes are relatively low in there is mild left basilar
atelectasis. Pigtail catheter projects over the right lung base at the
costophrenic angle. There is likely small right pleural effusion. No
definite pneumothorax.
IMPRESSION:
Pleural catheter projecting at the right costophrenic angle angle with
suspected small right residual effusion. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pancreatic cancer and right pleural effusion
s/p chest tube. Please perform at 6AM.// Eval for interval change. Please
perform at 6AM.
IMPRESSION:
In comparison with the study of ___, the right pigtail catheter is again
seen, with little if any pleural effusion. No evidence of pneumothorax.
Otherwise, little change and no evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old man with history of metastatic pancreatic cancer on
palliative study drug presents with chylothorax which is possibly due to
ascites- Please asses for largest pocket in preparation for possible nuclear
med test// ?ascities
TECHNIQUE: Grayscale ultrasound images were obtained of the 4 quadrants of
the abdomen.
COMPARISON: None available
FINDINGS:
Targeted grayscale ultrasound images were obtained of the 4 quadrants of the
abdomen, revealing trace ascites. No dominant pocket was appreciated..
IMPRESSION:
Trace intra-abdominal ascites without a dominant pocket or drainable
collection.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with metastatic pancreatic cancer and concern for
chylothorax. currently with chest tube// pleural effusion
TECHNIQUE: Frontal chest radiograph
COMPARISON: Multiple chest radiographs, most recently dated ___.
FINDINGS:
Right chest wall infusion port tip projects over the right atrium, unchanged
from prior exam. Left pigtail catheter remains projecting at the right base.
There is new small right pleural effusion. Right apical pneumothorax is
small, slightly increased. There is no left pleural effusion. The lungs are
well inflated and clear. The heart is mildly enlarged. Mediastinal and hilar
contours are unremarkable.
IMPRESSION:
New small pleural effusion since ___ with left basal pigtail in place.
Slightly increased right apical pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with effusion// effusion f/u
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
A right chest Wall Port-A-Cath is present with the tip over the right atrium.
A right basal pleural catheter is present. There is a small right apical
pneumothorax, unchanged. No new consolidation, pleural effusion or left
pneumothorax. The size of the cardiomediastinal silhouette is unchanged.
IMPRESSION:
Small unchanged right pneumothorax with a chest tube present. No new pleural
effusion.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ male with history of metastatic pancreatic cancer,
Whipple, Evaluate for thrombus leading to acute development of ascites
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Ultrasound from ___. CT of the abdomen from ___.
FINDINGS:
Limited study due to acoustic shadowing from overlying bowel gas. Within this
limitation,
Liver: The hepatic parenchyma is within normal limits. No focal liver
lesions are identified. There is no ascites.
Bile ducts: There is mild intrahepatic biliary ductal dilation. There is
also mild dilation of the extrahepatic ducts to 7 mm. This is unchanged from
prior and likely from cholecystectomy.
Gallbladder: The gallbladder is surgically absent.
Pancreas: The pancreas is obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture.
Spleen length: 12.1 cm
Kidneys: No stones, masses, or hydronephrosis are identified in the right
kidney.
Doppler evaluation:
The main portal vein is patent, and demonstrates probable bidirectional flow
noted proximally.
Main portal vein velocity is 48 cm/sec.
Right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
Splenic vein is only seen at the hilum, remainder of the splenic vein and
superior mesenteric vein not seen.
IMPRESSION:
Limited study due to acoustic shadowing from overlying bowel gas demonstrate
possible bidirectional flow of the proximal main portal vein. The splenic
vein and SMV are not visualized and thrombosis involving these vessel cannot
be excluded.
Radiology Report
INDICATION: Mr. ___ is a ___ male with metastatic
pancreatic cancer receiving palliative AbGn-107 on DF/HCC ___ who presents
with chest pain and shortness of breath and found to have a pleural effusion
concerning for chylothorax now with ascetic effusion without clear history of
portal hypertension. Please also perform transjugular liver biopsy at same
time.// Evaluate portal pressures in gentleman with new ascites with
subsequent pleural effusion without clear history of portal hypertension
COMPARISON: CT abdomen and pelvis ___
TECHNIQUE: OPERATORS: Dr. ___, attending Interventional
Radiologist and Dr. ___, Radiology resident performed the procedure.
Dr. ___ personally supervised the trainee during any key
components of the procedure where applicable and reviewed and agrees with the
findings as reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 80 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: 40 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 23.18 minutes, 159 mGy
PROCEDURE: 1. Right internal jugular venous access using ultrasound.
2. Right atrial and hepatic venous and balloon-occluded portal pressure
measurements.
3. Transjugular hepatic core biopsy with 2 passes.
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 neck 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. Hard copy
ultrasound images were obtained before and after intravenous access.
Subsequently a Nitinol wire was passed into the right atrium using
fluoroscopic guidance. A small incision was made at the needle entry site. The
needle was exchanged for a micropuncture sheath. The Nitinol wire was removed
and a short ___ wire was advanced distally into the IVC.
A 10 ___ sheath was advanced over the wire into the inferior vena cava.
Using a C2 Cobra catheter and a glide wire, access was obtained in the right
and accessory hepatic veins followed by the middle hepatic vein. Appropriate
position was confirmed with contrast injection and fluoroscopy. The glide wire
was exchanged for ___ wire and the sheath was advanced into the proximal
middle hepatic vein. Then, a 0.5 mm occlusion balloon was advanced over the
wire into the distal right hepatic vein. The wire was then removed and right
atrial and hepatic venous and balloon-occluded portal pressure measurements
were obtained after balloon occlusion.
The balloon was then removed and a liver access sheath was advanced into the
liver in appropriate position. The biopsy needle was advanced through the
liver access sheath and 2 18 gauge core biopsies were acquired while pointing
the biopsy sheath posteriorly. The core biopsies were placed in formalin and
labeled for pathology.
The wire, catheters and core biopsy needle were then removed, pressure was
held until hemostasis was achieved and sterile dressings were applied. The
patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Right atrial pressure of 9, free hepatic venous pressure of 6 and
balloon-occluded portal pressure measurement of 12.
2. 2 18G core biopsies of the liver acquired through transjugular access.
IMPRESSION:
Successful transjugular liver biopsy with slightly elevated hepatic venous
pressure gradient of 6 (normal HVPG is ___.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with right pleural effusion// How does the
effusion look on x-ray
IMPRESSION:
In comparison with the study of ___, there has been no reaccumulation of
right pleural effusion with the chest tube in place. Small pneumothorax is
again seen.
The cardiac silhouette is within normal limits and there is no vascular
congestion or acute focal pneumonia.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with elevated ALP// Evaluating for etiology of
persistently elevated ALP,
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Abdominal ultrasounds dated ___ and ___, CTA chest
dated ___, CT of the abdomen and pelvis dated ___, and MRI
of the abdomen dated ___.
FINDINGS:
Lower Thorax: A moderate right pleural effusion has decreased slightly in size
compared with ___. There is no left-sided pleural effusion or
pericardial effusion. A 9 mm left lower lobe pulmonary nodule is better
assessed by the recent chest CT (4:2).
Liver: Hepatic morphology is within normal limits. Patient is status post
segment VII ablation with the ablation cavity containing intrinsically T1
hyperintense material consistent with coagulation necrosis measuring up to 3.2
x 2.0 cm, previously 3.7 x 2.1 cm (10:60). There is no other focal liver
lesion. The portal and hepatic veins are patent.
Biliary: There is mild intrahepatic biliary ductal dilatation to the level of
the hepaticojejunostomy. The configuration and degree of ductal dilatation is
unchanged from the MRI of ___.
Pancreas: Patient is status post Whipple procedure. The remnant pancreas is
atrophic without ductal dilatation or focal lesion. Again seen is soft tissue
in the pancreatectomy bed that occludes the SMV and encases and narrows the
SMA appears slightly increased when compared with the prior MRI of ___ (1203:94), but is similar compared to more recent CTs.
Spleen: Spleen is normal in size and signal intensity without focal lesion.
Adrenal Glands: Unremarkable.
Kidneys: There is no suspicious lesion or hydronephrosis. An indistinct area
of hypoenhancement in the left upper pole that spares the cortex is slightly
more prominent when compared with the prior study and associated with relative
T2 hypointensity. Given the configuration this likely represents a small left
upper pole renal infarct related to an accessory upper pole renal vessel
(04:26, 1201:85).
Gastrointestinal Tract: Visualized loops of large and small bowel are
unremarkable with stable post Whipple changes.
Lymph Nodes: No upper abdominal lymphadenopathy.
Vasculature: There is marked focal narrowing of the celiac axis secondary to
median arcuate ligament effect (25:1). This is likely transient and related
to the expiratory phase of imaging as the celiac axis is patent on recent
prior studies.
Osseous and Soft Tissue Structures: There is no suspicious osseous lesion.
IMPRESSION:
1. Mild intrahepatic biliary ductal dilatation to the level of the
hepaticojejunostomy is unchanged from ___.
2. Redemonstration of soft tissue in the pancreatectomy bed that includes the
SMV and encases and narrows the SMA, which appears slightly increased compared
to MRI from ___, but is similar compared to more recent CTs.
3. Moderate right pleural effusion, slightly decreased from ___.
4. Probable small left upper pole renal infarct. Continued attention on
follow-up is recommended.
5. Otherwise expected post treatment changes following Whipple procedure and
right hepatic ablation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal CT, Dyspnea
Diagnosed with Chest pain, unspecified
temperature: 97.1
heartrate: 65.0
resprate: 16.0
o2sat: 97.0
sbp: 122.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ male with metastatic
pancreatic cancer receiving palliative AbGn-107 on DF/HCC ___
who presents with chest pain and shortness of breath and was
found to have a right pleural effusion
# Right Pleural Effusion:
# Chest Pain:
# Chylothorax:
# Abdominal ascites
Symptoms due to new right pleural effusion, concerning for a
chylothorax given pleural fluid with triglyceride level of 230.
Per light's criteria, the effusion was TRANSUDATIVE. The patient
underwent a nuclear medicine flow study which showed the pleural
effusion was likely due to ascitic fluid CROSSING A DEFECT in
the diaphragm. Ongoing drainage from the pleural catheter over
several days showed clear yellow fluid more consistent with
ABDOMINAL ASICTES CROSSING THROUGH A DIAPHRAGMATIC DEFECT given
high SAAG and low triglycerides on repeat studies.
He was started on furosemide and spironolactone with decreased
chest tube output and chest tube was removed ___. TTE did not
show elevated PASP. NO EVIDENCE OF CIRRHOSIS based on imaging
and labs and pancreatic mets to liver not numerous enough to
generally cause portal hypertension. He underwent portal
pressure measurements and liver biopsy which showed NO EVIDENCE
OF PORTAL HYPERTENSION and preliminary pathology results showed
NO EVIDENCE OF CIRRHOSIS. Discharged home on the following
diuretic doses to try to keep the effusion from reaccumulating:
80 MG furosemide BID and 50 mg spironolactone daily. He had
outpatient oncology and interventional pulmonology follow-up
scheduled ___. Note: If the results of the liver biopsy
later come back normal, the spironolactone should be stopped.
# Metastatic Pancreatic Cancer
# Secondary Neoplasm of Liver
# Secondary Neoplasm of Lung
Continued on home creon and ursodiol. Dr. ___ Dr.
___ of the admission. Study drug held on admission.
Patient will follow-up with his outpatient oncology on ___.
# ___ Syndrome:
Patient reported history of ___ syndrome which would
account for the slightly elevated bilirubin of 1.6. Bilirubin
remained stable this admission.
# Leukopenia:
# Anemia:
# Thrombocytopenia: Remained baseline.
OUTSTANDING ISSUES
[ ] If the results of the liver biopsy later come back normal,
the spironolactone should be stopped.
[ ] Ensure pt follow up with IP and heme onc |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pressure/shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ male with PMH of atrial fibrillation with RVR on
anticoagulation, SSS c/b syncope and dizziness s/p dual chamber
pacemaker placement who presents with acute worsening of chest
pressure and SOB. The patient reports that on ___ (2 days
prior to admission) the patient felt pressure in his chest with
associated increase in his baseline SOB. The pressure extended
from the substernal area to his neck, was ___ in severity at
its worst, and did not radiate. Lying down flat made the pain a
little better. Denies nausea, vomiting, fever, sweats.
The patient says that he felt no palpitations and that he began
to feel better after ___ hours, though he had the pressure again
yesterday and this morning. On the morning of admission the
patient presented to the ___ for evaluation of his
symptoms despite overall improvement. The patient was told that
his EKG showed a fast heart with with some "changes" that may
indicate ischemic disease, and he was sent to the ED.
The patient has a history of atrial fibrillation and is
currently on long-term anticoagulation with Coumadin. He was
seen by his electrophysiologist, Dr. ___ in ___
on ___ for adjustment of his pacemaker.
In the ED, initial vitals were pain:9 T: 97.8 HR: 116 BP: 124/78
RR:20 O2 SAT: 99% 2L Nasal Cannula. Patient's weight on day of
admission as recorded in clinic was 189lbs (dry weight is
188lbs). Patient was given sublingual nitroglycerin x1, which
didn't make any difference in terms of his pain. He also got
500cc NS bolus x2 and 324mg ASA chewed in the ED. Patient was
admitted to ___ for observation.
On arrival to the floor the patient was noted to be in Afib with
RVR rates into the 150s without symptoms of chest tightness or
pressure, except with deep breaths. Vital signs were: 97.6
129/92 135 18. The patient reported that he felt well and was
A+Ox4. The patient was given 5mg of IV metoprolol (his home dose
is Metoprolol succ 25mg BID) with a decrease in his rate to the
110's. He was then given 12.5mg of metoprolol tartrate.
On review of systems, 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. he denies recent fevers, chills or rigors.
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 paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
- Hyperlipidemia
- Atrial Fibrillation with RVR on coumadin for anticoagulation
- SSS with pacemaker
- Lumbago
- Epilepsy (hasn't had a seizure or needed medication for
decades)
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T97.6, BP 129/92, HR 135, RR 18, O2 100%RA
General: pleasant man in bed in NAD
HEENT: NCAT, MMM, EOMI
Neck: flat neck veins
CV: tachycardic, irregularly irregular, no m/r/g appreciated
Lungs: CTAB, no crackles or wheezes appreciated
Abdomen: soft, nontender, nondistended, +BS
GU: no foley
Extr: feet cool (pt endorses lifelong cold feet), no cyanosis,
clubbing, edema, 2+ DP pulses bilaterally
Neuro: A&Ox3
Skin: no lesions appreciated
DISCHARGE PHYSICAL EXAM:
VS: Tm=97.1, BP=94/56 (94-121/56-83), HR=83 (83-116) (in ___'s
overnight on tele), RR=16 O2 sat= 96%RA
I/O: BRP
Wt: 83.5 <- 83.4 <- 84.1 <- 86.3
General: pleasant man in bed in NAD
HEENT: NCAT, MMM, EOMI
Neck: flat neck veins
CV: tachycardic, irregularly irregular, no m/r/g appreciated
Lungs: CTAB, no crackles or wheezes appreciated
Abdomen: soft, nontender, nondistended, +BS
GU: no foley
Extr: feet cool (pt endorses lifelong cold feet), no cyanosis,
clubbing, edema, 2+ DP pulses bilaterally
Neuro: A&Ox3
Skin: no lesions appreciated
Pertinent Results:
ADMISSION LABS:
___ 12:52PM WBC-7.2 RBC-4.44* HGB-14.3 HCT-42.6 MCV-96
MCH-32.2* MCHC-33.6 RDW-13.2 RDWSD-46.7*
___ 12:52PM ___ PTT-40.7* ___
___ 12:52PM GLUCOSE-110* UREA N-15 CREAT-1.1 SODIUM-134
POTASSIUM-5.4* CHLORIDE-100 TOTAL CO2-21* ANION GAP-18
___ 12:52PM CALCIUM-9.0 PHOSPHATE-3.3 MAGNESIUM-2.2
___ 12:52PM cTropnT-<0.01
___ 12:52PM proBNP-1415*
___ 12:47PM LACTATE-2.5* K+-4.4
DISCHARGE LABS:
___ 05:05AM BLOOD WBC-6.1 RBC-4.22* Hgb-13.5* Hct-40.9
MCV-97 MCH-32.0 MCHC-33.0 RDW-13.3 RDWSD-47.3* Plt ___
___ 05:05AM BLOOD Glucose-126* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-21* AnGap-17
___ 05:05AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.0
TROPONIN TREND:
___ 12:52PM BLOOD cTropnT-<0.01
___ 09:27PM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:02AM BLOOD cTropnT-<0.01
MICROBIOLOGY:
Blood culture ___: no growth prelim
IMAGING/PROCEDURES:
Stress MIBI ___:
Stress:
No ischemic ECG changes. No anginal type symptoms. Exaggerated
ventricular response to exercise in the setting of atrial
fibrillation. Poor functional capacity demonstrated. Nuclear
report sent separately.
Perfusion:
The image quality is adequate.
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 64%.
CXR ___:
No acute cardiopulmonary abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO BID
2. Simvastatin 20 mg PO DAILY
3. Warfarin 2.5 mg PO 2X/WEEK (MO,FR)
4. Metoprolol Succinate XL 25 mg PO BID
5. Warfarin 3.75 mg PO 5X/WEEK (___)
6. Lunesta (eszopiclone) 1 mg oral QHS:PRN insomnia
Discharge Medications:
1. Gabapentin 300 mg PO BID
2. Simvastatin 20 mg PO DAILY
3. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. Lunesta (eszopiclone) 1 mg oral QHS:PRN insomnia
5. Metoprolol Succinate XL 150 mg PO Q12H
RX *metoprolol succinate [Toprol XL] 50 mg 3 tablet(s) by mouth
every twelve (12) hours Disp #*180 Tablet Refills:*0
6. Warfarin 3.75 mg PO DAILY16
take this dose 7 days per week.
7. Outpatient Lab Work
ICD-9 42___.31 Atrial Fibrillation
Please draw INR on ___ and fax results to PCP: ___
___, MD, Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
atrial fibrillation with rapid ventricular response
SECONDARY:
chest pain
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 pleuritic chest pain
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Left-sided dual-chamber pacemaker device is noted with leads terminating in
the right atrium and right ventricle. Moderate cardiomegaly is re-
demonstrated along with tortuosity of the thoracic aorta. Mediastinal and
hilar contours otherwise are stable. Lungs are clear. Pulmonary vasculature
is normal. No pleural effusion or pneumothorax is present. No acute osseous
abnormality is detected.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea on exertion, Abnormal EKG
Diagnosed with CHEST PAIN NOS, SHORTNESS OF BREATH, ATRIAL FIBRILLATION
temperature: 97.8
heartrate: 116.0
resprate: 20.0
o2sat: 99.0
sbp: 124.0
dbp: 78.0
level of pain: 9
level of acuity: 2.0 | ___ male with PMH of atrial fibrillation with RVR on
anticoagulation, SSS c/b syncope and dizziness s/p dual chamber
pacemaker placement who presents with acute worsening of chest
pain and SOB, found to be in RVR with rate in the 150's in the
ED. Rate responded well to IV metoprolol on the floor.
# Atrial fibrillation with RVR. The patient presented with Afib
with RVR into the 150s. The patient received no beta blockade
while in the ED and it is possible that the patient's symptoms
over the weekend were caused by increasing heart rate with
possible rate-related ischemia. The patient's pacemaker was
interrogated on admission and showed poorly controlled rate over
the last several months (only below 100BPM ~30% of the time). He
has also been in persistent AFib since ___. The
patient does report compliance with his home medications, which
include metoprolol succinate 25mg BID and coumadin for
anticoagulation. He took his metoprolol on the morning of
admission. An EKG on admission showed no ischemic changes, and
troponins were trended and negative. The patient's heart rate
initially responded well to IV metoprolol 5mg on the floor, with
decrease of HR from 130's to 110's. After this IV dose, we
initially struggled to control the patient's heart rate with
oral medication. Ultimately, the patient's rate was controlled
by increasing his metoprolol tartrate to 75mg q6h ___, and
adding digoxin with loading dose of 0.5mg BID, then maintainence
dose of 0.125 QD. The patient was discharged on this dose of
digoxin and metoprolol succinate 150mg q12h. In terms of his
anticoagulation, the patient's INR was slightly subtherapeutic
during this admission (INR decreased to 1.9 then 1.7), so we
increased his home warfarin regimen from 2.5mg ___ and
___, 3.75mg other 5 days, to 3.75mg daily, and discharged him
on this new regimen. The patient was discharged on ___ given
good rate control.
# Chest Pressure/shortness of breath: The patients' chest pain
is atypical. Troponins were trended and negative. There were no
ischemic changes on EKG. The patient's ProBNP was 1415, but
there were no signs of volume overload on exam. An exercise MIBI
on ___ showed no focal perfusion deficits, normal wall
motion, EF 64%, no ischemic EKG changes. With stress during the
MIBI, there were no anginal symptoms, exaggerated ventricular
response to exercise in the setting of Afib, and poor functional
capacity. Given these findings, we believe that the patient's
chest pressure and shortness of breath were likely secondary to
RVR, see above.
# SSS s/p Pacemaker: Chronic. The patient's pacemaker was
interrogated ___ and showed poorly controlled rate over the
last several months (only below 100BPM ~30% of the time). The
patient has also been in persistent AFib since ___.
# Lumbago: Chronic. We continue the patient's home gabapentin
100mg BID.
# Hyperlipidemia: Chronic. We continued the patient's home
simvastatin 20mg daily.
***Transitional Issues***
[ ] continued monitoring of INR and warfarin dosing. Pt given
script to have INR drawn on ___.
[ ] continued monitoring of heart rate and titration of rate
control medications, consider pacemaker interrogation for rate
trends. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / spironolactone / Optiflux Dialyzer
Attending: ___.
Chief Complaint:
Fatigue, ___ edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ woman with HBeAg-negative HBV cirrhosis
(c/b ascites, chronic hepatic hydrothorax, and hepatic
encephalopathy) s/p TIPS that was c/b right heart failure
requiring TIPS closure and aggressive diuresis, recently listed
for transplant, who presents with fatigue and ___ edema. She
recently left the hospital AMA as her mother is on home hospice
and she needed to spend time with her given her limited time
left. She unfortunately was unable to have HD set up prior to
her
leaving the hospital due to her hep B status.
During her last hospital stay she had a negative infectious
workup and was diuresed aggressively. She had a therapeutic
thoracentesis and pigtail drain for her hepatic hydrothorax,
pigtail was later removed. Her hospital course was complicated
by
ATN and she was started on HD. There was difficulty in finding
an
outpatient HD center given her insurance and she is hepB
positive.
She was unable to obtain dialysis, which was due on ___.
Her last session of dialysis was ___. She now returns
with increasing lower extremity swelling, increased fatigue,
generalized weakness, mild diffuse abdominal discomfort. Denies
fevers or chills. Denies vomiting or diarrhea. Denies chest pain
or shortness of breath. She denies any significant change in
symptoms since her last hospitalization, and is returning to
receive HD and resume search for OP HD center.
Past Medical History:
- chronic HBeAg-negative HBV cirrhosis
- hypertension
- type 2 diabetes
Social History:
___
Family History:
No knowledge of relevant family medical history.
Physical Exam:
Admission Exam:
===============
___ 2336 Temp: 98.6 PO BP: 156/70 L Lying HR: 74 RR:
18 O2 sat: 98% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CHEST: tunneled HD line present in R chest wall, TTP over
catheter without any erythema fluctuance or drainage
CARDIAC: Regular rhythm, normal rate. ___ SEM best heard at ___
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, mild TTP
diffusely,
no rebound or tenderness
EXTREMITIES: 2+ pitting edema to knee bilaterally
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Discharge Exam:
===============
97.9 144/48 76 20 94 ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CHEST: tunneled HD line present in R chest wall, TTP over
catheter without any erythema fluctuance or drainage
CARDIAC: Regular rhythm, normal rate. ___ SEM best heard at ___
LUNGS: Mild crackles in bases.
ABDOMEN: Normal bowels sounds, non distended, mild TTP
diffusely,
no rebound or tenderness
EXTREMITIES: trace edema b/l
NEUROLOGIC: + faint asterixis. AOx3. Months Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Pertinent Results:
Admission Labs:
================
___ 04:41PM K+-5.1
___ 03:35PM ___ PTT-32.4 ___
___ 03:00PM GLUCOSE-160* UREA N-32* CREAT-1.9* SODIUM-138
POTASSIUM-5.7* CHLORIDE-102 TOTAL CO2-27 ANION GAP-9*
___ 03:00PM ALT(SGPT)-20 AST(SGOT)-53* ALK PHOS-154* TOT
BILI-0.4
___ 03:00PM ALBUMIN-2.9* CALCIUM-8.4 PHOSPHATE-3.1
MAGNESIUM-2.3
___ 03:00PM WBC-5.2 RBC-3.10* HGB-8.0* HCT-25.6* MCV-83
MCH-25.8* MCHC-31.3* RDW-16.8* RDWSD-49.7*
___ 03:00PM NEUTS-61.6 ___ MONOS-12.4 EOS-3.1
BASOS-0.4 IM ___ AbsNeut-3.23 AbsLymp-1.15* AbsMono-0.65
AbsEos-0.16 AbsBaso-0.02
___ 03:00PM PLT COUNT-195
Discharge Labs:
===============
___ 09:00AM BLOOD WBC-5.9 RBC-3.11* Hgb-8.0* Hct-25.0*
MCV-80* MCH-25.7* MCHC-32.0 RDW-16.2* RDWSD-47.1* Plt ___
___ 09:00AM BLOOD Glucose-161* UreaN-16 Creat-1.9* Na-137
K-3.8 Cl-100 HCO3-30 AnGap-7*
___ 06:10AM BLOOD ALT-20 AST-44* LD(LDH)-300* AlkPhos-188*
TotBili-0.4
___ 09:00AM BLOOD Calcium-7.9* Phos-2.7 Mg-2.1
Microbiology:
=============
__________________________________________________________
___ 6:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:35 am URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 7:39 am BLOOD CULTURE #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Imaging:
=========
___ Abdominal Duplex:
1. Patent TIPS. No portal vein clot.
2. No biliary obstruction.
3. Small to moderate right pleural effusion and trace
perihepatic ascites. Gallstones or sludge.
___ Vein Mapping:
RIGHT:
The cephalic vein measures 0.14 cm at the distal forearm, 0.2 cm
deep to the skin, 0.16 cm at the mid forearm, 0.2 cm deep to the
skin, 0.23 cm at the antecubital fossa, 0.3 cm deep to the skin.
The cephalic vein at the level of the arm could not be
followed.
The basilic vein measures 0.16 cm at the antecubital fossa, 0.4
cm deep to the skin, 0.22 cm at its mid portion, 0.5 cm deep to
the skin and 0.17 cm at the proximal portion, 0.5 cm deep to the
skin.
The radial artery measures 0.19 cm. The brachial artery measures
0.41 cm. Mild arterial calcifications are present.
LEFT:
The cephalic vein measures 0.16 cm at the distal forearm, 0.3
cm deep to the skin, 0.16 cm at the proximal forearm, 0.3 cm
deep to the skin, 0.16 cm at the antecubital fossa, 0.3 cm deep
to the skin, 0.16 cm at the proximal arm, 0.5 cm deep to the
skin, 0.13 cm at the mid arm, 0.4 cm deep to the skin, and 0.5
cm at the distal arm, 0.5 cm deep to skin.
The basilic vein measures 0.23 cm at the distal forearm, 0.7 cm
deep to the skin, 0.16 cm at the mid forearm, 0.3 cm deep to the
skin, and 0.20 cm at the proximal forearm, 0.3 cm deep to the
skin.
The radial artery measures 0.39 cm. The brachial artery measures
0.18 cm. Mild arterial calcifications are present.
IMPRESSION:
The right cephalic vein could not be visualized at the level of
the proximal distal arm. Otherwise, the bilateral cephalic and
basilic veins are patent. Measurements as above.
Chest wall U/S ___: No fluid collection is identified within
the soft tissues surrounding the tunneled HD line within the
left chest.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
2. amLODIPine 10 mg PO DAILY
3. Entecavir 0.5 mg PO 1X/WEEK (MO)
4. Lactulose 30 mL PO TID
5. Nephrocaps 1 CAP PO DAILY
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
7. Pantoprazole 20 mg PO Q24H
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
9. Rifaximin 550 mg PO BID
10. sevelamer CARBONATE 800 mg PO TID W/MEALS
11. TraZODone 50 mg PO QHS:PRN insomnia
12. Vitamin D ___ UNIT PO 1X/WEEK (FR)
13. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
14. Torsemide 40 mg PO DAILY
Discharge Medications:
1. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Entecavir 1 mg PO 1X/WEEK (MO)
RX *entecavir 1 mg 1 tablet(s) by mouth once a week (___)
Disp #*12 Tablet Refills:*0
3. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
5. amLODIPine 10 mg PO DAILY
6. Lactulose 30 mL PO TID
7. Nephrocaps 1 CAP PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
10. Pantoprazole 20 mg PO Q24H
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
12. Rifaximin 550 mg PO BID
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
14. TraZODone 50 mg PO QHS:PRN insomnia
15. Vitamin D ___ UNIT PO 1X/WEEK (FR)
Discharge Disposition:
Home
Discharge Diagnosis:
ESRD
Hepatitis B Cirrhosis
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 ESRD on HD p/w volume overload, crackles at
bases, h/o hydrothorax// eval pulm edema/pleural effusion
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Right-sided dual lumen central venous catheter tip terminates in the low SVC.
Heart size is moderate to severely enlarged, as seen previously. The
mediastinal and hilar contours are similar to prior. The pulmonary
vasculature remains congested, though improved from prior. There has been
interval removal of previously noted right-sided pigtail catheter. Small
right pleural effusion has minimally decreased in the interval with component
loculated towards the apex. Persistent patchy opacity in the right lung base
likely reflective of atelectasis. Left lung is clear. No pneumothorax is
seen. There are no acute osseous abnormalities. TIPS is seen in the right
upper quadrant of the abdomen.
IMPRESSION:
1. Interval removal of right-sided pigtail catheter and redemonstration of a
small right pleural effusion, minimally decreased in the interval, with
component loculated towards the apex.
2. Patchy right basilar atelectasis.
3. Mild pulmonary vascular congestion, improved in the interval.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL PORT
INDICATION: ___ year old woman with HBV cirrhosis, abdominal pain// RUQUS w
doppler to evaluate biliary tree and for any clot
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: ___
FINDINGS:
There is a small to moderate right pleural effusion.
The liver appears minimally coarsened. No focal liver lesions are identified.
There is trace perihepatic ascites.
There is stable splenomegaly, with the spleen measuring 12.1 cm.
There is no intrahepatic biliary dilation. The CHD measures 4 mm.
There is no evidence of stones. Gallbladder wall is slightly edematous,
likely related to chronic liver disease, but not significant distended.
Dependent debris within the gallbladder probably represents sludge and stones.
The main portal vein is patent with hepatopetal flow.
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 30 cm/sec, previously 36 cm/sec
Proximal TIPS: 43-47 cm/sec, previously 123 cm/sec
Mid TIPS: 138 cm/sec, previously 178 cm/sec
Distal TIPS: 128 cm/sec, previously 141 cm/sec
Flow within the left portal vein is slow but towards the TIPS shunt. Flow
within the right anterior portal vein is towards the TIPS. Appropriate flow
is seen in the hepatic veins and IVC.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
KIDNEYS: Limited views of the kidneys demonstrate no hydronephrosis.
IMPRESSION:
1. Patent TIPS. No portal vein clot.
2. No biliary obstruction.
3. Small to moderate right pleural effusion and trace perihepatic ascites.
Gallstones or sludge.
Radiology Report
EXAMINATION: VENOUS MAPPING FOR DIALYSIS ACCESS
INDICATION: ___ year old woman with ESRD on HD with tunneled line.// mapping
for fistula
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of both
cephalic veins, radial artery, brachial artery, basilic vein and subclavian
veins was performed.
COMPARISON: None
FINDINGS:
RIGHT:
The cephalic vein measures 0.14 cm at the distal forearm, 0.2 cm deep to the
skin, 0.16 cm at the mid forearm, 0.2 cm deep to the skin, 0.23 cm at the
antecubital fossa, 0.3 cm deep to the skin. The cephalic vein at the level of
the arm could not be followed.
The basilic vein measures 0.16 cm at the antecubital fossa, 0.4 cm deep to the
skin, 0.22 cm at its mid portion, 0.5 cm deep to the skin and 0.17 cm at the
proximal portion, 0.5 cm deep to the skin.
The radial artery measures 0.19 cm. The brachial artery measures 0.41 cm. Mild
arterial calcifications are present.
LEFT:
The cephalic vein measures 0.16 cm at the distal forearm, 0.3 cm deep to the
skin, 0.16 cm at the proximal forearm, 0.3 cm deep to the skin, 0.16 cm at the
antecubital fossa, 0.3 cm deep to the skin, 0.16 cm at the proximal arm, 0.5
cm deep to the skin, 0.13 cm at the mid arm, 0.4 cm deep to the skin, and 0.5
cm at the distal arm, 0.5 cm deep to skin.
The basilic vein measures 0.23 cm at the distal forearm, 0.7 cm deep to the
skin, 0.16 cm at the mid forearm, 0.3 cm deep to the skin, and 0.20 cm at the
proximal forearm, 0.3 cm deep to the skin.
The radial artery measures 0.39 cm. The brachial artery measures 0.18 cm. Mild
arterial calcifications are present.
IMPRESSION:
The right cephalic vein could not be visualized at the level of the proximal
distal arm. Otherwise, the bilateral cephalic and basilic veins are patent.
Measurements as above.
Radiology Report
EXAMINATION: US CHEST WALL SOFT TISSUE RIGHT
INDICATION: ___ year old woman with tunneled HD line and pain at site.//
Assess tunneled line site for collection/abscess
TECHNIQUE: Grayscale and color Doppler ultrasound images were obtained of the
superficial tissues of the left chest.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
left chest at the site of the tunneled HD line. No fluid collection is
identified.
IMPRESSION:
No fluid collection is identified within the soft tissues surrounding the
tunneled HD line within the left chest.
Gender: F
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: Body aches, Cough, Weakness
Diagnosed with Weakness
temperature: 98.2
heartrate: 87.0
resprate: 16.0
o2sat: 98.0
sbp: 156.0
dbp: 56.0
level of pain: 7
level of acuity: 2.0 | ___ is a ___ woman with HBeAg-negative HBV cirrhosis
(c/b ascites, chronic hepatic hydrothorax, and hepatic
encephalopathy) s/p TIPS that was c/b right heart failure
requiring TIPS closure and aggressive diuresis, recently listed
for transplant who re-presented to receive HD as she is
difficult to place for outpatient HD given insurance and Hep B
status. She left AGAINST MEDICAL ADVICE to attend her mother's
funeral/cremation with plans to return to the hospital to
continue HD.
ACTIVE ISSUES
=============
# Disposition: Patient very difficult to find HD center given
her
insurance and hepatitis B status. She left AGAINST MEDICAL
ADVICE to attend her mother's funeral/cremation with plans to
return to the hospital to continue HD.
# ATN
# HD Dependent
# Chronic kidney disease stage 4 (eGFR ~18 by cystatin C)
Baseline CKD secondary to longstanding diabetes and hypertension
per ___ biopsy. Her renal function was complicated by
episodes of ATN in the setting of overdiuresis. She was
monitored for renal recovery however remained persistently
uremic with symptoms and HD was initiated. S/p tunneled line
placement. Had difficulty in being accepted by an outpatient HD
center due to Hep B status/insurance. Has been trialed off HD
several times in the past and becomes volume overloaded with
large hepatohydrothorax requiring chest tube. She therefore
continued receiving hemodialysis while inpatient. She received
vein mapping in preparation for fistula.
# HBV cirrhosis (MELD 22, Childs B on admission)
Cirrhosis decompensated by ascites, refractory hepatic
hydrothorax s/p chest tube, and hepatic encephalopathy, s/p TIPS
___ with revision ___ due to right heart failure. EGD w/o
varices. She remains on the transplant list. Entacavir was
increased to 1mg weekly given on HD and has decompensated
cirrhosis. Repeat HBV VL was undetected. Continued
lactulose/rifaximin
#Abdominal pain
#Leg pain
#Tunneled HD line site pain
Chronic. Unchanged. No e/o infection around HD line site.
Continued Tylenol and oxycodone PRN
CHRONIC ISSUES
==============
#Nocturnal hypoxia
Intermittent desats to ___ overnight during prior admission.
Suspect undiagnosed OSA.
#Hypertension
Continued home amlodipine. Re-started losartan
#Asthma
Continue albuterol nebs PRN.
#GERD
Continue home pantoprazole.
TRANSITIONAL ISSUES
======================
[ ] FYI: patient has PFO diagnosed on ___ bubble study.
[ ] Will need repeat Cystatin C 12 weeks after initial was
checked (initial checked ___.
[ ] Patient will benefit from liver-kidney transplant.
[ ] Outpatient sleep study given episodes of desaturation at
night
[ ] Gabapentin held iso renal failure, patient wasn't requiring
so continued to hold at discharge.
[ ] Triple phase CT scan to evaluate prior liver lesions on
re-admission to liver service |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Right spontaneous pneumothorax
Major Surgical or Invasive Procedure:
Right pigtail chest tube
History of Present Illness:
___ year-old previously healthy female woke up today AM with
right sided chest pain and shortness fo breath. She has never
had symptoms like this before. No history of recent trauma or
exercise. No contributory family history. Patient does note
that she was born premature at 25 weeks.
Patient states that when she awoke this morning, she felt a
general discomfort in her bilateral chest which localized to her
right chest with radiation to the righe back. She reports
wheezing and coughing as well as pleuritic chest pain. She
sough care at an outside facility where a chest x-ray was done
and found large right pneumothorax. She was placed on
non-rebreather and transferred to ___ ED.
Past Medical History:
PMH:
Born premature at 25 months
Right-sided central line during neo-natal hospitalization
PSH:
Rhinoplasty ___
Social History:
___
Family History:
Mother: alive and well
Father: alive and well
Siblings: alive and well
Offspring: N/A
Other: grandfather died of lung cancer. Other family history is
non-contributory, no other family history of lung disease
Physical Exam:
On initial evaluation in ED:
Temp: 98.4 HR: 67 BP: 114/95 RR: 18 O2 Sat: 99
non-rebreather
Gen: NAD, AAOx3, thin
CV: RRR
Pulm: right-sided chest sounds absent. Left chest sounds WNL
Abd: Soft, NT/ND
Ext: WWP, no c/c/e
On discharge:
98.4, 93, 123/67, 18, 100% RA
Gen: NAD, AAOx3
CV: RRR no m/r/g
Pulm: CTAB with breath sounds auscultated in all lung fields.
Pneumostat in place with air leak
Abd: Soft, NT/ND
Ext: WWP no c/c/e
Pertinent Results:
CT Chest ___:
IMPRESSION:
1. Areas of hyperlucency within the bilateral lungs likely
relate to remote respiratory insult as a child either as part of
prematurity or related to a predisposition to infections in
early childhood.
2. Moderate, anterior right pneumothorax despite right posterior
pigtail
pleural catheter.
CXR ___:
(Preliminary report)
Pig-tail-type left-sided chest tube is present. As before, there
is moderate-sized pneumothorax at the right lung apex which
appears slightly smaller on today's exam. Minimal atelectasis in
the right cardiophrenic region and minimal blunting of the right
costophrenic angle. Costophrenic angle blunting is new, though
no large effusion is identified. Mediastinum remains midline. On
the current exam, the cardiac silhouette appears small and
hanging compared to the prior study. No CHF, focal consolidation
or left-sided effusion. No left-sided pneumothorax. Elsewhere
and on the lateral view, cardiac silhouette is unchanged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Adderall (dextroamphetamine-amphetamine) 10 mg oral daily prn
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
4. Adderall (dextroamphetamine-amphetamine) 10 mg oral daily prn
Discharge Disposition:
Home
Discharge Diagnosis:
Spontaneous right pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
HISTORY: Chest tube placement.
COMPARISONS: ___, earlier in the same day.
TECHNIQUE: Chest, AP upright portable.
FINDINGS: A right-sided chest tube has been placed. There is persistent
moderate-to-large right-sided pneumothorax, but substantially decreased. Of
note, however, the contours of the right upper lobe are poorly defined with an
area of substantial concavity. This may indicate a substantial defect in the
visceral pleura, bullous changes, atelectasis or some combination of these.
Persistent short-term radiographic followup is recommended. The left lung
remains clear. The cardiac, mediastinal and hilar contours appear unchanged.
There is no mediastinal shift.
IMPRESSION: Some decrease in large pneumothorax following right-sided chest
tube placement. Irregularity and concavity of the contour of the right upper
lobe suggesting a possible source for air leakage and possibly an ongoing
defect; short-term follow-up reassessment is recommended.
Radiology Report
HISTORY: Spontaneous pneumothorax with chest tube.
FINDINGS: In comparison with the study of ___, there is little change in the
size of the small-to-moderate right pneumothorax with chest tube in place.
Otherwise, no change.
Radiology Report
INDICATION: ___ year old woman with right PTX with chest tube on water seal,
evaluate for interval change.
TECHNIQUE: Portable chest radiograph.
COMPARISON: Chest radiographs from ___ through ___.
FINDINGS:
Since prior, there is mild increase in size of a moderate right pneumothorax,
which measures approximately 2.1 cm. A right pigtail is unchanged in position.
The left lung is clear. Cardiomediastinal and hilar contours are normal. There
is no mediastinal shift or diaphragmatic flattening to suggest tension
physiology.
IMPRESSION:
Mild increase in size of moderate right apical pneumothorax.
NOTIFICATION: Findings were paged to ___ by Dr. ___ on ___ at 10:58, 5 min after they remain.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with pneumothorax and persistent air leak with
pigtail // Please evaluate for cause of pneumothorax. Additional history from
the medical record, patient with history of prematurity born at 25 weeks.
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent and reconstructed as contiguous 5- and 1.25-mm
thick axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial
images.
DOSE: DLP: 201 mGy-cm
COMPARISON: None prior
FINDINGS:
CT chest: The thyroid is unremarkable and there is no supraclavicular lymph
node enlargement. The airways are patent to the subsegmental level. Axillary
lymph nodes are notable more further number than size, measuring up to 7 mm.
No mediastinal or hilar lymph node enlargement by CT size criteria. Normal
heart size. The aorta and great vessels are of normal caliber. No pericardial
abnormalities. No hiatal hernia.
A right pigtail catheter is located in the right posterior pleural space.
Despite the catheter, a moderate right pneumothorax persists anteriorly.
Multiple hyperlucent areas within both lobes are due to heterogenous
distribution of regions of diminished vascularity and lung integument. These
are probably the result of remote widespread infection or injury to the
underdeveloped lung at birth. Bibasilar atelectasis worse on the right due to
volume loss related to the pneumothorax.
Osseous structures: No bone lesions in the chest case suspicious for
malignancy or infection. No soft tissue lesions within the chest wall or the
imaged portion of the upper abdomen suspicious for malignancy or infection.
IMPRESSION:
1. Areas of hyperlucency within the bilateral lungs likely relate to remote
respiratory insult as a child either as part of prematurity or related to a
predisposition to infections in early childhood.
2. Moderate, anterior right pneumothorax despite right posterior pigtail
pleural catheter.
Radiology Report
INDICATION: ___ year old woman with CT newly to water seal // Please eval for
possible worsening PTX at 1:30 ___
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
There has been mild interval increase in size of right apical pneumothorax
which measures approximate 2.4 cm. A right pigtail catheter is in unchanged
position. The left lung is clear. No new pleural effusion. Cardiomediastinal
and hilar contours are normal. No mediastinal shift or diaphragmatic
flattening to suggest tension physiology.
IMPRESSION:
Mild increase in size of moderate right apical pneumothorax.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 2:33 ___, 1 minutes after discovery of the
findings.
Radiology Report
HISTORY: Chest tube to waterseal.
CHEST, TWO VIEWS.
COMPARISON: Chest x-ray dated ___ at 14:17 p.m.
A right-sided pig-tail-type chest tube is present. As before, there is
moderate-sized pneumothorax at the right lung apex, which appears slightly
smaller on today's exam. A tiny ptx may also be present at the right
cardiophrenic angle. Minimal atelectasis in the right cardiophrenic region and
minimal blunting of the right costophrenic angle also noted. Costophrenic
angle blunting is new, though no large effusion is identified. Mediastinum
remains midline. On the current exam, the cardiac silhouette appears small
and hanging compared to the prior study, notably smaller than on the ___
CXR. No CHF, focal consolidation or left-sided effusion. No left-sided
pneumothorax. Elsewhere and on the lateral view, cardiac silhouette is
unchanged.
IMPRESSION:
1) Moderate right apical ptx, slightly smaller on tosays exam. Suspect tiny
ptx at right costophrenic angle.
2) Striking decrease is size of cardiac silhouette compared with ___.
3) Otherwise, doubt acute pulmonary process.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea, PNEUMOTHORAX
Diagnosed with OTHER PNEUMOTHORAX
temperature: 98.4
heartrate: 74.0
resprate: 20.0
o2sat: 93.0
sbp: 127.0
dbp: 95.0
level of pain: 6
level of acuity: 2.0 | Ms. ___ was admitted to the Thoracic Surgery service from the
ED, where thoracic surgery resident placed pigtail and put tube
to suction, resulting in partial resolution of the lung and
marked improvement of respiratory status. There was a small
apical pneumothorax still present after placement of the
pigtail.
The patient was briefly placed to water seal on HD#2 but a
prominent air leak was noted, and the pleurovac was returned to
suction. Attempt to place the CT to WS was again made on HD#3,
but post-WS CXR demonstrated a large recurrent pneumothorax, and
so the tube was returned to suction.
A CT was also conducted on HD#3. As noted in the initial
consult note, the patient was born at 25 weeks gestation, and
the CT found numerous areas of hyperlucency that may be
attributable to infection at an early age.
The air leak was slightly reduced on HD#4 and the possibility of
surgery to excise bleb(s) and to conduct mechanical pleurodesis
was discussed; the choice was made to wait and the CT was placed
to WS again on HD#5. The CXR after placing it to water seal
showed modest increase of PTX from 2.0 to 2.4 cm, and it was
decided to wait until the following day to decide how to
proceed. A pneumostat was placed in the evening of HD#5 to see
how well this would be tolerated.
The pneumothorax was read as being slightly decreased on
AP/lateral CXR on HD#6, and it was decided that discharge with
pneumostat in place and close follow-up would be appropriate.
Ms. ___ agreed with this plan and is discharged to home with
pneumostat in place and with appropriate instructions, warnings,
prescriptions, and follow-up on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Beta-Blockers
(Beta-Adrenergic Blocking Agts) / Erythromycin Base
Attending: ___.
Chief Complaint:
shortness of breath/wheezing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. ___ is a ___ with history of asthma/COPD (on 2L home O2
with exertion), CAD (s/p MI ___ years ago), mild OSA (not on
CPAP) who presents with 2 weeks of worsening asthma/COPD
symptoms. She reports onset of her allergy symptoms with runny,
nose, congestion, coughing, ithy eyes which then triggered her
astham/COPD including worsening shortness of breath, wheezing
and feeling really fatigued. She was seen by her PCP at ___
about 2 weeks ago and started on 60mg prednisone in addition to
her regular COPD/Asthma and allergy symptoms without much
improvment which promted her visit to the ___ emergency room.
Patient reports her cough has been productive of yellow sputum
but no fevers. No other infectious symptoms. Denies nausea,
vomiting or diarrhea. No chest pain, no recent travel. She is a
chronic smoker x ___ years however quit 2 weeks ago with onset of
her symptoms.
In the ED, initial vitals: 96.5 84 124/63 24 100% 10L
Non-Rebreather. Labs notable for WBC 13.3 otherwise normal
chem. CXR without consolidations. EKG without ischemic changes.
She did not repond to repeated neb treatments therefore she was
placed on continous albuterol along with scheduled ipratropium.
She was given mag, 125mg methylpred and levaquin and admitted
for further care.
On arrival to the FICU, patient reports continued wheezing and
chest tightness. This is ther first time she has been admitted
to ICU. No history of intubation or non-invasives. 3
hospitalizations for COPD/Asthma exacerbations over the past one
year.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
CAD s/p MI with prior stents (age ___
Asthma/COPD FEV1/FVC = 69% FEV1 38%
Allergic Rhinitis
OSA
Pulmonary HTN
Hypertension
Lumbar disk herniation with radiculopathy s/p Prior back and
neck surgery
Social History:
___
Family History:
No asthma. Mother died at ___ of breast cancer, father died of
pancreatic cancer in ___.
Physical Exam:
ADMISSION:
GENERAL: appears fatigued
HEENT: Dry mucous mebrane
NECK: supple, JVP not elevated, no LAD
LUNGS: Speaking in full sentences, no use of accessory muscles,
decreased breath sounds bilaterally with few wheezes, no rhonchi
or crackles.
CV: Tachycardic, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended,
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: alert and oriented, conversant
Pertinent Results:
ADMISSION LABS:
___ 10:00PM ___ PTT-25.7 ___
___ 10:00PM PLT COUNT-284
___ 10:00PM NEUTS-65.0 ___ MONOS-5.5 EOS-0.4
BASOS-0.5
___ 10:00PM WBC-13.7*# RBC-4.41 HGB-13.7 HCT-40.7 MCV-92
MCH-31.1 MCHC-33.7 RDW-16.3*
___ 10:00PM CALCIUM-9.0 PHOSPHATE-4.1 MAGNESIUM-2.3
___ 10:00PM estGFR-Using this
___ 10:00PM GLUCOSE-97 UREA N-17 CREAT-0.6 SODIUM-143
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16
___ 10:40PM LACTATE-2.5*
___ 10:40PM ___ PO2-193* PCO2-45 PH-7.40 TOTAL
CO2-29 BASE XS-2
MICRO:
__________________________________________________________
___ 5:45 am MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
__________________________________________________________
___ 10:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:10 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING:
CXR ___:
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Enalapril Maleate 10 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Gabapentin 100 mg PO TID
8. Montelukast 10 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Ranitidine 150 mg PO BID
11. TraMADOL (Ultram) 50-100 mg PO Q8H:PRN pain
12. Tiotropium Bromide 1 CAP IH DAILY
13. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
14. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
15. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
16. ciclopirox 0.77 % topical BID
17. Fexofenadine 180 mg PO DAILY
18. Benzonatate 100 mg PO TID
19. Chantix (varenicline) 1 mg oral BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Benzonatate 100 mg PO TID
5. Enalapril Maleate 10 mg PO DAILY
6. Fexofenadine 180 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Gabapentin 100 mg PO TID
10. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
11. Montelukast 10 mg PO DAILY
12. Pantoprazole 40 mg PO Q12H
13. Ranitidine 150 mg PO BID
14. Tiotropium Bromide 1 CAP IH DAILY
15. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*24 Tablet
Refills:*0
16. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
17. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
18. Amlodipine 5 mg PO DAILY
19. Chantix (varenicline) 1 mg oral BID
20. ciclopirox 0.77 % topical BID
21. TraMADOL (Ultram) 50-100 mg PO Q8H:PRN pain
22. zileuton 600 mg oral TID
RX *zileuton [Zyflo CR] 600 mg 2 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Seasonal allergies
COPD
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: Respiratory distress.
TECHNIQUE: Chest, AP upright portable.
COMPARISON: ___.
FINDINGS:
The cardiac, mediastinal and hilar contours appear stable. There is no
pleural effusion or pneumothorax. The lungs appear clear. There has been no
significant change.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Asthma exacerbation, Dyspnea
Diagnosed with ASTHMA W STATUS ASTHMAT
temperature: 96.5
heartrate: 84.0
resprate: 24.0
o2sat: 100.0
sbp: 124.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | ___ with history of asthma/COPD (on 2L home O2 with exertion),
CAD (s/p MI ___ years ago), mild OSA (not on CPAP) who presents
with 2 weeks of worsening asthma/COPD symptoms.
# Asthma/COPD Exacerbation: Patient has severe obstructive
disease based on her PFTs; current episode triggered by allergic
exposure and ongoing smoking; not improving with po prednisone
60mg as outpatient. Monitored in the ICU. Treated with standing
nebulizers, IV methylpred, singulair, Fexofenadine and
Fluticasone nasal spray, Benzonatate and mucinex with
improvement in her symptoms. She has a follow up appointment
with pulmonology on ___ and should be considered for
omalizumab. We did measure IgE levels here and they were
elevated to 666. Will require long, slow steroid taper given
refractory - being discharged on 60 mg PO prednisone tablets to
get her to pulmonology - at which point they will continue taper
based on her symptoms. We did start zileuton on discharge.
# CAD: Continued aspirin, atorvastatin. Held enalipril while in
the ICU.
# HTN: Normotensive, held amlodipine and enalipril
# GERD: Continued pantoprazole and ranitidine
# Communication: Brother, ___ ___
# Code: Full Code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Aggrenox / Persantine
Attending: ___.
Chief Complaint:
Pleuritic Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Primary Care Physician: Dr. ___
CHIEF COMPLAINT: Chest pain
SUBJECTIVE: Patient was discussed with ___ Resident
___, a ___ yo M PMHx HTN-ESRD recently started on
dialysis, CAD, HFpEF, ILD, and HLD presents with chest pain
during dialysis. Patient had been feeling okay since discharge
on ___. He presented to his first dialysis session at the
outpatient facility at ___ ___ overall session). The
session continued for an extended period and patient began to
have bilateral leg cramps that were rather uncomfortable. When
the session was complete, his stood up, leg cramps got worst and
he began to experience ___ subxiphoidal chest pain. Patient
when home and when it didnt improve in 3 hours he decided to
seek medical attention. Last night, patient attempted to take
nitroglycerin without any efficacy. Pain is currently ___
pressure, worst with inspiration, absent on expiration, and can
be avoided on CC7 if patient uses shallow breathing. Pain may
be slightly improved by sitting up versus lying supine.
Exertion, body movement, and food ___ seem to make any
difference. Per patient, the sensation is different from prior
heart attacks (in ___, the pain was less steady, I was
breathing heavily, and nitro made things feel a lot better) or
heartburn (burning pain, worst with foods, havent had one in
years). No radiation to neck, arm, or back.
Vitals in the ED: 101.1 74 139/64 16 98% RA. Labs notable for:
WBC 12.0 with 90.3% N. H/H 9.8/28.7. BUN/Cr 50/4.5. UA negative.
Lactate 1.5. Trop 0.02. BNP 17488. CXR unchanged since last
admission and CTA without evidence of aortic dissection. Bedside
echo with no pericardial effusion or right heart ?strain.
Patient given: Cefepime 2gm and Vancomycin 1gm and 250cc NS.
Vitals prior to transfer: 98.7 71 119/56 17 97% Nasal Cannula.
ROS: See HPI. Negative for fever/chills, rhinorrhea, sore
throat, lymphanopathy, changed cough (has had one for years, if
anything better recently, no cough or sputum during this
episode), worsening nausea (has some that caused his to initiate
dialysis, if anything overall improved), emesis, palpitations,
change in bowel movements, worsening leg swelling (overall
improved to resolved), rash, recent URI/GI illness. Otherwise
9-point ROS negative.
Past Medical History:
- ERSD from hypertensive nephrosclerosis with LUE AVG, on HD MWF
- CAD s/p failed PCI
- L Carotid Endarterectomy with Dacron® patch
- Chronic Diastolic Heart Failure
- Interstitial pneumonia (atypical UIP, NSIP, chronic
hypersensitivity)
- Emphysema w/o obstruction
- Right medial occipital strokes (___)
- AAA (5.8 cm last time measured)
- HTN
- HLD
- Eosinophilia
Social History:
___
___ History:
Mother had hypertension and ovarian cancer. Father died in ___.
No family history of kidney disease. No other family medical
problems. Paternal grandfather had lung cancer. No 1st degree
relatives with asthma or allergies.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vitals - 98.1, 72, 20, 120/58, 97% on 2L, EKG in chart
GENERAL: NAD, pleasant and conversant
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, JVD 10cm
CARDIAC: RRR with II/VI SEM at RUSB and apex
LUNG: Diffuse dry crackles and possible bibasilar wet crackles
(unchanged from 1 week ago)
ABDOMEN: Nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Trace LLE edema and no RLE edema (improved from 1
week ago), left ___
digit chronic ischemia, 1+ ___ pulses, LUE AVG with good
bruit/thrill
NEURO: CN II-XII intact, fluent speech, ___ ___ strength, gait
exam deferred
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAMINATION:
VITALS: 98.5, 66-72, 112-131/64, 20, 95-98% on RA, ___ Pain,
79.7kg, Ins 780, Outs 425
GENERAL: NAD, pleasant and conversant
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, JVD 10cm
CARDIAC: RRR with II/VI SEM at RUSB and apex, friction rub now
appreciated
LUNG: Diffuse dry crackles and possible bibasilar wet crackles
(unchanged from 1 week ago)
ABDOMEN: Nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Trace LLE edema and no RLE edema (improved from 1
week ago), left ___
digit chronic ischemia, 1+ ___ pulses, LUE AVG with good
bruit/thrill
NEURO: CN II-XII intact, fluent speech, ___ ___ strength, gait
exam deferred
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 09:30PM BLOOD WBC-12.0*# RBC-3.52* Hgb-9.5* Hct-28.7*
MCV-82 MCH-26.9* MCHC-32.9 RDW-16.8* Plt ___
___ 07:22AM BLOOD WBC-8.9 RBC-3.10* Hgb-8.5* Hct-25.5*
MCV-82 MCH-27.4 MCHC-33.4 RDW-16.8* Plt ___
___ 09:30PM BLOOD Neuts-90.3* Lymphs-4.1* Monos-3.9 Eos-1.6
Baso-0.1
___ 09:30PM BLOOD ___ PTT-28.4 ___
___ 09:30PM BLOOD Glucose-98 UreaN-50* Creat-4.5*# Na-136
K-3.7 Cl-96 HCO3-25 AnGap-19
___ 07:22AM BLOOD Glucose-86 UreaN-59* Creat-5.8*# Na-134
K-3.4 Cl-95* HCO3-23 AnGap-19
___ 09:30PM BLOOD ALT-14 AST-26 CK(CPK)-109 AlkPhos-66
TotBili-0.6
___ 09:30PM BLOOD Lipase-55
___ 09:30PM BLOOD CK-MB-3 ___
___ 09:30PM BLOOD cTropnT-0.02*
___ 05:35AM BLOOD cTropnT-0.02*
___ 12:45PM BLOOD cTropnT-0.03*
___ 09:38PM BLOOD Lactate-1.5
___ 02:35AM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ CXR: Relative to prior study dated ___,
pulmonary edema is improved on a background of interstitial lung
disease. Right pleural effusion and likely small left pleural
effusion. Elevation of the right hemidiaphragm may reflect
diaphragmatic eventration though question subpulmonic effusion.
___ EKG: Sinus rhythm at 71, 2 PVCs, no ST-T changes, no PR
depression, QTC 477, overall similar to priors
___ CTA: Diffuse parenchymal fibrosis progressed since study
dated ___. Pattern consistent with fibrosing NSIP in
morphology and distribution. Bulky central adenopathy has
additionally progressed since prior study dated ___,
thought associated. Moderate nonhemorrhagic layering pleural
effusions, right greater than left. No evidence of pulmonary
embolism. Extensive calcified and noncalcified atheromatous
disease of the descending aorta and aortic arch. Coronary artery
calcifications are moderate to severe.
___ Blood Cultures NGTD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO 3X/WEEK (___)
4. Clopidogrel 75 mg PO DAILY
5. Ezetimibe 10 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. HydrALAzine 25 mg PO TID
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Metoprolol Tartrate 50 mg PO BID
10. Minoxidil 2.5 mg PO DAILY
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Pravastatin 20 mg PO QPM
13. Torsemide 40 mg PO DAILY
14. Nephrocaps 1 CAP PO DAILY
15. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO 3X/WEEK (___)
4. Clopidogrel 75 mg PO DAILY
5. Ezetimibe 10 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. HydrALAzine 25 mg PO TID
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Metoprolol Tartrate 50 mg PO BID
10. Minoxidil 2.5 mg PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
13. Pravastatin 20 mg PO QPM
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. Torsemide 40 mg PO 4X/WEEK (___)
16. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
17. Acetaminophen 650 mg PO TID:PRN Pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Uremic Pericarditis
Chest Pain Rule-Out
Fever in Dialysis Patient
SECONDARY:
End-Stage Renal Disease on Hemodialysis
Hypertension
Coronary Artery Disease
Heart Failure with Preserved Ejection Fraction
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: ___ male with fevers and substernal chest pain.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
PA and lateral chest geographic is compared to radiograph dated ___. Relative to prior examination, prior central bronchovascular and diffuse
interstitial prominence is less conspicuous compatible with improved pulmonary
edema. Likely mild heart failure persists. A small right pleural effusion and
likely left pleural effusion is present. Elevation of the left hemidiaphragm
appears to have been present on radiograph dated ___. Though this
may reflect eventration of the hemidiaphragm, somewhat lateral displacement
raises suspicion of a sub pulmonic effusion. Hilar and mediastinal contours
are stable in appearance. Tortuous descending aorta is stable. No acute
osseous abnormality is detected.
IMPRESSION:
Relative to prior study dated ___, pulmonary edema is improved on
a background of interstitial lung disease.
Right pleural effusion and likely small left pleural effusion. Elevation of
the right hemidiaphragm may reflect diaphragmatic eventration though question
subpulmonic effusion.
Radiology Report
EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY
INDICATION: ___ male with chest pain hypoxia. Evaluate for
dissection.
TECHNIQUE: Axial multidetector CT scan from the upper chest to the diaphragm
was performed following the administration of intravenous contrast.
Multiplanar reformatted images in coronal and sagittal axis were generated.
Oblique maximum intensity projection images were prepared and reviewed.
Dose 547 mGy-cm
COMPARISON: CT chest dated ___.
FINDINGS:
The thyroid is unremarkable. There is no axillary adenopathy. Bulky central
adenopathy is present, markedly increased in size relative to prior study
dated ___. A prominent prevascular node measures 1.5 x 2.6 cm. A
conglomerate of subcarinal nodes measures approximately 2.2 x 3.6 cm. A right
lower tear paratracheal station node measures 2.1 x 1.8 cm. No apparent hilar
adenopathy.
Heart is within upper limits of normal in size. Coronary artery calcifications
are moderate. Extensive atherosclerotic calcified and noncalcified plaque
through the aortic arch is noted. The aorta appears normal in caliber without
aneurysmal dilatation. The pulmonary artery is enlarged measuring 3.1 cm,
suggestive of pulmonary hypertension. Trace pericardial fluid is felt
physiologic.
Diffuse parenchymal fibrosis appears to have progressed relative to prior
study dated ___. There is a subpleural predominant pattern of
fibrotic changes with architectural distortion, ground-glass opacities,
traction bronchiectasis as well as microcystic honeycombing. Present
previously, minimal calcifications are associated with the fibrotic changes.
Bilateral layering nonhemorrhagic pleural effusions are moderate in size,
right greater than left, and which tracks within the major fissures
bilaterally.
CTA Thorax: The aorta and main thoracic vessels are well opacified. The
aorta demonstrates normal caliber throughout the thorax without evidence of
dissection or aneurysmal dilatation. The pulmonary arteries are opacified to
the subsegmental level. There is no filling defect to suggest pulmonary
embolism.
The study is not tailored for subdiaphragmatic evaluation, image portions of
the upper abdomen demonstrate no acute abnormality.
Osseous structures: No suspicious lytic or blastic lesion is identified.
Diffuse calcification of the anterior longitudinal ligament is compatible with
diffuse idiopathic skeletal hyperostosis.
IMPRESSION:
Diffuse parenchymal fibrosis progressed since study dated ___. Pattern
consistent with fibrosing NSIP in morphology and distribution. Bulky central
adenopathy has additionally progressed since prior study dated ___,
thought associated.
Moderate nonhemorrhagic layering pleural effusions, right greater than left.
No evidence of pulmonary embolism. Extensive calcified and noncalcified
atheromatous disease of the descending aorta and aortic arch. Coronary artery
calcifications are moderate to severe.
Enlarged pulmonary artery suggestive of pulmonary hypertension.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with FEVER, UNSPECIFIED, PLEURAL EFFUSION NOS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, RENAL DIALYSIS STATUS, HYPERCHOLESTEROLEMIA
temperature: 101.1
heartrate: 74.0
resprate: 16.0
o2sat: 98.0
sbp: 139.0
dbp: 64.0
level of pain: 6
level of acuity: 2.0 | ___, a ___ yo M PMHx ESRD recently started on HD
___ and HTN presented with pleuritic chest pain during his ___
dialysis session worse when laying supine accompanied by
low-grade fever. Exam significant for improved heart failure
findings and friction rub ___ hours after start of chest pain.
Labs significant for elevated BNP and mildly elevated troponin
consistent with ESRD. CXR/CTA-Chest showed no pneumonia or
pulmonary embolism but improving heart failure. Given proximity
to dialysis initiation, typical symptoms, and lack of signs of
ACS/PE, patient was felt to have uremic pericarditis and should
continue to receive dialysis.
# Chest Pain / Uremic Pericarditis: Patient with significant
history of cardiovascular disease (CAD, CHF), cardiovascular
risk factors (ESRD, HTN, HLD), and pulmonary disease (ILD)
presents with pleuritic chest pain and possible fever in ED.
Differential includes ACS (known CAD but no ST-T changes, stable
trop 0.02 from prior, no exertional symptoms, unlike patients
prior ischemic disease), CHF (known CHF and very elevated BNP
but improving exam findings since starting HD), Pericarditis
(history would be typical but no EKG changes, effusion on ED
imaging, or friction rub and uremic pericarditis should not be
started after a ___ dialysis session), Pneumonia (fever and
pleuritic chest pain but no sign on chest plain film or
cross-sectional imaging or cough with purulent sputum),
Pulmonary Embolism (normal CTA-Chest), ILD flare (no worsening
hypoxemia), AAA (no vital sign abnormalities, pleuritic pain,
improving without interventions), GI (no heartburn, improving
nausea, no relation to food, patient hungry), and MSK (pain
nonreproducible, no change with body wall or arm movement). Of
note patient on ___ now has a friction rub (can occur >24 hours
after start of pain); differential includes viral/idiopathic
versus uremic (can occur around time of initiation and not just
before, treatment would just be dialysis) versus other
(hemorrhagic effusion from minoxidil, etc.). Repeated troponins
have been 0.02-0.03 compatible with ESRD. Given improvement
with dialysis, uremic pericarditis was the final diagnosis.
Patient was discharged with primary care, nephrology, and
cardiology followup appointments.
# Fever: Patient recently started on dialysis noted to have
fever and WBC 12 with 90% neutrophils in ED without any symptoms
or signs of infectious disease but given vancomycin/cefepime in
ED. UA/CXR unremarkable for infection, no other SIRS criteria
met, and negative for PE. Patient's leukocytosis normalized,
had no further fevers, and did not receive any further
antibiotics.
# Hypertensive ESRD / Dialysis Initiation: Patient with a
history of CKD V from hypertensive nephrosclerosis, presenting
from outpatient for initiation of dialysis (first session
___ given chronic uremic symptoms (nausea, pruritis,
anorexia, etc.). Patient tolerated two sessions of dialysis
without difficulty, was maintained on calcitriol and low
Na/K/Phos diet. He was continued on Nephrocaps and sevelamer
800mg PO TID with meals. It is possible that intradialysis
fluid shifts contributed to his chest pain presentation as
discussed above. On admission from ___ dialysis session,
patient has normal electrolytes. He was dialyzed on ___ and
will undergo a subsequent ___ and ___ dialysis
# Hypertension: Well-controlled on admission but requiring many
antihypertensives. Continued on home Amlodipine 10 mg PO DAILY,
Isosorbide Mononitrate 60 mg PO DAILY, Metoprolol Tartrate 50
mg PO BID, Minoxidil 2.5 mg PO DAILY, and HydrALAzine 25 mg PO
TID with appropriate holding parameters.
# Chronic Systolic Congestive Heart Failure: Chronic issue with
more elevated BNP than usual but improving physical exam
findings continued on home torsemide (held on dialysis days) and
will be further helped by dialysis.
# Prolonged QTc: Noted to have prolonged QTc on admission with
other sign of arrhythmia; will avoid QT prolonging drugs as much
as possible.
# Coronary Artery Disease: Chronic issue continued on home
aspirin and clopidogrel; role in chest pain discussed in chest
pain section
# Hyperlipidemia: Chronic stable issue maintained on home
pravastatin, ezetimibe, and fish oil |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
weakness, dry cough, chest pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is an ___ year-old lady with a history of CAD s/p
CABG (___), MI x 3, and 11 stents (last procedure in ___, and
anemia who presents from her assisted living facility with
weakness, dry cough and chest pressure.
Patient reports ___ weeks of dry cough and intermittent
subxiphoid pressure following a brief upper respiratory
infection. Per ED ___ 'it somewhat feels like prior cardiac
pain', although on the floor patient denies this. She feels like
she has been having chills but never measured her temperature.
Has been having black stool x ___ years since she started iron
supplementation. Over the last week she has feeling weaker and
fatigued and has not been eating or drinking well.
In the ED, initial vitals were: 97.6 90 165/89 18 97%RA
-ED exam: tenderness to palpation in epigastrium, crackles
- Labs were significant for:
*CBC: 10.3 > 13.0 / 29.0 < 164
*Chem: 140/4.1 | 100/27 | ___ (from b/l 1.5 ___ year ago), lact
1.9
*LFTs: AST 26 / ALT 19 / ALP 63 | TB 0.4 | Lip 63
*TnT 1700 <0.01
- Imaging revealed:
*RUQ US: no cholelithiasis or cholecystitis, gallblader
adenomyomatosis, 1cm hypoechoic lesion in upper pole of right
kidney
*CXR: No acute intrathoracic process
- The patient was given: ASA___, alum-mg-simethicone 30mL,
donnatal 10mL, lidocaine viscous 2% 10mL
Vitals prior to transfer were: 97.7 75 134/76 16 97% RA
Upon arrival to the floor, she feels her subxifoid pressure is
gone. She felt better after she coughed for a moment. She still
feels weaker than usual. She tells me she feels cold and hungry
and requests a blanket and hot chocolate.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies night sweats. Denies headache, sinus tenderness.
Denies shortness of breath. Denies palpitations. Denies nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
-CAD
-s/p MI ___
-s/p CABG (___)
-s/p PTCA with stenting x4 (___)
-s/p Cardiac Cath x4 (___)
-COPD (mild)
-?Factor 8 Deficiency
-asthma
-depression
-Abdominal AAA s/p endovascular stent graft repair (___)
-"head aneurysm"
-s/p lumbar disc surgery
-s/p left breast biopsy for lump
-s/p total abdominal hysterectomy, bilateral
salpingo-oophorectomy
-s/p appendectomy
-iron deficiency anemia
Social History:
___
Family History:
Youngest brother, deceased, melanoma. Has 8 other brothers, all
of whom have passed, some with history of heart disease. Has one
sister still living.
She does not know of any other cancers in the family.
Physical Exam:
Admission Physical:
Vitals: 98.0 | 182/71 | 66 | 18 | 98%RA
General: Pleasant, Alert, oriented, no acute distress
HEENT: Sclera anicteric, Very dry MM, oropharynx clear, EOMI
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, scant ronchi and
wheezes in both bases.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema, diffuse skin
xerosis, onychomycosis
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Discharge Physical:
Vitals: 97.8 74 166/66 18 98%RA
General: Pleasant, Alert, oriented, no acute distress, wearing
sunglasses
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOM grossly
intact
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, scant crackles in b/l
bases.
Abdomen: Soft, mild supra-pubic tenderness, non-distended, bowel
sounds present, no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: oriented to self, able to look at date on wall and read
it, able to state she's at ___
___ Results:
Admission Labs:
___ 05:00PM BLOOD WBC-10.3* RBC-4.45 Hgb-13.0# Hct-39.5#
MCV-89# MCH-29.2# MCHC-32.9# RDW-13.2 RDWSD-42.5 Plt ___
___ 05:00PM BLOOD Neuts-76.1* Lymphs-13.1* Monos-7.8
Eos-2.3 Baso-0.4 Im ___ AbsNeut-7.83* AbsLymp-1.35
AbsMono-0.80 AbsEos-0.24 AbsBaso-0.04
___ 05:00PM BLOOD ___ PTT-26.6 ___
___ 05:00PM BLOOD Plt ___
___ 05:00PM BLOOD Glucose-105* UreaN-27* Creat-2.4* Na-140
K-4.1 Cl-100 HCO3-27 AnGap-17
___ 05:00PM BLOOD ALT-19 AST-26 AlkPhos-63 TotBili-0.4
___ 05:00PM BLOOD Lipase-66*
___ 05:00PM BLOOD cTropnT-<0.01
___ 12:24AM BLOOD cTropnT-<0.01
___ 09:22AM BLOOD cTropnT-<0.01
___ 01:00AM URINE RBC-30* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
___ 01:00AM URINE U-PEP-NO PROTEIN Osmolal-331
___ 01:00AM URINE Hours-RANDOM Creat-97 Na-50 K-47 Cl-40
TotProt-28 Prot/Cr-0.3*
Pertinent Hospital Labs:
___ 05:29AM BLOOD PTH-14*
___ 05:29AM BLOOD PEP-ABNORMAL B IgG-563* IgA-62* IgM-744*
IFE-MONOCLONAL: ABNORMAL BAND IN GAMMA REGION
BASED ON IFE (SEE SEPARATE REPORT),
IDENTIFIED AS MONOCLONAL IGM KAPPA
NOW REPRESENTS, BY DENSITOMETRY, ROUGHLY
5% (310 MG/DL) OF TOTAL PROTEIN
INTERPRETED BY ___, MD, PHD
Discharge Labs:
___ 05:29AM BLOOD WBC-8.2 RBC-4.07 Hgb-12.0 Hct-37.1 MCV-91
MCH-29.5 MCHC-32.3 RDW-13.3 RDWSD-44.0 Plt ___
___ 05:29AM BLOOD Plt ___
___ 05:29AM BLOOD Glucose-82 UreaN-23* Creat-2.2* Na-141
K-4.2 Cl-106 HCO3-25 AnGap-14
___ 05:29AM BLOOD TotProt-6.2* Albumin-3.9 Globuln-2.3
Calcium-10.3 Phos-3.1 Mg-2.1
___ 05:29AM BLOOD PTH-14*
___ 05:29AM BLOOD PEP-AWAITING F IgG-563* IgA-62* IgM-744*
IFE-PND
Studies:
___ Liver/Gallbladder US:
IMPRESSION:
1. No evidence of cholelithiasis or cholecystitis.
2. Gallbladder adenomyomatosis.
3. 1 cm hypoechoic lesion in the upper pole of the right kidney
is not fully evaluated on this study, but may represent a small
cyst.
___ CXR:
IMPRESSION:
No acute intrathoracic process.
___ ECG: Sinus rhythm. Baseline artifact. Non-specific
inferolateral ST segment flattening. Compared to the previous
tracing of ___ no diagnostic change
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. FoLIC Acid 1 mg PO DAILY
3. Mirtazapine 30 mg PO QHS
4. TraZODone 25 mg PO QHS:PRN insomnia
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Ferrous Sulfate 325 mg PO BID
8. Calcium 600 (calcium carbonate) 600 mg (1,500 mg) oral DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Cyanocobalamin 50 mcg PO DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. FoLIC Acid 1 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Mirtazapine 30 mg PO QHS
6. Multivitamins 1 TAB PO DAILY
7. TraZODone 25 mg PO QHS:PRN insomnia
8. Calcium 600 (calcium carbonate) 600 mg (1,500 mg) oral DAILY
9. Cyanocobalamin 50 mcg PO DAILY
10. Ferrous Sulfate 325 mg PO BID
11. Vitamin D 1000 UNIT PO DAILY
12. Ciprofloxacin HCl 250 mg PO Q24H
Take last pill on ___ to complete treatment for your urinary
infection.
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
13. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
14. Outpatient Lab Work
Please draw complete metabolic panel with Cr on ___.
Fax to: ___ ___
ICD-9: Acute kidney injury 584
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
ACTIVE ISSUES:
#Urinary Tract Infection
___
#Hypercalcemia
#?GERD
CHRONIC ISSUES:
#Hypertension
#Depression
#Cognitive Dysfunction
Discharge Condition:
Mental Status: Confused - never.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with chest/epigastric pain // eval for acute process
COMPARISON: ___.
FINDINGS:
PA and lateral views of the chest provided. Midline sternotomy wires as well
as a stent within a bypass graft again noted. Cardiomediastinal silhouette is
stable with atherosclerotic calcifications along the unfolded thoracic aorta.
Lungs are clear. No pleural effusion or pneumothorax. Fixation hardware
projects over the right humerus.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with chest/epigastric pain // eval for acute process
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 6 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
Note is made of a small focus of adenomyomatosis within the gallbladder.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 7.7 cm.
KIDNEYS: Limited views of the right kidney demonstrate a 1 x 1 x 1 cm upper
pole hypoechoic lesion.
RETROPERITONEUM: Patient is status post endovascular repair of an abdominal
aortic aneurysm.
IMPRESSION:
1. No evidence of cholelithiasis or cholecystitis.
2. Gallbladder adenomyomatosis.
3. 1 cm hypoechoic lesion in the upper pole of the right kidney is not fully
evaluated on this study, but may represent a small cyst.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with CHEST PAIN NOS
temperature: 97.6
heartrate: 90.0
resprate: 18.0
o2sat: 97.0
sbp: 165.0
dbp: 89.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ is an ___ with history of CAD s/p CABG/PCI, COPD,
depression presents from ALF with ___ weeks of intermittent dry
cough and chest pressure following URI, worsening weakness and
hyporexia over a week, found to have UTI, ___ (unclear baseline)
and hypercalcemia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hypotension, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF THE PRESENTING ILLNESS: Mr. ___ is a ___ year old
gentleman (retired ED ___) with a history of paroxysmal
atrial fibrillation, embolic CVA resulting in R sided hemiplegia
and aphasia, hypertension, currently being treated for a urinary
tract infection, who presents from his nursing home for
evaluation of abdominal pain, hypotension, and new 02
requirement.
Patient notes that his symptoms started 4 days prior to
admission
with diffuse abdominal pain, chest pain, and more difficulty
breathing. Per review of nursing home notes he was noted to be
more lethargic on ___. He was started on D51/2NS for a total
of 4.5L. He was also started on levaquin for recurrent UTI (plan
per nursing home notes for treatment ___. In the 2 days
leading up to his admission he has required ___ 02, where he
has
never required oxygen in the past. CXR on ___ at his nursing
home was negative for pneumonia but did reveal a "mass in the
right lung field". This morning blood pressure at his nursing
home noted to be 80/60 and he was transferred to ___ ED.
Of note, he is currently being treated for a urinary tract
infection at his nursing home and is on day 4 of antibiotic
therapy.
Initial vitals on arrival: 97.8 HR 76 BP 104/79 RR 18 100% RA
Labs were notable for: CBC WNL, chemistry panel WNL, lactate
1.3,
LFTs/lipase WNL, UA bland. This morning white count rose to 11.4
from 9.2 on ___. Troponin negative. BNP measured at 1332 (no
baseline for comparison). An IJ was placed given difficult
access.
Imaging:
CXR: A focal ovoid densities seen overlying the diaphragms on
lateral view may represent overlying vascular structures and
chronic atelectasis, however a superimposed infection or focal
pulmonary lesion cannot be excluded.
CT A/P: No acute process
The ___ resident assumed care of the patient in the ED. Given
EKG findings of RBBB and atrial fibrillation, CTA was obtained,
which was negative for PE, though concerning for
de-differentiation of previously noted lipoma.
During the course of his ED stay (which spanned ___ he
received:
___ 16:22 PO Ondansetron ODT 4 mg
___ 16:22 PO Acetaminophen 650 mg
___ 17:01 IV CeftriaXONE
___ 20:38 IVF NS
___ 22:10 IVF NS 1 mL ___ Stopped (1h
___
___ 10:42 NEB Ipratropium-Albuterol Neb 1 NEB
___ 10:42 PO/NG Gabapentin 300 mg
___ 10:42 PO/NG Aspirin 81 mg
___ 10:42 IVF 500 mL NS
___ 10:57 PO Dabigatran Etexilate 150 mg
___ 11:00 PO/NG Levothyroxine Sodium 75 mcg
___ 11:00 PO/NG Sertraline 200 mg
___ 12:20 IVF 500 mL NS 500 mL
Vitals on transfer: 98.4 100 117/62 16 98% 2L NC
On arrival to the floor, he appears comfortable.
He denies fevers, chills, night sweats, weight change. He denies
headache, sinus congestion, rhinorrhea. He endorses chest
heaviness but denies cough. Abdominal pain has since improved
(though not yet entirely resolved). He denies nausea, vomiting,
constipation. He has occasional diarrhea at baseline. He was
having dysuria at his nursing home but this has resolved with
antibiotic therapy. Denies PND/orthopnea. Denies myalgias.
Past Medical History:
1. Paroxysmal atrial fibrillation
2. Vertebral artery dissection complicated by hemorrhage in
setting of elevated INR, on coumadin, lovenox, ASA
3. Hypertension
4. CVA ___ (embolic) - right hemiplegia and some aphasia
5 Multiple Aspiration Events
6. GERD
7. HLD
8. Insomnia
9. Urinary retention
10. Cataract
11. Essential tremor
12. Generalized anxiety disorder
13. Hypothyroidism
Social History:
___
Family History:
Father had MI at age ___
Mother with dystrophy
Physical Exam:
On Admission
Vital Signs: 98.7 PO 121 / 73 104 22 94 3L NC but 92% on RA
General: Lying in bed, alert and oriented x3, in NAD
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP challenging to assess as RIJ is in place. EJ
not
elevated.
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bibasilar crackles, no wheezing or rhonchi
Abdomen: Soft, non-tender, mildly distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses pedal pulses. Trace ___ edema
bilaterally. Two 1cm areas of ulceration from prior Mohs surgery
(4 weeks ago) with overlying dressing c/d/i.
Neuro: Right sided facial droop, right sided hemiparesis. Alert
and oriented x3
Pscych: Calm, appropriate
DISCHARGE
VS T 97.9 BP 92 / 61 (atenolol given today) HR 79 RR 16 O2 sat
98 2L NC
Gen: NAD, resting
Eyes: EOMI, no scleral icterus, R pupil 5mm reactive, left 3mm
reactive
HENT: NCAT, trachea midline
CV: RRR, S1-S2, no m/r/r/g, no pitting edema 2+ ___ BLE
Lungs: CTA B, no w/r/r/c
GI: +BS, soft, NTTP, ND
MSK: R sided flaccid paralysis in upper and lower extremities, L
sided ___ upper/lower strength, L palpable lipoma on chest
without tenderness
Neuro: A+Ox3, Left facial droop, R facial paralysis, R>L
pupillary dilation
Skin: R shin abrasion with gauze in place
Psych: Congruent affect, good judgment
Pertinent Results:
On Admission:
___ 04:30PM BLOOD WBC-9.2 RBC-4.77 Hgb-14.4 Hct-45.9 MCV-96
MCH-30.2 MCHC-31.4* RDW-13.6 RDWSD-48.8* Plt ___
___ 04:30PM BLOOD ___ PTT-64.6* ___
___ 04:30PM BLOOD Glucose-103* UreaN-11 Creat-0.7 Na-136
K-4.1 Cl-97 HCO3-30 AnGap-13
___ 04:30PM BLOOD ALT-17 AST-16 AlkPhos-81 TotBili-0.4
___ 04:30PM BLOOD Lipase-16
___ 10:55AM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-1332*
___ 05:47PM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:30PM BLOOD Albumin-3.5
MICROBIOLOGY:
___ Urine culture pending
___ Blood culture pending
___ Urine culture at nursing home:
E.coli >100,000 organisms. Resistant to Bactrim, but otherwise
pansensitive
IMAGING & STUDIES:
___ CXR (nursing home): Low lung volumes and patient body
habitus limit evaluation. Again seen is a pleural-based mass
superolaterally in the left upper lobe without significant
change. The right lung is clear. The heart and mediastinal
structures are unremarkable.
Impression: Pleural based mass is concerning for malignancy.
Further evaluation with a contrast-enhanced CT of the thorax is
recommended.
___ CXR:
1. Unchanged chronic elevation of the bilateral hemidiaphragms,
with chronic atelectasis in the right middle and bilateral lower
lobes.
2. A focal ovoid densities seen overlying the diaphragms on
lateral view may represent overlying vascular structures and
chronic atelectasis, however a superimposed infection or focal
pulmonary lesion cannot be excluded.
___ CT A/P:
1. No acute intra-abdominal or pelvic process.
2. Diverticulosis, with no evidence of acute diverticulitis.
3. Small fat containing umbilical hernia containing loop of
small
bowel and fat, without complications.
4. Subcentimeter hypodensities within the liver, likely biliary
hamartomas or cysts. 2 subcentimeter hyperdense foci in the
right
lobe of the liver, possibly hemangiomas, incompletely assessed.
___ CTA:
1. No evidence of pulmonary embolism or aortic abnormality.
2. 3.8 x 2.7 x 3.7 cm mass in the left chest wall, previously
identified as lipoma, now shows significant increase in
peripheral soft tissue component. While this finding may be due
to interval fat necrosis of the lipoma, liposarcoma would be
possible. Recommend non-urgent thoracic consultation.
3. Unchanged 3 mm right upper lobe lung nodule (series 3; image
53). No follow-up imaging is necessary.
4. Sclerotic lesion of left aspect of the T2 vertebral body has
the appearance of a bone island; however, this was not noted in
___. Attention of follow-up exams recommend
ECG: Rate 104, atrial fibrillation, RBBB
DISCHARGE
___ 05:22AM BLOOD WBC-9.3 RBC-4.29* Hgb-13.0* Hct-41.3
MCV-96 MCH-30.3 MCHC-31.5* RDW-13.6 RDWSD-48.1* Plt ___
___ 04:30PM BLOOD Neuts-74.7* Lymphs-18.6* Monos-5.2
Eos-0.7* Baso-0.3 Im ___ AbsNeut-6.86* AbsLymp-1.71
AbsMono-0.48 AbsEos-0.06 AbsBaso-0.03
___:22AM BLOOD Glucose-101* UreaN-12 Creat-0.7 Na-137
K-3.8 Cl-98 HCO3-34* AnGap-9
___ 05:22AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levofloxacin 750 mg PO Q24H
2. Melatin (melatonin) 5 mg oral QHS
3. Ramelteon 8 mg PO QHS:PRN insomnia
4. Phenazopyridine 200 mg PO TID:PRN urinary symptoms
5. Mupirocin Ointment 2% 1 Appl TP DAILY surgical wounds
6. Polyethylene Glycol 17 g PO DAILY
7. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN Pain - Moderate
8. GuaiFENesin ___ mL PO Q6H:PRN chest congestion
9. TraMADol 75 mg PO Q8H:PRN Pain - Moderate
10. Gabapentin 300 mg PO TID
11. Atenolol 50 mg PO DAILY
12. Docusate Sodium 100 mg PO DAILY
13. Senna 8.6 mg PO DAILY
14. Acetaminophen 650 mg PO DAILY
15. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe
16. Cyanocobalamin 1000 mcg PO DAILY
17. Sertraline 200 mg PO DAILY
18. Diazepam 10 mg PO Q8H:PRN anxiety
19. Acidophilus (Lactobacillus acidophilus) unknown mg oral
daily
20. Atorvastatin 10 mg PO QPM
21. Atropine Sulfate 1% 2 DROP SL EVERY 4 HOURS excessive
secretions
22. lidocaine 2% gel topical Q6H:PRN
23. Hyoscyamine 0.125 mg SL QID:PRN excessive secretions
24. Omeprazole 20 mg PO DAILY
25. Levothyroxine Sodium 75 mcg PO DAILY
26. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
27. Aspirin 81 mg PO DAILY
28. Decubi Vite (multivit-folic acid-zinc-vit C) 400-50-500
mcg-mg-mg oral daily
29. Furosemide 20 mg PO DAILY
30. Losartan Potassium 100 mg PO DAILY
31. Dabigatran Etexilate 150 mg PO BID
32. Prochlorperazine 10 mg PO Q12H:PRN nausea
33. Tizanidine 2 mg PO DAILY
Discharge Medications:
1. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN Pain - Moderate
2. Acetaminophen 650 mg PO DAILY
3. Acidophilus (Lactobacillus acidophilus) unknown oral DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Atropine Sulfate 1% 2 DROP SL EVERY 4 HOURS excessive
secretions
7. Cyanocobalamin 1000 mcg PO DAILY
8. Dabigatran Etexilate 150 mg PO BID
9. Decubi Vite (multivit-folic acid-zinc-vit C) 400-50-500
mcg-mg-mg oral daily
10. Diazepam 10 mg PO Q8H:PRN anxiety
RX *diazepam 10 mg 1 tab by mouth twice a day Disp #*10 Tablet
Refills:*0
11. Docusate Sodium 100 mg PO DAILY
12. Gabapentin 300 mg PO TID
13. GuaiFENesin ___ mL PO Q6H:PRN chest congestion
14. Hyoscyamine 0.125 mg SL QID:PRN excessive secretions
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
16. Levofloxacin 750 mg PO Q24H
17. Levothyroxine Sodium 75 mcg PO DAILY
18. lidocaine 2% gel topical Q6H:PRN
19. Melatin (melatonin) 5 mg oral QHS
20. Mupirocin Ointment 2% 1 Appl TP DAILY surgical wounds
21. Omeprazole 20 mg PO DAILY
22. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Severe
23. Phenazopyridine 200 mg PO TID:PRN urinary symptoms
24. Polyethylene Glycol 17 g PO DAILY
25. Prochlorperazine 10 mg PO Q12H:PRN nausea
26. Ramelteon 8 mg PO QHS:PRN insomnia
27. Senna 8.6 mg PO DAILY
28. Sertraline 200 mg PO DAILY
29. Tizanidine 2 mg PO DAILY
30. TraMADol 75 mg PO Q8H:PRN Pain - Moderate
RX *tramadol 50 mg 1.5 tablet(s) by mouth every eight (8) hours
Disp #*10 Tablet Refills:*0
31. HELD- Atenolol 50 mg PO DAILY This medication was held. Do
not restart Atenolol until SBP >150 and consider restarting at
25 mg dose
32. HELD- Losartan Potassium 100 mg PO DAILY This medication
was held. Do not restart Losartan Potassium until blood pressure
is >150 SBP
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypotension
Chest wall lipoma
Chronic aphasia/R sided hemiplegia from previous embolic CVA
Chronic atrial fibrillation
Acute Hypoxic Respiratory Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old man with afib but usually in sinus, with chest pain
and hypoxia, hypotension // evaluate for PE, pneumonia
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 403 mGy-cm.
COMPARISON: CT chest from ___ ; CTA chest from ___
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
There are calcifications noted in the thoracic aorta and coronary vessels.
There is unchanged ectasia of the main pulmonary artery with maximum with
measuring 3.5 cm. The pulmonary arteries are well opacified to the segmental
level, with no evidence of filling defect to suggest pulmonary embolism.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid appears unremarkable.
There is no evidence of pericardial effusion. There is no pleural effusion.
Low lung volumes are again noted with elevation of the bilateral
hemidiaphragms and bibasilar atelectasis. The airways are patent to the
segmental level. Previously identified lipoma associated with the pleura
overlying the left upper lobe measures 4.3 x 2.6 (previously 4.3 x 2.1) and
now shows a significantly increased soft tissue component at its periphery.
While this finding may be due to interval fat necrosis within the lipoma,
liposarcoma would be possible. Bilateral upper lobed calcified granulomas
again noted. Unchanged 3-mm right upper lobe lung nodule (series 3; image 53)
for which no additional workup is necessary given interval stability.
Limited images of the upper abdomen show cholelithiasis.
Again seen is scoliosis of the thoracic spine. Sclerotic lesion of the left
aspect of the T2 vertebral body has the appearance of a bone island; however,
this finding is new since ___. Attention on follow-up exam is recommended.
Severe degenerative changes noted at the right shoulder.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. A 3.8 x 2.7 x 3.7 cm mass in the left chest wall, previously compatible
with lipoma, with interval development of peripheral soft tissue component.
While this finding may be due to interval fat necrosis of the lipoma,
liposarcoma would be possible. Recommend non-urgent thoracic consultation.
3. Sclerotic lesion of left aspect of the T2 vertebral body has the appearance
of a bone island; however, this is new since ___. Attention of follow-up
exams recommend. No additional osseous abnormalities identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Hypotension, Lethargy, UTI
Diagnosed with Urinary tract infection, site not specified, Hypotension, unspecified
temperature: 97.8
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 104.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old gentleman with a
history of paroxysmal atrial fibrillation on dabigatran, embolic
CVA resulting in R sided hemiplegia and aphasia, hypertension,
currently being treated for a urinary tract infection who
presents from his nursing home for evaluation of hypotension.
# Hypotension: Broad differential but likely hypovolemia in
origin given improvement with fluids and holding
anti-hypertensive agents. Denies any new medication changes. No
localizing signs of infection. WBC improved, pending cultures.
Lipoma has been present ___ years without TTP at this time. TTE
originally showed hypokinesis of inferolateral wall of RV but
cardiology consult was obtained and did not believe this was
present (poor images). Trop neg x2. EKG with RBBB no other
changes. No chest pain and completely asymptomatic. His blood
pressures improved to systolic 120s-140s with holding
medications. Attempted to restart losartan 100 and atenolol
after fluids however BP dropped to ___. Today attempted
again to restart only atenolol with BP ___ that resolved on
own to SB ___. Completely asymptomatic. CTA chest was
negative for PE. No other source of infection.
- Continue treatment of urinary tract infection as below
- F/u ECHO
- Plan to hold losartan 100 and atenolol 50. Hold Lasix. Plan to
restart atenolol at smaller dose of 25 mg when sBP is >150.
Otherwise is controlled.
# Acute hypoxic respiratory Failure: Currently on 3.5 L what was
weaned to 98% on 2L. This was further weaned to room air 92%.
CTA no PE/PNA. Given
fluids in NH and ED (4.5L + 1.5L) but do not appreciate crackles
on exam. ? atelectasis and has improved with IS. BNP elevated
w/o TTE showing failure.
- IS, continue to hold Lasix pending BP trend today
- ECHO as above
- Wean 02 as able
# Lipoma - CTA was notable for "3.8 x 2.7 x 3.7 cm mass in the
left chest wall, previously identified as lipoma, now shows
significant increase in peripheral soft tissue component.
Discussed with patient, no TTP, no skin changes. Present ___
years. Pt would not like to pursue biopsy at this time so will
defer calling thoracic with clinical improvement.
# Complicated urinary tract infection: Patient is currently on
Day 5 of planned 10 day course of antibiotics for UTI (received
Ceftriaxone in ED yesterday instead of levaquin).
- Will continue levaquin initiated at the nursing home, though
with likely 7 day course for complicated UTI. End date levaquin
___ to complete ___bdominal pain: Patient with abdominal pain, more prominent 4
days ago. Appears to be resolving per patient history. CT A/P
without acute findings, LFTs within normal limits.
- Will continue to monitor |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o CVA x2, CAD s/p CABG, COPD presenting with vertigo
x 2 days. Pt reports acute onset of sensation of the "room
spinning" while watching television on ___. Symptoms have
been constant since onset and associated with nausea but no
vomiting, HA, weakness or numbness relative to baseline. Pt is
wheelchair dependent due to residual left sided weakness from
prior CVA, + residual dysarthria as well. Relies on visiting
nurse 7 days/week for assistance with ADLs.
In the ED, initial VS were 97.7 59 120/64 16 96% 2L nc. Labs
were notable for K 5.2, trop<0.01, D-dimer 947, negative UA. CXR
negative, CTPA was was negative for PE, CT head negative for
acute process. ___ and epley maneuvers attemtped.
Received SL nitro x 1, ASA, morphine, meclizine, zofran,
diazepam. Pt was transferred to medicine for further managment.
Transfer VS were 97.4 53 145/54 20 97%.
Pt received MRI head en route. On arrival to the floor, patient
reports continued vertigo. Although he initally reported chest
pain in the ED, currently believes that it is no different from
chronic chest discomfort from COPD/cough.
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:
- Chronic abdominal pain, followed by GI
- Esophagitis with esophageal stricture and GE junction ulcer
s/p esophageal dilation ___ c/b esophagitis and mediastinitis
- EtOH abuse with hx of alcoholic hepatitis
- h/o CVA with right carotid artery occlusion
- COPD (supposed to be on home O2 but does not use it)
- CAD : status post coronary artery bypass surgery in ___,
non-ST elevation MI in ___
- Stable angina
- paroxysmal Afib, not on warfarin given h/o UGIB (h/o
bradycardia and orthostasis w/ metoprolol ___, previously on
diltiazem)
- HTN
- Hyperlipidemia
- Anemia of chronic disease and from alcohol use
- Hypothyroidism
- global cerebellar degeneration (wheelchair bound)
- ataxia
- h/o UGIB
- h/o MRSA PNA
- s/p Aorto-innominate bypass at ___ in ___
Social History:
___
Family History:
Father ___ ___ MYOCARDIAL INFARCTION
Mother ___ 60 DIABETES MELLITUS
no family history of liver disease.
Several brothers with CAD in late ___ and early ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.5 143/57 58 20 99
GEN - Overweight elderly male, Alert, oriented, no acute
distress, dysarthric speech
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - no bruits
PULM - CTAB, diminished at bases
CV - RRR, S1/S2, ___ systolic murmur heard throughout
precordium no
ABD - soft, distended. NT, normoactive bowel sounds, no guarding
or rebound
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally
NEURO - PERRL, EOM intact, + nystagmus with lateral gaze,
decreased left sided facial sensation to light ___
strength LLE, ___ strength other extremities, +dysmetria on
finger to nose, difficulty with rapid alternating movements L>R,
no pronator drift, unable to maintain standing position without
support
SKIN - no ulcers or lesions
.
DISCHARGE PHYSICAL EXAM:
VS - Tm 98.2 108-144/48-54 50-51 18 97-98% RA
GEN - Overweight elderly male, pleasant, Alert, oriented, no
acute distress, dysarthric speech
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - no bruits
PULM - CTAB, diminished at bases
CV - RRR, S1/S2, ___ systolic murmur heard throughout
precordium
ABD - soft, distended. NT, normoactive bowel sounds, no guarding
or rebound
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally
Pertinent Results:
ADMISSION LABS:
___ 07:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
___ 07:20AM URINE RBC-1 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 06:55AM cTropnT-<0.01
___ 02:25AM D-DIMER-947*
___ 01:48AM K+-5.2*
___ 12:45AM GLUCOSE-104* UREA N-16 CREAT-0.9 SODIUM-136
POTASSIUM-6.4* CHLORIDE-101 TOTAL CO2-24 ANION GAP-17
___ 12:45AM cTropnT-<0.01
___ 12:45AM ___ PTT-26.7 ___
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-7.1 RBC-3.81* Hgb-11.2* Hct-33.9*
MCV-89 MCH-29.3 MCHC-33.0 RDW-17.3* Plt ___
___ 08:00AM BLOOD Glucose-82 UreaN-13 Creat-0.9 Na-141
K-4.3 Cl-106 HCO3-25 AnGap-14
___ 08:00AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.8 Iron-44*
Cholest-102
___ 08:00AM BLOOD calTIBC-355 VitB12-___ Ferritn-35 TRF-273
___ 08:00AM BLOOD %HbA1c-5.4 eAG-108
___ 08:00AM BLOOD Triglyc-139 HDL-46 CHOL/HD-2.2 LDLcalc-28
IMAGING/STUDIES:
ECGs ___
Sinus bradycardia. Low voltage in the precordial leads. Compared
to the
previous tracing of ___ low voltage is new and ST-T wave
changes are no longer present.TRACING #1
Sinus bradycardia. Low voltage in the precordial leads. Compared
to the
previous tracing of the same day there is no significant change.
TRACING #2
Sinus bradycardia. Compared to the previous tracing of ___
the criteria for low voltage in the mid-precordial leads is no
longer present. The heart rate is similar. There are no other
significant interval diagnostic changes
CXR ___
FINDINGS: As before, the patient is status post midline
sternotomy.
Fractures through the two superior-most sternotomy wires are not
significantly changed. There is minimal left lower lung
scarring/atelectasis, as before. There is minimal right mid lung
scarring. There are no definite pleural effusions. No
pneumothorax is seen. The heart size is top normal, slightly
increased compared to the prior study from ___. The
mediastinal contours are normal.
IMPRESSION: No acute cardiac or pulmonary findings.
CTA ___. No acute intrathoracic process. Specifically, no evidence
of pulmonary embolism to the subsegmental level bilaterally.
2. 3 mm right upper lobe pulmonary nodule, not identified on
the prior study from ___. A followup CT in one year
is recommended.
3. Decreased mediastinal lymphadenopathy, as described above,
nonspecific in nature.
4. Patulous thoracic esophagus, as seen on prior CT.
5. Central bronchial wall thickening, suggestive of chronic
small airways disease.
CT HEAD w/o CONTRAST ___. No acute intracranial process. If clinical concern for
stroke is high, MRI ___ be more sensitive.
2. Small air-fluid level in the left mastoid air cells.
MR/MRA BRAIN ___. No acute infarct or hemorrhage. Moderate degree of brain
volume loss and extensive white matter signal abnormality most
likely reflecting sequela of chronic small vessel disease.
2. Chronic occlusion (since at least ___ of the right
internal carotid
artery, with reconstitution in the supraclinoid segment via the
anterior
communicating artery.
3. Approximately 60% stenosis of the origin of the left
internal carotid
artery. Atherosclerotic narrowing of the origin of the right
vertebral
artery.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Finasteride 5 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Docusate Sodium 200 mg PO BID:PRN consti-pation
5. Ranitidine 300 mg PO BID
6. Rosuvastatin Calcium 10 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Fluticasone Propionate 110mcg 1 PUFF IH BID
9. Sucralfate 1 gm PO QID
10. esomeprazole magnesium *NF* 40 mg Oral daily
11. Calcium with Vitamin D *NF* (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit Oral daily
12. Aspirin 81 mg PO DAILY
13. Tamsulosin 0.4 mg PO HS
14. traZODONE 100-150 mg PO HS:PRN insomnia
15. Levothyroxine Sodium 100 mcg PO DAILY
16. FoLIC Acid 1 mg PO DAILY
17. Thiamine 100 mg PO DAILY
18. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q4: PRN wheeze, SOB
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 200 mg PO BID:PRN consti-pation
3. Finasteride 5 mg PO DAILY
4. Fluticasone Propionate 110mcg 1 PUFF IH BID
5. FoLIC Acid 1 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Ranitidine 300 mg PO BID
9. Rosuvastatin Calcium 10 mg PO DAILY
10. Sucralfate 1 gm PO QID
11. Tamsulosin 0.4 mg PO HS
12. Thiamine 100 mg PO DAILY
13. Calcium with Vitamin D *NF* (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit Oral daily
14. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q4: PRN wheeze, SOB
15. Esomeprazole Magnesium *NF* 40 mg ORAL DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
17. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
18. Diltiazem Extended-Release 120 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Vertigo
Erosive esophagitis
Secondary:
History of stroke
COPD
CABG
A fib
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chest pain. Assess for pneumonia.
COMPARISON: Chest radiograph from ___.
FINDINGS: As before, the patient is status post midline sternotomy.
Fractures through the two superior-most sternotomy wires are not significantly
changed. There is minimal left lower lung scarring/atelectasis, as before.
There is minimal right mid lung scarring. There are no definite pleural
effusions. No pneumothorax is seen. The heart size is top normal, slightly
increased compared to the prior study from ___. The mediastinal
contours are normal.
IMPRESSION: No acute cardiac or pulmonary findings.
Radiology Report
INDICATION: Shortness of breath and chest pain as well as an elevated
D-dimer. History of clots. Assess for pulmonary embolism.
COMPARISON: CT chest from ___.
TECHNIQUE: MDCT axial images were acquired through the chest during
administration of 100 cc of intravenous Omnipaque contrast material.
Multiplanar reformats were performed, including maximum intensity projection
oblique images.
TOTAL DLP: 586 mGy-cm.
FINDINGS: There is no evidence of pulmonary embolism to the subsegmental
level bilaterally. The thoracic aorta is normal in caliber. Calcifications
are seen throughout the thoracic aorta, head and neck vessels, and coronary
arteries. The heart is mildly enlarged. There is a trace non-hemorrhagic
pericardial effusion, likely physiologic. Multiple prominent mediastinal
lymph nodes are noted, the majority of which are decreased in size compared to
the prior study from ___. Representative nodes include an 11 x 10
mm right upper paraesophageal node (2:14) that previously measured 18 x 13 mm,
an 11 x 7 mm lower right paratracheal node (2:31) that previously measured 13
x 9 mm, and a 16 x 7 mm subcarinal node that previously measured 20 x 11 mm
(2:46). The thoracic esophagus is patulous, containing both air and layering
fluid, similar in appearance to the prior study.
There is moderate centrilobular emphysema. There is also subpleural
reticulation and honeycombing particularly along the posteroinferior aspect of
the right upper lobe, abutting the major fissure (2:49), not significantly
changed in appearance. There is subsegmental bilateral lower lobe
atelectasis/scarring, left greater than right. A 3 mm right upper lobe
pulmonary nodule was not identified on the previous study from ___
(3:29). The tracheobronchial tree is patent to the segmental level
bilaterally. A small quantity of debris is seen along the right lateral
aspect of the lower trachea (3:52). Central bronchial wall thickening is
likely secondary to chronic small airways disease. A previously seen small
left pleural effusion on CT from ___ has resolved.
This study was not optimized for evaluation of the subdiaphragmatic contents.
Limited assessment of the upper abdomen is unremarkable.
BONE WINDOW: No suspicious lytic or blastic lesions are identified.
Multilevel degenerative changes of the thoracic spine are noted. Midline
sternotomy wires are intact.
IMPRESSION:
1. No acute intrathoracic process. Specifically, no evidence of pulmonary
embolism to the subsegmental level bilaterally.
2. 3 mm right upper lobe pulmonary nodule, not identified on the prior study
from ___. A followup CT in one year is recommended.
3. Decreased mediastinal lymphadenopathy, as described above, nonspecific in
nature.
4. Patulous thoracic esophagus, as seen on prior CT.
5. Central bronchial wall thickening, suggestive of chronic small airways
disease.
Radiology Report
HISTORY: Dizziness, prior stroke.
TECHNIQUE: Noncontrast MDCT axial images are acquired through the head. Bone
reconstructions and coronal and sagittal reformations are provided for review.
COMPARISON: ___
FINDINGS:
There is no acute intracranial hemorrhage, edema, mass effect or major
vascular territorial infarct. Prominent ventricles and sulci have slightly
increased since ___ and compatible with moderate global atrophy. Basal
cisterns are preserved. There is no shift of normally midline structures.
Gray-white matter differentiation is preserved. Atherosclerotic calcifications
are seen in the intracranial internal carotid arteries. Hypoattenuation in
the subcortical and periventricular white matter is likely sequelae of
moderate chronic microvascular ischemic disease. Encephalomalacia in the right
parietal lobe (2:18) is unchanged since ___, likely from prior stroke. No
osseous abnormality is identified. There is mild mucosal thickening in the
right maxillary sinus. A small air-fluid level is seen in the left mastoid
air cells. The middle ear cavities are clear. The globes and orbits are
unremarkable.
IMPRESSION:
1. No acute intracranial process. If clinical concern for stroke is high, MRI
may be more sensitive.
2. Small air-fluid level in the left mastoid air cells.
Radiology Report
HISTORY: ___ man with history of stroke and sudden onset of vertigo.
Evaluate for posterior fossa CVA.
COMPARISON: MRI brain, ___.
TECHNIQUE: Non contrast MRI of the head was performed including axial
diffusion, FLAIR, T2, susceptibility sequences and sagittal T1 weighted
sequences.
FINDINGS:
The ventricles, sulci, and subarachnoid spaces are globally prominent likely
representing age related parenchymal volume loss. This is similar to the
prior examination. Additionally, there are extensive confluent and punctate
T2 FLAIR signal hyperintensities in the periventricular and subcortical white
matter bilaterally, also similar to the prior and most likely representing the
sequela of advanced chronic small vessel disease. There is right parietal
encephalomalacia. There is no evidence of acute infarct and no evidence of
hemorrhage. A punctate focus of susceptibility artifact in the left
cerebellar hemisphere is unchanged and may represent remote micro hemorrhage
or calcification.
Normal major intracranial vascular flow voids are present. There is mild
mucosal thickening in the right maxillary sinus and in the ethmoid air cells.
The remaining visualized paranasal sinuses and the mastoids are clear.
IMPRESSION:
1. No acute intracranial abnormality. No evidence of acute infarct,
hemorrhage, or mass.
2. Extensive white matter signal abnormality most likely representing the
sequela of chronic small vessel disease is similar to the prior exam.
Radiology Report
HISTORY: ___ with history of CVA X2, CAD status post CABG and COPD presenting
with vertigo, dysarthria.
Evaluate for stroke.
COMPARISON: MRI brain, ___. MRA head, ___. MRA neck,
___ Setpe___.
TECHNIQUE: Multi sequence multi planar imaging of the brain was performed
both prior to and following the intravenous administration of 20 mL MultiHance
as per standard department protocol. An MRA of the brain was performed
utilizing 3D time-of-flight technique with rotational reconstructions. Two
dimensional time-of-flight MRA of the neck was performed with coronal VIBE
imaging during infusion of intravenous contrast. Rotational reformatted
images were prepared.
FINDINGS:
MRI head: There is again generalized moderate global prominence of the
ventricles, sulci and subarachnoid spaces compatible with age related volume
loss. There is extensive confluent periventricular and subcortical white
matter T2 FLAIR signal hyperintensity compatible with the sequela of small
vessel disease. There is no acute infarction or hemorrhage. Right parietal
encephalomalacia is again noted. Tiny focus of susceptibility artifact in the
left cerebellar hemisphere is again noted, unchanged. There is no mass
lesion, mass effect, or shift of the midline structures. There is no abnormal
enhancement.
The visualized paranasal sinuses, mastoids, and orbits are unremarkable.
MRA head: The vertebral and basilar arteries are normal in appearance with a
normal branching pattern. There is no evidence of significant stenosis,
occlusion, dissection, or aneurysm. The right vertebral artery is dominant,
and the left vertebral artery terminates in the posterior inferior cerebellar
artery.
The right internal carotid artery shows absent flow, with distal
reconstitution at the level of the supra clinoid right internal carotid artery
via the anterior communicating artery. This is unchanged from prior MRA of
the head from ___. There is normal flow in the right anterior and
middle cerebral arteries. Right posterior communicating artery is present and
patent. Intracranial internal carotid arteries and the anterior, middle, and
posterior cerebral arteries are normal in appearance without evidence of
significant stenosis, occlusion, dissection, or aneurysm.
MRA neck: Irregularity of the aortic arch and origins of the great vessels
likely represents atherosclerotic disease. There is irregular narrowing of
the origin of the right vertebral artery compatible with atherosclerotic
disease. The left vertebral artery origin is not well visualized. The distal
V3 and V4 segments of the right vertebral artery are not visualized on the MRA
of the neck due to field of view selection.
There is occlusion of the right internal carotid artery just distal to its
origin. Irregularity of the right common carotid artery likely represents
atherosclerotic disease.
There is atherosclerotic disease of the left aortic bulb extending into the
proximal internal and external carotid arteries, with a minimal luminal
diameter approximately 2 mm compared against a distal luminal diameter of
approximately 5 mm for a calculated 60% stenosis.
IMPRESSION:
1. No acute infarct or hemorrhage. Moderate degree of brain volume loss and
extensive white matter signal abnormality most likely reflecting sequela of
chronic small vessel disease.
2. Chronic occlusion (since at least ___ of the right internal carotid
artery, with reconstitution in the supraclinoid segment via the anterior
communicating artery.
3. Approximately 60% stenosis of the origin of the left internal carotid
artery. Atherosclerotic narrowing of the origin of the right vertebral
artery.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PAIN (CARDIAC FEATURES)
Diagnosed with CHEST PAIN NOS, VERTIGO/DIZZINESS, HYPERCHOLESTEROLEMIA
temperature: 97.7
heartrate: 59.0
resprate: 16.0
o2sat: 96.0
sbp: 120.0
dbp: 64.0
level of pain: 7
level of acuity: 3.0 | ___ with h/o CVA x2, CAD s/p CABG, COPD admitted with vertigo x
2 days.
# Vertigo: Patient presented with 2 day h/o vertigo which,
although his story varied, appeared to have started acutely.
Negative orthostatics. Given h/o severe atherosclerotic disease
and 2 prior CVA, presentation was concerning for stroke. CT head
negative for acute Repeat MRI/MRA ___ showed no evidence of
acute process. Symptoms controlled with antiemetics initially
and then appeared to resolve without the need for additional
medication by time of discharge. He was discharged with plan to
follow up with his PCP and outpatient neurologist.
# Chest pain: Pt reported chest pain in ED, CTA chest negative
for PE, EKG with no acute ischemic changes and trop negative x 2
making cardiac etiology unlikely. Pt has long h/o esophagitis,
raising suspicion for GI etiology. Reported dull midline chest
pain shortly after arrival to floor, did not consider it similar
to prior ischemic pain, no other associated symptoms, EKG
unchanged, nothing on telemetry. Improved after restarting home
esophagitis rx including PPI, sucralfate. Added low dose ACE-I
as secondary prevention given h/o CAD.
# H/O Dementia: Patient scored 22 on mini-mental examination. He
lost points for inability to write a sentence, ___ on recall at
a few minutes, and inability to spell world backwards. Has
regular contact with family and home aid who assists with ADLs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Intraarticular (right knee) steroid injection, ___
Endoscopy and colonoscopy, ___
History of Present Illness:
___ male with history of insulin-dependent diabetes on
GlipiZIDE, hypertension, chronic lymphedema who presents via EMS
with bradycardia, hypoglycemia, and hypothermia after a fall.
Patient was found by his family member on the day of
presentation. The actual time of the fall is somewhat unclear,
potentially last night. Fell in his apartment, but apartment may
have been cold. Unknown length of time down. Patient states
couple of hours, but other family members suggested longer than
that. EMS arrival, patient was hypoglycemic, attempted oral
glucose but he remained hypoglycemic. Patient's med list
includes insulin, glipizide, metoprolol.
On arrival to the emergency department, patient noted to be
bradycardic to the ___, but maintaining blood pressure. He is
awake and alert and protecting his airway, somewhat confused but
able to interact. Noted to be significantly hypothermic to 29.9C
(rectal). Decreased lung sounds, particularly on the left.
Bedside echo shows good cardiac function, no large pericardial
effusion. EKG looks like slow A. fib with no ischemic changes.
IV access was established and patient received amp of dextrose,
1 g calcium gluconate, IV glucagon, and 50 mcg of Octreotide for
potential beta blocker overdose and GlipiZIDE overdose. Suspect
possible medication effect, including from glipizide, insulin,
and metoprolol. Also suspect bradycardia in part due to
hypothermia.
Patient being actively warmed, initially with bear hugger,
transitioned to ___. Heart rate improved to ___,
maintaining normal blood pressure. Received additional 2 g
calcium, additional IV glucagon. Started on glucagon drip. Also
received empiric cefepime and vancomycin for concern for sepsis.
Labs notable for anemia, creatinine 2.1 which appears to be his
baseline, CK 700. BNP elevated. Chest x-ray concerning for
pneumonia versus volume overload. Foley catheter placed, clear
yellow urine output.
In the ED, initial vitals were: HR 32, 135/64, RR20, 97%on RA,
glucose of 45.
- Exam notable for: chronic lymphadema in lower extremities, no
FND, mentating well, protecting airway
- Labs notable for: 0.23 trop, Cr 2.1 (baseline), anemia of
8.l4, CK of 704, BNP of 8964
- Imaging was notable for: CXR pna vs vol overload, bedside echo
shows good EF without pericardial effusion
- Patient was given: vanc, cefepime, IV glucagonx2 now on a
drip, 3g calcium Gluconate, 1amp of dextrose, Octreotide, fluids
Upon arrival to the ICU, patient reports no complaints
Review of systems was negative except as detailed above.
==========
MEDICINE FLOOR ADMISSION HP:
In brief, this patient is a ___ with a history of CKD, T2DM
followed by ___, atrial fibrillation not on anticoagulation,
OSA on CPAP, bilateral chronic venous stasis, who was brought in
by ambulance after he was found down at home for an unknown
period of time.
Per EMS note: "Upon arrival ___ M found lying on his Left side
x unknown time. Upon assessment pt was warm, dry, conscious and
altered w/ confusion and garbled speech. Fs was 45. Glucose and
juice was given. No change to BS. No obvious signs of trauma. No
facial droop or weakness noted. BFD on scene reports the pt's
brother found him on the ground. Pt had a rigid abdomen on the
LLQ and was incontinent w/ no signs of oral trauma. Pt's left
leg
was necrotic appearing, scabby and cold w/o a pulse. +CSMs in
right leg. Unknown last known well time. Unknown if any recent
illnesses."
In the ED, he remained hypoglycemic, found to be bradycardic and
hypothermic to 29.2C. Reheated with arctic sun. Given an amp of
dextrose, 1 g calcium gluconate, IV glucagon, and 50 mcg of
Octreotide for potential beta blocker overdose and GlipiZIDE
overdose.NCHCT and CT torso obtained; pertinent finding included
concern for multifocal/aspiration pneumonia and R>L pleural
effusions.
Mr. ___ was transferred to the MICU and started on Vanc/Cefepime
___, transitioned to Ceftriaxone/Azithromycin for CAP coverage
___. He converted to sinus rhythm with rates in the ___. He
required 1u pRBC for Hb 6.5 and was diuresed with 40 of IV
Lasix.
The Arctic Sun was removed 1 hour prior to being called out of
the MICU and he has remained normothermic.
On the floor, the patient endorses the above history. He says
that he was sleeping on his recliner (because he couldn't lie
flat) and fell forward, flat on his face and then couldn't get
up
because he was so weak. Cannot recall if he passed out, says he
may have been sleeping. He reports feeling like he had a viral
URI "or something" for a month, associated with increasing
dyspnea and orthopnea over for a month. When asked if he has
known about his anemia, he says his nephrologist told him it was
due to his kidney disease. Re: medication changes - he says he
was started on metoprolol four months ago (stopped his ACE-I);
does not think his dose of insulin has been changed. ROS notable
for +right knee pain secondary to osteoarthritis, "It's bone on
bone." He reports taking ibuprofen and aleve frequently to help
his symptoms. He specifically denies any abdominal symptoms or
changes in bowel habits; no constipation, diarrhea, black or
bloody stools. Denies weight loss. Has a good appetite but
describes eating "less protein" because his nephrologist told
him
to do so. No night sweats or fevers.
Past Medical History:
DIABETES TYPE II
CHRONIC KIDNEY DISEASE
HYPERTENSION
HYPERLIPIDEMIA
OBESITY
VENOUS STASIS
KNEE ARTHRITIS
**Comes with a diagnosis of atrial fibrillation not on AC but
patient does not think this is accurate
Social History:
___
Family History:
Parent with leukemia in their ___.
Physical Exam:
ADMISSION PHYSICAL:
VITALS: Reviewed in MetaVision.
GENERAL: Well-appearing in no acute distress.
HEENT: Normal oropharynx, no exudates/erythema
CARDIAC: RRR, no MGR.
PULMONARY: diminished breath sounds b/l. No
inspiratory/expiratory wheeze or crackles.
CHEST: No tenderness to palpation.
ABDOMEN: No tenderness or masses
EXTREMITIES: No deformities or signs of trauma
SKIN: scales and rough plaques noted on the lower extremities
without tenderness or erythema
NEURO: Sensation intact in the upper and lower extremities,
strength ___ upper and lower, CN II-XII intact, no focal
deficits
noted moving all extremities
DISCHARGE PHYSICAL EXAM:
Vitals: 24 HR Data (last updated ___ @ 742)
Temp: 98.7 (Tm 98.7), BP: 119/66 (119-146/59-81), HR: 73
(61-81), RR: 18 (___), O2 sat: 94% (91-98), O2 delivery: Ra
GENERAL: Pale but otherwise well appearing, obese male sitting
in
chair eating breakfast
HEENT: Normal oropharynx, no exudates/erythema
CARDIAC: distant heart sounds, RRR, no murmurs
PULMONARY: CTAB with mild bibasilar crackles
ABDOMEN: Soft, non tender, no masses
EXTRMEMITIES: improved swelling, right slightly more swollen
than
left, scaly with rough plaques, no tenderness or erythema.
Multiple ecchymosis
SKIN: scattered ecchymosis, most notable underneath both nipples
and on his arms bilaterally
NEURO: AOx3, moving all extremities with purpose, +facial
symmetry
Pertinent Results:
ADMISSION LABS:
==================
___ 06:33PM BLOOD WBC-9.2 RBC-3.18* Hgb-8.4* Hct-28.0*
MCV-88 MCH-26.4 MCHC-30.0* RDW-16.4* RDWSD-52.8* Plt ___
___ 11:30PM BLOOD WBC-16.0* RBC-2.55* Hgb-6.9* Hct-22.4*
MCV-88 MCH-27.1 MCHC-30.8* RDW-16.2* RDWSD-51.2* Plt ___
___ 06:33PM BLOOD Neuts-89.4* Lymphs-5.5* Monos-3.7*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-8.18* AbsLymp-0.50*
AbsMono-0.34 AbsEos-0.01* AbsBaso-0.02
___ 06:33PM BLOOD ___ PTT-35.6 ___
___ 06:33PM BLOOD Glucose-49* UreaN-42* Creat-2.1* Na-140
K-4.9 Cl-104 HCO3-24 AnGap-12
___ 06:33PM BLOOD ALT-17 AST-35 CK(CPK)-704* AlkPhos-89
TotBili-0.3
___ 06:33PM BLOOD Lipase-22
___ 06:33PM BLOOD CK-MB-15* MB Indx-2.1 proBNP-8964*
___ 06:33PM BLOOD cTropnT-0.23*
___ 11:30PM BLOOD CK-MB-17* cTropnT-0.21*
___ 06:33PM BLOOD Albumin-3.4* Calcium-8.2* Phos-4.7*
Mg-2.5
___ 04:51AM BLOOD Ret Aut-3.4* Abs Ret-0.09
___ 02:58PM BLOOD Ret Aut-3.0* Abs Ret-0.08
___ 11:30PM BLOOD calTIBC-248* Ferritn-49 TRF-191*
___ 04:51AM BLOOD Hapto-209*
___ 06:33PM BLOOD TSH-1.7
___ 04:51AM BLOOD TSH-0.87
___ 04:51AM BLOOD Cortsol-13.3
___ 08:15PM BLOOD ___ Temp-30.6 O2 Flow-15 pO2-47*
pCO2-50* pH-7.27* calTCO2-24 Base XS--4 Intubat-NOT INTUBA
Comment-NON-REBREA
___ 08:15PM BLOOD O2 Sat-87
RELEVANT LABS:
==================
___ 02:55PM BLOOD PEP-NO SPECIFI FreeKap-78.2*
FreeLam-56.6* Fr K/L-1.38
___ 06:20AM BLOOD tTG-IgA-7
DISCHARGE LABS:
==================
___ 07:10AM BLOOD WBC-7.9 RBC-2.81* Hgb-7.7* Hct-25.3*
MCV-90 MCH-27.4 MCHC-30.4* RDW-16.2* RDWSD-53.4* Plt ___
___ 07:10AM BLOOD Glucose-86 UreaN-62* Creat-2.9* Na-139
K-5.7* Cl-105 HCO3-20* AnGap-14
___ 07:10AM BLOOD Calcium-7.9* Phos-4.5 Mg-2.4
IMAGING:
==================
___ Right Knee XR:
All three compartments appear moderate to severely narrowed
especially the
medial and patellofemoral compartments. There small lateral and
medium size medial marginal osteophytes. Patellofemoral
osteophytes are large. It is difficult to exclude a small joint
effusion. Large spurs are noted along the inferior and superior
aspects of the patella on also along the tibial tubercle. There
is no evidence for fracture, dislocation or lysis.
IMPRESSION: Severe tricompartmental degenerative changes.
___ CXR, portable:
Bibasilar consolidation continues to clear. Moderate
cardiomegaly and
mediastinal vascular engorgement have decreased since ___ with
concurrent, continued improvement in previous pulmonary edema.
Small pleural effusions are likely.
___ CXR, portable:
Consolidation in the right lower lobe is unchanged.
Cardiomediastinal silhouette is stable. Small bilateral
effusions left greater than right are unchanged. No
pneumothorax is seen. Patchy parenchymal opacities bilaterally
are unchanged. No pneumothorax is seen.
___ ECHO:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/ global biventricular systolic
function. Mild aortic stenosis. Mild pulmonary hypertension.
___ CXR:
Combination of large scale consolidation right lower lobe and
moderate right pleural effusion have improved. Left lower lobe
atelectasis and mediastinal vascular engorgement have also
decreased. There may be small nodules in the right lung, which
should be followed with conventional radiographs to see if they
are small areas of infection or solid lesions.
___ CT Torso w/o CO:
1. Scattered patchy pulmonary opacities, predominantly on the
right,
concerning for multifocal pneumonia, underlying aspiration not
excluded. In the setting of trauma, pulmonary contusion is not
excluded, but felt unlikely in this case.
2. Bilateral, right greater than left pleural, effusions.
3. No evidence of acute intraabdominal injury within the
limitation of an unenhanced scan. No free fluid.
4. Subcutaneous edema.
___ NCHCT:
No acute intracranial process. Scalp edema, may relate to third
spacing.
___ CT C-Spine:
1. No acute fracture or traumatic malalignment.
2. Severe multilevel central canal narrowing due to ossification
of posterior longitudinal ligament spanning C2 through C5.
Given this degree of narrowing, the patient is at increased risk
for cord injury.
If there is concern for neurologic injury, MRI is more sensitive
and should be considered.
MICROBIOLOGY:
==================
H. pylori stool antigen and IgG/IgM: negative
BCx ___ x2 - coag neg staph in ___ bottles
Urine strep pneumo: negative
Urine legionella: negative
UCx ___ - negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Metoprolol Succinate XL 100 mg PO BID
4. Furosemide 20 mg PO BID
5. Levemir FlexTouch U-100 Insuln (insulin detemir U-100) 100
unit/mL (3 mL) subcutaneous QPM
6. amLODIPine 10 mg PO DAILY
7. GlipiZIDE XL 10 mg PO DAILY
8. Tradjenta (linaGLIPtin) 5 mg oral Q24H
9. Pravastatin 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Atorvastatin 80 mg PO QPM
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. CARVedilol 12.5 mg PO Q12H
5. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
6. Omeprazole 20 mg PO DAILY
7. Repaglinide 1 mg PO TIDAC
8. Sodium Chloride Nasal ___ SPRY NU BID
9. Torsemide 20 mg PO DAILY
10. amLODIPine 10 mg PO DAILY
11. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
12. FoLIC Acid 1 mg PO DAILY
13. Tradjenta (linaGLIPtin) 5 mg oral Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
====================
Fall, found down at home
SECONDARY:
====================
Hypothermia
Bradyarrhythmia
Type 2 diabetes mellitus: hypoglycemia and hyperglycemia
Anemia, normocytic (iron deficiency + iron sequestration)
Chronic kidney disease, stage IV
Hyperkalemia
Heart failure with preserved ejection fraction
Hypertension
NSTEMI
Obstructive sleep apnea
Aspiration pneumonia
Osteoarthritis of the right knee, severe
Tinea pedis and onychomycosis
Cervical spine stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT torso without contrast
INDICATION: History: ___ s/p fall, dyspnea, hypoxia, abd distension// eval
traumatic injury
TECHNIQUE: Contiguous axial images were obtained through the chest, abdomen
and pelvis without intravenous contrast. Coronal and sagittal reformats were
performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.0 s, 70.6 cm; CTDIvol = 23.9 mGy (Body) DLP =
1,683.8 mGy-cm.
Total DLP (Body) = 1,684 mGy-cm.
COMPARISON: None
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury based on an unenhanced scan. There are
atherosclerotic coronary artery calcifications and mild atherosclerotic
calcifications in the aortic arch. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: There is no pneumothorax. Bilateral, right greater than left
pleural effusions are noted with adjacent compressive atelectasis.
LUNGS/AIRWAYS: Scattered patchy opacities, predominantly on the right, are
worrisome for multifocal pneumonia, underlying aspiration is not entirely
excluded.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration within the limitation of an
unenhanced scan.There is no perihepatic free fluid. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder may contain
tiny stones.
PANCREAS: The pancreas is largely fatty replaced, however, there are no focal
lesions, pancreatic duct dilatation or 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: 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. Diverticulosis of the sigmoid colon is noted, without
evidence of wall thickening and fat stranding. A rectal probe is noted. The
appendix is normal. There is no evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS: A Foley catheter is in place within the bladder. 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.
BONES: There is no acute fracture. Multilevel degenerative changes are
moderate anterior bridging osteophytes are noted in the thoracic spine,
consistent with diffuse idiopathic skeletal hyperostosis. A Schmorl's node is
present in the inferior endplate of L5. There is narrowing of the central
canal canal, possibly related to short pedicles.
SOFT TISSUES: Small bilateral fat containing inguinal hernias are present. A
small fat containing umbilical hernia is also noted. There is diffuse soft
tissue edema.
IMPRESSION:
1. Scattered patchy pulmonary opacities, predominantly on the right,
concerning for multifocal pneumonia, underlying aspiration not excluded. In
the setting of trauma, pulmonary contusion is not excluded, but felt unlikely
in this case.
2. Bilateral, right greater than left pleural, effusions.
3. No evidence of acute intraabdominal injury within the limitation of an
unenhanced scan. No free fluid.
4. Subcutaneous edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with fall, hypothermia// Interval change in
pulmonary edema Interval change in pulmonary edema
IMPRESSION:
Compared to chest radiographs and chest CT ___.
Combination of large scale consolidation right lower lobe and moderate right
pleural effusion have improved. Left lower lobe atelectasis and mediastinal
vascular engorgement have also decreased. There may be small nodules in the
right lung, which should be followed with conventional radiographs to see if
they are small areas of infection or solid lesions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with multifocal pneumonia and bilateral pleural
effusions// interval change
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Consolidation in the right lower lobe is unchanged. Cardiomediastinal
silhouette is stable. Small bilateral effusions left greater than right are
unchanged. No pneumothorax is seen. Patchy parenchymal opacities bilaterally
are unchanged. No pneumothorax is seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with heart failure and PNA undergoing diuresis
and IV ABX treatment// interval change interval change
IMPRESSION:
Compared to chest radiographs ___.
Bibasilar consolidation continues to clear. Moderate cardiomegaly and
mediastinal vascular engorgement have decreased since ___ with
concurrent, continued improvement in previous pulmonary edema. Small pleural
effusions are likely.
Radiology Report
EXAMINATION: Right knee radiographs, three views.
INDICATION: Osteoarthritis and significant right knee pain.
COMPARISON: None available.
FINDINGS:
All three compartments appear moderate to severely narrowed especially the
medial and patellofemoral compartments. There small lateral and medium size
medial marginal osteophytes. Patellofemoral osteophytes are large. It is
difficult to exclude a small joint effusion. Large spurs are noted along the
inferior and superior aspects of the patella on also along the tibial
tubercle. There is no evidence for fracture, dislocation or lysis.
IMPRESSION:
Severe tricompartmental degenerative changes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with ams, hypoglycemia, hypoxia// eval pna, pulm
edema
TECHNIQUE: Single semi-erect AP portable view of the chest
COMPARISON: None
FINDINGS:
The chest is somewhat underpenetrated due to patient body habitus and there
may be slight patient motion. Given this, bilateral mid to lower lung
opacities are seen, with differential diagnosis being severe pulmonary edema
and/or multifocal pneumonia. No evidence of pneumothorax. Difficult to
exclude pleural effusion, particularly on the left. Left hemidiaphragm may be
elevated. Enlargement of the cardiomediastinal silhouettes may in part relate
to patient position and AP technique, although the superior mediastinum
appears widened. No prior available for comparison.
IMPRESSION:
Chest is somewhat underpenetrated due to patient body habitus and there may be
slight patient motion. Given this, bilateral mid to lower lung opacities are
seen, with differential diagnosis being severe pulmonary edema and/or
multifocal pneumonia. Difficult to exclude pleural effusion, particularly on
the left.
Enlargement of the cardiomediastinal silhouettes may in part relate to patient
position and AP technique, although the superior mediastinum appears widened;
if there is clinical concern for acute mediastinal process, chest CT would
further assess. No prior available for comparison.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ s/p fall, AMS// eval ich
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.1 cm; CTDIvol = 49.9 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute territorial infarction, hemorrhage, edema, or
mass effect. The ventricles and sulci are mildly prominent keeping with
age-related involutional change.
No acute fracture is seen. Aside from mild mucosal thickening in the
bilateral ethmoid air cell as, left maxillary sinus and bilateral sphenoid
sinuses, the paranasal sinuses, mastoid air cells, and middle ear cavities are
clear. Some scalp edema is noted, which may relate to third spacing.
IMPRESSION:
No acute intracranial process. Scalp edema, may relate to third spacing.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ s/p fall, AMS// eval ich
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.9 s, 23.3 cm; CTDIvol = 22.8 mGy (Body) DLP = 530.2
mGy-cm.
Total DLP (Body) = 530 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No acute fractures are identified. There is severe
spinal canal narrowing due to calcification of the posterior longitudinal
ligament spanning C2 through C5 as well as at T2-3 due to posterior
osteophytes. There is multilevel neural foraminal narrowing due to
uncovertebral osteophytes and facet hypertrophy, most pronounced bilaterally
at C3-4. There is no prevertebral soft tissue swelling.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Severe multilevel central canal narrowing due to ossification of posterior
longitudinal ligament spanning C2 through C5. Given this degree of narrowing,
the patient is at increased risk for cord injury. If there is concern for
neurologic injury, MRI is more sensitive and should be considered.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 9:33 pm, 2 minutes
after discovery of the findings.
Gender: M
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Altered mental status, Hypoglycemia
Diagnosed with Pneumonia, unspecified organism
temperature: nan
heartrate: 32.0
resprate: 20.0
o2sat: 97.0
sbp: 135.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | SUMMARY:
====================
___ with hypertension, diabetes and CKD was brought in by
ambulance after being found down in his apartment for an unknown
period of time. He was hypothermic, bradycardic, hypoxic and
confused. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
shellfish derived / Oxycodone
Attending: ___.
Chief Complaint:
Fall off porch, now with left femoral shaft fracture
Major Surgical or Invasive Procedure:
___: ORIF L diaphyseal femur fracture
History of Present Illness:
The patient is a ___ yo F who presents with L leg pain after a
fall from her porch yesterday at approximately 3pm. The fall
was about 10ft. She had immediate pain and deformity of the left
thigh. She was taken to ___ where xray showed a
diaphyseal femur fracture. She was placed in traction and
transferred to ___ for further management. She denies any
numbness or paresthesias in her LLE. There was no head strike or
LOC during the fall.
Past Medical History:
MVP
Social History:
___
Family History:
Non contributory
Physical Exam:
On arrival:
PE:
98.6 100 156/99 16 99%
LLE:
Skin intact
Gross deformity of the mid thigh
No tenderness to palpation of the hip knee or ankle
SILT dp/sp/s/s
+ ___
2+ ___
On discharge:
Patient is alert and oriented, in no acute distress
LLE: dressings are clean dry and intact in large ACE wrap. ___
FHL AT ___ fire, SILT DP SP S S T distributions, toes are warm
and well perfused.
Pertinent Results:
On admission:
___ 09:40AM BLOOD WBC-3.0* RBC-3.53* Hgb-10.4* Hct-31.3*
MCV-89 MCH-29.5 MCHC-33.2 RDW-15.2 Plt ___
___ 09:40AM BLOOD Neuts-73.2* Lymphs-17.6* Monos-8.3
Eos-0.4 Baso-0.5
___ 09:30AM BLOOD ___ PTT-26.2 ___
___ 09:40AM BLOOD Glucose-92 UreaN-20 Creat-0.8 Na-139
K-4.1 Cl-105 HCO3-26 AnGap-12
___ 06:42PM BLOOD Calcium-7.8* Phos-4.0 Mg-1.7
___ plain films of left femur:
Interval traction device placement and realignment of a
comminuted left femoral diaphyseal fracture, with improved
anatomic alignment, though with persistent displacement.
On discharge:
___ 06:05AM BLOOD WBC-2.6* RBC-2.61* Hgb-8.0* Hct-23.7*
MCV-91 MCH-
Seven fluoroscopic views of the left femur were obtained in the
OR without the presence of a radiologist that shows an
intramedullary rod with screws superiorly and inferiorly and a
well aligned comminuted fracture of the diaphysis. There is
less displacement of the fragments compared to prior study.
___ 07:00AM BLOOD WBC-1.8* RBC-2.68* Hgb-8.2* Hct-24.1*
MCV-90 MCH-30.6 MCHC-34.0 RDW-15.6* Plt ___
___ 09:40AM BLOOD Neuts-73.2* Lymphs-17.6* Monos-8.3
Eos-0.4 Baso-0.5
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-110* UreaN-12 Creat-0.6 Na-142
K-3.5 Cl-107 HCO3-28 AnGap-11
___ 07:00AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY Duration: 6 Weeks
2. Docusate Sodium 100 mg PO BID
3. Senna 1 TAB PO BID
4. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain
RX *tramadol 50 mg 1 tablet(s) by mouth up to every 4 hours Disp
#*40 Tablet Refills:*0
5. Acetaminophen 1000 mg PO Q8H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left midshaft femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with left femur fracture status post traction and
pin insertion. Assess for alignment.
COMPARISON: Left femoral radiographs from ___ at 4:58 a.m.
LEFT FEMORAL RADIOGRAPH, SEVEN IMAGES: There has been interval placement of a
traction device at the level of the proximal tibial metaphysis. A comminuted
fracture of the mid femoral diaphysis is redemonstrated; however, there is
improved alignment of the major fracture fragments. Previously seen varus
angulation of the distal fracture fragment is significantly improved.
However, there is still persistent displacement of the distal fragment,
laterally by almost entire shaft width. There is also minimal persistent
posterior displacement seen on the lateral view. The left femoroacetabular
joint appears normal without signs of dislocation. Limited images of the left
hemipelvis appear unremarkable.
IMPRESSION: Interval traction device placement and realignment of a
comminuted left femoral diaphyseal fracture, with improved anatomic alignment,
though with persistent displacement.
Radiology Report
LEFT FEMUR
REASON FOR EXAM: Intramedullary femoral rod placement.
Seven fluoroscopic views of the left femur were obtained in the OR without the
presence of a radiologist that shows an intramedullary rod with screws
superiorly and inferiorly and a well aligned comminuted fracture of the
diaphysis. There is less displacement of the fragments compared to prior
study.
Please refer to the OR note for more details of the surgery.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with FX FEMUR SHAFT-CLOSED, FALL FROM BUILDING, HYPERTENSION NOS
temperature: 98.6
heartrate: 100.0
resprate: 16.0
o2sat: 99.0
sbp: 156.0
dbp: 99.0
level of pain: 7
level of acuity: 2.0 | The patient was admitted to the orthopaedic surgery service on
___ with left midshaft femur fracture. Patient was taken
to the operating room and underwent intramedullary nailing of
the left femur. Patient tolerated the procedure without
difficulty and was transferred to the PACU, then the floor in
stable condition. Please see operative report for full details.
Musculoskeletal: prior to operation, patient was non weight
bearing. After procedure, patient's weight-bearing status was
transitioned to weight bearing as tolerated. Throughout the
hospitalization, patient worked with physical therapy.
Neuro: post-operatively, patient's pain was controlled by
Dilaudid PCA and was subsequently transitioned to oxycodone with
good effect and adequate pain control however patient developed
a rash, she was switched to Ultram and Tylenol with good effect.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was transfused 1 units of blood for
acute blood loss anemia and HCT of 21. Then patient was
transfused another unit of blood for HCT 20.7. HCT at discharge
was 24.1.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: Aspiring 325mg daily and was encouraged to get up
and ambulate as early as possible.
At the time of discharge on ___, POD #4, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on aspirin 325mg
DVT prophylaxis for 6 weeks post-operatively. All questions
were answered prior to discharge and the patient expressed
readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, Nausea, vomiting, AMS
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ yo M hx HCV, cirrhosis, thrombocytopenia with known left
frontal SDH recently discharged from our service ___ who
presents from rehab with HA, nausea and vomiting. Rehab and
wife
feel that he is more lethargic, less interactive than usual
today. Pt endorses HA and nausea. Denies new numbness,
weakness, tingling, vision changes. No Falls or trauma. During
his last hospitalization he was followed by Hematology who
ultimately recommended ITP directed therapy with steroids for
platelet goal > 40. He did not receive steroid therapy during
the hospitalization as platelets at the time of recommendation
were greater than 40.
Past Medical History:
HTN, DM, TBI, thrombocytopenia
Social History:
___
Family History:
Non-contributory
Physical Exam:
O: T:98.8 BP: 174/88 HR:55 R:18 O2Sats:98%
Gen: WD/WN, comfortable, NAD.
HEENT: atraumatic
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, not fully cooperative with exam,
Orientation: Oriented to person, place, and date.
Language: Speech slow and deliberate, Naming intact. No
dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields - pt refuses to participate
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. Tremulous in UE bilat.
Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Coordination: dysmetria on finger-nose-finger bilaterally
Pertinent Results:
CT head: slight increase in size of subdural collection by 2mm.
minimal mass effect.
Labs:
138 99 22
-------------<152
4.1 29 0.8
ALT: 68 AP: 74 Tbili: 1.0 Alb: 4.1 AST: 58 Lip: 39
15.3
9.8>------<53
44.1
N:68.8 L:24.1 M:4.9 E:1.8 Bas:0.___
IMPRESSION:
1. Slight interval increase in the acute subdural hematoma
layering along the left frontal convexity, both superiorly and
inferiorly, with minimal left frontal sulcal effacement.
2. Decreased subdural blood along the left falx and tentorium.
HEAD CT: ___
IMPRESSION:
Stable appearance of subdural hematoma over the left frontal
convexity, falx and tentorium. No new hemorrhage. No shift of
midline structures.
Medications on Admission:
-Colace
100 mg PO 2 times a day
-Famotidine
20 mg PO 2 times a day
-Gabapentin
100 mg PO once a day (at bedtime)
-HydrALAzine
___ mg IV every 6 hours as needed SBP > 160
-levetiracetam [KePPRA]
1,000 mg tablet (oral)
1000 mg PO 2 times a day
30 Tablet 2
-Lisinopril
20 mg PO Daily
-MetFORMIN (Glucophage)
500 mg PO 2 times a day
-Miralax
17 g PO Once daily as needed constipation
-Propranolol
40 mg PO 2 times a day
-Senna
8.6 mg PO at bedtime
Discharge Medications:
1. Famotidine 20 mg PO BID
2. Gabapentin 100 mg PO QHS
3. HydrALAzine 10 mg PO Q8H
4. Propranolol 40 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Lisinopril 5 mg PO DAILY
8. LeVETiracetam 1000 mg PO BID
9. HydrALAzine 10 mg IV Q6H:PRN SBP >160
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with subdural hematoma and thrombocytopenia.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal, sagittal and
thin-section bone algorithm-reconstructed images were acquired.
DOSE: DLP: 1003 mGy-cm
CTDI: 110 mGy
COMPARISON: CT Head ___ at 23:10
FINDINGS:
Compared to 10 hr earlier, the left frontal convexity subdural hematoma
appears stable, allowing for notable differences in head positioning. There is
stable mild effacement of the left frontal sulci without shift of midline
structures or mass effect on the ventricles. Stable appearance of subdural
blood along the left falx and tentorium. There is no new hemorrhage or edema.
Encephalomalacia is again demonstrated in the medial right frontal lobe. The
ventricles are prominent due to cerebral atrophy, unchanged in appearance
compared to the prior study. Bilateral periventricular and subcortical
hypodensities suggest chronic small vessel ischemic disease. Basal cisterns
are patent.
There is mild mucosal thickening of the left maxillary sinus.
IMPRESSION:
Stable appearance of the small left subdural hematoma compared to 10 hr
earlier.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V
Diagnosed with SUBDURAL HEM W/O COMA, OTHER FALL
temperature: 98.8
heartrate: 55.0
resprate: 18.0
o2sat: 98.0
sbp: 174.0
dbp: 88.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted to the ED with n/v and metal status
change on ___. He remained stable while in the ED. He was
transferred to the neurosurgical service on ___ for
observations. He remained neurologically stable on ___. A
repeat head CT was obtained and showed stable SDH. He required
one dose of IV hydralazine for SBP >170, with good effect. He
was transferred back to the rehabilitation center in stable
conditions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Lidocaine / Latex / ceftriaxone
Attending: ___.
Chief Complaint:
Altered mental status, UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with MS presenting with altered mental status from ___
___ Facility. Patient is confused, can answer simple questions
and follows commands intermittently. Denies headache, chest
pain, abdominal pain. Denies nausea, vomiting. Patient was
recently diagnosed with urinary tract infection and started on
ciprofloxacin, however, urine culture showed bacteria resistant
to cipro. Vitals from rehab reviewed, no fevers.
In ER: (Triage Vitals: 98.1 88 109/64 16 93% ) Meds Given: ,
Fluids given:Meropenem + 2l NS
Radiology Studies: none
consults called: none
PAIN ___
The patient is a very poor historian. She is unable to answer
even simple questions. All other limited review of sx is
negative.
Past Medical History:
- multiple sclerosis
- secondary depression and psychosis
- neurogenic bladder for ___ years.
- sleep apnea
- bipolar disorder
- Hypercholesterolemia
- Hearing loss
- OSA
- Urinary incontinence
- Urinary retention
Social History:
___
Family History:
Per note of Dr. ___ in ___:
Father: esophageal cancer
Mother: healthy
Physical ___:
Admission Exam:
1. VS: T 100.9, 114/55, 95, 18, 95% on RA.
GENERAL: Thin female laying in bed
Nourishment: at risk
Mentation: alert, opens eyes to her name,
2. Eyes: [] WNL
EOMI without nystagmus, Conjunctiva: clear
3. ENT [] WNL
[ ?]thrush
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[++] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[] Regular [X] Tachy [X] S1 [X] S2 [-] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None 1+ 2+ 3+ 4+ [] Bruit(s), Location:
[X] Edema LLE None 1+ 2+ 3+ 4+ [] PMI
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [X]
[x] CTA bilaterally [ ] Rales [ ] Diminshed
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [] WNL
[X] Soft [-] Rebound [] No hepatomegaly [X] Non-tender []
Tender
[] No splenomegaly
[] Non distended [] distended [] bowel sounds Yes/No []
guiac:
positive/negative
7. Musculoskeletal-Extremities [] WNL
Could not be assessed since pt does not obey commands.
She is able to wiggle her toes.
8. Neurological [] WNL
A and O x 1. [ ] 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
[X] Warm [X] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
Discharge Exam:
Vital Signs: 98.0 122/64 82 18 96%RA
GEN: Alert, NAD
HEENT: atraumatic, stabismus (documented in prior notes)
CV: RRR, no m/r/g
PULM: CTA B
GI: S/ND, BS present, mild TTP in the RLQ (chronic per pt)
NEURO: Oriented x 3
Pertinent Results:
Admission Labs:
___ 01:00PM BLOOD WBC-23.2*# RBC-4.20 Hgb-11.2* Hct-35.5*
MCV-85 MCH-26.6* MCHC-31.5 RDW-13.2 Plt ___
___ 01:00PM BLOOD Neuts-84.0* Lymphs-8.4* Monos-7.2 Eos-0.2
Baso-0.2
___ 01:00PM BLOOD Glucose-72 UreaN-24* Creat-0.8 Na-138
K-3.9 Cl-95* HCO3-27 AnGap-20
___ 01:00PM BLOOD Calcium-9.3 Phos-3.4 Mg-2.4
___ 01:26PM BLOOD Lactate-1.6
Discharge Labs:
___ 07:00AM BLOOD WBC-8.1 RBC-4.15* Hgb-11.1* Hct-34.3*
MCV-83 MCH-26.8* MCHC-32.4 RDW-13.6 Plt ___
___ 07:00AM BLOOD Glucose-94 UreaN-8 Creat-0.4 Na-142 K-4.1
Cl-104 HCO3-28 AnGap-14
___ 07:00AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.8
___ 03:05PM URINE Color-Yellow Appear-Hazy Sp ___
___ 03:05PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 03:05PM URINE RBC-16* WBC->182* Bacteri-MOD Yeast-NONE
Epi-2
URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
URINE CULTURE (Final ___: NO GROWTH.
Blood Cx x 2 PENDING
ECG - Sinus rhythm. Incomplete right bundle-branch block.
Borderline low voltage. T wave inversions in leads V1-V4
consistent with right bundle-branch block abnormality. Compared
to the previous tracing of ___ incomplete right
bundle-branch block pattern is now seen.
CXR - FINDINGS: The cardiac, mediastinal and hilar contours
appear stable. There is minimal medial basilar opacification
bilaterally probably due to minor atelectasis. Otherwise, the
lungs appear clear. There is no pleural effusion.
IMPRESSION: Clear lungs aside from minor suspected atelectasis.
Renal U/S - FINDINGS: The right kidney measures 10.3 cm. The
left kidney measures 10.9 cm. There is no hydronephrosis,
stones, or masses bilaterally. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally.
The bladder is moderately well distended and normal in
appearance.
IMPRESSION: Normal renal ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID
2. Ascorbic Acid ___ mg PO DAILY
3. Baclofen 20 mg PO TID
4. Divalproex (DELayed Release) 500 mg PO BID
5. Estrogens Conjugated 0.5 gm VG Q ___ AND ___
6. Gabapentin 300 mg PO TID
7. glatiramer 40 mg/mL subcutaneous Q ___
8. Omeprazole 20 mg PO DAILY
9. Sulfameth/Trimethoprim DS 1 TAB PO BID
10. BuPROPion (Sustained Release) 100 mg PO BID
11. TraZODone 25 mg PO HS:PRN INSOMNIA
12. TraMADOL (Ultram) 25 mg PO Q6H:PRN PAIN
Discharge Medications:
1. Acetaminophen 650 mg PO BID
2. Ascorbic Acid ___ mg PO DAILY
3. Baclofen 20 mg PO TID
4. BuPROPion (Sustained Release) 100 mg PO BID
5. Divalproex (DELayed Release) 500 mg PO BID
6. Gabapentin 300 mg PO TID
7. Omeprazole 20 mg PO DAILY
8. TraZODone 25 mg PO HS:PRN INSOMNIA
9. Estrogens Conjugated 0.5 gm VG Q ___ AND ___
10. glatiramer 40 mg/mL subcutaneous Q ___
11. TraMADOL (Ultram) 25 mg PO Q6H:PRN PAIN
12. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Complicated UTI
Altered mental status
Multiple Sclerosis
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: Altered mental status.
COMPARISON: ___.
TECHNIQUE: Chest, portable AP upright.
FINDINGS:
The cardiac, mediastinal and hilar contours appear stable. There is minimal
medial basilar opacification bilaterally probably due to minor atelectasis.
Otherwise, the lungs appear clear. There is no pleural effusion.
IMPRESSION:
Clear lungs aside from minor suspected atelectasis.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with UTI and fever // eval for any
obstruction, any evidence of pyelonephritis?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Renal ultrasound ___
FINDINGS:
The right kidney measures 10.3 cm. The left kidney measures 10.9 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with URIN TRACT INFECTION NOS, ALTERED MENTAL STATUS , DEHYDRATION
temperature: 98.1
heartrate: 88.0
resprate: 16.0
o2sat: 93.0
sbp: 109.0
dbp: 64.0
level of pain: nan
level of acuity: 2.0 | The patient is a ___ year old female with MS, BPAD, neurogenic
bladder admitted from ___ with altered mental status and sepsis
from Ecoli UTI.
DELIRIUM
SEVERE UROSEPSIS
TOXIC METABOLIC ENCEPHALOPATHY
The pt's UTI was initially treated at her facility with cipro,
but the bacteria returned resistant to fluoroquinolones. As a
result the pt was started on bactrim, but her mental status
continued to decline and thus she was admitted to ___. She
was found to be septic with wbc count to ___ and fever. The
pt was never in shock. She was fluid resuscitated and started
on meropenem given a history of possible anaphylactic reaction
to ceftriaxone and also a documented allergy to penicillins.
The pt's mental status and white count rapidly improved. She
did not demonstrate signs of pyelonephritis on exam given a lack
of flank or CVA tenderness. She was ultimately transitioned to
nitrofurantoin, which she will continue for a total 2 week
course. She was monitored overnight after switching to
nitrofurantoin, and she continued to improve clinically. Renal
ultrasound was performed and confirmed no evidence of
obstruction.
NEUROGENIC BLADDER, presumed from MS: This is a risk factor for
recurrent UTI's. Pt was encouraged to follow up with urology for
further management as outpt.
BPAD: Continued Depakote
MS: On baclofen and neurontin. Glatiramer not given in house
GERD: Continued PPI.
DEPRESSION: Continued bupropion
INSOMNIA: Continued trazodone. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o RA on immunosuppressants, PE/DVT, CAD s/p ___
transferred from ___ for chest pain and SOB concern for
ACS.
.
Per patient reports 2 weeks of gradual onset DOE and CP. CP,
described as a pressure, felt predominantly substernally with
occassional radiation to left shoulder. Lasts seconds-minutes.
Brought on by exertion. Also SOB with exertion. CP does not feel
like her CP with her prior cath. No nausea or diaphoresis with
CP. Sx prompted presentation at ___. There CTA negative,
BNP ~60, trop 0.02. Sent to ___ for further eval and possible
cardiac cath per ___.
.
Pt also reports a productive cough of yellow sputum; subjective
sweats, chills, fevers, Tm 99. This has been accompanied by a
sore throat, mild HA, runny nose, and generalized fatigue, all
starting ___ days ago. No known sick contacts but works around
lots of people.
.
Pt also reports intermittent symptoms of abdominal bloating and
epigastric burning for the last month. These symptoms are worse
with eating and are worse with certain foods (she names nuts,
vegetables, and alcohol in particular). The epigastric
discomfort is a differnt sensation than the above mentioned
chest pain.
.
REVIEW OF SYSTEMS:
Denies vision changes, nausea, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria. Positive
diffuse joint aching consistent with her RA pain. Also reports
mild numbness and tingling of hands and feet.
.
In the ED, initial VS: 97.3 58 132/71 18 97% 4L Nasal Cannula.
EKG showed diffuse T wave flattening but no significant ST
changes or acute ischemia signs. Trop neg and other labs normal.
Pt already got ASA at OSH. Admitted to ___ for further eval.
.
Currently, pt feels very fatigued due to the events of the last
24hrs. She is without chest pain or SOB currently. Although she
hasn't eaten in 24hrs she is not particularly hungry.
Past Medical History:
CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia,
(+)Hypertension
No previous caths, echoes, no arrhythmias
OTHER PAST MEDICAL HISTORY:
- Rheumatoid Arthritis: on methotrexate, methylprednisone,
remicaide infusions intermittently (last one this summer)
- Per ___, h/o blood clot in arm vein ___ years ago; was on
warfarin for 9 months although the patient reports ___ UE "blood
clots" in her life for which she was on coumadin for a few
months at a time last in ___ per report
- Per ___, COPD although the patient is not aware where
this diangosis originated from.
- Hypertension
- Depression
- Ovarian surgery
- Sinus surgery
- R shoulder surgery
Social History:
___
Family History:
- Mother: alive at ___ - hemorrhagic stroke, HTN
- Father: first MI at ___, deceased at ___ after recurrent MIs
- Sister deceased at ___ acutely from either MI vs CVA
- Nephew passed away at ___ with sudden cardiac death
Physical Exam:
Admission Exam:
VS - Temp 97.7F, BP 125/80, HR 63, R 20, O2-sat 95% RA
GENERAL - obese, tired appearing, NAD
HEENT - PERRLA, sclerae anicteric
NECK - supple, no JVD while sitting
LUNGS - intermittent fine crackles LLL, resp unlabored
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - Distended ___ to body habitus, TTP in epigastrium, no
masses, normoactive BS
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
.
Discharge Exam:
VS: T ___ BP 109-124/69-85 HR 54-68 RR 18 O2 Sat 96% RA
GEN: Obese woman in NAD, appropriate affect.
HEENT: EOMI, NCAT, MMM
Neck: Supple, unable to asses JVP ___ body habitus
CV: RRR, normal s1/s2, no s3/s4, no m/r/g.
PULM: Diffuse wheezing, markedly improved since yesterday, poor
effort, diminished breath sounds in all lung fields
ABD: Obese, NABS, TTP in the epigastrium, no rigidity, rebound
or guarding
EXT: WWP, no c/c/e
NEURO: A/Ox3, CN NN-XII intact, non focal.
Pertinent Results:
Admission Labs:
___ 12:50AM BLOOD WBC-10.2 RBC-3.87* Hgb-14.1 Hct-40.6
MCV-105* MCH-36.3* MCHC-34.7 RDW-14.3 Plt ___
___ 12:50AM BLOOD ___ PTT-28.4 ___
___ 12:50AM BLOOD Glucose-86 UreaN-14 Creat-0.6 Na-138
K-3.8 Cl-102 HCO3-26 AnGap-14
___ 12:50AM BLOOD ALT-39 AST-41* CK(CPK)-124 AlkPhos-63
TotBili-0.5
___ 12:50AM BLOOD CK-MB-5
___ 12:50AM BLOOD cTropnT-<0.01
___ 06:22AM BLOOD CK-MB-4 cTropnT-<0.01
___ 02:45PM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:22AM BLOOD %HbA1c-5.8 eAG-120
___ 06:22AM BLOOD TSH-4.4*
___ 02:45PM BLOOD Free T4-0.89*
___ 06:22AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0
.
Discharge Labs:
___ 06:50AM BLOOD WBC-9.7 RBC-4.13* Hgb-15.3 Hct-44.0
MCV-106* MCH-36.9* MCHC-34.7 RDW-14.4 Plt ___
___ 07:10AM BLOOD Glucose-84 UreaN-16 Creat-0.6 Na-142
K-3.8 Cl-104 HCO3-27 AnGap-15
Persantine MIBI (___):
Persantine-induced anginal symptoms without ischemic ST
segment changes. Normal hemodynamic response to Persantine.
Nuclear
report sent seperately.
.
Left ventricular cavity size is normal with an EDV of 69 ml.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium. Gated images reveal
normal wall motion. The calculated left ventricular ejection
fraction is 64%.
.
IMPRESSION: 1. Normal cardiac perfusion study. 2. LVEF of 64%
.
CXR PA/LAT (___):
As compared to the previous examination from an outside
hospital,
there is no relevant change. Low lung volumes without evidence
of pulmonary edema or pneumonia. No pleural effusions. Normal
size of the cardiac silhouette. Normal hilar and mediastinal
contours.
Medications on Admission:
ASA 81mg Qd
Plavix 75mg Qd
Coumadin 5mg Qd
Valsartan 100mg Qd / HCTZ 25mg Qd
Metoprolol succinate 50mg Qd
Rituximab 40mg SQ every other week
Methotrexate 25mg ___
Methylprednisolone 4mg Qd
Pravastatin 40mg Qd
Duloxetine 60mg Qd
Folic Acid 2mg Qd
Gabapentin 300mg Qhs
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
5. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
7. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. folic acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. methotrexate sodium 2.5 mg Tablet Sig: Ten (10) Tablet PO
QFRI (every ___.
12. methylprednisolone 8 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
13. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
14. rituximab 10 mg/mL Concentrate Sig: Four (4) 40mg
Intravenous every other week: inject 40mg SQ every other week.
15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Angina
Secondary:
GERD
RA
DVT/PE
HTN
HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: History of rheumatoid arthritis. Questionable infection.
COMPARISON: ___, outside hospital films.
FINDINGS: As compared to the previous examination from an outside hospital,
there is no relevant change. Low lung volumes without evidence of pulmonary
edema or pneumonia. No pleural effusions. Normal size of the cardiac
silhouette. Normal hilar and mediastinal contours.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P CP
Diagnosed with CHEST PAIN NOS, SHORTNESS OF BREATH
temperature: 97.3
heartrate: 58.0
resprate: 18.0
o2sat: 97.0
sbp: 132.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | Primary Reason for Admission: ___ h/o RA on immunosuppressants,
PE/DVT, CAD s/p ___ transferred from ___ for chest
pain and SOB concern for ACS who has angina as well as GERD and
URI Sx.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
ERCP ___:
A single balloon assisted ERCP (SB-ERCP) was performed using a
cap at the tip of the enteroscope.
Evidence of previous surgery was seen.
The jejuno-jejunal anastomosis was identified and it was
normal.
Previous tattoo was seen beyond the biliary/ afferent limb.
The hepaticojejunostomy was identified close to the tattoo.
The hepatico-jejunal anastomoses was successfully cannulated
using a balloon catheter.
Contrast was injected and there was brisk flow through the
ducts.
Contrast extended to the entire biliary tree.
There were no filling defects seen.
There was mild dilation of the distal CHD and PSC changes of
the
right and left intrahepatic system.
The biliary tree was swept with a 9-12mm balloon starting at
the
bifurcation.
Small amount of sludge was removed.
There was excellent contrast and bile drainage at the end of
the
procedure.
History of Present Illness:
Mr. ___ is a ___ year old man with primary sclerosing
cholangitis s/p liver transplant x2 (most recent in ___ and
ulcerative colitis s/p colectomy (___), and history of C
diff, who presents with fevers, nausea and lightheadedness.
The patient shares that the afternoon of presentation he began
to feel generally unwell. He had fevers up to 102. He felt
nauseous with dry heaving, but no vomiting. He was driving his
wife, but felt lightheaded and realized he needed to come to the
hospital. He had no subjective confusion or abdominal pain. He
reports he usually has loose stools, and this hasn't changed
recently. He has been on cipro/flagyl for pouchitis since
___.
In the ED, initial VS were: 100.9 95 107/69 16 98% RA. Spiked
to 102.6 while in ED. Exam was notable for right upper quadrant
abdominal tenderness with no rebound or guarding. Labs were
notable for WBC 9.6, Hb 14.3, Platelet 93, INR 1.3, AST 61, AP
306, Tbili 2.8, Cr 0.9, Lactate 1.2. CRP 18.4. UA was negative.
CXR showed no acute process and RUQ US showed coarsened liver
echotexture with patent vasculature. Hepatology was consulted
and recommended infectious workup, gram negative coverage with
antibiotics, and admission to the liver service. He was given 2L
NS, Zofran, Tylenol ___ mg, and 500 mg IV meropenem.
On arrival to the floor, patient gives the above history. He
says he feels a lot better after getting Tylenol and IV fluids.
He has no abdominal pain. He says this feels like prior episodes
of cholangitis.
Past Medical History:
Primary sclerosing cholangitis s/p 2 transplants, most recent
in ___ at ___
Ulcerative colitis diagnosed in ___, s/p colectomy ___ and
ileostomy takedown ___
Pouchitis, on cipro/flagyl since ___
Osteopenia
Hospitalizations for acute cholangitis, per patient treated
with ertapemem in the past
H/o C diff
H/o squamous cell carcinoma on the face
H/o CMV viremia
Social History:
___
Family History:
Father died of colon cancer.
Mother with depression and alcohol use disorder.
Physical Exam:
EXAM UPON ADMISSION:
VS: 98.5 ___ 18 97
GENERAL: lying flat in bed, appears comfortable
HEENT: unable to appreciate icteric sclerae, moist mucosa
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: healed scar traversing the abdomen, right lower
abdominal scar, nontender on palpation
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
EXAM UPON DISCHARGE:
VS: T 98.7 BP 99/66 HR 55 RR 18 02 SAT 98%
GENERAL: Pleasant gentleman sitting up in the bed. In NAD
HEENT: Anicteric sclerae. MMM
HEART: RRR, S1/S2, No m/r/g
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: healed scar traversing the abdomen, right lower
abdominal scar, mild RUQ TTP
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS UPON ADMISSION:
=====================
___ 12:49PM BLOOD WBC-6.4 RBC-4.71 Hgb-14.7 Hct-40.7 MCV-86
MCH-31.2 MCHC-36.1 RDW-13.1 RDWSD-39.9 Plt ___
___ 12:49PM BLOOD Neuts-65.8 ___ Monos-12.1 Eos-1.7
Baso-0.5 Im ___ AbsNeut-4.21 AbsLymp-1.25 AbsMono-0.77
AbsEos-0.11 AbsBaso-0.03
___ 12:49PM BLOOD ___
___ 12:49PM BLOOD UreaN-17 Creat-1.0 Na-140 K-4.4 Cl-99
HCO3-21* AnGap-20*
___ 12:49PM BLOOD ALT-38 AST-55* AlkPhos-303* TotBili-2.5*
___ 12:49PM BLOOD Albumin-4.5 Calcium-9.7 Phos-3.2 Mg-1.8
___ 12:49PM BLOOD 25VitD-49
___ 12:49PM BLOOD CRP-18.4*
___ 11:58PM BLOOD Lactate-1.2
LABS UPON DISCHARGE:
=====================
___ 06:00AM BLOOD WBC-4.0 RBC-3.95* Hgb-12.5* Hct-34.9*
MCV-88 MCH-31.6 MCHC-35.8 RDW-13.2 RDWSD-42.5 Plt Ct-77*
___ 06:00AM BLOOD ___ PTT-30.2 ___
___ 06:00AM BLOOD Glucose-119* UreaN-10 Creat-0.8 Na-143
K-3.7 Cl-107 HCO3-24 AnGap-12
___ 06:00AM BLOOD ALT-28 AST-34 LD(LDH)-156 AlkPhos-233*
TotBili-1.3 DirBili-0.6* IndBili-0.7
___ 06:00AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.5*
OTHER LABS:
=====================
___ 06:00AM BLOOD tacroFK-7.5
MICRO DATA:
=====================
Blood cultures ___: negative to date
Urine culture ___: NGTD
C diff ___: Negative
IMAGING/OTHER:
=====================
RUQ US with DOPPLER ___:
IMPRESSION:
1. Patent hepatic vasculature with appropriate waveforms.
2. Heterogeneous liver echotexture. No focal liver lesion.
CXR ___:
IMPRESSION:
No acute cardiopulmonary process.
ERCP ___:
Impression:
A single balloon assisted ERCP (SB-ERCP) was performed using a
cap at the tip of the enteroscope.
Evidence of previous surgery was seen.
The jejuno-jejunal anastomosis was identified and it was
normal.
Previous tattoo was seen beyond the biliary/ afferent limb.
The hepaticojejunostomy was identified close to the tattoo.
The hepatico-jejunal anastomoses was successfully cannulated
using a balloon catheter.
Contrast was injected and there was brisk flow through the
ducts.
Contrast extended to the entire biliary tree.
There were no filling defects seen.
There was mild dilation of the distal CHD and PSC changes of
the right and left intrahepatic system.
The biliary tree was swept with a 9-12mm balloon starting at
the bifurcation.
Small amount of sludge was removed.
There was excellent contrast and bile drianage at the end of
the procedure.
I supervised the acquisition and interpretation of the
fluoroscopic images.
The quality of the fluoroscopic images was good.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tacrolimus 5 mg PO Q12H
2. Ursodiol 500 mg PO BID
3. Calcitrate (calcium citrate) 400 mg oral daily
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Ciprofloxacin HCl 500 mg PO Q24H
7. MetroNIDAZOLE 500 mg PO TID
8. Vitamin D 5000 UNIT PO DAILY
9. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice daily Disp #*23 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Calcitrate (calcium citrate) 400 mg oral daily
4. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Tacrolimus 5 mg PO Q12H
8. Ursodiol 500 mg PO BID
9. Vitamin D 5000 UNIT PO DAILY
10. HELD- Ciprofloxacin HCl 500 mg PO Q24H This medication was
held. Do not restart Ciprofloxacin HCl until ___
11. HELD- MetroNIDAZOLE 500 mg PO TID This medication was held.
Do not restart MetroNIDAZOLE until ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Cholangitis
Sepsis
Secondary diagnoses:
History of liver cirrhosis s/p transplant
Primary sclerosing cholangitis
Ulcerative Colitis
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 recurrent primary sclerosing cholangitis, s/p
liver transplant// evaluate for biliary and liver pathology
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: None.
FINDINGS:
Liver echotexture is heterogeneous. There is no evidence of focal liver
lesions or biliary dilatation. The common hepatic duct measures 2 cm. There
is no right pleural effusion. There is trace perihepatic free fluid.
DOPPLER: The main hepatic arterial waveform is within normal limits, with
prompt systolic upstrokes and continuous antegrade diastolic flow. Peak
systolic velocity in the main hepatic artery is 176 cm per sec. Appropriate
arterial waveforms are seen in the right hepatic artery and the left hepatic
artery with resistive indices of 0.67, and 0.58, respectively. The main
portal vein and the right and left portal veins are patent with hepatopetal
flow and normal waveform. Appropriate flow is seen in the hepatic veins and
the IVC.
IMPRESSION:
1. Patent hepatic vasculature with appropriate waveforms.
2. Heterogeneous liver echotexture. No focal liver lesion.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with fever, transplant, infectious work-up//
evaluate for PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 100.9
heartrate: 44.0
resprate: 16.0
o2sat: 98.0
sbp: 107.0
dbp: 69.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old man with primary sclerosing
cholangitis s/p liver transplant x2 (most recent in ___ and
ulcerative colitis s/p colectomy (___), and history of C
diff, with recent diagnosis of pouchitis (on ciprofloxacin and
flagyl since ___ who was admitted to ___ with sepsis
secondary to cholangitis.
#SEPSIS
#CHOLANGITIS
Presented with fevers, nausea and lightheadedness. In the ED had
temp 100.9 HR 95 and RUQ pain. Labs were notable for WBC 9.6, Hb
14.3, Platelet 93, INR 1.3, AST 61, AP 306, Tbili 2.8, Cr 0.9,
Lactate 1.2. CRP 18.4. Pt was admitted for sepsis ___
cholangitis. Other infectious etiologies were ruled out as u/a
and urine culture as well as CXR was w/o infection. Blood
cultures with NGTD. Ciprofloxacin and flagyl were held. Pt was
was started on IV Meropenem for cholangitis and received IVF.
RUQ US showed patent hepatic vasculature with appropriate
waveforms and heterogeneous and coarsened liver echotexture. He
was taken for ERCP, which showed mild dilation of distal CHD and
PSC, no filling defects. Biliary tree was swept and a small
amount of sludge was removed. On the floor he progressively
improved. His vitals were stable and he remained afebrile. LFTs
and improved, and Tbili normalized to 1.3. On ___ he was
switched to Augmentin to complete a 14 day course (end date
___.
#PSC s/p transplant x2
PSC was diagnosed in ___ and he has undergone two liver
transplants at ___, most recently in ___. He was
continued on tacrolimus 5 mg PO q 12 hours and ursodiol 500 mg
PO BID while in the hospital.
#Ulcerative Colitis
#Chronic pouchitis
Patient's ulcerative colitis was refractory to medication and he
ultimately underwent total colectomy in ___, IPAA
creation in ___, and diverting ileostomy takedown in
___. Patient has been on ciprofloxacin and flagyl for
pouchitis since ___ of this year. Patient will resume treatment
of pouchitis with ciprofloxacin and flagyl after he completes
course of augmnetin.
**Transitional issues** |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
L wrist pain
Major Surgical or Invasive Procedure:
I&D, ORIF L distal radius fracture
History of Present Illness:
___ RHD w/ Alzheimer's Dementia presents to ___ ED with L
wrist
pain s/p mechanical fall at 7:30 pm after tripping while walking
up stone steps. No HS or LOC. Mechanical fall. Noted immediate
pain, deformity, swelling, and deep laceration with ?visible
bone. Denies numbness, tingling, weakness distally. States
otherwise has been healthy with no recent fevers/chills. When
arrived in ED, patient reported up to date on Tdap, and received
abx per ED. Denies other injuries.
Past Medical History:
Past Medical History:
Anxiety
Alzheimer's Dementia
Past Surgical History:
BSO
Social History:
___
Family History:
Family Hx:
Father-CHF
___ Dementia
Physical Exam:
Gen: healthy appearing female in NAD
LUE:
splint in place
fires EPL/FPL/DIO
fingers warm and well perfused
Radiology Report
EXAMINATION: FOREARM (AP AND LAT) LEFT
INDICATION: History: ___ with post reduction// eval post reduction films
eval post reduction films
TECHNIQUE: Frontal and lateral views of the forearm
COMPARISON: ___ left forearm radiograph
FINDINGS:
Overlying cast limits visualization and evaluation of fine osseous details.
Within the limitations of this study the previously seen comminuted,
displaced, impacted and dorsally angulated fractures of the distal radius and
ulnar are again noted. There is interval improvement of the previously seen
dorsal angulation. There is no evidence of proximal radius and ulna fracture.
Limited visualization of the upper joint demonstrates no acute fractures or
dislocations. Incidental note is made of a supracondylar spur, congenital
variant, along the anterior aspect of the distal humerus.
IMPRESSION:
1. Status post cast placement, there is interval improvement of the previously
seen dorsal angulation involving the comminuted, displaced and impacted distal
radius and ulnar fractures.
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) IN O.R. LEFT
INDICATION: History: ___ with post reduction// eval post reduction films
eval post reduction films
eval post reduction films
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left wrist.
COMPARISON: Same day ___ left wrist radiograph
FINDINGS:
Overlying cast limits evaluation for fine osseous details. Status post cast
placement there is improved alignment of the previously seen comminuted
impacted fractures of the distal radius and ulna. There is improved anatomic
alignment since the previous study. There is generalized demineralization.
IMPRESSION:
Status post cast placement there is improved alignment of the previously seen
comminuted, impacted, fractures of the distal radius and ulna.
Radiology Report
INDICATION: History: ___ with pre-op wrist fx// pre-op,, ?PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ chest radiograph.
FINDINGS:
The lungs are well expanded and clear. There is no focal consolidation,
pleural effusion or pneumothorax. The curvilinear opacity projecting over the
left lung base likely represents atelectasis versus chronic scarring.
Cardiomediastinal silhouette is unremarkable. Left sided rib fractures are of
varying ages, however likely chronic.
IMPRESSION:
1. No acute intrathoracic abnormalities identified..
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) IN O.R. LEFT
IMPRESSION:
Fluoroscopic images from the operating suite show steps in internal fixation
procedure involving comminuted fractures of the distal radius and ulna.
Further information can be gathered.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Wrist injury
Diagnosed with Oth fx of lower end of left radius, init for opn fx type I/2, Oth fx lower end of left ulna, init for opn fx type I/2, Fall on same level, unspecified, initial encounter
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 10
level of acuity: 1.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an open L distal radius fx and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for I&D, ORIF L distal radius fx,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to SNF was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweight bearing in the left upper extremity, and will be
discharged on no medication 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 / Prevacid / Cyclosporine
Attending: ___.
Chief Complaint:
Right groin drainage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p EVAR presents with R groin puncture site bleeding
and hematoma since 3 am today. Pt was discharged 3 days ago and
has been doing well at home. She resumed her rivaroxaban 2 days
ago as instructed. This AM she got up quickly to go to the
bathroom and realized her R groin was bleeding. She held
pressure but it did not stop so she came to the ED. Reports
dizziness when standing up quickly. Denies any other symptoms.
Past Medical History:
PMH:AAA, CAD, PAF, HTN, Hypertrophic obstructive cardiomyopathy,
dyslipidemia, hypothyroidism, ischemic colitis
PSH:Pacemaker placement
Physical Exam:
Alert and oriented x 3
VS:BP 138/74 HR 68 RR 16
Resp: Lungs clear
Abd: Soft, non tender
Ext: Pulses: Left DP palp ,___ palp
Right DP palp ,___ palp
Feet warm, well perfused. No open areas
Right groin puncture site: open to 0.5 cm x 0.5 cm. Wound base
100% granulated. Slight oozing. Surrounding ecchymosis. Area is
firn and tender but no palpable hematoma.
Pertinent Results:
___ 08:10AM BLOOD WBC-8.2 RBC-3.61* Hgb-10.5* Hct-32.8*
MCV-91 MCH-28.9 MCHC-31.9 RDW-13.4 Plt ___
___ 08:10AM BLOOD Glucose-114* UreaN-13 Creat-0.7 Na-144
K-3.9 Cl-103 HCO3-30 AnGap-15
Right femoral ultrasound ___:
Turbulent flow was seen in the right femoral artery without
frank
pseudoaneurysm or evidence of AV fistula. The common femoral
artery and vein are patent with appropriate direction of flow.
No distinct regional hematoma is seen.
Medications on Admission:
Amiodarone 100', Aspirin 81', Atorvastatin 40', Diltiazem ER
360', Synthroid ___ M/T/R/F/Sa 88 ___, Estrogens Conjugated 1g
VG 1X/Wk (SA), Glycerin Supps 1 SUPP PR PRN, MVI, Tylenol ___
Q6H:PRN, Rivaroxaban 10'
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Amiodarone 100 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Cephalexin 500 mg PO Q8H
RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
6. Diltiazem Extended-Release 360 mg PO DAILY
7. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___)
___
8. Levothyroxine Sodium 88 mcg PO 2X/WEEK ___
9. Multivitamins 1 TAB PO DAILY
10. Rivaroxaban 10 mg PO DAILY
11. Estrogens Conjugated 1 gm VG 1X/WEEK (SA)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right groin hematoma
Endovascular repair of abdominal aortic aneurysm ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Limited right groin ultrasound.
CLINICAL INFORMATION: Post-op day EVAR with right groin hematoma since this
morning, rule out pseudoaneurysm.
COMPARISON: None.
FINDINGS: Turbulent flow was seen in the right femoral artery without frank
pseudoaneurysm or evidence of AV fistula. The common femoral artery and vein
are patent with appropriate direction of flow. No distinct regional hematoma
is seen.
IMPRESSION: Turbulent flow in the femoral artery without evidence of frank
pseudoaneurysm or AV fistula. No distinct hematoma seen.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: WOUND EVAL
Diagnosed with HEMORR COMPLIC PROCEDURE, ABN REACT-PROCEDURE NOS
temperature: 97.9
heartrate: 78.0
resprate: 18.0
o2sat: 93.0
sbp: 163.0
dbp: 58.0
level of pain: 0
level of acuity: 4.0 | ___ year old woman sp EVAR ___ presents to ER with sudden
bleeding from the right groin puncture site. She was admitted
to the hosptial for observation and serial hematocrits. Right
groin ultrasound showed no AV fistula or pseudoaneurysm. The
bleeding was felt to from a surface hematoma (collection of
blood). Her hct was stable throughout her stay. We opened the
right groin to drain the old blood and have arranged for a
visting nurse to come in daily for dressing changes and
monitoring. She was also prescibed Keflex for one week. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Shellfish / Keflex / Amoxicillin / Chantix
Starting Month ___
Attending: ___
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
Upper Endoscopy
History of Present Illness:
Ms ___ is a ___ female patient with history
of hypertension, hyperlipidemia, COPD (still smoking) who
presents with left-sided headache, dizziness, shortness of
breath. She presented iniatially to the PCP office today and was
refered to the ED. In the PCP ___ "the patient describes her
headache as left-sided, pain, sensation of skiing "peeling off,"
she also has been having dizziness on and off since ___.
The patient started having shortness of breath today. She cannot
describe it exactly, just states that it is different from COPD,
shortness of breath. The patient is a retired ___; however,
she is unable to describe her symptoms fully. She also mentioned
that she had an episode of diarrhea last week that lasted for
about couple of days, she vomited few times, all the symptoms
went away last ___. The patient does not have chest pain.
She denies palpitations, however, heart rate is 120 today, no
abdominal pain, no visual abnormalities. Does have generalized
weakness. No fever or chills, no sick contacts." The concern in
the PCP office was for a COPD vs TIA
In the ED initial vitals were: 97.6 96 120/52 18 95% 4L Nasal
Cannula
- Labs were significant for WBC 14.9, H/H 10.3/32.2, BUN 36,
negative U/A, D-dimer 281, Trop <0.01.
- Patient was given Aspirin 162mg Po x1 and ___ of NS.
Exam was notable for Orthostatic: SBP 156-126 HR 90-118 laying
to standing, and rectal exam with guaiac + brown stool. No frank
blood
CT Head: No acute intracranial abnormality, CXR: Frontal and
lateral radiographs of the chest demonstrate hyperexpanded,
clear lungs. Chronic blunting of the posterior left costophrenic
angle is unchanged, and likely represents pleural thickening.
The cardiomediastinal and hilar contours are unremarkable. There
is no pneumothorax, pleural effusion, or consolidation.
Vitals prior to transfer were: 98.3 110 135/72 16 97% RA
On the floor, she reports that she is feeling slightly better.
She reports that the above history is true but in addtion she
would add that it is not true dizziness, it is in fact a feeling
of being unsteady on her feet, with it moving as if she were on
a boat. She reports that she only ___ the feeling when she is
changing posistion, in particular, going from sitting/laying to
standing. She notes that uncomfortableness (not pain) is in the
epigastric region and is like someone punched her in the stomach
and caused to to loose her breath. This pain with come and go
and is not constant. She is unsure if it is associated with
foods. She denies any recent blood in her stools, black stools,
tarry stools. She reports that she has had a duodenal ulcer in
the past but that this pain is different. That pain was in a
simlar location, maybe slightly lower in the abdomen, but was a
buring sensation, not like someone was driving the air out of
her.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Arthritis
HYPERLIPIDEMIA
HYPERTENSION
COPD
Duodenal Ulcer in the past, details uncertain
Social History:
___
Family History:
father died @ ___ - stroke, EtOH
mother died @ ___ - lung CA (smoker), hyperlipidemia, htn,
carotid
artery stenosis. stroke @ ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T:98.0 BP:97/53 HR:95 RR:19 02 sat:94%RA
GENERAL: NAD, laying in bed, ___
___: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD
CARDIAC: RRR, S1/S2, no murmurs
LUNG: Ronchi bilaterally that improve with cough. Breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
RECTAL: guaiac + brown stool. No frank blood
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals- 98.5 94 140/60 20 94% RA (required 2L overnight at
95%)
General- Alert, oriented, no acute distress
___- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, mild wheezing and dry
cough
CV- Regular rate and rhythm, tachycardic, 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- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
___ 11:45AM BLOOD WBC-14.9*# RBC-3.18*# Hgb-10.3*#
Hct-32.3*# MCV-102* MCH-32.3* MCHC-31.8 RDW-13.8 Plt ___
___ 06:10AM BLOOD WBC-9.0 RBC-2.40* Hgb-7.7*# Hct-24.4*
MCV-101* MCH-32.3* MCHC-31.8 RDW-14.3 Plt ___
___ 12:55PM BLOOD WBC-10.5 RBC-2.24* Hgb-7.3* Hct-22.6*
MCV-101* MCH-32.4* MCHC-32.2 RDW-14.4 Plt ___
___ 11:45AM BLOOD Ret Man-2.8*
___ 06:10AM BLOOD Glucose-82 UreaN-17 Creat-0.5 Na-139
K-4.1 Cl-108 HCO3-27 AnGap-8
___ 11:45AM BLOOD Lipase-56
___ 06:10AM BLOOD VitB12-308
DISCHARGE LABS
___ 08:00AM BLOOD WBC-10.4 RBC-3.58* Hgb-11.3* Hct-34.9*
MCV-97 MCH-31.6 MCHC-32.4 RDW-17.0* Plt ___
___ 08:00AM BLOOD Glucose-91 UreaN-7 Creat-0.5 Na-142 K-4.0
Cl-105 HCO3-29 AnGap-12
___ 08:00AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.8
UPPER ENDOSCOPY ___
Findings: Esophagus:
Mucosa: Normal mucosa was noted.
Stomach:
Excavated Lesions A single superficial 5 mm clean-based ulcer
was found near the pyloric channel. No evidence of old or fresh
blood was seen.
Duodenum:
Mucosa: Diffuse erythema, friability and granularity of the
mucosa with contact bleeding were noted in the duodenal bulb
compatible with duodenitis.
Excavated Lesions A single non-bleeding 5 mm ulcer was found in
the distal bulb.
Impression: Normal mucosa in the esophagus
Ulcer in the pylorus
Erythema, friability and granularity in the duodenal bulb
compatible with duodenitis
Ulcer in the distal bulb
Otherwise normal EGD to third part of the duodenum
IMAGING
CXR ___
FINDINGS:
Frontal and lateral radiographs of the chest demonstrate
hyperexpanded, clear
lungs. Chronic blunting of the posterior left costophrenic
angle is
unchanged, and likely represents pleural thickening. The
cardiomediastinal and
hilar contours are unremarkable. There is no pneumothorax,
pleural effusion,
or consolidation.
IMPRESSION:
No acute cardiopulmonary process.
CT SCAN ___
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or acute
vascular
territorial infarction. The ventricles and sulci are normal in
size and
configuration for age. Basal cisterns are patent. Gray- white
matter
differentiation is preserved.
No fracture is identified. Partially imaged paranasal sinuses,
mastoid air cells, and middle ear cavities are clear with the
exception of opacification of a single left anterior ethmoid air
cell. Orbits are unremarkable.
IMPRESSION:
No evidence of acute intracranial abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
4. Vitamin D ___ UNIT PO DAILY
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
4. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Gastric and Duodenal ulcer with duodenitis
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 COPD, presenting with SOB, chest
tightness, headache, dizziness // eval for pneumothorax
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Frontal and lateral radiographs of the chest demonstrate hyperexpanded, clear
lungs. Chronic blunting of the posterior left costophrenic angle is
unchanged, and likely represents pleural thickening. The cardiomediastinal and
hilar contours are unremarkable. There is no pneumothorax, pleural effusion,
or consolidation.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with dizziness, left sided headaches // eval for
intracranial pathology
TECHNIQUE: Contiguous axial MDCT images were obtained from the skull base
through the vertex, without IV administration of contrast. Reformatted coronal
and sagittal and thin-section bone algorithm-reconstructed images were
acquired, and all images are viewed in brain and bone window on the
workstation.
DOSE: DLP (mGy-cm): 892
COMPARISON: ___
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or acute vascular
territorial infarction. The ventricles and sulci are normal in size and
configuration for age. Basal cisterns are patent. Gray- white matter
differentiation is preserved.
No fracture is identified. Partially imaged paranasal sinuses, mastoid air
cells, and middle ear cavities are clear with the exception of opacification
of a single left anterior ethmoid air cell. Orbits are unremarkable.
IMPRESSION:
No evidence of acute intracranial abnormality.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with shortness of breath // ?focal
consolidation
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
___ right upper lobe opacity is present concerning for right upper lobe
pneumonia. Aspiration giving the location is less likely. There is no evidence
of pulmonary edema. Heart size and mediastinum are unchanged in position. No
appreciable pleural effusion is seen. No pneumothorax is seen
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness
Diagnosed with SYNCOPE AND COLLAPSE, HEADACHE, SHORTNESS OF BREATH
temperature: 97.6
heartrate: 96.0
resprate: 18.0
o2sat: 95.0
sbp: 120.0
dbp: 52.0
level of pain: 0
level of acuity: 2.0 | ___ female patient with history of hypertension,
hyperlipidemia, COPD (still smoking) who presents with
left-sided headache, dizziness, shortness of breath with hx of
duodenal ulcer, melena, guaic positive stool and NSAID use
concerning for upper GI bleed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ativan
Attending: ___.
Chief Complaint:
breast edema
Major Surgical or Invasive Procedure:
breast biopsy
portacath placement in R leg (___)
cyberknife to cerebellar metastasis (___)
History of Present Illness:
Ms. ___ is an otherwise healthy ___ pre-menopausal
G0P0 lady who presented to the ___ yesterday with a large
left breast wound and painful swelling of the left upper
extremity. She underwent imaging that revealed a left subclavian
DVT and findings concerning for brain and liver metastases, and
she was subsequently transferred to the ___.
Her history begins in ___ when she first felt a hard mass
at the upper central portion of her left breast, around the 12
o'clock position. She did not seek medical attention as she
frequently feels "lumps and bumps" in her breasts. She also
noticed some clear discharge from her left nipple in ___ that
was associated with pruritus. In ___, she had an accident
at work with an ice pick that resulted in a wound on the left
breast in close proximity to the mass. She treated this wound
with bacitracin ointment and bandages, but she felt that it
continued to worsen. In late ___, she noticed
that her left upper extremity was becoming progressively
swollen. She denies paresthesias, but she does have significant
pain with movement of the left shoulder. She denies pain in her
left breast, however. Her left shoulder pain became quite
distressing yesterday, and she noticed, for the first time
yesterday, that her skin appeared yellow. These concerns led her
to seek medical attention at ___.
In terms of systemic symptoms, she denies fever, chills, weight
loss, night sweats, pain in her body other than the left arm
(including chest pain and abdominal pain), shortness of breath,
vision or hearing changes, difficulty with balance, and
headache. She endorses dark yellow urine and light gray colored
stool. She also felt that there may have been some blood in her
urine yesterday. She has been eating less over the last month
due to being very busy at work and not having time to eat and is
surprised that she has not lost weight. She denies loss of
appetite.
Since arrival to the ___, Ms. ___ has received dexamethasone
10 mg IV x 1 and ampicillin-sulbactam 3000 mg IV q6h. Vascular
surgery was consulted and recommended therapeutic
anticoagulation with heparin gtt for her left subclavian DVT and
consequent LUE edema, in addition to ace wrap and elevation.
Interventional radiology was consulted for breast biopsy for
tissue diagnosis but deferred to breast surgery for potential
skin biopsy given the extent of her disease.
Past Medical History:
Breast Cancer
BREAST CANCER RISK FACTORS:
Menarche at 10. She is premenopausal though thinks her periods
may be becoming somewhat less regular; last menstrual period in
___. She is a G0P0. Her uterus and ovaries are intact to
the best of her knowledge. She never took hormonal birth control
of any sort.
BREAST HISTORY:
Ms. ___ endorses frequent trauma to her bilateral breasts from
her fairly laborious work. She has never had a mammogram. She
irregularly performs breast self checks and frequently feels
nontender hard lumps in both breasts that tend to come and go.
Social History:
___
Family History:
father died ___, mother died 5 weeks later ___ of unknown
metastatic cancer at ___. Ms. ___ has two sisters who have both
been diagnosed with breast cancer within the past several
months. One is age ___ and the other is age ___.
Physical Exam:
Admission:
Vitals: T:98 BP:140/76 P:88 R:18 O2:94%ra
PAIN: 0
General: nad
EYES: icteric
Lungs: clear
Lymph: L supraclavicular firm enlarged node
CV: rrr, systolic murmur
Abdomen: bowel sounds present, soft, nt/nd
Ext: BLLE pitting edema, severe pitting edema of entire LUE
Skin: L breast firm, contracted, peau d'orange with malordorus
exudate
Neuro: alert, follows commands
Discharge:
Vitals: Tm 97.5 120/66 89 18 97% RA
General: Pleasant female in NAD
HEENT: MMM, clear oropharynx, no tonsillar enlargement or
exudates
Neck: Non-tender ~7mm LN in left lateral neck region, another
~4mm LN nearby
Chest: L breast with wound bandaged with xeroform, malodorous,
dressing c/d/i
Cardiac: RRR, nl S1 and S2, no MRG
Lungs: CTAB, no w/r/r
Abd: Soft, NTND
Ext: no ___ edema, LUE with 2+ pitting edema and limited ROM ___
edema.
Neuro: CNII-XII intact.
Pertinent Results:
___ IMAGING
CT scan chest with ___
Findings: Diffuse edema of the imaged left arm, and the proximal
left shoulder girdle muscles. Left axillary fat totally replaced
by a poorly defined soft tissue density, believed to represent
confluent axillary lymphadenopathy. The left subclavian and
axillary artery and hands, but the vein are not seen to enhance
and are believed to be thrombosed. Duplex sonography of the
axilla and upper arm are suggested for confirmation. There is
significant left breast skin thickening, diffuse breast
infiltration with soft tissue attenuation, suspicious for
locally advanced breast malignancy and peau d'orange. Left
pectoralis major and minor demonstrate edema. There are a few
lymph nodes inferior medially close to pectoralis near the
sternum. There are a few small left supraclavicular lymph nodes.
There is a small to moderate left pleural effusion with
compressive LLL atelectasis relatively sparing the superior
segment. Left upper lobe compared to normal. 3 lung base right
pulmonary nodules on image 45. Additional right lower lobe
pulmonary nodule on image 28 suspicious for a few small
hematogenous metastases. Right lung otherwise normal. There are
small indeterminate nonspecific bilateral 1 cm hilar lymph
nodes. There is a small pericardial effusion. Innumerable mixed
osteolytic and sclerotic metastases throughout the thoracic
vertebrae innumerable permeative lytic lesions in the sternum.
Accentuated thoracic kyphosis with no dominant thoracic
vertebral collapse.
Conclusion:
1. Thickening of left breast skin, diffuse breast infiltration
with soft tissue density, diffuse left axillary soft tissue
suspicious for confluent axillary malignant adenopathy. 2.
Suspected left axillary and subclavian vein thrombosis. Consider
duplex sonography for confirmation of the left upper extremity.
3. Small to moderate left pleural effusion which may be
malignant. 4. No subcutaneous emphysema or organizing abscess.
5. Left supraclavicular lymphadenopathy. A few small sub-CM
right pulmonary hematogenous metastases. 6. Innumerable lytic
and sclerotic axial skeleton bone metastases.
CT scan abdomen and pelvis with contrast ___
Findings: Upper abdominal solid organs: Liver: Numerous
hypoenhancing metastases seen in both lobes of the liver,
ranging in size from 1.5-3.5 cm, most conspicuous on the
arterial and portal phase images. No significant common duct
dilatation. Mild intrahepatic biliary dilatation. There appear
to be numerous small periportal also gastrohepatic ligament
region sub-CM lymph nodes.
Biliary tract: Extrahepatic common duct is not dilated, no
evidence of gallstones. However the gallbladder is contracted
and appears thick-walled, evaluation not ideal. Correlation with
timing of last meal is advised.
Pelvic organs:Normal. Moderate amount of pelvic ascites.
Retroperitoneum: Numerous small sub-CM left para-aortic lymph
nodes, which should be considered suspicious.
Incidental skeletal findings: Diffuse permeative lytic and
sclerotic involvement of the lumbar skeleton, pelvis consistent
with innumerable bone metastases. No pathologic fracture seen.
Conclusion:
1. Diffuse involvement of liver by solid metastases. Mild
intrahepatic biliary dilatation.
2. Gallbladder partially contracted, thick-walled.
3. Innumerable small subcentimeter lymph nodes, in left
para-aortic gastrohepatic ligament, periportal regions.
4. Pelvic ascites.
5. Innumerable lytic and sclerotic bone metastases in the imaged
axialskeleton without pathologic fracture.
Admission labs:
___ 06:20AM BLOOD WBC-4.3 RBC-3.52* Hgb-10.1* Hct-29.1*
MCV-83 MCH-28.7 MCHC-34.8 RDW-15.7* Plt ___
___ 06:20AM BLOOD ___ PTT-32.7 ___
___ 06:20AM BLOOD Glucose-116* UreaN-13 Creat-0.6 Na-136
K-4.1 Cl-100 HCO3-24 AnGap-16
___ 06:20AM BLOOD ALT-67* AST-152* AlkPhos-709*
TotBili-10.9* DirBili-8.5* IndBili-2.4
___ 06:20AM BLOOD Albumin-2.7* Calcium-8.4 Phos-4.1 Mg-2.1
Iron-108
___ 06:20AM BLOOD calTIBC-148* Ferritn-2466* TRF-114*
___ 03:02PM BLOOD CEA-1.3 ___
Imaging:
CT Head: Findings concerning for metastatic lesion in the left
cerebellar hemisphere.
An MRI may be performed to further assess. No hemorrhage or
herniation.
Breast biopsy: Invasive carcinoma, grade 3, with necrosis,
measuring up to 1.4 cm in this limited sample, see note. Note:
The tumor has some features of invasive pleomorphic lobular
carcinoma. Assays for ER, PR and HER2 are in progress; results
will be issued in a revised report.
MR Head: Enhancing lesion of the left lobe of the cerebellum
consistent with metastatic
disease.
MRCP: Presumed left inflammatory breast cancer with diffuse
osseous, nodal and hepatic metastases. The latter results in
multifocal segmental and subsegmental bile duct obstruction.
While the left lateral segment is most significantly dilated,
stenting of this single segment would be unlikely to provide
clinical relief, given the diffuse multifocal nature of
obstruction. There is no evidence of cholangitis or parenchymal
abscess.
MR thoracic/cervical:
IMPRESSION:
1. Diffuse osseous metastases throughout the cervical, thoracic,
and lumbar spine. No pathologic fracture or evidence of epidural
tumor, spinal cord metastases, or leptomeningeal metastases
throughout the cervical, thoracic, and lumbar spine.
2. Left cerebellar 1.8 cm enhancing metastasis, better seen on
recent
dedicated MRI head from ___.
3. Asymmetric enlargement of the left breast and left
posterolateral chest wall soft tissues corresponding to
suspected primary breast malignancy, better seen on CT from ___.
4. Large left pleural effusion, increased in size from CT on ___.
5. Numerous liver metastases and numerous osseous metastases
throughout the visualized pelvis.
Echo ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
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. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. No definite structural heart disease or pathologic
flow identified.
Discharge labs:
___ 07:07AM BLOOD WBC-4.3 RBC-2.56* Hgb-7.4* Hct-21.5*
MCV-84 MCH-29.1 MCHC-34.6 RDW-20.0* Plt Ct-69*
___ 07:07AM BLOOD Neuts-48* Bands-3 ___ Monos-11
Eos-0 Baso-0 ___ Metas-4* Myelos-1* NRBC-7*
___ 07:07AM BLOOD Plt Smr-VERY LOW Plt Ct-69*
___ 07:07AM BLOOD ___ PTT-33.4 ___
___ 06:37AM BLOOD ___
___ 07:07AM BLOOD Glucose-92 UreaN-18 Creat-0.4 Na-136
K-3.6 Cl-106 HCO3-25 AnGap-9
___ 06:37AM BLOOD ALT-91* AST-51* LD(LDH)-621* AlkPhos-398*
TotBili-2.6*
___ 07:07AM BLOOD Calcium-7.5* Phos-3.5 Mg-2.1
___ 06:37AM BLOOD VitB12-539
___ 06:20AM BLOOD calTIBC-148* Ferritn-2466* TRF-114*
___ 06:37AM BLOOD T3-107 Free T4-1.0
___ 06:45AM BLOOD T4-3.4* T3-36* Free T4-0.44*
___ 08:00AM BLOOD Cortsol-12.4
___ 07:30AM BLOOD Cortsol-7.3
___ 06:45AM BLOOD Cortsol-0.8* 25VitD-6*
___ 06:25AM BLOOD Anti-Tg-LESS THAN Thyrogl-13
antiTPO-LESS THAN
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Zolpidem Tartrate 5 mg PO HS:PRN Insomnia
RX *zolpidem 5 mg 1 tablet(s) by mouth at night Disp #*30 Tablet
Refills:*0
2. VinORELbine (Navelbine) 15 mg IV Days 1, 8 and 15.
___ and ___
(30 mg/m2 (Weight used: Actual Weight = 92.31 kg BSA: 2.13 m2)
- dose reduced by 75% to 7.5 mg/m2)
Reason for dose reduction: liver toxicity
Your oncologist will administer this medication to you
3. Outpatient Lab Work
ICD-9 Code 255.4 - Adrenal insufficiency
Please check cortisol level
Please fax results to ___ clinic, fax number
___ - c/o Dr. ___
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. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [___] 8.6 mg 1 tablet by mouth daily
Disp #*30 Tablet Refills:*0
6. Levothyroxine Sodium 50 mcg PO DAILY
RX *levothyroxine 50 mcg 1 tablet(s) by mouth each morning Disp
#*30 Tablet Refills:*0
7. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID
RX *metronidazole 1 % apply thin area twice a day Refills:*0
8. PredniSONE 10 mg PO DAILY
RX *prednisone 2.5 mg 3 tablet(s) by mouth each morning Disp
#*90 Tablet Refills:*0
9. Ondansetron ODT 8 mg PO ASDIR
RX *ondansetron 8 mg 1 tablet(s) by mouth prior to chemotherapy
Disp #*4 Tablet Refills:*0
10. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain
RX *tramadol 50 mg ___ tablet(s) by mouth every 6 hours Disp
#*90 Tablet Refills:*0
11. Enoxaparin Sodium 100 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL 1 mL subcutaneous twice a day Disp #*60
Syringe Refills:*0
12. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Docusil] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
14. DiphenhydrAMINE 12.5-25 mg PO Q6H:PRN itching
15. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
reflux
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL 15 mL by
mouth four times a day Refills:*0
16. Calcium Carbonate 500 mg PO BID:PRN indigestion
RX *calcium carbonate [Calci-Chew] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: metastatic her2+ breast cancer
Secondary: hepatic failure, anemia, thrombocytopenia, adrenal
insufficiency, hypothyroidism, pharyngitis, hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LEFT BREAST ULTRASOUND GUIDED CORE BIOPSY
INDICATION: ___ woman presenting with advanced metastatic cancer,
unknown primary, but likely with advanced infiltrative left breast cancer,
here for diagnosis.
COMPARISON: Comparison to recent chest and abdominal CT from ___.
FINDINGS:
Pre-procedure imaging at 12:00 6 cm from the nipple demonstrated a large
irregular hypoechoic mass with associated skin thickening measuring at least
2.8 x 2.1 x 2.8 cm mass. The remaining breast was not imaged as the skin was
friable and ulcerated.
PROCEDURE: Consent: The procedure, risks, benefits and alternatives were
discussed with the patient and written informed consent was obtained.
Time-out certification: Performed using three patient identifiers, with
confirmation of side and site.
Allergies / Medication: The patient's medication list and history of allergies
were reviewed prior to beginning the procedure.
Clinicians: ___. ___, M.D. The procedure was supervised by ___,
M.D.(Attending).
Description: Using ultrasound guidance, aseptic technique and local
anesthesia, a 13-gaugecoaxial needle was placed adjacent to the mass and 3
cores were obtained using a 14-gauge Bard spring-loaded biopsy device. As the
patient was experiencing substantial pain despite additional local anesthesia,
no additional cores were obtained. The needle was removed and hemostasis was
achieved.
Estimated blood loss: < 1 cc.
Specimens: Sent to pathology.
Anesthesia: ___ cc 1% lidocaine
Complications: No immediate complications.
Post procedure diagnosis: Same.
POST-PROCEDURE MAMMOGRAM: Deferred due to advanced state of disease.
IMPRESSION:
Technically successful US-guided core biopsy of suspicious left breast mass
at 12:00. Pathology is pending.
Standard post care instructions were provided to the patient.
As the Attending radiologist, I personally supervised the Resident / Fellow
during the key components of the above procedure and I reviewed and agree with
the Resident's / Fellow's findings and dictation.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with metastatic breast cancer. T bili 10,
trying to see if intervenable obstruction to determine chemo options. //
please eval for focal biliary obstruction amenable to stenting
TECHNIQUE: T1 and T2 weighted multiplanar images of the abdomen were acquired
within a 1.5 T magnet, including 3D dynamic sequences obtained prior to,
during, and following the administration of 10 cc of Eovist intravenous
contrast. The patient also received oral contrast of 1 cc of Gadavist diluted
in 50 cc of water.
COMPARISON: CT abdomen pelvis dating ___
FINDINGS:
There are innumerable masses randomly distributed throughout all segments of
the liver. These lesions are randomly distributed throughout all segments of
the liver, ranging in size from several mm to the largest having a diameter of
4.1 cm within segment VII (04:10). Each is T2 hyperintense, T1 hypointense,
markedly restricted in diffusion and hypoenhancing relative to the surrounding
liver parenchyma. The appearance is consistent with diffuse metastatic
disease, as noted in the clinical history.
There is multifocal resultant obstruction of the biliary tree. While this is
most apparent within the lateral segment of the left lobe (05:16 and 4:15),
drainage of this segmental obstruction would be unlikely to provide any
symptomatic relief due to the multifocality of the process. There is no
parenchymal abscess or evidence of cholangitis.
The extrahepatic biliary tree is not abnormally dilated. In fact, the common
bile duct is difficult to visualize with numerous small lymph nodes filling
the porta hepatis (3:!8). Scattered retroperitoneal nodes are present as
well.
The gallbladder is decompressed rounded multiple stones. There is marked wall
thickening of the gallbladder which follows the signal intensity and
enhancement of the metastases. Direct invasion into the gallbladder wall is
suspected (3:13).
The spleen, pancreas, adrenal glands and kidneys are unremarkable in
appearance.
Markedly asymmetric thickening and nodularity of the left breast skin is noted
(4:5). Appearance is most suggestive of inflammatory breast cancer.
There is diffuse soft tissue third spacing of fluid, particularly involving
the left flank region. Partial visualization of the left arm also demonstrates
significant edema. There are bilateral pleural effusions, moderate on the
left and trace on the right. Adjacent consolidative changes are noted at the
left lung base.
Diffusely abnormal bone marrow signal is seen throughout the visualized spine.
Extensive osseous metastases, restricted on diffusion and enhancing, correlate
with diffuse sclerotic metastases on prior CT.
IMPRESSION:
Presumed left inflammatory breast cancer with diffuse osseous, nodal and
hepatic metastases. The latter results in multifocal segmental and
subsegmental bile duct obstruction. While the left lateral segment is most
significantly dilated, stenting of this single segment would be unlikely to
provide clinical relief, given the diffuse multifocal nature of obstruction.
There is no evidence of cholangitis or parenchymal abscess.
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR spine without and with
intravenous contrast
INDICATION: ___ year old woman with metastatic breast ca // mets?
TECHNIQUE: Sagittal imaging of the cervical, thoracic, and lumbar spine was
performed with T2 and IDEAL technique. Axial T2 weighted imaging was performed
of the cervical, thoracic, and lumbar spine. 9 cc of Gadavist was
administered intravenously. Sagittal and axial T1 post-contrast sequences were
obtained of the cervical, thoracic, and lumbar spine.
COMPARISON: MRI head ___ CT chest abdomen pelvis ___
FINDINGS:
CERVICAL SPINE:
Alignment is normal. There are innumerable T1 hypointense, T2 hyperintense,
water-IDEAL hyperintense, enhancing lesions throughout the bones of the
cervical spine, consistent with osseous metastases. Vertebral bodies are
preserved in height. There is no pathologic fracture. There is no evidence of
epidural tumor or spinal cord metastases.
There is a disc osteophyte complex at C5-6 causing mild to moderate spinal
canal stenosis and remodeling the ventral spinal cord. There is no cord signal
abnormality. There is no high-grade neural foraminal stenosis.
THORACIC SPINE:
Alignment is normal. There are innumerable T1 hypointense, T2 hyperintense,
water-IDEAL hyperintense, enhancing lesions throughout the bones of the
thoracic spine, consistent with osseous metastases. There is irregularity of
the superior endplate of T9, but no significant height loss or pathologic
fracture. Vertebral bodies are maintained in height. There is no pathologic
fracture throughout the thoracic spine. There is no evidence of epidural tumor
or spinal cord metastases. The spinal cord is normal in course, caliber, and
signal. There is no significant degenerative disease in the thoracic spine to
cause spinal canal or neural foraminal stenosis.
LUMBAR SPINE:
There is degenerative appearing grade I anterolisthesis at L4-5. Alignment is
otherwise preserved. There are innumerable T1 hypointense, T2 hyperintense,
water-IDEAL hyperintense, enhancing lesions throughout the bones of the lumbar
spine, consistent with osseous metastases. Vertebral bodies are preserved in
height. There is no pathologic fracture. The conus is normal in appearance and
position, terminating at L1-2. There is no evidence of epidural tumor or
leptomeningeal metastases.
There is degenerative disc and joint disease of the lumbar spine. The most
significant level of degenerative disease is at L4-5 where there grade I
anterolisthesis, a mild diffuse disc bulge, and facet arthropathy causing
moderate left and mild right neural foraminal stenosis.
There is an approximately 1.5 x 1.8 cm (AP x TV) enhancing mass in the left
cerebellum with surrounding edema consistent with a metastasis, better seen on
recent dedicated MRI of the head from ___. There is asymmetric
enlargement of the left breast and left posterolateral chest wall soft
tissues, partially seen on the localizer views but better seen on recent CT
chest from ___. There is a large left pleural effusion, increased
from CT on ___. There are numerous liver metastases. There are
osseous metastases throughout the bones of the pelvis and free fluid in the
pelvis.
IMPRESSION:
1. Diffuse osseous metastases throughout the cervical, thoracic, and lumbar
spine. No pathologic fracture or evidence of epidural tumor, spinal cord
metastases, or leptomeningeal metastases throughout the cervical, thoracic,
and lumbar spine.
2. Left cerebellar 1.8 cm enhancing metastasis, better seen on recent
dedicated MRI head from ___.
3. Asymmetric enlargement of the left breast and left posterolateral chest
wall soft tissues corresponding to suspected primary breast malignancy, better
seen on CT from ___.
4. Large left pleural effusion, increased in size from CT on ___.
5. Numerous liver metastases and numerous osseous metastases throughout the
visualized pelvis.
Radiology Report
INDICATION: Metastatic breast cancer with a left upper extremity DVT needing
a femoral MediPort placed for chemotherapy.
COMPARISON: Outside hospital chest CT ___.
TECHNIQUE: OPERATORS: Dr. ___, Radiology residents and Dr.
___ radiologist performed the proecdure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100 mcg of fentanyl throughout the total intra-service time of 50 min 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: 1 g cefazolin IV.
CONTRAST: 10 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 3.5 min, 17.6 mGy
PROCEDURE
1. Right femoral approach groin single lumen Port-a-cath placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper chest was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent right femoral vein was
compressible. On initial access, we noticed pulsatile bleeding, suggesting
arterial access, which was confirmed with gentle hand injection of 5 mL of
contrast. The needles was drawn and manual pressure was held for 10 min until
hemostasis was achieved. There is no residual hematoma or evidence of
pseudoaneurysm by ultrasound.
On second attempt, the right femoral vein was accessed using ultrasound
guidance and a micropuncture needle. Ultrasound images were obtained before
and after intravenous access, which confirmed vein patency. Subsequently a
Nitinol wire was passed into the right common iliac vein 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 right atrium.
Next, attention was turned towards creation of a subcutaneous pocket over the
right anterior superior iliac spine. After instilling superficial and deeper
local anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse
incision was made and a subcutaneous pocket was created by using blunt
dissection. The single lumen port was then connected to the catheter. The
catheter was tunneled from the subcutaneous pocket towards the venotomy site
from where it was brought out using a tunneling device. The port was then
connected to the catheter and checks were made for any leakage by accessing
the diaphragm using a non-coring ___ needle. No leaks were found.
The port was then placed in the subcutaneous pocket and secured with ___
prolene sutures on either side. The peel-away sheath was placed over the
___ wire through which the port was threaded into the right side of the
heart with the tip in the mid IVC. The sheath was then peeled away.
The subcutaneous pocket was closed with ___ interrupted subcuticular
continuous Vicryl sutures and a rib aunt. ___ subcuticular Vicryl sutures and
Dermabond were used to close the venotomy incision site. Final spot
fluoroscopic image demonstrating good alignment of the catheter and no
kinking. The tip is in the mid IVC.
The port was accessed using a non coring ___ needle and could be aspirated
and flushed easily. Sterile dressings were applied. The patient tolerated the
procedure well without immediate complication. The port was left accessed as
requested.
FINDINGS:
Patent right femoral vein. Final fluoroscopic image showing port with catheter
tip terminating in the mid IVC.
IMPRESSION:
Successful placement of a single lumen chest power Port-a-cath via the right
femoral vein approach. The tip of the catheter terminates in the mid iVC with
the total length of 45 cm. The catheter is ready for use.
Radiology Report
EXAMINATION:
CT HEAD W/O CONTRAST
INDICATION: Breast cancer. Evaluate for metastatic lesions.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed. Motion artifact necessitating repeat imaging.
DOSE: DLP: 1783.85 mGy-cm; CTDI: 109.8 mGy
COMPARISON: None.
FINDINGS:
There is poorly defined hypodensity within the left cerebellar hemisphere
likely representing vasogenic edema. There is a subtle isodense to gray
matter lesion along the central aspect of this hypodensity though incompletely
imaged seen on series 5, image 1. No hemorrhage is identified. There is local
mass effect with mild effacement of the fourth ventricle. No hydrocephalus.
There is no evidence for an acute vascular territorial infarction. The sulci
are of normal configuration for age. Included paranasal sinuses and left
mastoid air cells are well-aerated. There is trace amount of fluid in the
right mastoid tip. There is no fracture. The lenses and globes are normal.
IMPRESSION:
Findings concerning for metastatic lesion in the left cerebellar hemisphere.
An MRI may be performed to further assess. No hemorrhage or herniation.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: Concern for left upper extremity DVT on outside hospital CT scan.
History of inflammatory breast cancer.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: Outside hospital chest CT ___.
FINDINGS:
There is normal flow with respiratory variation in the right subclavian veins.
There is extensive edema, tumor burden and lymphadenopathy in the left axilla
and upper extremity, limiting evaluation. Within this limitation, there is no
flow within the left subclavian vein compatible with thrombosis. The remaining
upper extremity vessels could not be imaged. The left cephalic vein is patent.
The left internal jugular vein is patent. The left subclavian artery is
patent.
IMPRESSION:
Thrombosis within the left subclavian vein. The full extent of thrombus could
not be evaluated given the significant tumor burden in the axilla.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with new diagnosis of breast cancer //
metastasis
TECHNIQUE: Multiplanar, multisequence MR images of the brain were obtained
before and after the administration of intravenous contrast.
COMPARISON: CT of the head dated ___.
FINDINGS:
There is a 1.8 x 1.4 cm enhancing lesion in the left lobe of the cerebellum,
with surrounding vasogenic edema, which is consistent with metastatic disease.
There is no intracranial hemorrhage. Diffusion weighting imaging does not
demonstrate evidence of acute infarct. The major intracranial vessels exhibit
the expected signal void related to vascular flow. Two small foci of T2/FLAIR
hyperintensity in the right frontal lobe are nonspecific. Gray white matter
differentiation is maintained. Ventricles and extra axial CSF spaces are
within normal limits.
There is no abnormal parenchymal, leptomeningeal, or dural focus of
enhancement. The sella turcica, craniocervical junction, and orbits are
unremarkable. The paranasal sinuses and mastoid air cells demonstrate normal
signal.
IMPRESSION:
Enhancing lesion of the left lobe of the cerebellum consistent with metastatic
disease.
These findings were discussed with Dr. ___ By Dr. ___ telephone at
5:30pm on ___, 20 minutes after discovery.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Wound eval, DVT, Transfer
Diagnosed with MALIGN NEOPL BREAST NOS, SECOND MALIG NEO LIVER, SECONDARY MALIG NEO BONE, ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VEINS OF UPPER EXTREMITY
temperature: 98.0
heartrate: 99.0
resprate: 18.0
o2sat: 96.0
sbp: 133.0
dbp: 72.0
level of pain: 0
level of acuity: 3.0 | ___ with a PMHx of EtOH and tobacco abuse, who presented to BI
___ with breast ulceration, L arm swelling and jaundice; was
diagnosed with Her2+ metastatic breast cancer, LUE DVT, hepatic
failure, and was transferred to OMED for further management.
Breast cancer was determined to be stage IV Her2+ with
metastasis to brain, spine, liver, lung. She had MRCP which
shows numerous metastatic lesions with subsegmental biliary
dilatation. Given the number and location of metastatic lesions,
no ERCP or ___ interventions were thought to be helpful.
Patient was initially on dexamethasone for cerebellar met, which
was tapered to prednisone 7.5mg daily after cyberknife on ___.
Given liver failure, patient was placed on combination herceptin
q3weeks/navelbene q1week ___ - further doses of navelbene
have been held due to thrombocytopenia). Patient's liver failure
markedly improved on herceptin (Tbili from ___ to ___ with
improvement in jaundice). R sided femoral port was placed on
___. Patient's left upper extremity DVT was treated with
lovenox 1mg/kg dosing. Patient with anemia and thrombocytopenia
during admission, likely ___ chemotherapy, liver failure
(anemia, thrombocytopenia), anemia of chronic disease and marrow
infiltration (NRBCs and toxic granulations on smear). Patient
required RBC transfusions as well as platelet transfusions
through course of hospitalization. Central endocrine dysfunction
was noted with central hypothyroidism and adrenal insufficiency.
Patient d/c on 7.5mg prednisone daily. plan to follow up with
endocrine in ___ weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
nafcillin / amoxicillin
Attending: ___.
Chief Complaint:
New right chest pain and chronic left hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ w/hx of heroin IVDU c/b multiple infections (MSSA
endocarditis c/b spinal OM ___, R shoulder MSSA OM ___,
vertebral MSSA OM and epidural abscess ___, left SI MSSA
septic joint arthritis, iliacus abscess, c/b septic pulmonary
emboli (___), and R sternoclavicular OM, L SI joint septic
arthritis, and pectoral abscess, also w/HCV cirrhosis, DM, HTN,
and nephrolithiasis, who presents with newly onset right-sided
chest pain and chronic left hip pain.
Of note, she was recently hospitalized in ___ with
left hip pain, later found to have polyarticular septic
arthritis including the R subclavian joint and pectoral muscle
abscess. She was also found to have osteomyelitis of the L SI
joint as well as fracture of the L pubic ramus w/possible
infection. Orthopoedic surgery and ___ recommended medical mgmt.
She completed a 6 week course of IV vancomycin on ___. She was
at the ___ in rehab and discharged at the end of ___.
During that stay she also waqs started on 15mg methadone BID for
pain mgmt and IVDU. After discharge, pt was able to ambulate
with a walker.
In the ED, initial vitals were: T96.9, P70, BP137/80, RR16,
100@RA. Exam notable for grossly intact ROM in hips bilaterally
with tenderness of left hip extension and no tenderness of
passive left hip flexion, internal/external rotation. Received
60mg methadone. She refused CT scan because she felt
uncomfortable at the time.
Labs were notable for: WBC 3.8, lactate 1.1. U/A showed lg
leuks, 165 WBCs, neg Nit. Patient was given 60 mg methadone.
On the floor, the patient complains of right sided chest pain
and chronic left hip pain. The right sided chest pain began 4
days ago, though she does not note the specific inciting factor.
She says that the pain is ___ in severity, greatly worsens with
any movement, and is associated w/SOB and production of green
sputum with some episodes of light blood-tinged sputum. She also
notes having fever, chills, and nausea yesterday, but denies any
dizziness, headache, fainting, vomiting, heart palpitations, or
back pain. Denies any trauma to her chest recently.
She also notes a chronic left-sided hip pain which has been a
constant source of pain since she was discharged from the
hospital and has not gotten better or worse. It is in the same
spot and has not changed. The pain is worse on movement, and she
finds it particularly difficult to stand and bear weight. She
uses a walker to get around. Denies paresthesias or
bowel/bladder dysfunction. She notes that she received one
"injection" treatment in her hip recently but did not know what
it was.
Finally, she denied having any dysuria or other urinary
symptoms.
She is amenable to getting a CT scan today and denies having any
other active issues today.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough. Denies palpitations. Denies vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies pain anywhere else in her
body. Most recent period many years ago.
Past Medical History:
- Heroin IVDU
- Hep C
- Cirrhosis
- Type 2 DM
- Kidney stones; previous ureteral stents
- MSSA endocarditis
- Spinal OM ___
- R shoulder OM ___
- MRSA left SI joint septic arthritis, iliacus abscess, septic
PEs in ___
- HTN
PAST SURGICAL HISTORY:
- s/p cholecystectomy ___
- s/p hysterectomy
Social History:
___
Family History:
History of DMII; children have renal stones.
Physical Exam:
Physical Exam on Admission:
Vitals: 97.9 126/70 66 18 99RA
General: Alert, oriented, NAD. Woman with larger body habitus
resting comfortably in bed in her own clothing.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL. No
rhinorrhea. Minimal dentition.
Neck: Supple, JVP not elevated, no LAD. Hyperpigmented skin
around her neck. No hepatojugular reflex.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, somewhat distended, bowel sounds
present, no organomegaly appreciated, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Bilaterally hypopigmented patches on her legs and
numerous ulcerations on ___ bilaterally. Numerous scarred
papular lesions on arms and chest.
On anterior right chest, no signs of blunt trauma; no erythema
or swelling. Non-tender to light palpation but tender on deep
palpation with guarding.
On left hip, no signs of blunt trauma, erythema, or swelling.
Tenderness to deep palpation on palpation along her groin crease
from ischial tuberosity to pubic tubercle. No tenderness over
left SI joint on light and deep palpation. Strength and
sensation intact of ___. Full ROM on passive flexion but unable
to perform actively due to pain. Very limited passive ROM on hip
abduction due to extreme pain. Minimal pain on passive left hip
adduction. No paraspinal tenderness.
DP pulses 2+ bilaterally.
Neuro: CNII-XII intact, 3+/5 right deltoid strength, 4+/5 left
deltoid strength; 4+ strength on dorsiflexion bilaterally.
Grossly normal sensation; gait deferred.
============================================================
Physical Exam on Discharge:
Vitals: 97.9 110s-130s/60s-70s ___ 99RA
General: Alert, oriented, NAD. Woman with larger body habitus
resting comfortably in bed in her own clothing.
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition.
Neck: Supple, Hyperpigmented skin around her neck.
Breast: Symmetrical, no palpable masses throughout. Few
hyperpigmented papules.
CV: RRR, faint systolic murmur at apex, flat JVP.
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, somewhat distended, bowel sounds
present, no hepatosplenomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No paraspinal tenderness. DP pulses 2+ bilaterally.
Neuro: CNII-XII intact, 3+/5 right deltoid strength, 4+/5 left
deltoid strength; 4+ strength on dorsiflexion bilaterally.
Grossly normal sensation
Pertinent Results:
Labs on Admission:
___ 10:54PM BLOOD WBC-3.8* RBC-3.24* Hgb-10.4* Hct-32.7*
MCV-101* MCH-32.1* MCHC-31.8* RDW-17.7* RDWSD-66.7* Plt Ct-38*
___ 10:54PM BLOOD Neuts-53.2 ___ Monos-6.3 Eos-0.8*
Baso-0.0 Im ___ AbsNeut-2.03 AbsLymp-1.50 AbsMono-0.24
AbsEos-0.03* AbsBaso-0.00*
___ 10:54PM BLOOD Plt Ct-38*
___ 10:54PM BLOOD Glucose-89 UreaN-15 Creat-0.9 Na-131*
K-4.0 Cl-101 HCO3-23 AnGap-11
___ 10:54PM BLOOD Plt Ct-38*
___ 10:54PM BLOOD Glucose-89 UreaN-15 Creat-0.9 Na-131*
K-4.0 Cl-101 HCO3-23 AnGap-11
=
=
=
=
================================================================
Labs on Discharge:
___ 07:07AM BLOOD WBC-2.8* RBC-2.95* Hgb-9.4* Hct-29.9*
MCV-101* MCH-31.9 MCHC-31.4* RDW-17.4* RDWSD-65.1* Plt Ct-42*
___ 07:07AM BLOOD WBC-2.8* RBC-2.95* Hgb-9.4* Hct-29.9*
MCV-101* MCH-31.9 MCHC-31.4* RDW-17.4* RDWSD-65.1* Plt Ct-42*
___ 07:07AM BLOOD Plt Ct-42*
___ 07:07AM BLOOD Glucose-115* UreaN-22* Creat-0.9 Na-134
K-4.5 Cl-106 HCO3-23 AnGap-10
___ 07:07AM BLOOD Calcium-8.6 Phos-4.7* Mg-1.9
___ 07:07AM BLOOD CRP-11.3*
=
=
=
=
================================================================
Micro:
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination with mixed fecal flora. Clinical significance of
isolate(s)uncertain. Interpret with caution.
ESCHERICHIA COLI: >100,000 ORGANISMS/ML..
Cefepime sensitivity testing performed by ___.
SENSITIVITIES: MIC expressed in MCG/ML
_______________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
=
=
=
=
================================================================
Clinical Studies/Imaging:
___: U/S Chest Soft Tissue
FINDINGS:
Transverse and sagittal images were obtained of the superficial
tissues of the right anterior chest, which show no underlying
mass, fluid collection or other abnormality.
IMPRESSION:
No evidence of underlying mass or fluid collection involving the
right
anterior chest wall.
___: Pelvis Xray
IMPRESSION:
Sclerosis and irregular widening of the left sacroiliac joint
and a left
inferior pubic ramus lucency are consistent with known
osteomyelitis.
___: Chest Xray
IMPRESSION:
No evidence of pneumonia. Reticular opacities predominantly at
the lung bases bilaterally may represent mild volume overload.
___: EKG
Sinus rhythm. Compared to the previous tracing of ___ the
rate has
increased.
Radiology Report
EXAMINATION: PELVIS (AP ONLY)
INDICATION: History: ___ with history of IVDU c/b hip osteo and endocarditis
p/w acute on chronic hip pain. Has refused CT scan // Is there e/o infection?
Is there e/o infection?
TECHNIQUE: Single view the pelvis
COMPARISON: MR pelvis ___
FINDINGS:
A large amount sclerosis seen at the left sacroiliac joint with widening of
the joint space and irregularity of the margins. There is lucency and
cortical irregularity at the left inferior pubic ramus are consistent with
prior, known osteomyelitis. There is no additional fracture or dislocation.
There is no radio opaque foreign body.
IMPRESSION:
Sclerosis and irregular widening of the left sacroiliac joint and a left
inferior pubic ramus lucency are consistent with known osteomyelitis.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old woman with right chest pain, hemoptysis. // eval for
PE, also for soft tissue infection of right chest wall
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) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 4.6 mGy (Body) DLP = 2.3
mGy-cm.
4) Spiral Acquisition 4.0 s, 30.9 cm; CTDIvol = 14.7 mGy (Body) DLP = 454.9
mGy-cm.
5) Spiral Acquisition 3.4 s, 36.5 cm; CTDIvol = 16.6 mGy (Body) DLP = 606.1
mGy-cm.
Total DLP (Body) = 1,063 mGy-cm.
COMPARISON: Ultrasound chest wall ___, MRI chest ___
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
The thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: Multiple mildly enlarged lymph nodes including
right peritracheal node measuring 1.0 cm short axis (02:10), anterior
mediastinal lymph node measuring 8 mm short axis (02:46), and cardiophrenic
lymph node measuring 1.2 cm short axis (02:67).
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Left greater than right lower lobe linear atelectasis. Lungs
are otherwise clear without masses or areas of parenchymal opacification. The
airways are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is demonstrate splenomegaly
and enlarged liver with a nodular contour consistent with history of
cirrhosis.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality. No chest wall mass
or soft tissue infection is identified.
Multiple mildly enlarged lymph nodes in the chest as detailed above, which may
be reactive .
Partially visualized upper abdomen demonstrates splenomegaly and cirrhotic
liver morphology.
Radiology Report
EXAMINATION: CT pelvis with contrast
INDICATION: ___ year old woman with right chest pain, hemoptysis and left hip
pain, h/o left septic hip joint // Any evidence of infection of left hip?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 4.6 mGy (Body) DLP = 2.3
mGy-cm.
4) Spiral Acquisition 4.0 s, 30.9 cm; CTDIvol = 14.7 mGy (Body) DLP = 454.9
mGy-cm.
5) Spiral Acquisition 3.4 s, 36.5 cm; CTDIvol = 16.6 mGy (Body) DLP = 606.1
mGy-cm.
Total DLP (Body) = 1,063 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CTA CHEST
WANDW/O CANDRECONS, NON-CORONARY)
COMPARISON: CT abdomen and pelvis with contrast ___
MR pelvis with and without contrast from ___.
FINDINGS:
LOWER ABDOMEN:
URINARY: The left kidney is only partially visualized, but the inferior pole
shows an atrophic and multi cystic appearance of visualized portions of the
left kidney are consistent with previously described diagnosis of chronic
hydronephrosis. A small 2.9 mm non-obstructing radiopaque stone is seen in
the proximal ureter. Small capsular calcification is seen in the inferior
pole of the left kidney (2:7) The visualized lower pole of the right kidney is
unremarkable.
GASTROINTESTINAL: The partially imaged stomach is distended with food.
Visualized small and large bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. There is mild fatty stranding adjacent
to the sigmoid colon which is nonspecific but likely reactive to prior left
sacroiliac joint infection.
PELVIS: A punctate focus of nondependent air is seen in the bladder (308:76).
This could represent sequela of prior instrumentation, but requires clinical
correlation to confirm this. The urinary bladder and distal ureters are
grossly unremarkable. No gross free fluid in the pelvis.
REPRODUCTIVE ORGANS: An anteverted uterus is grossly unremarkable.
LYMPH NODES: There are mildly enlarged retroperitoneal lymph nodes with
adjacent stranding. However none of these lymph nodes are pathologically
enlarged by CT size criteria, and they appear smaller as compared to ___. This is a nonspecific finding but lymphadenopathy is likely
reactive to prior infectious process in the left sacroiliac joint.
VASCULAR: There is no abdominal aortic aneurysm in the visualized portion of
the aorta. Mild atherosclerotic disease is noted.
BONES: At the junction of the left superior pubic ramus and acetabulum, there
is a focal area of sclerosis and periosteal bone formation (308:80) compatible
with a non-acute nondisplaced fracture. At the left inferior pubic
ramus(308:96), there are 2 mildly displaced transverse fractures with callus
formation. At both of the sites of fracture, there has been new periosteal
bone formation since ___ compatible with non-acute fractures. At
the left sacroiliac joint, there is joint space widening, erosive changes, and
talus bone formation, all of which appear grossly stable from comparison
study. In the left iliac bone adjacent to the SI joint, there is an area of
lucency likely representing extension of osteolysis measuring 1.9 x 1.4 cm
(308:39). There is no fracture.
SOFT TISSUES: Multiple soft tissue foci in the subcutaneous fat along the
anterior abdominal wall are seen, non-specific in appearance. In the
appropriate clinical setting, these could represent injection granulomas in
the anterior abdominal wall. There is asymmetrical mild fatty atrophy of the
left piriformis and left gluteus minimus and medius muscles likely secondary
to adjacent infectious process in the left sacroiliac joint.
IMPRESSION:
1. Left SI joint space widening, erosive changes, and surrounding sclerosis
compatible with septic arthritis with surrounding osteomyelitis and lytic area
in the left iliac bone, extending to the joint space. However, the appearance
is quite similar to CT pelvis ___. The differential of this
could represent residua from treated septic arthritis. The possibility of
residual infection would be difficult to entirely exclude. The right SI joint
is within normal limits.
2. No acute fracture is detected.
3. Non-acute fractures of the junction of the left superior pubic ramus and
acetabulum and left inferior pubic ramus with a new periosteal bone formation
since ___. These could be due to mechanical stresses introduced
by the abnormal left SI joint.
4. Reactive retroperitoneal lymphadenopathy which appears improved from ___.
5. Incompletely imaged left kidney shows evidence of atrophy and
hydronephrosis, similar to abdominal CT from ___.
6. Again seen is stranding along the left anterior Gerota's fascia, in the
retroperitoneal region, and and along the left pelvis adjacent to the
left-sided iliac vessels (02:26, 2:13, 2:14, 02:21), of uncertain etiology or
significance. This could represent residua from previous reactive
inflammatory changes.
7. Presumed injection granulomas along the anterior abdominal wall. Clinical
correlation to confirm this is requested, as other soft tissue nodular
densities could also account for this appearance.
Radiology Report
EXAMINATION: US CHEST WALL SOFT TISSUE RIGHT
INDICATION: 56W w/hx of heroin IVDU c/b multiple infections (MSSA
endocarditis c/b spinal OM ___, R shoulder MSSA OM ___, vertebral MSSA OM and
epidural abscess ___, left SI MSSA septic joint arthritis, iliacus abscess,
c/b septic pulmonaryemboli (___), and R sternoclavicular OM, L SI joint
septic arthritis, and pectoral abscess, w/ R chest pain, low suspicion for
infection but r/o soft tissue infx. // 56W w/hx of heroin IVDU c/b multiple
infections (MSSA endocarditis c/b spinal OM ___, R shoulder MSSA OM ___,
vertebral MSSA OM and epidural abscess ___,
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right anterior chest.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right anterior chest, which show no underlying mass, fluid collection or other
abnormality..
IMPRESSION:
No evidence of underlying mass or fluid collection involving the right
anterior chest wall.
Radiology Report
EXAMINATION: MR pelvis with contrast
INDICATION: History of hepatitis-C cirrhosis, diabetes, hypertension and
intravenous struck views complicated by endocarditis, multiple areas of
osteomyelitis most recently hospitalized in ___ with left SI joint septic
arthritis presenting again with new right-sided chest pain and chronic left
hip pain. Evaluate for persistent septic arthritis or osteomyelitis.
TECHNIQUE: Multiplanar, multi sequence MR images of the pelvis were acquired
on a 1.5 Tesla magnet prior to and after the uneventful intravenous
administration of 9 cc Gadovist.
COMPARISON: CT pelvis ___. MR pelvis ___.
FINDINGS:
There is persistent widening of the left SI joint though previous left SI
joint effusion has resolved. Bone marrow edema in the left sacral ala and
iliac bone has decreased in severity compared to prior examination however
there is persistent T1 hyperintensity and post gadolinium enhancement. A
small focus of edema in the right sacral ala with post gadolinium enhancement
adjacent to the right SI joint has decreased compared to the prior exam.
Again there is mild edema and enhancement of the pubic symphysis, right
greater than left though reduced in severity compared to the prior
examination.
Nondisplaced healing fractures of the left superior and inferior pubic rami
are again demonstrated with prominent surrounding bony and soft tissue edema
and enhancement. Edema and enhancement of the superior pubic ramus fracture
appears increased, with edema tracking further along into the left acetabulum.
While there is residual edema and enhancement in the left obturator externus
muscle, punctate rim enhancing fluid collections for the majority appear to
have resolved. There is again prominent edema and enhancement of the adjacent
adductor musculature on the left.
There is a small left hip joint effusion. There are mild degenerative changes
of bilateral hips. Rectus femoris and iliopsoas tendons appear intact. There
is no frank fluid in the greater trochanteric bursa bilaterally. The gluteus
medius and minimus tendons are grossly intact bilaterally. Again there is
mild fluid/edema and enhancement at the bilateral hamstring origins at the
ischial tuberosities. Mild edema of the paraspinal musculature at the level
of the sacrum has decreased in conspicuity compared to the prior exam.
Areas of edema are noted in the anterior subcutaneous soft tissues of the
lower abdomen, likely from prior injection. Limited evaluation of the
intrapelvic structures is grossly unremarkable. Mildly prominent bilateral
inguinal lymph nodes are not pathologically enlarged. Limited evaluation of
the imaged lower lumbar spine demonstrates mild degenerative change.
IMPRESSION:
1. Persistent edema and enhancement of left sacral ala and iliac bone around
the left SI joint though decreased compared to the prior examination. Left SI
joint effusion has resolved. Surrounding soft tissue edema has decreased in
conspicuity compared to the prior examination and punctate rim enhancing fluid
collections within the left obturator externus muscle have resolved.
2. Edema and enhancement within the left acetabulum has mildly increased
compared to the prior examination.
3. Additional areas of edema within the right sacral ala and pubic symphysis
have decreased compared to prior examination.
4. Persistent left superior and inferior pubic ramus fractures with extensive
adjacent bony and soft tissue edema, though there is been interval callus
formation and findings have mildly improved compared to the prior exam.
Overall, the above findings are persistent but improved compared to the MR
examination from ___. This constellation of findings may
represent lagging imaging findings related to resolving osteomyelitis versus
persistent but improved osteomyelitis.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, L Hip pain
Diagnosed with Pain in left hip, Cough
temperature: 96.9
heartrate: 70.0
resprate: 16.0
o2sat: 100.0
sbp: 137.0
dbp: 80.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ y/o F w/ complex hx of HCV cirrhosis, DM,
HTN, and heroin IVDU c/b MSSA endocarditis c/b spinal osteo
(___), MSSA right shoulder osteo (___), left renal staghorn
calculi, xanthogranulomatous pyelo c/b renal abscess (___),
MSSA vertebral osteo and epidural abscess (___), and MRSA
left SI joint septic arthritis, iliacus abscess, c/b septic
pulmonary emboli (___) s/p extended vancomycin therapy @ the
___ (___), and most recently hospitalized in ___
w/ L SI joint septic arthritis, and R pectoral abscess now s/p 6
weeks of IV vancomycin, who was admitted for a new right-sided
chest pain and chronic left hip pain.
# Right-sided chest pain: Patient reported having 4 days of
R-sided chest pain that was tender with touch. On examination,
she was afebrile, CTAB and breathing comfortably with good O2
saturation. There were no skin changes to suggest Zoster. EKG
did not demonstrate any evidence of ischemia and trops were
negative. A chest Xray, R chest soft tissue ultrasound and CTA
of the chest were negative for any blood clots, fluid collection
or evidence of infection. The etiology of her R-sided chest pain
is unclear, but presence of +TTP may be suggestive of
costochondritis or post-infectious inflammation from her recent
pectoral abscess. She was discharged on ibuprofen for
anti-inflammation and pain control.
# Chronic L Hip Pain: Patient reported chronic L hip pain during
this admission. She states that it has not changed since her
previous admission. Patient had decreased ROM of her L hip on
exam. A CT scan of her L hip demonstrated sacroiliac erosive
changes with sclerosis and edema, concerning for persistent
septic arthritis. Orthopedic surgery and infectious disease
teams were consulted and recommended an MRI to further
characterize. The MRI was notable for persistent swelling of SI
joint but interval improvement in previous punctuate abscesses.
The L pubic rami fractures were persistent. Patient remained
afebrile with a stable leukopenia, and CRP/ESR was only mildly
elevated since last admission. Blood cultures were no growth to
date. The orthopedic and infectious disease team recommended
conservative management given there is a low suspicion for an
acute infectious process. Patient was evaluated by ___ who
cleared her for ambulation with walker. Patient will follow-up
with her outpatient primary care physician for pain control.
Patient was discharged on Tylenol and ibuprofen.
# Urinary tract infection: During this hospitalization, patient
developed sx of UTI, including change in color, frequency, and
smell of her urine. Urine cx grew Bactrim-sensitive E.coli, and
patient was treated with a 3-day course (___). Patient's
symptoms were resolved at the time of discharge.
# Heroin Abuse/opiate withdrawal: Patient has a significant hx
of heroin IVDU but reports no IVDU since ___. She was
continued on methadone 60mg daily as confirmed by her ___
clinic (___). Patient will continue to
follow-up with outpatient ___ clinic in the outpatient
setting.
# HCV Cirrhosis: Patient has a history of HCV Cirrhosis but no
evidence of acute decompensation during this hospital stay. LFTS
remained mildly elevated at baseline but remained stable.
Patient will f/u with PCP as outpatient for further management.
# Pancytopenia: Patient is at baseline pancytopenic and all
lines remained near baseline during this admission; likely ___
combination of ACD and Cirrhosis.
# DM: Blood sugars remained at goal during this hospitalization.
Patient was continued on home lantus 28U Qpm and insulin sliding
scale.
# Nicotine dependence: Patient smokes 6 cigarettes per day but
denied a Nicotine patch during this admission.
=
================================================================ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Tetracaine
Attending: ___.
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
___: Cystoscopy, clot evacuation, attempted fulguration of
prostatic bleeding
___: Prostatic embolization
History of Present Illness:
___ with significant BPH who presents in clot retention.
Patient was recently seen for a void trial one week ago after a
prolonged bout with urinary retention and an episode of clot
retention. Foley was removed and patient left before voiding. He
now returns after the onset of gross hematuria beginning
yesterday evening. He became unable to urinate and so presented
to the ED with worsening suprapubic discomfort and passage of
clots. An ___ 3-way was unfortunately placed which reportedly
failed to drain urine. Hand irrigation was attempted but with
minimal clot return. A bedside ultrasound showed a distended
bladder with a large hyperechoic structure in the bladder.
Urology was consulted for assistance.
Of note, patient with close to 450cc g prostate. He's had prior
CT with contrast shopwing no upper tract lesions. He's refused a
cystoscopy in the office previously.
Past Medical History:
BPH, with very recent foley catheter placement
CAD
Glaucoma
HTN
HLD
H/o Upper GI bleed in ___ NSAID use
Varicose veins
Nose lesion
Basal cell Ca Lt ear s/p resection
s/p Chole ___ years ago
Social History:
___
Family History:
Non-contributory to this acute presentation
Physical Exam:
AVSS
NAD
WWP
Unlabored breathing
Abd soft, NT, ND
Foley with clear, yellow urine
Ext WWP
Pertinent Results:
___ 06:25AM BLOOD WBC-13.4*# RBC-2.74*# Hgb-9.1*#
Hct-27.2*# MCV-99* MCH-33.4* MCHC-33.6 RDW-18.0* Plt ___
___ 07:20AM BLOOD WBC-6.8 RBC-2.04* Hgb-6.8* Hct-21.0*
MCV-103* MCH-33.4* MCHC-32.5 RDW-15.7* Plt ___
___ 12:45PM BLOOD WBC-7.0 RBC-2.37* Hgb-8.4* Hct-24.5*
MCV-103* MCH-35.6* MCHC-34.4 RDW-15.6* Plt ___
___ 08:30AM BLOOD WBC-8.6 RBC-2.44* Hgb-8.5* Hct-25.2*
MCV-103* MCH-34.9* MCHC-33.8 RDW-15.4 Plt ___
___ 07:40AM BLOOD WBC-8.2 RBC-3.01* Hgb-10.4* Hct-30.9*
MCV-103* MCH-34.5* MCHC-33.7 RDW-15.4 Plt ___
___ 04:40PM BLOOD WBC-12.5* RBC-3.36* Hgb-11.7* Hct-34.6*
MCV-103* MCH-34.7* MCHC-33.7 RDW-15.3 Plt ___
___ 05:20AM BLOOD WBC-8.7 RBC-3.92* Hgb-13.8* Hct-39.8*
MCV-102* MCH-35.2* MCHC-34.6 RDW-15.9* Plt ___
___ 06:25AM BLOOD Glucose-113* UreaN-20 Creat-1.1 Na-138
K-3.9 Cl-103 HCO3-20* AnGap-19
___ 07:45AM BLOOD Glucose-120* UreaN-16 Creat-0.9 Na-138
K-4.0 Cl-104 HCO___-27 AnGap-11
___ 05:20AM BLOOD Glucose-115* UreaN-20 Creat-1.0 Na-138
K-4.1 Cl-105 HCO3-24 AnGap-13
Medications on Admission:
. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 1 TAB PO BID
8. Simvastatin 20 mg PO DAILY
9. Bacitracin Ointment 1 Appl TP BID
RX *bacitracin zinc 500 unit/gram apply to penis twice daily
Disp #*1 Tube Refills:*0
10. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
RX *betamethasone dipropionate 0.05 % apply to penis twice daily
Disp #*1 Tube Refills:*0
11. Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
2. Finasteride 5 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Docusate Sodium 100 mg PO BID
8. Senna 1 TAB PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
URINARY CLOT RETENTION, HEMATURIA (LIKELY PROSTATIC SOURCE)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Hematuria and dropping hematocrit with a history of BPH.
COMPARISON: CT of the abdomen pelvis ___.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow), Dr.
___ resident), and Dr. ___ radiology attending)
performed the procedure. The
attending, Dr. ___, was present and supervising throughout the procedure.
ANESTHESIA: Right femoral local anesthesia with 15 mL of Lidocaine 1%.
Moderate sedation was provided by administrating divided doses of 100 mcg of
fentanyl throughout the total intra-service time of 1 hour 40 min during
which the patient's hemodynamic parameters were continuously monitored.
MEDICATIONS: 200 ml of normal saline was administered.
CONTRAST: 70 ml of Optiray contrast.
FLOURORSCOPY TIME AND DOSE: 50.41 min, 458.83 mGy.
PROCEDURE:
1. Right common femoral artery access.
2. Left internal iliac arteriogram.
3. Left internal pudendal artery angiogram.
4. ___ vial of 300-500 micron micron particle embolization of the left
prostate artery to near stasis.
5. Right internal iliac arteriogram.
6. Right internal pudendal artery angiogram.
7. ___ vial of 300-500 micron particle embolization of the right prostate
arteries to near stasis.
8. Abdominal aortogram extending from the bifurcation to the superficial
femoral arteries.
PROCEDURE DETAILS: Following the explanation of the risks, benefits, and
alternatives to the procedure, written informed consent was obtained using an
interpreter. The patient was then brought to the angiographic suite and
placed supine on the imaging table. Both groins were prepped and draped in
the usual sterile fashion. A pre-procedure time out was performed according
to departmental protocol.
Using palpatory, ultrasound and fluoroscopic guidance, the right common
femoral artery was punctured using a micropuncture needle. A Nitinol wire was
advanced easily through the needle and a skin ___ was made over the needle.
The needle was then exchanged for a micropuncture sheath. The inner dilator
and Nitinol wire was removed and ___ wire was advanced under fluoroscopy
into the aorta. The micropuncture sheath was exchanged for a 5 ___ sheath
which was attached to a heparinized saline side arm flush.
A C2 catheter was advanced over the wire and the ___ wire was exchanged
for a Glidewire. The glidewire was used to select the left external iliac
artery, and the C2 catheter was exchanged for a pudendal catheter.
The pudendal catheter was used to cannulate the internal iliac artery and an
arteriogram was performed. The left prostate artery was identified as a
branch arising from the internal pudendal artery. Using the arteriogram as a
road map a pre-loaded high-flow Renegade catheter and Transcend wire was
advanced distally into the uterine artery. A left prostate arteriogram was
performed. Half a vial of 300-500 micron embospheres were injected to near
stasis. The micro catheter was then removed and the pudendal catheter was
withdrawn into the aorta and used to engage the right internal iliac artery.
A right internal iliac arteriogram was performed and the right prostate artery
was identified. The pre-loaded high-flow renegade catheter and transcend wire
were advanced distally into the right prostate artery. A right prostate
arteriogram was performed. Half a vial of 300-500 micron embospheres were
injected to near stasis. The micro catheter was then removed. A ___ wire
was introduced and the pudendal catheter was exchanged over the wire for an
Omni flush catheter.
An aortogram was performed at the aortic bifrucation to evaluate pelvic
vessels. The ___ wire was used to remove the Omni flush catheter. The
wire and sheath were then removed and manual pressure held for 35 min.
Hemostasis was achieved and sterile dressings were applied. The patient
tolerated the procedure well but was complicated by a groin hematoma which was
marked on the skin.
FINDINGS:
1. Left and right internal pudendal/vesicle arteries supplying enlarged
bilateral prostatic arteries to an enlarged prostate.
2. Post-procedure near stasis of the prostate arteries bilaterally confirming
successful imaging end point.
3. Moderate groin hematoma post-procedure, which was marked on the skin after
hemostasis was achieved using 35 minutes of manual pressure.
IMPRESSION: Successful bilateral prostate artery embolization to near stasis.
Gender: M
Race: SOUTH AMERICAN
Arrive by AMBULANCE
Chief complaint: HEMATURIA
Diagnosed with HEMATURIA, UNSPECIFIED
temperature: 97.6
heartrate: 73.0
resprate: 18.0
o2sat: 94.0
sbp: 84.0
dbp: 59.0
level of pain: 13
level of acuity: 1.0 | HOSPITAL COURSE: Patient was transferred to the Urologic surgery
service after undergoing a c with Dr. ___. Patient
tolerated the procedure well and without complications. 500 cc
of clot was evacuated and a 3 way Foley was placed on CBI,
please see operative note for complete details. Patient was
extubated in the OR and taken to the PACU in stable condition.
He further recovered in the PACU before being transferred to the
floor for further post-operative care.
NEURO: Patient's pain was controlled during his stay with low
dose IV and oral pain medications and tylenol
CV: Patients vital signs remained stable throughout hospital
stay. .
PULM: Patient was weaned to RA on POD 0
GI: The patient tolerated a regular diet during his stay.
GU: Patient had a ___ 3way foley placed in the OR. He required
intermittent hand irrigation for continued hematuria and blood
clots. The ___ Fr catheter placed in the OR was exchanged to ___
on ___ with irrigation of 500 cc of clot to clear. The
patient's hematocrit had trended down to 21 on ___. The patient
then developed worsening hematuria refractory to hand irrigation
and CBI, so ___ was consulted for embolization of the prostate.
He tolerated the procedure well and urine was clear initially
after the procedure. The following day the patient's catheter
again began draining poorly with increased hematuria. The
catheter was aggressively hand irrigated free of 1L-1.5 L of old
clot. The urine was subsequently clear on CBI and remained clear
for the duration of his hospitalization.
HEME: Patient was offered subcutaneous heparin and pneumoboots
for DVT prophylaxis. Hematocrit was trended during his stay in
the setting of continued hematuria. His HCT was 40 on admission
and slowly trended down to 21 on ___. He was transfused 2 units
of pRBC on ___ and HCT improved to 27 on ___
ID: Patient received appropriate ___ antibiotics.
ENDO: No issues.
MSK: Patient ambulating on floors independently. ___ was
consulted and felt it was safe to return home.
The patient was deemed ready for discharge on POD6 with ___. On
the day of discharge the physical exam upon d/c was
unremarkable. He was AVSS, hemodynamically stable,
neurologically intact and his urine was yellow off CBI. Pt was
given explicit instructions to follow-up in clinic with Dr.
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
==============
___ 04:05PM BLOOD WBC-5.2 RBC-4.37 Hgb-13.8 Hct-41.2 MCV-94
MCH-31.6 MCHC-33.5 RDW-11.7 RDWSD-40.0 Plt ___
___ 04:05PM BLOOD Neuts-51.3 ___ Monos-8.1 Eos-0.8*
Baso-0.4 Im ___ AbsNeut-2.66 AbsLymp-2.02 AbsMono-0.42
AbsEos-0.04 AbsBaso-0.02
___ 04:05PM BLOOD ___ PTT-28.9 ___
___ 04:05PM BLOOD D-Dimer-858*
___ 04:05PM BLOOD Glucose-90 UreaN-18 Creat-0.9 Na-142
K-4.6 Cl-104 HCO3-22 AnGap-16
___ 08:00AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.0
DISCHARGE LABS
==============
___ 08:20AM BLOOD WBC-4.2 RBC-3.75* Hgb-12.0 Hct-35.7
MCV-95 MCH-32.0 MCHC-33.6 RDW-11.8 RDWSD-40.6 Plt ___
___ 08:20AM BLOOD Glucose-90 UreaN-22* Creat-0.8 Na-142
K-4.1 Cl-106 HCO3-24 AnGap-12
IMAGING
=======
Arterial Duplex Ultrasound RUE ___rtery is totally occluded.
Unilateral ___ US Veins ___
No evidence of deep venous thrombosis in the left lower
extremity veins.
CTA Upper Extremity with and without contrast ___rtery is opacified
along the proximal forearm, however, is non-opacified across a
2.9 cm segment
at the distal forearm, just proximal to the wrist (series 309,
image 27).
There is reconstitution of flow distally, though diminutive
(series 301, image
247).
There is no acute fracture. No concerning sclerotic or lytic
lesion is
detected.
There is no focal fluid collection or hematoma along the right
upper
extremity. No subcutaneous edema is seen.
The visualized brain appears normal.
IMPRESSION:
The right radial artery is opacified along the proximal forearm,
however, is non-opacified across a 2.9 cm segment at the distal
forearm, just proximal to the wrist (series 309, image 27).
There is reconstitution of flow distally, though diminutive
(series 301, image 247).
Occlusion of a 2.9 cm segment of the distal left radial artery
(series 309, image 27).
DISCHARGE PHYSICAL EXAM
=======================
VS: 24 HR Data (last updated ___ @ 1125)
Temp: 97.7 (Tm 98.8), BP: 107/74 (97-123/64-83), HR: 72
(63-73), RR: 16 (___), O2 sat: 98% (97-98), O2 delivery: Ra
GENERAL: Alert, interactive, NAD
HEENT: NC/AT, EOMI, PERRL, sclera anicteric, MMM
CARDIAC: RRR, no m/r/g
RESP: CTAB, unlabored respirations, no wheezes or rales
GI: abdomen soft, NTND, +BS
MSK: right radial pulse faint but slightly palpable, ecchymosis
of right forearm and mildly tender to palpation
NEUROLOGIC: CN2-12 intact on exam ___ am, ___ strength
throughout UE and ___, decreased sensation of right hand and
fingers can distinguish which finger is being touched during
exam
light touch and pain. Improved ROM per pt, able to make fist and
squeeze with ___ strength in right hand.
Radiology Report
EXAMINATION: ART DUP EXT UP UNI OR LMTD RIGHT
INDICATION: ___ year old woman s/p Pipeline on ___. Complains of pain
in wrist, decrease strength // Assess for arterial occlusion.Evaluate right
arm radial arterial site. s/p A-line placement for Pipeline on ___.
With constant post op pain
TECHNIQUE: Grayscale and color Doppler ultrasound images were performed of
the right upper extremity arteries.
COMPARISON: None
FINDINGS:
Peak systolic velocities in the right upper extremity arteries (proximal to
distal):
Subclavian artery: 65, 68, 78 cm per second, triphasic waveform
Axillary artery: 46, 92 cm per second, triphasic waveform
Brachial artery: 92, 87, 75 cm per second, triphasic waveform
Radial artery: 22 cm per second in the upper forearm, 15 cm per second in the
midforearm, totally occluded in the distal forearm.
Ulnar artery: 49, 55, 89 cm per second triphasic waveform
IMPRESSION:
Distal right radial artery is totally occluded.
NOTIFICATION: ___ was notified at 14:45 on ___ at the
time of the scan.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old woman with recent cerebral anerusym embolization.
Having L calf pain and intermittent SOB // ?DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: No pertinent prior studies.
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: CTA UPPER EXT WANDW/O C AND RECONS RIGHT Q55R
INDICATION: ___ year old woman with ultrasound evidence of complete occlusion
of distal right radial artery. // Pls evaluate occlusion of right radial
artery
TECHNIQUE: Axial CT images of the right upper extremity were obtained prior
to and following the administration of intravenous contrast. Coronal and
sagittal reformats were performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.2 s, 82.2 cm; CTDIvol = 2.1 mGy (Body) DLP = 172.1
mGy-cm.
2) Spiral Acquisition 6.2 s, 82.2 cm; CTDIvol = 5.3 mGy (Body) DLP = 437.0
mGy-cm.
3) Spiral Acquisition 4.1 s, 54.7 cm; CTDIvol = 3.9 mGy (Body) DLP = 211.6
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.8 mGy (Body) DLP = 1.9
mGy-cm.
5) Stationary Acquisition 4.2 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
Total DLP (Body) = 836 mGy-cm.
COMPARISON: None.
FINDINGS:
The thyroid gland appears normal.
Multiple pulmonary blebs are partially visualized (series 301 image 26, 2),
without pneumothorax. The upper mediastinum appears grossly normal. The
visualized thoracic aortic arch is normal.
The right subclavian artery, right brachial artery, and right over artery
appear patent and normal in caliber. The right radial artery is opacified
along the proximal forearm, however, is non-opacified across a 2.9 cm segment
at the distal forearm, just proximal to the wrist (series 309, image 27).
There is reconstitution of flow distally, though diminutive (series 301, image
247).
There is no acute fracture. No concerning sclerotic or lytic lesion is
detected.
There is no focal fluid collection or hematoma along the right upper
extremity. No subcutaneous edema is seen.
The visualized brain appears normal.
IMPRESSION:
Occlusion of a 2.9 cm segment of the distal left radial artery (series 309,
image 27).
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal ultrasound, R Arm pain
Diagnosed with Pain in right forearm
temperature: 98.8
heartrate: 79.0
resprate: 16.0
o2sat: 100.0
sbp: 139.0
dbp: 94.0
level of pain: 6
level of acuity: 3.0 | Ms. ___ is a ___ female with ___ R paraclinoid
aneurysm s/p recent embolization (___) who presented to the
emergency department with persistent RUE pain since her
embolization procedure procedure. She noted that she had had
pain with placement of an arterial line for the procedure and
that it had to be replaced during procedure. Ultrasound
completed in the ED demonstrated occlusion of right radial
artery and she was started on a heparin gtt, CTA completed the
day after admission demonstrated occlusion of distal left radial
artery with reconstitution of flow distally. Etiology was
thought to be most likely likely provoked right radial artery
occlusion given recent arterial line for embolization procedure.
Patient was initially on heparin gtt with transition to apixaban
___ after discussion with patient, vascular medicine and
neurosurgery. Patient symptoms of pain and decreased sensation
in her right hand continued to improve during hospitalization.
She was discharged home on dual therapy with ticagrelor (for
recent emolization procedure) and apixaban for arterial thrombus
with followup by neurosurgery and vascular medicine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive tape / latex
Attending: ___
Chief Complaint:
Abdominal Pain, Body Pain, Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with recurrent adult
type
granulosa cell tumor on carboplatin/paclitaxel who presents with
pain.
Patient reports multiple complaints including abdominal pain,
total body pain, bone pain in her bilateral legs, headache,
lightheadedness, nausea, hot flashes, and blurry vision since
___. She reports similar pattern of symptoms after her first
chemotherapy cycle at the beginning of the month. She denies any
fevers/chills and viral symptoms.
On arrival to the ED, initial vitals were 98.6 91 139/111 20
100%
RA. Exam was notable for soft non-distended diffusely tender
abdomen and diffuse bilateral lower extremity pain to palpation.
Labs were notable for WBC 7.2, H/H 12.9/41.7, Plt 214, Na 131, K
5.3, BUN/Cr ___, trop-T <0.01, and UA negative. Influenza PCR
negative. CXR negative for pneumonia. Abdominal CT negative for
acute process. Patient was given morphine 4mg IV x 2, zofran 4mg
IV, and 1L NS. Prior to transfer vitals were 98.0 77 123/65 18
99% RA.
On arrival to the floor, patient reports feeling more
comfortable. She denies fevers/chills, weakness/numbness,
shortness of breath, cough, hemoptysis, chest pain,
palpitations,
vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria,
hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
The patient was diagnosed in ___ in the setting of work-up
done for abdominal pain. At that time CT findings were c/f a
ruptured hemorrhagic cyst. She underwent a laparoscopic
evacuation of hemoperitoneum, right oophorectomy and partial
right salpingectomy. Final pathology revealed adult type
granulosa cell tumor, calretinin (+) and inhibin (focally +), ER
(focally +), PR (focally +), CK7 (-), CK20 (-), and PAX8 (-).
The
patient did not undergo full staging or adjuvant treatment after
the procedure. She continued follow-up with imaging. Imaging in
___ and ___ were concerning for soft tissue nodules and
LN
progression. Inhibin was also rising.
Thus, on ___ the surgical team proceeded to LSC LOA, LSO,
right salpingectomy, infracolic omentectomy, resection of pelvic
peritoneal nodules, right pelvic peritonectomy, right complete
ureterolysis, and cystoscopy. Pathology evaluation was
consistent
with granulosa cell tumor involving the presacral, sidewall,
cecal, and pelvic nodules. Omental biopsy with multiple
microscopic foci (1mm). Right fallopian tube with serosal
involvement. Of note, morphologically the tumor was similar to
that of the patient's prior surgical specimen. Based on these
data, the patient was diagnosed with recurrent adult type
granulosa cell tumor. She was referred to oncology for systemic
treatment.
- ___: C1D1 Carboplatin/Paclitaxel
- ___: C2D1 Carboplatin/Paclitaxel
PAST MEDICAL HISTORY:
- Asthma, she reports having required intubation and steroids
with development of pneumonia in the past. She does use an
inhaler on occasion.
- Hypertension
- Neuropathy
- GERD
- History of cocaine abuse
- s/p TVH for AUB, fibroids --> adenomyosis, inactive
endometrium
- s/p D&Cs and endometrial ablation in the past.
- s/p open cholecystectomy
- s/p LSC RO with partial salpingectomy
- s/p LSC LOA, LSO, R salpingectomy, infracolic omentectomy,
resection of pelvic peritoneal nodules, R pelvic peritonectomy,
R
complete ureterolysis
Social History:
___
Family History:
Notable for mother with breast cancer and some
sort of cancer that required a colon resection and splenectomy.
Her mother is alive at age ___. Maternal aunt with pancreatic
cancer, a paternal uncle with bone cancer and father with colon
cancer.
Physical Exam:
VS: Temp 97.9, BP 125/85, HR 76, RR 18, O2 sat 100% RA.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-distended, diffuse tenderness to palpation,
normal
bowel sounds, well-healed incisions.
EXT: Warm, well perfused, no lower extremity edema or erythema.
Diffuse bilateral leg tenderness to palpation.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: No significant rashes.
Pertinent Results:
___ 06:26AM BLOOD WBC-4.8 RBC-4.20 Hgb-11.1* Hct-36.4
MCV-87 MCH-26.4 MCHC-30.5* RDW-14.0 RDWSD-44.0 Plt ___
___ 06:26AM BLOOD Glucose-94 UreaN-18 Creat-0.7 Na-139
K-4.5 Cl-101 HCO3-26 AnGap-12
___ 06:26AM BLOOD ALT-14 AST-11 AlkPhos-108* TotBili-0.5
___ 10:51AM BLOOD Lipase-152*
___ 10:51AM BLOOD cTropnT-<0.01
___ 06:26AM BLOOD Calcium-9.6 Phos-3.4 Mg-1.6
___ 10:56AM BLOOD Lactate-1.7 K-5.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
2. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
4. Dexamethasone 4 mg PO AS DIRECTED WITH CHEMOTHERAPY
5. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
6. Acetaminophen 500 mg PO Q4H:PRN Pain - Mild/Fever
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Multivitamins 1 TAB PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Hair, Skin and Nails Advanced (multivit min-iron-FA-herb
186) 3.3 mg iron-25 mcg oral DAILY
Discharge Medications:
1. Naproxen 250 mg PO Q12H:PRN pain
Reason for PRN duplicate override: Alternating agents for
similar severity
do not take on an empty stomach. always take w/ food. if causes
heartburn, take omeprazole
RX *naproxen 250 mg 1 tablet(s) by mouth twice a day prn pain
Disp #*30 Tablet Refills:*0
2. Omeprazole 20 mg PO DAILY to help tolerate motrin or
naproxen
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
3. Acetaminophen 1000 mg PO Q6H:PRN pain
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
5. Dexamethasone 4 mg PO AS DIRECTED WITH CHEMOTHERAPY
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Hair, Skin and Nails Advanced (multivit min-iron-FA-herb
186) 3.3 mg iron-25 mcg oral DAILY
9. Multivitamins 1 TAB PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
11. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
12.rolling walker
dx: unsteady gait
px: good
___: 13 mo
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Recurrent Adult Type Granulosa Cell Tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with body pain, chills, on chemotherapy.//
Pneumonia, pneumothorax, effusion
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___.
FINDINGS:
Lungs are expanded and without focal consolidation. There is no pleural
effusion or pneumothorax. Cardiomediastinal silhouette is within normal
limits. The upper abdomen is unremarkable.
IMPRESSION:
No focal consolidation.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with history of granulosa cell tumor
of the ovary, status post LOA, LSO, resection of peritoneal nodules in late
___, undergoing second round of chemotherapy for tumor recurrence,
presenting with diffuse abdominal tenderness and pain. Evaluate for
intra-abdominal abscess, obstruction.
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 7.0 s, 0.5 cm; CTDIvol = 33.7 mGy (Body) DLP =
16.9 mGy-cm.
2) Spiral Acquisition 6.9 s, 54.1 cm; CTDIvol = 24.1 mGy (Body) DLP =
1,303.2 mGy-cm.
Total DLP (Body) = 1,320 mGy-cm.
COMPARISON: CT from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
biliary dilatation. The common bile duct is mildly dilated but tapers
normally to the ampulla. The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Bilateral cortical hypodensities compatible with renal cysts, some too small
to characterize, similar to the prior study. 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. Diverticulosis of
the sigmoid colon is noted. The wall of the sigmoid colon appears slightly
thickened but there is no significant fat stranding or fluid to suggest
diverticulitis. The appendix is normal.
PELVIS: The uterus and ovaries are surgically absent. In the left adnexa
there is an indeterminate slightly elongated cystic structure measuring
approximately 2.6 x 4.1 x 1.3 cm (series 2, image 79; series 602, image 56;
series 601, image 32).
LYMPH NODES: Prominent presacral nodule is largely unchanged (series 2, image
67. Additional smaller retroperitoneal nodules do not meet criteria for
lymphadenopathy. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
-No evidence of obstruction, pneumoperitoneum, or other acute findings in the
abdomen or pelvis.
-Sigmoid diverticulosis without significant signs of inflammation to suggest
diverticulitis.
-Left adnexal cyst measuring up to 2.6 cm.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain, Body aches, Headache
Diagnosed with Myalgia, unspecified site
temperature: 98.6
heartrate: 91.0
resprate: 20.0
o2sat: 100.0
sbp: 139.0
dbp: 111.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ is a ___ w/ recurrent adult type granulosa cell
tumor on
carboplatin/paclitaxel who presents with diffuse pain syndrome.
# Cancer-Related Pain: Patient with multiple pain complaints
including abdomen, knee, bone, head pain along w/ "cartoon
vision." Abdominal CT non-acute. She improved w/ moprhine and
pain resolved on admission and vision quickly improved. Symptoms
occurred to a greater degree w/ prior cycle of chemo, so suspect
with the timing of this syndrome of diffuse body pain, most
likely related to that. Discussed w/ her oncologist who is in
agreement.
- avoiding narcotic use due h/o polysubstance abuse
- pain relieved w/ apap, encouraged its use
- advised to consider naproxen PRN during the pain episodes
- ___ consulted, advised RW for home and discharged w/ home ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Tegaderm / latex / adhesive tape
Attending: ___.
Chief Complaint:
Chest pain, lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with history of HFPEF, CAD status post MI
with PCI ___, sick sinus syndrome status post PPM, atrial
fibrillation on apixaban, moderate MR, type 2 diabetes, CKD,
hypertension, dyslipidemia, who presented with transient
vertigo,
slurred speech, and chest pain.
Patient developed exertional angina this morning in the setting
of walking into clinic for ___ appointment. Pain was
similar
to prior cardiac chest pain for her. Pain was nonradiating, not
associated nausea or vomiting, not associated with diaphoresis,
constant and nonpleuritic, and worse with exertion, unclear if
resolved with nitroglycerin. Shortly after receiving
nitroglycerin for the treatment of her chest pain, she developed
a sensation of forward linear movement that resolved after about
1 minute. At approximately the same time, she had difficulty
with
speech, but this was in the setting of actively chewing the Tums
that had been given to her. She had a recurrence of the
sensation
of forward linear movement while being triaged in the ED, again
self-resolving after 1 minute, but this time was not accompanied
by any other neurological changes.
Of note, she was admitted to ___ in ___ for chest
heaviness, dyspnea on exertion, orthopnea and shortness of
breath
at rest. She
required BiPAP for increased work of breathing, and was placed
on a nitro drip for squeezing substernal chest discomfort. She
was treated for CHF exacerbation that was thought to be
triggered
by PPM
generator dying and going into backup VVI mode when she is
normally A-paced and V-sensed. Upon battery exchange, the
patient
no longer had chest pain and her orthopnea improved drastically.
In the ED, initial vital signs were: 97.3 111/43 59 18 100/RA
Exam notable for: baseline left-sided weakness (4+/5 in the L
triceps, ___ in the L wrist extensors and finger extensors, 2+/5
in the L IP, ___ in the L hamstring, ___ in the L TA, 4+/5 in
the
L gastrocnemius) and bilateral distally decreased sensation to
vibration (L>R). Shortness of breath with sitting up.
Labs were notable for:
- Cr 1.6 at baseline, lytes otherwise within normal limits
- CBC within normal limits, no leukocytosis
- INR 1.8
- Trop <0.01 x2
Studies performed include:
- CXR: No acute cardiopulmonary abnormality.
- CT head: No acute intracranial abnormality. Please note that
MRI is more sensitive for detection of acute infarction.
- EKG: NSR at 60, NAD, intervals wnl, inferior ST segments
unchanged from prior.
Consults: Neurology: The sensation of forward movement is not
associated with a vascular territory and the only time she had
abnormal speech today was while she was chewing medication. We
strongly suspect that her lowered blood pressure in the setting
of treatment with nitroglycerin caused her to feel lightheaded /
presyncopal, and this is what gave her the sensation of
movement.
There is no indication for further neurological work-up at this
time. If she is admitted for further treatment of her chest
pain,
our neurology consult service will follow.
Upon arrival to the floor, the patient reported that she has
been
experiencing daily chest tightness and shortness of breath for
several months. She reported that the chest tightness is present
almost every day, comes and goes, worse after a big meal. When
specifically asked about heartburn, she said that the chest
tightness feels like burning, so severe that sometimes she feels
the food going up from her stomach. As for the shortness of
breath, it is also present most of the times, worse with
exertion. She denies cough, fever, chills, lower extremity
edema.
When asked about her meds, she said that she has been waiting
for
some meds refill to be mailed to her, otherwise she is taking
the
meds she has at home.
Past Medical History:
Hypertension
Dyslipidemia
Type 2 diabetes mellitus
Coronary artery disease s/p MI s/p PCI in ___ and ___
Diastolic CHF
Sick sinus syndrome s/p permanent pacemaker placement
Right basal ganglia infarct with residual left-sided weakness
MGUS
Chronic kidney disease
? Atrial fibrillation
Social History:
___
Family History:
Multiple family members with gallstone disease. Sister with
stroke.
Physical Exam:
Vitals- 98.3 PO 159/75 60 22 100% RA
GENERAL: AOx3, in no acute distress, initially tachyoneic then
improved with reassurance, able to speak full sentences
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. No
conjunctival
pallor or injection, sclera anicteric and without injection. ___
clear bilaterally with normal light reflex. Moist mucous
membranes. Oropharynx is clear.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No
JVD.
LUNGS: Clear to auscultation bilaterally with appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
Resonant to percussion.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. Tympanic to percussion. No
organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation. No ataxia, dysmetria, disdiadochokinesia. Gait is
normal.
Pertinent Results:
PERTINENT LABS:
===============
___ 02:55PM BLOOD WBC-7.8 RBC-3.96 Hgb-11.5 Hct-35.6 MCV-90
MCH-29.0 MCHC-32.3 RDW-14.4 RDWSD-46.6* Plt ___
___ 02:55PM BLOOD ___ PTT-35.3 ___
___ 02:55PM BLOOD Glucose-105* UreaN-39* Creat-1.6* Na-143
K-4.7 Cl-104 HCO3-25 AnGap-14
___ 02:55PM BLOOD cTropnT-<0.01
___ 10:11PM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:50AM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:55PM BLOOD TSH-4.0
IMAGING/STUDIES:
================
CT HEAD ___:
No acute intracranial abnormality. Please note that MRI is more
sensitive for detection of acute infarction.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Gabapentin 300 mg PO DAILY:PRN pain
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Bisacodyl ___AILY:PRN constipation
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID:PRN constipation
7. amLODIPine 5 mg PO DAILY
8. Apixaban 2.5 mg PO BID
9. Rosuvastatin Calcium 10 mg PO QPM
10. Furosemide 60 mg PO DAILY
11. Spironolactone 12.5 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. Omeprazole 20 mg PO DAILY
14. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
15. Aspirin 81 mg PO DAILY
16. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
3. amLODIPine 5 mg PO DAILY
4. Apixaban 2.5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Bisacodyl ___AILY:PRN constipation
7. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
8. Docusate Sodium 100 mg PO BID
9. Furosemide 60 mg PO DAILY
10. Gabapentin 300 mg PO DAILY:PRN pain
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. Polyethylene Glycol 17 g PO DAILY
14. Rosuvastatin Calcium 10 mg PO QPM
15. Senna 8.6 mg PO BID:PRN constipation
16. Spironolactone 12.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with shortness of breath and chest pain//eval
consolidation
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Left-sided pacer device is noted with leads in the right atrium and right
ventricle. Mild enlargement of the cardiac silhouette is noted with a
coronary artery stent again seen. The aorta is slightly tortuous but
unchanged. The mediastinal and hilar contours are normal. Pulmonary
vasculature is not engorged. Apart from minimal atelectasis in the lung
bases, the lungs are clear. No pleural effusion or pneumothorax is present.
No acute osseous abnormalities detected.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with ___ vertigo and dysarthria at 1100h, now
resolved// eval stenosing/hemorrhagic pathology, specifically posterior
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.0 cm; CTDIvol = 47.3 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head and neck ___
FINDINGS:
There is no evidence of acute large territorial infarction, hemorrhage, edema,
or mass. The ventricles and sulci are mildly prominent, consistent with
involutional changes. There is extensive periventricular and subcortical
white matter hypodensity, consistent with chronic microvascular ischemic
changes. Again seen is a hypodensity in the right cerebellum, consistent with
encephalomalacia from prior infarct.
No acute osseous abnormalities seen. Minimal mucosal thickening of some
anterior ethmoidal air cells. Otherwise, the paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The patient is status post right
lens replacement. Otherwise, the orbits are unremarkable. Moderate
atherosclerotic calcifications are seen within the cavernous carotid arteries.
IMPRESSION:
No acute intracranial abnormality. Please note that MRI is more sensitive for
detection of acute infarction.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Dyspnea, unspecified
temperature: 97.3
heartrate: 59.0
resprate: 18.0
o2sat: 100.0
sbp: 111.0
dbp: 43.0
level of pain: 0
level of acuity: 2.0 | ___ with history of HFPEF, CAD status post MI with PCI ___,
sick sinus syndrome status post PPM, atrial fibrillation on
apixaban, moderate MR, type 2 diabetes, CKD, hypertension,
dyslipidemia,
who presented with transient dysequilibrium, and chest pain.
#DYSEQUILIBRIUM: Described as a sense of sitting and moving
forward, denied vertigo. Evaluated by neurology in ED, felt that
this was not a TIA. CT head negative for acute process. Likely
transient cerebral hypoperfusion induced by nitroglycerin.
#GERD: Patient reported chest burning for the past 1 week
associated with meals, starting a short while after eating and
sometimes resulting in vomiting. Denied chest pain when walking
or climbing stairs, or at rest when not eating. ECG w/o ischemic
changes and 3 sets of troponins negative. Sx improved with
Maalox and increased PPI. Her symptoms are likely related to
severe GERD, and less likely cardiac. If sx continue should
consider evaluation for potential ulcer, gastritis, esophagitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Chief Complaint: fever
Reason for MICU transfer: hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
A ___ year old male with PMH Cholelithiasis and biliary colic s/p
unsuccessful open cholecystectomy is called out of the MICU
after a one day hospitalization for hypotension following ERCP.
.
According to the patient, he had an episode of abdominal pain ___
___ and presented to ___ where he underwent an
attempted laparoscopic cholecystectomy which was converted to an
open proceedure due to fibrosis. He reports that the surgeon was
able to remove some stones and closed leaving a bile drain ___
place. He was then sent to ___ for ERCP on ___ with
biliary stent placement which was successful. Following the
procedure, the patient noted decreased output from the external
biliary drain and had resolution of abdominal pain. On the day
of admission (___) the patient presented for an repeat ERCP
to place a larger biliary stent which was performed
successfully. He returned home where he noted chills and an oral
temperature of 100.7. He called his PCP who recommended referral
to the ED. ___ the ED, initial VS were: 98.3 78 91/52 18 94%,
Labs were remarkable for WBC 5.0 73%PMN 3% Bands, he was given
amp/sulbactam and 2L IVNS and admitted to the MICU.
.
While ___ the MICU, antibiotics were changed to vancomycin and
zosyn. Biliary drain fluid was cultured with initial gram stain
showing Gram Neg Rods and Gram positive Cocci and culture
showing polymicrobial growth. ERCP fellow was contacted who
noted that the fluid ___ a cholecystomy bag is rarely cultured
and is likely to be colonized with non-pathogenic bacteria. The
patient was given a total of 5 liters of fluid ___ the ED and
MICU. BP has now been stable without requring fluid for over 24
hrs and therefore patient was able to leave the MICU.
.
On arrival to the floor, patient denies any current complaints
and states that he feels as well as he normally does at home.
.
REVIEW OF SYSTEMS
On review of systems, 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. 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:
HTN
hyperlipidemia
Type II DM
Status post carotid endarterectomy
Thrombocytopenia
Fibrotic lung disease: Likely due to asbestosis
Bladder CA status post TURBT
Social History:
___
Family History:
Denies family history of coronary artery disease, congestive
heart failure.
Physical Exam:
Admission Physical Exam
Vitals: 98.9 HR 75 BP 105/51 RR 16 97% 2 liters n/c
General: Alert, oriented, no acute distress, slightly agitated
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: bibasilar crackles that clear somewhat with ventilation,
rare wheeze LUL
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly. biliary drain ___ place
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
Pertinent Results:
Admission Labs
==============
___ 10:00AM BLOOD WBC-5.0 RBC-3.20* Hgb-9.8* Hct-30.9*
MCV-96 MCH-30.7 MCHC-31.8 RDW-16.8* Plt Ct-76*
___ 11:25PM BLOOD Neuts-73* Bands-3 Lymphs-10* Monos-8
Eos-5* Baso-0 Atyps-1* ___ Myelos-0
___ 10:00AM BLOOD ___ PTT-28.2 ___
___ 10:00AM BLOOD Glucose-121* UreaN-21* Creat-1.1 Na-136
K-4.4 Cl-100 HCO3-27 AnGap-13
___ 10:00AM BLOOD ALT-28 AST-39 AlkPhos-207* Amylase-31
TotBili-0.6 DirBili-0.3 IndBili-0.3
___ 10:00AM BLOOD Lipase-11
___ 06:15AM BLOOD Albumin-2.5* Calcium-7.5* Phos-3.4
Mg-1.5*
___ 11:25PM BLOOD Iron-26*
___ 11:25PM BLOOD calTIBC-251* VitB12-450 Folate-11.8
Ferritn-135 TRF-193*
___ 11:25PM BLOOD TSH-1.5
___ 06:15AM BLOOD Cortsol-27.3*
___ 11:30PM BLOOD Lactate-1.1 K-4.2
.
Discharge Labs:
===============
___ 06:27AM BLOOD WBC-2.8* RBC-3.02* Hgb-9.0* Hct-28.3*
MCV-94 MCH-30.0 MCHC-31.9 RDW-16.7* Plt Ct-85*
___ 06:27AM BLOOD Glucose-111* UreaN-21* Creat-1.3* Na-139
K-3.9 Cl-100 HCO3-31 AnGap-12
___ 05:56AM BLOOD ALT-21 AST-40 AlkPhos-235* TotBili-0.6
___ 06:27AM BLOOD Mg-1.8
.
Other Studies:
==============
CXR ___:
1. Diffuse interstitial opacities likely pulmonary fibrosis
(evidence of
asbestos exposure) with or without interstial pulmonary edema or
atypical
infection.
2. Dilated azygous vein indicates elevated central venous
pressure or volume.
.
CXR ___:
As compared to the previous radiograph, there is no relevant
change. Borderline diameter of the azygos vein indicating
minimal systemic
fluid overload. However, there is no other indicator for
pulmonary fluid
overload, ___ particular no widening of the mediastinum, no
presence of pleural effusions and no interval enlargement of the
cardiac silhouette. Unchanged extensive bilateral interstitial
opacities, ___ the context of known pulmonary fibrosis. No
interval appearance of new focal parenchymal opacities.
.
TTE ___:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The 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.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild diastolic LV dysfunction. No
clinically-significant valvular disease seen.
.
MICROBIOLOGY:
=============
___ 12:10 am BILE
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Preliminary):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
.
Blood Cultures ___ and ___: NGTD
Medications on Admission:
lisinopril 5 mg daily
simvastatin 40 mg daily
metformin 850 daily
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. metformin 850 mg Tablet Sig: One (1) Tablet PO once a day.
4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Last dose ___ evening on ___.
Disp:*5 Tablet(s)* Refills:*0*
5. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Last dose ___ evening on ___.
Disp:*7 Tablet(s)* Refills:*0*
6. Home Oxygen Therapy
2 Liters/Minute
For portability: pulse dose system
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
- Sepsis
- Post ERCP fever
- Hypoxemia
- Pulmonary Fibrosis
Secondary
- Pancytopenia
- Type 2 DM
- Hypertension
- Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with fever.
COMPARISON: None available in the ___ system.
PA AND LATERAL CHEST RADIOGRAPH:
A calfified pleural plaque overlies the right diaphragm apex and additional
plaques are identified bilaterally, findings indicative of prior asbestos
exposure. Interstial opacities are present bilaterally which may reflect
underlying pulmonary fibrosis though no comparison images are available.
Alternatively findings could reflect interstial pulmonary edema as there is
engorgement of the azygous vein, though a normal heart size. A third
alternative could be atypical infection. Consider chest CT for further
characterization if clinically indicated. There is no pneumothorax or large
pleural effusion.
IMPRESSION:
1. Diffuse interstitial opacities likely pulmonary fibrosis (evidence of
asbestos exposure) with or without interstial pulmonary edema or atypical
infection.
2. Dilated azygous vein indicates elevated central venous pressure or volume.
Consider chest CT for further characterization if clinically indicated.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Pulmonary fibrosis and hypoxia, evaluation for pulmonary edema.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. Borderline diameter of the azygos vein indicating minimal systemic
fluid overload. However, there is no other indicator for pulmonary fluid
overload, in particular no widening of the mediastinum, no presence of pleural
effusions and no interval enlargement of the cardiac silhouette. Unchanged
extensive bilateral interstitial opacities, in the context of known pulmonary
fibrosis. No interval appearance of new focal parenchymal opacities.
Gender: M
Race: UNABLE TO OBTAIN
Arrive by AMBULANCE
Chief complaint: FEVER, S/P ERCP
Diagnosed with POSTPROCEDURAL FEVER, HYPOTENSION NOS
temperature: 98.3
heartrate: 78.0
resprate: 18.0
o2sat: 94.0
sbp: 91.0
dbp: 52.0
level of pain: 0
level of acuity: 2.0 | ___ year old male with history of HTN, hyperlipidemia, who
presented with fever and relative hypotension after elective
ERCP.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / codeine
Attending: ___
___ Complaint:
Peristomal skin irritation, abdominal discomfort
Major Surgical or Invasive Procedure:
___ CT pelvis with rectal contrast
___ Ososcopy
History of Present Illness:
Per ED Note:
___ hx of diverticular stricture s/p lap ___ on
___ presents from rehab with change in stoma appearance. Per
family's report patient had been doing ok at rehab, some issues
with stoma care but doing better. Noticed some white/greenish
plaques on stoma at rehab and sent to ED for eval. Reports
passing gas and liquid stool into bag. Not taking much by mouth.
No appetite. Walking some at rehab. Denies fevers, chills, or
cough.
Past Medical History:
PMH:
DIABETES MELLITUS
HYPERLIPIDEMIA
HYPERTENSION
DIVERTICULOSIS
BASAL CELL CARCINOMA
CERVICAL ARTHRITIS
MEMORY LOSS
VERTIGO
HEARING LOSS
CATARACT SURGERY
TAH/BSO
DIVERTICULITIS
PULMONARY NODULE
Past Surgical History:
TAH/BSO
CCY
Social History:
___
Family History:
Relative Status Age Problem
Mother ___ ___ DIABETES TYPE II
Father ___ ___ MYOCARDIAL
INFARCTION
Sister ___ ___ STROKE
Sister Living ___ HYPERCHOLESTEROLEMIA
CEREBRAL HEMORRHAGE
Sister Living ___ HYPERTENSION
Physical Exam:
Admission Physical Exam:
VS: T: 97 63 143/51 16 93%Ra
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR,
PULM: no respiratory distress
ABD: soft, NT, midline incision c/d/I, stoma in LLQ, with ___
fibrinous plaques on end of stoma, patent to fascia
PELVIS: deferred
EXT: WWP, tender lower legs
=======================
Discharge Physical Exam:
Pertinent Results:
___ 08:23AM BLOOD WBC-8.0 RBC-3.23* Hgb-9.8* Hct-30.9*
MCV-96 MCH-30.3 MCHC-31.7* RDW-13.7 RDWSD-48.8* Plt ___
___ 07:30AM BLOOD WBC-10.6* RBC-3.57* Hgb-10.8* Hct-33.6*
MCV-94 MCH-30.3 MCHC-32.1 RDW-13.8 RDWSD-47.2* Plt ___
___ 07:19PM BLOOD WBC-12.0* RBC-3.86* Hgb-11.7 Hct-36.3
MCV-94 MCH-30.3 MCHC-32.2 RDW-14.0 RDWSD-47.6* Plt ___
___ 07:19PM BLOOD Neuts-79.7* Lymphs-11.7* Monos-5.0
Eos-2.0 Baso-0.4 Im ___ AbsNeut-9.56* AbsLymp-1.40
AbsMono-0.60 AbsEos-0.24 AbsBaso-0.05
___ 08:23AM BLOOD Glucose-134* UreaN-16 Creat-0.9 Na-139
K-4.8 Cl-105 HCO3-24 AnGap-10
___ 07:30AM BLOOD Glucose-84 UreaN-23* Creat-1.0 Na-138
K-4.9 Cl-104 HCO3-21* AnGap-13
___ 07:19PM BLOOD Glucose-53* UreaN-28* Creat-1.4* Na-136
K-4.6 Cl-98 HCO3-19* AnGap-19*
___ 08:23AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.6
___ 07:30AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.7
___ 07:29PM BLOOD Lactate-1.2
___ 02:32PM URINE Color-Straw Appear-Cloudy* Sp ___
___ 02:32PM URINE Blood-SM* Nitrite-POS* Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 02:32PM URINE RBC-9* WBC->182* Bacteri-FEW* Yeast-NONE
Epi-6 TransE-1
___ 02:32PM URINE WBC Clm-MANY* Mucous-RARE*
Imaging:
CHEST (PA & LAT) Study Date of ___ 11:53 ___
IMPRESSION: No acute cardiopulmonary process.
CT PELVIS W/CONTRAST Study Date of ___ 2:57 ___
IMPRESSION:
1. The patient is status post partial sigmoid colectomy and left
colostomy. Contrast is seen in the rectal stump with no
extravasation of p.r. contrast. It is noted the contrast is only
in the lower rectum, not near the stump, but there is no air,
fluid or fat stranding near the staple line at the stump which
would suggest any likelihood of a leak or active inflammation at
that site.
2. No incidental findings of note.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 40 mg SC DAILY
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
2. Psyllium Wafer ___ WAF PO DAILY
3. amLODIPine 7.5 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. GlipiZIDE XL 10 mg PO DAILY
6. Lisinopril 10 mg PO BID
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*5 Tablet Refills:*0
3. amLODIPine 7.5 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Enoxaparin Sodium 40 mg SC DAILY
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
6. GlipiZIDE XL 10 mg PO DAILY
7. Lisinopril 10 mg PO BID
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Psyllium Wafer ___ WAF PO DAILY
10. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Peristomal skin irritation
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with diverticula stricture s/p lap Hartmanns
now presents with ___ and leukocytosis with lower abdominal pain Please give
IV contrast and 60cc of rectal contrast// Rule out rectal stump leak, colitis,
or other infectious sources
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.5 s, 42.4 cm; CTDIvol = 14.5 mGy (Body) DLP = 606.2
mGy-cm.
Total DLP (Body) = 606 mGy-cm.
COMPARISON: Prior CT abdomen done ___
FINDINGS:
PELVIS: The patient is status post partial sigmoid colectomy and left
colostomy. Contrast is seen in the rectal stump with no extravasation of p.r.
contrast. The urinary bladder and distal ureters are unremarkable. There is
no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The patient is status post hysterectomy.
LYMPH NODES: There is no pelvic or inguinal lymphadenopathy.
VASCULAR: Moderate atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Degenerative changes are noted.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. The patient is status post partial sigmoid colectomy and left colostomy.
Contrast is seen in the rectal stump with no extravasation of p.r. contrast.
It is noted the contrast is only in the lower rectum, not near the stump, but
there is no air, fluid or fat stranding near the staple line at the stump
which would suggest any likelihood of a leak or active inflammation at that
site.
2. No incidental findings of note.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ILEOSTOMY EVAL
Diagnosed with Other complications of enterostomy, Form of external stoma cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause
temperature: 97.0
heartrate: 63.0
resprate: 16.0
o2sat: 93.0
sbp: 143.0
dbp: 51.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ presented to the Emergency Department at ___ on
___ with reports of peristomal skin changes and some
abdominal discomfort. She was evaluated by the colorectal
surgery department in the emergency room and was admitted onto
the service.
#Peristomal skin irritation: The patient had large white firm
lesions on her peristomal region. These lesions were evaluated
in the emergency department and attempted to remove. She had an
infectious work up- c.diff, chest x-ray, CT pelvis with both
rectal and IV contrast, and an ososcopy all of which were
negative. The wound ostomy nurses also evaluated the patient and
gave their input on how to manage the stoma. With a negative
infectious work up and the patient clinically doing very well,
it was decided that these lesions are of unclear etiology and
the patient can continue her recovery in rehab.
#Urinary tract infection: While the patient was undergoing an
infectious work up, an incidental urinary tract infection was
found. This is likely the source of her pelvic pain. She was
started on Bactrim and will be on it for a 3 day course.
#Hypomagnesemia: The patient was found to have low levels of
Magnesium of 1.6 on ___, she was given 4gm of magnesium
sulfate.
#Acute pain: The patient denied any abdominal or pelvic pain.
However, with abdominal exams, she was very tender in the
suprapubic and left lower quadrant. The patient was given
Tylenol as needed for pain which the patient reported helped
relieve discomfort.
#S/p ___ resection: The patient continues to recover well
from her surgery (___). She will continue her prophylactic
dose of Lovenox at rehab.
On ___, the patient was discharged to rehab. At discharge,
she was tolerating a regular diet, passing flatus, voiding, and
ambulating with a walker. She will follow-up in the clinic in
___ weeks. This information was communicated to the patient
directly prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
scopolamine / cefepime
Attending: ___.
Chief Complaint:
dysphagia, difficulty handling secretions
Major Surgical or Invasive Procedure:
PEG tube placement
History of Present Illness:
Patient is a ___ female with past medical history
significant for cerebellar hemorrhage (___) due to AVM s/p s/p
suboccipital craniotomy (___) with recurrent hemorrhage
(___) s/p repeat craniotomy and
excision of AVM with duraplasty and pericranial graft and
titanium mesh placement (___) complicated by craniotomy site
infection (___), residual dysarthria/dysphagia, RA on
methotrexate, who is referred from ___ with concern for
ongoing aspiration, UTI.
Briefly, patient was admitted to ___ in ___ for a cerebellar
hemorrhage with intraventricular extension ___ a cerebellar AVM.
She underwent suboccipital craniotomy and evacuation of
hematoma. THis was then complicated by a recurrent hemorrhage
after falling at home. She underwent a planned AVM excision in
___. FOllowing these admission, she spent extended time at a
rehab facility, with PEG tube. Since her ICH, she has had
residual deficits including ataxia, diplopia as well as
dysphagia.
Regaeding her severe dysphagia, she was previously being fed via
G-tube. She has had multiple aspiration pneumonias in the past
year. She is now on a modified diet with thickened liquids and
soft solids. She has had cough after meals. She has been
evaluated by speech and language therapist and initially noted
significant improvement after e-stim stimulation. SHe has also
had drooling with difficulty clearing her secretions. TO this
end, her neurologist switched her from gabapentin to low-dose
nortriptyline 10 mg at bedtime with dual purpose of treating her
pain and helping with her drooling. SHe also saw ENT in ___
and was diagnosed with sialorrhea/ptyalism, oropharyngeal
dysphagia with aspiration based on flexible videostroboscopy and
review of prior modified barium swallow. ENT felt that her
aspiration pnas were due to the
saliva rather than her diet and recommended Botox injection to
the saliva glands, which she underwent on ___
Since this time she states she has worsening dysphagia, as well
as coughing and difficulty managing the secretions. The patient
has also been reporting dysuria and urinary latency, however she
is unclear how long this has been going on. She had previous
been treated with a course of Bactrim for this. Patient denies
any fevers, chills, chest pain, shortness of breath, abdominal
pain. Reports intermittent diarrhea. She presented to ___,
where labs were remarkable for ___ positive, positive nitrite,
and chest x-ray showed right middle lobe opacity which had
actually decreased from prior studies. The patient was treated
with levofloxacin 750mg IV. Patient was transferred for
evaluation by ENT for concern for aspiration.
In the ED, initial VS were: 96.8 106 122/70 20 100% RA
ENT consulted, felt that it was difficult to tell whether
symptoms are new since botox injection or she is at her
baseline. Recommended continued work-up of dysphagia, NPO, SLP
evaluation
REVIEW OF SYSTEMS:
A ten point ROS was conducted and was negative except as above
in the HPI.
Past Medical History:
Cerebellar hemorrhage (___) due to AVM s/p neurosurgical
evacuation complicated by wound infection
Osteoporosis
Nephrolithiasis
Surgical Hx
Hip replacement
Cataract surgery
Retinal detachment
Hysterectomy
Appendectomy
Social History:
___
Family History:
No history of brain hemorrhage
Physical Exam:
Admission Exam:
Gen: NAD, extremely cachectic, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: dry MM, OP clear
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: chronic contractures of bilateral upper extremities
Skin: No visible rash. No jaundice.
Neuro: AAOx3. Baseline dysarthria noted
Psych: Tearful at times
Discharge exam:
Vitals: AF 100s-130s/60s-80s ___ 95-97% RA
Gen: Lying in bed in no apparent distress, awake, interactive
HEENT: AT, NC, L eye ptosis, MMM, hearing grossly intact
GI: (+) BS, PEG site clean/dry, minimal erythema around entry
site mild tenderness, soft, ND, no HSM
Extr/vasc: wwp, No edema
Skin: No rashes or ulcerations evident
MSK: bilateral hand contractures
Neuro: A+O, speech dysarthric, moving all extremities
Psych: somber mood, appropriate affect
Pertinent Results:
=============================
___ ___
UA
___ 500, positive nitrite, ___ WBC
CBC, BMP wnl
============================
Blood culture ___ neg
Video swallow ___
There is aspiration of nectar thick liquids and honey thick
liquids secondary to significant pharyngeal weakness.
Head CT ___
Skin breakdown overlying the suboccipital craniectomy mesh with
subjacent air. No evidence of intradural extension.
CT Chest ___
IMPRESSION:
No pulmonary nodule corresponding to the abnormality seen on the
chest
radiograph.
Potential bibasal aspirations versus infection.
Mild cylindric bronchiectasis. 3 mm right para fissure all
nodule that should be reassessed in ___ year.
Liver hemangiomas.
Suggestion of renal pelvic fullness that should be further
assessed with
ultrasound.
Severe compression fracture of T12, unchanged since ___. 016.
=============================
Labs prior to dicharge
___ 08:10AM BLOOD WBC-6.3# RBC-3.96 Hgb-10.7* Hct-33.7*
MCV-85 MCH-27.0 MCHC-31.8* RDW-14.6 RDWSD-44.5 Plt ___
___ 08:10AM BLOOD ___
___ 07:50AM BLOOD Glucose-112* UreaN-10 Creat-0.4 Na-136
K-4.3 Cl-101 HCO3-23 AnGap-16
___ 07:50AM BLOOD Phos-3.9 Mg-2.0
=============================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Famotidine 20 mg PO BID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Senna 17.2 mg PO QHS:PRN constipation
7. Sertraline 50 mg PO DAILY
8. metHOTREXate sodium (PF) unknown injection unknown
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Famotidine 20 mg PO BID
4. Senna 17.2 mg PO QHS:PRN constipation
5. Levothyroxine Sodium 75 mcg PO DAILY
6. LORazepam 0.5 mg PO Q12H:PRN anxiety
7. metHOTREXate sodium 2.5 mg oral 2X/WEEK
8. Sertraline 50 mg PO DAILY
Discharge Disposition:
Extended ___
Facility:
___
Discharge Diagnosis:
-progressive severe dysphagia
-moderate protein calorie malnutrition
Discharge Condition:
Mental Status: intact and at baseline
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with prior craniotomies due to prior
intracranial bleed, now with worsening dysphagia after 2 traumatic falls in
the past 2 weeks.// rule out intracranial bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 15.1 cm; CTDIvol = 49.8 mGy (Head) DLP =
752.0 mGy-cm.
Total DLP (Head) = 752 mGy-cm.
COMPARISON: Noncontrast head CT of ___.
FINDINGS:
The patient is status post suboccipital craniotomy and resection of a AV
malformation. Dural thickening along the resection bed is identified.
Encephalomalacia of the bilateral cerebellar hemispheres is unchanged. There
is no evidence of intra or extra-axial mass effect, acute hemorrhage or acute
territorial infarct. The sulci, ventricles and cisterns, allowing for the
cerebellar encephalomalacia is within expected limits for the patient's mild
senescent related global cerebral volume loss. No acute calvarial fracture is
noted. The visualized paranasal sinuses are essentially clear. The orbits
are unremarkable noting bilateral lens replacements. The mastoid air cells
and middle ears are well pneumatized and clear.
IMPRESSION:
1. No significant interval change since the previous CT of ___.
2. No acute intracranial hemorrhage or mass effect.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman s/p NJ tube placement// confirm NG or NJ tube
placement.
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest radiographs from ___
FINDINGS:
Serial images demonstrate advancement of a Dobhoff into the stomach..
Otherwise, the lungs appear grossly clear without focal consolidation. There
is no pulmonary edema, pneumothorax, or large pleural effusion. The
cardiomediastinal silhouette and hilar contours appear unchanged. The
previously noted nodular opacity in the left upper lung demonstrated no CT
correlate on the CT chest exam in ___. Costochondral calcifications
are unchanged.
IMPRESSION:
An NG tube is seen terminating in the stomach.
Radiology Report
INDICATION: ___ year old woman with dysphagia// identify aspiration risk
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 2:06 min.
COMPARISON: None
FINDINGS:
There is delayed initiation of swallowing followed by spill-over into the
vallecula and piriform sinus. There is aspiration of nectar thick liquids and
honey thick liquids secondary to significant pharyngeal weakness.
C4 vertebral body demonstrates anterior height loss and anterior osteophyte.
IMPRESSION:
There is aspiration of nectar thick liquids and honey thick liquids secondary
to significant pharyngeal weakness.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
INDICATION: ___ year old woman with PMH of recurrent cerebellar hemorrhage ___
AVM with residual dysarthria and dysphagia and sialorrhea s/p recent botox
injections to help control secretions that resulted in profound dysphagia.//
PEG tube placement desired to allow time for botox injections to wear off in
hopes she will regain swallow function.
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
25 mcg of fentanyl and 0.5 mg of midazolam throughout the total intra-service
time of 32 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: 1 mg of intravenous glucagon.
CONTRAST: 25 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 4.0 min, 5 mGy
PROCEDURE: 1. Placement of a 12 ___ Wills ___ gastrostomy tube.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The tube site was prepped and draped in the usual sterile fashion.
A scout image of the abdomen was obtained. The stomach was insufflated through
the indwelling nasogastric tube. Using a marker, the skin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Permanent ultrasound images were stored.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilute contrast. A ___ wire was
introduced into the stomach. A small skin incision was made along the needle
and the needle was removed.
After sequential dilation using 8 and 11 ___ dilators, a 12 ___ Wills
___ gastrostomy catheter was advanced over the wire into position. The
catheter was secured by forming the retaining loop in the stomach after
confirming the position of the catheter with a contrast injection. The
catheter was then flushed, capped and secured to the skin with 0-silk sutures.
Sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Successful placement of a 12 ___ Wills ___ gastrostomy tube.
IMPRESSION:
Successful placement of a 12 ___ Wills ___ gastrostomy tube. The
catheter should not be used for 24 hours.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Difficulty swallowing, Transfer
Diagnosed with Dysphagia, unspecified
temperature: 96.8
heartrate: 106.0
resprate: 20.0
o2sat: 100.0
sbp: 122.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ female with history of cerebellar
hemorrhage (___) due to AVM s/p s/p multiple craniotomies
(___) and recurrent hemorrhage complicated by
residual dysarthria/dysphagia (required PEG tube for a period of
time in ___, later removed), RA on methotrexate. She has had
progressive issues with recurrent aspiration pneumonias and
suspected aspiration of her secretions for which she underwent a
botox injection to her saliva glands by ENT on ___ after which
she noted an acute decline in her speech and ability to swallow.
Referred from ___ with concern for ongoing aspiration now
s/p PEG tube placement.
#HX of AVM s/p s/p suboccipital craniotomy (___) with
recurrent hemorrhage (___)
#Baseline dysphagia/dysarthria
#Moderate Protein Calorie Malnutrition
She has had a modified barium swallow most recently in ___
at ___ with trace aspiration. Ongoing aspiration was felt
due to copious secretions and sialorrhea by ENT so she underwent
botox injection of salivary glands ___. Notably, back in ___,
she had spent an extended time at a rehab facility with PEG tube
feeds which were later discontinued. The patient has expressed
resistance to the idea of having a PEG tube placed again. Due to
2 reported falls within the past 2 weeks prior to admission
combined with patient reports of worsening ability to ambulate
during that time, head Ct was ordered to rule out bleed, which
was unchanged since prior in ___. It is possible she may have
had a small ischemic stroke, not detected by head CT however
there would frankly be little to be done within her goals of
___ and her weakness and swallowing issues began worsening over
a week ago.
Discussed with SLP and pt noted to be frankly aspirating. Made
her strict NPO (was previously on thickened liquids and soft
solids at baseline).
After failing a bedside S/S, a feeding tube was placed ___
after family meeting resulted in agreement to use artificial
feeding temporarily pending VFSS. VFSS revealed profound
dysphagia and severe aspiration and asphyxiation risk. If this
were strictly effect from botox, we could see improvement as
early as 2 weeks from now, or it could take up to a few months.
PEG tube was placed ___ to allow time for improvement. Plan to
discharge to rehab for intensive SLP therapy at rehab in hopes
her swallow function will improve overtime. On ___ had some
nausea after bolus tube feed, so was placed on continuous
overnight. However bolus feeding was successful on ___ without
significant nausea.
- continue Jevity 1.5, 1 240 cc can 4x daily (if using Jevity
1.2, can use 5 cans daily)
- 60 cc water flush before and after each bolus
- speech/swallow therapy - hope is that function will return
#Mechanical falls
Due to 2 reported falls within the past 2 weeks prior to
admission combined with patient reports of worsening ability to
ambulate during that time. ___ unchanged since ___.
#RA: held methotrexate in setting of poor po intake. Will
restart at discharge
#Overactive bladder
Family reports h/o overactive bladder resulting in many
nocturnal
awakenings and inquired about starting meds. Should definitely
be
explored but will hold introducing a new medication at this time
and defer this decision to her PCP.
#Code Status: DNR/DNI
#Contacts: husband is ___ proxy ___ ___ (has
granddaughter ___ and daughter ___ who are both ___
affiliated with ___). ___ can be reached at ___
============================================= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with past medical history
significant for recurrent UTIs, schizoaffective disorder,
parkinsonism with gait instability who presented with altered
mental status and ___. History is limited by the patient's
confusion.
Most of the history was obtained from the patient's daughter and
HCP, ___, as the patient is AAOx1-2. The patient fell and
broke her hip on ___. She was seen at ___.
___ and had three pins inserted in her L hip.
About a week later, she was discharged to ___.
She was progressing well, but has been more belligerent with
___. They tested her urine for an infection, which was
negative, but C. diff came back positive. She was started on PO
flagyl on ___. She then had a positive UA on ___ and was
started on Levofloxacin on ___. Her daughter reports that her
dementia has slowly been getting worse, and she has been
intermittently refusing medications.
Before the fall, she lived at home with her husband, and used a
walker to ambulate. She had aids help her in the morning and the
evening.
In the ED, initial VS were 98.9, 57, 111/50, 18, 96% RA
Exam notable for AAOx1
Labs showed WBC 14.4, Hb 11.8, Plt 306, Cr 1.5.
Imaging showed CXR without acute cardiopulmonary process
Received 500cc NS, and IV ciprofloxacin.
Decision was made to admit to medicine for further management of
altered mental status and ___.
On arrival to the floor, the patient reports that she "hurts all
over". She thinks that she is at ___. She
doesn't know the date. She denies dysuria, fever, chills. She
only has been answering questions intermittently.
Past Medical History:
- Schizophrenia (schizoaffective type)
- Parkinsonism ___ antipsychotics
- Recurrent UTIs
- Glaucoma
- Anxiety
- h/o basal cell carcinoma of face
- Dementia
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: PO 171 / 74 65 20 91 RA
GENERAL: AAOx2 (knows name and that she is in a hospital, thinks
she's at ___, frail appearing
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, dry
mucous membranes, poor dentition
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=======================
VS: 97.4 145 / 74 71 18 95 RA
GENERAL: AAOx1, frail appearing, calm
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, moist
mucous membranes, poor dentition
NECK: non-tender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LAB RESULTS
====================
___ 01:55PM BLOOD WBC-14.4*# RBC-3.77* Hgb-11.8 Hct-36.7
MCV-97 MCH-31.3 MCHC-32.2 RDW-14.1 RDWSD-50.4* Plt ___
___ 01:55PM BLOOD Glucose-103* UreaN-28* Creat-1.5* Na-138
K-5.0 Cl-101 HCO3-23 AnGap-19
___ 06:35AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.2
___ 02:36PM BLOOD Lactate-1.7
DISCHARGE LAB RESULTS
====================
IMAGING/STUDIES
==============
___ CXR:
No acute cardiopulmonary process.
MICROBIOLOGY
============
___ Blood culture: pending
___ Urine culture: pending
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: ___ with fatigue// eval for pna
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Bilateral low lung volumes again limits evaluation.The lungs overall appear
clear without focal consolidation. No pleural effusion or pneumothorax is
seen. Cardiomediastinal silhouettes are unchanged allowing for differences in
technique and positioning.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Confusion
Diagnosed with Acute kidney failure, unspecified
temperature: 98.9
heartrate: 57.0
resprate: 18.0
o2sat: 96.0
sbp: 111.0
dbp: 50.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman with past medical history
significant for recurrent UTIs, schizoaffective disorder,
parkinsonism with gait instability, and dementia who presented
with altered mental status, found to have acute kidney injury
and positive UA concerning for urinary tract infection. She was
also found to have severe c.diff colitis and was started on
treatment with PO vancomycin. ___ was thought to be pre-renal in
setting of diarrhea and improved with fluids and treatment of
infection. Her mental status improved with treatment of
infection though still somewhat fatigued compared to reported
baseline.
#Urinary Tract Infection:
Last hospital admission in ___, the patient had
pansensitive UTI, which was treated with a 7 day course of
ciprofloxacin. She was discharged with prophylactic fosfomycin
3g weekly every ___ for recurrent UTI and known post-void
residual. Per recent Atrius notes, she was still getting UTIs
even with the fosfomycin, so it was stopped. She was also
started on vaginal estrogen cream to help maintain normal
vaginal flora. UA in ED was concerning for infection even though
urine culture was sterile by the time it resulted. Urine culture
from SNF noted to be growing Klebseilla which was sensitive to
Bactrim. She received a dose of IV ciprofloxacin in ED. She was
continued on ceftriaxone but then transitioned to oral Bactrim
for a seven day course (Last day ___.
#Severe clostridium difficile colitis:
Patient had a positive C.diff assay from ___, when she was
started on PO flagyl. She was transitioned to PO vancomycin
given severe c.diff with Cr elevation starting on ___. She will
need 14 days of treatment for c. diff after antibiotic course
for UTI finishes (From ___ to projected end date: ___.
#Toxic Metabolic Encephalopathy
#Dementia
Patient presented with worsening altered mental status in
setting of UTI, ___, and c. diff infection. Baseline mental
status is AAOx2. There is no history of falls at rehab, and no
focal neurological deficits. Low concern for intracranial bleed.
Her mental status improved with treatment of the UTI and c.
diff, however she was still somewhat fatigued compared to
baseline per her daughter.
#Schizoaffective disorder:
Continued home zyprexa 5mg daily sublingual. Continued home
Divalproex ___ 500mg daily.
TRANSITIONAL ISSUES
=================
[ ] Antibiotic course for UTI: Bactrim DS 1 tab BID (Last day
___
[ ] Antibiotic course for sever c.diff: Vancomycin 125 mg POG
Q6H for 2 weeks after UTI course (___)
[ ] Meloxicam held in setting of ___, consider restarting as
clinically indicated
#CODE: DNR/DNI (confirmed)
#CONTACT/HCP: ___ (daughter/HCP), ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / Penicillins
Attending: ___.
Chief Complaint:
Pain after mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ blind
female with history of atrial fibrillation who presented for
right hip pain after mechanical fall, unrevealing trauma survey,
admitted for better analgesia and renal insufficiency. Two
nights
ago, patient was returning from the bathroom, counting her steps
as she typically does, attempted to sit back in bed, but
miscounted, so did so before having reached it. She fell
backward, striking her head on the ground. She never lost
consciousness. Her daughter was home and promptly helped her
from
the ground. She developed right gluteal pain that radiated to
her
right posterior thigh the next day. She is afebrile,
hemodynamically stable with normal oxygenation on arrival.
Primary and secondary surveys were within normal limits. CT head
revealed known large intracranial lesion involving the left
sphenoid triangle, middle cranial fossa, sphenoid sinus, and
orbit as well as a second vertical meningioma. There were
otherwise no new hemorrhages or large territorial infarct. CT
neck likewise did not demonstrate a traumatic injury. Hip x-ray
was reassuring. She had mild pulmonary vascular congestion and
pulmonary edema on chest x-ray. CBC was notable for hemoglobin
10.2, greater than baseline. Creatinine 3.2. Sodium 132. WB
potassium 4.5. INR 1.6. A1C 7.9%. Urinalysis with 3 WBC, 1+ ___,
few bacteria.
REVIEW OF SYSTEMS: Constitutionally, she otherwise feels well.
She has not documented a fever at home and denies rigors,
anorexia, weight loss, or recent illnesses. She denies
presyncope, lightheadedness, or dizziness. She denies chest
pain,
shortness of breath, palpitations. She sleeps flat in bed. She
denies gastrointestinal and urinary symptoms too. Her pain
persists tonight. She has no bony pains elsewhere. Her
granddaughter adds that she has not been hydrating well, which
parallels a new sense of dysphagia. She is exceedingly concerned
that she might choke on both solids and fluids and "panics"
after
swallowing.
GERIATRICS REVIEW OF SYSTEMS:
-Cognitive screen: Vascular Dementia. Independent with basic
ADLs. Mostly dependent on instrumental ADLs.
-Depression screen: Positive.
-Nutrition: Appetite preserved.
-Gait/falls: Ambulated with cane.
-___ Equipment: cane.
-Vision: Total left blindness. Right significant vision loss.
-Hearing: Mild presbycusis.
-Bowel: No fecal incontinence.
-Bladder: No urinary incontinence.
-Social environment and support: Lives with daughter.
-Caregiver status: None currently.
Past Medical History:
1. Chronic kidney disease.
2. Congestive heart failure (diastolic stress test ___
outside hospital, EF of 60%)
3. Coronary artery disease status post myocardial infarction
4. Type 2 diabetes
5. GERD
6. Hyperlipidemia
7. Hypertension
8. Atrial fibrillation
9. Pulmonary hypertension
10. Chronic anemia
11. Osteoarthritis
12. Paget's disease of the pelvis
13. Glaucoma
14. Peripheral neuropathy (on gabapentin)
15. Macular degeneration (legally blind)
16. L temporal-parietal grade 2 meningioma s/p resection ___
17. Depression
18. L frontal lobe infarct (___)
Social History:
___
Family History:
(per OMR, confirmed with patient/daughter)
Her mother is deceased in her ___ of breast cancer with
metastasis to the brain. Her father died at the age of ___ of an
MI.
Physical Exam:
ADMISSION EXAM
=================
VITALS: T 98.6, HR 58, BP 174/55, 92% RA.
GENERAL: Frail elderly female in no apparent distress.
HEENT: Right corneal opacification. Left proptosis. Anicteic
sclerae. Oropharynx clear.
NECK: External jugular is prominent, yet JVP is at the clavicle
at a thirty degree angle. No hepatojugular reflux. She has no
spinous process tenderness.
CV: Regular rate and rhythm. S1/physiologic split S2. Subtle
systolic murmur across precordium. No gallop.
LUNGS: Unlabored. Lungs clear bilaterally.
ABDOMEN: Soft, non-tender, non-distended, normoactive.
RIGHT LOWER EXTREMITY: Point tenderness overlying greater
trochanter. No obvious deformity, swelling, warmth, erythema, or
contusion. ROM is intact.
EXTREMITY: All warm, well perfused, without edema.
SKIN: Within normal limits.
NEURO: Non-focal.
DISCHARGE EXAM
===================
24 HR Data (last updated ___ @ 002)
Temp: 98.3 (Tm 98.5), BP: 128/59 (128-175/51-75), HR: 61
(40-72), RR: 18, O2 sat: 94% (94-100), O2 delivery: Ra
GENERAL: Frail elderly female in no apparent distress.
HEENT: Right corneal opacification. Left proptosis with
significant swelling around the left eye. Anicteric sclerae.
Oropharynx clear.
NECK: Supple.
CV: Regular rate and rhythm. S1/physiologic split S2. Subtle
systolic murmur across precordium. No gallop.
LUNGS: Unlabored. Lungs clear bilaterally.
ABDOMEN: Soft, non-tender, non-distended, normoactive bowel
sounds in all quadrants.
RIGHT LOWER EXTREMITY: No tenderness over the right posterior
thigh/gluteus maximus. No tenderness over the right femur. No
obvious deformity, swelling, warmth, erythema, or contusion.
LEFT UPPER EXTREMITY: No tenderness anywhere in the left upper
extremity, including the left shoulder joint. No gross
deformities.
EXTREMITY: All warm, well perfused, without edema.
SKIN: Within normal limits.
NEURO: A&Ox3. Normal speech and mentation. Normal sensation to
light touch in the extremities. Full and symmetric hand grip
strength.
Pertinent Results:
====ADMISSION LABS====
___ 09:39PM GLUCOSE-154* UREA N-57* CREAT-3.1* SODIUM-138
POTASSIUM-5.2 CHLORIDE-100 TOTAL CO2-25 ANION GAP-13
___ 09:39PM CALCIUM-9.2 PHOSPHATE-4.5 MAGNESIUM-2.4
___ 10:50AM WBC-7.5 RBC-3.95 HGB-10.2* HCT-32.4* MCV-82
MCH-25.8* MCHC-31.5* RDW-17.2* RDWSD-50.0*
___ 10:50AM NEUTS-69.8 LYMPHS-17.0* MONOS-4.0* EOS-8.4*
BASOS-0.5 IM ___ AbsNeut-5.27 AbsLymp-1.28 AbsMono-0.30
AbsEos-0.63* AbsBaso-0.04
___ 10:50AM PLT COUNT-176
___ 10:50AM ___ PTT-21.0* ___
___ 05:00PM proBNP-349
====PERTINENT LABS====
Creatine Kinase (___): 149
proBNP (___): 349
HbA1c (___): 7.9
SPEP (___): FreeKappa 70.5, FreeLambda 29.4, Fr K/L 2.4
UPEP (___): albumin is the only protein detected
Urine culture (___): NEGATIVE
====DISCHARGE LABS====
___ 08:23AM BLOOD WBC-6.1 RBC-3.55* Hgb-9.1* Hct-28.8*
MCV-81* MCH-25.6* MCHC-31.6* RDW-17.4* RDWSD-50.8* Plt ___
___ 08:23AM BLOOD Glucose-141* UreaN-43* Creat-2.0* Na-140
K-4.8 Cl-105 HCO3-24 AnGap-11
___ 08:23AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.3
====IMAGING====
###MRI Brain and orbits with and without contrast on ___
EXAMINATION: MRI ORBITS AND BRAIN WANDW/O CONTRAST T714 MR
___
INDICATION: ___ year old woman with CKD and hx of sphenoid
meningioma s/p left
pteronial craniotomy resection in ___, p/w chronic worsening of
left
proptosis c/f progression of known recurrent meningioma.
Evaluation for
intra-/extra-cranial mass near the left eye, interval change,
other
intracranial masses.
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.
Orbit images acquired at 3 mm slice thickness. Precontrast
sequences included
axial and coronal T1, coronal STIR. Postcontrast sequences
included axial and
coronal T1 with fat saturation.
COMPARISON: ___ noncontrast head
CT.
FINDINGS:
Study is moderately degraded by motion. Within these confines:
MRI BRAIN:
There is no evidence of hemorrhage orinfarction.
There is an enhancing, partially calcified soft tissue lesion
along the right
vertex which appears contiguous with the dura, measuring 2.1 x
1.3 x 1.2 cm
(___), compatible with a meningioma. Allowing for
difference
technique, finding is grossly similar compared to prior ___
exam.
Left sphenoid subtotal resection postsurgical changes and left
temporal lobe
encephalomalacia are grossly unchanged, allowing for difference
technique.
There is prominence of the ventricles and sulci suggestive of
involutional
changes, unchanged. No midline shift. Small chronic infarct
again
demonstrated within the right posterior cerebellum.
Periventricular and
subcortical white matter T2/FLAIR signal hyperintensities,
findings which are
nonspecific though likely sequela of chronic small vessel
ischemic disease.
Mild mucosal thickening of the bilateral maxillary sinuses, left
sphenoid
sinus, and bilateral ethmoid air cells. The remaining paranasal
sinuses and
mastoid air cells are clear.
MRI ORBITS:
There is a heterogeneously enhancing mass which appears centered
upon the left
sphenoid bone and along the left zygomatic arch measuring
approximately 7.6 x
4.1 x 6.0 cm (14:14, 15:9), compatible with known recurrent left
sphenoid
meningioma. There is encroachment upon the left orbital apex,
as well as mass
effect and medial displacement of the superior and lateral
rectus muscles.
Mild medial displacement of the left optic nerve. The mass
surrounds the left
internal carotid artery cavernous segment, with grossly
preserved flow void.
Associated left proptosis remains similar in appearance to prior
study.
Bilateral globes demonstrate postoperative changes. Otherwise,
the right
orbit is grossly preserved.
A left temporal approximately 1.4 x 0.8 cm homogeneously
enhancing dural-based
mass is noted, minimally increased in size compared to ___xam (see
6, 14:4 on current study and 02:13 on ___ prior exam).
Limited imaging of the cervical spine suggests severe vertebral
canal
narrowing at C4-5 (see 03:12).
IMPRESSION:
1. Study is moderately degraded by motion.
2. Redemonstration of known recurrent left sphenoid meningioma,
which appears
centered upon the left sphenoid bone and along the left
zygomatic arch
measuring approximately 7.6 x 4.1 x 6.0 cm, with encroachment
upon the left
orbital apex with associated mass effect resulting in medial
displacement of
the superior and lateral rectus muscles and the left optic
nerve.
3. Associated left proptosis remains similar in appearance to
prior study.
4. Probable meningioma along the right vertex measures up to 2.1
cm, grossly
similar to ___ prior exam, allowing for difference in
technique.
5. Minimal interval increase in size of left temporal probable
meningioma, now
measuring up to approximately 1.4 x 0.8 cm, without definite
evidence of edema
in adjacent frontal or temporal lobe.
6. No evidence of intracranial hemorrhage or infarction.
7. Limited imaging of the cervical spine suggests moderate to
severe vertebral
canal narrowing at C4-5. If clinically indicated, consider
dedicated cervical
spine MRI for further evaluation.
###Video Swallow Test
EXAMINATION: Video swallow study.
INDICATION: ___ year old woman with afib on apixaban, admitted
for pain
management and acute-on-chronic kidney injury after mechanical
fall, now also
complaining of longstanding dysphagia, difficulty swallowing,
and occasional
choking while eating.// ?etiology of patient's dysphagia
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 minutes 23 seconds.
COMPARISON: None
FINDINGS:
There was no gross aspiration or penetration. No pharyngeal
residue.
IMPRESSION:
Normal oropharyngeal swallowing videofluoroscopy.
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).
###EXAMINATION: SHOULDER ___ VIEWS NON TRAUMA LEFT (___)
INDICATION: ___ year old woman with afib on apixaban, admitted
for pain mgmt after mechanical fall. Originally admitted for
right hip/femur pain, but now reporting 1 day of left
mid-humeral/shoulder while hospitalized. No reported trauma to
the shoulder.// ?dislocation ?fracture
FINDINGS:
There is no fracture or dislocation involving the glenohumeral
or AC joint. Mild degenerative changes of the glenohumeral
joint, moderate degenerative changes of the AC joint. There is
remodeling of the greater tuberosity, secondary to rotator cuff
tendinopathy. No suspicious lytic or sclerotic lesions are
identified. No periarticular calcification or radio-opaque
foreign body is seen.
IMPRESSION:
Rotator cuff tendinopathy, with moderate degenerative changes of
the AC joint and mild degenerative changes of the glenohumeral
joint. No acute fracture or dislocation.
###EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE (___)
INDICATION: ___ year old woman with fall, left hip pain and
lower back pain, no fracture on radiographs. Evaluate for
fracture.
TECHNIQUE: Non-contrast helical multidetector CT of the lumbar
spine was
performed. Soft tissue and bone algorithm images were generated.
Coronal and sagittal reformations were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.7 s, 29.1 cm; CTDIvol = 27.2 mGy
(Body) DLP = 791.5 mGy-cm. Total DLP (Body) = 791 mGy-cm.
COMPARISON: CT pelvis from ___.
Renal ultrasound ___.
FINDINGS:
There are 5 lumbar-type vertebrae. The bones appear
demineralized. No acute displaced fracture is seen. There is a
well corticated linear lucency through the right L1 lamina on
images 2:15, 601:41, 602:34, likely a nutrient channel, less
likely a chronic fracture. There is mild deformity of the left
L1 transverse process, images 2:14 and 601:40, compatible with a
chronic healed fracture.
Evaluation of the spinal canal and neural foramina by CTs
limited compared to MRI.
T12-L1: No spinal canal narrowing. At least mild bilateral
neural foraminal narrowing by facet osteophytes.
L1-L2: Mild disc bulge and mild facet arthropathy. No
significant spinal
canal narrowing. Neural foraminal narrowing appears moderate
bilaterally.
L2-L3: Mild disc bulge and mild facet arthropathy. The ventral
thecal sac is mildly indented. Mild right and mild-to-moderate
left neural foraminal
narrowing.
L3-L4: Moderate disc bulge, infolding of the ligamentum flavum,
moderate facet arthropathy. The thecal sac appears moderately
narrowed. Subarticular zones are narrowed. Neural foraminal
narrowing appears moderate to severe on the right and moderate
on the left.
L4-L5: Grade 1 anterolisthesis secondary to severe facet
arthropathy, without L4 pars defect. Infolding of the
ligamentum flavum. Uncovered and bulging disc. The thecal sac
appears severely narrowed. The neural foramina are
foreshortened with moderate to severe narrowing.
L5-S1: Loss of disc height, vacuum phenomenon in the disc, mild
disc bulge, and endplate osteophytes. Moderate facet
arthropathy. The thecal sac does not appear significantly
narrowed, but the subarticular zones are narrowed. Neural
foraminal narrowing appears moderate to severe bilaterally.
Degenerative changes of the sacroiliac joints are partially
imaged.
Concurrent CT pelvis is reported separately.
Atherosclerotic calcifications are noted in the imaged
retroperitoneum.
Diverticulosis of the partially imaged sigmoid colon is noted.
There are
multiple hypodense and hyperdense cystic lesions in both
kidneys, better
assessed on the same-day ultrasound.
IMPRESSION:
1. No evidence for acute displaced fracture allowing for loss of
bone
mineralization.
2. Mild deformity of the distal left L1 transverse process is
compatible with a chronic healed fracture. Well corticated
linear lucency through the right L1 lamina may represent a
nutrient channel, less likely a chronic fracture.
3. Extensive multilevel degenerative disease. Spinal canal
stenosis appears severe at L4-L5 and moderate at L3-L4. Neural
foraminal narrowing appears advanced at multiple levels, as
detailed above. The thecal sac, traversing nerve roots, and
exiting nerve roots may be better assessed by MRI if clinically
warranted.
4. Concurrent CT pelvis is reported separately.
###EXAMINATION: CT PELVIS ORTHO W/O C (___)
INDICATION: ___ year old woman with fall, left hip pain and
lower back pain, no Fx on xray// eval for fracture pelvis, L
spine
TECHNIQUE: Multidetector CT images of the abdomen and pelvis
were acquired without intravenous contrast. Non-contrast scan
has several limitations in detecting vascular and parenchymal
organ abnormalities, including tumor detection.
Oral contrast was not administered. Coronal and sagittal
reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.0 s, 29.9 cm; CTDIvol = 21.3 mGy
(Body) DLP = 637.4 mGy-cm. Total DLP (Body) = 637 mGy-cm.
COMPARISON: CT pelvis ___.
FINDINGS:
PELVIS: The partially visualized small and large bowel are
unremarkable. The appendix appears unremarkable. There are
scattered diverticulosis without evidence of diverticulitis.
The urinary bladder and distal ureters are unremarkable. There
is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal
abnormality is seen.
LYMPH NODES: There is no pelvic or inguinal lymphadenopathy.
VASCULAR: Moderately severe atherosclerotic disease is noted.
BONES: Sclerotic appearance of the right inferior pubic ramus is
similar to the prior study. A mottled appearance with
relatively dense sclerosis. No definite trabecular or cortical
thickening to suggest Paget's disease. Moderate degenerative
changes are noted in bilateral sacroiliac joints, similar in
appearance when compared to the prior study. Severe
degenerative changes are noted at L5-S1. Grade 1
anterolisthesis of L4 on L5 is again demonstrated.
SOFT TISSUES: A umbilical hernia containing fat is noted.
IMPRESSION:
1. No acute fracture or dislocation.
2. Sclerosis of the right inferior pubic ramus is again noted.
The
appearances are not typical of Paget's disease. If the patient
has a history of malignancy, recommend further evaluation with
bone scan.
###EXAMINATION: RENAL U.S. (___)
INDICATION: ___ female with acute on chronic kidney
injury. Evaluate for cortical atrophy, hydronephrosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of
the kidneys were obtained.
COMPARISON: None.
FINDINGS:
Bilateral simple renal cysts are demonstrated the largest
measuring up to 1.7 x 1.7 x 1.7 cm in the right lower pole
kidney. A left interpolar cyst
measures 3.3 x 3.2 x 3.2 cm and demonstrates a thin internal
septation. There is no hydronephrosis, stones, or concerning
masses bilaterally. Normal cortical echogenicity and
corticomedullary differentiation are seen
bilaterally.
Right kidney: 8.4 cm
Left kidney: 8.6 cm
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
1. Bilateral anechoic cysts, the largest measuring up to 3.3 cm
in the left interpolar kidney with a single thin internal
septation consistent with a Bosniak 2 cyst.
2. Otherwise normal renal ultrasound. Specifically, no
hydronephrosis.
###EXAMINATION: CT C-SPINE W/O CONTRAST (___)
INDICATION: History: ___ with headache, right hip pain status
post fall, on Eliquis// Eval for fracture, eval for bleeding
TECHNIQUE: Contiguous axial images obtained through the
cervical spine
without intravenous contrast. Coronal and sagittal reformats
were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 19.8 cm; CTDIvol = 22.6 mGy
(Body) DLP = 446.6 mGy-cm. Total DLP (Body) = 447 mGy-cm.
COMPARISON: None.
FINDINGS:
Stepwise 2 mm retrolisthesis of C4 on C5 and C5 on C6 is almost
certainly
degenerative. Otherwise, cervical alignment is anatomic.
Vertebral body
heights are preserved. No acute fractures are identified.
There is
multilevel degenerative change including intervertebral disc
height loss,
subchondral sclerosis and subchondral cystic change. No
prevertebral edema.
There is mild-to-moderate stenosis of the cervical spine at
C2-C4, secondary to degenerative changes.
The lung apices are unremarkable. There is a 1.5 cm hypodensity
within the right thyroid lobe. Please refer to concurrent CT
head for description of left sphenoid wing mass, with
involvement of the pterygoid muscles.
IMPRESSION:
1. No acute displaced fracture.
2. 2 mm retrolisthesis of C4 on C5 and C5 on C6 are almost
certainly
degenerative. However, if there is high clinical suspicion for
ligamentous injury, MRI, if there are no contraindications would
be more sensitive.
3. Degenerative changes as above.
4. 1.5 cm hypodense right thyroid nodule. Findings could be
further evaluated nonurgent thyroid ultrasound if not previously
obtained.
RECOMMENDATION(S): Thyroid nodule. Ultrasound follow up
recommended.
___ College of Radiology guidelines recommend further
evaluation for
incidental thyroid nodules of 1.0 cm or larger in patients under
age ___ or 1.5 cm in patients age ___ or ___, or with suspicious
findings.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or invasion of local tissues by the thyroid nodule.
###EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD (___)
INDICATION: History: ___ with headache, right hip pain status
post fall, on Eliquis// Eval for fracture, eval for bleeding
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 8.0 s, 16.5 cm; CTDIvol = 48.7 mGy
(Head) DLP =802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm.
COMPARISON: Prior head CT ___
FINDINGS:
Along the right vertex, there is a 1.6 x 1.0 cm
hyperattenuating, partially calcified mass (series 2, image 24),
similar to slightly increased in size from prior study. No
intracranial hemorrhage. No large territorial infarction. Left
temporal lobe encephalomalacia is chronic and unchanged in
extent. There is periventricular and subcortical white matter
hypodensity, as well as relative volume loss along the left
frontal lobe near the anterior horn of the left lateral
ventricle (series 2, image 17) which appears unchanged from the
prior study. Findings likely suggest sequela of chronic
microangiopathy.
There is a lytic lesion along the left zygomatic arch and
sphenoid bone
measuring approximately 5.1 x 3.2 cm, not grossly changed from
___ (series 2, image 8). There is associated left proptosis,
also unchanged from prior. The optic nerve is strain, however
this is unchanged (series 2, image 6). The lesion appears to
involve the left pterygoid muscles, temporalis and lateral
rectus muscles.
Evidence of prior left craniotomy. Stable appearance of the
bilateral sinuses and mastoid air cells. No acute fractures.
IMPRESSION:
1. No acute intracranial hemorrhage or evidence of a new large
territorial
infarction.
2. Similar to slightly increased size of a left sided lytic
lesion centered
about the sphenoid bone, similar extent of skullbase and left
middle cranial
fossa extension. There is left-sided proptosis with some
straightening of the
optic nerve however this is unchanged from the prior study. The
lesion
appears to involve the left pterygoid muscles, temporalis and
lateral rectus
muscles.
3. Hyperattenuating and calcified 1.6 cm right sided lesion at
the vertex
previously characterized as a meningioma is unchanged.
###EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT
(___)
INDICATION: History: ___ with headache, right hip pain status
post fall, on Eliquis// Eval for fracture, eval for bleeding
Eval for fracture, eval for bleeding
Eval for fracture, eval for bleeding
COMPARISON: CT pelvis ___
FINDINGS:
AP pelvis and AP and lateral view of the right hip show no
fracture or
dislocation. Multiple soft tissue in pelvic calcifications are
noted most of which are probably vascular in etiology. Some
could represent injection granulomas.
IMPRESSION:
No acute fracture or dislocation.
###EXAMINATION: CHEST (PA AND LAT) (___)
INDICATION: History: ___ with fall, cough// eval for pna
eval for pna
COMPARISON: Chest x-ray ___
FINDINGS:
Cardiomegaly with mild pulmonary vascular congestion and
pulmonary edema.
Costophrenic angles are sharp. No focal consolidation. No
pneumothorax.
IMPRESSION:
Cardiomegaly with mild pulmonary vascular congestion and
pulmonary edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID
2. Losartan Potassium 100 mg PO QPM
3. Mirtazapine 3.75 mg PO QHS
4. CARVedilol 25 mg PO BID
5. Bisacodyl 10 mg PO DAILY:PRN Constipation
6. amLODIPine 10 mg PO QAM
7. SITagliptin 100 mg oral DAILY
8. Apixaban 2.5 mg PO BID
9. Atorvastatin 20 mg PO QPM
10. Detemir 18 Units Breakfast
11. Furosemide 60 mg PO DAILY
12. Spironolactone 25 mg PO DAILY
13. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
14. PreserVision AREDS-2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral DAILY
15. Aspirin 81 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q6H
3. Timolol Maleate 0.25% 1 DROP LEFT EYE BID
4. Furosemide 40 mg PO DAILY
5. Detemir 18 Units Breakfast
6. Losartan Potassium 50 mg PO DAILY
7. Mirtazapine 7.5 mg PO QHS
8. amLODIPine 10 mg PO QAM
9. Apixaban 2.5 mg PO BID
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 20 mg PO QPM
12. Bisacodyl 10 mg PO DAILY:PRN Constipation
13. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID
14. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
15. PreserVision AREDS-2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral DAILY
16. SITagliptin 100 mg oral DAILY
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Mechanical fall
Acute kidney injury on chronic kidney disease
Left-sided proptosis
History of Meningioma
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: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT
INDICATION: History: ___ with headache, right hip pain status post fall, on
Eliquis// Eval for fracture, eval for bleeding Eval for fracture, eval
for bleeding Eval for fracture,
eval for bleeding
COMPARISON: CT pelvis ___
FINDINGS:
AP pelvis and AP and lateral view of the right hip show no fracture or
dislocation. Multiple soft tissue in pelvic calcifications are noted most of
which are probably vascular in etiology. Some could represent injection
granulomas.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with fall, cough// eval for pna eval for pna
COMPARISON: Chest x-ray ___
FINDINGS:
Cardiomegaly with mild pulmonary vascular congestion and pulmonary edema.
Costophrenic angles are sharp. No focal consolidation. No pneumothorax.
IMPRESSION:
Cardiomegaly with mild pulmonary vascular congestion and pulmonary edema.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with headache, right hip pain status post fall, on
Eliquis// Eval for fracture, eval for bleeding
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 8.0 s, 16.5 cm; CTDIvol = 48.7 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Prior head CT ___
FINDINGS:
Along the right vertex, there is a 1.6 x 1.0 cm hyperattenuating, partially
calcified mass (series 2, image 24), similar to slightly increased in size
from prior study. No intracranial hemorrhage. No large territorial
infarction. Left temporal lobe encephalomalacia is chronic and unchanged in
extent. There is periventricular and subcortical white matter hypodensity, as
well as relative volume loss along the left frontal lobe near the anterior
horn of the left lateral ventricle (series 2, image 17) which appears
unchanged from the prior study. Findings likely suggest sequela of chronic
microangiopathy.
There is a lytic lesion along the left zygomatic arch and sphenoid bone
measuring approximately 5.1 x 3.2 cm, not grossly changed from ___ (series 2, image 8). There is associated left proptosis, also unchanged
from prior. The optic nerve is strain, however this is unchanged (series 2,
image 6). The lesion appears to involve the left pterygoid muscles, temporalis
and lateral rectus muscles.
Evidence of prior left craniotomy. Stable appearance of the bilateral sinuses
and mastoid air cells. No acute fractures.
IMPRESSION:
1. No acute intracranial hemorrhage or evidence of a new large territorial
infarction.
2. Similar to slightly increased size of a left sided lytic lesion centered
about the sphenoid bone, similar extent of skullbase and left middle cranial
fossa extension. There is left-sided proptosis with some straightening of the
optic nerve however this is unchanged from the prior study. The lesion
appears to involve the left pterygoid muscles, temporalis and lateral rectus
muscles.
3. Hyperattenuating and calcified 1.6 cm right sided lesion at the vertex
previously characterized as a meningioma is unchanged.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with headache, right hip pain status post fall, on
Eliquis// Eval for fracture, eval for bleeding
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 19.8 cm; CTDIvol = 22.6 mGy (Body) DLP = 446.6
mGy-cm.
Total DLP (Body) = 447 mGy-cm.
COMPARISON: None.
FINDINGS:
Stepwise 2 mm retrolisthesis of C4 on C5 and C5 on C6 is almost certainly
degenerative. Otherwise, cervical alignment is anatomic. Vertebral body
heights are preserved. No acute fractures are identified. There is
multilevel degenerative change including intervertebral disc height loss,
subchondral sclerosis and subchondral cystic change. No prevertebral edema.
There is mild-to-moderate stenosis of the cervical spine at C2-C4, secondary
to degenerative changes.
The lung apices are unremarkable. There is a 1.5 cm hypodensity within the
right thyroid lobe. Please refer to concurrent CT head for description of
left sphenoid wing mass, with involvement of the pterygoid muscles.
IMPRESSION:
1. No acute displaced fracture.
2. 2 mm retrolisthesis of C4 on C5 and C5 on C6 are almost certainly
degenerative. However, if there is high clinical suspicion for ligamentous
injury, MRI, if there are no contraindications would be more sensitive.
3. Degenerative changes as above.
4. 1.5 cm hypodense right thyroid nodule. Findings could be further evaluated
nonurgent thyroid ultrasound if not previously obtained.
RECOMMENDATION(S): Thyroid nodule. Ultrasound follow up recommended.
___ College of Radiology guidelines recommend further evaluation for
incidental thyroid nodules of 1.0 cm or larger in patients under age ___ or 1.5
cm in patients age ___ or ___, or with suspicious findings.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ female with acute on chronic kidney injury. Evaluate
for cortical atrophy, hydronephrosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
Bilateral simple renal cysts are demonstrated the largest measuring up to 1.7
x 1.7 x 1.7 cm in the right lower pole kidney. A left interpolar cyst
measures 3.3 x 3.2 x 3.2 cm and demonstrates a thin internal septation. There
is no hydronephrosis, stones, or concerning masses bilaterally. Normal
cortical echogenicity and corticomedullary differentiation are seen
bilaterally.
Right kidney: 8.4 cm
Left kidney: 8.6 cm
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
1. Bilateral anechoic cysts, the largest measuring up to 3.3 cm in the left
interpolar kidney with a single thin internal septation consistent with a
Bosniak 2 cyst.
2. Otherwise normal renal ultrasound. Specifically, no hydronephrosis.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE
INDICATION: ___ year old woman with fall, left hip pain and lower back pain,
no fracture on radiographs. Evaluate for fracture.
TECHNIQUE: Non-contrast helical multidetector CT of the lumbar spine was
performed. Soft tissue and bone algorithm images were generated. Coronal and
sagittal reformations were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.7 s, 29.1 cm; CTDIvol = 27.2 mGy (Body) DLP = 791.5
mGy-cm.
Total DLP (Body) = 791 mGy-cm.
COMPARISON: CT pelvis from ___.
Renal ultrasound ___.
FINDINGS:
There are 5 lumbar-type vertebrae. The bones appear demineralized. No acute
displaced fracture is seen. There is a well corticated linear lucency through
the right L1 lamina on images 2:15, 601:41, 602:34, likely a nutrient channel,
less likely a chronic fracture. There is mild deformity of the left L1
transverse process, images 2:14 and 601:40, compatible with a chronic healed
fracture.
Evaluation of the spinal canal and neural foramina by CTs limited compared to
MRI.
T12-L1: No spinal canal narrowing. At least mild bilateral neural foraminal
narrowing by facet osteophytes.
L1-L2: Mild disc bulge and mild facet arthropathy. No significant spinal
canal narrowing. Neural foraminal narrowing appears moderate bilaterally.
L2-L3: Mild disc bulge and mild facet arthropathy. The ventral thecal sac is
mildly indented. Mild right and mild-to-moderate left neural foraminal
narrowing.
L3-L4: Moderate disc bulge, infolding of the ligamentum flavum, moderate facet
arthropathy. The thecal sac appears moderately narrowed. Subarticular zones
are narrowed. Neural foraminal narrowing appears moderate to severe on the
right and moderate on the left.
L4-L5: Grade 1 anterolisthesis secondary to severe facet arthropathy, without
L4 pars defect. Infolding of the ligamentum flavum. Uncovered and bulging
disc. The thecal sac appears severely narrowed. The neural foramina are
foreshortened with moderate to severe narrowing.
L5-S1: Loss of disc height, vacuum phenomenon in the disc, mild disc bulge,
and endplate osteophytes. Moderate facet arthropathy. The thecal sac does
not appear significantly narrowed, but the subarticular zones are narrowed.
Neural foraminal narrowing appears moderate to severe bilaterally.
Degenerative changes of the sacroiliac joints are partially imaged.
Concurrent CT pelvis is reported separately.
Atherosclerotic calcifications are noted in the imaged retroperitoneum.
Diverticulosis of the partially imaged sigmoid colon is noted. There are
multiple hypodense and hyperdense cystic lesions in both kidneys, better
assessed on the same-day ultrasound.
IMPRESSION:
1. No evidence for acute displaced fracture allowing for loss of bone
mineralization.
2. Mild deformity of the distal left L1 transverse process is compatible with
a chronic healed fracture. Well corticated linear lucency through the right
L1 lamina may represent a nutrient channel, less likely a chronic fracture.
3. Extensive multilevel degenerative disease. Spinal canal stenosis appears
severe at L4-L5 and moderate at L3-L4. Neural foraminal narrowing appears
advanced at multiple levels, as detailed above. The thecal sac, traversing
nerve roots, and exiting nerve roots may be better assessed by MRI if
clinically warranted.
4. Concurrent CT pelvis is reported separately.
Radiology Report
EXAMINATION: CT PELVIS ORTHO W/O C
INDICATION: ___ year old woman with fall, left hip pain and lower back pain,
no Fx on xray// eval for fracture pelvis, L spine
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.0 s, 29.9 cm; CTDIvol = 21.3 mGy (Body) DLP = 637.4
mGy-cm.
Total DLP (Body) = 637 mGy-cm.
COMPARISON: CT pelvis ___.
FINDINGS:
PELVIS: The partially visualized small and large bowel are unremarkable. The
appendix appears unremarkable. There are scattered diverticulosis without
evidence of diverticulitis. The urinary bladder and distal ureters are
unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
LYMPH NODES: There is no pelvic or inguinal lymphadenopathy.
VASCULAR: Moderately severe atherosclerotic disease is noted.
BONES: Sclerotic appearance of the right inferior pubic ramus is similar to
the prior study. A mottled appearance with relatively dense sclerosis. No
definite trabecular or cortical thickening to suggest Paget's disease.
Moderate degenerative changes are noted in bilateral sacroiliac joints,
similar in appearance when compared to the prior study. Severe degenerative
changes are noted at L5-S1. Grade 1 anterolisthesis of L4 on L5 is again
demonstrated.
SOFT TISSUES: A umbilical hernia containing fat is noted.
IMPRESSION:
1. No acute fracture or dislocation.
2. Sclerosis of the right inferior pubic ramus is again noted. The
appearances are not typical of Paget's disease. If the patient has a history
of malignancy, recommend further evaluation with bone scan.
RECOMMENDATION(S): Consider bone scan as above
Radiology Report
EXAMINATION: SHOULDER ___ VIEWS NON TRAUMA LEFT
INDICATION: ___ year old woman with afib on apixaban, admitted for pain mgmt
after mechanical fall. Originally admitted for right hip/femur pain, but now
reporting 1 day of left mid-humeral/shoulder while hospitalized. No reported
trauma to the shoulder.// ?dislocation ?fracture
FINDINGS:
There is no fracture or dislocation involving the glenohumeral or AC joint.
Mild degenerative changes of the glenohumeral joint, moderate degenerative
changes of the AC joint. There is remodeling of the greater tuberosity,
secondary to rotator cuff tendinopathy. No suspicious lytic or sclerotic
lesions are identified. No periarticular calcification or radio-opaque foreign
body is seen.
IMPRESSION:
Rotator cuff tendinopathy, with moderate degenerative changes of the AC joint
and mild degenerative changes of the glenohumeral joint. No acute fracture or
dislocation.
Radiology Report
EXAMINATION: MRI ORBITS AND BRAIN WANDW/O CONTRAST T714 MR ___
INDICATION: ___ year old woman with CKD and hx of sphenoid meningioma s/p left
pteronial craniotomy resection in ___, p/w chronic worsening of left
proptosis c/f progression of known recurrent meningioma. Evaluation for
intra-/extra-cranial mass near the left eye, interval change, other
intracranial masses.
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.
Orbit images acquired at 3 mm slice thickness. Precontrast sequences included
axial and coronal T1, coronal STIR. Postcontrast sequences included axial and
coronal T1 with fat saturation.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
Study is moderately degraded by motion. Within these confines:
MRI BRAIN:
There is no evidence of hemorrhage orinfarction.
There is an enhancing, partially calcified soft tissue lesion along the right
vertex which appears contiguous with the dura, measuring 2.1 x 1.3 x 1.2 cm
(___), compatible with a meningioma. Allowing for difference
technique, finding is grossly similar compared to prior ___ exam.
Left sphenoid subtotal resection postsurgical changes and left temporal lobe
encephalomalacia are grossly unchanged, allowing for difference technique.
There is prominence of the ventricles and sulci suggestive of involutional
changes, unchanged. No midline shift. Small chronic infarct again
demonstrated within the right posterior cerebellum. Periventricular and
subcortical white matter T2/FLAIR signal hyperintensities, findings which are
nonspecific though likely sequela of chronic small vessel ischemic disease.
Mild mucosal thickening of the bilateral maxillary sinuses, left sphenoid
sinus, and bilateral ethmoid air cells. The remaining paranasal sinuses and
mastoid air cells are clear.
MRI ORBITS:
There is a heterogeneously enhancing mass which appears centered upon the left
sphenoid bone and along the left zygomatic arch measuring approximately 7.6 x
4.1 x 6.0 cm (14:14, 15:9), compatible with known recurrent left sphenoid
meningioma. There is encroachment upon the left orbital apex, as well as mass
effect and medial displacement of the superior and lateral rectus muscles.
Mild medial displacement of the left optic nerve. The mass surrounds the left
internal carotid artery cavernous segment, with grossly preserved flow void.
Associated left proptosis remains similar in appearance to prior study.
Bilateral globes demonstrate postoperative changes. Otherwise, the right
orbit is grossly preserved.
A left temporal approximately 1.4 x 0.8 cm homogeneously enhancing dural-based
mass is noted, minimally increased in size compared to ___ prior CT exam (see
6, 14:4 on current study and 02:13 on ___ prior exam).
Limited imaging of the cervical spine suggests severe vertebral canal
narrowing at C4-5 (see 03:12).
IMPRESSION:
1. Study is moderately degraded by motion.
2. Redemonstration of known recurrent left sphenoid meningioma, which appears
centered upon the left sphenoid bone and along the left zygomatic arch
measuring approximately 7.6 x 4.1 x 6.0 cm, with encroachment upon the left
orbital apex with associated mass effect resulting in medial displacement of
the superior and lateral rectus muscles and the left optic nerve.
3. Associated left proptosis remains similar in appearance to prior study.
4. Probable meningioma along the right vertex measures up to 2.1 cm, grossly
similar to ___ prior exam, allowing for difference in technique.
5. Minimal interval increase in size of left temporal probable meningioma, now
measuring up to approximately 1.4 x 0.8 cm, without definite evidence of edema
in adjacent frontal or temporal lobe.
6. No evidence of intracranial hemorrhage or infarction.
7. Limited imaging of the cervical spine suggests moderate to severe vertebral
canal narrowing at C4-5. If clinically indicated, consider dedicated cervical
spine MRI for further evaluation.
Radiology Report
EXAMINATION: Video swallow study.
INDICATION: ___ year old woman with afib on apixaban, admitted for pain
management and acute-on-chronic kidney injury after mechanical fall, now also
complaining of longstanding dysphagia, difficulty swallowing, and occasional
choking while eating.// ?etiology of patient's dysphagia
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 minutes 23 seconds.
COMPARISON: None
FINDINGS:
There was no gross aspiration or penetration. No pharyngeal residue.
IMPRESSION:
Normal oropharyngeal swallowing videofluoroscopy.
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: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: R Hip pain, s/p Fall
Diagnosed with Acute kidney failure, unspecified
temperature: 97.1
heartrate: 56.0
resprate: 17.0
o2sat: 100.0
sbp: 139.0
dbp: 54.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is an ___ year old female with PMHx of CAD, HTN, T2DM,
HFpEF, CKD IV, afib on apixaban, left MCA stroke in ___, left
sphenoid wing meningioma s/p ___ resection, progressive left
proptosis, and legal blindness, who was admitted for pain
management and ___ on CKD after a mechanical fall.
#mechanical fall
#right hip pain
#left shoulder pain
The patient initially presented with right hip pain after a
mechanical fall. 2 days prior to arrival, the patient counted an
incorrect number of steps while returning to her bed from the
bathroom and fell backward. She struck her head on the ground,
did not lose consciousness. The pain was located in the right
gluteal region and radiated to the right posterior thigh. A
trauma survey, including hip XR, CT head without contrast, CT
c-spine without contrast, CT pelvis without contrast, CT L-spine
without contrast was unrevealing. The patient was admitted for
better pain control.
On hospital day 2, the patient also developed new onset left
shoulder pain over the joint and mid-humeral region. She did not
have this pain on admission and denied having any trauma to the
area during the initial fall or during her hospitalization. Of
note, she did pull herself up from the floor using her left arm.
Shoulder X-ray showed no fracture or dislocation.
On exam, the patient remained neurovascularly intact in her
upper and lower extremities throughout her hospital stay, with
normal pulses and sensation to light touch in all extremities.
She was able to move all 4 extremities equally although range of
motion was limited due to pain.
Her pain steadily improved over the course of the
hospitalization, initially requiring standing oxycodone and
eventually improving such that she no longer needed oxycodone.
Upon discharge, she was having no pain in the right hip/gluteal
regions or left shoulder. Given this improvement and given
negative imaging findings, the pain was most likely due to
musculoskeletal strain from the mechanical fall.
#acute kidney injury on chronic kidney disease.
Admission weight: 139.33 pounds
Discharge weight: 145.72 pounds
On admission, her BUN/Cr was 57/3.2 with electrolytes notable
for sodium 132, potassium 7.5. She received a total of 2750 cc
of fluids over the course of the hospitalization with resultant
improvements in her creatinine every day. By discharge, her
BUN/Cr was ___ with normal sodium and potassium levels.
Given this improvement in creatinine with the administration of
intravenous fluids, the acute kidney injury was most likely
pre-renal in the setting of possible decreased PO intake.
#left proptosis
#hx of left sphenoid wing meningioma
For the past ___ years, the patient has been having worsening
swelling around her left eye and proptosis. Of note, she is
legally blind in both eyes, presumably due to diabetes.
Immediately prior to this admission, the patient was not having
any acute worsening of her swelling or proptosis. At baseline,
she has pain around both eyes (left more so than right) that is
improved with putting pressure around the eyes and massaging
them.
Because the patient's primary care physician, ___
that the patient's proptosis was worsening, a neurology consult
was placed, which recommended neurosurgical evaluation, MRI of
brain/orbits with contrast, and initiation of steroid therapy
for possible cerebral edema seen on CT scan from earlier in the
admission. An ophthalmology consult was also placed.
Neurosurgery was consulted and agreed with neurology's
recommendations, except that they recommended discontinuing the
steroids as there was little or no cerebral edema on imaging. In
total, the patient received 2 days of IV dexamethasone.
There was extensive discussion with the patient, her family,
neurology, and neurosurgery, about the risks and benefits of
obtaining a MRI with contrast, especially in the context of the
patient's ___ on CKD. There was also discussion regarding
inpatient vs. outpatient workup. The patient's preference was to
have an inpatient MRI with contrast. At the beginning of these
discussions, the patient's creatinine was 2.9, but the
creatinine steadily improved to 2.0 on ___ after giving the
patient 1750cc of fluid over 2 days. Given that her baseline is
1.8-2.2 and the patient's preference for inpatient MRI, the
decision was made on ___ to obtain the MRI with contrast.
Radiology was notified of the patient's borderline GFR.
The MRI of brain/orbits with and without contrast was obtained
on ___ and did not show any acute worsening of the intracranial
mass or proptosis. As of discharge, the plan from neurosurgery
was to discuss the patient's case at tumor board on ___. The
patient was also set up with oculoplastics follow-up on an
outpatient basis.
#bradycardia
Throughout her admission, the patient had heart rates in the
60-70s with intermittent episodes of bradycardia down to ___ to
___ usually overnight. On admission, the patient was on 25 mg
carvedilol PO BID. The carvedilol was steadily decreased over
the hospitalization and subsequently discontinued on ___ for
continued intermittent episodes of bradycardia. The patient
remained asymptomatic throughout all of these episodes.
====CHRONIC ISSUES====
#Chronic HFpEF
Admission weight: 63.2 kg
Discharge weight: 66.1 kg
She did not have any heart failure exacerbations during the
hospitalization. She had normal oxygenation at all times with
normal BNP and no signs of peripheral fluid retention. Her
carvedilol was reduced and eventually discontinued on discharge.
She was continued on furosemide (40 mg, reduced from home dose),
amlodipine (home). Initially, the losartan was held due to ___.
On discharge, she was resumed on losartan 50 mg daily for
hypertension.
Spironolactone was held throughout hospitalization.
#Paroxysmal afib
CHA2DS2-VASC of 9. She was continued on home apixaban.
#Hypertension
BPs generally in the 120-150s/50-60s. Continued on home
amlodipine. Carvedilol reduced during hospitalization and
eventually discontinued on ___ (2 days prior to discharge).
#Diabetes
A1C 7.9%. Blood sugars generally in the ___. Between ___
and ___, blood sugars were higher in the 200s as she was
receiving IV dexamethasone during those days. She received
Glargine 20 units QAM. Sitagliptin was held in favor of
corrective Humalog scale.
#Dysphagia
The patient reported chronic worsening of dysphagia, so
speech/language and swallow consults were ordered. A video
swallow test was also ordered and showed normal oropharyngeal
swallowing on fluoroscopy.
====TRANSITIONAL ISSUES====
[] #Repeat labs: patient was resumed on losartan on day of
discharge. Please re-check labs within ___ days after discharge.
[] #thyroid nodule: Thyroid nodule found on CT c-spine without
contrast (___): ultrasound follow-up recommended. ___
College of Radiology guidelines recommend further evaluation for
incidental thyroid nodules of 1.0 cm or larger in patients under
age ___ or 1.5 cm in patients age ___ or ___, or with suspicious
findings.
[] #bradycardia: Please follow-up with PCP and cardiology
regarding intermittent episodes of bradycardia. Carvedilol
currently discontinued due to the bradycardia.
[] #HFpEF: has been kept on reduced Lasix, home amlodipine.
Losartan 50 mg daily was resumed on discharge. Spironolactone
was held during hospitalization. Please follow-up with PCP about
medication regimen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abd pain, jaundice
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
___ year old female with a PMH of GERD and
depression presenting with abdominal pain.
Patient reports that she has been in her usual state of health
until 2 days prior to admission when she suddenly developed
severe abdominal pain, mostly located in the epigastric area,
but
also throughout her entire abdomen. Associated with
orange-colored urine. No fevers or chills, and no history of a
similar pain. No fevers or chills, and no change in bowel
movements. She initially presented to urgent care, and was found
to have elevated LFTs with a bili of 2.1. A RUQUS was done
showing cholelithiasis with multiple echogenic shadowing calculi
but no gallbladder wall thickening or pericholecystic fluid. She
was referred to an urgent surgery appointment the day of
admission. Given concern for a CBD stone with resultant
pancreatitis, patient was referred to the ED for ERCP.
In the ED:
Initial vital signs were notable for: T 96.3, HR 67, BP 136/85,
RR 16, 100% RA
Exam notable for: Abd: soft, nondistended, mild RUQ and
epigastric tenderness, neg ___ sign
Labs were notable for:
- CBC: WBC 8.1 (66%n), hgb 12.7, plt 249
- Lytes:
140 / 104 / 5 AGap=12
-------------- 96
4.3 \ 24 \ 0.7
- LFTS: AST: 321 ALT: 586 AP: 142 Tbili: 5.2 Alb: 4.5
- lipase 2901
- lactate 0.8
- u/a with few bacteria
Patient was given: no medications or fluids
Vitals on transfer: T 98, HR 59, BP 129/72, RR 16, 99% RA
Upon arrival to the floor, patient recounts history as above.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- GERD
- depression
- sleep disorder
- vit D deficiency
Social History:
___
Family History:
- father - ___
- sister - thyroid disorder
Physical Exam:
ADMISSION EXAM
VITALS: T 98.1, HR 54, BP 118/73, RR 19, 97% ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Normal bowel sounds. Soft, mildly tender to palpation in
epigastric area without rebound or guarding. No organomegaly.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
Vitals: 24 HR Data (last updated ___ @ 1636)
Temp: 97.2 (Tm 98.2), BP: 115/67 (98-131/56-87), HR: 67
(65-77), RR: 67 (___), O2 sat: 98% (97-98), O2 delivery: Ra
Fluid Balance (last updated ___ @ 1829)
Last 8 hours Total cumulative 280ml
IN: Total 480ml, PO Amt 480ml
OUT: Total 200ml, Urine Amt 200ml
Last 24 hours Total cumulative 3106ml
IN: Total 3306ml, PO Amt 1260ml, IV Amt Infused 2046ml
OUT: Total 200ml, Urine Amt 200ml
Physical exam:
Gen: NAD, AxOx3
Card: RRR, no m/r/g
Pulm: CTAB, no respiratory distress
Abd: Soft, non-tender, non-distended, normal bs.
Wounds: c/d/i
Ext: No edema, warm well-perfused
Pertinent Results:
___ 03:34PM BLOOD WBC-8.1 RBC-4.06 Hgb-12.7 Hct-39.5 MCV-97
MCH-31.3 MCHC-32.2 RDW-13.5 RDWSD-48.9* Plt ___
___ 05:50AM BLOOD Glucose-71 UreaN-5* Creat-0.7 Na-141
K-4.6 Cl-104 HCO3-25 AnGap-12
___ 03:34PM BLOOD ALT-586* AST-321* AlkPhos-142*
TotBili-5.2*
___ 06:45AM BLOOD ALT-395* AST-113* AlkPhos-129*
TotBili-1.6*
___ 05:55AM BLOOD ALT-279* AST-39 AlkPhos-112* TotBili-1.3
___ 05:50AM BLOOD ALT-225* AST-27 AlkPhos-109* TotBili-1.0
___ 03:34PM BLOOD Lipase-2901*
___ 05:50AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.8
___ 03:34PM BLOOD Albumin-4.5
___ 03:42PM BLOOD Lactate-0.8
___ abd ultrasound:
IMPRESSION: Cholelithiasis with multiple echogenic shadowing
calculi but no gallbladder wall thickening or pericholecystic
fluid
MRCP:
Cholelithiasis, but no features of acute cholecystitis. Mild
wall thickening involving the distal body and fundus of the
gallbladder which may represent low-grade chronic cholecystitis.
No intra or extrahepatic bile duct dilatation. No CBD stone.
No imaging
features of pancreatitis. The pancreatic duct is not dilated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every six (6)
hours Disp #*8 Tablet Refills:*0
2. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
gallstone pancreatitis
choledolcholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old female with abdominal pain with labs and imaging
concerning for gallstone pancreatitis- rapidly improving without
intervention// pls assess for retained CBD stone
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: None
FINDINGS:
Lower Thorax: No pleural or pericardial effusion.
Liver: Normal hepatic morphology. No hepatic steatosis. No focal suspicious
hepatic lesions.
Biliary: Multiple small gallstones. No features of acute cholecystitis.
There is mild thickening of the distal body and fundal gallbladder wall which
may represent low-grade chronic cholecystitis. No edema surrounding the
gallbladder. No intra or extrahepatic bile duct dilatation. No CBD stone
visualized
Pancreas: No conclusive imaging findings of pancreatitis
Spleen: No splenomegaly. No focal splenic lesions.
Adrenal Glands: Unremarkable
Kidneys: No hydronephrosis. No suspicious focal lesions.
Gastrointestinal Tract: Unremarkable
Lymph Nodes: No adenopathy
Vasculature: There is narrowing of the origin of the celiac axis with mild
poststenotic dilatation (however imaging done in expiration). No prominent
collateral arteries. The major vessels are patent.
Osseous and Soft Tissue Structures: No suspicious bony lesions.
IMPRESSION:
Cholelithiasis, but no features of acute cholecystitis. Mild wall thickening
involving the distal body and fundus of the gallbladder which may represent
low-grade chronic cholecystitis.
No intra or extrahepatic bile duct dilatation. No CBD stone. No imaging
features of pancreatitis. The pancreatic duct is not dilated.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Calculus of bile duct w/o cholangitis or cholecyst w/o obst, Biliary acute pancreatitis without necrosis or infection, Right upper quadrant pain
temperature: 96.3
heartrate: nan
resprate: 16.0
o2sat: 100.0
sbp: 136.0
dbp: 85.0
level of pain: 7
level of acuity: 3.0 | This is a ___ year old female with past medical history of GERD
and depression admitted ___ with gallstone pancreatitis
# Gallstone pancreatitis
# Abnormal LFTs
# Suspected Calculus of Bile Duct with Obstruction
Patient was admitted with 3 days of severe prandial abd pain and
was found to have LFTs suggestive of biliary obstruction, with
Tbili 5.2, as well as lipase > ___. Imaging showed
cholelithiasis without choledocholithiasis or obstruction.
Patient suspected to have gallstone pancreatitis secondary to a
biliary calculus that passed prior to presentation. Patient
managed conservatively with improvement. She was seen by Acute
care surgery....and
# GERD
Continued Ranitidine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine / contrast dye
Attending: ___.
Chief Complaint:
OUTPATIENT CARDIOLOGIST:
PCP: ___. with ___ ___
CHIEF COMPLAINT: Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with CAD s/p CABG at ___ in
the ___, Ischemic CM w/ EF 45% in ___, Hx AFlutter s/p
ablation, severe COPD, and newly dx Lung cancer who presents
with symptomatic sick sinus syndrome requiring admission for ppm
placement.
Patient now has lung cancer, for which he will likely undergo
radiation and chemotherapy, as he is a poor surgical candidate.
He now has symptomatic sick sinus syndrome. Noted to be dizzy
while out golfing. He was golfing on day of admission and it was
cart path only so had to walk to his ball. When doing that he
felt dizzy and lightheaded and felt like going to pass out. He
also felt very winded. He notes a few episodes similar to this
over the past week.
In clinic, patient with HR ___ with junctional or sinus,
which is a decrease from his rate of 58 on EKG in ___.
He is followed by Dr. ___ in ___ and has appt at ___ for tx
of lung cancer. Looks like from Dr. ___, pursuing
palliative chemo and XRT. He is felt not to be a surgical
candidate. He has severe COPD and wears oxygen 2 liters most of
the time.
On floor, no pain and breathing is at baseline on home O2.
ROS: detailed 10pt review of systems negative except for HPI. Of
note, no fevers, chest pain, abd pain, nausea, vomiting,
diarrhea.
Past Medical History:
- CAD: s/p Coronary artery bypass x4 in ___ at ___. Last cath
___ at ___ right dominant system. No significant left main
disease, but proximal occlusion of all 3 vessels. LIMA to LAD
was widely patent, SVG to right PDA with 30% ostial stenosis.
SVG to OM1 widely patent, but jump segment to OM2 occluded. OM2
well collateralized, and no evidence of diffuse disease to
explain PET findings. Hemodynamics: RA ___ RV 38/8; PA
35/24; PCWP ___ LV 138/14; Ao 138/67.
- Ischemic Cardiomyopathy: last echo ___ at ___, LVEF mildly
reduced at 45% but poor endocardial resolution. No significant
valvular disease.
- Hypertension
- Diabetes Mellitus Type II
- Peripheral vascular disease, status post stent to the right
leg in ___, angioplasty to right femoral, mid ___ at the
___, s/p left iliac stent ___, left femoral to AK bypass
___ at at ___ by Dr ___.
- Atrial flutter, pt was cardioverted at ___ by Dr ___ on
___, a flutter ___, atrial flutter ablation was
successful. Coumadin was stopped by Dr ___ ___ due to his
history of GI bleeds.
- COPD, severe: on home O2
Social History:
___
Family History:
- mother died at ___ from lung cancer
- father died at ___ from emphysema, consumption
- brother ___, healthy
- sister ___, healthy
- 3 sons, one with hyperlipidemia
- Negative for early CAD
Physical Exam:
ADMISSION:
VS: 97.6 143/72 HR 64 sat 97% on 2L NC (home O2)
General: NAD
HEENT: clear OP
Neck: no JVD
CV: NR, RR, no murmurs
Lungs: CTAB, decreased breath sounds throughout, nonlabored
Abdomen: soft, NT, ND
GU: no Foley
Ext: trace/1+ edema ___ to knee
Neuro: A&O, no gross deficits
Skin: no lesions noted
Psych: appropriate
DISCHARGE:
VS: afebrile 98.0 138/64 71 (HR's ___) on 2LNC (home O2)
General: NAD
HEENT: clear OP
Neck: no JVD
CV: NR, RR, no murmurs
Lungs: CTAB, decreased breath sounds throughout, nonlabored
Abdomen: soft, NT, ND
GU: no Foley
Ext: trace/1+ edema ___ to knee
Neuro: A&O, no gross deficits
Skin: no lesions noted
Psych: appropriate
Pertinent Results:
ADMISSION LABS:
___ 12:15PM BLOOD WBC-8.8 RBC-4.67 Hgb-12.6* Hct-38.4*
MCV-82 MCH-26.9* MCHC-32.7 RDW-14.0 Plt ___
___ 12:15PM BLOOD Neuts-75.1* Lymphs-14.4* Monos-5.6
Eos-4.1* Baso-0.7
___ 11:35AM BLOOD Glucose-178* UreaN-36* Creat-1.9* Na-138
K-4.4 Cl-102 HCO3-27 AnGap-13
___ 11:35AM BLOOD cTropnT-<0.01
___ 12:15PM BLOOD cTropnT-<0.01
___ 07:05AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.2
-------
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-6.4 RBC-5.02 Hgb-13.5* Hct-40.6
MCV-81* MCH-26.8* MCHC-33.2 RDW-14.0 Plt ___
___ 07:35AM BLOOD ___ PTT-33.4 ___
___ 07:35AM BLOOD Glucose-112* UreaN-34* Creat-1.5* Na-140
K-4.3 Cl-101 HCO3-29 AnGap-14
___ 07:35AM BLOOD Calcium-9.6 Phos-3.5 Mg-2.0
===========
-ECHO ___: The left atrium is elongated. Left ventricular
wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with hypokinesis
of the entire lateral wall (EF ~40%). Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets are mildly thickened (?#).
There is no aortic stenosis. 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 borderline pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Regional left ventricular
systolic dysfunction c/w CAD. Mildly dilated aortic root and
ascending aorta. Mild mitral regurgitation. Borderline pulmonary
hypertension. Biatrial dilatation. EF 40%.
===========
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Glargine 26 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Omeprazole 40 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Aspirin 81 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Fluocinonide 0.05% Ointment 1 Appl TP BID
apply sparingly to affected area; avoid face, under armpits and
groin
10. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
for rash on hands, not on face
11. Diltiazem 60 mg PO BID
12. Vitamin D 1000 UNIT PO DAILY
13. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea
14. Nitroglycerin SL 0.4 mg SL PRN chest pain
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea
2. Aspirin 81 mg PO DAILY
3. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
4. Fluocinonide 0.05% Ointment 1 Appl TP BID
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Furosemide 40 mg PO DAILY
7. Glargine 26 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Omeprazole 40 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Nitroglycerin SL 0.4 mg SL PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Bradycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with presyncope. History of non-small cell lung
carcinoma.
COMPARISON: ___. CT chest from ___.
FINDINGS:
PA and lateral views of the chest. Again seen is a dense right basilar region
of consolidation which has not significantly changed from prior CT and plain
film. Elsewhere, the lungs remain clear. There is no visualized nodule in
the left mid lung seen on most recent CT scan. Cardiomediastinal silhouette
is stable as are the osseous structures.
IMPRESSION:
Persistent right basilar region of consolidation compatible with patient's
known non-small-cell lung carcinoma. No evidence of superimposed acute
cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: LIGHTHEADED
Diagnosed with VERTIGO/DIZZINESS, SINOATRIAL NODE DYSFUNCT
temperature: 97.4
heartrate: 48.0
resprate: 20.0
o2sat: 88.0
sbp: 136.0
dbp: 61.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ man with CAD s/p CABG at ___ in
the ___, Ischemic CM w/ EF 45% in ___, Hx AFlutter s/p
ablation, severe COPD, and newly dx Lung cancer who presents
with symptomatic sick sinus syndrome.
.
# Sick Sinus Syndrome: Patient symptomatic on admission as
evidenced by dizziness while bradycardic with activity. His
metoprolol was likely contributing, and less likely his home
diltiazem. Echo ___ showed regional left ventricular
systolic dysfunction c/w CAD w/ EF 40%. Discontinued Diltiazem.
Continue Metoprolol at home dose. No evidence of bradycardia
while admitted. Due to poor overall prognosis with his newly dx
lung cancer, and lack of symptoms, pacemaker deferred at this
time. Could consider decreasing metoprolol as outpatient if
becomes symptomatic again.
.
# CAD: s/p Coronary artery bypass x4 in ___ at ___. Last cath
___ at ___ right dominant system. No significant left main
disease, but proximal occlusion of all 3 vessels. LIMA to LAD
was widely patent, SVG to right PDA with 30% ostial stenosis.
SVG to OM1 widely patent, but jump segment to OM2 occluded. OM2
well collateralized, and no evidence of diffuse disease to
explain PET findings. Last cath at ___ in ___ per pt which
showed "1 blockage." Metoprolol as above, Aspirin 81mg daily,
and Simvastatin 20mg daily.
.
# Ischemic Cardiomyopathy: Echo ___ showed regional left
ventricular systolic dysfunction c/w CAD w/ EF 40%. No
significant valvular disease. Continued home Lasix 40mg po
daily.
.
# Diabetes Mellitus Type II: Continued home Humalog and
Glargine.
.
# Hypertension: Discontinued Diltiazem. Continue Metoprolol as
above.
.
# PVD: s/p stent to the right leg in ___, angioplasty to right
femoral, mid ___ at the ___, s/p left iliac stent ___,
left femoral to AK bypass ___ at at ___ by Dr ___. He has
claudication and followed by Dr. ___ was considering an
angiogram and revasc prior to the diagnosis of the lung cancer.
.
# AFlutter: s/p cardioversion at ___ by Dr ___ on ___, a
flutter ___, atrial flutter ablation was successful. Coumadin
was stopped by Dr ___ ___ due to his history of GI bleeds.
Defer anticoagulation due to hx GI bleeds per outpatient
provider.
.
# Lung Adenocarcinoma: Newly diagnosed. As outpatient, he will
likely undergo radiation and chemotherapy, as he is a poor
surgical candidate. He is followed by Dr. ___ in ___ and has
appt at ___ for tx of lung cancer. Looks like from Dr. ___
___, pursuing palliative chemo and XRT.
.
# COPD, severe: On home 2L NC when at home or driving. Able to
play golf without O2. Continued Advair and Spiriva.
.
# CKD: Baseline creat 1.5-2.0. Admission creat 1.9.
.
# CODE: FULL-confirmed
# CONTACT: ___ (son/HCP) ___ ; ___
# DISPO: ___ cardiology service to home.
.
### TRANSITIONAL ISSUES ###
- For sick sinus: Continue Metoprolol at home dose. No evidence
of bradycardia while admitted. Due to poor overall prognosis
with his newly dx lung cancer, and lack of symptoms, pacemaker
deferred at this time. Could consider decreasing metoprolol as
outpatient if becomes symptomatic again.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Penicillins / Ceclor
Attending: ___.
Chief Complaint:
neck abscess
Major Surgical or Invasive Procedure:
S/p transcervical drainage of multiple neck abscesses
History of Present Illness:
___ with IDDM type ___ s/p transcervical drainage of
multiple neck abscesses (retropharyngeal, mediastinal, anterior
neck) likely stemming from pharyngitis (undertreated due to
odynophagia). Hospital course notable for severe pharyngeal
phase dysphagia on videoswallow study ___, status post ___
guided G-tube placement on ___. PICC line placed on ___
for long term antibiotic therapy.
Past Medical History:
IDDM type 1
Family History:
NC
Physical Exam:
Gen: No acute distress
HEENT: Wick in place with minimal purulence. Neck soft, flat.
CV: Hemodynamically stable
Resp: Unlabored breathing on room air
Neuro: Alert and oriented
Pertinent Results:
___ 06:09AM BLOOD WBC-5.9 RBC-3.24* Hgb-10.1* Hct-30.7*
MCV-95 MCH-31.2 MCHC-32.9 RDW-12.7 RDWSD-42.6 Plt ___
___ 06:09AM BLOOD Glucose-201* UreaN-4* Creat-0.6 Na-138
K-3.9 Cl-103 HCO3-22 AnGap-13
___ 06:49PM BLOOD Vanco-16.5
___ 05:25AM BLOOD WBC-3.9* RBC-3.34* Hgb-10.2* Hct-31.3*
MCV-94 MCH-30.5 MCHC-32.6 RDW-12.8 RDWSD-43.2 Plt ___
___ 05:25AM BLOOD Glucose-137* UreaN-7 Creat-0.7 Na-143
K-3.8 Cl-106 HCO3-24 AnGap-13
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation
BID
3. Glargine 10 Units Breakfast
Glargine 10 Units Dinner
Humalog Unknown Dose
Insulin SC Sliding Scale using HUM Insulin
4. Ondansetron ODT 4 mg PO Q8H:PRN nausea
5. OxycoDONE Liquid ___ mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg NG Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H infection Duration: 4 Weeks
3. Docusate Sodium 100 mg PO BID
4. MetroNIDAZOLE 500 mg PO TID infection Duration: 4 Weeks
5. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
6. Vancomycin 1250 mg IV Q 12H
7. Glargine 8 Units Breakfast
Glargine 3 Units Bedtime
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Humalog 3 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
8. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
10. Ondansetron ODT 4 mg PO Q8H:PRN nausea
11. Pulmicort Flexhaler (budesonide) 180 mcg/actuation
inhalation BID
12. Outpatient Lab Work
ICD 10 L02.11
___, MD, Infectious Disease
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY: CBC with differential, BUN, Cr, Vancomycin trough, CRP
To be drawn on ___ : AST, ALT, Total Bili, ALK PHOS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Neck abscess
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: ___ year old woman with retropharyngeal abscess s/p drainage
remains intubated// ETT placement
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph ___
FINDINGS:
2 sequential images were acquired the second of which shows an ETT
approximately 3 cm above carina.
Lung volumes are low. There is moderate retrocardiac and right lung base
atelectasis. A small left pleural effusion is seen. The cardiomediastinal
silhouette is within normal limits. An NG tube is seen with its tip within
the stomach. Fixation screws are seen along the jaw.
IMPRESSION:
The ETT ends 3 cm above the carina. Small left pleural effusion and bibasilar
atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ett// ?changes ?changes
IMPRESSION:
Comparison to ___. The tip of the endotracheal tube projects
approximately 4 cm above the carinal. The feeding tube shows a normal course,
the tip projects over the middle parts of the stomach. Improved ventilation
of the retrocardiac lung areas. Mild cardiomegaly persists. Otherwise
unchanged radiograph.
Radiology Report
INDICATION: ___ yof with a PMH of DMI presents with retropharyngeal abscess w/
extension into the mediastinum now POD2 from I D deep neck abscess-
retropharyngeal, mediastinal, anterior neck, s/p ETT exchange// eval location
of ETT and OGT
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
The ET tube and NG tube are unchanged. Small bilateral effusions left greater
than right are stable. Consolidative opacities in both lower lobes most
likely represents subsegmental atelectasis. No pneumothorax is seen.
Cardiomediastinal silhouette is stable
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with dobhoff placement// ?placement
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph from ___
FINDINGS:
There has been interval placement of an NG tube with the tip and side port
seen within the stomach. There is mild bibasilar atelectasis. A small left
pleural effusion is unchanged. The cardiomediastinal silhouette is stable.
IMPRESSION:
Interval placement of an NG tube in appropriate position.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with abcess// dobhoff placement
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph from 1 hour prior
FINDINGS:
NG tube is seen with its tip and side port within the stomach. Otherwise
there has been little interval change. There is persistent bibasilar
atelectasis and a small left pleural effusion. The cardiomediastinal
silhouette is stable.
IMPRESSION:
An NG tube is seen in appropriate position.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old woman with new LUE swelling, please eval for DVT//
LUE DVT evaluation
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
vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial and basilic veins are patent,
compressible and show normal color flow.
There is nearly occlusive thrombus along the length of the left cephalic vein.
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper extremity.
2. Superficial thrombophlebitis of the left cephalic vein.
Radiology Report
INDICATION: ___ year old woman with DHT that appears to be slowly migrating
out.// position of DHT
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: None
FINDINGS:
The tip of a Dobhoff tube descends just beneath the diaphragm in the region of
the proximal stomach or gastroesophageal junction.
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Tip of Dobhoff in the region of the proximal stomach or gastroesophageal
junction. Advancement is recommended.
Radiology Report
EXAMINATION: VIDEO SWALLOW
INDICATION: ___ year old woman with dysphagia on bedside swallow evaluation.
Status post transcervical drainage of multifocal deep neck abscesses.//
Swallow evaluation
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: 02:30 min.
COMPARISON: CT neck from ___.
FINDINGS:
There was aspiration with thin, nectar and pudding consistencies.
Again seen is prevertebral soft tissue thickening corresponding to the
prevertebral edema seen on prior CT.
IMPRESSION:
1. Aspiration with thin, nectar and pudding consistencies.
2. Redemonstration of prevertebral edema.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with right PICC// Right 40cm PICC ___ ___
Contact name: ___: ___
TECHNIQUE: Portable semi upright view of the chest
COMPARISON: Chest radiograph from ___
FINDINGS:
A new right PICC tip is seen in the right atrium. No pneumothorax. No focal
consolidation is appreciated. There is no pulmonary edema, pneumothorax, or
large pleural effusion. The cardiomediastinal silhouette is normal. Surgical
clips are incidentally noted projecting over the left lower neck.
IMPRESSION:
A new right PICC tip is seen in the right atrium, approximately 2 cm beyond
the cavoatrial junction. No pneumothorax.
Radiology Report
INDICATION: ___ year old woman with T1DM with neck abscess s/p drainage and
abx// G tube placement for failed S S multiple times, refuses NG tube
placement
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___,
performed the procedure. .
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
250 mcg of fentanyl and 5 mg of midazolam throughout the total intra-service
time of 43 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: No glucagon was administered given the patient's diabetes
CONTRAST: 25 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 10.8 Min, 33 mGy
PROCEDURE: 1. Placement of a 18 ___ MIC gastrostomy 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 tube site was prepped and draped in the usual sterile fashion.
A scout image of the abdomen was obtained. The stomach was insufflated through
the indwelling nasogastric tube. Using a marker, theskin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Permanent ultrasound images were stored.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilute contrast. A ___ wire was
introduced into the stomach. A small skin incision was made along the needle
and the needle was removed.
Initially, attempts were made at balloon assisted gastrostomy tube placement,
however the mid tube was unable to be successfully advanced over the balloon
therefore serial dilatation was performed. After sequential dilation using
dilators and a 20 ___ peel-away, a MIC gastrostomy catheter was advanced
over the wire into position. The catheter was secured by instilling 7 ml of
dilute contrast into the balloon in the stomach after confirming the position
of the catheter with a contrast injection. The catheter was then flushed,
capped and secured to the skin with 0-silk sutures. Sterile dressings were
applied.
The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Successful placement of a 18 ___ MIC gastrostomy tube.
IMPRESSION:
Successful placement of a 18 ___ MIC gastrostomy tube.
Radiology Report
INDICATION: ___ year old woman with right PICC line. Please confirm
location.// Right PICC line. Please confirm location.
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of a right PICC line projects over the cavoatrial junction.
There is a new consolidation seen in the right midlung projecting over the
right eighth posterior rib/anterior fourth rib which is new since ___. No pleural effusion or pneumothorax. The size of the cardiomediastinal
silhouette is within normal limits.
IMPRESSION:
The tip of a right PICC line projects over the cavoatrial junction.
New somewhat well-defined consolidation seen in the right midlung.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Hypoglycemia, Peritonsillar abscess, Transfer
Diagnosed with Cutaneous abscess of neck, Type 1 diabetes mellitus without complications, Long term (current) use of insulin
temperature: 99.0
heartrate: 106.0
resprate: 18.0
o2sat: 95.0
sbp: 126.0
dbp: 63.0
level of pain: 8
level of acuity: 2.0 | The patient was admitted to the Otolaryngology-Head and Neck
Surgery Service for I&D of multiple neck abscesses. Please see
the separately dictated operative note for details of procedure.
The patient was extubated and transferred to the hospital floor
for further post-operative care. The post-operative course was
uneventful and the patient was discharged to home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Dipyridamole
Attending: ___.
Chief Complaint:
Bright red Blood Per Rectum
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH CHF (last EF 25%), Afib (not on coumadin), CKD stage
4, SSS w/ pacer, and previous fibroid surgery presenting from
___ she was found to have bleeding from the genital
area.
Per ___ records, her diaper was noted to be saturated
with blood this morning. At the time BP was 126/73, HR 100-115,
sats 100%RA.
In the ED, initial vitals: 97.0 108 ___ 98% RA. There EKG
showed a-fib at 119, rectal exam showed gross blood, vaginal
exam without bleeding. Labs were notable for creatinine: 3.4
(baseline around 3.2-3.4), H/H 11.0/34.9 (baseline around
13.6/44.0 although discharge with hemoglobin of 11.1 in ___. Outside records show hct of 33.8 (___) and 34.5
(___). K: 5.7. CXR showed no acute process. Old records
were obtained that showed colonoscopy records from ___ and ___
obtained from ___ showing internal hemorrhoids and
polpys/diverticuli. GI was notified, but not formally
consulted. IV fluids given - 500cc.
Vitals prior to transfer were: 98.4 80 104/66 18 100%.
Currently, the patient does not know why she was taken to the
hospital. She says she feels well, though she does endorse
dizziness. ___ records note poor PO intake over the
past few months, though pt says she has been eating well. Denies
headache, fevers, chills, chest pain, dyspnea, abdominal pain,
nausea, vomiting, diarrhea, dysuria, urine discoloration. No
pain with bowel movements. Says she has been moving her bowels
daily, no overly hard stools. No pain with bowel movements. She
does say she has a history of hemorrhoids but cannot recall if
she has had bleeding from the rectum in the past. Per her son
___, HCP) her mental status appears to be at baseline.
.
10 point ROS is otherwise negative
.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +Diabetes II, +Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: n/a
-PACING/ICD: Sick sinus syndrome with severe sinus bradycardia
with AV conduction disease s/p pacemaker implantation
3. OTHER PAST MEDICAL HISTORY:
- HTN
- CHF
- TIA
- CAD - no prior catheterizations
- Diabetes on insulin
- Diabetic retinopathy
- Rheumatoid arthritis
- Hyperlipidemia
- Stage 4 kidney disease
- Obesity
- Anemia of Chronic Disease
- Heart Block
- Atrial Fibrillation
- Hyperparathyroidism, secondary renal
.
PAST SURGICAL HISTORY
- Cataracts
- Appendectomy
- C section x 3
- Fibroid surgery
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam:
VS - Temp 97.5F, BP 116/65, HR 110, R 20, O2-sat 93% RA
GENERAL - alert, interactive, responding to questions
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - irregularly irregular, no M/R/G
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding. Firm palpable
lower abdominal mass.
EXTREMITIES - 1+ pitting edema to ankles b/l, 2+ DP pulses
SKIN - no rashes or lesions
RECTAL - dark red blood in rectal vault
NEURO - awake, A+O to person, "fall," "hospital." Gives date as
___ Does not know where she lives or how she ended
up in the hospital. Able to say days of week forward and
backward. Tangential in conversation. CNs II-XII grossly intact,
muscle strength ___ throughout, sensation grossly intact
throughout, DTRs 2+ and symmetric, cerebellar exam intact, gait
deferred.
.
Discharge Exam
Exam grossly unchanged
.
Pertinent Results:
Admission Labs:
___ 08:00AM BLOOD WBC-5.7 RBC-3.82* Hgb-11.0* Hct-34.9*
MCV-91 MCH-28.9 MCHC-31.6 RDW-14.8 Plt ___
___ 08:00AM BLOOD Glucose-118* UreaN-46* Creat-3.4* Na-142
K-5.7* Cl-108 HCO3-26 AnGap-14
Discharge Labs:
___ 05:45AM BLOOD WBC-6.2 RBC-3.84* Hgb-11.6* Hct-35.2*
MCV-92 MCH-30.1 MCHC-32.9 RDW-14.9 Plt ___
___ 05:45AM BLOOD UreaN-44* Creat-3.1* Na-139 K-4.5 Cl-109*
HCO3-22 AnGap-13
IMAGING:
CXR from ___:
FINDINGS: AP and lateral chest radiographs were obtained. The
lungs are well expanded and clear. There is no focal
consolidation, effusion, or
pneumothorax. Biventricular pacing leads are unchanged.
Cardiac and
mediastinal contours are normal.
IMPRESSION:
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Metoprolol Succinate XL 50 mg PO TID
5. Ezetimibe 10 mg PO DAILY
6. Quetiapine Fumarate 12.5 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. HydrALAzine 10 mg PO BID
9. Atorvastatin 80 mg PO DAILY
10. Senna 2 TAB PO HS
11. traZODONE 12.5 mg PO DAILY:PRN delusions, anxiety
12. Quetiapine Fumarate 12.5 mg PO BID:PRN agitation
13. Mirtazapine 15 mg PO HS
14. Amlodipine 2.5 mg PO DAILY
15. traZODONE 12.5 mg PO HS
16. Acetaminophen 650 mg PO Q4H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Atorvastatin 80 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Ezetimibe 10 mg PO DAILY
6. Mirtazapine 15 mg PO HS
7. Quetiapine Fumarate 12.5 mg PO BID
8. Quetiapine Fumarate 12.5 mg PO BID:PRN agitation
9. Senna 2 TAB PO HS
10. traZODONE 12.5 mg PO DAILY:PRN delusions, anxiety
11. traZODONE 12.5 mg PO HS
12. Vitamin D 1000 UNIT PO DAILY
13. Aspirin 81 mg PO DAILY
14. Metoprolol Tartrate 50 mg PO Q8H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Lower Gastrointestinal Bleed
Atrial fibrillation
.
Secondary Diagnosis:
Systolic heart failure (EF- 25%)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive although A&Ox1 at
baseline
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Altered mental status.
COMPARISON: ___, to ___.
FINDINGS: AP and lateral chest radiographs were obtained. The lungs are well
expanded and clear. There is no focal consolidation, effusion, or
pneumothorax. Biventricular pacing leads are unchanged. Cardiac and
mediastinal contours are normal.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: VAGINAL BLEED VS RECTAL BLEEDING
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 97.0
heartrate: 108.0
resprate: 18.0
o2sat: 98.0
sbp: 109.0
dbp: 97.0
level of pain: 0
level of acuity: 3.0 | ASSESSMENT & PLAN: ___ w/ PMH CHF (last EF 25%), Afib (not on
coumadin), CKD stage 4, dementia, SSS w/ pacer, and previous
fibroid surgery presenting from ___ with BRBPR.
#. GI bleed. Patient presented to the floor and was asymptomatic
and heart rate in low 100s. She was given IVF and was not
responsive to fluids. Her heart rate increased to 140s and rpt
Hct showed drop 34.9-->31.7. She was given 1 unit of blood and
post transfusion Hct was lower at 30.8. Given another unit of
blood and bumped appropriately to 33.1. Heart rate has
improved, but also back on metoprolol 50mg PO Q8H. BP has been
stable throughout and continues to be asymptomatic. Repeat
hematocrit were stable. She remained stable and hct stabilized
as well. No need for colonoscopy on this admission and patient
was discharged back to ___. Patient continued to have
some bloody discharge from below but this was minimal and
communicated with MD at ___ prior to transfer. If
patient has recurrent Bright Red Blood Per Rectum, will have to
have conversation with the son regarding the risk vs. benefits
of continued aspirin use, but for now would continue to reduce
the risk of stroke in this elderly lady with atrial
fibrillation.
#Tachycardia: On arrival to the floow rate in the ___. Pt
asymptomatic, BPs stable. She became tachycardic in the setting
of hct drop. 1 unit of blood given and her heart rate decreased
to the ___ when receiving blood. rhythm was a-fib with
potential intermittent flutter. After 1 unit of blood heart
rate increased to the 160s and was sustained. No evidence of GI
bleed and since beta blockers had been held, felt this was
secondary to a-fib with RVR as opposed to acute bleed.
Metoprolol 5mg IV and 50mg PO given. Heart rate decreased to
the 110's. Post transfusion hct showed persistent drop in hct
as discussed above. A second unit of blood given. After ___
unit heart rate decreased to the ___. She was continued on
metoprolol tartrate 50mg PO Q8H during her hospital stay and her
hct stable.
#Hyperkalemia: Resolved. K was 5.7 on arrival and resolved with
fluids. No acute EKG changes.
#ST changes: EKG shows submillimeter ST depressions in V5 and
V6, appear new from prior. Pt asymptomatic. Possibly ___
increased cardiac demand as pt has been tachycardic. Repeat EKG
when hear rate in the ___ showed resolution of depressions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
naproxen
Attending: ___.
Chief Complaint:
IVC thrombus
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ female with a history of polycythemia
___ c/b IJ thrombosis, managed with phlebotomy, migraines, PFO
presented as a transfer from OSH for evaluation of a IVC
thrombus
and PE.
Patient presented to an outside hospital today with right flank
pain since ___. While there, she underwent a CT scan which
was notable for a 3.7 cm long and 1.4 cm wide thrombus in the
IVC
extending into the right renal vein with partial outflow
obstruction. Furthermore, a CT angiogram of the chest showed
multiple subsegmental PEs as well as evidence of cardiomegaly.
She did endorse a headache with some b/l facial numbness, so
underwent a NCHCT without acute intracranial process. She was
then transferred to ___ for evaluation.
Of note, patient has a history of polycythemia ___ which is
controlled intermittent therapeutic blood draws and a baby
aspirin. Her course has been complicated by a IJ thrombus in
___, for which she was on Pradaxa.
- In the ED, initial vitals were:
T 98.3 HR 70 BP 131/87 RR 16 O2 99% RA
- Exam was notable for:
"Noncontributory"
- Labs were notable for:
140 104 6
-------------<99
4.6 24 0.6
10.3
10.0>----<467
41.6
proBNP: 259
- Studies were notable for:
RUQUS- 2.3 cm thrombus in the inferior vena cava.
CT HEAD- No acute infarction, intracranial hemorrhage, mass
lesion, or midline shift.
CT ANGIOGRAM ABDOMEN PELVIS W WO CONTRAST-
Impression
1. Small pulmonary emboli in the right anterior and posterior
basal segmental arteries.
2. Inferior vena cava thrombus measuring up to 3.7 cm in
craniocaudal dimension with extension into the right renal vein
with associated hypoattenuation of the right renal pelvis,
secondary to probable partial venous outflow obstruction.
3. Cardiomegaly.
- The patient was given:
___ 01:58 IV Heparin
- Vascular was consulted who recommended.
- hep gtt, goal PTT ___
- monitor for ___, currently no renal dysfunction
- heme/onc consult for management of her PV, currently only on
baby ASA
- likely will need medical admission to the hospital
- No vascular surgery intervention at this time
On arrival to the floor, the patient confirms the history as
above. Her last phlebotomy was 8 week ago. She said her flank
pain had improved after receiving pain medications. She denies
any current head ache, facial numbness, paresthesias, or changes
in vision
Past Medical History:
OSA
Polycythemia ___ (JAK2) positive, managed with phlebotomy
HX of Thrombosis of the distal R transverse sinus extending into
the sigmoid sinus and the proximal R internal jugular vein.
Social History:
___
Family History:
Mother- diabetes, hypertension, stroke, dementia
Maternal Grandmother- dementia
___ uncle with PV
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.6 PO 142 / 92 82 18 95 Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: Sclera anicteric and without injection.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales.
BACK: No CVA tenderness.
ABDOMEN: Non-distended, no TTP in RUQUS
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. fluent speak
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: Alert and interactive. In no acute distress.
HEENT: Sclera anicteric and without injection.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales.
ABDOMEN: Non-distended, no TTP in RUQUS
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. fluent speak
Pertinent Results:
___ 06:49AM BLOOD ___ PTT-58.6* ___
___ 12:53PM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-Test
___ 12:53PM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-Test
___ 02:00PM URINE Hours-RANDOM Creat-50 TotProt-45
Prot/Cr-0.9*
___ 06:49AM BLOOD Glucose-92 UreaN-8 Creat-0.7 Na-143 K-4.8
Cl-103 HCO3-25 AnGap-15
bilateral LENIs
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Vitamin D ___ UNIT PO DAILY
3. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 80 mg SC every twelve (12) hours
Disp #*14 Syringe Refills:*1
2. Warfarin 5 mg PO DAILY16
RX *warfarin 2.5 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
3. Calcium Carbonate 500 mg PO QHS:PRN vitamin
4. Vitamin D ___ UNIT PO DAILY
5.Outpatient Lab Work
I___.220
___, INR
Results to:
Name: ___.
Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
deep vein thrombosis
pulmonary embolism
renal vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with PV who presented with IVC thrombus and
PE.// r/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: SECOND OPINION CT ABD/PELVIS
INDICATION: ___ year old woman with PV, p/w IVC thrombus, PE, R renal vein
thrombus// evaluate whether clot originated from renal vein if able per
hematology request
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: 2856 mGy-cm.
COMPARISON: None.
FINDINGS:
Please refer to the separate chest CT dictation regarding intrathoracic
findings.
The liver density appears normal. There are multiple very well-circumscribed
hypodense lesions scattered throughout the liver, demonstrating no appreciable
internal contrast enhancement, likely representing cysts. No definitely
enhancing liver lesion is seen. There is no intra or extrahepatic bile duct
dilation. The gallbladder is normal. No ductal stones are detected.
The pancreas demonstrates normal density and bulk, without duct dilation or
focal lesion.
The spleen is mildly enlarged, measuring 13.8 cm (series 613 image 56). There
is no focal splenic lesion.
The adrenal glands are normal in size and shape.
There is a slightly delayed right nephrogram (series 613, image 54). The left
kidney appears normal. There is thrombus extending from the right main renal
vein into the IVC (series 613, image 48), however, it is unclear whether not
this is enhancing thrombus. No discrete renal mass is detected. The
collecting system is not well visualized on this single-phase examination.
There is no hydroureter. No radiopaque stones are seen.
The bladder is moderately distended, and appears grossly normal.
The stomach and intra-abdominal and intrapelvic loops of small and large bowel
are normal in caliber. There is a moderate amount of colonic stool. The
appendix appears normal (series 9, image 137).
The uterus is in mid position, and normal in size. No concerning adnexal
lesions are detected.
The abdominal aorta, celiac trunk, SMA, renal arteries, ___, and iliac
branches are patent and normal in caliber.
There are no osseous lesions concerning for malignancy or infection. There is
a moderate levoscoliosis centered about the thoracolumbar junction (series
613, image 60).
IMPRESSION:
1. Thrombus extending from the right renal vein into the IVC. It is unclear
if this thrombus is enhancing.
2. Slightly delayed right nephrogram secondary to underlying venous thrombus.
3. The calices, renal pelvis, and ureters are not well assessed on this single
phase study. No discrete renal lesion detected.
4. No hydroureter or collecting system stone.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abnormal CT, Transfer
Diagnosed with Other pulmonary embolism without acute cor pulmonale, Acute embolism and thrombosis of right internal jugular vein
temperature: 98.3
heartrate: 70.0
resprate: 16.0
o2sat: 99.0
sbp: 131.0
dbp: 87.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ YO female with a hx of PV c/b previous
transverse sinus thrombosis managed with therapeutic phlebotomy,
presenting as a transfer from OSH for evaluation and management
of IVC thrombus and PEs. She was placed on a heparin gtt and
converted to warfarin with lovenox bridge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending: ___.
Chief Complaint:
Non-functioning AV Fistula
Major Surgical or Invasive Procedure:
Temporary Hemodialysis line placement ___
AV Graft placement ___
Tunnelled HD line placement ___
History of Present Illness:
___ male with ESRD on HD, PVD s/p b/l BKA, CLL, HTN, DM,
CAD presenting with non-functioning AV fistula. Pt had left
radiocephalic AV fistula placed in ___ that failed and
subsequently underwent placement of left brachiocephalic AV
fistula. He has required thrombectomy and stening of his AVF x 3
___ and this AM ___. He underwent HD on
___ without complications. When he went for his next session
on ___ the fistula was non-functioning. He underwent ___
stent placement on ___ and went to HD after the procedure.
Fistula worked for 15 minutes and again was non-functioning. Pt
reports that he is 10lbs above his dry weight and also has
associated thigh and scrotal edema. (Per ___ clinic, pt has
had 23lb weight gain since ___ Denies SOB.
In the ED, initial VS: 98.8 81 115/54 18 96%. Labs were
significant for Cr 6.4 with K of 6.4. EKG was largely
unremarkable. He was seen by transplant surgery and renal who
recommended admission to medicine for placement of temporary HD
access. Renal did not feel urgent HD was warranted. He was given
calcium gluconate 2g IV and kayexelate 30gm for his hyperkalemia
as well as 4mg iv zofran.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation.
Past Medical History:
-ESRD on hemodialysis MWF (last dialysis yesterday)
-left arm AV fistula
-CAD (may have had a prior inferior infarction per note by Dr.
___ in ___
-anemia (baseline ___
-peripheral neuropathy
-s/p bronchial lymph node biopsy + for CLL
-hypertension
-cataracts
-anemia
-cholelithiasis
-splenomegaly,
-prior hypovolemic shock
-BPH
-Diabetes
Social History:
___
Family History:
Multiple relatives with DM; brother and sister both died from
complications from DM. Sister had fatal ovarian cancer. +CAD in
family.
Physical Exam:
On Admission
VS - 98.6 124/58 92 18 97%RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVD difficult to assess given
pt's cervical LAD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - Limited exam as listened anteriorly, grossly clear to
auscultation, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - b/l BKA, swelling of both thighs, genitals and
scrotum
LYMPH - prominent cervical, axillary, inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
On Discharge
GENERAL - Alert, interactive, chronically ill-appearing in NAD
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVP low, Tunnelled HD line in
place C/D/I without erythema, bleeding or exudate
HEART - PMI non-displaced, irregularly irregular S1-S2 clear and
of good quality, no MRG
LUNGS - Clear to auscultation bilaterally, moving air well and
symmetrically
ABDOMEN - NABS, soft/NT/ND, no HSM, palpable mesenteric ___
EXTREMITIES - b/l BKA, non-pitting edema of both thighs,
genitals and scrotum. AV graft site C/D/I, palpable, pulsatile,
thrill
LYMPH - prominent cervical, axillary, inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Admission
___ 07:40PM BLOOD WBC-69.8* RBC-2.21*# Hgb-6.9*# Hct-22.7*
MCV-103*# MCH-31.3 MCHC-30.4* RDW-19.0* Plt Ct-52*
___ 07:40PM BLOOD Neuts-4* Bands-0 Lymphs-86* Monos-1*
Eos-0 Baso-0 Atyps-9* ___ Myelos-0
___ 07:40PM BLOOD ___ PTT-25.2 ___
___ 07:40PM BLOOD Glucose-96 UreaN-86* Creat-6.4*# Na-141
K-6.4* Cl-102 HCO3-24 AnGap-21*
___ 05:45AM BLOOD Calcium-8.2* Phos-6.8*# Mg-2.4
___ 07:52PM BLOOD K-6.4*
___ 07:40PM BLOOD VitB12-840 Folate-19.3
Micro:
BCx negative x2
Discharge Labs:
___ 12:00PM BLOOD WBC-81.2* RBC-2.30* Hgb-7.1* Hct-22.6*
MCV-98 MCH-30.7 MCHC-31.3 RDW-18.8* Plt Ct-43*
___ 12:00PM BLOOD Glucose-110* UreaN-54* Creat-5.0* Na-138
K-4.5 Cl-96 HCO3-29 AnGap-18
___ 12:00PM BLOOD Calcium-7.7* Phos-5.9* Mg-2.1
Reports:
CXR ___ Cardiomegaly and mild edema with small effusions.
UE Ultrasound of venous and arteriograms ___: IMPRESSION:
Patent inflow brachial arteries with potentially a short segment
of patent vein just beyond the anastomosis. The vein has
organized thrombus at and below the stent
Medications on Admission:
Patient cannot recall meds, med list compiled from both ___
___ and ___ in ___, ___
Metoprolol Tartate 25mg BID
Pantoprazole 40mg BID
Gabapentin 100mg daily
Nephrocaps 1 cap daily
Leukeran (chlorambucil) 2mg po daily
Bisacodyl PR PRN
Kayexalate daily
Bactroban nasal ointment BID
Advair 500 BID
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
4. neomycin-bacitracnZn-polymyxin 3.5-400-5,000 mg-unit-unit/g
Ointment Sig: One (1) Appl Topical ONCE (Once) for 1 doses.
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q6H (every 6 hours) as needed for SOB.
6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. chlorambucil 2 mg Tablet Sig: One (1) Tablet PO once a day.
8. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
9. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
IH Inhalation twice a day.
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every ___ hours
as needed for Pain for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Non-functioning AV Fistula
End Stage Renal Disease
Hyperkalemia
Pancytopenia
CLL
CAD
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: ___ male with end-stage renal disease and weight gain,
clogged hemodialysis line, question acute process.
COMPARISON: Multiple chest radiographs, the latest from ___.
TWO VIEWS OF THE CHEST: Cardiomegaly is again noted with mild pulmonary edema
and bilateral small pleural effusions. Mediastinal and hilar prominence due
to known lymphadenopathy is grossly stable. There is diffuse sclerosis of the
visible osseous structures.
IMPRESSION: Cardiomegaly and mild edema with small effusions.
Radiology Report
TEMPORARY HEMODIALYSIS CATHETER PLACEMENT
INDICATION: ___ man with end-stage renal disease, on hemodialysis,
with nonfunctional left upper extremity AV fistula.
OPERATORS: Drs. ___ (fellow), ___ (resident), and ___.
___ (attending physician).
CONTRAST: None.
SEDATION: None.
PROCEDURE AND FINDINGS: Consent was obtained from the patient after
explaining the benefits, risks, and alternatives. Patient was placed supine
on the imaging table in the interventional suite. Timeout was performed as
per ___ protocol.
Under aseptic conditions and sonographic guidance, a micropuncture needle was
placed in the patent left internal jugular vein, just above the level of
clavicle. A 0.018 wire was advanced through the needle and into the SVC.
Needle was exchanged for a 4.5 ___ microsheath. The inner cannula and wire
were removed to place a 0.035 ___ wire, which was advanced into the IVC.
Sonographic images were obtained prior to and following needle placement.
After appropriate measurements and sequentially dilating the tract under
fluoroscopy with 12 and 14 ___ dilators, a 14 ___ 20 cm hemodialysis
catheter was placed over the wire. Inner plastic stiffener and wire were
removed. Catheter tip was confirmed under fluoroscopy to be in the lower SVC.
Ports were aspirated and flushed. Catheter was secured by 0 silk sutures.
Site was appropriately dressed. Patient tolerated the procedure well and no
immediate post-procedure complication was seen.
IMPRESSION: Uncomplicated ultrasound and fluoroscopic guided placement of a 14
___ 20 cm hemodialysis catheter via the patent left internal jugular vein,
and with its tip in the lower SVC. Catheter is ready for use.
Radiology Report
INDICATION: ___ male with clotted AV graft. Please evaluate stent in
the left cephalic vein fistula.
FINDINGS: The brachial arteries are duplicated with diameters of 3.5 and 5.8
mm respectively. The subclavian and brachial artery inflow is patent with
biphasic brachial and radial waveforms.
The area of the fistula anastomosis may be patent for short distance with
highly resistive flow. The cephalic vein outflow has organized thrombus prior
to and including the area of the stent in the forearm portion of the vein.
IMPRESSION: Patent inflow brachial arteries with potentially a short segment
of patent vein just beyond the anastomosis. The vein has organized thrombus
at and below the stent.
Radiology Report
INDICATION: Conversion of temporary dialysis line to a tunneled dialysis line
in a patient with end-stage renal disease being started on dialysis.
COMPARISON: Temporary dialysis line placement from ___.
CLINICIANS: Dr. ___ fellow), and Dr. ___
resident) directly supervised by Dr. ___.
PROCEDURE: Following a detailed discussion of all the risks, benefits, and
alternatives to the procedure, written informed consent was obtained. The
patient was transported to the angiography suite and placed supine on the
imaging table. The left neck and left internal jugular temporary hemodialysis
line were prepped and draped in usual sterile fashion. A preprocedure timeout
and huddle were performed using three patient identifiers as per ___
protocol. Prior to any intervention, physical exam of the left neck revealed a
mildly erythematous, finely vesicular rash around the exit site of the
temporary catheter. The patient reported this began yesterday (after platelet
infusion) and was slightly pruritic, not painful.
Local anesthesia was achieved using 1% bicarbonate-buffered lidocaine solution
as well as a lidocaine-epinephrine mixture. Moderate sedation was provided
throughout the procedure using a mixture of 75 mcg of fentanyl and 1 mg of
Versed throughout the total intraoperative time of 48 minutes, during which
the patient's hemodynamic parameters were continuously monitored by radiology
nurse. A 0.035 J wire was advanced into the right atrium using the temporary
dialysis line under fluoroscopic guidance. Following appropriate measurements
for the catheter length and marking of the venous catheter site, the wire was
advanced into the inferior vena cava.
Attention was turned to the creation of a subcutaneous tunnel. After local
anesthesia, a small skin incision was made and a 15.5 ___ tunneled catheter
was passed through the incision site to the venotomy site with the aid of a
metal tunneling device. The temporary dialysis line was removed at this
point. The venotomy tract was dilated with 7 and 9 ___ dilators. A
peel-away sheath was passed over the wire. The wire and inner cannula were
removed and the catheter was passed through the peel-away sheath. The
peel-away sheath was then removed while the catheter was pushed into the right
atrium under fluoroscopic guidance. Position was confirmed with fluoroscopic
image. The lumens withdrew blood and flushed easily. The catheter was
secured using silk external stitches. The venotomy site was closed using
vicryl sutures. Dry sterile dressings were applied. There were no immediate
post-procedure complications. The patient tolerated the procedure well.
Tip-to-cuff length: 23 cm.
IMPRESSION: Successful conversion of a left internal jugular temporary
dialysis line to a tunneled hemodialysis line. This line is now ready for
use.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: CLOGGED DIALYSIS SHUNT
Diagnosed with MALFUNC VASC DEVICE/GRAF, ABN REACT-RENAL DIALYSIS, HYPERKALEMIA, OTHER FLUID OVERLOAD, 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, CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
temperature: 98.8
heartrate: 81.0
resprate: 18.0
o2sat: 96.0
sbp: 115.0
dbp: 54.0
level of pain: 0
level of acuity: 2.0 | ___ male with ESRD on HD, PVD s/p b/l BKA, CLL, HTN, DM,
CAD presenting with non-functioning AV fistula.
# ESRD/Non-functioning AV fistula: Pt with left AV fistula that
was nonfunctioning despite stenting on ___. Hospital Day 1 a
temporary HD line was placed and patient immediately was started
on ugent HD for volume overload and electrolyte abnormalities (K
6.4). Renal and transplant surgery were consulted. Hemodialysis
was completed on HD2 as a make up for prior missed HD.
Transplant surgery took patient to OR on HD3 for which patient
received a jump AV graft. After surgery patient receied
hemodialysis on HD4. He received a tunnelled HD line on HD6 to
use while AV graft matures. Prior to discharged to restart HD
per regular MWF schedule.
# Hyperkalemia: K 6.4 on presentation, received kayexalate x2
with resulting BMs. Also received calcium gluconate. EKG without
significant changes. Patient received HD with improvement in
electrolytes.
# Pancytopenia: Hct in low ___ which is near baseline, likely
multifactorial (from ESRD, CLL, ?folate/B12 deficiency). Plt
count 52K (ranges widely, most recently ___. Vitamin B12
840 (240 - 900 pg/mL) and Folate 19.3 (2.0 - 20 ng/mL) so
Macrocytic anemia likely CLL and ESRD related rather than
nutritional deficiency. CBCs were monitored and
Heparin/anti-platelet products were not initiated given
thrombocytopenia.
# CLL: Pt with prominent axillary, cervical, inguinal lymph
nodes. WBC stable >60. Follows up with OSH oncologist, Dr
___. He is on chlorambucil which requires heme/onc
approval. Heme/Onc consulted for Chloramcucil consent.
# CAD: Aspirin and plavix discontinued by OSH physician per pt.
and continued to be held given significant thrombocytopenia and
risk of bleeding. This should continue to be considered in the
outpatient setting particularly if treatment of CLL leads to
improvement in platelet count. Patient is intolerant of statin.
His metoprolol was continued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ___
Allergies:
erythromycin base / Zithromax / tetracycline / ceftriaxone /
morphine
Attending: ___
Chief Complaint:
Abdominal pain, nausea, diarrhea
Major Surgical or Invasive Procedure:
___ tube placement
History of Present Illness:
Mr. ___ is a ___ female with alcohol use disorder
and recurrent necrotizing pancreatitis (c/b ARDS ___, most
recent admission ___ - ___ who was transferred from ___
for management of acute pancreatitis.
The patient was admitted from ___ - ___ with epigastric
abdominal pain and lipase > 500 consistent with acute
pancreatitis. The trigger was thought to be related to tobacco
and increased PO intake after her NJ had been inadvertently
removed. She had an MRCP which did not identify any structural
cause for her pancreatitis. Her NJ was replaced and her pain
improved so she was discharged home on ___.
After her discharge on ___t home on ___ and
___ she had 2 glasses of bourbon and began to increase her
tobacco use to a pack per day. She woke up with abdominal pain
at
3AM on ___ morning with associated nausea and diarrhea c/w
prior episodes of pancreatitis. She was hopeful the pain would
improve but it progressed throughout the day so she had her son
take her to ___. At ___, she received IV
dilaudid and requested to be sent to ___.
Of note, she was admitted from ___ for acute pancreatitis,
thought to be triggered by tobacco use. She was started on NJ
feeds and transitioned from IV dilaudid to PO oxycodone, PPI,
and
her creon was stopped. She was also evaluated by Pancreas team
with plan for outpatient MRCP ___ wks once inflammation
improved.
Prior to this admission she was also admitted from ___ for
necrotizing pancreatitis c/b hypoxemic respiratory failure from
ARDS and septic shock requiring intubation/pressors.
Post-extubation course was c/b aspiration pneumonia. She had a
post-pyloric feeding tube placed and at discharge she was
tolerating some PO as well as tube feeds and was discharged
home.
In the ED, temp 99.1, HRs 110s, BPs 120s/70s, RR 16, SpO2 100%
RA.
Exam notable for epigastric tenderness without distension. Her
cardiopulmonary exam was unremarkable and she was breathing
comfortably. Labs notable for WBC 15 (no bands), Hgb 10.1 (at
baseline), Plt 847 (844 on ___, normal Glc, Cr and BUN normal,
lipase 434, calcium 8.8, TGs 198, lactate 1.0. No imaging was
performed. She received 1L IVF and 1mg dilaudid IV.
Transfer VS were: 98.2 107 136/86 16 98% RA
On arrival to the floor, patient is complaining of ___
epigastric discomfort. She denies emesis but reports watery
diarrhea that is typical when she has pancreatitis. She denies
blood in stool or melena. Her feet have been swollen since her
last hospitalization but they have decreased substantially in
size. She denies any dyspnea, chest pain, cough, fevers, or
chills. She does report depressed mood iso several repeat
hospitalizations and decreased quality of life with her
abdominal
pain.
Past Medical History:
- Alcohol use disorder
- Depression
- Anxiety
- GERD
- Tobacco use
- Recurrent pancreatitis
- Recent hospitalization (d/c ___ for acute necrotizing
pancreatitis complicated by severe ARDS, hypoxemic respiratory
failure, ventilator associated pneumonia, septic shock and
aspiration
Social History:
___
Family History:
Family history of alcoholism negative for pancreatic cancer or
GI malignancies.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
___ 2341 Temp: 98.5 PO BP: 151/89 R Lying HR: 110 RR: 20 O2
sat: 100% O2 delivery: Ra
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, tenderness to palpation of
epigastrum, voluntary guarding, no hepatosplenomegaly
EXTREMITIES: trace pedal edema in b/l ___: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, very mild tenderness to
palpation of epigastrum, no longer voluntarily guarding, no
hepatosplenomegaly
EXTREMITIES: no ___ edema, warm, well perfused
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 06:37PM BLOOD WBC-15.4* RBC-3.36* Hgb-10.1* Hct-31.9*
MCV-95 MCH-30.1 MCHC-31.7* RDW-14.2 RDWSD-48.7* Plt ___
___ 06:37PM BLOOD Neuts-63.5 ___ Monos-7.2 Eos-1.6
Baso-0.7 Im ___ AbsNeut-9.80* AbsLymp-4.08* AbsMono-1.11*
AbsEos-0.24 AbsBaso-0.11*
___ 06:37PM BLOOD Glucose-92 UreaN-11 Creat-0.4 Na-138
K-4.0 Cl-101 HCO3-24 AnGap-13
___ 06:37PM BLOOD ALT-10 AST-14 AlkPhos-226* TotBili-0.2
___ 06:37PM BLOOD Lipase-434*
___ 06:37PM BLOOD Albumin-2.8* Calcium-8.8 Phos-3.9 Mg-1.7
___ 06:37PM BLOOD Triglyc-198*
___ 05:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:43PM BLOOD Lactate-1.0
___ 06:18PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:18PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 06:18PM URINE bnzodzp-NEG barbitr-NEG opiates-POS*
cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG
DISCHARGE LABS:
===============
___ 06:06AM BLOOD WBC-12.1* RBC-3.37* Hgb-10.0* Hct-33.1*
MCV-98 MCH-29.7 MCHC-30.2* RDW-14.9 RDWSD-53.2* Plt ___
___ 06:06AM BLOOD ___
___ 06:06AM BLOOD Glucose-116* UreaN-6 Creat-0.4 Na-139
K-5.3 Cl-101 HCO3-27 AnGap-11
___ 06:06AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.1
IMAGING STUDIES:
================
CT HEAD (___):
No acute intracranial abnormality.
BILATERAL LOWER EXTREMITY VEINS (___):
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
TTE (___):
CONCLUSION: The left atrial volume index is normal. There is no
evidence for an atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is ___ mmHg. There is normal
left ventricular wall thickness with a mildly increased/dilated
cavity. There is mild global left ventricular hypokinesis and
relative preservation of apical function. Quantitative biplane
left ventricular ejection fraction is 42 %. Left ventricular
cardiac index is high (>4.0 L/min/m2). There is no resting left
ventricular outflow tract gradient. Normal right ventricular
cavity size with normal free wall motion. The aortic sinus
diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal. There
is no evidence for an aortic arch coarctation. The aortic valve
leaflets (3) appear structurally normal. There is no aortic
valve stenosis. There is no aortic regurgitation. The mitral
valve leaflets appear structurally normal with no mitral valve
prolapse. There is mild to moderate [___] mitral regurgitation.
The tricuspid valve leaflets appear structurally normal. There
is physiologic tricuspid regurgitation. The pulmonary artery
systolic pressure could not be estimated. There is no
pericardial effusion.
IMPRESSION: Mildly dilated left ventricle with mild global
hypokinesis in a pattern most consistent with a non-ischemic
cardiomyopathy or other diffuse process. Despite this cardiac
output is high (? cirrhosis given alcohol history and high
output state). Mild to moderate mitral regurgitation. Could not
estimate pulmonary pressure.
EGD (___):
- Esophagus: Diffuse white plaques of mucosa were noted in the
esophagus. Mutliple cold forceps biopsies were preformed for
histology in the esophageal plaques.
- Stomach: Normal mucosa was noted in the whole stomach.
- Duodenum: Normal mucosa was noted in the whole examined
duodenum. An NJ tube was placed passed the third portion of the
duodenum. The tube was moved from the mouth into the nose and
bridled at 117cm. The tube flushed without difficulty.
MICROBIOLOGY:
=============
________________________________________________________
___ 10:00 pm URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 6:00 pm URINE Site: NOT SPECIFIED
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 6:37 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 6:18 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. FoLIC Acid 1 mg PO DAILY
3. Gabapentin 800 mg PO TID
4. LORazepam 0.5 mg PO BID:PRN anxiety
5. Multivitamins 1 TAB PO DAILY
6. Thiamine 100 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. TraZODone 25 mg PO QHS:PRN insomnia
9. Venlafaxine 18.75 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Cephalexin 500 mg PO Q6H cellulitis
12. Sulfameth/Trimethoprim DS 1 TAB PO BID
13. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS
14. Ondansetron ODT 4 mg PO Q8H:PRN nausea
15. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
16. Nicotine Patch 7 mg/day TD DAILY
Discharge Medications:
1. Creon 12 1 CAP PO TID W/MEALS
RX *lipase-protease-amylase [Creon] 12,000 unit-38,000
unit-60,000 unit 1 capsule(s) by mouth TID w/ meals Disp #*90
Capsule Refills:*0
2. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
4. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. LORazepam 0.5 mg PO BID:PRN anxiety
9. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS
10. Multivitamins 1 TAB PO DAILY
11. Nicotine Patch 7 mg/day TD DAILY
12. Ondansetron ODT 4 mg PO Q8H:PRN nausea
13. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 10 mg 1 tablet(s) by mouth q6 hrs Disp #*28 Tablet
Refills:*0
14. Pantoprazole 40 mg PO Q12H
15. Thiamine 100 mg PO DAILY
16. TraZODone 25 mg PO QHS:PRN insomnia
17. Venlafaxine 18.75 mg PO BID
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Pancreatitis due to Alcohol
New Congestive Heart Failure
Malnutrition
Alcohol Use Disorder
SECONDARY DIAGNOSIS
===================
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: NJ tube placement confirmation// NJ tube placement confirmation
IMPRESSION:
In comparison with the study of ___, there has been placement of a
Dobhoff tube that extends well beyond the ligament of Treitz. Otherwise,
little change.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with HA this AM and change mental status this
afternoon// ? acute abnormality
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.1 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema, or mass. The
ventricles and sulci are normal in size and configuration.
An NG tube is partially imaged. There is no evidence of fracture. The
visualized portion of the paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with new pitting edema bilaterally.// R/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Pancreatitis, Transfer
Diagnosed with Other chronic pancreatitis
temperature: 99.1
heartrate: 110.0
resprate: 16.0
o2sat: 100.0
sbp: 126.0
dbp: 77.0
level of pain: 9
level of acuity: 3.0 | SUMMARY:
========
Ms. ___ is a ___ female with alcohol use disorder
and recurrent necrotizing pancreatitis (c/b ARDS ___, most
recent admission ___ - ___ who was transferred from ___
for management of acute pancreatitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o ___ female w h/o CAD, MI s/p catherizations
2x ___, HTN, HLD, breast cancer, and CLL who p/w a first
syncopal event with chest pain. At 11 pm last night, she awoke
to go to the bathroom, felt dizzy in the bathroom, and fell.
This is her first fall and first syncopal episode. Although she
denies prodrome, she does report feeling that prior to falling
both ears felt clogged and eyes could not see as well. Does not
recall the fall. She regained consciousness 35-40 min later and
took her own BP which was 130/70s. Denies post-syncopal
confusion. Denies h/o seizures. Also denies decreased PO intake;
she drinks lots of H20 everyday and urinates without a problem.
She went back to bed.
In the morning, she awoke to Health Aid call. Told aid she does
not feel well. BP 180/90 at that time and she presented to ED.
In the ED, she was found to have some bruises and scratches.
Troponin was negative. Negative CXR. Admitted for syncope and
troponin cycling.
ROS:
(+) HA ___
(-) CP, SOB, abd pain, dysuria, n/v/d, constipation, blood in
stools, edema
Past Medical History:
# CARDIAC RISK FACTORS:
(+) Diabetes (diet controlled), (+) Dyslipidemia, (+)
Hypertension
.
# CARDIAC HISTORY:
- CAD, one vessel disease ( RCA )
-- PTCA to with overlapping DES to ostial/ proximal RCA in ___
-- PTCA to RCA with DES to ostial RCA for 90% in stent
restenosis.
.
# OTHER PAST MEDICAL HISTORY:
- CAD as described above
- Hypertension
- Type 2 diabetes mellitus controlled with diet
- Dyslipidemia
- Breast cancer in ___, treated with a left mastectomy
including lymph node dissection. She also received radiotherapy
___ years of tamoxifen
- CLL with stable white cell counts
Social History:
___
Family History:
No family history of early MI, otherwise NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.8, 64, 127/46, 18 100 RA
Gen: well appearing, lying in bed, NAD, ___
HEENT: AT, NC, EOMI, MMM, alert & oriented
Neck: supple
CV: RRR, normal S1 and S2
Lungs: mild crackles RLL base. Otherwise CTAB
Abd: soft, non-tender, non-distended, no rebound/guarding, +BS
Extr: warm and well-perfused, DP 2+ b/l
Derm: no rashes
Psych: appears normal mood and affect
Neuro: AOx3, no focal deficits
DISCHARGE PHYSICAL EXAM:
VS: 98.2, 66, 109/54, 18, 99 RA
Gen: well appearing, NAD, sitting upright in chair
HEENT: AT, NC, EOMI, MMM, alert
Neck: supple
CV: RRR, normal S1 and S2, on telemetry
Lungs: CTAB
Abd: soft, non-tender, non-distended, no rebound/guarding, +BS
Extr: warm and well-perfused, DP 2+ b/l
Derm: no rashes
Psych: appears normal mood and affect
Neuro: Alert, no focal deficits
Pertinent Results:
ADMISSION LABS:
___ 01:00PM BLOOD WBC-8.7 RBC-3.54* Hgb-11.4* Hct-32.4*
MCV-92 MCH-32.3* MCHC-35.3*# RDW-14.0 Plt ___
___ 01:00PM BLOOD Neuts-46* Bands-2 Lymphs-48* Monos-2
Eos-1 Baso-0 Atyps-1* ___ Myelos-0
___ 01:00PM BLOOD Glucose-115* UreaN-24* Creat-1.1 Na-138
K-4.0 Cl-100 HCO3-26 AnGap-16
___ 08:50PM BLOOD CK(CPK)-96
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-7.7 RBC-3.49* Hgb-11.1* Hct-32.2*
MCV-92 MCH-31.7 MCHC-34.4 RDW-14.1 Plt ___
___ 06:50AM BLOOD Glucose-123* UreaN-26* Creat-1.3* Na-137
K-3.5 Cl-100 HCO3-27 AnGap-14
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 12.5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Rosuvastatin Calcium 20 mg PO DAILY
5. Nitroglycerin Patch 0.4 mg/hr TD PRN Chest pain
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
8. Pancrelipase 5000 1 CAP PO TID W/MEALS
9. Ferrous Sulfate 140 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
3. Hydrochlorothiazide 25 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
6. Nitroglycerin Patch 0.4 mg/hr TD PRN Chest pain
7. Pancrelipase 5000 1 CAP PO TID W/MEALS
8. Rosuvastatin Calcium 20 mg PO DAILY
9. Ferrous Sulfate 140 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Syncope and chest pain.
COMPARISONS: ___ and ___.
FINDINGS: PA and lateral chest radiographs demonstrate no focal
consolidation, pleural effusion or pneumothorax. There is a nodular opacity
projecting adjacent to the right interlobar artery which was also faintly seen
on the prior study and likely represents overlap of vascular structures.
Aortic tortuosity is unchanged. The heart size is stable.
IMPRESSION: No acute cardiopulmonary process.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: DIZZINESS, HTN
Diagnosed with SYNCOPE AND COLLAPSE, CHEST PAIN NOS
temperature: 97.3
heartrate: 66.0
resprate: 18.0
o2sat: 100.0
sbp: 177.0
dbp: 77.0
level of pain: 2
level of acuity: 2.0 | PRIMARY REASON FOR HOSPITALIZATION
___ y/o ___ female w h/o CAD, MI s/p catherizations
2x ___, HTN, HLD, breast cancer, and CLL who p/w a first
syncopal event with chest pain.
ACUTE DIAGNOSES
# SYNCOPE: first syncope, unwitnessed, unclear prodromal history
but pt mentioned acutely decreased hearing and vision prior to
falling. Unclear etiology. Troponin negative x 2, no abnormal
EKG findings or telemetry recordings. Vasovagal was thought to
be the most likely given the fall happened shortly after rising
out of bed to go to the bathroom; patient is also on HCTZ at
home. Brain mets also a possibility given prior h/o breast
cancer but patient without symptoms to suggest seizure (no
tongue biting, no incontinence). Pt advised to rise from bed
slowly to monitor for symptoms of dizziness in the future. Some
volume depleting medications were lowered on discharge.
# UTI: U/A concerning for infection, although patient without
symptoms. Treated empirically with bactrim. Culture pending at
discharge.
CHRONIC DIAGNOSES
# CAD: s/p MI in ___ w/ catherization x 2. Troponins negative.
TRANSITIONAL ISSUES
Pt lives alone and loves her independence. She has a Health Aid
who spends 7 hours per week with her. She is ambulatory and does
not need ___. She has a caring daughter who can serve as her
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
dexamethasone
Attending: ___.
Chief Complaint:
Migraine headache, right eye vision loss
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ yo woman with PMH significant for complicated
migraine headaches with history of status migranosis and right
sided numbness/weakness along with history of functional
movement disorder who presented to the ED on ___ with migraine
headache
The patient reported that her headache started on ___, and was
described as right-sided throbbing and squeezing in character
and associated with photo and phonophobia. it is moderate to
severe in intensity. On ___, the patient noticed blurring in
her right eye with is unusual for her headaches. She also noted
that when she turns her head to the right she has pain starting
in her lateral trapezius and radiating up to her vertex. She saw
her PCP ___ ___ who referred her to the ED to rule out a
dissection. She denied any trauma and recent stressors including
physical activities.
The patient underwent CTA of the head and neck, which
demonstrated no abnormalities.
In the ED the patient received:
10 mg IV dexamethasone
3L IVF prior to ___ eval
Proclorperazine 10 mg 2 hours prior to ___ eval
3L IVF ___ eval
IV lorazepam, IV morphine, ketorolac, metoclopramide, Benadryl,
caffeine-sodium benzoate at various times throughout her ED
course
After the patient received the IV dexmethasone, she developed
whole body intermittent jerky movements along with complains of
right hand and foot numbness and trouble with her gait. She was
able to ambulate without assistance to the bathroom prior to
examination. The patient and her brother (at the bedside) noted
that she has experienced these symptoms before after being given
steroids.
The patient was evaluated by neurology in the ED, and was found
to have numerous function signs, including gait disturbance
which was felt to be functional, and sensory changes which
respect the hairline and split the midline with vibration
(non-physiologic). The patient also demonstrated decreased
visual acuity which improved to ___ with pinhole testing. They
felt that her headache and vision changes were consistent with
migraine, with a possible cervicogenic component. They felt that
her symptoms may have been a reaction to the dexamethasone. The
patient was last evaluated by neurology in ___ when she also
had a prolonged migraine with associated right sided numbness,
gait instability and myoclonic movements. Her workup was
negative including EEG. Her presentation was thought most
consistant with a somatoform disorder and possible
pseudoseizures. She has not followed up with neurology since.
The patient was seen by ___ regarding her gait disturbance, and
was found to have orthostatic hypotension despite her 3L IVF.
Supine BP 114/56, sit 96/57, stand 86/50 with reports of
dizziness and lightheadedness. Pt. recovered to BP of 119/58 in
supine. She has since received 3 more liters of IVF and 10 mg
proclorperazine 2 hours prior to her eval. After her eval, she
developed tachycardia which failed to resolve with IVF, Ativan,
or Benadryl. After further discussion with neuro it was decided
to admit her to medicine
In the ED, initial vitals were:
97.8 73 117/58 16 100% RA
Initial labs demonstrated hypophosphatemia at 2.5, but were
otherwise wnl. Her urine and serum tox were negative.
Labs prior to transfer:
7.2>12.4/37.6<160
Chem 7 wnl except for bicarb of 21
AST/ALT ___, ALP 71, Alb 4.0, Mg 1.6
On the floor, the patient says that she still has a headache
over the right eye and right occipital area that is described as
throbbing, ___ pain, associated with right eye right peripheral
vision loss that is improved from ED presentation, and was
improved with medications in the ED. The patient also reports
intermittent whole body jerks with associated squeezing chest
pain and palpitations that occur during these episodes. She says
she also experiences SOB after this chest pain.
The patient also endorses numbness in the tips of the fingers on
her right hand as well as tingling in her right foot. She
endorses chills but denies fevers, N/V, cough, abd pain, changes
in bowel or bladder, or weakness.
Past Medical History:
Restrictive Pericarditis at age ___, no sequelae.
- Migraines per HPI
- Likely somataform disorder with "intermittent brief jerks of
all four extremities with preserved consciousness" "right foot
numbness and weakness" and functional gait disorder with
astasia-abasia
- nonalcoholic fatty liver disease
- Depression/PTSD/suicidal ideations/Remote history of bulimia.
Social History:
___
Family History:
negative for strokes, hypercoagulable disorders, or seizures
Physical Exam:
ADMISSION EXAM
==============
Vital Signs: 99.3 123/69 79 16 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated,
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: The patient demonstrates whole-body myoclonic jerks
intermittently during her examination. These jerks are worsened
when talking about them and during examination of the
heart/lungs, and are lessened when the patient is talking and
distracted.
Initial inattention with CN exam. CNII-XII intact, ___ strength
with hand grip on right, ___ strength at right shoulder
adductors, and ___ strength with dorsiflexion of right foot.
Otherwise ___ strength throughout. The patient exhibits
diminished sensation in the V2 distribution of the trigeminal
nerve, but has normal sensation throughout otherwise. No foot
clonus, Babinski negative.
DISCHARGE EXAM
==============
Vitals: T:98.1 BP:116/58 P: 72 R:20 O2: 100 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur, no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: Myoclonic jerks noted during this exam, they were
distractable and occurred mainly in the RLE. CNII-XII intact,
___ strength with hand grip on right, ___ strength at right
shoulder adductors. Notably, ___ strength on bilateral
dorsiflexion. Otherwise ___ strength throughout. Attention
difficulty noted (days of the week), but able to recount
personal details of her life.
Pertinent Results:
ADMISSION LABS
==============
___ 10:16PM BLOOD WBC-4.2 RBC-4.53 Hgb-13.0 Hct-39.9 MCV-88
MCH-28.7 MCHC-32.6 RDW-13.1 RDWSD-41.8 Plt ___
___ 10:16PM BLOOD Neuts-72.9* ___ Monos-2.4*
Eos-1.2 Baso-0.5 Im ___ AbsNeut-3.07 AbsLymp-0.96*
AbsMono-0.10* AbsEos-0.05 AbsBaso-0.02
___ 10:16PM BLOOD Glucose-113* UreaN-8 Creat-0.6 Na-136
K-5.7* Cl-107 HCO3-21* AnGap-14
___ 11:24AM BLOOD ALT-27 AST-23 AlkPhos-71 TotBili-0.5
___ 10:16PM BLOOD Calcium-8.6 Phos-2.5* Mg-1.8
___ 11:24AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:53PM URINE Color-Straw Appear-Clear Sp ___
___ 02:53PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 02:53PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
DISCHARGE LABS
==============
___ 05:47AM BLOOD WBC-5.5 RBC-4.57 Hgb-12.8 Hct-40.1 MCV-88
MCH-28.0 MCHC-31.9* RDW-13.3 RDWSD-42.4 Plt ___
___ 05:47AM BLOOD Glucose-84 UreaN-13 Creat-0.6 Na-138
K-3.8 Cl-106 HCO3-24 AnGap-12
___ 05:47AM BLOOD Calcium-9.0 Phos-4.2 Mg-1.8
___ 05:40AM BLOOD VitB12-646
___ 05:40AM BLOOD TSH-2.3
IMAGING
=======
___ Imaging CTA HEAD & CTA NECK
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. No evidence of aneurysm greater than 3 mm, dissection or
vascular
malformation, or significant luminal narrowing.
3. There is no internal carotid artery stenosis by NASCET
criteria.
MICRO
=====
NONE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Ibuprofen 600 mg PO Q8H:PRN headache
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
capsule(s) by mouth every 6 hours Disp #*6 Capsule Refills:*0
3. Lorazepam 0.5 mg PO QHS insomnia
Please do not drink alcohol and drive while taking
RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth at night Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
-Migraine headache
-Orthostatic hypotension
-Myoclonic jerks
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ female with right-sided headache and vision changes,
different from her typical headaches that are bilateral without vision
changes. Evaluate for dissection.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) 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) Sequenced Acquisition 1.6 s, 4.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
224.3 mGy-cm.
5) Sequenced Acquisition 1.6 s, 4.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
224.3 mGy-cm.
6) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 87.1 mGy (Head) DLP =
43.6 mGy-cm.
7) Spiral Acquisition 5.0 s, 39.2 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,255.3 mGy-cm.
Total DLP (Head) = 2,645 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Evaluation the skullbase is motion degraded. Within these confines:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
The visualized portion of the mastoid air cells, and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable. The maxillary
sinuses are diminutive in size but clear. Minimal mucosal thickening is seen
in the ethmoid sinuses.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria. Partially visualized median sternotomy wires are seen. There
surgical clips in the anterior mediastinum.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. No evidence of aneurysm greater than 3 mm, dissection or vascular
malformation, or significant luminal narrowing.
3. There is no internal carotid artery stenosis by NASCET criteria.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Headache
Diagnosed with Tachycardia, unspecified, Migraine, unsp, not intractable, without status migrainosus
temperature: 97.8
heartrate: 73.0
resprate: 16.0
o2sat: 100.0
sbp: 117.0
dbp: 58.0
level of pain: 8
level of acuity: 3.0 | BRIEF SUMMARY
Ms ___ is a ___ year old female with a past medical history
significant for complicated migraine headaches with history of
status migranosus and right sided numbness/weakness along with
history of functional movement disorder who presented to the
emergency department on ___ with migraine headache at the
request of her PCP.
ACUTE ISSUES
#Migraine headache: The patient presented to the ED at the
request of her PCP ___ throbbing and squeezing pain located
above her right eye as well as in the right occipital area. She
also described vision loss in the outer periphery of her right
eye, which is atypical for her migraines. She has a history of
complicated migraine and status migranosus, but says she has not
had a migraine since ___.
A CT angiogram of the head/neck was performed to rule out
dissection, which was normal. Neurology was consulted, and felt
that her symptoms were consistent with migraine headache with a
possible cervicogenic component to her headaches. She was
treated with metoclopramide, ibuprofen, and fioricet for her
pain with some improvement in her headache symptoms. She was
discharged with a short course of Fioricet.
#Myoclonic jerks/numbness/weakness:
After the patient was given dexamethasone in the ED for her
migraine, she subsequently developed whole-body myoclonic jerks,
right-sided hand and foot numbness, and difficulty walking,
which she has reportedly experienced in ___ after receiving
steroids for migraine. She has had none of these symptoms in the
interim between ___ and now. She was seen by neurology, who
felt that her headache and vision changes were likely due to her
migraine, and that her body symptoms were due to a reaction to
the steroid versus functional/somatoform. No further studies
were recommended. Psychiatry was consulted, and felt that her
signs and symptoms should resolve on their own as they did in
___. The patient did slip on the day of discharge when her leg
began jerking while ambulating to the bathroom (no head strike
and she was supported to the ground by the patient care tech),
but after ___ evaluation and discussion with her family, it was
felt she would be safe for discharge if 24 he assist was
available from the brother for all ambulatory/ upright
activities.
#Orthostatic hypotension: The patient was evaluated by ___ and
was noted to have orthostatic hypotension with an inappropriate
heart rate response upon admission. The patient was euvolemic,
and had received 3L IVF prior to her evaluation, so it is
unlikely that volume loss played a role. She had been given
proclorperazine and benadryl for migraine prior to her ___
evaluation, which is the likely culprit. Orthostatic vitals
after admission to the floor were normal.
#insomnia: Endorses poor sleep while in hospital
- lorazepam 0.5 mg PO QHS recommended by psychiatry
# Chest pain: Occurred in the setting of the myoclonic jerks;
likely musculoskeletal in nature. Unlikely to be cardiac in
nature, EKG wnl.
TRANSITIONAL ISSUES
===================
-Patient will f/u with her primary care physician and may choose
to establish care with neurology or psychiatry if she wishes.
She was also scheduled for an ophthalmology appointment per
neurology, but they are booking into ___ at ___. She may
need to locate a different ophthalmology practice to obtain a
sooner appointment depending on whether she experiences
recurrent visual symptoms.
-At discharge, Ms. ___ was still experiencing jerking
movements that significant improved with distraction. Her family
was trained in how to use a gait belt to stabilize her. She will
have home ___.
-She was discharged on a trial of fioricet and lorazepam per
neurology and psychiatry, respectively.
-Dexamethasone was added to the patient's allergy list.
# CODE: Full (confirmed)
# CONTACT: ___ (brother) ___
___ (brother) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Demerol
Attending: ___
___ Complaint:
Anorexia Nervosa
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with severe anorexia nervosa, weight 78 lbs,
bmi approx 14, needs medicine admit for eating disorder
protocol/refeeding. No complaints today. No thoughts of HI/SI.
Mother is her ___ who can be reached at
___. Mother in agreement with plan. Suspected emesis in
MD office today. Pt referred in by PCP ___.
Per PCP visit from ___: weight was 79 pounds giving her a BMI
of 14.4 which is extremely low and her blood pressure is 98/60
in the office.
Recent admission ___ for hypotension and bradycardia.
In the ED, initial vital signs were 98.9 60 118/70 15 100%. Labs
notable for Hct 33.4 (MCV 81), WBC 9.3, K 3.6, Mg 2.1. Urine hcg
negative. UA with mod leuks and 40 WBC, 2 epis and no bacteria.
On the floor, pt reports that she feels fine but does not want
to be in the hospital. Denies current laxative or diuretic use.
Pt last used laxatives in ___. Denies current use of diet
pills, last use was in high school. Pt's LMP was in ___ when she
d/c'd OCPs. Denies taking emetics. Pt run 2 miles, 3x/wk. Denies
binging or purging, SI/HI.
Past Medical History:
Multiple Sclerosis
Social History:
___
Family History:
Mother with lupus.
Grandfather with MI at ___
Diabetes: aunt, uncle, cousins
Eating ___
MGM, Maternal Aunt: ___ CA
Physical Exam:
Initial Physical Exam
Vitals- T 98.3 BP 95/63 P 60 R 16 O2Sat 100% RA
General: Alert, Oriented, NAD, Extremely Thin
HEENT: EOMI, No Oropharyngeal Erythema
Neck: Supple, No cervical/supraclavicular LAD
CV: Regular rate and rhythm, no m/r/g
Lungs: Clear to Auscultation B/L
Abdomen: soft, non-tender, non-distended, no organomegaly
GU: no foley
Ext: no ___ edema, radial pulse 2+ b/l no cyanosis, clubbing, or
edema
Neuro: motor function grossly intact
Skin: No Rash or lesion
Discharge Physical Exam;
Vitals: T 98 HR 61 BP 94/52 RR 16 O2Sat 98%RA Wt pending
General: extremely thin young woman, lying in bed, NAD
HEENT: PERRL, Sunken Eyes, temporal wasting, oropharynx clear
Neck: No cervical lymphadenopathy or palpable thyroid
Lungs: clear to auscultation b/l, no wheezes, rales, or rhonchi
CV: regular rate and rhythm, no murmurs, rubs, or gallops
Abdomen: Mild suprapubic tenderness without rebound or guarding
soft, non-distended, normal bowel sounds
Ext: No ___ Edema, warm and well perfused
Neuro: AAOx3, motor and sensory exam grossly intact
Pertinent Results:
INITAL LAB RESULTS
___ 01:50PM BLOOD WBC-9.3 RBC-4.11* Hgb-12.0 Hct-33.4*
MCV-81* MCH-29.1 MCHC-35.8* RDW-13.3 Plt ___
___ 01:50PM BLOOD Glucose-88 UreaN-6 Creat-0.7 Na-138 K-3.6
Cl-103 HCO3-26 AnGap-13
___ 01:50PM BLOOD ALT-12 AST-18 LD(LDH)-148 AlkPhos-42
Amylase-58 TotBili-0.3 DirBili-0.1 IndBili-0.2
___ 01:50PM BLOOD TotProt-6.3* Albumin-4.4 Globuln-1.9*
Calcium-9.3 Phos-3.6 Mg-2.1 UricAcd-3.8 Cholest-152
___ 01:50PM BLOOD TSH-0.56
___ 01:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:50PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 01:50PM URINE RBC-1 WBC-40* Bacteri-NONE Yeast-NONE
Epi-2
Discharge Lab results
___ 06:25AM BLOOD Glucose-78 UreaN-8 Creat-0.6 Na-140 K-4.3
Cl-103 HCO3-30 AnGap-11
___ 06:25AM BLOOD Calcium-9.3 Phos-5.0* Mg-2.1
MICRO:
___ **FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ KUB
IMPRESSION:
No dilated loops of small or large bowel to suggest obstruction.
Mild fecal
loading of the colon.
___ 08:11AM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:11AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM
___ 08:11AM URINE RBC-1 WBC-12* Bacteri-MOD Yeast-NONE
Epi-0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ocella (drospirenone-ethinyl estradiol) ___ mg Oral daily
2. Fluoxetine 10 mg PO DAILY
3. ClonazePAM 0.5 mg PO TID
4. TYSABRI (natalizumab) 300 mg/15 mL Injection monthly
Discharge Medications:
1. ClonazePAM 0.5 mg PO TID
RX *clonazepam 0.5 mg 1 tablet(s) by mouth three times a day
Disp #*10 Tablet Refills:*0
2. Fluoxetine 10 mg PO DAILY
RX *fluoxetine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Capsule Refills:*0
3. Ocella (drospirenone-ethinyl estradiol) ___ mg Oral daily
4. Docusate Sodium 200 mg PO BID constipation
RX *docusate sodium 100 mg 2 tablet(s) by mouth twice a day Disp
#*120 Capsule Refills:*0
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
6. Neutra-Phos 2 PKT PO BID
RX *potassium & sodium phosphates [Phos-NaK] 280 mg-160 mg-250
mg 2 packets by mouth twice a day Disp #*120 Packet Refills:*0
7. TYSABRI (natalizumab) 300 mg/15 mL Injection monthly
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Anorexia Nervosa
Seconary: multiple sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with anorexia nervosa and
multiple sclerosis, admitted for management.
PA and lateral upright chest radiographs were reviewed in comparison to ___.
Heart size and mediastinum are unremarkable. Lungs are clear with no pleural
effusion or pneumothorax.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Radiology Report
HISTORY: ___ woman with history of anorexia and constipation assess
for stool burden.
COMPARISON: None available.
FINDINGS:
One frontal view of the abdomen shows a normal bowel gas pattern. There are
no dilated loops of small or large bowel to suggest obstruction. There is
mild fecal loading throughout the colon. There is no pneumatosis or secondary
evidence of free air. The visualized osseous structures are unremarkable.
IMPRESSION:
No dilated loops of small or large bowel to suggest obstruction. Mild fecal
loading of the colon.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ANOREXIA
Diagnosed with ANOREXIA NERVOSA
temperature: 98.9
heartrate: 60.0
resprate: 15.0
o2sat: 100.0
sbp: 118.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ year old woman with severe anorexia
nervosa, with an admission weight of 35.1 kg at 74% of her ideal
body weight. She required admission to the medicine service for
the eating disorder
protocol/refeeding. ___ has had multiple admissions
for hypotension and bradycardia assoc. w/ anorexia most recently
in ___.
ACUTE ISSUES
#Anorexia Nervosa: Pt has had a long hx of anorexia since ___ yrs
of age, with multiple admissions for hypotension and bradycardia
___ anorexia. The Eating disorder treatment team meetings were
held weekly to reassess patient's status and plans for
discharge. The treatment team included psychiatry, nutrition,
and social work representatives. Per the eating disorder
protocol, she received daily multi-vitamins with minerals with
neutra-phos repletion, and received the eating disorder diet
which she had to consume while monitored. Daily weights were
obtained, as well as daily orthostatics. Throughout her
admission, ___ BP recordings were negative for
orthostatic hypotension. Her electrolytes were monitored
closely, and rarely required repletion. Her admission was
complicated by multiple room searches revealing laxatives and
caffeine pills. The patient was also found to be pouring ensure
into her napkins. She was also observed switching/sharing food
with her roommate, resulting in a room change. The patient was
also monitored on telemetry. Her HR increased intermittently to
the 130's while in the bathroom, where the patient was believed
to have been exercising. Patient showed poor insight into her
disease throughout admission and was adamant regarding discharge
home instead of an inpatient or residential treatment facility.
During her admission she increased in weight to 38.7 kg or about
81% of IBW. As a bed was not available at the treatment center
to which she was accepted for 3 weeks, patient was discharged
home to her parents house with plans for close medical and
psychological followup until she could start at ___ in
___.
#Constipation: Pt complained of constipation during admission
with assoc. lower quadrant abdominal pain. Her abdomen remained
non-distended, soft, without peritoneal signs. She was written
for colace 200 mg BID PRN constipation, as well as metamucil.
Despite this regimen, pt cont. to c/o constipation, asking
specifically for miralax, which was not given. A subsequent room
search revealed multiple packs of laxatives and caffeine pills
which were removed from her room.Patient complained of
suprapubic tenderness so UA/Ucx were obtained which showed no
evidence of UTI. A KUB showed mild fecal loading which was not
consistent with patient's claims of severe constipation. She was
continued on colace, metamucil, and prune juice throughout
admission.
CHRONIC ISSUES
# Multiple Sclerosis: The patient has a known diagnosis of
multiple sclerosis. She takes monthly injections of Tysabri,
with her next dose due ___. The patient remained clinically
stable throughout admission.
# Contraception: Patient took Ocella OCP's. She had her own
medications which she took per pharmacy approval. Pt ran out of
Ocella, and because Ocella is non-formulary, she was encouraged
to refill her prescription at outside pharmacy and gain ___
pharmacy approval for in house consumption. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
acetaminophen / oxycodone
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
___ Iliac/Pelvic ARTERIOGRAM and embolization
___ Pseudoaneurysm Embolization
History of Present Illness:
___ is a ___ PMH COPD, HTN, NIDDM, HFpEF who was recently
admitted to ___ ___ for dyspnea and was found to have MVP
with severe MR. ___ was discharged ___ with planned readmission
___ for ___.
His most recent hospital admission was notable for the
following. ___ initially presented to an OSH after calling 911
for dyspnea. Prior to this ___ had been treated for a COPD
exacerbation with prednisone with no improvement. ___ was
transferred from the OSH to ___ where ___ had an ECHO that
showed MVP with 4+MR. ___ was evaluated by C-surg who said ___ was
not a surgical candidate. ___ was diuresed with IV Lasix while in
the hospital. ___ also had a troponin elevation on admission and
cath on ___ that showed non-obstructive coronary artery disease.
No interventions were performed.
___ developed AF ___ and was started on a hep gtt. ___ was started
on metoprolol 6.25mg Q6H. This was stopped prior to discharge as
___ converted to sinus and was having symptomatic bradycardia.
Prior to discharge ___ was started on warfarin with lovenox
bridge given CHADSVASc of 5.
___ had a fall while on the hep gtt and was found to have an
abdominal hematoma on CTA without evidence of active
extravasation. ACS was consulted and recommended observation. ___
was given 2U pRBCs and hemoglobin stabilized.
___ also had hyponatremia felt to be due to SIADH, which improved
with fluid restriction to 125 on day of discharge ___.
On ___ ___ found him to be orthostatic (syst 120 -> 90
standing). Later that afternoon his family found him to be
confused. The PCP was notified and recommended they bring him to
the ED for readmission.
On arrival to the ED his vital signs were 97.1 76 130/75 16 99%
NC.
___ was confused, and unable to corroborate above history. ___ was
denying any headache, vision changes, weakness, numbness; chest
pain, dyspnea, palpitations, lightheadedness; nausea, abdominal
pain; dysuria. Basic labs were obtained and ___ was found to have
a drop in his Hgb so a CTA was obtained which showed rectus
sheath hematoma and RP hematoma with evidence of active
extravasation. Surgery was consulted and recommended ___
consultation. ___ recommended serial H/H and making him NPO for
___ intervention AM of ___.
On arrival to the MICU, the patient says that ___ is having
significant pain in his lower back. ___ says that pain started
one week ago and has been getting progressively worse. ___ is
also feeling some mild shortness of breath. ___ denies chest pain
or headaches. ___ has some pain with urination but says this is
chronic from his BPH
Past Medical History:
DM
HTN
AF
COPD
Colorectal CA s/p colostomy
Benign non-nodular prostatic hyperplasia with lower urinary
tract symptoms
Uses hearing aid
Glaucoma
Osteoporosis
Revision of TKR ___
Hernia repair x 2
Bilateral knee replacement
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.4, 143/55, 70, 96%RA
GENERAL: Alert, oriented, no acute distress
HEENT: 2-3cm ecchymoses over R forehead, sclera anicteric, MMM,
oropharynx clear, EOMI, PERRL
LUNGS: Bibasilar crackles but otherwise CTAB, no wheezes or
ronchi
CV: irregularly irregular rhythm, ___ holosystolic murmur heard
loudest at the cardiac apex
ABD: NABS, colostomy in place with clean dry borders, ecchymoses
on abdomen and in L groin down to scrotum
BACK: R flank with large Hematoma that is tender to palpation,
borders marked
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: AAOx3, strength ___ bilateral upper extremities, ___
bilateral lower extremities, CN II-XII intact
DISCHARGE PHYSICAL EXAM:
=========================
97.8 PO 105/58 R Sitting 56 18 95 Ra
GENERAL: Alert, oriented, no acute distress
HEENT: improving head ecchymoses, sclera anicteric, MMM,
oropharynx clear, EOMI, PERRL
LUNGS: CTAB, no adventitious breath sounds
CV: irregularly irregular rhythm, ___ holosystolic murmur heard
loudest at the cardiac apex
ABD: colostomy in place with clean dry borders, ecchymoses
on abdomen. No abdominal tenderness.
BACK: R flank with large hematoma that is tender to palpation
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Slight tenderness to palpation of R inguinal area near
catheterization site.
NEURO: AAOx3, strength grossly full/symmetric, CN II-XII intact
Pertinent Results:
ADMISSION LABS:
===============
___ 09:10PM BLOOD WBC-11.4* RBC-2.41* Hgb-8.0* Hct-23.1*
MCV-96 MCH-33.2* MCHC-34.6 RDW-15.7* RDWSD-53.2* Plt ___
___ 09:10PM BLOOD Neuts-80* Bands-0 Lymphs-15* Monos-3*
Eos-0 Baso-0 Atyps-1* ___ Myelos-1* AbsNeut-9.12*
AbsLymp-1.82 AbsMono-0.34 AbsEos-0.00* AbsBaso-0.00*
___ 09:10PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-1+ Polychr-NORMAL Stipple-OCCASIONAL
___ 09:10PM BLOOD ___ PTT-33.3 ___
___ 09:10PM BLOOD Plt Smr-LOW Plt ___
___ 09:10PM BLOOD Glucose-132* UreaN-11 Creat-0.8 Na-122*
K-4.1 Cl-89* HCO3-24 AnGap-13
___ 09:10PM BLOOD ALT-17 AST-27 AlkPhos-78 TotBili-2.5*
DirBili-0.5* IndBili-2.0
___ 09:10PM BLOOD cTropnT-0.02*
___ 02:51AM BLOOD Hgb-8.7* calcHCT-26
INTERVAL LABS:
___ 07:25AM BLOOD WBC-6.9 RBC-2.53* Hgb-8.0* Hct-24.2*
MCV-96 MCH-31.6 MCHC-33.1 RDW-17.2* RDWSD-59.1* Plt ___
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-5.9 RBC-2.63* Hgb-8.3* Hct-25.6*
MCV-97 MCH-31.6 MCHC-32.4 RDW-16.4* RDWSD-56.6* Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-115* UreaN-10 Creat-0.6 Na-125*
K-3.9 Cl-91* HCO3-26 AnGap-12
___ 06:45AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.8
IMAGING:
==========
___ CHEST (PA & LAT)
AP upright and lateral views of the chest provided.
Heart size is stably prominent. The aorta remains calcified and
slightly
unfolded. Tiny pleural effusions are present which appear
slightly improved from prior exam. Subtle bibasilar atelectasis
is also noted. No convincing evidence for pneumonia or edema.
No pneumothorax. Bony structures are intact.
___ CT CHEST/ABD/PELVIS W
1. Right retroperitoneal hematoma abutting the right psoas
muscle which
measures approximately 7.0 x 5.5 cm (series 2: Images 150) is
new as compared to CTA abdomen pelvis ___ with small
internal hyperattenuated foci likely representing areas of
active extravasation.
2. Right rectus sheath hematoma and hematoma is minimally
changed in size from ___. However, there are internal
foci hypoattenuated foci (2: 180, 182, in 207), new since ___ and likely representing active
extravasation.
3. Severe pancreatic ductal dilatation in the distal pancreatic
body and tail with an abrupt cutoff in the pancreatic body and
atrophy of the pancreatic
head is unchanged in appearance compared to ___ and
suspicious for an obstructive mass. Nonurgent MRCP is
recommended for further characterization.
___ CT HEAD W/O CONTRAST
1. Study limited by motion degradation.
2. Within limits of study, no definite evidence of intracranial
hemorrhage or fracture.
3. Small right frontal supraorbital scalp subgaleal hematoma.
4. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
5. Paranasal sinus disease , as described.
___ ILIAC/PELVIC ARTERIOGRA
Successful right lumbar and right inferior epigastric angiogram
with selective embolization of the right L3 lumbar and right
inferior epigastric arteries with no residual extravasation seen
on post embolization aortogram.
___ CTA abdomen/pelvis
FINDINGS:
LOWER CHEST:
There is an unchanged right pleural effusion with underlying
subsegmental atelectasis. Trace left pleural effusion also
noted. Mild diffuse interlobular septal thickening in the
visualized portions of both lower lobes, the lingula and right
middle lobe likely represent presence of underlying mild
pulmonary edema. There is mild unchanged traction
bronchiectases in both lower lobes. Mild cardiomegaly noted.
ABDOMEN:
GENERAL: There is no intra-abdominal free air or free fluid.
HEPATOBILIARY: The hepatic parenchyma enhances homogeneously.
Within limitations of this single phase contrast-enhanced exam,
no focal liver lesions identified.
The gallbladder is distended with layering contrast within the
gallbladder from vicarious excretion related to a prior CT exam.
No pericholecystic inflammation.
PANCREAS: There is abrupt transition and significant dilation
of the main pancreatic duct in the region of the distal body and
tail, measuring up to 8 mm in diameter. Normal enhancing
pancreatic parenchyma is not visualized.
There is lobulated soft tissue in the mid body of the pancreas
just proximal to ductal dilation measuring approximately 24 by
1.0 cm in size suspicious for a primary pancreatic neoplasm.
Severe atrophy of the head and proximal body of the pancreas
noted. MRI of the pancreas with MRCP is recommended.
SPLEEN: No splenomegaly or focal splenic lesions..
ADRENALS: No adrenal nodules.
URINARY: There are bilateral nonobstructing renal calculi
measuring 2 mm in the superior pole of the right kidney and 5
mm, located in the superior pole of the left kidney
respectively. No hydronephrosis seen on either side. No solid
enhancing renal masses. Right renal superior pole, measuring
2.2 cm in size, exophytic simple cyst and another simple cyst in
the lower pole cortex of the left kidney respectively.
GASTROINTESTINAL: There is a small hiatus hernia. No bowel
obstruction.
Moderate stool burden is present throughout the colon. The
patient has a left lower quadrant colostomy without bowel
obstruction.
LYMPH NODES: There are no enlarged lymph nodes in the abdomen
or pelvis..
VASCULAR: Extensive atherosclerotic calcification of the
abdominal aorta and its branches without aneurysmal dilation.
The bilateral common iliac arteries are highly ectatic, without
aneurysmal dilation.
PELVIS:
The bladder is distended, unremarkable..
BONES AND SOFT TISSUES:
There is severe diffuse demineralization with chronic sacral
insufficiency fractures.
Again visualized is a 6.3 x 4.8 x 13.0 cm right psoas hematoma
with locules of air within it (likely related to Gel-Foam
embolization), with no interval change. Right anterior rectus
sheath hematoma measuring 7.1 x 4.8 by 11.1 cm in size,
unchanged.
No active extravasation of blood into the right rectus sheath
or psoas hematomas.
IMPRESSION:
1. Minimally changed size of a retroperitoneal hematoma
abutting the psoas with evidence of Gel-Foam embolization. No
active extravasation.
2. Minimally changed size of right rectus sheath and right
anterior pelvic hematomas with no residual evidence of active
extravasation.
3. No new hematoma.
4. Cardiomegaly, interlobular septal thickening, small right
and trace left pleural effusions diffuse bronchial wall
thickening suggest a component of heart failure with
interstitial pulmonary edema.
5. Unchanged appearance of the pancreas with findings
suspicious for malignancy. Recommend nonemergent MRCP for
further evaluation.
6. Chronic sacral insufficiency fractures are unchanged.
7. Punctate nonobstructing upper pole nephrolithiasis.
8. Small hiatal hernia. Left lower quadrant colostomy with no
bowel obstruction.
___ R CFA Pseudoaneurysm Embolization
FINDINGS:
Immediately cephalad to the common femoral artery bifurcation,
in the area of the 8 mm pseudoaneurysm seen on recent CTA, there
is a small neck arising superficially from the common femoral
artery, but no definable flow on color Doppler images. This
area was prophylactically compressed for 10 minutes.
Post compression ultrasound again demonstrated no flow in the
pseudoaneurysm neck.
IMPRESSION:
Successful ultrasound-guided compression of the right common
femoral artery immediately cephalad to the bifurcation, in the
region of the 8 mm pseudoaneurysm seen on recent CT. No pre or
post compression color Doppler flow was seen in this area.
RECOMMENDATION(S): If clinical concern for right groin
pseudoaneurysm, repeat ultrasound in ___ days is recommended.
MICRO:
========
___ BLOOD CULTURE Blood Culture, Routine-NGTD
___ BLOOD CULTURE Blood Culture, Routine-NGTD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Tamsulosin 0.4 mg PO QHS
3. Atorvastatin 80 mg PO QPM
4. Warfarin 3 mg PO DAILY16
5. brimonidine 0.2 % ophthalmic BID
6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Ipratropium-Albuterol Inhalation Spray 1 INH IH QID
9. multivitamin with iron-mineral (multivit-minerals-ferrous
fum) 0.8 mg oral DAILY
10. Oxybutynin 10 mg PO DAILY
11. Enoxaparin Sodium 60 mg SC Q12H
12. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. brimonidine 0.2 % ophthalmic BID
4. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Ipratropium-Albuterol Inhalation Spray 1 INH IH QID
7. Metoprolol Succinate XL 25 mg PO DAILY
8. multivitamin with iron-mineral (multivit-minerals-ferrous
fum) 0.8 mg oral DAILY
9. Oxybutynin 10 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. HELD- Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
This medication was held. Do not restart Enoxaparin Sodium until
seeing your primary care doctor/ cardiologists
12. HELD- Warfarin 3 mg PO DAILY16 This medication was held. Do
not restart Warfarin until seeing your primary care doctor/
cardiologists
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Rectus Sheath and Retroperitoneal Hematoma
SECONDARY DIAGNOSIS:
Paroxysmal Atrial Fibrillation on Anticoagulation
Mitral Valve Prolapse with 4+ Mitral Regurgitation
Heart Failure with Preserved Ejection Fraction
Syndrome of inappropriate antidiuretic hormone
Pancreatic mass suspicious for neoplasm.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with confusion, forehead hematoma of unknown chronicity.
Evaluate for intracranial hemorrhage.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.9 cm; CTDIvol = 47.6 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 9.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 1,706 mGy-cm.
COMPARISON: None.
FINDINGS:
Study limited by motion degradation.
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. There is a very small right frontal subgaleal hematoma (02:23).
Prominent ventricles sulci compatible age-related involution changes.
Periventricular subcortical white matter hypodensities likely represent
chronic small vessel ischemic disease. There are moderate atherosclerotic
calcifications of bilateral carotid siphons.
There is mucosal thickening in the bilateral ethmoid air cells. Remaining
paranasal sinuses are clear. Mastoid air cells and middle ear cavities are
well aerated. The bony calvarium is intact.
IMPRESSION:
1. Study limited by motion degradation.
2. Within limits of study, no definite evidence of intracranial hemorrhage or
fracture.
3. Small right frontal supraorbital scalp subgaleal hematoma.
4. Please note MRI of the brain is more sensitive for the detection of acute
infarct.
5. Paranasal sinus disease , as described.
Radiology Report
EXAMINATION: CT torso with IV contrast
INDICATION: History: ___ with fall with hematomas and confusion and worsening
anemia with flank hematoma// fall with hematomas and confusion and worsening
anemia with flank hematoma. History of colon cancer status post colostomy.
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.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.8 s, 69.3 cm; CTDIvol = 19.3 mGy (Body) DLP =
1,338.2 mGy-cm.
Total DLP (Body) = 1,338 mGy-cm.
COMPARISON: None.
CTA abdomen and pelvis ___
Abdominal ultrasound ___
FINDINGS:
Study limited by motion degradation.
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. There are moderate to severe atherosclerotic
calcifications of the aorta and takeoff of the great vessels. There is mild
cardiomegaly. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is mild interlobular septal thickening. There is
moderate dependent atelectasis in the bilateral lower lobes. There is no
consolidation. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: There hypoattenuating nodules in the bilateral lobes of the
thyroid measuring up to 0.5 cm in left lobe (02:19)
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: There is significant pancreatic ductal dilatation in the distal
pancreatic body and tail with an abrupt cut off in the pancreatic body (2:116)
with atrophy of the pancreatic head. This is grossly unchanged in appearance
as compared to ___.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There are multiple nonobstructive calculi in the bilateral kidneys. There are
hypoattenuated rounded foci in the left and right kidneys measuring up to 2.1
cm in maximal diameter in the right kidney (2:116) likely representing simple
cysts.
GASTROINTESTINAL: There is a paraesophageal hiatal hernia. The stomach is
unremarkable. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout. Patient is status post presumed distal colonic
resection. Left lower lobe colostomy is unremarkable. Appendix not
visualized but there are no secondary signs of acute appendicitis. See
There is no free fluid or free air in the abdomen.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is small
amount of free fluid in the pelvis.
REPRODUCTIVE ORGANS: The 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 or retroperitoneal hematoma.
Extensive atherosclerotic disease is noted. There are severe atherosclerotic
calcifications at the celiac origin, superior mesenteric artery origin and
takeoff the bilateral renal arteries.
BONES: There is no acute fracture. No focal suspicious osseous abnormality.
Severe degenerative changes of the bilateral sacroiliac joints and moderate to
severe degenerative changes of the bilateral hips and lower lumbar spine are
noted. Heterotopic ossification adjacent to the greater trochanters of the
bilateral femurs is again noted.
SOFT TISSUES:
There is a right retroperitoneal hematoma expanding the right psoas muscle
which is difficult to discern from the adjacent muscles but measures
approximately 7.0 x 5.5 cm (2:150) with small hyperattenuating foci (2:150)
within the hematoma likely representing areas of active extravasation. This
is new as compared to ___.
Right rectus sheath hematoma measuring 6.4 x 4.5 cm (2:180, 182, 207) is
unchanged from CTA abdomen pelvis ___. Linear focus of hyperdensity
in the right rectus sheath hematoma (2:182) reflects a vessel or focus of
active extravasation. There are 2 adjacent hematomas in the right space of
Retzius measuring 4.5 x 3.1 cm (2:210) and 2.8 x 2.5 cm (2:208), respectively
as well as adjacent blood products which appear grossly unchanged in
appearance from ___.
IMPRESSION:
1. Right retroperitoneal hematoma expanding the right psoas muscle which
measures approximately 7.0 x 5.5 cm (series 2: Images 150) is new as compared
to CTA abdomen pelvis ___ with small internal hyperattenuated foci
likely representing areas of active extravasation.
2. Right rectus sheath hematoma and hematoma is minimally changed in size from
___. However, there are internal foci of hyperattenuation, new since ___ and likely representing active extravasation.
3. Severe pancreatic ductal dilatation in the distal pancreatic body and tail
with an abrupt cutoff in the pancreatic body and atrophy of the pancreatic
head is unchanged in appearance compared to ___ and suspicious for an
obstructive mass or stone. Nonurgent MRCP is recommended for further
characterization.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephone on ___ at 9:32 am, 2 minutes after discovery of
the findings.
Radiology Report
INDICATION: ___ year old man with RP hematoma// bleed, embolize.
COMPARISON: CT torso ___.
TECHNIQUE: OPERATORS: Dr. ___ resident and Dr. ___,
___ radiologist performed the procedure. Dr. ___ supervised
the trainee during the key components of the procedure and has reviewed and
agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
250mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 5 hours 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: As above
CONTRAST: 220 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 123.8 min, 637 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Left common femoral artery access.
3. Right common femoral arteriogram.
4. Left common femoral arteriogram.
5. Right T12 intercostal arteriogram.
6. Right L1 lumbar arteriogram.
7. Right L3 lumbar arteriogram.
8. Right inferior epigastric arteriogram.
9. Right L3 lumbar artery embolization with coils and Gelfoam.
10. Right inferior epigastric Gelfoam and coil embolization.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. Both groins were
prepped and draped in the usual sterile fashion.
Using palpatory and fluoroscopic guidance, the left common femoral artery was
punctured using a micropuncture set at the level of the mid-femoral head. A
0.018 wire was passed easily into the vessel lumen. A small skin incision was
made over the needle. Then the inner dilator and wire were removed and a
___ wire was advanced under fluoroscopy into the aorta. The micropuncture
sheath was exchanged for a 5 ___ sheath which was attached to a continuous
heparinized saline side arm flush.
A ___ catheter was advanced over the ___ wire. The wire was removed
and the catheter was used to engage the T12 intercostal artery on the right.
A T12 right intercostal arteriogram was performed.
The catheter was advanced to disengage from this ostium and retracted to the
level of L3, where a right L3 lumbar arteriogram was performed. Next, a
renegade ___ microcatheter and Transcend micro wire were used to cannulate the
right L3 lumbar artery in advance distally in the artery. A sub selective
arteriogram was performed. Gel-Foam embolization of this branch was performed
near stasis. Additionally, 4mm x 3cm and 3mm x 3cm Hilal coils were used to
embolize this branch. Repeat arteriogram was performed. Subsequent
deposition of 3mm x 2cm Hilal coils was performed. Repeat arteriogram post
embolization was performed.
The microcatheter and micro wire were withdrawn and the ___ catheter was
advanced to disengaged from the L3 lumbar artery. Next, the catheter was
manipulated and attempt was made to cannulate the right L2 lumbar artery,
without success. The catheter was advanced to the level of L1 where position
was confirmed via contrast injection. A L1 lumbar arteriogram was performed.
Next, the catheter was withdrawn and multiple attempts were made to accessed
the right inferior epigastric artery via the left-sided access, however these
were not successful.
Under ultrasound guidance, the right common femoral artery was accessed at the
level of the inferior femoral head, using a micropuncture set. A 5 ___
sheath was advanced into the external iliac artery and using a combination of
a 5 ___ Kumpe catheter, renegade ___, and Transcend wire, the right
inferior epigastric artery was cannulated. A right inferior epigastric
arteriogram was performed. This branch was subsequently embolized with
Gelfoam and a single Concerto coil.
Next, multiple attempts were made to access the right L4 lumbar artery,
without success. An aortogram was performed demonstrating no residual active
extravasation. Right and left common femoral arteriograms were performed
prior to use of closure devices. Manual pressure was held until hemostasis
was achieved.
Sterile dressings were applied. The patient tolerated the procedure well.
FINDINGS:
1. No active extravasation from the T12 intercostal artery.
2. No active extravasation from the right L1 lumbar artery.
3. Active extravasation from a branch of the L3 lumbar artery, embolized with
Gelfoam and coils, with no residual extravasation on the post embolization
arteriogram.
4. No active extravasation from the right inferior epigastric artery, however
this vessel was empirically embolized with Gelfoam and a Concerto coil given
the active extravasation seen on preprocedure CTA.
5. No residual active extravasation on the final post embolization aortogram.
IMPRESSION:
Successful right lumbar and right inferior epigastric angiogram with selective
embolization of the right L3 lumbar and right inferior epigastric arteries
with no residual extravasation seen on post embolization aortogram.
RECOMMENDATION(S): Close hemodynamic monitoring is recommended.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ PMH COPD, HTN, NIDDM, HFpEF who was recently admitted to
___ ___ for dyspnea and was found to have MVP with severe MR,
discharged ___ with planned readmission ___ for ___, re-presented to
ED ___ after being found orthostatic and confused by ___ and family, and is
now found to have rectus sheath hematoma and RP hematoma with evidence of
active extravasation on CTA, now s/p difficult ___ embolization.// Evaluate for
RP bleed or other active extravasation in setting of new crit drop, most
recent contrast ___
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
Oral contrast was not administered.
IV contrast: 130ml Omnipaque
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.5 s, 50.0 cm; CTDIvol = 2.4 mGy (Body) DLP = 121.5
mGy-cm.
2) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 13.7 mGy (Body) DLP =
6.8 mGy-cm.
3) Spiral Acquisition 6.1 s, 48.3 cm; CTDIvol = 10.7 mGy (Body) DLP = 515.4
mGy-cm.
4) Spiral Acquisition 6.1 s, 48.3 cm; CTDIvol = 10.7 mGy (Body) DLP = 519.1
mGy-cm.
Total DLP (Body) = 1,163 mGy-cm.
COMPARISON: CT angio of the abdomen and pelvis dated, ___ and ___
FINDINGS:
LOWER CHEST:
There is an unchanged right pleural effusion with underlying subsegmental
atelectasis. Trace left pleural effusion also noted. Mild diffuse
interlobular septal thickening in the visualized portions of both lower lobes,
the lingula and right middle lobe likely represent presence of underlying mild
pulmonary edema. There is mild unchanged traction bronchiectases in both
lower lobes. Mild cardiomegaly noted.
ABDOMEN:
GENERAL: There is no intra-abdominal free air or free fluid.
HEPATOBILIARY: The hepatic parenchyma enhances homogeneously. Within
limitations of this single phase contrast-enhanced exam, no focal liver
lesions identified.
The gallbladder is distended with layering contrast within the gallbladder
from vicarious excretion related to a prior CT exam. No pericholecystic
inflammation.
PANCREAS: There is abrupt transition and significant dilation of the main
pancreatic duct in the region of the distal body and tail, measuring up to 8
mm in diameter. Normal enhancing pancreatic parenchyma is not visualized.
There is lobulated soft tissue in the mid body of the pancreas just proximal
to ductal dilation measuring approximately 24 by 1.0 cm in size suspicious for
a primary pancreatic neoplasm. Severe atrophy of the head and proximal body
of the pancreas noted. MRI of the pancreas with MRCP is recommended.
SPLEEN: No splenomegaly or focal splenic lesions..
ADRENALS: No adrenal nodules.
URINARY: There are bilateral nonobstructing renal calculi measuring 2 mm in
the superior pole of the right kidney and 5 mm, located in the superior pole
of the left kidney respectively. No hydronephrosis seen on either side. No
solid enhancing renal masses. Right renal superior pole, measuring 2.2 cm in
size, exophytic simple cyst and another simple cyst in the lower pole cortex
of the left kidney respectively.
GASTROINTESTINAL: There is a small hiatus hernia. No bowel obstruction.
Moderate stool burden is present throughout the colon. The patient has a left
lower quadrant colostomy without bowel obstruction.
LYMPH NODES: There are no enlarged lymph nodes in the abdomen or pelvis..
VASCULAR: Extensive atherosclerotic calcification of the abdominal aorta and
its branches without aneurysmal dilation. The bilateral common iliac arteries
are highly ectatic, without aneurysmal dilation.
PELVIS:
The bladder is distended, unremarkable..
BONES AND SOFT TISSUES:
There is severe diffuse demineralization with chronic sacral insufficiency
fractures.
Again visualized is a 6.3 x 4.8 x 13.0 cm right psoas hematoma with locules of
air within it (likely related to Gel-Foam embolization), with no interval
change. Right anterior rectus sheath hematoma measuring 7.1 x 4.8 by 11.1 cm
in size, unchanged.
No active extravasation of blood into the right rectus sheath or psoas
hematomas.
IMPRESSION:
1. Minimally changed size of a retroperitoneal hematoma abutting the psoas
with evidence of Gel-Foam embolization. No active extravasation.
2. Minimally changed size of right rectus sheath and right anterior pelvic
hematomas with no residual evidence of active extravasation.
3. No new hematoma.
4. Cardiomegaly, interlobular septal thickening, small right and trace left
pleural effusions diffuse bronchial wall thickening suggest a component of
heart failure with interstitial pulmonary edema.
5. Unchanged appearance of the pancreas with findings suspicious for
malignancy. Recommend nonemergent MRCP for further evaluation.
6. Chronic sacral insufficiency fractures are unchanged.
7. Punctate nonobstructing upper pole nephrolithiasis.
8. Small hiatal hernia. Left lower quadrant colostomy with no bowel
obstruction.
Radiology Report
INDICATION: ___ year old man with R CFA pseudoaneurysm// Please perform
injection
COMPARISON: CTA abdomen pelvis ___
TECHNIQUE: OPERATORS: Dr. ___ resident and Dr. ___,
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: None
MEDICATIONS: None
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0 min, 0 mGy
PROCEDURE: 1. Ultrasound-guided pseudoaneurysm compression.
Grayscale and color Doppler ultrasound images of the right groin were
performed. Ultrasound-guided compression of the area of the pseudoaneurysm
seen on recent CTA was performed for 10 minutes. Post compression ultrasound
of the area was performed. Sterile dressings were applied. The patient
tolerated the procedure well.
FINDINGS:
Immediately cephalad to the common femoral artery bifurcation, in the area of
the 8 mm pseudoaneurysm seen on recent CTA, there is a small neck arising
superficially from the common femoral artery, but no definable flow on color
Doppler images. This area was prophylactically compressed for 10 minutes.
Post compression ultrasound again demonstrated no flow in the pseudoaneurysm
neck.
IMPRESSION:
Successful ultrasound-guided compression of the right common femoral artery
immediately cephalad to the bifurcation, in the region of the 8 mm
pseudoaneurysm seen on recent CT. No pre or post compression color Doppler
flow was seen in this area.
RECOMMENDATION(S): If clinical concern for right groin pseudoaneurysm, repeat
ultrasound in ___ days is recommended.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Transfer
Diagnosed with Hemoperitoneum, Anemia, unspecified, Abn lev hormones in specimens from female genital organs
temperature: 97.1
heartrate: 76.0
resprate: 16.0
o2sat: 99.0
sbp: 130.0
dbp: 75.0
level of pain: 3
level of acuity: 2.0 | ___ PMH COPD, HTN, NIDDM, HFpEF who was recently admitted to
___ ___ for dyspnea and was found to have MVP with severe
MR, discharged ___ with planned readmission ___ for ___,
re-presented to ED ___ after being found orthostatic and
confused by ___ and family, and is now found to have rectus
sheath hematoma and RP hematoma with evidence of active
extravasation on CTA, undergoing an ___ embolization with stable
hemodynamics afterward.
========================
MICU COURSE
========================
# Rectus Sheath, RPA hematoma
Pt was recently admitted to ___ ___ for dyspnea and was
found to have MVP with severe MR, discharged ___ with planned
readmission ___ for ___, re-presented to ED ___ after
being found orthostatic and confused by ___ and family, ___ was
found to have rectus sheath hematoma and RP hematoma with
evidence of active extravasation on CTA. ___ was transfused 1U
pRBCs over 4h prior to be taken for angiogram by ___ did
embolization of the right L3 lumbar and right inferior
epigastric arteries without evidence of active extravasation
seen afterwards. ___ returned to the ICU afterwards for
monitoring, and his Hgb remained stable.
# HFpEF
For his HFpEF with 4+MR, diuresis was held in the setting of
active GIB, and the structural heart team was alerted as ___ was
planned to have ___ done ___. The structural heart team
cancelled the procedure. For his paroxysmal AF his lovenox and
warfarin were held i/s/o active bleed. ___ did not require rate
or rhythm control while in the ICU as his rate was persistently
in the ___.
============================
Floor Course
============================
# Rectus Sheath, RPA hematoma: on ___ patient was transferred
to medical floor for CBC monitoring after his ___ embolization
procedure. His Hb was noted to drop to 6.8 on the evening of
___, prompting an urgent 1u PRBCs administration and another
CTA to assess the possibility of active extravasation. His CTA
was without abnormality with regard to bleeding concern, though
revealed a small pancreatic mass (see below). On ___ patient
had a R CFA pseudoaneurysm injection performed by ___ due to a
complication from access achieved during the prior procedure. ___
was resumed on metoprolol succinate once his Hb's were
demonstrated as stable. For the remainder of his hospitalization
warfarin/enoxaparin were held. Patient was resumed on aspirin on
___.
#MVP with 4+ MR #___: Further conversations with the
structural heart team revealed that mitral clip consideration
would not take place until patient went to rehab and
demonstrated several weeks of stability following his recent
hematomas. ___ was discharged off of anticoagulation, solely on
aspirin, as above.
#Paroxysmal atrial fibrillation: Given CHADSVasc 5 patient was
thought to be a significant risk for stroke in the setting of
atrial fibrillation, though with his recent fall related
hematomas it is clear ___ is a higher risk for anticoagulation.
Patient was kept off of lovenox and warfarin given his recent
bleed. ___ was resumed on aspirin ___.
# Leukocytosis: patient demonstrated a transient leukocytosis
that was thought to be ___ inflammation from multiple hematomas.
Resolved.
# SIADH: Patient had a history of recurrent ___ had
also been diagnosed with SIADH on last hospitalization. ___
presented at a similarly low value for Na. ___ was kept on free
water restriction to 1500cc's and improved slightly.
# Pancreatic mass: during the CTA procedure performed on ___,
there was an incidental pancreatic mass that was discovered.
This was not fully characterized given the focus of the study.
The patient was informed about the possibility of a pancreatic
neoplasm, and expressed his preference to pursue an MRCP. This
may be done as an outpatient to further characterize his lesion.
*CHRONIC ISSUES:
#h/o Non-ST elevation myocardial infarction: patient was kept
off of aspirin initially in the setting of above bleed, though
was resumed on his home dose on day of discharge.
#COPD: continued Ipratropium Q6H, Albuterol nebs PRN
#NIDDM c/b polyneuropathy: remained diet controlled
#Osteoporosis: Continued home calcium and vitamin D
#Rectal cancer: In remission, has colostomy in place. No acute
issues.
#BPH: Continued home tamsulosin, oxybutynin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Piperacillin / Tegaderm Frame Style / Zosyn / Tegaderm
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
Mr. ___ is a ___ with history of nonischemic cardiomyopathy
with systolic heart failure (LVEF ___, recent admission ___
to ___ for incompletely characterized tachyarrhythmia, cystic
fibrosis, and HCV genotype 1 status post abbreviated
interferon/ribavirin therapy who presents with dyspnea increased
from baseline. He has felt ill for the past 3 days, with
productive cough, dyspnea on exertion, and malaise. He notes
chronic lower extremity edema that is not improved since last
discharge. He denies fevers or chills.
He called EMS and was transported by ambulance to the ___ ED,
where he was afebrile, but tachycardic with TnT of 0.1, up from
0.08 at baseline. CR revealed increased right lower lobe and
left midlung opacities. He received cefepime, but declined
vancomycin due to concern for acute kidney injury.
Of note, he has highly resistant Pseudomonas, for which he was
treated with ciprofloxacin and chloramphenicol in ___ by his
pulmonologist Dr. ___. He describes acute kidney injury
following prior tobramycin use.
Review of systems is negative for lack of chest pain, rash, or
gastrointestinal symptoms. He has chronic 4 pillow orthopnea
that is unchanged from baseline and no new paroxysmal nocturnal
dyspnea. He stopped rivaroxaban for recent PICC associated deep
venous thrombosis due to bruising and resolution of clot.
Past Medical History:
- Cystic fibrosis - diagnosed age ___, currently followed at
___ (Dr. ___
- Congestive heart failure and non-ischemic cardiomyopathy -
followed by Dr. ___. Severe global left ventricular
hypokinesis (EF ___.
- ?Afib per ___ records
- RUE DVT ___ in the setting of PICC line, repeat ultrasound
___ showing no clot, now off warfarin
- Hepatitis C - genotype I, interferon/ribavirin started and
then stopped in ___ due to side effects
- Chronic renal insufficiency - thought to be ___ repeated
tobramycin
- Vitamin D deficiency
- Osteoporosis, no recent fractures
- HTN
- GERD (minor)
- h/o EToH abuse
- Musculoskeletal body pains, on tramadol
- MRSA cellulitis of hand
- Rib fracture
- Cholestasis
- Personality disorder
- End stage bronchiectasis
- Corticoadrenal insufficiency diagnosed ___
- History of Aspergilliosis
- h/o ARF on tobra and vanc
- s/p ventral hernia repair
- s/p ORIF of leg
Social History:
___
Family History:
Sister with cystic fibrosis.
Mother with end-stage Alzheimer's disease, which began in her
___, also with hypertension and obesity.
Cousin with myocardial infarction at ___ years old.
Physical Exam:
On admission:
VS: 97 120/86 111 100% 4L NC
chronically ill appearing overweight male who is working
somewhat hard to breathe using some accessory chest muscles. he
can speak in few sentences
diminished BS superiorly, no wheezes, soft coarse insp rales
inferiorly
regular s1 and s2
obviously distended EJ with apparent JVP to upper neck
soft abdomen
scar on R wrist and R ankle
slightly increased edema on R leg compared with L, both pitting
+1
AOX3
At discharge:
VS: wt: 85.9 (from 86.2 kg), T 97.6, P: 90, BP: 99/74, RR: 18,
94% on RA
GENERAL: no acute distress.
NECK: JVP is not elevated
CARDIAC: regular rhythm. No appreciable murmurs.
LUNGS: diffuse rhonchi, without crackles. overall lung exam
seems stable since yesterday
ABDOMEN: Soft, NT/ND.
EXTREMITIES: trace edema around the ankles
Pertinent Results:
PERTINENT LABS:
On admission:
___ 09:43PM BLOOD WBC-7.2 RBC-4.47* Hgb-11.8* Hct-36.4*
MCV-81* MCH-26.3* MCHC-32.4 RDW-20.5* Plt ___
___ 09:43PM BLOOD Glucose-113* UreaN-42* Creat-1.1 Na-139
K-4.4 Cl-96 HCO3-28 AnGap-19
___ 09:43PM BLOOD ___
___ 09:43PM BLOOD Calcium-9.7 Phos-4.4
___ 09:43PM BLOOD Digoxin-0.8*
In the interim:
___ 07:00AM BLOOD ALT-24 AST-44* AlkPhos-79 TotBili-1.4
___ 05:42AM BLOOD proBNP-7814*
___ 05:11AM BLOOD proBNP-4427*
___ 05:40PM BLOOD Tobra-0.3*
___ 07:56AM BLOOD ___ PTT-29.6 ___
___ 05:59AM BLOOD Hapto-246*
___ 05:59AM BLOOD Ret Aut-1.2
At discharge:
___ 07:40AM BLOOD WBC-6.1 RBC-4.51* Hgb-11.8* Hct-35.6*
MCV-79* MCH-26.3* MCHC-33.3 RDW-18.1* Plt ___
___ 07:40AM BLOOD Neuts-65.3 ___ Monos-6.8 Eos-5.2*
Baso-0.9
___ 07:40AM BLOOD Glucose-111* UreaN-44* Creat-1.4* Na-133
K-4.7 Cl-95* HCO3-25 AnGap-18
___ 07:40AM BLOOD Calcium-9.3 Mg-1.9
Microbiology:
Sputum Cx (___):
MODERATE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
CHLORAMPHENICOL , AMIKACIN AND COLISTIN Susceptibility
testing
requested by ___. ___ ___ ___.
COLISTIN AND CHLORAMPHENICOL sensitivity testing
performed by
___. SENSITIVE TO COLISTIN.
ZONE SIZE FOR CHLORAMPHENICOL IS 14 MM.
Zone size determined using a method that has not been
standardized
for this drug- organism combination and for which no
CLSI or
FDA-approved interpretative standards exist. Interpret
results
with caution.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND
MORPHOLOGY.
CHLORAMPHENICOL , AMIKACIN AND COLISTIN Susceptibility
testing
requested by ___. ___ ___ ___.
Piperacillin/Tazobactam sensitivity testing confirmed
by ___
___.
SENSITIVE TO Colistin sensitivity testing performed by
___
___.
CHLORAMPHENICOL = 15 MM, sensitivity testing performed
by ___
___.
Zone size determined using a method that has not been
standardized
for this drug- organism combination and for which no
CLSI or
FDA-approved interpretative standards exist. Interpret
results
with caution.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
CHLORAMPHENICOL, AMIKACIN AND COLISTIN SUSCEPTIBILITY
REQUESTED BY
___. ___ (___). COLISTIN Sensitive.
sensitivity testing performed by ___.
CHLORAMPHENICOL 6 MM.
Zone size determined using a method that has not been
standardized
for this drug- organism combination and for which no
CLSI or
FDA-approved interpretative standards exist. Interpret
results
with caution.
Susceptibility results were obtained by a procedure
that has not
been standardized for this organism Results may not be
reliable
and must be interpreted with caution.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
PROBABLE IDENTIFICATION ___ MORPHOLOGY.
IDENTIFICATION REPORTED TO AND READ BACK BY ___ ___
@ 1440,
___. sensitivity testing performed by Microscan.
MIC BREAKPOINTS USED FOLLOWING PSEUDOMONAS AERUGINOSA
BREAKPOINS
AS PER CLSI ___ GUIDE.
CHLORAMPHENICOL sensitivity testing performed by ___
___.
CHLORAMPHENICOL = 6 MM.
CHLORAMPHENICOL Zone size determined using a method
that has not
been standardized for this drug- organism combination
and for
which no CLSI or FDA-approved interpretative standards
exist.
Interpret results with caution. CEFEPIME MIC: => 32
MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| | PSEUDOMONAS
AERUGINOSA
| | |
PSEUDOMONAS AERU
| | | |
AMIKACIN-------------- 16 S =>64 R 32 I
CEFEPIME-------------- =>64 R =>64 R R R
CEFTAZIDIME----------- 8 S =>64 R R =>32 R
CIPROFLOXACIN--------- 1 S 2 I R =>4 R
GENTAMICIN------------ 8 I =>16 R R =>16 R
MEROPENEM------------- =>16 R =>16 R R =>16 R
PIPERACILLIN/TAZO----- 8 S R S =>128 R
TOBRAMYCIN------------ 2 S 8 I S 4 S
___ 11:00 pm SPUTUM Source: Expectorated.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
OF THREE COLONIAL MORPHOLOGIES.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
___ 2:57 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 3:04 pm BLOOD CULTURE Source: Line-central.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:52 pm BLOOD CULTURE Source: Line-central.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Studies:
Portable CXR (___):
Extensive bronchiectasis with chronic right upper lobe and
lingular collapse and consolidation. Patchy opacities in the
left mid and right lung base appear progressed in the interval,
which is concerning for worsening airways infection or
inflammation. Possible small left pleural effusion.
CXR PA/lateral (___):
Improved ventilation with mild reduced opacification of the
right
lung, especially in the RUL. Persistent cardiomegaly.
Fluoroscopically guided central line placement (___):
Uncomplicated placement of ___ 20cm single lumen central line
through patent
right internal jugular vein.
TTE (___):
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is severely depressed (LVEF= 15
%). No masses or thrombi are seen in the left ventricle. The
right ventricular cavity is dilated with depressed free wall
contractility. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Biatrial enlargement.
Moderately dilated left ventricle with severely depressed global
systolic function. Dilated, hypokinetic right ventricle. No
clinically significant valvular regurgitation or stenosis.
Borderline pulmonary artery systolic hypertension.
CXR PA/lateral (___):
Enlarged heart size but stable. Advanced chronic interstitial
pulmonary changes including airway distortions of ectatic-type,
superimposed lateral parenchymal infiltrates that have not
changed significantly during the latest examination interval.
There is no radiographic evidence for acute pulmonary edema. No
pleural effusion was seen, and no pneumothorax is present.
Comparison chest examination of ___, indicates that the
patient has undergone a long-lasting episode of superimposed
infectious processes.
CXR PA/lateral (___):
There are again seen areas of consolidation and scarring
throughout both lung fields. Emphysematous changes are also
identified in the apices. The overall configuration of the
parenchymal changes appears stable. There are no new
areas of consolidation and no signs of definite fluid overload.
There is a right-sided central line with distal lead tip in the
cavoatrial junction.
Heart size is upper limits of normal. On lateral view, there is
osteopenia and minimal wedging of several thoracic vertebral
bodies.
CXR AP (___):
1. Newly accentuated interstitial markings compared with ___
could reflect superimposed interstitial edema. Possibility of
another interstitial prpoces, such as an infectious infiltrate
is in the differential.
2. Extensive background changes consistent with cystic fibrosis
again noted. Probable bilateral hilar enlargement also again
noted.
2. Focal right upper zone opacity is unchanged.
CXR ___
FINDINGS: The lungs remain hyperinflated. There is interval
improved
aeration of both lungs with persistent opacification of the
right upper lung zone and bilateral hilar prominence. Extensive
abnormal background
interstitial lung markings are stable over multiple prior
studies. There is no pleural effusion or pneumothorax. A right
central venous catheter projects over the cavoatrial junction,
unchanged. The cardiomediastinal silhouette is stable. There
is exaggerated thoracic kyphosis. A tapered appearance of the
left distal clavicle is redemonstrated. Healed right posterior
rib fractures are again seen, likely sequela of prior trauma.
IMPRESSION: Improved ventilation with persistent right upper
lobe
opacification and chronic interstitial changes.
The study and the report were reviewed by the staff radiologist.
TTE ___ to evaluate for tamponade
The estimated right atrial pressure is ___ mmHg. Overall left
ventricular systolic function is severely depressed (LVEF= ___
%). Right ventricular chamber size and free wall motion are
normal. The aortic valve is not well seen. The mitral valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: No significant pericardial effusion is seen.
Moderate pulmonary hypertension.
Curernt exam with focused views to evaluate pericardium,
limiting meaningful comparison with prior study done ___
(images reviewed). No significant interval change in ventricular
function.
PERTINENT EKGs:
EKG (___):
Sinus tachycardia. Occasional premature atrial contractions.
Biatrial
abnormality. Left bundle-branch block. Compared to the previous
tracing
of ___ heart rate is faster but no other significant
diagnostic change.
IntervalsAxes
___
___
EKG (___):
Sinus tachycardia. Occasional atrial ectopy. Compared to tracing
#1 there is no significant diagnostic change.
IntervalsAxes
___
___
EKG (___):
Supraventricular tachycardia, either A-V nodal re-entrant
tachycardia or a paroxysmal atrial tachycardia. Rightward axis.
Left bundle-branch block. Compared to the previous tracing of
___ the findings are similar. Compared to the previous
tracing of ___ the similar morphology P waves are no longer
present consistent with a supraventricular tachycardia.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
147 0 ___ 0 100 -34
EKG (___):
Supraventricular tachycardia. Either A-V nodal re-entrant
tachycardia or
paroxysmal atrial tachycardia. No clear P waves are identified.
There is a rightward axis. Left bundle-branch block. Compared to
the previous tracing of ___ the findings are similar.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
149 0 ___ 0 76 -37
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Albuterol Sulfate (Extended Release) 4 mg PO QID:PRN SOB
4. Alendronate Sodium 70 mg PO QSUN
5. Bumetanide 2 mg PO BID
6. Calcium Carbonate 500 mg PO BID
7. Digoxin 0.125 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU BID
9. Montelukast Sodium 10 mg PO DAILY
10. Spironolactone 25 mg PO DAILY
11. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
12. Colistin 150 mg IH BID
13. Lisinopril 2.5 mg PO DAILY
14. dornase alfa 1 mg/mL Inhalation qd
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Alendronate Sodium 70 mg PO QSUN
4. Calcium Carbonate 500 mg PO BID
5. Digoxin 0.125 mg PO DAILY
6. dornase alfa 1 mg/mL Inhalation qd
7. Fluticasone Propionate NASAL 2 SPRY NU BID
8. Lisinopril 2.5 mg PO DAILY
9. Montelukast Sodium 10 mg PO DAILY
10. Spironolactone 25 mg PO DAILY
11. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
12. Albuterol Sulfate (Extended Release) 4 mg PO QID:PRN SOB
13. Cepastat (Phenol) Lozenge 1 LOZ PO Q2H:PRN sore throat
14. Guaifenesin-CODEINE Phosphate ___ mL PO Q4H:PRN sore throat
15. Colistin 150 mg IH BID
16. Torsemide 40 mg PO EVERY OTHER DAY
RX *torsemide 20 mg as directed tablet(s) by mouth take 2 tabs
alternating with one tab daily Disp #*60 Tablet Refills:*0
17. Torsemide 20 mg PO EVERY OTHER DAY
18. Acetaminophen 1000 mg PO Q8H:PRN pain, fever
19. Ciprofloxacin HCl 750 mg PO Q12H
20. Senna 1 TAB PO BID:PRN Constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Cystic fibrosis
Acute on chronic systolic heart failure
Atrial tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Dyspnea.
TECHNIQUE: Upright AP view of the chest.
COMPARISON: ___ chest radiograph, chest CTA ___.
FINDINGS:
Moderate to severe cardiomegaly is re- demonstrated. Mediastinal and hilar
contours are unchanged. Diffuse severe bronchiectasis, most pronounced within
the upper lobes, with architectural distortion is compatible with the
patient's known history of cystic fibrosis. There is persistent collapse and
consolidation of the right upper lobe and lingula, findings which appear
relatively unchanged compared to the previous exams. Slight rightward shift
of the trachea likely reflects volume loss in the right lung. No pulmonary
vascular congestion is demonstrated. Patchy opacities within the right lung
base and left mid lung field appear slightly worse in the interval. There is
a possible small left pleural effusion. No pneumothorax is identified.
Remote right-sided rib fracture is noted.
IMPRESSION:
Extensive bronchiectasis with chronic right upper lobe and lingular collapse
and consolidation. Patchy opacities in the left mid and right lung base
appear progressed in the interval, which is concerning for worsening airways
infection or inflammation. Possible small left pleural effusion.
Radiology Report
INDICATION: Poor venous access. Needs central line for antibiotics.
OPERATORS: Dr ___ (attending radiologist) performed the procedure.
PROCEDURE:
After risks, benefits, alternatives and procedure were explained to the
patient a written informed consent was obtained. The patient was brought to
angiography suite and placed supine on angiography table. Right neck was
prepped and draped in usual sterile manner. Time out was performed per ___
protocol.
Local anesthesia was provided with 1% Lidocaine solution. Sedation was given
with 1mg of Versed. Patient was monitored throughout the procedure by the
trained radiological nurse.
Access to the patent right internal jugular vein was obtained with ultrasound
guidance with micropuncture set. Hard copy images were saved. 0.035 in ___
wire was then passed into the IVC. ___ 20cm single lumen central line was
placed over the wire. The line was connected through connection tubing to ease
the access. The line and tubing were aspirated and flushed easily. Sterile
dressings were applied.
Patient tolerated procedure well. No immediate complications were noted.
IMPRESSION:
Uncomplicated placement of ___ 20cm single lumen central line through patent
right internal jugular vein.
Radiology Report
PATIENT HISTORY: ___ years old man with CHF exacerbation and CF.
INDICATION: Edema versus infiltrate.
TECHNIQUE: Chest x-ray in two views.
COMPARISON: Exam is compared to chest x-ray of ___.
FINDINGS: Lung fields are more inflated with subtle improvement of right lung
opacity, in particular in the right upper lobe.
The left base opacification are stable.
Cardiac size is persistently enlarged.
IMPRESSION: Improved ventilation with mild reduced opacification of the right
lung, especially in the RUL. Persistent cardiomegaly.
Radiology Report
TYPE OF EXAMINATION: Chest, PA and lateral.
INDICATION: ___ male patient with chronic fibrosis and history of
systolic congestive heart failure. Admitted with exacerbation of both,
improving symptoms, evaluate for degree of improvement in pulmonary edema or
focal consolidations.
FINDINGS: PA and lateral chest views were obtained with patient in upright
position, and analysis is made in direct comparison with the next preceding
similar study of ___. The heart size remains unchanged. The
widespread chronic pulmonary changes including fibrosis, bronchiectasis and
overlying infiltrates have not changed significantly during the latest four
days examination interval. Comparison is therefore extended to the PA and
lateral chest examination of ___. It can be stated that some
regress of hazy infiltrates in the right upper lobe area has occurred and also
some scattered infiltrates in the right lower lobe area appear to have
diminished. Left-sided changes again appear rather stable. Pulmonary
congestive vascular pattern is difficult to assess in the presence of chronic
interstitial disease and ectasia or it can be stated that no pleural effusion
was present on examination of ___. Comparison with chest
examination of ___, demonstrates the chronic pulmonary changes but
markedly less extension of superimposed patchy parenchymal infiltrates.
IMPRESSION: Enlarged heart size but stable. Advanced chronic interstitial
pulmonary changes including airway distortions of ectatic-type, superimposed
lateral parenchymal infiltrates that have not changed significantly during the
latest examination interval. There is no radiographic evidence for acute
pulmonary edema. No pleural effusion was seen, and no pneumothorax is
present. Comparison chest examination of ___, indicates that the
patient has undergone a long-lasting episode of superimposed infectious
processes.
Radiology Report
STUDY: PA and lateral chest, ___.
CLINICAL HISTORY: ___ man with cystic fibrosis. Evaluate for
pneumonia.
FINDINGS: Comparison is made to prior study from ___.
There are again seen areas of consolidation and scarring throughout both lung
fields. Emphysematous changes are also identified in the apices. The overall
configuration of the parenchymal changes appears stable. There are no new
areas of consolidation and no signs of definite fluid overload. There is a
right-sided central line with distal lead tip in the cavoatrial junction.
Heart size is upper limits of normal. On lateral view, there is osteopenia
and minimal wedging of several thoracic vertebral bodies.
Radiology Report
HISTORY: CF, LVEF 15%, short of breath.
CHEST, SINGLE AP PORTABLE VIEW.
___ at 15:24 p.m.
Again seen is hyperinflation, denser opacity in the right upper zone and
prominence of the hila, with extensive background bullous change and
increased interstitial markings. Compared with ___ at 15:24 p.m., lung
volumes are lower and there is accentuation of the interstitial markings,
which could reflect superimposed CHF or other interstitial
process.Cardiomediastinal silhouette is unchanged.
Thin right-sided central line tip overlies the SVC/RA junction, unchanged. No
pneumothorax is detected.
Tapered appearance of the left distal clavicle again noted, question related
to old trauma.
IMPRESSION:
1. Newly accentuated interstitial markings compared with ___ could reflect
superimposed interstitial edema. Possibility of another interstitial prpoces,
such as an infectious infiltrate is in the differential.
2. Extensive background changes consistent with cystic fibrosis again noted.
Probable bilateral hilar enlargement also again noted.
2. Focal right upper zone opacity is unchanged.
Radiology Report
INDICATION: ___ man with cystic fibrosis and atrial tachycardia, now
with fever, here to evaluate for pneumonia.
COMPARISON: Chest radiographs dated ___ and ___.
TECHNIQUE: PA and lateral radiographs of the chest.
FINDINGS: The lungs remain hyperinflated. There is interval improved
aeration of both lungs with persistent opacification of the right upper lung
zone and bilateral hilar prominence. Extensive abnormal background
interstitial lung markings are stable over multiple prior studies. There is
no pleural effusion or pneumothorax. A right central venous catheter projects
over the cavoatrial junction, unchanged. The cardiomediastinal silhouette is
stable. There is exaggerated thoracic kyphosis. A tapered appearance of the
left distal clavicle is redemonstrated. Healed right posterior rib fractures
are again seen, likely sequela of prior trauma.
IMPRESSION: Improved ventilation with persistent right upper lobe
opacification and chronic interstitial changes.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 97.9
heartrate: 120.0
resprate: 22.0
o2sat: 97.0
sbp: 138.0
dbp: 93.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with history of nonischemic cardiomyopathy
with systolic heart failure (LVEF ___, recent admission ___
to ___ for incompletely characterized tachyarrhythmia, cystic
fibrosis, and HCV genotype 1 status post abbreviated
interferon/ribavirin therapy who was admitted initially to the
medicine service with dyspnea increased from baseline and
productive cough attributed to cystic fibrosis exacerbation and
acute on chronic systolic heart failure, later transferred to
the cardiology service for further management of atrial
tachycardia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Unsteady gait
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History obtained from ED and neurology notes as pt. is very poor
historian and son not at bedside. ___ year-old right-handed man
with a past medical history including hypertension,
hyperlipidemia, dementia and previous vascular events including
a presumed right pontine stroke who presents with progressively
worsening gait instability since ___. He looks like his
feet are stuck on the floor he was unable to move them and was
dragging them with instability. His blood sugars have been very
labile, ranging from 250-> 60 per the son, and has been checking
twice a day with fluctuating sliding scale of insulin 70/30.
However, his gait instability did not improve and his glucose
has been running a little higher. His son states that he has
been even more confused lately (very confused at baseline) and
despite the care at home he has been refusing to eat and drink.
He was seen in the ED one week ago for hypoglycemia and
discharged from the ED.
In the ED, initial VS: 98 60 137/78 16 100% 2L RA. EKG was
V-paced with only change being QRS now upward in V6. Exam was
notable for gait ataxia and mild dysmetria on FNF. Lasb notable
for Cr 1.4 (baseline 1.3), Na 148, neg UA with SG 1.022.
Neurology was consulted and felt this likely represented toxic
metabolic encephalopathy and recommended NCHCT which showed no
acute process, volume resuscitation, ___, and re-evaluation in
the AM. CXR showed borderline cardiomegaly but no acute process.
Cultures were drawn. He was not given any IVF in the ED. VS at
transfer: 98 60 151/78 16 99% RA.
Past Medical History:
HTN
glaucoma (R)
DM2 c/b neuropathy and possibly retinopathy
Depression
Dementia (etiology unknown)
Hypokalemia
Hypercholesterolemia
2nd degree AV block s/p PCM
CRI likely ___ DM, HTn. Baseline 1.3
Decreased vision-Right homonymous hemianopsia
B12 deficiency
BPH
Social History:
___
Family History:
Has a sister with type 2 diabetes mellitus, and who has needed
amputations. History about the parents is unknown.
Physical Exam:
Physical Exam on Admission
VS - Temp 97.6F, BP 142/61, HR 66, R 18, O2-sat 99% RA
GENERAL - elderly man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM slightly dry,
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 - Distant heart sounds, 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, intermittently dysarthric, A&O to person only,
muscle strength ___ throughout, sensation grossly intact
throughout, gait exam deferred, FNF shows dysmetria B/L, limited
abduction of EOM
Physical Exam on Discharge
Physical exam:
VS T98.2 102-146/61-79 HR 66 RR18 98%RA
GEN not oriented, no acute distress
PULM productive cough, scattered ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT scant hair on legs and feet, onychomycosis
NEURO awake, intermittently dysarthric, A&O to person only,
muscle strength ___ throughout, sensation grossly intact
throughout, gait exam deferred, FNF shows dysmetria B/L, limited
abduction of EOM
Pertinent Results:
___ 04:15PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
___ 04:15PM URINE RBC-<1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 04:15PM URINE HYALINE-8*
___ 04:15PM URINE MUCOUS-RARE
___ 01:40PM GLUCOSE-196* UREA N-22* CREAT-1.4*
SODIUM-148* POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-32 ANION GAP-14
___ 01:40PM CALCIUM-9.5 PHOSPHATE-3.4 MAGNESIUM-2.2
___ 01:40PM WBC-6.4 RBC-4.64 HGB-14.1 HCT-43.2 MCV-93
MCH-30.4 MCHC-32.6 RDW-14.1
___ 01:40PM NEUTS-47.5* ___ MONOS-4.4 EOS-8.0*
BASOS-0.9
___ 01:40PM PLT COUNT-182
CT Head without contrast ___ IMPRESSION: No acute intracranial
process.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
2. Doxazosin 2 mg PO HS
3. Lisinopril 20 mg PO DAILY
Hold for SBP<100
4. Atenolol 50 mg PO DAILY
Hold for HR<55, SBP<100
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
6. Docusate Sodium 100 mg PO BID
7. Amlodipine 10 mg PO DAILY
Hold for SBP<100
8. Simvastatin 20 mg PO DAILY
9. Aspirin 325 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours
Hold for K >
12. Clopidogrel 75 mg PO DAILY
13. albuterol sulfate *NF* 90 mcg/actuation Inhalation Q4H:PRN
cough
14. Hydrochlorothiazide 25 mg PO DAILY
Hold for SBP<100
15. Cyanocobalamin 1000 mcg IM/SC QMONTH
16. NPH 15 Units Breakfast
NPH 10 Units Dinner
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
2. Doxazosin 2 mg PO HS
3. Lisinopril 20 mg PO DAILY
Hold for SBP<100
4. Atenolol 50 mg PO DAILY
Hold for HR<55, SBP<100
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
6. Docusate Sodium 100 mg PO BID
7. Amlodipine 10 mg PO DAILY
Hold for SBP<100
8. Simvastatin 20 mg PO DAILY
9. Aspirin 325 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours
Hold for K >
12. Clopidogrel 75 mg PO DAILY
13. albuterol sulfate *NF* 90 mcg/actuation Inhalation Q4H:PRN
cough
14. Hydrochlorothiazide 25 mg PO DAILY
Hold for SBP<100
15. Cyanocobalamin 1000 mcg IM/SC QMONTH
16. NPH 15 Units Breakfast
NPH 10 Units Dinner
Discharge Medications:
1. albuterol sulfate *NF* 90 mcg/actuation Inhalation Q4H:PRN
cough
2. Cyanocobalamin 1000 mcg IM/SC QMONTH
3. Amlodipine 10 mg PO DAILY
Hold for SBP<100
4. Aspirin 325 mg PO DAILY
5. Atenolol 50 mg PO DAILY
Hold for HR<55, SBP<100
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
7. Clopidogrel 75 mg PO DAILY
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
9. Doxazosin 2 mg PO HS
10. Hydrochlorothiazide 25 mg PO DAILY
Hold for SBP<100
11. Lisinopril 20 mg PO DAILY
Hold for SBP<100
12. Multivitamins 1 TAB PO DAILY
13. Simvastatin 20 mg PO DAILY
14. NPH 10 Units Breakfast
NPH 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
15. Docusate Sodium 100 mg PO BID
1. albuterol sulfate *NF* 90 mcg/actuation Inhalation Q4H:PRN
cough
2. Cyanocobalamin 1000 mcg IM/SC QMONTH
3. Amlodipine 10 mg PO DAILY
Hold for SBP<100
4. Aspirin 325 mg PO DAILY
5. Atenolol 50 mg PO DAILY
Hold for HR<55, SBP<100
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
7. Clopidogrel 75 mg PO DAILY
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
9. Doxazosin 2 mg PO HS
10. Hydrochlorothiazide 25 mg PO DAILY
Hold for SBP<100
11. Lisinopril 20 mg PO DAILY
Hold for SBP<100
12. Multivitamins 1 TAB PO DAILY
13. Simvastatin 20 mg PO DAILY
14. Docusate Sodium 100 mg PO BID
15. NPH 10 Units Breakfast
NPH 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
1. albuterol sulfate *NF* 90 mcg/actuation Inhalation Q4H:PRN
cough
2. Cyanocobalamin 1000 mcg IM/SC QMONTH
3. Amlodipine 10 mg PO DAILY
Hold for SBP<100
4. Aspirin 325 mg PO DAILY
5. Atenolol 50 mg PO DAILY
Hold for HR<55, SBP<100
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
7. Clopidogrel 75 mg PO DAILY
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
9. Doxazosin 2 mg PO HS
10. Hydrochlorothiazide 25 mg PO DAILY
Hold for SBP<100
11. Lisinopril 20 mg PO DAILY
Hold for SBP<100
12. Multivitamins 1 TAB PO DAILY
13. Simvastatin 20 mg PO DAILY
14. Docusate Sodium 100 mg PO BID
15. NPH 10 Units Breakfast
NPH 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Dehydration, dementia
Secondary: chronic kidney disease, diabetes type 2
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
___.
CLINICAL HISTORY: Cough, weakness, assess pneumonia.
FINDINGS: AP upright and lateral views of the chest were obtained. Dual-lead
pacer is unchanged. The heart size is top normal in size. There is no
definite sign of pneumonia or CHF. No pleural effusion or pneumothorax. Bony
structures are intact. Cardiomediastinal silhouette is stable.
Atherosclerotic calcification along the aortic knob noted.
IMPRESSION: Top normal heart size. Otherwise normal.
Radiology Report
INDICATION: ___ male with lightheadedness and unstable gait, evaluate
for acute intracranial process.
COMPARISONS: ___.
TECHNIQUE: Continuous axial sections were obtained through the brain without
the administration of IV contrast. Coronal and sagittal reformations were
provided and reviewed.
FINDINGS: There is no acute hemorrhage, edema or shift of the normally
midline structures. No large territorial vascular infarction is seen.
Prominence of the ventricles and sulci is compatible with age-related volume
loss. A left thalamic hypodensity is likely a prior lacunar infarct. A
hypodensity within the left occipital lobe represents encephalomalacia also
prior infarction. Confluent, subcortical white matter hypodensities are
nonspecific but are often seen in the setting of small vessel ischemic
disease.
The visualized portion of the globes are normal. Mastoid air cells and
visualized paranasal sinuses are well aerated. There are no suspicious
osseous lesions. Dense calcifications are seen in the carotid siphons.
IMPRESSION: No acute intracranial process.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: DIFF AMBULATING
Diagnosed with ABNORMALITY OF GAIT, DEHYDRATION, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE
temperature: 98.0
heartrate: 60.0
resprate: 16.0
o2sat: 100.0
sbp: 137.0
dbp: 78.0
level of pain: 0
level of acuity: 3.0 | ___ yo M h/o right pontine stroke in the past, DM2, dementia, CKD
brought in by son for worsening gait instability, decreased PO,
fluctuating blood glucose levels and more confusion than usual
(at baseline he is confused).
ACUTE ISSUES
# Worsening Confusion, ataxia: Pt has gait instability at
baseline as well as disoriented to place and time from dementia.
Patient was worked up with a CT scan which showed no new acute
process. Neurology was consulted and felt his symptoms were due
to worsening of pre-existing gait disorder in setting of known
dementia, significant cerebrovascular disease in past. Recent
worsening was considered to be multifactorial in nature,
dehydration likely played a role in the setting of recent
decreased PO intake. Pt was given LR @ 150cc/hr x 1.5L Patient
went home with services. His family is very involved in his care
as he is dependant on all daily activities of living. Speech
and swallow came by to evaluate patient and they felt he should
be observed while eating upright to avoid aspiration. They felt
he would be ok with a normal diet.
# Diabetes: Patient's blood sugar levels fluctuated from
___. We changed his NPH to 10 units in the morning and 5
units in the evening.
# Acute on Chronic kidney disease: Patient's creatinine
corrected with fluids. After fluids his creatinine went back to
his baseline 1.2 (baseline 1.3).
CHRONIC ISSUES
# h/o CVA: no evidence of new stroke on CT. We continued ASA
325mg, plavix 75mg
# HTN: Was normotensive in house. We continued atenolol,
amlodipine, lisinopril, HCTZ. Pt came in on PO potassium though
we discontinued this because his potassium levels were within
normal limits and he is on lisinopril already and we didnt want
him to become hyperkalemic.
# Glaucoma: stable. We continued brimonidine,
timolol/dorzolamide eye drops
# HL: was stable we continued simvastatin
# BPH: Pt had condom cath while in hospital. This was removed at
the time of discharge. We continued doxazosin
Transitional Issues |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right open tib/fib s/p trip and fall
Major Surgical or Invasive Procedure:
___ Right tibia intramedullary nail.
History of Present Illness:
___ presents with an open R tib/fib fracture transfer from
___. Patient was walking on the street around 12PM
today when she tripped on a curb and fell. She immediatly
noticed bleeding from the right leg and was unable to bear
weight on that side. She did not hit her head and has no other
injuries. EMS was called and the patient was taken to ___
___, an X-ray was performed and R open
tibia/fibular fracture was diagnosed. She receieved 2gm of Ancef
and tetanus shot in the ambulance. Patient was transferred to
___ for operative management.
Past Medical History:
Hypertension
Social History:
___
Family History:
Non contributory
Physical Exam:
On Admission
A&O x 3
Calm but appearing in pain
BUE
skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearm compartments soft
No pain with passive motion
2+ radial pulses
Elbow stable to varus, valgus, rotatory stresses.
R/L Shoulder TTP at the AC joint, long head of biceps,
subdeltoid
BLE
There is an obvious open tibial fracture just proximal to ankle
with a 3cm skin defect with bone evident underneath, obvious
deformity above ankle
Thighs and leg compartments soft
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ ___ ___ TA Peroneals Fire
1+ ___ and DP pulses
On Discharge
A&O x 3
No acute distress.
BLE
Dressings and incisions clean dry intact over right leg.
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ ___ ___ TA Peroneals Fire
1+ ___ and DP pulses
Pertinent Results:
On Admission:
___ 04:26PM BLOOD WBC-10.6 RBC-4.82 Hgb-13.6 Hct-41.7
MCV-86 MCH-28.2 MCHC-32.7 RDW-15.1 Plt ___
___ 04:26PM BLOOD Neuts-89.8* Lymphs-6.8* Monos-3.1 Eos-0.1
Baso-0.2
___ 04:26PM BLOOD ___ PTT-29.3 ___
___ 04:26PM BLOOD Glucose-129* UreaN-15 Creat-0.6 Na-141
K-3.5 Cl-103 HCO3-26 AnGap-16
On Discharge
___ 05:35AM BLOOD WBC-9.7 RBC-3.83* Hgb-10.6* Hct-33.1*
MCV-86 MCH-27.6 MCHC-31.9 RDW-15.6* Plt ___
___ 05:35AM BLOOD Plt ___
___ 05:35AM BLOOD Glucose-113* UreaN-9 Creat-0.7 Na-142
K-3.7 Cl-106 HCO3-28 AnGap-12
___ 05:35AM BLOOD Calcium-7.9* Phos-2.5* Mg-2.0
___ X-ray of right tibia fibula
1. Status post open reduction internal fixation of a comminuted
right
tibia
fracture. Fracture fragments in near anatomic alignment.
2. Hardware intact, no evidence for hardware failure.
3. Improved alignment of a mid right fibular fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Docusate Sodium 100 mg PO BID
5. Senna 1 TAB PO BID
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg take ___ capsule(s) by mouth every 4 hours
Disp #*100 Capsule Refills:*0
7. Enoxaparin Sodium 40 mg SC DAILY Duration: 2 Weeks
RX *enoxaparin 40 mg/0.4 mL Inject 40mg Daily Disp #*14 Syringe
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right open tibia fibular fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Intraoperative evaluation, status post open reduction internal
fixation of a comminuted left tibial fracture.
TECHNIQUE: Twelve intraoperative fluoroscopic images of the left lower
extremity.
COMPARISON: Radiographs of the left lower extremity performed ___.
FINDINGS:
Intramedullary nail is in place within the left tibia. Proximal and distal
transverse interlocking screws are in place and intact. No evidence for
hardware failure.
Surgical hardware appears intact. Fracture fragments of the tibia are in
anatomic alignment. Comminuted fibular fracture demonstrates improved
alignment.
IMPRESSION:
1. Status post open reduction internal fixation of a comminuted left tibia
fracture. Fracture fragments in near anatomic alignment.
2. Hardware intact, no evidence for hardware failure.
3. Improved alignment of a mid left fibular fracture.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: LOWER EXTREMITY INJURY
Diagnosed with FX ANKLE NOS-OPEN, UNSPECIFIED FALL
temperature: 99.6
heartrate: 76.0
resprate: 18.0
o2sat: 98.0
sbp: 140.0
dbp: 90.0
level of pain: 3
level of acuity: 3.0 | The patient was admitted to the orthopaedic surgery service on
___ with open right tibia and fibula fracture. Patient
was taken to the operating room and underwent Irrigation and
debridement and ORIF of tibia fracture on ___. Patient
tolerated the procedure without difficulty and was transferred
to the PACU, then the floor in stable condition. Please see
operative report for full details.
Musculoskeletal: prior to operation, patient was nonweight
bearing. After procedure, patient's weight-bearing status was
transitioned to weight bearing as tolerated with support.
Throughout the hospitalization, patient worked with physical
therapy.
Neuro: post-operatively, patient's pain was controlled by
Dilaudid PCA and was subsequently transitioned to oxycodone with
good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient hemodynamically stable.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #4, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with placement of bare metal stent
History of Present Illness:
This is a ___ year old male with HLD presenting with chest
tightness and elevated heart rate after exercise.
He was in his usual state of health until 10 days ago he noted
chest pressure while lying down hours after a large meal. He
attributed it to indigestion, noting it lasted several hours and
conincided with burping. He had no nausea/sweating, no neck
fullness, no arm pain, no shortness of breath. The pain would
come and go over the course of hours, usually when he was
climbing stairs. He saw his PCP who recommended quitting smoking
and arranging a stress test.
Yesterday, ___, he started using an exercise bike for the first
time and noted some chest pressure that was ___, the worst he's
had yet, and took an hour to resolve with rest. He again used
the bike today and again had chest pressure. His wife noted his
heart rate was quite elevated and seemed "erratic." She brought
him to the ED.
Of note he ruptured his achilles several months ago, had been in
a surgical boot which was removed last ___. He has been
relatively immobilized with it.
Past Medical History:
HYPERCHOLESTEROLEMIA
HEARING LOSS, UNSPEC
Herniation of Intervertebral Disc
Tobacco dependency
Rotator cuff tear
SLAP (superior glenoid labrum lesion)
Achilles tendon tear
Benign neoplasm of colon
Social History:
___
Family History:
Mother MI age ___, mother and father with stroke, father bladder
___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T 97.7 118/81 71 18 100%RA
GENERAL: NAD
HEENT: MMM, EOMI
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: Irregular, normal S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Left ankle brace, 2+ DP pulses, moving all
extremities well, no cyanosis, clubbing or edema
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
___ 08:00PM BLOOD WBC-12.1* RBC-4.98 Hgb-15.3 Hct-46.1
MCV-93# MCH-30.7 MCHC-33.1 RDW-13.9 Plt ___
___ 08:00PM BLOOD Neuts-70.1* ___ Monos-4.4 Eos-1.2
Baso-0.4
___ 08:00PM BLOOD Plt ___
___ 08:00PM BLOOD ___ PTT-28.5 ___
___ 08:00PM BLOOD Glucose-102* UreaN-22* Creat-1.3* Na-144
K-4.1 Cl-105 HCO3-26 AnGap-17
___ 08:00PM BLOOD cTropnT-0.12*
___ 08:00PM BLOOD Calcium-10.1 Phos-3.1 Mg-1.9
___ 08:00PM BLOOD D-Dimer-196
CARDIAC ENZYMES:
___ 07:50AM BLOOD CK-MB-13* cTropnT-1.07*
___ 08:40PM BLOOD CK-MB-29* cTropnT-0.96*
___ 02:06AM BLOOD CK-MB-61* cTropnT-0.82*
___ 08:00PM BLOOD cTropnT-0.12*
IMAGING AND PROCEDURES:
___ COMMENTS:
Initial angiography revealed 100% mid Circumflex lesion which is
the
likely culprit, with intermediate disease in the right coronary
artery.
We planned to treat the LCx with stenting and angiogplasty using
bivalirudin.
A 6 ___ XB 3.5 guide was used and provided excellent support
in sub
selecting the circumflex artery. After the ACT was > 250, a
prowater
wire was inserted into the LCx and passed distal to the lesion,
within a
large OM branch. Then a 2.0 x 12 mm Apex balloon was used to
predilate
the vessel, followed by a 2.75 mm x 28 mm Vision stent and post
dilated
with a 3.0 x 20 mm NC balloon with 0% residual stenosis from
100%
original and TIMI 3 Flow.
Final angiography revealed no residual stenosis and good distal
flow, no
apparent dissection and TIMI 3 flow.
ANGIOGRAPHY:
1. Selective coronary angiography of this right dominant system
revealed an mormal LMCA, a mildly diseased LAD diffusely, a 99%
proximal
LCx lesion, and a RCA with a 50% proximal, 60% distal, and mild
diffuse
disease.
2. PCTA as above.
FINAL DIAGNOSIS:
1. Single vessel CAD with subtotal occlusion of the proximal LCx
treated
with one 2.75mm x 28 mm Bare Metal Stent.
2. Dual Anti-platelet therapy for at least 30 days
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sildenafil 50 mg PO 1 HR BEFORE SEX
2. Atorvastatin 40 mg PO DAILY
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*0
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*0
4. Sildenafil 50 mg PO 1 HR BEFORE SEX
5. Metoprolol Succinate XL 12.5 mg PO DAILY
Please take this once daily in the morning.
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
DAILY Disp #*30 Tablet Refills:*0
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest Pain
Do not take with viagra. Do not take more than 3 doses, call
your doctor otherwise.
RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually
EVERY 5 MINUTES AS NEEDED Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: NSTEMI
Secondary diagnosis: Atrial fibrillation with rapid ventricular
response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with chest tightness // ?cause for chest pain
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear. There is no effusion, consolidation, or pneumothorax. The
cardiomediastinal silhouette is normal. No acute osseous abnormalities
identified.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Palpitations
Diagnosed with ATRIAL FIBRILLATION
temperature: 97.4
heartrate: 142.0
resprate: 16.0
o2sat: 100.0
sbp: 151.0
dbp: 95.0
level of pain: 4
level of acuity: 1.0 | # NSTEMI: patient presented with chest pain following exercise
and was found to have ST changes on initial EKG. Repeat EKGs
were negative but patient continued to have troponin elevation.
A cardiac catheterization procedure was done which showed 100%
occlusion of the left circumflex artery and also RCA disease
which was not the culprit lesion. A single bare metal stent was
placed in the left circumflex artery which resolved his chest
pain. Patient remained chest pain free after procedure and will
be discharged on plavix for 12 months, high dose atorvastatin
80mg, ASA 325, and metoprolol for rate control. We are also
sending him home with a prescription for SL nitroglycerin for
return of anginal symptoms. He will follow up with his Atrius
cardiologist for further management of his heeart condition and
his primary care physician.
# Afib with RVR: pt inially presented in afib w/ RVR when he had
his chest pain. HR was irregular and in the 140s on arrival to
the ED. He was rate controlled with 25mg metoprolol tartarate
and converted back to NSR. He remained in NSR for the duration
of his admission and had a few episodes of bradycardia with HR
in the ___. The metoprolol was held in light of the bradycardia;
however, patient's heart rate returned to the mid ___ post
catheterization. He is to be discharged on metoprolol XL 25mg
daily.
# HLD: continued atorvastatin during his admission. Adjusted the
dose from 40mg daily to 80mg.
# Transitional issues:
-Follow up with outpatient cardiologist, the ___
cardiologist's office will contact you with a time and place for
your follow up appointment
-Continue taking plavix 75mg daily for one year unless otherwise
specified by your cardiologist
-Continue taking Metoprolol XL 12.5mg daily in the morning
-We changed your atorvastatin from 40mg daily to 80mg
-Continue taking aspirin 81mg daily |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Statins-Hmg-Coa Reductase Inhibitors / anastrozole
/ Vicodin
Attending: ___.
Chief Complaint:
behavior change
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of Recurrent serous endometrial adenocarcinoma,
Dermatomyositis (on prednisone), Vague psychiatric history,
presented from rehab with changes in behavior, admitted for
possible UTI
As per documentation from ___:
Patient admitted to be ___ on ___ status post
mechanical fall with head strike for which she had CT head and
neck negative for fracture though required 4 staples to head
laceration. TSH B12 within normal limits at the time, UA
negative. Right knee x-ray showed soft tissue swelling
anteriorly though cause for fall unclear from paperwork. During
hospitalization had troponin elevation but no EKG changes,
stress
test negative for ischemia or infarct and showed normal ejection
fraction. Family/patient declined cardiac catheterization.
Patient then transferred to rehab on ___ for
rehabilitation
where she was noted to be dizzy with positional changes and very
anxious. MD was concerned that prednisone dose may be
contributing so decreased dose from 80->60mg, then patient sent
to ED for evaluation
As per outpatient team's discussion with family:
"At rehab, has not participated in any therapy. Is "mean" Not
herself, saying rude/inappropriate things, throwing things at
staff. Feels she is becoming manipulative; not willing to get
up to use the bathroom so is now in diaper. Prior to this,
___
found out was not being compliant with amitriptyline. Unclear
if
compliant with other meds. All of this is out of character for
___
Pt reports that she is unsure why she was brought to the
hospital, but is happy because she feels safe here, and did not
feel that way at rehab. She noted that rehab was a dirty place
which she disliked, and she did not like the ideas of doctors
___ than Dr. ___ trying to order tests or prescribing
medications for her. She notes that she has had 2 falls which
she describes as mechanical, tripping on objects on the floor
but
noted none since being at rehab. He noted that she feels
unsteady at baseline when walking so she uses a walker. She
denied any headache or new neurologic changes. Denied fever
chills. Noted that she has decreased p.o. intake due to lack of
appetite, denied any nausea, vomiting, abdominal pain, fever,
chills. Denied dysuria but noted increased urinary frequency.
Denied any anxiety, depression. When I asked why she left the
stove on at home she noted that she was unfamiliar with it
because it was new but had a difficult time providing further
detail. Overall patient struggled with fine detail and can only
speak in general terms. Is therefore alert and oriented but has
significant gaps in memory/recall.
In the ED, initial vitals: 98.9 125 115/64 17 95% RA. HR
decreased to 107 during time in ED, was 112 when transferred to
medical ward. WBC 2.8 (77% PMN), Hgb 9.8, plt 183, CHEM wnl,
Lactate wnl, UA with 14WBC, 13 RBC, + prot/glucose, Tr Leukest,
neg nitrite, 1c 6.4. Urine/Blood cx sent.
CXR: No acute process
EKG: Sinus at 116bpm, no acute ST changes compared to baseline,
old inferior infarct likely as qwave in III/AVF
CTH Ordered but patient refused. Patient was given CTX, had
scalp staples removed and admitted for further care.
Past Medical History:
Health Maintenance:
-Mammogram: last year
-Colonoscopy: never
-Bone Mineral Density: ?
Past Medical History:
DIABETES TYPE II
ARTHRITIS
HYPERTENSION
BURSITIS
FRACTURED ARM
Past Surgical History:
Denies
Past OB History: G5P5004; SVD x 5
Past GYN History:
- Menopause in her ___
- pap ___: AGUS, favor neoplastic
- Denies history of pelvic infections or STIs
- Denies use of hormone replacement therapy/OCPs
- Denies history of fibroids or cysts
Social History:
___
Family History:
Family history:
Relative Status Age Problem Comments
Mother HEART DISEASE
Father HEART DISEASE
CANCER
Sister DIABETES
CARDIAC
Brother HEART DISEASE
PROSTATE
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: ___ 2212 Temp: 98.4 PO BP: 100/68 HR: 99 RR: 18 O2
sat: 95% O2 delivery: Ra
GENERAL: Patient lying in bed, calm, comfortable, no acute
distress
EYES: Pupils equally round and reactive to light, anicteric
sclera
HEENT: Oropharynx clear, moist mucous membranes, cranial nerves
intact 2 through 12, no focal deficits, scalp lesion
appropriately healed no surgical staples remaining
NECK: Supple, normal range of motion
LUNGS: Clear to auscultation bilaterally without wheezes rales
or
rhonchi, normal respiratory rate
CV: Regular rate and rhythm, normal distal perfusion without
edema
ABD: Soft, nondistended, nontender, normoactive bowel sounds
GENITOURINARY: No Foley or suprapubic tenderness
EXT: Strength 5 out of 5 in upper extremities, strength 3 out of
5 in lower extremities which she notes is baseline, decreased
muscle bulk
SKIN: Warm dry, no rash, stage II pressure ulcer
NEURO: Alert and oriented x3 however patient lacks detail in
history and clearly has difficulty with ___
memory and recall. Unclear if patient has capacity to make
decisions
PSYCH: Normal mood/affect, judgment/insight difficult to assess
and unclear
ACCESS: PIV
Discharge Exam
Appears comfortable
Comfort measures only
Pertinent Results:
ADMISSION LABS:
___ 05:52PM BLOOD WBC-2.8* RBC-3.06* Hgb-9.8* Hct-30.6*
MCV-100* MCH-32.0 MCHC-32.0 RDW-21.6* RDWSD-78.1* Plt ___
___ 05:52PM BLOOD Neuts-77.6* Lymphs-11.7* Monos-9.6
Eos-0.0* Baso-0.0 Im ___ AbsNeut-2.18 AbsLymp-0.33*
AbsMono-0.27 AbsEos-0.00* AbsBaso-0.00*
___ 07:05AM BLOOD ___ PTT-22.2* ___
___ 05:52PM BLOOD Glucose-151* UreaN-30* Creat-0.5 Na-139
K-4.2 Cl-99 HCO3-27 AnGap-13
___ 07:05AM BLOOD ALT-89* AST-54* LD(LDH)-370* AlkPhos-61
TotBili-0.4
___ 07:05AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.6 UricAcd-4.5
___ 06:30AM BLOOD VitB12-412 Folate-6
___ 07:32PM BLOOD %HbA1c-6.4* eAG-137*
___ 07:05AM BLOOD TSH-2.7
___ 07:05AM BLOOD T4-6.4
___ 05:57PM BLOOD Lactate-1.7
No discharge labs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line
2. Senna 17.2 mg PO DAILY:PRN Constipation - Second Line
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Aspirin 81 mg PO DAILY
5. Calcium Carbonate 500 mg PO QID:PRN gerd
6. Lisinopril 20 mg PO DAILY
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. LORazepam 0.25 mg PO Q6H:PRN anxiety
9. Niacin 500 mg PO QHS
10. Simethicone 40-80 mg PO QID:PRN gas
11. Amitriptyline 20 mg PO QHS
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
14. PredniSONE 80 mg PO DAILY
15. Glucosamine (glucosamine sulfate) 750 mg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line
3. LORazepam 0.25 mg PO Q6H:PRN anxiety
4. PredniSONE 80 mg PO DAILY
5. Senna 17.2 mg PO DAILY:PRN Constipation - Second Line
6. Simethicone 40-80 mg PO QID:PRN gas
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic Endometrial Carcinoma
Dermatomyositis
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 AMS// eval pna
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___. Chest CT from ___.
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or edema. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 98.9
heartrate: 125.0
resprate: 17.0
o2sat: 95.0
sbp: 115.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | ___ PMH of Recurrent serous endometrial
adenocarcinoma,
Dermatomyositis (on prednisone), Vague psychiatric history,
presented from rehab with changes in behavior, admitted for
possible UTI and arrange for home with hospice.
#Behavior Change
#Vague Psych History
#?UTI:
Differential for her behavior change includes side effects from
prednisone, metastatic cancer to brain, SDH, UTI, underlying
psychiatric disorder/pseudodementia. UA was not overwhelming and
UCx was contaminated unlikely to be UTI. TSH, B12 and CK normal.
# Metastatic endometrial cancer
A team meeting was held at patients bedside which included
hospice nurse, ___, patient's family ___ (___), another
daughter - ___. We discussed the patients
prognosis, and addressed her goals of care. She cited clearly
that she does not wish to pursue aggressive measures anymore and
wants to go home and be comfortable. These wishes were also
reiterated by family who cite this is consistent with her
values. They are all in agreement to withdrawal care and to
focus on comfort. The plan was ultimately decided to be
discharged home with hospice. She is confirmed DNR/DNI and a new
MOLST was completed.
#Pancytopenia, predominantly leukopenia: 3 weeks out from
chemotherapy with carboplatin. Possible that the drop in cell
counts is due to this. Also possibly due to infection, though no
overwhelming symptoms/signs of infection. Lastly, patient has
underlying autoimmune disease and this could be worsening of her
underlying disease. Given pursuit of hospice goals, did not work
up further
#HTN
#HLD
#T2DM
Discontinued all medications not directly focused on comfort |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Facial fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with no known past medical history presents to
___ ED after sustaining a blow to the right jaw during rugby
plan one week ago (last ___. Patient denies loss of
consciousness, head strike, or down time. Patient had some
swelling of jaw which resolved but pain has continued. He has
some right lower lip paresthesia but is otherwise sensate and
neuro-intact. He constituted a liquid and semi-soft diet
initially with improvement of pain but was convinced to come to
___ ED by college friend tonight. Patient has non displaced R
mandibular body fx and L mandibular angle fx seen on CT
sinus/max/mandible and was seen by OMFS with operative plan.
Request for ACS consult for ___ admission.
Patient denies other symptoms. No head aches or evidence of head
injury, no nose bleeds, ear bleeds, or oral bleeds, no injury to
tongue. Patient denies fevers, chills, night sweats. No chest
pain, shortness of breath, trouble breathing or managing
secretions. No change in bowel habits. No dysuria or hematuria.
No abdominal pain. No ___ swelling or MSK pain. Patient is
otherwise healthy.
Past Medical History:
Childhood cardiac murmur w/o treatment or further f/u
Social History:
___
Family History:
NC
Physical Exam:
VS: 97.2 63 140/67 20 100% RA
Gen: AAOx3, affable, white young male, NAD
Neuro: PERRLA, EOMI, CN2-12 intact
HEENT: no maxillary ttp, head atraumatic, no hematympanium,
right
mandibular ttp, minimal malocclusion right jaw, no evidence of
oral trauma or other external injury
CV: RRR no MRG, split S2
Pulm: CTAB No adventitious breath sounds
Abd: Soft nttp no guarding or rebound
Ext: distal pulses, UE and ___ ___ strength, no evidence of
injury
Chest: no sternal or chest wall ttp no evidence of injury
Medications on Admission:
None
Discharge Medications:
1. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate [Peridex] 0.12 % Oral Rinse 15mL
twice a day Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Cephalexin 500 mg PO QID
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*8 Capsule Refills:*0
4. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL 5 ml by mouth q4hrs Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
R mandibular body fx and L mandibular angle fx
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: Mandible fractures. Preoperative evaluation.
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. Cardiomediastinal silhouette and hilar contours are
unremarkable. Lungs are clear. Pleural surfaces are clear without effusion
or pneumothorax.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Jaw pain
Diagnosed with Fx unsp part of body of mandible, unspecified side, init, Accidental strike or bumped into by another person, init
temperature: 97.2
heartrate: 63.0
resprate: 20.0
o2sat: 100.0
sbp: 140.0
dbp: 67.0
level of pain: 4
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the Acute Care Surgery Team. The patient was found
to have R mandibular body fx and L mandibular angle fx and was
admitted to the Acute Care Surgery Team for operative treatment
by ___. On HD1 it was determined by ___ that the patient
should follow-up outpatient on ___ 8:30am, ___ ___ outpatient operative intervention.
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
will follow up with ___ 8:30am, ___ ___.
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: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness and worsening right sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ Stroke Scale Score: 9
NIHSS performed within 6 hours of presentation at: ___ at
2325
NIHSS Total: 9
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 2 (residual)
5a. Motor arm, left: 0
5b. Motor arm, right: 2 (residual)
6a. Motor leg, left: 0
6b. Motor leg, right: 1 (residual)
7. Limb Ataxia: 0
8. Sensory: 1 (residual?)
9. Language: 1 (residual?)
10. Dysarthria: 1 (residual?)
11. Extinction and Neglect: 1 (residual?)
REASON FOR CONSULTATION: dizziness, intermittent right lower
extremity weakness throughout day
HPI:
___ is a ___ year old woman with history of
hypertension, hyperlipidemia, prior stroke with residual right
hemiparesis, localization-related epilepsy on Keppra and
lamotrigine, hypothyroidism, and glaucoma who presented to ED
from nursing home after new-onset dizziness this morning with
subsequent acute-on-chronic right lower extremity weakness.
History obtained by patient and as per chart review.
The patient reports that she was she had seen Dr. ___
yesterday in clinic to establish new neurology clinic follow-up.
No outside records were available for evaluation at that time
but
her baseline exam prior to new symptom onset was documented.
After her clinic appointment, she returned to her nursing home
in
usual state of health. She woke up this morning and felt well.
At
around 11AM, while urinating, she suddenly felt room-spinning
dizziness that resolved but was followed by an atypical
sensation
in her right lower extremity, described as heaviness and
weakness. She notes that she has lived with her residual stroke
deficits for ___ years and never felt anything like this in her
right leg. She tried to get up from the commode but did not have
the strength and as such called for help. Throughout the rest of
the day, she notes that her right sided weakness and heaviness
was intermittent. Her dizziness has since resolved. This
evening,
she noted that she was again feeling weaker in her right lower
extremity, requiring assistance to mobilize which is atypical
for
her. She thus requested ED evaluation and was brought to ___.
Since arrival at ___ (~ 15 minutes prior to my evaluation) she
notes her symptoms have started to improve again. She now thinks
she may be back at baseline, or close to it.
Per Dr. ___ initial clinic note on ___:
" Based on history, the patient suffered a stroke ___ years ago
and was left with right hemiparesis. Since the stroke she has
been on ASA 81 mg and had no recurrent events. She also suffers
from seizures with mouth foaming, shaking and urinary
incontinence, but no generalization. She is on Keppra for
her seizures and she has not had a seizure for a long time." His
exam at the time was notable for "mild aphasia and dysarthria
with right facial droop and right hemiparesis." He had no
outside
records at that time and as primary reason for visit was to
establish neurological care, he continued her on home dose of
atorvastatin 60mg, aspirin 81 mg per his note, Keppra, and
lamictal (for mood? is what is questioned in Dr. ___.
ROS:
Notable for above findings, otherwise noncontributory
PMH:
====
HYPERTENSION
HYPERLIPIDEMIA
HYPOTHYROIDISM
STROKE
SEIZURE DISORDER
GLAUCOMA
Surgical History (Last Verified ___ by ___,
MD):
Surgical History updated, no known surgical history.
Medications:
===========
***NEEDS MEDICATION RECONCILLIATION***
Keppra 500mg BID
lamotrigine 200mg BID (for mood)
Aspirin (either 81 or 325, unclear per chart review/med review
in
OMR)
metoprolol succinate 25mg ER qday
levothyroxine 50ucg qday
furosemide 20mg qday
baclofen 10mg PRN muscle spasm (BID)
atorvastin 60mg qPM
Allergies:
=========
no known drug allergies
SOCIAL HISTORY:
Social History (Last Verified ___ by ___,
MD):
Lives with: Group setting
Tobacco use: Never smoker
Alcohol use: Denies
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
- Modified Rankin Scale:
[] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[x] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
FAMILY HISTORY:
notable for stroke and hypertension
PHYSICAL EXAMINATION:
Vitals:
T96.9, HR70-80s, RR16-24, BP140-180/70s 95 SaO2
Orthostatics:
137/81 supine with HR 78 --> standing HR 95; BP 161/92
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: trace pedal edema.
Neurologic:
-Mental Status: Alert and interactive with examiner. Oriented to
self and to situation. Able to follow midline and appendicular
commands. Has difficulty with two-step commands. Able to name
high and low frequency objects with exception of wristwatch
clasp
(refers to as band). Difficulty with ___ backwards and ___
backwards, after multiple attempts with either task says
___ Repetition intact.
No neglect.
-Cranial Nerves: PERRL 3>2. No nystagmus. Right eye does not
fully bury sclera on lateral gaze. Visual fields full to finger
counting. ? prior left bells palsy?. Right NLFF with delayed
activation. Facial musculature symmetric. Hearing intact to
conversation. Tongue midline. Slight dysarthria with guttural
sounds.
-Motor: Right hemibody is with increased tone and spasticity at
baseline. No adventitious movements.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 3 ___ 0 0 0 3 4 4 4 4 0
Per Dr. ___ ___
"R 2 ___ 0 0 0 2 -___ 4 2"
-Sensory: Diminished sensation to pinprick on right lower
extremity compared to left. Extinguishes to light touch with DSS
on right. Temperature, proprioception intact.
-Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 3 2 3 3
Plantar response was ? extensor on right, flexor on left.
-Coordination: No intention tremor. No dysmetria on FNF on left
and no decreased augmentation of movements with heel tapping on
right or left lower extremity.
-Gait: Deferred in setting of acute illness, without baseline
walker on hand
LABORATORY DATA:
___ 12:00AM BLOOD WBC: 4.4 RBC: 4.24 Hgb: 11.7 Hct: 38.5
MCV: 91 MCH: 27.6 MCHC: 30.4* RDW: 15.2 RDWSD: 50.4* Plt Ct: 244
___ 12:10AM BLOOD ___: 11.8 PTT: 28.3 ___: 1.1
___ 12:00AM BLOOD Glucose: 82 UreaN: 9 Creat: 0.8 Na: 142
K:
4.0 Cl: 104 HCO3: 28 AnGap: 10
___ 12:00AM BLOOD ALT: 18 AST: 28 AlkPhos: 90 TotBili: 0.5
___ 12:00AM BLOOD cTropnT: <0.01
___ 12:00AM BLOOD Albumin: 4.3 Calcium: 10.0 Phos: 2.7 Mg:
2.1
___ 12:00AM BLOOD ASA: NEG Ethanol: NEG Acetmnp: 8*
Tricycl:
NEG
___ 12:06AM BLOOD Glucose: 82 Lactate: 1.5 Creat: 0.7 Na:
139 K: 4.7 Cl: 108 calHCO3: 29
___ 12:06AM BLOOD Hgb: 12.5 calcHCT: 38
___ 02:36AM URINE Blood: NEG Nitrite: NEG Protein: NEG
Glucose: NEG Ketone: NEG Bilirub: NEG Urobiln: NEG pH: 6.5
Leuks:
NEG
___ 02:36AM URINE bnzodzp: NEG barbitr: NEG opiates: NEG
cocaine: NEG amphetm: NEG oxycodn: NEG mthdone: NEG
EKG: NSR
IMAGING:
NCHCT: multiple areas of encephalomalacia, including left
frontoparietal, left occipital, right frontal and right parietal
lobe suggestive of chronic incarcts. Prominent ventricles. ?
periventricular white matter hypodensity.
CTA head and neck: no large vessel occlusion, no significant
intracranial disease.
ASSESSMENT:
THis is a ___ year old woman with HTN, hyperlipidemia, prior
stroke with right hemiparesis, recently seen in stroke neurology
clinic, who presents today for new onset dizziness and
intermittent stuttering right lower extremity
weakness/heaviness.
Exam is notable for mild aphasia, which I suspect is at her
baseline as per Dr. ___ on ___. She is
slightly
inattentive to ___, which his mental exam also suggests was the
case two days prior. However, I do not some slightly more
profound right hemibody weakness as compared to his exam, with 0
in ___ (previously documented as 2). The patient also endorses
loss of pinprick sensation in right lower extremity and
extinguishes on the right with DSS.
The underlying etiology for her new symptoms remains unclear. I
am reassured by the resolution since arrival to the ED but am
concerned about the possibility of a stuttering lacune given the
intermittent right lower extremity weakness vs flow-dependent
perfusion states vs subclinical seizures vs stroke
recrudescence.
No obvious infectious triggers on routine lab work in ED. Given
new onset of waxing/waning symptoms with significant stroke risk
factors, admission is warranted for expedited management.
PLAN:
- Admit to stroke neurology service under attending Dr. ___.
# Neuro:
- MRI head
- Check risk factors: fasting lipid panel and HBA1c
- Consider increasing/transitioning aspirin
- Allow BP to autoregulate as below
- ___ consults
# CV:
- R/o MI with cardiac enzymes
- Monitor cardiac telemetry
- Allow BP to autoregulate with goal SBP<180 (goal 140-180s)
- Hydralazine 10 mg IV q6h prn SBP > 180
- Hold home antihypertensives / halve dose of beta-blocker
- Trans-thoracic echo
# Pulmonary:
- Monitor oximetry
- Screening CXR
# GI/Nutrition:
- NPO until passes water swallowing screen
- Cardiac heart healthy diet once passess
- Bowel regimen with Senna, Colace
# Renal:
- Baseline Cr: 0.7
- Continue to trend
- mIVF @ 70cc/hr for 1L pending PO eval
# Endocrine:
- TSH, A1c
- Finger sticks QID
- Insulin sliding scale
# Toxic/Metabolic:
- Check LFTs
- Check urine and serum toxin screens
# ID:
- Check UA
- Check CXR
# Heme:
- Baseline Hgb: 11.7
# Psychiatric/Behavioral:
- No active issues
# Hospital Issues:
- DVT PPx: Pneumoboots, SQ heparin
- Precautions: Fall, Aspiration
- Restraints: none
- Health Care Proxy: unknown
- Code Status: full
Past Medical History:
HYPERTENSION
HYPERLIPIDEMIA
HYPOTHYROIDISM
STROKE
SEIZURE DISORDER
GLAUCOMA
Social History:
___
Family History:
notable for stroke and hypertension
Physical Exam:
24 HR Data (last updated ___ @ 423)
Temp: 98.3 (Tm 98.4), BP: 113/71 (113-145/71-84), HR: 72
(65-94), RR: 16 (___), O2 sat: 96% (96-98), O2 delivery: Ra
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.
Extremities: trace pedal edema.
Neurologic:
-Mental Status: Alert and interactive with examiner. Oriented to
self and to situation. Able to follow midline and appendicular
commands. Has difficulty with two-step commands. Repetition
intact.
-Cranial Nerves: PERRL 3>2. No nystagmus. Right eye does not
fully bury sclera on lateral gaze. Visual fields full to finger
counting. Right NLFF with delayed activation. Facial musculature
symmetric. Hearing intact to conversation. Tongue midline.
Slight
dysarthria with guttural sounds.
-Motor: Right hemibody is with increased tone and spasticity at
baseline. No adventitious movements.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 3 4 4- 0 0 0 0 3 4 4 4- 4 0
Per Dr. ___ ___
"R 2 ___ 0 0 0 2 -___ 4 2"
-Sensory: deferred
-Reflexes: deferred
Plantar response was extensor on right, flexor on left.
-Coordination: No intention tremor. No dysmetria on FNF on left
and no decreased augmentation of movements with heel tapping on
right or left lower extremity.
-Gait: Deferred
Pertinent Results:
___ 06:00AM ALT(SGPT)-16 AST(SGOT)-22 LD(LDH)-236
CK(CPK)-134 ALK PHOS-83 TOT BILI-0.4
___ 06:00AM CK-MB-3 cTropnT-<0.01
___ 06:00AM ALBUMIN-3.9 CALCIUM-9.5 PHOSPHATE-2.6*
MAGNESIUM-2.1 CHOLEST-154
___ 06:00AM %HbA1c-5.3 eAG-105
___ 06:00AM TRIGLYCER-40 HDL CHOL-76 CHOL/HDL-2.0
LDL(CALC)-70
___ 06:00AM TSH-7.9*
___ 06:00AM T4-8.1
___ 06:00AM WBC-4.7 RBC-4.00 HGB-11.0* HCT-36.4 MCV-91
MCH-27.5 MCHC-30.2* RDW-15.2 RDWSD-50.2*
___ 06:00AM ___ PTT-28.2 ___
___ 02:36AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 12:10AM ___ PTT-28.3 ___
___ 12:06AM GLUCOSE-82 LACTATE-1.5 CREAT-0.7 NA+-139
K+-4.7 CL--108 TCO2-29
___ 12:06AM HGB-12.5 calcHCT-38
___ 12:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-8*
tricyclic-NEG
CT Head/ neck:
1. Multifocal areas of encephalomalacia as described above,
largest in the
left frontoparietal lobe. This limits sensitivity for acute
territorial
infarction. Consider further evaluation with MRI.
2. Small chronic infarct left thalamus.
3. No evidence of acute intracranial hemorrhage.
4. Patent head and neck vasculature with no evidence of focal
stenosis,
occlusion, or aneurysm.
5. Right thyroid lobe nodule measuring 1.9 cm.
MR brain:
1. Study is moderately degraded by motion.
2. Multiple bilateral supratentorial chronic infarcts, largest
in the left MCA territory, with evidence of probable chronic
blood products within right parieto-occipital infarct.
3. No acute infarct or extra-axial collection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Vitamin D ___ UNIT PO MONTHLY
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. LevETIRAcetam 500 mg PO BID
7. LamoTRIgine 200 mg PO BID
8. Furosemide 20 mg PO DAILY
9. Baclofen 15 mg PO QPM
10. Atorvastatin 60 mg PO QPM
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 60 mg PO QPM
3. Baclofen 15 mg PO QPM
4. Furosemide 20 mg PO DAILY
5. LamoTRIgine 200 mg PO BID
6. LevETIRAcetam 500 mg PO BID
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Vitamin D ___ UNIT PO MONTHLY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Nonspecific Sequela of Infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ female with history of CVA presents with dysmetria,
dizziness. Eval for vascular abnormality, dissection.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.9 mGy (Body) DLP =
10.0 mGy-cm.
3) Spiral Acquisition 4.6 s, 36.0 cm; CTDIvol = 15.2 mGy (Body) DLP = 546.9
mGy-cm.
Total DLP (Body) = 557 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There are areas of encephalomalacia in the left frontoparietal lobes, left
occipital lobe, right frontal lobe, and right parietal lobe. There is
associated ex vacuo dilatation of the left lateral ventricle. There is also a
small chronic infarct in the left thalamus. No evidence of acute intracranial
hemorrhage. Mild prominence of ventricles and sulci are compatible with age
related involutional changes. No midline shift.
The intraorbital contents are unremarkable. The paranasal sinuses and mastoid
air cells are clear. The calvarium is intact.
The examination is limited due to timing of the contrast bolus.
CTA HEAD:
There are mild nonocclusive atherosclerotic calcifications of the cavernous
and supraclinoid internal carotid arteries. Otherwise, the vessels of the
circle of ___ and their principal intracranial branches demonstrate
opacification without focal stenosis, occlusion, or aneurysm formation.
CTA NECK:
There is slight medialization/retropharyngeal course of the left common
carotid artery. The left vertebral artery is dominant with a smaller caliber
right vertebral artery. Otherwise, the carotid and vertebral arteries and
their major branches demonstrate opacification with no evidence of stenosis or
occlusion. There is no evidence of internal carotid stenosis by NASCET
criteria.
OTHER:
Mosaic attenuation of the visualized lungs likely relates to air-trapping and
expiratory phase. The thyroid is heterogeneous. There is a 1.9 cm
low-density nodule in the right thyroid lobe.
No lymphadenopathy by CT size criteria. No suspicious osteolytic or
osteoblastic lesions.
IMPRESSION:
1. Multifocal areas of encephalomalacia as described above, largest in the
left frontoparietal lobe. This limits sensitivity for acute territorial
infarction. Consider further evaluation with MRI.
2. Small chronic infarct left thalamus.
3. No evidence of acute intracranial hemorrhage.
4. Patent head and neck vasculature with no evidence of focal stenosis,
occlusion, or aneurysm.
5. Right thyroid lobe nodule measuring 1.9 cm.
RECOMMENDATION(S): Right thyroid lobe nodule measuring 1.9 cm. Ultrasound
follow up recommended.
___ College of Radiology guidelines recommend further evaluation for
incidental thyroid nodules of 1.0 cm or larger in patients under age ___ or 1.5
cm in patients age ___ or ___, or with suspicious findings.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
Radiology Report
EXAMINATION: STROKE PROTOCOL (BRAIN W/O) ___ MR HEAD
INDICATION: ___ year old woman with prior strokes and new dizziness worsening
right lower extremity weakness// rule out new stroke, evaluate prior stroke
burden, rule out CAA
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CTA head and neck ___.
FINDINGS:
Study is moderately degraded by motion. Within these confines:
There are multiple areas of encephalomalacia reflecting sequelae of chronic
infarction involving the left frontoparietal MCA territory, left PCA territory
in the occipital lobe, right parieto-occipital region, and the right frontal
lobe, with surrounding white matter FLAIR hyperintensity.
Chronic petechial hemorrhage is seen at the site of the chronic right
parieto-occipital infarct.
There is no evidence of acute infarct or extra-axial collection.
The ventricles and sulci are normal in caliber and configuration. Minimal
periventricular and a few small scattered deep white matter foci of FLAIR
hyperintensity are nonspecific but compatible with very mild changes of
chronic white matter microangiopathy.
There is a trace right mastoid effusion. Minimal bilateral maxillary sinus
and ethmoid air cell mucosal thickening is present. The visualized portion of
the major intracranial vascular flow voids are preserved.
IMPRESSION:
1. Study is moderately degraded by motion.
2. Multiple bilateral supratentorial chronic infarcts, largest in the left MCA
territory, with evidence of probable chronic blood products within right
parieto-occipital infarct.
3. No acute infarct or extra-axial collection.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dizziness, R Leg weakness
Diagnosed with Dizziness and giddiness
temperature: 96.9
heartrate: 76.0
resprate: 16.0
o2sat: 95.0
sbp: 144.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | Hospital Course:
___ is a ___ year old woman with history of
hypertension, hyperlipidemia, prior stroke with residual right
hemiparesis, localization-related epilepsy on Keppra and
lamotrigine, hypothyroidism, and glaucoma who presented to ED
from nursing home after new-onset dizziness with subsequent
acute-on-chronic right lower extremity weakness. Dizziness
resolved but reported right sided "heaviness" persisted more so
than her baseline deficit and thus was admitted to the stroke
service. Upon admission to stroke service, underlying etiology
for her new symptoms remained unclear. Cardiac origin ruled out
with EKG and telemetry. There was resolution since arrival to
the ED but concerning with possibility of a stuttering lacune
given the intermittent right lower extremity weakness vs
flow-dependent perfusion states vs subclinical seizures vs
stroke recrudescence. No obvious infectious triggers on routine
lab work in ED. Ultimately determined to have no stroke on MRI
but given risk factors and past stroke burden, diagnosis of
nonspecific sequela of cerebral infarction.
#Nonspecific Sequela of infarction: patient reportedly had
intermittent weakness and dizziness while at her facility. Upon
assessment in the ED, her symptoms had significantly improved
and she reported basically being back to baseline. NCHCT was
ordered and read as showing multiple areas of encephalomalacia,
including left frontoparietal, left occipital, right frontal and
right parietal lobe suggestive of chronic infarcts. Prominent
ventricles and periventricular white matter hypodensity. CTA
head and neck showed no large vessel occlusion, no significant
and no intracranial disease. She was admitted to the stroke
service and an MRI brain was ordered. MR brain read as: Multiple
bilateral supratentorial chronic infarcts, largest in the left
MCA territory, with evidence of probable chronic blood products
within right parieto-occipital infarct. No acute infarct or
extra-axial collection. Stroke risk factor labs sent. TTE was
done and found to have EF of 60, no cardiac origin of emboli
observed and no PFO. ___ recommended ___ rehab. She was
kept on ASA 325 mg. Atorvastatin 60mg kept on.
#HYPERTENSION
She was initially taken off of her home BP meds and given BP
chance to autoregulate given concern for stroke. Once new
infarct ruled out on imaging, home BP meds added back.
Metoprolol 25mg PO daily
#HYPERLIPIDEMIA
She will be sent home on atorvastatin 60mg.
#HYPOTHYROIDISM
Her TSH was found to be elevated at 7.9 and her home
levothyroxine was increased from 50 to 62mg qday. Her PCP ___
need to continue trending TSH while outpatient.
#SEIZURE DISORDER
Initial concern that her symptoms potentially were related to
seizure however no further concern and home medications were not
changed. She arrived on lamotrigine 200mg BID and keppra 500 BID
which she remained on.
#GLAUCOMA
No issues while inpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Tetracycline Analogues
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with a history of diverticulosis who
developed abdominal pain over the past few days along with
diarrhea that continued to progress.
She also endorses a fever yesterday but no chills. Denies any
nausea or vomitting. States she had a normal BM today but the
pain, described ascontinuous and crampy in the suprapubic
region, has persisted.
Past Medical History:
1. Idiopathic intracranial hypertension (Pseudotumor cerbri).
Continues to befollowed at ___.
___, stable on ___. No vision OD.
2. Hyperlipidemia. Now on simvastatin 40 mg.
3. Depression/anxiety. Doing well on citalopram.
4. Multiple nevi. Benign biopsies ___.
Social History:
___
Family History:
Father deceased w/ lung CA
Physical Exam:
PHYSICAL EXAMINATION: upon admission ___
Temp: 99.7 HR: 102 BP: 134/74 Resp: 16 O(2)Sat: 98 Normal
Constitutional: Uncomfortable. Non-toxic
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft. dIffuse lower abdominal TTP with voluntary
guarding
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Physical examination upon discharge: ___
t=98.6, hr=87, bp=123/71,rr=19, 99% room air
General: NAD, skin warm and dry
CV: ns1, s2, -s3 -s4
LUNGS: clear
ABDOMEN: soft, mild tenderness RLQ, no rebound
EXT: no calf tenderness bil., no pedal edema bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 05:11AM BLOOD WBC-11.0 RBC-3.98* Hgb-12.3 Hct-35.6*
MCV-90 MCH-30.9 MCHC-34.5 RDW-13.0 Plt ___
___ 06:03AM BLOOD WBC-11.8* RBC-4.05* Hgb-12.7 Hct-36.6
MCV-90 MCH-31.4 MCHC-34.8 RDW-13.1 Plt ___
___ 02:20PM BLOOD WBC-15.3*# RBC-4.43 Hgb-13.8 Hct-39.4
MCV-89 MCH-31.2 MCHC-35.1* RDW-13.0 Plt ___
___ 02:20PM BLOOD Neuts-89.1* Lymphs-8.1* Monos-2.3 Eos-0.3
Baso-0.2
___ 05:11AM BLOOD Plt ___
___ 05:38AM BLOOD Glucose-118* UreaN-5* Creat-0.7 Na-143
K-4.1 Cl-112* HCO3-19* AnGap-16
___ 02:20PM BLOOD Glucose-127* UreaN-22* Creat-0.9 Na-136
K-3.2* Cl-100 HCO3-18* AnGap-21*
___ 02:20PM BLOOD ALT-20 AST-18 AlkPhos-110* TotBili-0.6
___ 05:38AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.1
___ 02:42PM BLOOD Lactate-1.7
___: cat scan of abdomen and pelvis:
1. Complicated acute sigmoid diverticulitis including small
area of
ill-defined fluid and gas bubbles in addition to secondary
inflammation along adjacent course of the ileum.
Thin enhancing lines between the distal ileum and sigmoid may be
due to
inflammatory hyperemia but the possibility that very early sinus
tracts may be starting to form is not excluded by this study.
Also, given wall thickening along the affected portion of the
sigmoid,
although the etiology is likely inflammatory, follow-up
colonoscopy should be considered if not recently performed.
2. Fatty infiltration of the liver.
Medications on Admission:
ACETAZOLAMIDE [DIAMOX SEQUELS] - Diamox Sequels 500 mg
capsule,extended release. 1 capsule(s) by mouth once a day -
(Prescribed by Other Provider)
CITALOPRAM - citalopram 40 mg tablet. TAKE ___ TABLET BY MOUTH
ONCE A DAY
SIMVASTATIN - simvastatin 40 mg tablet. TAKE 1 TABLET BY MOUTH
EVERY DAY
Medications - OTC
ASPIRIN - aspirin 81 mg tablet. 1 Tablet(s) by mouth once a day
MULTIVITAMIN [MULTIPLE VITAMINS] - Dosage uncertain - (___)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. AcetaZOLamide S.R. 500 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Ciprofloxacin HCl 500 mg PO Q12H
last dose ___
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*26 Tablet Refills:*0
5. Citalopram 20 mg PO DAILY
6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*20 Tablet Refills:*0
7. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
last dose ___
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*39 Tablet Refills:*0
8. Simvastatin 40 mg PO QPM
9. 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
10. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT OF THE ABDOMEN AND PELVIS
INDICATION: Abdominal pain, diarrhea, and leukocytosis.
TECHNIQUE: Multidetector CT images of the abdomen pelvis were obtained with
intravenous contrast. Sagittal and coronal reformations were also performed.
DOSE: 795.7 mGy-cm.
COMPARISON: None.
FINDINGS:
Aside from minor dependent changes, the visualized lung bases appear clear.
The liver is hypodense consistent with fatty infiltration. There is no biliary
dilatation. The gallbladder, pancreas, and adrenal glands appear within normal
limits. A simple cystic structure in the spleen which measures up to 29 x 22
mm in axial ___ is doubtful in clinical significance. The kidneys
appear within normal limits.
The stomach is nondistended. Proximal small bowel appears within normal
limits. There is marked inflammatory change about diverticula along the lower
sigmoid. In the vicinity there is an area of ill-defined fluid spanning over
about 3 cm in the coronal plane but only up to 1.8 cm enter anteroposteriorly.
Its represents potentially the very beginnings of abscess formation but does
not represent a very well-defined organized collection at this point. The
fluid abuts the distal ileum, which shows wall thickening suggesting secondary
inflammatory change. Small bubbles within the fluid suggest perforation of
the sigmoid with minimal regional free air. There is no distal free air. Thin
enhancing lines span the interval between the sigmoid and distal ileum with no
definite open tracts. Along the region of sigmoid inflammation, the wall is
mildly thickened over a fairly long segment.
The uterus is bulky, probably reflecting fibroids. Adnexa are unremarkable.
Distal ureters and bladder appear within normal limits. There is no
lymphadenopathy or ascites. Major mesenteric arteries and veins appear patent.
There no suspicious lytic or blastic bone lesions.
IMPRESSION:
1. Complicated acute sigmoid diverticulitis including small area of
ill-defined fluid and gas bubbles in addition to secondary inflammation along
adjacent course of the ileum.
Thin enhancing lines between the distal ileum and sigmoid may be due to
inflammatory hyperemia but the possibility that very early sinus tracts may be
starting to form is not excluded by this study.
Also, given wall thickening along the affected portion of the sigmoid,
although the etiology is likely inflammatory, follow-up colonoscopy should be
considered if not recently performed.
2. Fatty infiltration of the liver.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 99.7
heartrate: 102.0
resprate: 16.0
o2sat: 98.0
sbp: 134.0
dbp: 74.0
level of pain: 8
level of acuity: 3.0 | The patient was admitted to the hospital with right lower
quadrant abdominal pain. Upon admission, the patient was made
NPO, given intravenous fluids, and underwent imaging. Cat scan
imaging showed acute sigmoid diverticulitis. The patient was
started on a course of ciprofloxacin and flagyl. She underwent
serial abdominal examinations. Her white blood cell count was
closely monitored. She had return of bowel function on HD # 2
and was started on clear liquids. She advanced to a regular
diet by HD #5. The patient was discharged home on HD #5 in
stable condition. She was instructed to complete a 14 day
course of ciprofloxacin and flagyl. In addition to this, she was
informed of the need for a repeat colonoscopy in ___ weeks. An
appointment was made with Dr. ___ follow-up in the acute
care clinic.
repeat colonoscopy in ___ weeks
US for evaluation of "bulky" uterus |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Motrin / lisinopril / spironolactone
Attending: ___.
Chief Complaint:
right ankle pain
Major Surgical or Invasive Procedure:
___ ORIF Right ankle fracture
___: ruptured open globe repair left eye
History of Present Illness:
___ year old male with h/o CKD BPH HTN cerebral palsy with left
sided deficits here after a fall. Patient reports fall in the
bathroom today in which he
tripped over something falling down onto his buttocks had
head strike without LOC. Reports immediate pain to right
ankle. He is complaining of pain and decreased vision from
his left eye as well as clear fluid drainage. No
anticoagulation. He denies any nausea vomiting abdominal
pain fevers or chills. He was able to crawl over to the bed
and pull on his emergency call bell and EMS was called and
he was transported here
Past Medical History:
- Cerebral palsy with mild cognitive impairment
- Mild dementia
- BPH
- Hypertension
- SVT
- Depression
Social History:
___
Family History:
No family history of early coronary artery disease, sudden
cardiac death, or early cardiomyopathy.
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 97 HR: 66 BP: 156/68 Resp: 16 O(2)Sat: 96 Normal
Constitutional: uncomfortable
HEENT: left eye with watery discharge, corneal clouding, no
vision in affected eye
c collar in place
Chest: no chest wall tenderness, Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Extr/Back: left ankle with obvious deformity with skin
tenting, no laceration, intact distal sensation pulses and
perfusion, extremities otherwise with full painless ROm and
no bony tenderness
Skin: Warm and dry, No rash
Neuro: Speech fluent, GCS 15
Psych: Normal mentation, Normal mood
___: No petechiae
Physical examination upon discharge: ___:
98.8 hr=53, bp=151/76, rr=18 94% room air
GENERAL: resting in bed, skin warm and dry, left eye patch
CV: ns1, s2
LUNGS: clear
ABDOMEN: soft, non-tender, no rebound, no guarding
EXT: splint right leg with ace wrap, + dp, toes warm
NEURO: oriented x 2 to name and place, follows commands
Pertinent Results:
___ 10:40AM BLOOD WBC-7.7 RBC-3.90* Hgb-12.8* Hct-38.5*
MCV-99* MCH-32.8* MCHC-33.2 RDW-12.0 RDWSD-43.8 Plt ___
___ 01:54AM BLOOD WBC-9.8 RBC-3.58* Hgb-11.7* Hct-35.1*
MCV-98 MCH-32.7* MCHC-33.3 RDW-11.9 RDWSD-43.0 Plt ___
___ 01:45PM BLOOD WBC-13.9* RBC-4.53* Hgb-14.9 Hct-43.0
MCV-95 MCH-32.9* MCHC-34.7 RDW-12.7 RDWSD-43.8 Plt ___
___ 01:45PM BLOOD Neuts-82.9* Lymphs-8.7* Monos-7.0
Eos-0.5* Baso-0.4 Im ___ AbsNeut-11.56* AbsLymp-1.21
AbsMono-0.97* AbsEos-0.07 AbsBaso-0.05
___ 10:40AM BLOOD Plt ___
___ 10:40AM BLOOD Glucose-95 UreaN-16 Creat-0.9 Na-143
K-4.5 Cl-106 HCO3-25 AnGap-12
___ 01:54AM BLOOD Glucose-132* UreaN-29* Creat-1.4* Na-137
K-3.7 Cl-102 HCO3-26 AnGap-9*
___ 01:45PM BLOOD Glucose-106* UreaN-23* Creat-1.2 Na-135
K-7.5* Cl-105 HCO3-19* AnGap-11
___ 01:54AM BLOOD cTropnT-0.45*
___ 09:21PM BLOOD cTropnT-0.41*
___ 04:42PM BLOOD cTropnT-0.03*
___ 10:40AM BLOOD Calcium-8.8 Phos-2.1* Mg-1.8
___ 05:05PM BLOOD K-3.8
___: CT of c-spine:
1. Trace grade 1 anterolisthesis of C7 on T1 is most likely
degenerative in etiology.
2. No fracture.
3. Multilevel degenerative changes of the cervical spine are
most severe at the C5-6 and C6-7 levels, notable for severe
spinal canal narrowing and severe bilateral neural foraminal
stenosis, progressed from ___. If clinical concern
for spinal cord injury, MRI is more sensitive.
___: ct head:
. No acute intracranial pathology.
2. Subtle irregularity/buckling of the medial posterior wall of
the left
globe.
3. Left parietal and frontal lobe encephalomalacia.
___: ankle:
1. Displaced distal fibular fracture.
2. The talus is a laterally displaced in relation to the distal
tibia.
Significantly widened and disrupted medial ankle mortise.
3. Probable posterior malleolar fracture.
___: right ankle:
Improved alignment of the previously seen fracture dislocation
at the ankle.
Persistent widening of the medial clear space in association
with the distal fibular fracture consistent with an unstable
injury.
___: right ankle:
Fluoroscopic documentation of ankle fixation. No radiologist
was present.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Finasteride 5 mg PO DAILY
4. LORazepam 0.5 mg PO DAILY:PRN anxiety
5. Metoprolol Succinate XL 75 mg PO DAILY
6. Sertraline 50 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
9. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QHS
10. Vitamin D 400 UNIT PO DAILY
11. Docusate Sodium 100 mg PO DAILY
12. Senna 17.2 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
2. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID
3. Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl LEFT EYE
BID
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
5. Ciprofloxacin 0.3% Ophth Soln 1 DROP LEFT EYE QID
6. Heparin 5000 UNIT SC BID
7. Lidocaine 5% Patch 1 PTCH TD ONCE Duration: 1 Dose
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
10. Ramelteon 8 mg PO QPM
11. Senna 8.6 mg PO BID
12. Sertraline 75 mg PO DAILY
13. amLODIPine 5 mg PO DAILY
14. Atorvastatin 10 mg PO QPM
15. Docusate Sodium 100 mg PO DAILY
16. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QHS
17. Finasteride 5 mg PO DAILY
18. LORazepam 0.5 mg PO DAILY:PRN anxiety
19. Metoprolol Succinate XL 75 mg PO DAILY
20. Senna 8.6 mg PO BID:PRN Constipation - First Line
21. Tamsulosin 0.4 mg PO QHS
22. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Open globe injury, left eye - Zone ___
Right Ankle Fracture
Unstable supraventricular tachycardia
urinary retention
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: History: ___ with s/p fall // ?traumatic injury
TECHNIQUE: AP chest
COMPARISON: Chest radiographs from ___.
FINDINGS:
Patient is rotated to the right. The cardiomediastinal and hilar contours are
normal. No focal consolidations are seen. There is no pulmonary edema or
pleural abnormality.
IMPRESSION:
No acute intrathoracic process or acute displaced fracture seen.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: History: ___ with s/p fall // ?traumatic injury
?traumatic injury
TECHNIQUE: Right ankle three views.
COMPARISON: None.
FINDINGS:
Right ankle fracture-dislocation. There is in oblique fracture involving the
distal fibula with distal bone fragment displaced laterally and posteriorly.
There is likely posterior malleolar fracture. There is significant widening
intraoperative the medial ankle mortise in the talus laterally displaced in
relation to the distal tibia. There is significant soft tissue swelling
overlying the right ankle.
IMPRESSION:
1. Displaced distal fibular fracture.
2. The talus is a laterally displaced in relation to the distal tibia.
Significantly widened and disrupted medial ankle mortise.
3. Probable posterior malleolar fracture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with s/p fall // ?traumatic injury
TECHNIQUE: Contiguous axial images of the brain and orbits were obtained
without contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Spiral Acquisition 1.4 s, 11.0 cm; CTDIvol = 24.3 mGy (Head) DLP = 267.8
mGy-cm.
Total DLP (Head) = 1,171 mGy-cm.
COMPARISON: CT head dated ___.
FINDINGS:
There is no evidence of fracture, infarction,hemorrhage,edema, or mass effect.
Prominence of the ventricles and sulci is consistent with involutional
changes. There is encephalomalacia involving the left frontal and parietal
lobe. There is mild periventricular white matter disease. There is a chronic
lacunar infarct involving the left subinsular region.
There is a mucous cyst in the right maxillary sinus. There is mild mucosal
thickening involving bilateral ethmoid air cells. The visualized portion of
the mastoid air cells, and middle ear cavities are clear.
There is mild irregularity of the medial posterior wall of the left globe, new
since the prior study from ___. There is no evidence of
retrobulbar hematoma. The extraocular muscles and optic nerves are intact.
Bilateral lenses are intact.
IMPRESSION:
1. No acute intracranial pathology.
2. Subtle irregularity/buckling of the medial posterior wall of the left
globe.
3. Left parietal and frontal lobe encephalomalacia.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with s/p fall // ?traumatic injury
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.2 s, 20.3 cm; CTDIvol = 22.8 mGy (Body) DLP = 462.7
mGy-cm.
Total DLP (Body) = 463 mGy-cm.
COMPARISON: CT C-spine from ___.
FINDINGS:
There is trace grade 1 anterolisthesis of C7 on T1, most likely degenerative
in etiology. Alignment is otherwise anatomic. No fractures are identified.
Multilevel degenerative changes are seen, most extensive at C5-6 and C6-7 and
notable for severe intervertebral disc disease, severe spinal canal narrowing
secondary to posterior osteophytes and ossification of the posterior
longitudinal ligament, and severe bilateral neural foraminal stenosis
secondary to uncovertebral and facet degenerative change.There is no
prevertebral edema.
The thyroid is unremarkable. A small calcified granuloma is seen in the left
lung apex. No pathologically enlarged cervical lymph nodes are seen.
IMPRESSION:
1. Trace grade 1 anterolisthesis of C7 on T1 is most likely degenerative in
etiology.
2. No fracture.
3. Multilevel degenerative changes of the cervical spine are most severe at
the C5-6 and C6-7 levels, notable for severe spinal canal narrowing and severe
bilateral neural foraminal stenosis, progressed from ___. If
clinical concern for spinal cord injury, MRI is more sensitive.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: ___ year old man with R distal fibular fracture s/p closed
reduction // re-evaluate R distal fibular fracture
TECHNIQUE: Three views right ankle
COMPARISON: Right ankle radiographs ___
FINDINGS:
Fine bony detail is obscured by an overlying cast. There has been interval
reduction of the previously seen ankle dislocation however there is persistent
subluxation with widening of the medial clear space consistent with small bony
fragments consistent with severe ligamentous disruption. An oblique fracture
through the distal fibula extends the level of the syndesmosis. This is
laterally displaced by approximately 6 mm. No additional fractures seen
IMPRESSION:
Improved alignment of the previously seen fracture dislocation at the ankle.
Persistent widening of the medial clear space in association with the distal
fibular fracture consistent with an unstable injury.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: RT ANKLE FX.ORIF
IMPRESSION:
Fluoroscopic documentation of ankle fixation. No radiologist was present.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Unsp physeal fracture of lower end of right fibula, init, Fall on same level, unspecified, initial encounter
temperature: 97.0
heartrate: 66.0
resprate: 16.0
o2sat: 96.0
sbp: 156.0
dbp: 68.0
level of pain: 5
level of acuity: 3.0 | ___ year old male who presented to the emergency room after a
fall resulting in a right ankle injury. The patient attempted
to walk and fell hitting his left eye on the edge of a chair
resulting in a left globe injury. Upon admission, the patient
was made NPO, and given intravenous fluids. Because of his
injuries, the Orthopedic and Ophtholomogy services were
consulted.
Because of the open left globe injury, the patient was taken to
the operating room by Ophtholomolgy where he underwent left
globe repair. A patch was applied to the eye and eye drops
instilled. The patient underwent a follow-up exam on ___.
On HD #3, the patient was taken to the operating room with the
Orthopedic service where he underwent an ORIF of a right ankle
fracture. The operative course was stable with a 50cc blood
loss. The patient was extubated after the procedure and
monitored in the recovery room. Activity restrictions were
outlined which included partial weight-bearing (50%) in the
right lower extremity with bilateral upper extremity assist.
Physical therapy was involved in mobilizing the patient.
During the patient's hospitalization, he experienced urinary
retention and required placement of a foley catheter. His
urinary output has remained stable. The patient will require
follow-up with his primary care provider or ___ for
removal of the foley. The patient also experienced a bout of
narrow complex tachycardia with stable vital signs. The
cardiology service was consulted and the patient underwent
carotid massage which corrected the rapid heart rate. The
patient's metoprolol was resumed and no further episodes of
tachycardia occurred.
The Geriatric service provided input regarding delirium which
the patient exhibited during his hospitalization.
In preparation for discharge, the patient was evaluated by
physical therapy and recommendations were made for discharge to
a rehabilitation facility. The patient was discharged on HD #7.
His vital signs were stable and he was afebrile. He was
tolerating a regular diet and voiding via the foley catheter. A
follow-up appointment was made in the ___ clinic. He has
a follow-up appointment with Ophtholomololy on ___. Discharge
instructions were reviewed and questions answered. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ejected driver, high speed MVC
Major Surgical or Invasive Procedure:
Left forearm open reduction and internal fixation
History of Present Illness:
___ year old male S/P MVC. Patient was ejected driver, high speed
MVC, found 20 feet from car. Seen at OSH had pan scan
demonstrating small L PTX, L clavicle fx, L ___ rib fx, R ___
rib fx, t5/t7 vertebral body fractures. CT head, c-spine
negative, abd negative. Received ancef. Tetanus UTD.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
Upon arival:
General: laying in bed, mild distress
HEENT: Large left forehead laceration
Chest: no respiratory distress, multiple sites of tenderness to
palpation
Vascular: Radial, DP and ___ pulses palpable bilaterally.
Ext: Left upper extremity with some superficial abrasions, not
in
communcation with fracture. No tenting of the skin. Compartments
soft. Right upper and bilateral lower extremities with
abrasions,
no other sites ___ deformity or point ___ tenderness to
palpation.
Neuro: strength and sensation intact throughout including distal
to injury in radial/ulnar/median distribution.
At discharge:
General: comfortable, TLSO brace in place
Chest: no respiratory distress
CV: RRR
Left upper ext: orthoplast splint in place, compartments soft,
neurovascularly intact
Pertinent Results:
___ 08:00AM ___ 08:00AM ___ PTT-28.1 ___
___ 08:00AM PLT COUNT-255
___ 08:00AM WBC-17.2* RBC-5.32 HGB-16.0 HCT-45.4 MCV-85
MCH-30.1 MCHC-35.3* RDW-12.7
___ 08:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:00AM LIPASE-17
___ 08:00AM estGFR-Using this
___ 08:00AM UREA N-24* CREAT-1.0
___ 08:20AM freeCa-1.16
___ 08:20AM HGB-16.1 calcHCT-48 O2 SAT-79 CARBOXYHB-2 MET
HGB-0
___ 08:20AM GLUCOSE-162* LACTATE-3.2* NA+-141 K+-3.9
CL--105
___ 08:20AM PH-7.30* COMMENTS-GREEN TOP
___ 05:00PM PLT COUNT-198
___ 05:00PM WBC-11.3* RBC-4.67 HGB-14.3 HCT-40.6 MCV-87
MCH-30.6 MCHC-35.2* RDW-13.3
___ 05:00PM CALCIUM-8.3* MAGNESIUM-1.6
___ 05:00PM CALCIUM-8.3* MAGNESIUM-1.6
___ 05:00PM GLUCOSE-130* UREA N-21* CREAT-1.0 SODIUM-139
POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-25 ANION GAP-12
Medications on Admission:
Denies
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
every six (6) hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 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 #*30 Tablet Refills:*0
4. Cyclobenzaprine 10 mg PO BID:PRN muscle spasm
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bilateral 1st rib fractures
Left ___ rib fractures
Left clavicle/scapula and left radius fractures
T5&7 spine compression tractures
Small left pneumothorax
Left forehead laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Trauma.
COMPARISON: Outside hospital CT torso ___.
FINDINGS: The cardiomediastinal and hilar contours are unremarkable. There
is no pleural effusion or pneumothorax. The left upper lobe opacity is again
seen, consistent with contusion. The right lung is relatively clear. No
nondisplaced rib fractures are identified.
IMPRESSION: Left upper lobe contusion.
Radiology Report
HISTORY: ___ man status post motor vehicle collision and ejection,
transferred from outside hospital with bilateral 1st rib fractures, evaluate
for vascular injuries.
COMPARISON: None available.
TECHNIQUE: Contiguous axial images were obtained through the neck during the
dynamic infusion also IV contrast. Curved reformats, volume-rendered
reformats, and CTA maximum intensity projection images were generated on an
independent work station.
Total Exam DLP: 566mGy-cm
CTDIvol:16mGy
FINDINGS:
There is no evidence of vascular injury of the vertebral or carotid arteries.
The left vertebral artery however, comes in very close proximity to the
fracture fragment of the left 1st rib. There is a hypoplastic left vertebral
artery, which is likely congenital. There is no carotid stenosis by NASCET
criteria.
There are bilateral 1st rib fractures. In addition, there are left ___,
and ___ posterior rib fractures. There is a left scapular and left clavicular
fracture as well. The cervical spine maintains its alignment. There are no
visualized cervical spine fractures.
There is opacification of the left lung apex, which in the setting of trauma
and multiple rib fractures is concerning for pulmonary contusion. In
addition, within the left lung apex there are also areas of ground-glass
opacification and thickened septa. Just before the tracheal bifurcation,
there are aerosolized secretions which may represent normal respiratory
secretions or aspiration. The thyroid is unremarkable. The include paranasal
sinuses and mastiod air cells are clear.
IMPRESSION:
1. No vascular injury of the vertebral or carotid arteries although the left
vertebral artery is in very close proximity to the bony fragment of the left
1st rib fracture.
2. Multiple fractures including bilateral 1st rib fractures, left ___ and
___ posterior rib fractures, left scapular, and left clavicular fractures.
Maintained alignment of the cervical spine without visualized fracture.
2. Opacification in the left lung apex which is concerning for pulmonary
contusion in this clinical setting. In addition, aerosolized secretions in
the trachea may represent aspiration or normal pulmonary secretions.
Radiology Report
STUDY: MRI of the thoracic spine.
CLINICAL INDICATION: ___ man, status post motor vehicle accident,
evaluate for ligamentous injury.
COMPARISON: CTA of the neck dated ___ no prior examinations
of the thoracic spine are available on PACS at the time of this
interpretation.
TECHNIQUE: Sagittal T1, T2 and sagittal STIR sequences were obtained
throughout the thoracic spine, axial T2-weighted images were also obtained.
FINDINGS: The alignment of the thoracic spine appears maintained, multiple
levels with high signal intensity are demonstrated on the STIR sequence
involving the superior endplates at the level of T4, T5 and T7 with minimal
height loss of T4 and T5 and approximately 20% of loss at the level of T7,
likely consistent with acute compression fractures. There is no evidence of
bony retropulsion or spinal cord signal abnormality, no epidural collection is
seen. Additionally, there is mild posterior disc protrusion at the level of
T6/T7, causing anterior thecal sac deformity without significant stenosis.
There is no evidence of ligamentous injury.
IMPRESSION: Increased STIR signal at the level of T4, T5 and T7 involving the
superior endplates, likely consistent with acute compression fractures with no
evidence of retropulsion, there is no evidence of abnormal signal throughout
the thoracic spinal cord to indicate spinal cord edema or cord expansion.
There is no evidence of epidural collection or ligamentous injury. Disc
degenerative changes are noted at T6/T7, consistent with posterior disc
protrusion, indenting the ventral thecal sac without significant stenosis.
A preliminary report was discussed via phone with Dr. ___ at the time of
the discovery of these findings at 00:51 hours, by Dr. ___ on
___.
Radiology Report
INDICATION: Left forearm fracture.
COMPARISON: ___.
Two fluoroscopic spot images of the left forearm were obtained and demonstrate
plate and screw fixation of the proximal radial fracture. There is improved
alignment. The total fluoroscopic time is 2.7 seconds. For further details,
please see the intraoperative report.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Small left pneumothorax, evaluation.
COMPARISON: Chest x-ray from ___.
FINDINGS: Small and overall unchanged apicolateral left-sided pleural
effusion without evidence of enlargement or other contour abnormalities at the
level of the aortic arch. Currently, no left-sided pneumothorax is seen. The
lung volumes remain low. Normal size of the cardiac silhouette. No pulmonary
edema, no pneumonia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P MVC TRANS
Diagnosed with FRACTURE FIVE RIBS-CLOSE, FX RADIUS SHAFT-CLOSED, FX DORSAL VERTEBRA-CLOSE, FX CLAVICLE NOS-CLOSED, FX SCAPULA NOS-CLOSED, OPEN WOUND OF SCALP, MV COLLISION NOS-DRIVER
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 the acute care surgery service
following a motor vehicle collision on ___ with HPI as
stated above. He was diagnosed with left rib ___ fractures,
left clavicle and scapula fractures, and a left radial fracture,
as well as T5&7 compression fractures, a small pneumothorax, and
a deep left forehead laceration. He was taken to the OR on the
same day for ORIF of the radial fracture. He was placed in a
TLSO brace prior to discharge for T5 and T7 compression
fractures. His forehead laceration was sutured. The
pneumothorax was treated non-operatively.
Pain Control: The patient received IV pain medication with good
effect and adequate pain control. When tolerating oral intake,
the patient was transitioned to oral pain medications.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: The patient was given IV fluids until tolerating oral
intake. His diet was advanced when appropriate, which was
tolerated well. She was also started on a bowel regimen to
encourage bowel movement. Intake and output were closely
monitored.
.
ID: The patient's temperature was closely watched for signs of
infection.
.
Prophylaxis: The patient received subcutaneous heparin 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
with stable vital signs, tolerating a regular diet, ambulating
in the TLSO brace, voiding without assistance, and pain was well
controlled. He was discharged in stable condition and with
appropriate prescriptions, knowledge of warning signs for which
to be on alert, and instructions to follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L abd pain
Major Surgical or Invasive Procedure:
L ureteral stent placement ___
History of Present Illness:
___ male with a PMH of Crohn's disease, abdominal hernia
repairs, recurrent nephrolithiasis and other issues who presents
now with 24 hours of abdominal pain associated with nausea and
retching, along with 5 days of decreased bowel movements.
Patient denies any fevers black or bloody stools. Patient last
passed flatus yesterday and has not today. Patient last had a
bowel movement yesterday, which he reports was diarrhea. He has
not had difficulty urinating, dysuria, or frequency. He has not
had CP/SOB/cough and reports adequate PO intake. He called his
surgeon's office when his abdominal pain worsened, as he
wondered if his symptoms were due to another hernia, and his
surgeon advised him to go to the ED.
In the ED, initial VS were 98.4 61 150/68 16 97% RA. Labs were
notable for WBC 12.8 w/ 87% PMNs, BUN/Cr ___ (baseline Cr
1.0), otherwise normal lytes and LFTs, Lactate 1.8, CRP 53.9,
UAw/ 180 RBCs, 6 WBCs and few bacteria, and INR 1.2. CT abd/pel
showed moderate L hydroureteronephrosis w/ an obstructing 10 mm
stone and some small perinephric fluid suggestive of forniceal
rupture, multiple non-obstructing stones in the L kidney, as
well
as acute-on-chronic inflammation in the distal and terminal
ileum consistent with crohn's disease. Urine and blood cultures
were obtained, and a foley catheter was placed. GI was
consulted and recommended ruling out C. diff and starting
antibiotics. Urology was consulted and recommended taking him
to the OR for cystoscopy and L ureteral stent placement, which
was performed. Prior to going to the OR, in the ED the patient
received 3L IVF, ondansetron, acetaminophen, morphine, a
belladonna suppository,and was started on
ciprofloxacin/metronidazole.
An L-sided ureteral stent was successfully placed in the OR, and
a foley catheter was replaced post-procedure. On arrival to the
floor, the patient was comfortable and had no complaints apart
from discomfort from his foley catheter with any movement.
ROS: A 10-point review of systems was performed and was negative
with the exception of those systems noted in the HPI.
Past Medical History:
-Recurrent nephrolithiasis requiring lithotripsy, passes stones
approx. twice a year, follows w/ Dr. ___ disease, Dx in ___, follows w/ Dr. ___
-? Rheumatic fever - was told that he would need abx prophylaxis
prior to dental procedures or operations. Unable to give
details.
-B12 deficiency
-Bilateral inguinal herniorraphies
-Carpal tunnel release L hand
-Depression
-HLD
-Ventral herniorraphy
-Essential Tremor
-BPH s/p TURP in ___
Social History:
___
Family History:
Mother - died of a stroke at age ___
Father - died of lupus complications at age ___
___ younger brothers - reportedly healthy
Physical Exam:
ADMISSION EXAM
VITALS: 98.0 PO 130 / 70 L Lying 52 18 92 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air
movementbilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation. Foley
___ in place with bloody urine draining.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
24 HR Data (last updated ___ @ 1413)
Temp: 98.1 (Tm 99.2), BP: 133/66 (90-133/48-70), HR: 49 (49-54),
RR: 18 (___), O2 sat: 92% (90-93), O2 delivery: Ra
GENERAL: NAD
EYES: PERRL, anicteric sclerae
ENT: OP clear
CV: RRR, nl S1, S2, no M/R/G, no JVD
RESP: CTAB, no crackles, wheezes, or rhonchi
GI: + BS, soft, NT, ND, no rebound/guarding, no HSM
GU: No suprapubic fullness or tenderness to palpation
SKIN: No rashes or ulcerations noted
NEURO: AOx3, CN II-XII intact, ___ strength in all extremities,
sensation grossly intact throughout, gait testing deferred
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 12:30PM WBC-12.8* RBC-5.55 HGB-16.1 HCT-47.8 MCV-86
MCH-29.0 MCHC-33.7 RDW-13.7 RDWSD-43.6
___ 12:30PM PLT COUNT-225
___ 12:30PM NEUTS-87.4* LYMPHS-4.9* MONOS-6.6 EOS-0.2*
BASOS-0.3 IM ___ AbsNeut-11.15*# AbsLymp-0.63*
AbsMono-0.84* AbsEos-0.03* AbsBaso-0.04
___ 12:30PM ALBUMIN-3.8
___ 12:30PM LIPASE-18
___ 12:30PM ALT(SGPT)-6 AST(SGOT)-12 ALK PHOS-107 TOT
BILI-0.8
___ 12:30PM GLUCOSE-108* UREA N-16 CREAT-1.5* SODIUM-139
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-27 ANION GAP-13
___ 12:45PM LACTATE-1.8
___ 04:05PM CRP-53.9*
___ 04:35PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 07:30AM BLOOD WBC-8.9 RBC-4.29* Hgb-12.5* Hct-38.0*
MCV-89 MCH-29.1 MCHC-32.9 RDW-13.8 RDWSD-44.6 Plt ___
___ 07:30AM BLOOD Glucose-84 UreaN-14 Creat-1.2 Na-142
K-4.0 Cl-103 HCO3-24 AnGap-15
CT Abdomen/pelvis ___:
IMPRESSION:
1. Moderate left-sided hydroureteronephrosis with an obstructing
10 mm stone in the midportion of the left ureter. Small amount
of perinephric fluid may represent an element of forniceal
rupture.
2. Multiple other non-obstructing renal calculi are seen within
the left kidney.
3. Evidence of active on chronic inflammation within the distal
and terminal ileum, compatible with patient's known history of
Crohn's. There is no evidence of obstruction, abscess, or
fistula. Similar in appearance as compared to the prior study.
4. Focal area of dissection in the proximal right common iliac
artery, unchanged.
KUB ___:
There is a left kidney that stone measures 1.8 cm and projects
over the lower pole.
There is no evidence of bowel obstruction or ileus.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. colestipol 2 g oral DAILY
3. potassium citrate 10 mEq (1,080 mg) oral BID
4. Aspirin 81 mg PO DAILY
5. Calcium Carbonate 500 mg PO QID:PRN indegestion
6. Vitamin D 800 UNIT PO DAILY
7. Cyanocobalamin 250 mcg PO DAILY
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY:PRN constipatoin
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*10 Packet Refills:*0
2. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [Senna Laxative] 8.6 mg 1 tablet by mouth twice a
day Disp #*30 Tablet Refills:*0
3. Allopurinol ___ mg PO DAILY
4. Calcium Carbonate 500 mg PO QID:PRN indegestion
5. Cyanocobalamin 250 mcg PO DAILY
6. potassium citrate 10 mEq (1,080 mg) oral BID
7. Vitamin D 800 UNIT PO DAILY
8. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until told to do so by your primary care
doctor.
9. HELD- colestipol 2 g oral DAILY This medication was held. Do
not restart colestipol until you are having normal bowel
movements.
Discharge Disposition:
Home
Discharge Diagnosis:
L ureteral stone with obstruction
___
Crohn's disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with crohns and obstructing nephrolithiasis with
abd distension// ? ileus
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Comparison includes CT abdomen and pelvis done on ___
and abdominal x-ray done and ___.
FINDINGS:
There is a kidney stone that measures 1.8 cm and projects over the lower pole
of the left renal shadow. There are no other radiopaque kidney stones
visualized projecting over the bilateral kidneys, ureters and bladder. There
is cluster of radiopaque densities in the right upper quadrant consistent with
multiple cholelithiasis better seen on CT abdomen and pelvis done on ___. There are no abnormally dilated loops of large or small bowel.
There is no evidence of bowel obstruction.
There is no free intraperitoneal air.
Left-sided double-J stent is appropriately placed.
IMPRESSION:
There is a left kidney that stone measures 1.8 cm and projects over the lower
pole.
There is no evidence of bowel obstruction or ileus.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Lower abdominal pain
Diagnosed with Hydronephrosis with renal and ureteral calculous obstruction
temperature: 98.4
heartrate: 61.0
resprate: 16.0
o2sat: 97.0
sbp: 150.0
dbp: 68.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ is a ___ male with a PMH of Crohn's disease
(not requiring any targeted therapy, only on colestipol),
abdominal hernia repairs, recurrent nephrolithiasis and other
issues admitted with an obstructing L ureteral stone with ___,
complicated by ileus, but with evidence of active inflammation
on CT abdomen/pelvis concerning for Crohn's flare. Exam and
imaging was not, in the end concerning for ileus. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anasarca ___ nephrotic syndrome and membranous nephropathy
Dyspnea on exertion
Prostate cancer
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ male with sig PMHx of nephrotic
syndrome iso secondary membranous nephropathy ___ newly
diagnosed
prostate adenocarcinoma who was admitted to ___ for worsening
anasarca.
Pt was is his usual state of health until 4 months ago, when he
noticed progressively worsening edema, beginning in his ankles
to
all of his extremities. Over the past 1 week, he also began
noticing mild dyspnea on exertion and a dry cough. At baseline,
he could walk on flat surfaces, and now can only walk <100 ft.
He
has also had a worsening appetite and increased indigestion ___
abdominal bloating. He was seen by his PCP who started him on
Torsemide 100mg in ___, however his anasarca has not
improved.
He was seen again by his PCP who referred him to ___ for IV
diuresis.
On the floor, pt states he has persistent edema, dyspnea on
exertion, indigestion, and a nonproductive cough. He denies any
fevers, chills, lightheadedness, chest pain or pressure,
abdominal pain, n/v/d. He has occasional dysuria, urinary
frequency, and worsening hesitancy. He is able to maintain a
stream while using a urinal. He denies any orthopnea or PND.
Of note, he has noticed a new L medial malleolar wound that is
clean but appeared 2 weeks ago iso his worsening edema. He
states
it is starting to heal. He has not used anything topically to
treat the wound.
Exam notable for:
T97.5 HR61 BP137/82 RR16 SPO2 98% RA
Labs showed:
136 100 *27 88 AGap=12
------------------
4.6 24 *2.4
Ca: 7.3 Mg: 2.0 P: 4.0
3.9 *10.3 233
--------------
31.1
Alb: 1.4*
Lactate:2.0
UA: Sm bld, neg leuk, *600 prot, WBC 5, Bact none
Casts: Hyaline, rare mucous casts
Urine Cx: pnd
Blood Cx: pnd
Imaging showed:
CXR ___
IMPRESSION:
Increased small bilateral pleural effusions with bibasilar
atelectasis.
ECG:
PR 346 low voltage 1 PVC QTc 456
Received:
IV Furosemide 80mg X1
IV Albumin 25% (12.5g / 50mL) 12.5
Transfer VS were:
T97.8 HR59 BP166/85 RR18 SPO299% RA
Past Medical History:
Prostate cancer
Nephrotic syndrome
Membranous nephropathy
CKD
NPH
HTN
HFrEF
Varicose veins
L leg crush injury s/p surgical repair
Social History:
___
Family History:
-Cancer (breast, GI in sister and niece)
-HTN
Physical Exam:
ADMISSION EXAM:
==============================
VS: Baseline weight: 172 lbs Current Weight: 197.2 lbs
T97.3 BP 182 / 74 L Sitting HR 56 RR 20 SPO2 97 Ra
GENERAL: pleasant elderly AA male, sitting comfortably upright
in bed.
HEENT: MMM. EOMI. PEERLA. Oropharynx clear. Neck supple.
CARDIOVASCULAR: RRR. +S1/S2. ___ holosystolic murmur
at the right upper sternal border. No other murmurs, rubs or
gallops. +JVD to 10cm at 60 degrees. +HJR.
LUNGS: Good inspiratory effort. b/l crackles at the base.
ABDOMEN: Soft, +moderate distension ___ fluid, non tender. No
HSM.
EXTREMITIES: 3+ tense and pitting lower extremity edema b/l to
abdomen. 2+ pitting edema in arms b/l R>L. + 3cmX 1cm
superficial
wound over L medial malleolus without purulence.
NEUROLOGIC: CN2-12 grossly intact. A+OX3. sensation intact in UE
and ___ b/l to light touch. Full ROM and ___ strength in UE and
___. 2+ patellar reflexes.
DISCHARGE EXAM:
==================================
Vitals: 98.0 126/66 73 99 Ra
Wt: 160.49 lb (___)
General: sitting comfortably upright in bed
Mental status: awake, alert, and oriented
HEENT: MMM, EOMI grossly intact, PERRL
CV: RRR, NS1&S2, soft systolic murmur
Lungs: slight crackles at a left base, no wheezes or rhonchi. no
respiratory distress.
Abdomen: soft, mild distension, non-tender
Extremities: Trace pitting edema in lower extremities L> R.
Trace pitting edema in upper extremities bilaterally. Warm, well
perfused.
Neuro: Grossly intact. Moving all extremities antigravity.
Pertinent Results:
ADMISSION LABS:
====================================
___ 11:26AM BLOOD WBC-3.9* RBC-3.98* Hgb-10.3* Hct-31.1*
MCV-78* MCH-25.9* MCHC-33.1 RDW-17.9* RDWSD-50.8* Plt ___
___ 11:26AM BLOOD Neuts-47.8 ___ Monos-10.3 Eos-2.8
Baso-1.6* Im ___ AbsNeut-1.85# AbsLymp-1.44 AbsMono-0.40
AbsEos-0.11 AbsBaso-0.06
___ 11:26AM BLOOD Glucose-88 UreaN-27* Creat-2.4* Na-136
K-4.6 Cl-100 HCO3-24 AnGap-12
___ 11:26AM BLOOD Albumin-1.4* Calcium-7.3* Phos-4.0 Mg-2.0
___ 11:54AM BLOOD Lactate-2.0
Pertinent/Interval Labs:
=====================================
___ 08:15AM BLOOD LD(LDH)-408*
___ 08:15AM BLOOD Testost-180* SHBG-82* calcFT-21*
___ 08:15AM BLOOD PSA-10.2*
___ 11:54AM BLOOD Lactate-2.0
___ 11:26AM BLOOD Neuts-47.8 ___ Monos-10.3 Eos-2.8
Baso-1.6* Im ___ AbsNeut-1.85# AbsLymp-1.44 AbsMono-0.40
AbsEos-0.11 AbsBaso-0.06
___ 11:26AM BLOOD WBC-3.9* RBC-3.98* Hgb-10.3* Hct-31.1*
MCV-78* MCH-25.9* MCHC-33.1 RDW-17.9* RDWSD-50.8* Plt ___
___ 06:37AM BLOOD WBC-3.7* RBC-3.61* Hgb-9.3* Hct-27.6*
MCV-77* MCH-25.8* MCHC-33.7 RDW-17.4* RDWSD-48.7* Plt ___
___ 06:50AM BLOOD WBC-5.4 RBC-3.63* Hgb-9.4* Hct-28.0*
MCV-77* MCH-25.9* MCHC-33.6 RDW-17.6* RDWSD-49.5* Plt ___
___ 06:15AM BLOOD WBC-5.1 RBC-3.45* Hgb-8.8* Hct-26.1*
MCV-76* MCH-25.5* MCHC-33.7 RDW-17.3* RDWSD-46.8* Plt ___
___ 07:30PM BLOOD WBC-5.2 RBC-3.69* Hgb-9.3* Hct-28.2*
MCV-76* MCH-25.2* MCHC-33.0 RDW-17.2* RDWSD-48.0* Plt ___
___ 08:15AM BLOOD WBC-4.8 RBC-3.43* Hgb-8.7* Hct-25.6*
MCV-75* MCH-25.4* MCHC-34.0 RDW-17.1* RDWSD-46.2 Plt ___
___ 06:10AM BLOOD WBC-4.6 RBC-3.55* Hgb-9.1* Hct-26.6*
MCV-75* MCH-25.6* MCHC-34.2 RDW-17.2* RDWSD-46.8* Plt ___
___ 08:00AM BLOOD WBC-4.8 RBC-3.83* Hgb-9.6* Hct-29.0*
MCV-76* MCH-25.1* MCHC-33.1 RDW-17.2* RDWSD-47.2* Plt ___
___ 06:15AM BLOOD WBC-4.5 RBC-3.68* Hgb-9.4* Hct-27.7*
MCV-75* MCH-25.5* MCHC-33.9 RDW-17.2* RDWSD-47.4* Plt ___
___ 07:35AM BLOOD WBC-5.6 RBC-3.69* Hgb-9.6* Hct-27.6*
MCV-75* MCH-26.0 MCHC-34.8 RDW-17.1* RDWSD-45.8 Plt ___
___ 06:34AM BLOOD WBC-6.1 RBC-3.76* Hgb-9.6* Hct-28.0*
MCV-75* MCH-25.5* MCHC-34.3 RDW-17.1* RDWSD-45.8 Plt ___
___ 06:50AM BLOOD WBC-5.9 RBC-3.35* Hgb-8.5* Hct-25.4*
MCV-76* MCH-25.4* MCHC-33.5 RDW-17.2* RDWSD-46.4* Plt ___
___ 06:00PM BLOOD WBC-6.8 RBC-3.72* Hgb-9.5* Hct-28.3*
MCV-76* MCH-25.5* MCHC-33.6 RDW-17.3* RDWSD-48.0* Plt ___
___ 06:10AM BLOOD WBC-6.0 RBC-4.03* Hgb-10.3* Hct-30.2*
MCV-75* MCH-25.6* MCHC-34.1 RDW-17.2* RDWSD-46.1 Plt ___
___ 11:26AM BLOOD Glucose-88 UreaN-27* Creat-2.4* Na-136
K-4.6 Cl-100 HCO3-24 AnGap-12
___ 06:37AM BLOOD Glucose-73 UreaN-26* Creat-2.4* Na-139
K-3.5 Cl-101 HCO3-27 AnGap-11
___ 03:30PM BLOOD Glucose-102* UreaN-28* Creat-2.5* Na-137
K-3.7 Cl-100 HCO3-25 AnGap-12
___ 06:50AM BLOOD Glucose-99 UreaN-28* Creat-2.5* Na-135
K-3.9 Cl-99 HCO3-26 AnGap-10
___ 04:30PM BLOOD Glucose-102* UreaN-29* Creat-2.5* Na-134
K-3.7 Cl-97 HCO3-26 AnGap-11
___ 06:15AM BLOOD Glucose-91 UreaN-30* Creat-2.5* Na-133
K-3.7 Cl-96 HCO3-28 AnGap-9
___ 07:30PM BLOOD Glucose-83 UreaN-31* Creat-2.5* Na-137
K-4.2 Cl-96 HCO3-29 AnGap-12
___ 08:15AM BLOOD Glucose-87 UreaN-30* Creat-2.5* Na-133
K-3.7 Cl-96 HCO3-29 AnGap-8
___ 03:55PM BLOOD Glucose-98 UreaN-31* Creat-2.5* Na-135
K-4.3 Cl-96 HCO3-30 AnGap-9
___ 06:10AM BLOOD Glucose-100 UreaN-32* Creat-2.3* Na-136
K-4.0 Cl-95* HCO3-29 AnGap-12
___ 08:00AM BLOOD Glucose-91 UreaN-31* Creat-2.5* Na-135
K-4.3 Cl-97 HCO3-29 AnGap-9
___ 02:50PM BLOOD Glucose-93 UreaN-31* Creat-2.4* Na-136
K-4.6 Cl-94* HCO3-32 AnGap-10
___ 06:15AM BLOOD Glucose-92 UreaN-32* Creat-2.5* Na-135
K-4.0 Cl-92* HCO3-31 AnGap-12
___ 03:10PM BLOOD Glucose-107* UreaN-33* Creat-2.5* Na-133
K-3.9 Cl-91* HCO3-30 AnGap-12
___ 07:35AM BLOOD Glucose-86 UreaN-34* Creat-2.5* Na-135
K-3.8 Cl-92* HCO3-35* AnGap-8
___ 03:20PM BLOOD Glucose-98 UreaN-35* Creat-2.5* Na-134
K-3.8 Cl-89* HCO3-35* AnGap-10
___ 06:34AM BLOOD Glucose-98 UreaN-37* Creat-2.7* Na-135
K-3.7 Cl-91* HCO3-34* AnGap-10
___ 03:15PM BLOOD Glucose-119* UreaN-40* Creat-2.9* Na-135
K-3.7 Cl-90* HCO3-34* AnGap-11
___ 06:50AM BLOOD Glucose-102* UreaN-42* Creat-2.9* Na-134
K-3.8 Cl-90* HCO3-34* AnGap-10
___ 03:25PM BLOOD Glucose-113* UreaN-42* Creat-2.9* Na-134
K-4.2 Cl-90* HCO3-34* AnGap-10
___ 06:10AM BLOOD Glucose-86 UreaN-43* Creat-3.1* Na-133
K-3.9 Cl-88* HCO3-36* AnGap-9
___ 11:26AM BLOOD Albumin-1.4* Calcium-7.3* Phos-4.0 Mg-2.0
___ 06:37AM BLOOD Calcium-7.0* Phos-3.8 Mg-1.8
___ 03:30PM BLOOD Calcium-7.1* Phos-4.1 Mg-2.1
___ 06:50AM BLOOD Albumin-1.3* Calcium-7.1* Phos-4.1 Mg-2.2
___ 04:30PM BLOOD Calcium-6.9* Phos-4.1 Mg-2.1
___ 06:15AM BLOOD Calcium-7.2* Phos-3.8 Mg-2.1
___ 07:30PM BLOOD Calcium-7.5* Phos-3.6 Mg-2.2
___ 08:15AM BLOOD Albumin-1.3* Calcium-7.2* Phos-3.4 Mg-2.1
___ 03:55PM BLOOD Calcium-7.5* Phos-3.5 Mg-2.2
___ 06:10AM BLOOD Calcium-7.6* Phos-3.4 Mg-2.1
___ 08:00AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.2
___ 02:50PM BLOOD Calcium-8.0* Phos-3.5 Mg-2.2
___ 06:15AM BLOOD Calcium-7.6* Phos-3.6 Mg-2.2
___ 03:10PM BLOOD Calcium-7.7* Phos-3.7 Mg-2.2
___ 07:35AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.3
___ 03:20PM BLOOD Calcium-8.0* Phos-3.9 Mg-2.3
___ 06:34AM BLOOD Calcium-7.6* Phos-3.6 Mg-2.3
___ 03:15PM BLOOD Calcium-7.8* Phos-3.7 Mg-2.4
___ 06:50AM BLOOD Calcium-7.5* Phos-3.8 Mg-2.5
___ 03:25PM BLOOD Calcium-7.8* Phos-3.7 Mg-2.5
___ 06:10AM BLOOD Calcium-7.9* Phos-4.0 Mg-2.5
___ 08:25AM URINE Color-Straw Appear-Clear Sp ___
___ 08:25AM URINE RBC-4* WBC-5 Bacteri-NONE Yeast-NONE
Epi-0
___ 08:25AM URINE Blood-SM* Nitrite-NEG Protein-600*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 08:25AM URINE CastHy-11*
___ 08:25AM URINE Mucous-RARE*
___ 02:30AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 02:30AM URINE Blood-SM* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG*
___ 02:30AM URINE RBC-12* WBC-175* Bacteri-FEW* Yeast-NONE
Epi-<1
___ 02:30AM URINE WBC Clm-MANY*
MICROBIOLOGY:
======================================
___ 11:26 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:25 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 1:07 am STOOL CONSISTENCY: NOT APPLICABLE
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___. ___ ON ___
AT 0650.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
___ 3:46 pm URINE Source: ___.
URINE CULTURE (Pending):
IMAGING:
======================================
___ CXR
FINDINGS:
Cardiac silhouette size is normal. The aorta remains tortuous.
The
mediastinal and hilar contours are similar. The pulmonary
vasculature is not engorged. Small bilateral pleural effusions
are increased from the previous exam. There is bibasilar
atelectasis. No pneumothorax. Moderate to severe degenerative
changes of both glenohumeral and acromioclavicular joints are
noted.
IMPRESSION:
Increased small bilateral pleural effusions with bibasilar
atelectasis.
CT ABD & PELVIS W/O CONTRAST (___)
IMPRESSION:
1. No evidence of metastases within the chest abdomen or pelvis.
2. Moderate bilateral pleural effusions, ascites and anasarca
are likely
reflective of volume overload.
3. Bilateral renal hypodensities are incompletely evaluated on
this
noncontrast study. The largest of the hypodensities are
reflective of simple cysts.
CT CHEST W/O CONTRAST (___)
IMPRESSION:
1. No evidence of metastases within the chest abdomen or pelvis.
2. Moderate bilateral pleural effusions, ascites and anasarca
are likely
reflective of volume overload.
3. Bilateral renal hypodensities are incompletely evaluated on
this
noncontrast study. The largest of the hypodensities are
reflective of simple cysts.
___ BONE SCAN
IMPRESSION: There is a circular area of increased uptake of
radiotracer in the left occipitoparietal region.
NOTIFICATION: Dr. ___ PCP, was contacted but had not seen
the patient in a year.
RECOMMENDATION(S): A radiograph or CT of the skull is
recommended for further evaluation of the area to rule out
metastasis.
Above report was corrected to state that the site of the skull
uptake is on the LEFT.
___ SKULL, ___ VIEWS
IMPRESSION:
No previous images. No evidence of discrete lytic lesion is
appreciated.
However, the CT would be far more sensitive in demonstrating an
abnormality in the occiput or underlying intracranial tissues.
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. Heterogeneous calvarium, with asymmetrically increased
sclerosis involving left frontoparietal skull where there is a
small focus of periosteal reaction. Given that this corresponds
to the region of increased tracer uptake on
___, this is suspicious for osseous metastases. No definite
evidence of soft tissue extension/breakthrough.
2. Mild atrophy and probable chronic small vessel ischemic
disease.
DISCHARGE LABS:
======================================
___ 06:10AM BLOOD WBC-6.0 RBC-4.03* Hgb-10.3* Hct-30.2*
MCV-75* MCH-25.6* MCHC-34.1 RDW-17.2* RDWSD-46.1 Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-86 UreaN-47* Creat-2.9* Na-133
K-3.9 Cl-88* HCO3-33* AnGap-12
___ 06:15AM BLOOD Calcium-7.6* Phos-4.4 Mg-2.6
___ 03:46PM URINE Color-Yellow Appear-Cloudy* Sp ___
___ 03:46PM URINE Blood-MOD* Nitrite-NEG Protein-300*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG*
___ 03:46PM URINE RBC-144* WBC->182* Bacteri-FEW*
Yeast-NONE Epi-0
___ 03:46PM URINE WBC Clm-MANY*
___ 3:46 pm URINE Source: ___. URINE CULTURE (Pending):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Lisinopril 10 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Labetalol 100 mg PO BID
5. Torsemide 100 mg PO DAILY
6. Tamsulosin 0.8 mg PO QHS
7. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*20 Capsule Refills:*0
2. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*40 Tablet
Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Finasteride 5 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Tamsulosin 0.8 mg PO QHS
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY
9. HELD- Labetalol 100 mg PO BID This medication was held. Do
not restart Labetalol until your primary care physician says it
is okay to restart
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary problems:
=================
Nephrotic syndrome
Prostate adenocarcinoma
Clostridium difficile infection
Secondary problems:
===================
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: SKULL, ___ VIEWS
INDICATION: prostate adenocarcinoma ___ 9)// The pt had a bone scan
yesterday, showing increased circular area of uptake of radiotracer in right
occipital region. Radiology recommend further eval with skull radiograph.
IMPRESSION:
No previous images. No evidence of discrete lytic lesion is appreciated.
However, the CT would be far more sensitive in demonstrating an abnormality in
the occiput or underlying intracranial tissues.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with prostate cancern and concerning skull
lesion// r/o met/lytic lesion
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 844 mGy-cm.
COMPARISON: Bone scan ___.
FINDINGS:
There is no evidence of acute major vascular territorial
infarction,hemorrhage, edema, or mass. There is prominence of the ventricles
and sulci suggestive of involutional changes. Mild periventricular white
matter hypodensities are non-specific, but may reflect chronic small vessel
ischemic disease.
Osseous structures are heterogeneous in appearance, however an asymmetric area
of sclerosis, particularly the left frontoparietal calvarium is seen. There
is additionally a small focus of periosteal reaction along inner table of the
left parietal skull (3:25), which likely corresponds to the focus of increased
tracer uptake on the recent bone scan. No evidence of a pathological
fracture. The visualized portion of the paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. Heterogeneous calvarium, with asymmetrically increased sclerosis involving
left frontoparietal skull where there is a small focus of periosteal reaction.
Given that this corresponds to the region of increased tracer uptake on
___, this is suspicious for osseous metastases. No definite evidence of
soft tissue extension/breakthrough.
2. Mild atrophy and probable chronic small vessel ischemic disease.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with shortness of breath//acute process
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac silhouette size is normal. The aorta remains tortuous. The
mediastinal and hilar contours are similar. The pulmonary vasculature is not
engorged. Small bilateral pleural effusions are increased from the previous
exam. There is bibasilar atelectasis. No pneumothorax. Moderate to severe
degenerative changes of both glenohumeral and acromioclavicular joints are
noted.
IMPRESSION:
Increased small bilateral pleural effusions with bibasilar atelectasis.
Radiology Report
INDICATION: ___ with CKD (Cr 2.4), newly diagnosed prostate adenocarcinoma
___ score 9)// Staging for prostate cancer
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.5 s, 70.7 cm; CTDIvol = 18.9 mGy (Body) DLP =
1,337.3 mGy-cm.
Total DLP (Body) = 1,337 mGy-cm.; Acquisition sequence:
1) Spiral Acquisition 4.5 s, 70.7 cm; CTDIvol = 18.9 mGy (Body) DLP =
1,337.3 mGy-cm.
Total DLP (Body) = 1,337 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: None.
FINDINGS:
CHEST: There are moderate bilateral pleural effusions with mild subjacent
atelectasis. Scattered thin-walled cysts are noted throughout both lungs.
Breathing motion limits the assessment for small pulmonary nodules.
Calcification of the coronary arteries, aortic valve and thoracic aorta are
present. The size of the main pulmonary artery and thoracic aorta are within
normal limits. There is no axillary lymphadenopathy. Evaluation for hilar
lymphadenopathy is limited on the noncontrast study. There is a single
pretracheal lymph node measuring up to 1 cm in short axis. The airways are
patent through the subsegmental level.
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 demonstrates gallstones.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys demonstrate bilateral hypodense lesions, incompletely
evaluated on this noncontrast study however of the largest of the lesions
likely reflect simple cysts. 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. Apart from diverticulosis, the
colon and rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder is decompressed around a Foley catheter. There is
a trace amount of abdominopelvic nonhemorrhagic fluid
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There are marked degenerative changes around both glenohumeral joints.
Ossified fragments projecting along the medial aspect of the right proximal
femur may be the sequela of prior injury.
SOFT TISSUES: There is diffuse anasarca.
IMPRESSION:
1. No evidence of metastases within the chest abdomen or pelvis.
2. Moderate bilateral pleural effusions, ascites and anasarca are likely
reflective of volume overload.
3. Bilateral renal hypodensities are incompletely evaluated on this
noncontrast study. The largest of the hypodensities are reflective of simple
cysts.
Radiology Report
INDICATION: ___ with CKD (Cr 2.4), newly diagnosed prostate adenocarcinoma
___ score 9)// Staging for prostate cancer
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.5 s, 70.7 cm; CTDIvol = 18.9 mGy (Body) DLP =
1,337.3 mGy-cm.
Total DLP (Body) = 1,337 mGy-cm.; Acquisition sequence:
1) Spiral Acquisition 4.5 s, 70.7 cm; CTDIvol = 18.9 mGy (Body) DLP =
1,337.3 mGy-cm.
Total DLP (Body) = 1,337 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: None.
FINDINGS:
CHEST: There are moderate bilateral pleural effusions with mild subjacent
atelectasis. Scattered thin-walled cysts are noted throughout both lungs.
Breathing motion limits the assessment for small pulmonary nodules.
Calcification of the coronary arteries, aortic valve and thoracic aorta are
present. The size of the main pulmonary artery and thoracic aorta are within
normal limits. There is no axillary lymphadenopathy. Evaluation for hilar
lymphadenopathy is limited on the noncontrast study. There is a single
pretracheal lymph node measuring up to 1 cm in short axis. The airways are
patent through the subsegmental level.
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 demonstrates gallstones.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys demonstrate bilateral hypodense lesions, incompletely
evaluated on this noncontrast study however of the largest of the lesions
likely reflect simple cysts. 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. Apart from diverticulosis, the
colon and rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder is decompressed around a Foley catheter. There is
a trace amount of abdominopelvic nonhemorrhagic fluid
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There are marked degenerative changes around both glenohumeral joints.
Ossified fragments projecting along the medial aspect of the right proximal
femur may be the sequela of prior injury.
SOFT TISSUES: There is diffuse anasarca.
IMPRESSION:
1. No evidence of metastases within the chest abdomen or pelvis.
2. Moderate bilateral pleural effusions, ascites and anasarca are likely
reflective of volume overload.
3. Bilateral renal hypodensities are incompletely evaluated on this
noncontrast study. The largest of the hypodensities are reflective of simple
cysts.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Acute kidney failure, unspecified
temperature: 97.5
heartrate: 61.0
resprate: 16.0
o2sat: 98.0
sbp: 137.0
dbp: 82.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is an ___ year old man with a PMH of nephrotic syndrome
due to biopsy-proven membranous nephropathy, likely secondary to
newly diagnosed prostate adenocarcinoma ___ score 9), who
presented with worsening anasarca and dyspnea, failing
outpatient diuresis and admitted for IV diuresis.
ACUTE ISSUES:
====================================
#ANASARCA:
#NEPHROTIC SYNDROME:
#MEMBRANOUS NEPHROPATHY:
The patient has a history of biopsy proven PLA2R negative
immunofluorescence membranous nephropathy, most likely in the
setting of prostate adenocarcinoma. Prior to admission, he had
progressive anasarca over several months, dyspnea on exertion,
and pitting edema in the setting of nephrotic syndrome, despite
taking torsemide 100mg PO daily x 2 months. The patient's weight
on admission was 89.4kg, which was increased from a discharge
weight of 82.7kg in ___. The patient had severe
hypoalbuminemia, with albumin 1.4 on admission. Nephrology was
consulted and followed the patient. While inpatient, he was
diuresed with furosemide IV 20mg/hr drip, with additional
boluses of furosemide as needed, and po metolazone. Electrolytes
were repleted as needed. He had excellent output with the above
diuresis achieving a net negative of 13 L, after which the Lasix
grip and metolazone were discontinued and he was started on po
Torsemide, first 40 mg BID and then a low dose of 20 mg QD in
the setting of rising creatinine following large volume
diuresis. At discharge, his weight was 106.5 lbs.
#PROSTATE ADENOCARCINOMA:
The patient has new biopsy proven prostate cancer with ___
Score 9 and intraductal carcinoma, likely locally advanced. Per
urology, he is not a surgical candidate but could benefit from
hormonal therapy with or without radiation as an adjunct. CTCAP
(___) showed no signs of metastases. Bone scan showed an area
of increased uptake in right occipital region and a skull XR was
equivocal. However, a follow up CT skull showed a focus of
periosteal reaction corresponding to the region of increased
tracer uptake on the bone scan, concerning for osseus
metastasis. The patient's case was reviewed in the ___ Tumor
Board, where the consensus was to defer biopsy of the skull
lesion for now given its sensitive location. Per the oncology
consult team's recommendations, the patient was given
androgen-deprivation therapy with Lupron 7.5 mg IM on ___, with
a plan for once monthly injections. Otherwise, patient was
continued on finasteride 5mg PO daily, tamsulosin 0.8mg PO QHS.
PSA was 10.2 on ___, downtrending from 28.6 in ___. Prior to
starting Lupron, testosterone was 180, SHBG 82, and calcFT 21.
LDH was 408.
#CHRONIC KIDNEY DISEASE:
Patient had slowly rising creatinine from 1.7 to 2.4 over the
past 3 months ___ to ___, with old baseline from
___ of 1.1. Creatinine on admission was 2.4, with estimated
GFR ___. The patient's CKD was thought to be secondary to
underlying membranous nephropathy as well as possibly decreased
renal perfusion in the setting of venous congestion. The patient
had also been receiving PO torsemide and lisinopril, which could
have contributed to pre-renal azotemia. Per the Nephrology
consult team, lisinopril was increased to 15mg PO daily to
improve proteinuria. Following large volume loss from IV
diuresis, the patient's Creatinine began to rise from 2.5 to
3.1, so po diuresis was decreased to allow renal reperfusion and
recovery. At discharge, creatinine was 2.9.
#Hypertension: The patient initially presented with SBPs in 180s
on admission, but blood pressure was well controlled thereafter
with SBPs in 110s-140s. The patient's home labetalol was
discontinued due to bradycardia and PR prolongation. He was
started on amlodipine 5mg daily on ___, with good effect.
Amlodipine was later discontinued given softer blood pressures
once the course of IV diuresis was complete.
#DYSURIA/HEMATURIA: During hospitalization, the patient had
dysuria/hematuria that was likely Foley related given multiple
placement attempts, less likely infection (initially no pyuria).
The patient was written for Tylenol PRN(could not give pyridium
due to low GFR). Following removal of the patient's Foley on
___, he again had dysuria, with repeat UA w/reflex showing
pyuria, large leuks, moderate blood, and a few bacteria. Urine
culture was pending on discharge. Empiric antibiotic treatment
for potential UTI was held due to C. diff infection.
#C diff infection: C diff stool PCR was positive on ___. The
patient was started on Vancomycin Oral Liquid ___ mg PO/NG Q6H
with plan to continue until ___.
CHRONIC ISSUES:
====================================
#Hyperlipidemia: Continued atorvastatin 40mg PO QPM
#RASH: Pt had resolving pruritic, patchy, hyperpigmented rash on
back and upper arms bilaterally. Triamcinolone acetonide 0.1%
Cream 1 Appl TP daily was continued.
TRANSITIONAL ISSUES:
====================================
-Follow-up: He will follow-up with a ___ PCP (but he would like
to transfer all his care to ___, oncology, and nephrology.
-New medications: Vancomycin 125 mg q6h to complete 2 week
course for C.diff on ___.
-Held medications: Labetalol (please restart if BP permits as an
outpatient)
-Changed medications: Torsemide was changed from 80 mg qd to 20
mg qd. Please uptitrate as needed.
-DRY WEIGHT on discharge: 160.5 lbs
-Please follow-up with patient regarding prostate cancer
diagnosis and any questions he may have. He received a dose of
Lupron 7.5 mg IM while hospitalized.
-Please evaluate him for diarrhea at his next appointment as he
was treated for c.diff.
-Labs: Please check a cbc and bmp at his next appointment. His
last hgb was 10.3 and cr was 2.9.
-Please follow up on bilateral renal hypodensities that were
incompletely evaluated on noncontrast CT. The largest of the
hypodensities are reflective of simple cysts.
-Code status: Full
-CONTACT: ___ (Cell) |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Betalactams / Iodine-Iodine Containing / Meropenem /
vancomycin
Attending: ___.
Chief Complaint:
CC: ___ Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ y/o F with PMHx of CLL, currently C1D15 of
ofatumumab, CAD s/p PCI, ___, afib, CKD, DM, who was
transferred to the ED after she developed chest pain while
receiving blood and platelet transfusion in clinic. Of note, she
was admitted to ___ ___ when she developed similar
symptoms in the setting of receiving chemotherapy. Ultimately,
symptoms were attributed to either medication side effect vs.
demand ischemia in the setting of fluid load.
She presented for routine clinic appointment today and was given
1 unit of blood and 1 unit of platelets ___ low cell counts.
During infusion, she states that she developed central chest
tightness, non-radiating. There was associated shortness of
breath and lightheadedness. She was given tylenol and IV pain
medications with resolution of her symptoms.
Of note, she endorses poor exercise tolerance at baseline,
reporting shortness of breath walking around her house or going
up 1 flight of stairs. She also reports PND and 4 pillow
orthopnea.
She endorses a low grade temperature 2 days PTA, associated with
chills and fatigue. She also reports a headache since last
night. Of note, she also reports a recent UTI with some
lingering mild dysuria.
ED Course:
Initial VS: 99.6 66 94/54 16 97% Pain ___
Labs significant for Hct 18.3 (while pRBCs still infusing), Plts
27 (up from 13 after tranfusion of 1 unit of plts). WBC 59.4, Cr
1.4 (both around baseline).
Imaging: CXR with mild congestive heart failure and small right
pleural effusion.
Meds given: percocet, 2 tabs. She was not given ASA given low
plts.
VS prior to transfer: 99.1 71 132/40 22 98% Pain ___
On arrival to the floor, the patient denies any chest pain. In
addition to the above symptoms, she reports chronic right leg
pain and left abdominal pain (with some associated nausea). She
also endorses constipation.
ROS: As above. Denies sore throat, sinus congestion, cough,
vomiting, diarrhea, constipation, urinary symptoms, muscle or
joint pains, focal numbness or tingling, skin rash. The
remainder of the ROS was negative.
Past Medical History:
PAST MEDICAL HISTORY:
-CLL
-Chronic ITP
-CAD s/p stent to mid-proximal LAD in ___
-Diastolic dysfunction, last EF 65%, ___
-H/o hypertensive cardiomyopathy, now resolved
-Atrial fibrillation
-CKD ___ hypertensive nephrosclerosis, baseline Cr 1.5-1.8
-DM, Type II: Diet controlled. Last A1C of 5.5% on ___.
-GERD
-Gout
-Hypothyroidism
-Hypertension
-Dyslipidemia
-Secondary hyperparathyroidism
-h/o hypogammaglobulinemia, last IVIG on ___
Social History:
___
Family History:
-Mother died of myocardial infarction at the age of ___.
-Sister died of myocardial infarction at the age of ___.
-Brother died of MI at ___.
-Reports heavy history of CAD in many other family members.
-___ any family history of cancer.
Physical Exam:
ADMISSION
VS - 99.1 148/64 66 20 95%RA
GEN - Alert, NAD
HEENT - NC/AT, EOMI, PERRL, MMM
NECK - supple, no LVD appreciated
CV - RRR, ___ systolic murmur loudest at the LUSB
RESP - CTA B
ABD - Soft, BS present, TTP in the left side, no r/g
EXT - trace BLE edema, TTP of the distal RLE (chronic), no calf
tenderness
SKIN - no appreciable rashes
NEURO - non-focal
PSYCH - calm, appropriate
DISCHARGE
98.9 154/58 58 22 98% RA
GEN: NAD
HEENT: OP clear, MMM
NECK: supple, no thyromegaly, JVP flat
CV: RRR
LUNGS: CTAB
ABD: s/nt/nd normoactive BS
EXTR: no edema, 2+ pulses
NEURO: nonfocal
Pertinent Results:
ADMISSION
___ 09:15AM BLOOD WBC-64.2* RBC-2.03* Hgb-6.3* Hct-18.4*
MCV-91 MCH-31.1 MCHC-34.3 RDW-15.5 Plt Ct-13*
___ 09:15AM BLOOD Neuts-8* Bands-0 Lymphs-91* Monos-1*
Eos-0 Baso-0 ___ Myelos-0
___ 09:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 08:05PM BLOOD ___ PTT-23.9* ___
___ 08:05PM BLOOD Glucose-158* UreaN-35* Creat-1.4* Na-138
K-4.3 Cl-104 HCO3-26 AnGap-12
___ 12:40PM BLOOD ALT-23 AST-32 LD(LDH)-275* CK(CPK)-21*
AlkPhos-72 TotBili-0.5
___ 12:40PM BLOOD Albumin-3.5 Calcium-8.0* Phos-3.8 Mg-2.2
___ 02:15AM URINE Color-Straw Appear-Clear Sp ___
___ 02:15AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 02:15AM URINE RBC-<1 WBC-9* Bacteri-NONE Yeast-NONE
Epi-1
DISCHARGE
___ 02:10AM BLOOD WBC-59.6* RBC-3.04* Hgb-9.2* Hct-26.2*
MCV-86 MCH-30.2 MCHC-35.0 RDW-15.0 Plt Ct-22*
___ 02:10AM BLOOD Neuts-4* Bands-1 Lymphs-94* Monos-1*
Eos-0 Baso-0 ___ Myelos-0
___ 02:10AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL
___ 02:10AM BLOOD ___ PTT-25.2 ___
___ 02:10AM BLOOD Glucose-91 UreaN-33* Creat-1.1 Na-141
K-4.1 Cl-103 HCO3-29 AnGap-13
___ 02:10AM BLOOD ALT-23 AST-33 LD(LDH)-295* AlkPhos-79
TotBili-0.6
___ 02:10AM BLOOD Albumin-3.6 Calcium-8.0* Phos-3.8 Mg-2.1
UricAcd-5.8*
___ 12:40PM BLOOD Hapto-134
___ 02:15AM URINE Color-Straw Appear-Clear Sp ___
___ 02:15AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 02:15AM URINE RBC-<1 WBC-9* Bacteri-NONE Yeast-NONE
Epi-1
pMIBI ___
INTERPRETATION: This ___ year old woman with h/o HTN, HLD, CKD,
and
dCHF; s/p LAD stent in ___ was referred to the lab for
evaluation of
chest pain. The patient was administered 0.142 mg/kg/min of
Persantine
over four minutes. No chest, neck, back, or arm discomforts were
reported by the patient throughout the study. There were no
significant
ST segment changes throughout the study. The rhythm was sinus
with
rare, isolated APBs and VPBs throughout the study. Baseline
systolic
hypertension with an appropriate hemodynamic response to the
infusion.
Post-MIBI, the Persantine was reversed with 125 mg of
Aminophylline IV.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Baseline
systolic hypertension.
Nuclear report:
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic function.
3. Tracer uptake uptake in left chest wall/breast. This is
potentially
compatible with malignant disease.
CXR (___) - IMPRESSION:
Mild congestive heart failure and small right pleural effusion.
ECG: SR with 1st degree AVB, diffuse TW flattening, no evidence
of ischemia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Bacitracin Ointment 1 Appl TP BID:PRN to affected area
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Carvedilol 12.5 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Doxepin HCl 50 mg PO HS
8. Ferrous Sulfate 325 mg PO BID
9. Fluoxetine 20 mg PO DAILY
10. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
11. Levothyroxine Sodium 150 mcg PO DAILY
12. Lorazepam 0.5-1 mg PO Q8H:PRN nausea
13. Omeprazole 20 mg PO DAILY
14. Ondansetron 8 mg PO Q8H:PRN nausea
15. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
16. Senna 2 TAB PO BID:PRN constipation
17. Simvastatin 40 mg PO DAILY
18. traZODONE 50 mg PO HS:PRN insomnia
19. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
20. Fluticasone Propionate 110mcg 1 PUFF IH PRN SOB
21. Loratadine *NF* 10 mg Oral daily
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Carvedilol 12.5 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Doxepin HCl 50 mg PO HS
8. Ferrous Sulfate 325 mg PO BID
9. Fluoxetine 20 mg PO DAILY
10. Fluticasone Propionate 110mcg 1 PUFF IH PRN SOB
11. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
12. Levothyroxine Sodium 150 mcg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Ondansetron 8 mg PO Q8H:PRN nausea
15. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
16. Senna 2 TAB PO BID:PRN constipation
17. Simvastatin 40 mg PO DAILY
18. traZODONE 50 mg PO HS:PRN insomnia
19. Bacitracin Ointment 1 Appl TP BID:PRN to affected area
20. Loratadine *NF* 10 mg Oral daily
21. Lorazepam 0.5-1 mg PO Q8H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Chest Pain
Anemia
Thrombocytopenia
CLL
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Congestive heart failure, receiving blood.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
There is moderate cardiomegaly. The aortic knob is calcified. The
mediastinal and hilar contours are unchanged, with mild unfolding of the
thoracic aorta. There is mild pulmonary edema. Trace right pleural effusion
is present. No pneumothorax or focal consolidation is present. There are no
acute osseous abnormalities.
IMPRESSION:
Mild congestive heart failure and small right pleural effusion.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with ANEMIA NOS, CHEST PAIN NOS
temperature: 99.6
heartrate: 66.0
resprate: 16.0
o2sat: 97.0
sbp: 94.0
dbp: 54.0
level of pain: 7
level of acuity: 2.0 | Pt is a ___ y/o F with PMHx of CLL, dCHF, CAD with DES to LAD in
___, who was transferred to the ED after developing chest pain
in clinic while receiving blood products.
ACUTE
# Chest Pain/CAD s/p PCI: Developed while blood products
infusing in clinic. Similar to prior clinic events. Pt also
reports recent exertional chest pain over the past 2 weeks.
This was concerning for unstable angina given hx of CAD. Chest
pain free on presentation. EKG was unchanged compared to
baseline and trops were neg x 2. PMIBI was normal except for
tracer uptake in the left chest wall. Pt was discharged home
after being transfuse to a HCT of 26 as her chest pain could be
related to demand in the setting of severe anemia. Was
discharged on home beta blocker, isosorbide, and statin.
# Anemia/Thrombocytopenia: Pt is transfusion dependent. Likely
related to CLL, ITP, and chronic kidney disease. HCT now 26 on
discharge from 18 after 4U PRBCs in last 36 hrs. Platelets
stable at 20. Hemolysis labs negative. Transfused another unit
of platelets prior to discharge. Will f/u in hemotology next
week. Of note, stools were guiac positive with only trace blood
present on outside of stools, likely c/w hemorrhoidal bleed.
# Dysuria: Per pt report, she recently completed tx for UTI with
some lingering dysuria. UA negative for UTI and no growth
preliminarily in urine culture.
CHRONIC
# Diastolic HF: No clear evidence of fluid overload on exam.
Continued home torsemide. Did receive lasix 20 x 1 given
numerous recent transfusions.
# CLL: Currently C1D15 of Ofatumumab. Followed by Drs. ___
___. Will resume outpatient management per onc recs on
discharge.
# HTN: continued home amlodipine, carvedilol, isosorbide MN.
# Depression: continued home fluoxetine and doxepin
# DM2: diet-controlled.
# GERD: continued home omeprazole
# Gout: continued home allopurinol
# Hypothyroidism: continued home levothyroxine
# Hyperlipidemia: continued home simvastatin
TRANSITIONAL
# ofatumumab therapy
# determine ideal transfusion threshold given ? demand ischemia |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
___: AVNRT ablation
History of Present Illness:
Mr ___ is a ___ year old man with a history of CAD
s/p stenting (LAD, OM1), cardiomyopathy (ETOH vs ischemic) with
systolic CHF (EF ___, history of VT s/p ICD placement,
HTN, COPD, anemia, presenting after syncopal episode, found to
have VT on ICD interrogation and ___ with hyperkalemia.
On the evening of presentation, patient was watching TV. His
wife, in the next room reading, heard a loud crash coming from
the TV room, and came in to find the patient off the couch with
his head on a nearby table. He was able to be awoken after
several seconds by his wife and son, and although he was dazed
momentarily, he had no confusion afterwards. Denied injury to
his head, face, or any other part of his body. Denies any
preceding symptoms such as palpitations, chest pain, dyspnea,
lightheadedness.
For the the past several weeks patient reports decent health;
has had dry hacking cough with occasional severe paroxysms,
intermittent rhinorrhea, and approx. 1 month of dry skin.
Otherwise feeling well without fevers, chills, sore throat,
sputum production, chest pain, dyspnea on exertion, weight gain,
palpitations, orthopnea, lower extremity edema, abdominal pain,
N/V, dysuria, urinary frequency, hematuria, BRBPR, melena.
EMS was called, and noted him to have SPO2 89% on arrival, and
en route to ___ had multiple ___ beat runs of PVCs.
In the ED, initial vital signs were: T 98.8, BP 90/61, HR 90,
RR 18, SPO2 100% on NC (subsequently on RA).
- Labs were notable for:
-- WBC 7.9, Hgb 10.8 (MCV 101), plt 138
--INR 1.2
--Na 128, K 7.3, Creat 2.0, HCO3 17, BUN 58, Anion gap 14,
glucose 100
--after treatment, K 7.3 ->7.1 -> 5.3 -> 5.2. HCO3 improved to
20, Na to 131. Glucose dropped to 68 required additional
dextrose
--troponin elevated at 0.11, proBNP 7780
- Imaging:
#CT C-spine No acute fracture or traumatic malalignment.
#CT Head: no acute process
#CXR: my read: no acute abnormality
- The patient was given: calcium gluconate 2g IV, insulin 10U
IV, 1 amp D50 IV x 2, furosemide 40mg IV, D5NS started at
100cc/hr
- Consults: cardiology (Atrius); on interrogation of ICD noted
to have run of VT, which on review appeared to be approximately
30 second of slight irregular tachycardia at 160bp (AT/AF or
VT).
Vitals prior to transfer were: T 97.4, BP 90/50, HR 66, RR 14,
SPO2 96% on RA.
Upon arrival to the floor, patient feels well, back to
baseline, without complaint.
Past Medical History:
-ICD
--Date of Implant: ___
Indication: VT/Cardiomyopathy
Device brand/name: ___
Model Number: ___ S VR
-Chronic Systolic CHF, ischemic vs ETOH
-CAD: TO of mid RCA, 90% LAD s/p stent ___, ___ LAD DES ___
95% ostial ___ s/p DES ___
-GERD
-Hypertension
-Raynaud's
-Hypercholesterolemia
-Esophageal stricture
-COPD
-Anemia
Social History:
___
Family History:
Father died at ___ from MI
Mother: died of cancer at ___
Frat Grandfather: MI died in ___
Brother CABG at ___
Physical Exam:
==========================
ADMISSION PHYSICAL EXAM
==========================
General: Well developed, no distress
Eyes: PERRL, pink conjunctivae, no xanthelasma
ENT: Normal dentition, MMM without pallor or cyanosis
Neck: Normal carotid upstrokes, no carotid bruits, no jugular
venous distention, no goiter
Lungs: Clear, normal effort
Heart: RRR, normal S1 and S2, no m/r/g, PMI normal, precordium
quiet
Abd: Soft, NTND, NABS, no organomegaly, normal aorta without
bruit
Msk: Normal muscle strength and tone, normal gait and station,
no
scoliosis or kyphosis
Ext: No c/c/e, normal femoral and pedal pulses
Skin: No ulcers, xanthomas or skin changes due to arterial or
venous insufficiency
Neuro: A and O to self, place and time, appropriate mood and
affect
.
.
==========================
DISCHARGE PHYSICAL EXAM
==========================
Weight 56.8kg
98.0/97.9 65 (65-76) 91/56 (___) 18 100%RA
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, 6cm
CARDIAC: RRR, normal S1/S2, +S3, no murmurs rubs or gallops.
PULMONARY: Faint expiratory wheezes at bases, otherwise CTAB,
unlabored breathing on RA
ABDOMEN: Normal bowel sounds, soft, non-tender, mildly
distended, no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Multiple areas of dry, excoriated skin on extremities and
back
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
==========================
ADMISSION LABS
==========================
___ 11:22PM BLOOD WBC-7.9# RBC-3.29* Hgb-10.8* Hct-33.3*
MCV-101* MCH-32.8* MCHC-32.4 RDW-13.5 RDWSD-49.9* Plt ___
___ 11:22PM BLOOD Neuts-65.1 Lymphs-14.2* Monos-10.5
Eos-9.2* Baso-0.5 Im ___ AbsNeut-5.17 AbsLymp-1.13*
AbsMono-0.83* AbsEos-0.73* AbsBaso-0.04
___ 11:22PM BLOOD ___ PTT-27.8 ___
___ 11:22PM BLOOD Glucose-100 UreaN-58* Creat-2.0* Na-128*
K-7.3* Cl-97 HCO3-17* Calcium-9.0 Phos-4.2 Mg-1.6
___ 11:22PM BLOOD estGFR 34
.
.
==========================
PERTINENT COURSE LABS
==========================
___ 11:22PM BLOOD proBNP-7780*
.
___ 11:22PM BLOOD cTropnT-0.11*
___ 08:58AM BLOOD cTropnT-0.11*
___ 03:26PM BLOOD cTropnT-0.10*
.
___ 12:58AM BLOOD K-7.1*
___ 02:12AM BLOOD K-5.2*
.
___ 01:57AM BLOOD UreaN-59* Creat-2.0* K-5.3*
___ 08:58AM BLOOD UreaN-56* Creat-1.7* K-6.9*
___ 03:26PM BLOOD UreaN-55* Creat-1.6* K-4.6
___ 10:00PM BLOOD UreaN-55* Creat-1.5* K-5.0
___ 06:45AM BLOOD UreaN-45* Creat-1.3* K-4.5
___ 03:52AM BLOOD UreaN-45* Creat-1.4* K-3.9
___ 09:05PM BLOOD UreaN-36* Creat-1.3* K-4.4
.
.
==========================
DISCHARGE LABS
==========================
___ 06:35AM BLOOD WBC-8.1 RBC-3.15* Hgb-10.4* Hct-30.9*
MCV-98 MCH-33.0* MCHC-33.7 RDW-13.7 RDWSD-49.1* Plt ___
___ 06:35AM BLOOD Glucose-107* UreaN-33* Creat-1.2 Na-134
K-4.6 Cl-99 HCO3-25 Calcium-9.3 Phos-3.4 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prasugrel 10 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Spironolactone 25 mg PO DAILY
6. Furosemide 20 mg PO EVERY OTHER DAY
7. Furosemide 40 mg PO EVERY OTHER DAY
8. Carvedilol 25 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Carvedilol 25 mg PO BID
4. Prasugrel 10 mg PO DAILY
5. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour apply to skin once daily Disp #*28
Patch Refills:*1
6. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*3
7. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*3
8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
atrial tachycardia
acute decompensated heart failure
Secondary diagnosis:
acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with syncope w/ head strike // eval bleed or
fracture
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.6 cm; CTDIvol = 48.4 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no evidence of fracture, infarction, hemorrhage, edema, or mass.
There is prominence of the ventricles and sulci in a mild atrophic pattern.
The imaged portion of the paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The imaged portion of the orbits are unremarkable. There
is moderate bilateral cavernous carotid artery calcification.
IMPRESSION:
Mild atrophy. Otherwise normal study.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with syncope w/ head strike // eval bleed or
fracture
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.5 s, 25.3 cm; CTDIvol = 37.4 mGy (Body) DLP = 946.7
mGy-cm.
Total DLP (Body) = 947 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is moderate to severe degenerative change, worst at C4-5, C5-6 and C6-7,
where there is severe disc height loss, endplate sclerosis, and
intervertebral, facet and uncovertebral osteophytes. These produce canal
narrowing and neural foraminal narrowing. There is also minimal
retrolisthesis of C4 on 5, most likely related to degenerative change.
Alignment is otherwise normal. There is no prevertebral edema. No fractures
are identified. The posterior arch of C1 is unfused. There is no significant
canal narrowing.
The thyroid is partially obscured by artifact. There is a possible 2 cm right
thyroid nodule, best seen on image 74 of series 3. This appearance may be
entirely due to overlying artifacts. However, ___ College of Radiology
guidelines recommend elective ultrasound for evaluation of incidental thyroid
nodules of this size. . There is moderate biapical scarring and
emphysematous change in the imaged lung apices. There is moderate vascular
calcification.
IMPRESSION:
No evidence of fracture.
Minimal retrolisthesis of C4 on C5, likely due to degenerative disease.
Possible 2 cm right thyroid nodule versus artifact. If the thyroid has not
been previously evaluated, ACR guidelines would recommend ultrasound.
RECOMMENDATION(S): Ultrasound for evaluation of possible right thyroid
nodule.
NOTIFICATION: The finding of possible right thyroid nodule and the
recommendation for ultrasound for further evaluation was entered in the
Radiology department non urgent critical imaging findings system.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with cough // eval infiltrate
COMPARISON: ___
FINDINGS:
There is no focal consolidation, effusion, or pneumothorax. Heart size is
top-normal. Imaged osseous structures are intact. No free air below the right
hemidiaphragm is seen. Left chest cardiac device and lead tip in the right
ventricle are similar to prior.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with systolic CHF, CKD, DM2, HTN, presenting with
___, evaluate for obstruction or other structural abnormality.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 10.4 cm. The left kidney measures 10.8 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Syncope
Diagnosed with Hypokalemia, Syncope and collapse, Tachycardia, unspecified
temperature: 98.8
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 90.0
dbp: 61.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ yo man ___ CAD s/p stenting (LAD, OM1),
cardiomyopathy (ETOH vs ischemic) with systolic CHF (EF ___
___, history of VT s/p ICD placement, HTN, COPD, anemia,
presenting after syncopal episode, found to have VT vs.
afib/atach on ICD interrogation and ___ with hyperkalemia.
.
Based on the patient's cardiac history (prior ischemia and VT)
and interrogation of his ICD, it is likely that he experienced a
malignant arrhythmia, either AT or VT, that provoked cardiogenic
syncope. He regained consciousness without defibrillation. We
suspect that arrhythmia was provoked by hyperkalemia, although
ddx includes ischemia (mild troponin elevation) or CHF
exacerbation (elevated proBNP). Troponin elevation likely due to
transient ischemia during arrhythmia. Patient overall appears
hypervolemic and with BNP elevation.
.
He was evaluated by the EP service who lowered initial treatment
zone to ~160 and reduced monitor zone to 150. He subsequently
had sustained episodes of SVT to 130s on the floor (~45min),
during which he remained asymptomatic and hemodynamically
stable. Both episodes broke spontaneously. He was taken to the
EP lab and underwent successful AVNRT ablation. Post-ablation he
continued to have occasional ectopy of various morphologies,
suggestive of other potential foci, however no sustained
arrhythmias were observed.
.
Patient also had Creatinine 2 on admission with hyperkalemia to
6.9. He was given IVF and Creatinine improved. Renal ultrasound
was unremarkable and urine electrolytes were consistent with
pre-renal etiology. He is being discharged on home 40mg
furosemide daily dosing and lisinopril restarted at lower dose
of 5 mg daily. Spironolactone is held at discharge to be
restarted at outpatient provider's discretion.
.
Echo during admission with reduced EF of ___ as compared to
prior ___ in ___.
.
============================
Transitional Issues
============================
- Discharge weight: 56.8kg
- Increase furosemide dosing to 40mg daily
- Decrease lisinopril dosing to 5mg daily
- Holding home spironolactone at discharge
- Needs to follow-up with PCP and cardiology as scheduled.
- Cr and electrolytes to be checked ___ (to be ordered by ___
provider).
- CT C-spine with |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Demerol / acetaminophen
Attending: ___
Chief Complaint:
abdominal distention/cough/sob
Major Surgical or Invasive Procedure:
EGD and Sigmoidoscopy ___
History of Present Illness:
___ with HCV and AIH with cirrhosis c/b ascites, grade II
esophageal varices, and recurrent SBP, IVDU presents with cough
and shortness of breath. Pt reports that he has not been taking
his diuretics. Also reports nausea, dry heaves, and diarrhea.
Denies chest pain. Denies abdominal pain. Has had some nausea,
some dry heaves yesterday but no vomiting. For last 2 days has
had liquid, watery diarrhea. Patient reports that his last use
of heroin was approximately 3 days ago. His diarrhea began
approximately 12hrs after his last use of heroin. He reports
that he has been off of his diuretics for at least 2 weeks. He
presented to the ED after his mother noted that his abdomen
looked distended and his cough had progressed over the last two
days.
In the ED the initial vitals were 97.7 106 134/79 22 100%.
Patient had blood cultures, urine cultures, cxr and RUQ
ultrasound. The US showed patent portal vein and right pleural
effusion. Labs were significant for a Lactate of 3.5, tbili of
2.8, alb of 2.7, H/H of 10.8/35.8, INR of 1.8 and cr of 0.7.
Patient CXR showed right pleural effusion, no focal
consolidation. Patient was given 5mg of Morphine and brought to
the floor. Vitals prior to transfer were: 98.1 101 121/72 18
100% RA.
Vitals on arrival to the floor were: 97.9 105 117/71 18 100 on
RA. Patient was not in acute distress, lying in bed comfortably,
and breathing without difficulty. He was able to recount the
history without difficulty.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. Autoimmune hepatitis.
2. Anal condyloma.
3. Penile condyloma.
4. Hepatitis C infection, acute in ___, genotype 1
5. Cirrhosis
6. Esophageal, gastric, rectal varices
7. Portal hypertension, hypersplenism
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 97.9 105 117/71 18 100RA
GENERAL: NAD, lying comfortable in bed with slight increased
work of breathing
HEENT:EOMI, PERRL, +scleral icterus, MMM
NECK: nontender neck, no LAD, no JVD
CHEST: + spider angiomas
CARDIAC: RRR, S1/S2, S4, no rubs, or murmurs.
LUNG: mild dullness in RLL; rest of lung fields were CTAB; no
wheezes, rales or rhonchi
ABDOMEN: distended w/ caput medusa present. Hepatomegaly w/ no
tenderness to palpation. No rebound/guarding. Visible/palpable
splenomegaly w/ no overlying tenderness.
EXTREMITIES: No cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. no focal deficits
SKIN: Warm and well perfused. No splinter hemorrhages, ___
lesions, ___ nodes noted
DISCHARGE PHYSICAL EXAM:
Vitals - 97.9 114/63 89 18 97% on RA
BMx8
GENERAL: Sitting in chair eating breakfats, AAOx3
HEENT: Mild scleral icterus, MMM
NECK: No JVD
CHEST: + spider angiomas
CARDIAC: RRR, S1/S2, no rubs, or murmurs
LUNG: CTAB no w/r/r
ABDOMEN: Soft, non-tender, non-distended, spleen palpable
EXTREMITIES: No cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: Moving all 4 extremities
SKIN: No rashes
Pertinent Results:
ADMISSION LABS
___ 09:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 09:00PM HGB-9.2* HCT-31.0*
___ 10:36AM LACTATE-3.5*
___ 10:20AM GLUCOSE-90 UREA N-11 CREAT-0.7 SODIUM-135
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-20* ANION GAP-15
___ 10:20AM estGFR-Using this
___ 10:20AM ALT(SGPT)-79* AST(SGOT)-108* ALK PHOS-133*
TOT BILI-2.8*
___ 10:20AM LIPASE-88*
___ 10:20AM ALBUMIN-2.7*
___ 10:20AM WBC-2.5* RBC-4.60 HGB-10.8* HCT-35.8*
MCV-78*# MCH-23.4*# MCHC-30.1* RDW-18.9*
___ 10:20AM NEUTS-75.1* ___ MONOS-3.8 EOS-0.8
BASOS-0.2
___ 10:20AM PLT COUNT-25*
___ 10:20AM ___ PTT-37.3* ___
DISCHARGE LABS
___ 05:55AM BLOOD WBC-3.5* RBC-4.67 Hgb-10.9* Hct-35.2*
MCV-75* MCH-23.4* MCHC-31.1 RDW-18.8* Plt Ct-31*
___ 05:55AM BLOOD Plt Ct-31*
___ 05:55AM BLOOD ___ PTT-44.0* ___
___ 05:55AM BLOOD Glucose-88 UreaN-7 Creat-0.7 Na-134 K-3.5
Cl-107 HCO3-19* AnGap-12
___ 05:55AM BLOOD ALT-58* AST-71* AlkPhos-108 TotBili-2.1*
___ 05:55AM BLOOD Calcium-7.3* Phos-4.1 Mg-1.8
STUDIES
CXR ___
IMPRESSION:
Small suspected right pleural effusion versus scarring, but
including a small
rounded posterior density, atelectasis versus infection.
Follow-up
radiographs are recommended to show resolution and exclude a
developing mass although less likely. Recommendation discussed
with Dr. ___ on ___.
RUQUS ___
IMPRESSION:
1. The portal vein is patent.
2. The liver is coarsened and nodular in echotexture consistent
with
cirrhosis.
3. Stable marked splenomegaly.
4. Right pleural effusion, probably at least small to moderate.
5. Questionable medullary nephrocalcinosis is noted in the right
kidney.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Nadolol 40 mg PO DAILY
4. PredniSONE 10 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Simethicone 40-80 mg PO QID:PRN gas pain
7. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
8. Calcium Carbonate 500 mg PO DAILY
9. Spironolactone 150 mg PO DAILY
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Medications:
1. Nadolol 60 mg PO DAILY
RX *nadolol [Corgard] 20 mg 3 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*3
2. Omeprazole 20 mg PO DAILY
3. Simethicone 40-80 mg PO QID:PRN gas pain
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Calcium Carbonate 500 mg PO DAILY
7. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
8. PredniSONE 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
# Esophageal, gastric and rectal varices
# Colonic polyp
# Bright red blood per rectum
SECONDARY DIAGNOSIS:
====================
# Cirrhosis secondary to HCV and autoimmune hepatitis
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: Shortness of breath.
COMPARISON: ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS:
The heart is normal in size. The mediastinal and hilar contours appear within
normal limits. There is a small pleural effusion on the right, although none
is found on the left. In addition there is a somewhat rounded subpleural
opacity seen on the lateral view posteriorly in the posterior right
costophrenic sulcus. Bony structures are unremarkable.
IMPRESSION:
Small suspected right pleural effusion versus scarring, but including a small
rounded posterior density, atelectasis versus infection. Follow-up
radiographs are recommended to show resolution and exclude a developing mass,
although less likely. Recommendation discussed with Dr. ___ on ___.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with cirrhosis, abdominal pain // portal vein thrombosis?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Liver or gallbladder ultrasound ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is smooth. There is no focal liver mass. Main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 6 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic body and
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 27 cm.
KIDNEYS: There is questionable medullary nephrocalcinosis noted in the right
kidney. There is no evidence of stones or hydronephrosis.
A small to moderate pleural effusion is noted on the right.
IMPRESSION:
1. The portal vein is patent.
2. The liver is coarsened and nodular in echotexture consistent with
cirrhosis.
3. Stable marked splenomegaly.
4. Right pleural effusion, probably at least small to moderate.
5. Questionable medullary nephrocalcinosis is noted in the right kidney.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, CIRRHOSIS
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 97.7
heartrate: 106.0
resprate: 22.0
o2sat: 100.0
sbp: 134.0
dbp: 79.0
level of pain: 0
level of acuity: 3.0 | ___ with HCV and AIH with cirrhosis c/b ascites, grade II
esophageal varices, and recurrent SBP, IVDU presents with cough
and shortness of breath. Pt had reportedly not been taking any
medications for the past month. RUQ ultrasound was notable for
evidence of cirrhosis and portal hypertension, but did not
demonstrate ascites. Chest X-ray did not demonstrate evidence of
cough. Pt's labs were notable for being at baseline. Pt did have
one episode of BRBPR, and EGD was performed given history of
varices. EGD demonstrated medium sized esophageal, gastric and
rectal varices. Pt's H/H was stable and he did not receive any
transfusions. Pt's nadolol was titrated up from 40mg to 60mg.
Given pt presented without ascites or evidence of volume
overload off of diuretics, his home diuretics were held. Pt was
discharged home with follow up with a new PCP at ___ and his
hepatologist, Dr. ___, as an outpatient.
ACUTE ISSUES
## BRBPR: Patient had maroon stool overnight on first night in
the hospital w/ hx of varices: Last EGD ___ demonstrated 5
cords of grade II varices were seen in the lower third of the
esophagus, as well as fundal gastric varices. Report of maroon
stool overnight, however stable H/H and VS. H/H remained stable
on ___. EGD and sigmoidoscopy showed no active bleeding. We
increased nadolol to 60mg PO DAILY, titrate to HR 55-65.
## Cough: Pt reports cough for the last ___ days. Likely in the
setting of mild fluid overload secondary to not taking his
diuretics. CXR showed mild right sided pleural effusions, but no
signs of consolidation on preliminary read. It is also possible
that the patient had a viral illness prior to presentation to
the ED. US in the ED showed minimal ascites. Cultures negative.
Patient will need to follow up CXR in clinic and a follow up
imaging study in the ___ months.
## Heroin Use: Pt reports last use 3 days prior to admission.
Diarrhea followed the use. Pt denies any use in the last 3 days
and no feelings of withdrawal. He reports seeing a new doctor
near ___ that ___ be starting an injection to prevent
heroin use. Social work consult about IVDU. Pt to get vivitrol
shot as outpatient in ___.
CHRONIC ISSUES
## ASCITES: Pt has no ascites present on ultrasound. Pt reports
that he hasn't been taking his medications for >2wks. Hold
diuresis given no ascites and non-compliance with medications.
## SBP:Patient has history of recurrent SBP, and was treated for
presumed SBP during last admission. Patient not febrile or
septic on admission. Continued Bactrim SS 1 tab Daily for SBP
prophylaxis.
## Cirrhosis, autoimmune hepatitis and HCV: Pt is not currently
a transplant candidate. He has HCV/Autoimmune cirrhosis. He is
on prednisone 10mg PO daily as outpt. LFT's/Bili/INR/Platelets
are all at baseline. Will continue to monitor. MELD of 17 on
admission. Patient has minimal increased fluid status. Continued
prednisone 10mg PO Daily for autoimmune cirrhosis. |