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Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Levofloxacin Attending: ___. Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: ___ with BPAD on lithium, h/o cocaine abuse, HTN, HLD and DM sent in from ___ on ___ for increased confusion and altered mental status, worse this AM. She was admitted to ___ on ___ with depression and agitation. She was started on lithium a week prior to admission and had a level checked on ___ which was 1.3. Her Cr prior to admission was 0.8. After a week on lithium, she was noted to be "slowed down" per nursing staff. A level was checked on ___ which was She was found to have a lithium level of 2.4 on ___. Last FSBG was 70. She also complains of decreased appetite and a hand tremor that began today. In the ED, initial vitals were: T:96.8 HR 67 BP: 96/65 RR 16 O2sat 100%. Labs were notable for an eosinophilia of 17%, Na 132 and Cr 1.3. Tox screen was negative. VBG was 7.36/47/39/28. On the floor, VS were 98.6, 94/82, 64, 18, 95%. Pt was awake, alert, oriented x3, tearful. Interviewed with help of ___ interpreter, speech was slurred. 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. Past Medical History: PSYCHIATRIC HISTORY: No known consistent outpatient treaters. States that she was last seen at ___. Notes struggling with periods of low mood throughout her life. Has past history of several suicide attempts - notes pill overdose several months ago before meeting her boyfriend, and past attempt in ___. Reports using street drugs to manage periods of depression or thoughts of suicide. No previous treatments for substance abuse. PAST MEDICAL HISTORY: Hypertension Hyperlipidemia Asthma Type II diabetes Rpeorted history of past DVT and left pulmonary embolus, past treatmetn with coumadin Seen regularly by Dr. ___ in ___ for pain management. Apparently has history of back pain and shoulder pain for which she has gotten steroid injections and been perscribed percocet for pain control. ALLERGIES: Levofloxacin Social History: ___ Family History: Per patient: - Daughter has heart disease and bipolar disorder. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.6, 94/82, 64, 18, 95%RA General: Well-appearing older female, tremor evident in both upper extremities, R>L, tearful HEENT: PERRL, EOMI, tongue protrudes midline, MMM Neck: supple CV: RRR, nml S1/S2, no m/r/g Lungs: CTAB, crackles at bases, otherwise clear Abdomen: BS+, obese, nontender GU: No Foley Ext: wwp, no edema Neuro: A&O x3, CN II-XII intact, strength ___ in upper extremities and lower extremities, 2+ reflexes biceps, brachioradialis, patellar Skin: no rashes or lesions DISCHARGE PHYSICAL EXAM: Vitals: 98.6, 98.3, 63-64, 94-109/68-82, ___, 96%RA General: Well-appearing older female, tremor evident in both upper extremities, R>L HEENT: PERRL, EOMI, tongue protrudes midline, MMM Neck: supple CV: RRR, nml S1/S2, no m/r/g Lungs: CTAB, crackles at bases, otherwise clear Abdomen: BS+, obese, nontender GU: No Foley Ext: wwp, no edema Neuro: A&O x2, CN II-XII intact, strength ___ in upper extremities and lower extremities, 2+ reflexes biceps, brachioradialis, patellar Skin: no rashes or lesions Pertinent Results: ADMISSION LABS: ============== ___ 09:44PM URINE OSMOLAL-621 ___ 09:44PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 09:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-4* PH-7.0 LEUK-SM ___ 09:44PM URINE RBC-0 WBC-3 BACTERIA-FEW YEAST-NONE EPI-<1 ___ 09:44PM URINE HYALINE-6* ___ 11:51AM ___ PO2-39* PCO2-47* PH-7.36 TOTAL CO2-28 BASE XS-0 INTUBATED-NOT INTUBA ___ 11:51AM O2 SAT-68 ___ 11:40AM GLUCOSE-104* UREA N-27* CREAT-1.3* SODIUM-132* POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-24 ANION GAP-16 ___ 11:40AM estGFR-Using this ___ 11:40AM cTropnT-0.01 ___ 11:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 11:40AM WBC-11.0 RBC-4.78 HGB-14.6 HCT-44.0 MCV-92 MCH-30.6 MCHC-33.2 RDW-13.4 ___ 11:40AM NEUTS-69.5 LYMPHS-8.3* MONOS-4.8 EOS-17.0* BASOS-0.4 ___ 11:40AM PLT COUNT-184 DISCHARGE LABS: =============== ___ 07:40AM BLOOD Lithium-1.3 ___ 07:40AM BLOOD Calcium-9.4 Phos-2.4* Mg-1.6 ___ 07:40AM BLOOD Glucose-92 UreaN-10 Creat-0.6 Na-137 K-3.7 Cl-109* HCO3-20* AnGap-12 LITHIUM: ======== ___ 11:40AM LITHIUM-2.8* ___ 04:55PM LITHIUM-2.3* ___ 07:55AM BLOOD Lithium-1.9* CREATININE: =========== ___ 04:55PM GLUCOSE-78 UREA N-22* CREAT-1.0 SODIUM-136 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-23 ANION GAP-12 ___ 09:44PM URINE HOURS-RANDOM CREAT-132 SODIUM-83 POTASSIUM-39 CHLORIDE-62 ___ 07:55AM BLOOD Glucose-82 UreaN-16 Creat-0.8 Na-138 K-3.8 Cl-109* HCO3-19* AnGap-14 IMAGING: ======== ___ CXR IMPRESSION: Opacity in the superior segment of the right lower lobe could reflect atelectasis particularly given low lung volumes, however infection should be considered in the appropriate clinical setting. Consider repeat evaluation with improved inspiration when patient is able. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY Do Not Crush 2. Tiotropium Bromide 1 CAP IH DAILY 3. Amlodipine 5 mg PO DAILY Hold for SBP<90, HR<60 4. Lisinopril 10 mg PO DAILY Hold for SBP <90 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Haloperidol 5 mg PO TID 7. OLANZapine 15 mg PO HS 8. Lithium Carbonate 300 mg PO DAILY 9. Lithium Carbonate 600 mg PO QHS 10. Aspirin 81 mg PO DAILY 11. Lorazepam 1 mg PO Q6H:PRN anxiety 12. TraZODone 50 mg PO HS:PRN insomnia 13. Mylanta *NF* 1 tablet Oral daily prn gas 14. Ibuprofen 400 mg PO Q6H:PRN pain 15. Haloperidol 5 mg PO TID:PRN agitation 16. DiphenhydrAMINE 50 mg PO Q6H:PRN agitation, axiety 17. Guaifenesin ___ mL PO Q6H:PRN cough Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 3. Guaifenesin ___ mL PO Q6H:PRN cough 4. Mylanta *NF* 1 tablet Oral daily prn gas 5. Tiotropium Bromide 1 CAP IH DAILY 6. Amlodipine 5 mg PO DAILY 7. Ibuprofen 400 mg PO Q6H:PRN pain 8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 9. Lorazepam 1 mg PO Q6H:PRN anxiety 10. OLANZapine 15 mg PO HS 11. TraZODone 50 mg PO HS:PRN insomnia 12. Haloperidol 5 mg PO TID:PRN agitation 13. Haloperidol 5 mg PO TID 14. Docusate Sodium 100 mg PO BID 15. Senna 1 TAB PO BID:PRN constipation 16. Lisinopril 10 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: Lithium toxicity Secondary diagnoses: bipolar disorder, diabetes mellitus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Cough and lethargy with lithium toxicity. COMPARISON: ___. FINDINGS: AP upright and lateral chest radiographs were obtained. The lungs are low in volume with an opacity in the superior segment of the right lower lobe. There is no pleural effusion or pneumothorax. The heart is normal in size with normal cardiomediastinal contours. IMPRESSION: Opacity in the superior segment of the right lower lobe could reflect atelectasis particularly given low lung volumes, however infection should be considered in the appropriate clinical setting. Consider repeat evaluation with improved inspiration when patient is able. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: ALTERED MENTAL STATUS Diagnosed with UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE, RENAL & URETERAL DIS NOS, ADV EFF PSYCHOTROPIC NEC temperature: 96.8 heartrate: 67.0 resprate: 16.0 o2sat: 100.0 sbp: 96.0 dbp: 65.0 level of pain: 0 level of acuity: 1.0
Dear Ms. ___, It was a pleasure taking care of you during your hospitalization at ___. You were admitted for altered mental status and confusion which was due to an increased lithium level. You likely became dehydrated, your kidneys got injured and you developed a high level of the drug in your blood which caused adverse effects. You were given fluids and your level decreased. Your kidneys improved.
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: STEMI Major Surgical or Invasive Procedure: LHC with PCI History of Present Illness: Ms. ___ is a ___ y/o female with a history of HTN and HLD who presented with chest pain and presyncope this morning and was found to have STEMI. Ms. ___ was in her usual state of health until this morning when she developed substernal chest pain at rest according to notes from the emergency room. Unfortunately, Ms. ___ does not remember any events from this morning except for feeling unwell and going outside her ___ to get help. According to her son, the patient's daughter-in-law stopped by this morning to drop off food. The patient did not answer the door which was surprising to the daughter-in-law. The daughter-in-law then opened the door with an extra key and found the patient on the kitchen floor. EMS was called, and she received 500 cc NS and a full dose aspirin. She does note that she has been very healthy and takes no medications. She denies any history of chest pain either at rest or with exertion. She is a never smoker and drinks alcohol occasionally. She normally receives care at ___ in ___. In the ED: - Initial VS: T 97.7, HR 70, BP 142/94, RR 18, O2 100% RA - Labs notable for: - WBC 9.7, Hgb 12.1, Plt 268 - Na 133, K 10.0, Bicarb 18, Cr 1.2 (grossly hemolyzed) - Na 138, K 4.4, Bicarb 17, Cr 1.2 (not hemolyzed) - EKG notable for: Supraventricular bigeminy, ventricular rate 72, STE in II, III, aVF, TWI in V1-V2 and V4-V5, STD and TWI in 1 and aVL. - Patient was taken emergently to the cath lab. Coronary angiogram was performed via right radial access. He was noted to have 100% occlusion of the ___ RCA and 70% of the mid RCA, felt to the culprit. He received DESx2 to the ___ and mid RCA. He received atropine due to low HR. Given the increased amount of contrast required, he was ordered for post-procedure IVF. He was loaded with ticagrelor 180 mg. On the floor, the patient confirms the above history. She denies active chest pain or dyspnea. She reports feeling well. Patient indicates she would like to be DNR/DNI but is ok with her code status being Full Code in the ___ period (___). Past Medical History: - Hypertension - Hyperlipidemia - Osteoarthritis Social History: ___ Family History: Father with HTN and HLD. Both mother and father are deceased. Physical Exam: ADMISSION EXAM: ================= VITALS: BP 101 / 70, HR 97, RR 16, O2 96 RA GENERAL: Appears younger than stated age. Lying in bed. Alert and oriented x 3. HEENT: NCAT. Sclera anicteric. PERRL NECK: Supple with JVD CARDIAC: RRR, normal s1 and s2 LUNGS: Clear to auscultation, no wheezes ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No lower extremity edema. PULSES: Warm. Distal pulses palpable and symmetric DISCHARGE EXAM: ================== ___ 0720 Temp: 98.0 PO BP: 118/79 HR: 130 RR: 20 O2 sat: 96% O2 delivery: 2L ___ Total Intake: 1440ml PO Amt: 1440ml ___ Total Output: 450ml Urine Amt: 450ml GENERAL: Sitting up on bed AOx3 NECK: JVP at clavicle at 45 degrees CARDIAC: tachycardic s1 and s2, irregularly irregular rythm LUNGS: Clear to auscultation b/l, no wheezes ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. L forearm with large ecchymosis from IV infiltrate (blood). SKIN: No lower extremity edema. PULSES: Warm. Distal pulses palpable and symmetric Pertinent Results: ADMISSION LABS: ============== ___ 09:17PM POTASSIUM-4.5 ___ 09:17PM cTropnT-6.84* ___ 09:17PM PLT COUNT-272 ___ 01:00PM GLUCOSE-161* UREA N-19 CREAT-1.2* SODIUM-138 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-17* ANION GAP-17 ___ 01:00PM TSH-2.6 ___ 01:00PM FREE T4-1.6 ___ 12:19PM GLUCOSE-175* UREA N-18 CREAT-1.2* SODIUM-133* POTASSIUM-10.0* CHLORIDE-101 TOTAL CO2-18* ANION GAP-14 ___ 12:19PM estGFR-Using this ___ 12:19PM WBC-9.7 RBC-4.84 HGB-12.1 HCT-41.1 MCV-85 MCH-25.0* MCHC-29.4* RDW-15.1 RDWSD-46.1 ___ 12:19PM NEUTS-82.0* LYMPHS-8.4* MONOS-8.0 EOS-0.2* BASOS-0.7 IM ___ AbsNeut-7.97* AbsLymp-0.82* AbsMono-0.78 AbsEos-0.02* AbsBaso-0.07 ___ 12:19PM PLT COUNT-268 DISCHARGE LABS: =============== ___ 06:25AM BLOOD WBC-7.8 RBC-3.59* Hgb-9.3* Hct-31.4* MCV-88 MCH-25.9* MCHC-29.6* RDW-17.9* RDWSD-55.9* Plt ___ ___ 06:25AM BLOOD Glucose-98 UreaN-15 Creat-0.9 Na-143 K-4.3 Cl-105 HCO3-24 AnGap-14 IMAGING: ======== ___ IMPRESSIONS: - Mucosa suggestive of ___ esophagus - Erosions in the antrum and hiatial hernia - Erosions in the duodenal bulb - There was no evidence of blood or recent bleeding and no high-risk stigmata on her erosions and ulcers - Esophageal hiatial hernia - Tortuous esophagus RECOMMENDATIONS: - High dose PO BID PPI for at least ___ wks - Recommend repeat EGD in ___ wks to evaluate for healing of the lower esophageal ulcers surrounded by ___ esophagus, if the benefits of a repeat EGD to rule out cancer out weigh the risks in the context of her overall health - Close monitoring of CBC and stool output - If brisk bleeding continues, consider, CTA. If slower bleeding continues despite PPI, will need to reassess for small bowel or colonic source ___ ABD & PELVIS W/O CON IMPRESSION: 1. No evidence of retroperitoneal hemorrhage. ___ Echo Report The left atrial volume index is mildly increased. There is no evidence for an atrial septal defect by 2D/ color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal inferior and inferolateral walls (see schematic) and preserved/normal contractility of the remaining segments. Quantitative biplane left ventricular ejection fraction is 47 %. There is no resting left ventricular outflow tract gradient. Dilated right ventricular cavity with moderate global free wall hypokinesis. The aortic sinus is mildly dilated with mildly dilated ascending aorta. The aortic arch diameter is normal with a normal descending aorta diameter. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is a centrally directed jet of mild [1+] aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate mitral annular calcification. There is trivial mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a trivial pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with mild regional hypokinesis c/w CAD (RCA/LCx distribution). DIlated right ventricle with mild-moderate free wall hypokinesis. MIldly dilated thoracic aorta with mild aortic regurgitation. Mild tricuspid regurgitation. ___ Cath-Endovascular Single severe vessel CAD (RCA 100% and 70%) wihtout collaterals which was hard to open, s/p PCI with 2 DES and good result. Mild LAD disease (30%) distal. LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. There is a 30% stenosis in the proximal segment. The Diagonal, arising from the proximal segment, is a medium caliber vessel. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel. The ___ Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. The ___ Obtuse Marginal, arising from the mid segment, is a medium caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. There is a 100% stenosis in the proximal segment. There is a 70% stenosis in the proximal segment. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. The Right Posterolateral Artery, arising from the distal segment, is a medium caliber vessel. ___ Supraventricular bigeminy, ventricular rate 72, STE in II, III, aVF, TWI in V1-V2 and V4-V5, STD and TWI in 1 and aVL. MICROBIOLOGY: ============= None Radiology Report EXAMINATION: CHEST (PORTABLE AP) ___ INDICATION: ___ year old woman with recent h.o. STEMI s/p stent x 2. Now w/ Afib RVR and increasing O2 reqs.// Acute change Acute change IMPRESSION: Prior chest radiographs available. Heterogeneous opacification in the left lower lung is new. Most likely this is atelectasis but close follow-up is recommended for the possibility of aspiration and potential subsequent pneumonia. Upper lungs clear. Heart size normal. No mediastinal widening. No pneumothorax or pleural effusion. Radiology Report EXAMINATION: CT ABD AND PELVIS W/O CONTRAST INDICATION: ___ y/o female who presented with chest pain and presyncope this morning and was found to have STEMI s/p PCI DES ___ with R fem access with Hgb now 8.3// eval for retroperitoneal bleed after fem access on ___ with decreasing Hgb TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 12.6 s, 43.3 cm; CTDIvol = 16.2 mGy (Body) DLP = 677.5 mGy-cm. Total DLP (Body) = 689 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: There is mild bronchiectases seen in lower lobes. Dependent atelectasis is seen in lung bases. ABDOMEN: HEPATOBILIARY: Multiple hepatic cysts are seen largest in the left hepatic lobe measuring 1.7 cm there is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: Foci of calcifications are seen in the pancreas likely due to prior episodes of pancreatitis. Otherwise 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. There are calcified granuloma in the spleen. There is a small accessory spleen. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: the kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: There is a small to moderate size hiatal hernia. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Diverticulosis of the colon is noted, without evidence of wall thickening and fat stranding. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is not seen. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. BONES: There is a Schmorl's nodes in superior endplate of L1. No suspicious osseous lesion noted SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No evidence of retroperitoneal hemorrhage. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status, STEMI Diagnosed with ST elevation (STEMI) myocardial infarction of unsp site temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: Critical level of acuity: 1.0
Dear Ms. ___, It was a privilege caring for you at ___. Please see below for more information on your hospitalization. WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had chest pain. You were found to have had a heart attack. WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - Your heart arteries were examined (cardiac catheterization) which showed a blockage of one of the arteries. This was opened by placing a tube called a stent in the artery. You were given medications to prevent future blockages. - We started you on medications to help your heart - You had a low blood count (anemia) and we did imaging and the GI team looked at your esophagus, stomach and first part of your intestines with EGD. They saw some ulcers and changes in your esophagus but no obvious signs of bleeding. - We gave you blood to maintain your blood counts - You blood counts remained stable and you were ready to go home. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - It is very important to take your aspirin and clopidogrel (also known as Plavix every day. - These two medications keep the stents in the vessels of the heart open and help reduce your risk of having a future heart attack. - If you stop these medications or miss ___ dose, you risk causing a blood clot forming in your heart stents and having another heart attack - Please do not stop taking either medication without taking to your heart doctor. - You are also on other new medications for your atrial fibrillation including Metoprolol and Digoxin to help control your heart rate. You were also started on Rivaroxaban to help prevent stroke. - Weigh yourself every morning, seek medical attention if your weight goes up more than 3 lbs from your discharge weight of 163.8 lbs. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, chest pain, abdominal distention, or shortness of breath at night. - Follow up with your doctors as listed below It was a pleasure taking part in your care here at ___! We wish you all the best! - Your ___ Care Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Augmentin / Zithromax Z-Pak Attending: ___. Chief Complaint: Decreased PO intake, Hypotension, Dysphagia Major Surgical or Invasive Procedure: PEG Tube (___) History of Present Illness: ___ with h/o RSD (reflex sympathetic dystrophy), HTN, GERD, IBS, asthma, PE with acute cor pulmonale and pulmonary fibrosis on 4 L of oxygen at home with chronic pain requiring a brain stimulator with recent bulbar symptoms causing her to become severely dysphasic requiring an outpatient eval for G-tube who presents for inability to tolerate p.o. for several days and was found to be hypotensive at her PCPs office. She states that she has had difficulty with swallowing for "awhile" now and was previously on a soft/pureed diet. Over the last week it has become increasingly difficult for her to swallow solids or liquids and as a result she has been unable to take many of her medications. She was recently seen by her pain doctor who was recommending a G-tube be placed so that she would be able to take enteral nutrition/medications again. The plan was initially to try and hold off until after ___ to have her come into the hospital but today in her PCPs office she was noted to be hypotensive and was sent to the ED. Patient notes that this morning she felt weak and "not like [herself]". She attributes this to not eating or drinking more than a intermittent sips for the past few days. Patient also notes that she had a fall recently due to lower extremity weakness which has exacerbated her chronic back pain. In the ED, initial vitals were: HR:90 BP:75/41 RR:16 95% 3L NC - Exam: Con: alert, oriented and in no acute distress HEENT: NCAT. PERRLA, no icterus or injection bilaterally. EOMI. No erythema or exudate in posterior pharynx; uvula midline; MMM. Neck: neck veins flat with full ROM LAD: no cervical LAD Resp: Breathing comfortably on 4L NC. No incr WOB, CTAB with no crackles or wheezes. CV: RRR. Normal S1/S2. NMRG. 2+ radial and DP pulses bilateral. Abd: Soft, Nontender, Nondistended with no organomegaly; no rebound tenderness or guarding. MSK: ___ without edema bilaterally Skin: No rash, Warm and dry, No petechiae Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves all 4 ext to command. Psych: Normal mentation - Labs: INR: 1.2 Cr: 1.3 WBC: 7.4 lactate: 1.0 - Imaging: CXR: Multiple devices and wires project over the chest. Bibasilar atelectasis. - Micro: UA: leuk (lg) WBC (49) Bact (few) - Consults: none - Patient was given: 3L NS 1gm ceftriaxone Upon arrival to the floor, patient reports that she has her chronic nausea and back pain but is otherwise feeling well. She notes that she is open to having a G-tube and is willing to do whatever we suggest in terms of food/medications. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative Past Medical History: HYPERTENSION MIGRAINE HEADACHES PAIN CRPS HAND PAIN BACK PAIN RLE PAIN SLEEP DISORDER NAUSEA ARM PAIN THORACIC OUTLET SYNDROME PULMONARY EMBOLISM Social History: ___ Family History: Mother: cardiac stents Father: heart disease Sister: small cell lung cancer SisterL shydrager syndrome (multisystem atrophy) Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 98.0 PO, BP 120/61, HR 74, RR 18, ___ ___: Weight: 220 GEN: Alert, cooperative, no distress, appears stated age HENT: NC/AT, MMM. OP Clear EYES: PERRL, EOM intact, conjunctivae clear, no scleral icterus. NECK: No cervical lymphadenopathy. No JVD, no carotid bruit. LUNG: Absent breath sounds posterior lung fields, normal breath sounds anterior fields, no accessory muscle use HEART: RRR, Normal S1/S2, No M/R/G BACK: No CVA tenderness. ABD: Soft, non-tender, non-distended; nl bowel sounds; no rebound or guarding, no organomegaly GU: Not examined EXTRM: Extremities warm, trace edema, no cyanosis, positive ___ pulses bilaterally SKIN: Skin color and temperature, appropriate. No rashes or lesions NEUR: CN II-XII intact grossly. Moving all extremities with purpose PSYC: Mood and affect appropriate DISCHARGE EXAM: =============== 24 HR Data (last updated ___ @ 912) Temp: 97.8 (Tm 98.0), BP: 101/72 (90-114/59-74), HR: 81 (74-88), RR: 18 (___), O2 sat: 95% (92-98), O2 delivery: 4L, Wt: 232.14 lb/105.3 kg GENERAL: NAD, but significant stuttering with speech. HEENT: AT/NC, anicteric sclera, MMM PERRLA CV: RRR, S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles, but with small breath volumes GI: abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert, and oriented. Speech coherent but with stuttering repeating the end of sentences x3-4 times. CN II-XII intact but requires some encouragement to keep eyes closed and to keep shoulders shrugged. Normal tone. No tongue fasciculations. Strength appears ___ bilaterally with encouragement but then gives way after ___ seconds. DERM: Warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: =============== ___ 04:29PM BLOOD WBC-7.4 RBC-4.18 Hgb-10.7* Hct-34.5 MCV-83 MCH-25.6* MCHC-31.0* RDW-16.4* RDWSD-49.4* Plt ___ ___ 04:31PM BLOOD ___ PTT-33.9 ___ ___ 04:29PM BLOOD Glucose-132* UreaN-31* Creat-1.3* Na-144 K-4.7 Cl-106 HCO3-24 AnGap-14 ___ 06:54AM BLOOD cTropnT-<0.01 ___ 05:05PM BLOOD cTropnT-<0.01 ___ 04:29PM BLOOD Lipase-21 ___ 04:29PM BLOOD Albumin-4.1 Calcium-9.6 Phos-3.9 Mg-2.0 RELEVANT LABS: ============== ___ 04:34PM BLOOD Lactate-1.0 ___ 06:59AM BLOOD calTIBC-235* Ferritn-122 TRF-181* ___ 06:59AM BLOOD Albumin-3.5 Calcium-8.8 Phos-2.8 Mg-1.9 Iron-69 Test Result Reference Range/Units ZINC 110 60-130 mcg/dL MICROBIOLOGY: ============= URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING: ======= CXR ___: Multiple devices and wires project over the chest. Bibasilar atelectasis. PEG ___: There is a percutaneous gastrostomy tube projecting over the left upper quadrant of the abdomen. There are no abnormally dilated loops of small or large bowel. No free intraperitoneal air is identified. No suspicious radiopaque calculi are visualized. The osseous structures are unremarkable. Spinal cord stimulator leads are noted in the lower thoracic and upper lumbar spine. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. Pregabalin 300 mg PO BID 3. Mirtazapine 45 mg PO QHS 4. erenumab-aooe 70 mg/mL subcutaneous Monthly 5. Lidocaine 5% Ointment 1 Appl TP TID:PRN pain 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Tizanidine 8 mg PO TID 8. amLODIPine 7.5 mg PO DAILY 9. Rivaroxaban 20 mg PO DAILY 10. ketamine (bulk) 100 % miscellaneous TID:PRN 11. Furosemide 20 mg PO DAILY 12. HYDROmorphone (Dilaudid) ___ mg PO QID:PRN Pain - Moderate 13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH QAM 14. Promethazine 12.5 mg PO BID:PRN nausea 15. Sumatriptan Succinate 6 mg SC ONCE:PRN migraine Discharge Medications: 1. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals [Vitamins and Minerals] 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth daily Disp #*3 Capsule Refills:*0 4. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. erenumab-aooe 70 mg/mL subcutaneous Monthly 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH QAM 7. HYDROmorphone (Dilaudid) ___ mg PO QID:PRN Pain - Moderate 8. ketamine (bulk) 100 % miscellaneous TID:PRN 9. Lidocaine 5% Ointment 1 Appl TP TID:PRN pain 10. Mirtazapine 45 mg PO QHS 11. Pregabalin 300 mg PO BID 12. Promethazine 12.5 mg PO BID:PRN nausea 13. Sumatriptan Succinate 6 mg SC ONCE:PRN migraine 14. Tizanidine 8 mg PO TID 15. HELD- amLODIPine 7.5 mg PO DAILY This medication was held. Do not restart amLODIPine until you see your primary care doctor 16. HELD- Furosemide 20 mg PO DAILY This medication was held. Do not restart Furosemide until you see your primary care doctor 17. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until you see your primary care doctor Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Oral pharyngeal and esophageal dysphasia Acute kidney injury hypotension SECONDARY DIAGNOSIS ===================== Urinary tract infection Chronic regional pain syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with weakness// acute process? COMPARISON: Prior CT of the chest from ___ FINDINGS: AP portable upright view of the chest. Spinal cord stimulator projects over the cervical spine. Electrodes representing neural stimulators project over the right hemithorax and right side of the neck. There is bibasilar atelectasis without convincing evidence for pneumonia. Please note the implanted device within the left chest wall obscures the underlying portion of the heart and lung. No large effusion or pneumothorax is seen. Overall cardiomediastinal silhouette appears grossly unremarkable. Imaged bony structures are intact. IMPRESSION: Multiple devices and wires project over the chest. Bibasilar atelectasis. Radiology Report EXAMINATION: Chest radiographs, two AP upright portable views. INDICATION: Dobhoff tube placement. Oro pharyngeal dysmotility. COMPARISON: Prior study from ___. FINDINGS: Second of two views shows a Dobhoff tube partly coiled in the stomach. Lung volumes are very low. Cardiac, mediastinal and hilar contours appear stable. Atelectasis at each lung base is improved. There is no pneumothorax or pleural effusion. Spinal catheters appear unchanged. IMPRESSION: Dobhoff terminating in the stomach. Mostly resolved atelectasis at each lung base. Radiology Report INDICATION: ___ year old woman with recent dobhoff placement and reporting chest tightness.// PTX? COMPARISON: Radiographs from ___ IMPRESSION: There is a Dobhoff tube with distal tip in the fundus of the stomach. There are markedly low lung volumes. Atelectasis at the lung bases. There are no pneumothoraces. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with oropharyngeal dysphagia with dobhoff placement. Concern for movement of tube?// interval change in tube placement? interval change in tube placement? IMPRESSION: Compared to chest radiographs since ___ most recently ___ through ___. Transesophageal feeding tube coiled appropriately in the upper stomach. Multiple indwelling stimulator leads unchanged in their respective positions. Lung volumes remain exceedingly small, exaggerating mild cardiomegaly. No definite pulmonary abnormality. Pleural effusions small if any. No pneumothorax. Radiology Report INDICATION: ___ year old woman with history of oropharyngeal and esophageal dysphagia and concern for diaphragmatic weakness potentially secondary to CRPS who presented with hypotension iso poor PO intake. Failed s/s and needs long term enteral access for nutrition.// PEG placement COMPARISON: Chest x-ray dated ___. 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 1 mg of midazolam throughout the total intra-service time of 20 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 g of Ancef CONTRAST: 10 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 11.3 minutes, 76 mGy PROCEDURE: 1. Placement of a Ponsky pull-through 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, 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 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, and a 5 ___ vascular sheath was placed. A short Kumpe catheter was advanced over the wire. The ___ wire was exchanged for a Glidewire. The Glidewire was advanced into the esophagus in the Kumpe catheter followed up to the level of the midesophagus. The Glidewire was exchanged for ___ wire. The Kumpe catheter was removed The snare was attached to the gastric end of the ___ wire. Under continuous fluoroscopic guidance, the ___ wire was advanced into the oral cavity. A hemostat was used to secure the ___ wire. Under continuous fluoroscopic guidance, the snare device was pulled through the stomach into the esophagus and out of the oral cavity. The snare was released, the ___ wire was removed and the Ponsky tube was attached to the snare and secured. Under continuous fluoroscopic guidance, the Ponsky tube was then pulled through the oral cavity into the esophagus and finally the stomach. The Ponsky tube was cut and an overlying disc, lock and adapter were placed. Contrast was injected through the Ponsky tube to confirm appropriate placement. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate complications. FINDINGS: 1. Successful placement of a Ponsky gastrostomy tube. IMPRESSION: Successful placement of a 20 ___ Ponsky gastrostomy tube via pull technique. Radiology Report INDICATION: ___ year old woman s/p PEG placement w/ worsening abdominal pain// R/o free air, s/p PEG placement TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: Chest radiograph ___. IMPRESSION: There is a percutaneous gastrostomy tube projecting over the left upper quadrant of the abdomen. There are no abnormally dilated loops of small or large bowel. No free intraperitoneal air is identified. No suspicious radiopaque calculi are visualized. The osseous structures are unremarkable. Spinal cord stimulator leads are noted in the lower thoracic and upper lumbar spine. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Failure to thrive, Hypotension Diagnosed with Hypotension, unspecified temperature: nan heartrate: 90.0 resprate: 16.0 o2sat: 95.0 sbp: 75.0 dbp: 41.0 level of pain: 0 level of acuity: 1.0
====================== DISCHARGE INSTRUCTIONS ====================== Dear Ms. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You came to the hospital because you were found to have a low blood pressure by your outpatient providers. WHAT HAPPENED TO ME IN THE HOSPITAL? - Your blood pressure improved after providing you with fluid. This was likely caused by your low food intake from not being able to eat properly. - We placed a tube to provide you extra nutrition with the hopes we may be able to improve your ability to swallow. You were very nausea and uncomfortable with the tube in your nose so you had a tube in your belly placed. - You received teaching on how to use the tube feeds. - Please follow up with your primary care doctor, ___ ___ neurologist, Dr. ___ to determine need for long term need for supplemental feeding. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Make sure you continue to have bowel movements. Can take senna or miralax if you do not have a bowel movement in 2 days. - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim DS / Sulfa (Sulfonamide Antibiotics) / vancomycin / Coreg / metoprolol / atorvastatin Attending: ___ Chief Complaint: hyperglycemia Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ female with the past medical history notable for uncontrolled DM, HTN, pyoderma of right hip, recurrent necrotizing fasciitis of abdomen/groin s/p multiple debridements and now wound vac, who presents from her SNF with concerns for her care there. Per patient and OMR, she has had a recently prolonged hospitalization of 2 months for the necrotizing fasciitis (please see d/c summary ___ - her course was complicated by wound infection, gastroparesis requiring GJ tube, depression, hypotension, uncontrolled diabetes, UTI, and bacteremia. She was ultimately discharged to ___ for rehab and was there until 1 week ago, when she was transferred to ___. While there, she was concerned re: suboptimal care in terms of wound management and management of her diabetes - she reports multiple episodes of hyperglycemia while there. No other new symptoms - no f/c/s, chest pain, shortness of breath, dizziness, lightheadedness, n/v/abd pain, constipation, ___ edema. +baseline chronic diarrhea of ___ BMs per day (loose). No rashes. No changes in mood. She came into our ED for the above reason and was here for the past 1.5 days; she was admitted to the medical service for optimization of her DM and rehab placement. Per patient, she was seen by ___ in the ED and surgery, who replaced her wound vac today. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: DM 2, uncontrolled Graves' disease s/p RAI pyoderma of right hip HTN HL LBBB necrotizing fasciitis of lower abdomen and b/l groins, s/p multiple debridements and wound vac closures Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Oropharynx without visible lesion, erythema or exudate, mucous membranes moist CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GJ tube c/d/I; pressure ulcer proximal to this site with significant depth and some drainage, no erythema or foul odor. +wound vac of the lower abdomen, wound not fully examined due to vac GU: No suprapubic fullness or tenderness to palpation, +catheter 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 PHYSICAL EXAM: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Oropharynx without visible lesion, erythema or exudate, mucous membranes moist CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GJ tube c/d/I; pressure ulcer proximal to this site with significant depth and some drainage, no erythema or foul odor. +wound vac of the lower abdomen, wound not fully examined due to vac GU: No suprapubic fullness or tenderness to palpation, +catheter SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS: ___ 01:30PM BLOOD WBC-9.1 RBC-3.35* Hgb-9.2* Hct-29.5* MCV-88 MCH-27.5 MCHC-31.2* RDW-17.1* RDWSD-54.2* Plt ___ ___ 01:30PM BLOOD Neuts-70.2 Lymphs-17.2* Monos-6.6 Eos-5.0 Baso-0.6 Im ___ AbsNeut-6.36* AbsLymp-1.56 AbsMono-0.60 AbsEos-0.45 AbsBaso-0.05 ___ 01:30PM BLOOD Glucose-176* UreaN-26* Creat-0.8 Na-136 K-7.2* Cl-97 HCO3-26 AnGap-13 ___ 01:30PM BLOOD Calcium-9.3 Phos-4.5 Mg-1.8 DISCHARGE LABS: ___ 05:54AM BLOOD WBC-7.4 RBC-3.15* Hgb-8.7* Hct-27.7* MCV-88 MCH-27.6 MCHC-31.4* RDW-17.0* RDWSD-54.0* Plt ___ ___ 05:54AM BLOOD Glucose-208* UreaN-30* Creat-0.8 Na-139 K-4.8 Cl-96 HCO3-25 AnGap-18 ___ 05:54AM BLOOD ALT-10 AST-10 AlkPhos-166* TotBili-<0.2 ___ 05:54AM BLOOD Albumin-2.9* Calcium-9.1 Phos-4.8* Mg-1.6 GI/G-tube check ___: Percutaneous gastrojejunostomy catheter is looped in the stomach with tip in the region of the pylorus, as seen on the prior CT exam. No extraluminal oral contrast material seen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Senna 17.2 mg PO DAILY:PRN constipation 2. Heparin 5000 UNIT SC BID 3. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Moderate 4. Levothyroxine Sodium 150 mcg PO DAILY 5. Moexipril 3.75 mg PO DAILY 6. Furosemide 20 mg PO DAILY 7. Dronabinol 10 mg PO TID 8. Aspirin 81 mg PO DAILY 9. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line 10. Mirtazapine 15 mg PO QHS 11. Famotidine 20 mg PO Q12H 12. Ferrous Sulfate 325 mg PO DAILY 13. melatonin 5 mg oral QHS 14. Multivitamins 1 TAB PO DAILY 15. TraZODone 25 mg PO QHS:PRN insomnia 16. Escitalopram Oxalate 10 mg PO DAILY 17. Ondansetron ODT 4 mg PO Q8H:PRN nausea 18. Glargine 30 Units Bedtime NPH 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 19. LORazepam 0.5 mg PO Q8H:PRN anxiety The Preadmission Medication list is accurate and complete. 1. Senna 17.2 mg PO DAILY:PRN constipation 2. Heparin 5000 UNIT SC BID 3. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Moderate 4. Levothyroxine Sodium 150 mcg PO DAILY 5. Moexipril 3.75 mg PO DAILY 6. Furosemide 20 mg PO DAILY 7. Dronabinol 10 mg PO TID 8. Aspirin 81 mg PO DAILY 9. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line 10. Mirtazapine 15 mg PO QHS 11. Famotidine 20 mg PO Q12H 12. Ferrous Sulfate 325 mg PO DAILY 13. melatonin 5 mg oral QHS 14. Multivitamins 1 TAB PO DAILY 15. TraZODone 25 mg PO QHS:PRN insomnia 16. Escitalopram Oxalate 10 mg PO DAILY 17. Ondansetron ODT 4 mg PO Q8H:PRN nausea 18. Glargine 30 Units Bedtime NPH 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 19. LORazepam 0.5 mg PO Q8H:PRN anxiety Discharge Medications: 1. Glargine 25 Units Bedtime Regular 7 Units Lunch Regular 7 Units Dinner Regular 7 Units at 0000 Insulin SC Sliding Scale using REG Insulin 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line 4. Dronabinol 10 mg PO TID 5. Escitalopram Oxalate 10 mg PO DAILY 6. Famotidine 20 mg PO Q12H 7. Ferrous Sulfate 325 mg PO DAILY 8. Furosemide 20 mg PO DAILY 9. Heparin 5000 UNIT SC BID 10. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Moderate 11. Levothyroxine Sodium 150 mcg PO DAILY 12. LORazepam 0.5 mg PO Q8H:PRN anxiety 13. melatonin 5 mg oral QHS 14. Mirtazapine 15 mg PO QHS 15. Moexipril 3.75 mg PO DAILY 16. Multivitamins 1 TAB PO DAILY 17. Ondansetron ODT 4 mg PO Q8H:PRN nausea 18. Senna 17.2 mg PO DAILY:PRN constipation 19. TraZODone 25 mg PO QHS:PRN insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Hyperglycemia Recurrent necrotizing fasciitis Sacral uclers Gastroparesis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with GJ tube// Correct placement? TECHNIQUE: Supine scout AP view of the abdomen was obtained. Subsequently, 20 cc of Gastrografin oral contrast material was injected through the patient's GJ tube and subsequent supine AP view of the abdomen was obtained. COMPARISON: CT abdomen pelvis ___ FINDINGS: Percutaneous gastrojejunostomy catheter seen which is looped within the stomach and tip terminating in the region of the pylorus. Contrast injected through this catheter opacifies the stomach and proximal duodenum. No extraluminal oral contrast material seen. Bowel gas pattern is unremarkable. Multiple soft tissue anchors project over the right iliac bone. No acute osseous abnormality. IMPRESSION: Percutaneous gastrojejunostomy catheter is looped in the stomach with tip in the region of the pylorus, as seen on the prior CT exam. No extraluminal oral contrast material seen. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Failure to thrive Diagnosed with Diarrhea, unspecified temperature: 98.9 heartrate: 109.0 resprate: 20.0 o2sat: 98.0 sbp: 112.0 dbp: 67.0 level of pain: 0 level of acuity: 3.0
You came in with high blood sugars as you felt your diabetes was not well managed at the facility you were at. We increased your long-acting insulin and your blood sugars improved. We are sending you to a different facility for you to continue getting rehab and the nursing care you need It was a pleasure taking care of you at ___ ___.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: N/A History of Present Illness: Mr. ___ is a ___ man with complicated medical comorbidities including CAD status post three-vessel CABG, along with systolic CHF with EF around 30%, with recent finding of kidney mass suspicious of RCC presenting for sudden onset dyspnea. Patient reports that he was home yesterday morning developed sudden onset dyspnea after breakfast. No chest pain or palpitations. Dyspnea worse with exertion. Rested for several hours but dyspnea persisted. Of note, he has a history of significant systolic CHF with an ejection fraction estimated around 30% or so, maintained on torsemide diuretic along with beta blockade and ___ therapy. He underwent a nuclear stress test with nuclear imaging on ___ which revealed left ventricular dilation at rest and during stress, with a global ejection fraction of ___ with diffuse hypokinesis with akinesis in the interventricular septum, inferior infarct without ischemia. An echo on ___ revealed LV enlargement with moderate systolic dysfunction with an EF of 35%, 2+ mitral insufficiency, 2+ tricuspid insufficiency, severe pulmonary hypertension and right ventricular systolic pressures of 60-65. In the ED, initial vitals were: Labs were significant for BNP of 3190, trop x1 negative, creatinine of 1.3 and UA negative for infection. Imaging significant for : EKG - sinus rhythm CXR - pulmonary edema Patient was given: ___ 21:50 IV Furosemide 80 mg ___ 22:25 IV Ondansetron 4 mg ___ 22:25 IV LORazepam 1 mg ___ 22:35 PO Potassium Chloride 40 mEq On the floor, patient reports improvement in his breathing. He reports his daughter came back from ___ on ___ and has been throwing up and having loose stools. He reports as of yesterday, he has been having nausea, abdominal pain and throwing up as well. He feels over the weekend, he has noticed his ankles swell up more and has had some weight gain. He was walking around watering his plants when he experienced sudden onset dyspnea (which is moderate exertion for him). He has been exercising every other day to lose weight for a scheduled ?partial nephrectomy for newly diagnosed renal mass in the near future. He reports he has not felt anything like this before. Denies any chest pain at the time. Reports he did experience some orthopnea. He has been taking his medication as prescribed and did notice an improvement in his breathing after he received the IV Lasix in the ED. Review of systems: (+) Per HPI Past Medical History: 1. CAD status post three-vessel CABG in ___ after a stress test. 2. Systolic CHF with ejection fraction 30% 3. Hypertension. 4. Non-insulin-dependent diabetes. 5. Morbid obesity. 6. GERD. 7. Obstructive sleep apnea, on CPAP. 8. Episodic atrial fibrillation, status post cardioversion one year ago. 9. Renal mass, c/f renal cell carcinoma SURGICAL HISTORY: 1. CABG x 3, ___. 2. Elective cardioversion, ___ for AFib. 3. Right rotator cuff. Social History: ___ Family History: Mother had myasthenia ___, deceased. Father had CAD, deceased. Physical Exam: ADMISSION PHYSICAL EXAMINATION: =============================== VITAL SIGNS: T98 BP 147/87 HR 96 RR 22 Sats 95 on 4L GENERAL: Well-appearing and obese. NAD HEENT: Anicteric sclerae. Mucous membranes are moist and pink. NECK: Difficult to assess with body habitus LUNGS: Bilateral crackles up to mid zones of lungs HEART: Normal rate, regular rhythm. Soft ___ systolic ejection murmur, heard throughout the precordium. ABDOMEN: Obese, soft, nontender, nondistended. No palpable masses. EXT: 2+ pitting edema bilaterally up to knees NEURO: A and O x3. No asterixis. Normal gait. Power ___ in all four extremities. CnII-XII intact LABS: see below DISCHARGE PHYSICAL EXAM: ======================== VITAL SIGNS: Tm 98.0 104-122/44-57 ___ 18 99/CPAP Weight: 125.5 <- 125.5 <- 124.6 <- 124.0 <- 125.8 <- 126.6 <- 127 <- 131.6 <- 132.2 <- 133.8 I/Os: 8 ___ 24 ___ GENERAL: Well-appearing and obese. NAD HEENT: NCAT NECK: no JVD LUNGS: CTABL HEART: Normal rate, regular rhythm. Soft ___ systolic ejection murmur, heard throughout the precordium. ABDOMEN: Obese, soft, nontender, nondistended. EXT: trace edema bilaterally up to knees NEURO: grossly non-focal Pertinent Results: ADMISSION ========= ___ 09:00PM BLOOD WBC-10.9*# RBC-4.22* Hgb-11.7* Hct-36.8* MCV-87 MCH-27.7 MCHC-31.8* RDW-15.4 RDWSD-48.2* Plt ___ ___ 09:00PM BLOOD Neuts-86.8* Lymphs-5.8* Monos-6.5 Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.49*# AbsLymp-0.63* AbsMono-0.71 AbsEos-0.02* AbsBaso-0.03 ___ 09:00PM BLOOD ___ PTT-36.4 ___ ___ 09:00PM BLOOD Glucose-147* UreaN-17 Creat-1.3* Na-140 K-3.2* Cl-100 HCO3-28 AnGap-15 ___ 07:00AM BLOOD ALT-16 AST-18 AlkPhos-144* TotBili-1.4 ___ 07:00AM BLOOD Lipase-42 ___ 09:00PM BLOOD proBNP-3190* ___ 09:00PM BLOOD cTropnT-<0.01 ___ 07:00AM BLOOD CK-MB-2 cTropnT-0.01 ___ 07:00AM BLOOD Albumin-4.1 Calcium-8.8 Phos-4.5 Mg-1.9 ___ 04:55PM BLOOD Lactate-1.9 PERTINENT ========= ___ 03:20PM BLOOD Glucose-135* UreaN-31* Creat-1.8* Na-140 K-3.5 Cl-103 HCO3-25 AnGap-16 ___ 06:32AM BLOOD Glucose-109* UreaN-21* Creat-1.4* Na-139 K-3.6 Cl-101 HCO3-24 AnGap-18 ___ 03:00PM BLOOD UreaN-24* Creat-1.8* Na-140 K-3.9 Cl-100 HCO3-26 AnGap-18 ___ 03:05PM BLOOD UreaN-38* Creat-2.5* Na-135 K-4.4 Cl-100 HCO3-24 AnGap-15 DISHCARGE ========= ___ 07:10AM BLOOD WBC-5.7 RBC-4.21* Hgb-11.6* Hct-37.2* MCV-88 MCH-27.6 MCHC-31.2* RDW-16.1* RDWSD-51.5* Plt ___ ___ 06:30AM BLOOD ___ PTT-32.9 ___ ___ 07:10AM BLOOD Glucose-106* UreaN-33* Creat-1.6* Na-137 K-4.5 Cl-101 HCO3-26 AnGap-15 ___ 07:10AM BLOOD Calcium-9.3 Phos-4.7* Mg-2.2 ___ 09:07PM BLOOD Lactate-1.1 MICROBIOLOGY: ============== URINE CULTURE (Final ___: NO GROWTH. Blood Culture, Routine (Final ___: NO GROWTH. IMAGING ======= - Nuclear Stress ___ IMPRESSION: 1. Normal myocardial perfusion. 2. Severely enlarged left ventricular cavityL. 3. Reduced left ventricular ejection fraction calculated to be 32 percent. -TTE ___ The left atrium is moderately dilated. The right atrium is markedly dilated. The estimated right atrial pressure is at least 15 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is severely dilated. There is moderate regional left ventricular systolic dysfunction with hypokinesis of the mid to distal inferior wall and a dyskinetic septum. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is markedly dilated with moderate global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. 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. Mild to moderate (___) mitral regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Severely dilated, moderately hypokinetic left ventricle with regional wall motion abnormalities consistent with coronary artery disease. Dilated, hypokinetic right ventricle. Mildly dilated aortic root and ascending aorta. Mild to moderate mitral regurgitation. Severe pulmonary artery systolic hypertension. -EKG - sinus rhythm - no ST changes -CXR ___: pulmonary edema Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 40 mg PO QPM 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Omeprazole 40 mg PO DAILY 4. Potassium Chloride 20 mEq PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. Torsemide 20 mg PO DAILY 7. Aspirin 325 mg PO DAILY 8. Losartan Potassium 100 mg PO DAILY 9. PNEUMOcoccal 23-valent polysaccharide vaccine 0.5 ml IM NOW X1 Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 2. Atorvastatin 40 mg PO QPM 3. Losartan Potassium 100 mg PO DAILY 4. Omeprazole 40 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. PNEUMOcoccal 23-valent polysaccharide vaccine 0.5 ml IM NOW X1 Start: ___, First Dose: Next Routine Administration Time 7. Spironolactone 12.5 mg PO DAILY RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 8. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY RX *isosorbide mononitrate 30 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 9. HydrALAZINE 25 mg PO TID RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 10. Carvedilol 3.125 mg PO BID RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 11. Torsemide 40 mg PO DAILY RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY ====== Acute on Chronic Systolic CHF Cardiogenic Shock SECONDARY ======== ___ on CKD CAD s/p CABG Renal Mass GERD BPH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ male with dyspnea and lower extremity edema. Evaluate for pneumonia and pleural effusions. TECHNIQUE: Frontal and lateral views of the chest. COMPARISON: CT chest ___. FINDINGS: Moderately severe pulmonary edema is accompanied by a small right pleural effusion. There is no consolidation, large pleural effusion or pneumothorax. Cardiomegaly is severe. Sternal wire disruption and displacement are consistent with known sternal dehiscence,unchanged since ___. There is a large air-fluid level in the stomach. IMPRESSION: Cardiomegaly and moderate pulmonary edema consistent with congestive heart failure. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Abd pain Diagnosed with Heart failure, unspecified temperature: 98.9 heartrate: 95.0 resprate: 16.0 o2sat: 95.0 sbp: 166.0 dbp: 96.0 level of pain: 2 level of acuity: 2.0
Dear Mr. ___, You were admitted after you were found to have worsening heart failure. We were nervous that you might have been developing a condition called "cardiogenic shock," where your body has difficulty delivering enough oxygen to the organs in your body. You were therefore briefly on a medication that helps strengthen your heart's pumping abilities. We also started you on a lot of the Lasix via a drip, and you had excellent urine output in response, and your heart failure improved. Please weigh yourself every morning, and call your PCP or cardiologist if your weight goes up more than 3 lbs. Your dry weight is 125.5kg.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fall Major Surgical or Invasive Procedure: 1. IVC filter placement History of Present Illness: ___ woman, factor V leiden carrier not on anticoagulation, who had a syncopal event with headstrike earlier on ___. She reports she felt unwell upon awakening, having noted chest heaviness, plus left ankle and calf soreness. While at the bank, she felt diaphoretic and dizzy, and subsequently lost consciousness, striking her head on the fall. She awoke in the ambulance and was alert and aware of her surroundings. She denies any prior syncopal episodes or prior clots or taking anticoagulation. She was taken to an OSH where she received dilt x1 for AF (this is the first time she's been diagnosed with AF). Past Medical History: PAST MEDICAL HISTORY HTN Hyperlipidemia factor V leiden carrier Social History: ___ Family History: FAMILY HISTORY: Daughter - Factor V ___ homozygote, SLE Son - UC Other daughter - healthy Father - Died age ___ of Lung cancer Mother - Died age ___ of CHF and COPD Physical Exam: Discharge Physical Exam: VS: T 98.5HR 56 BP 105/56 RR 18 SpO297%RA GEN: AA&O x 3, NAD, calm, cooperative. HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI, PERRL. CHEST: Clear to auscultation bilaterally, (-) cyanosis. ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation incisionally, non-distended. EXTREMITIES: Warm, well perfused, pulses palpable. LLE edema and tenderness. Compression stockings in place. Pertinent Results: ___ 01:10PM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-Test ___ 01:10PM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-Test ___ 01:49AM BLOOD CA ___ -Test ___ 01:49AM BLOOD CEA-0.3 ___ 01:10PM BLOOD Lupus-POS ___ 06:00PM BLOOD WBC-11.2* RBC-3.82* Hgb-12.2 Hct-36.2 MCV-95 MCH-31.9 MCHC-33.7 RDW-12.8 RDWSD-44.3 Plt ___ ___ 04:28AM BLOOD WBC-9.7 RBC-3.39* Hgb-10.5* Hct-32.4* MCV-96 MCH-31.0 MCHC-32.4 RDW-12.7 RDWSD-43.9 Plt ___ ___ 06:00PM BLOOD Glucose-119* UreaN-10 Creat-0.7 Na-139 K-4.1 Cl-103 HCO3-22 AnGap-18 ___ 04:28AM BLOOD Glucose-95 UreaN-9 Creat-0.7 Na-138 K-4.8 Cl-103 HCO3-23 AnGap-17 ___ 04:28AM BLOOD ___ PTT-67.0* ___ ___ 05:00AM BLOOD ___ PTT-70.3* ___ ___ 09:15AM BLOOD ___ Medications on Admission: Hydrochlorithiazide 25 QD Lisinopril 7.5 QD Calcium with vit D Multivit Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Amiodarone 400 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Metoprolol Tartrate 25 mg PO TID Hold for HR<55 or SBP <90 5. Senna 8.6 mg PO BID:PRN constipation 6. Warfarin 5 mg PO DAILY16 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. bilateral pulmonary emboli 2. subarachnoid hemorrhage 3. left DVT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: History: ___ with bilateral subsegmental PEs, ___ edema, also with subdurals and difficult risk/benefit calculation on treatment for venous thrombi // 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 right common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is loss of normal compressibility, flow, and augmentation of the left common femoral, femoral, and duplicated popliteal veins with echogenic material noted within the veins, compatible with DVT. The thrombus extends into the left posterior tibial and peroneal veins, with loss of normal color flow and compressibility. Of note, the proximal extent of the thrombus is not seen. There is normal respiratory variation in the common femoral vein on the right. There is loss of normal respiratory variation in the common femoral vein on the left. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: 1. Extensive thrombus is noted within the left common femoral vein and extends into the superficial femoral, duplicated popliteal veins, posterior tibial, and peroneal veins. Of note, the proximal extent of the clot is not seen and could extend into the pelvis. 2. No evidence of deep venous thrombosis in the right lower extremity veins. Radiology Report EXAMINATION: CT ABDOMEN AND PELVIS WITH AND WITHOUT CONTRAST INDICATION: ___ year old woman with SAH, bilateral PEs, and LLE DVT that extends at least into Lt CFV. // please evaluate extent of DVT found by ultrasound in left CFV. Please protocol study for venous phase TECHNIQUE: Pre and post contrast with split bolus: MDCT axial images were acquired through the abdomen and pelvis prior to and 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) Spiral Acquisition 6.6 s, 51.6 cm; CTDIvol = 6.5 mGy (Body) DLP = 335.0 mGy-cm. 2) Spiral Acquisition 6.6 s, 51.6 cm; CTDIvol = 20.6 mGy (Body) DLP = 1,063.9 mGy-cm. Total DLP (Body) = 1,399 mGy-cm. COMPARISON: Lower extremity ultrasound from ___ FINDINGS: LOWER CHEST: There is mild bilateral dependent subsegmental atelectasis. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: The pancreas has normal attenuation throughout. Several cystic lesions are seen in the tail of the pancreas, the largest measuring 2.2 cm (image 3:45). There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout. A 4 mm hypodensity is seen, too small to be characterize (image 3:39). ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: A small hiatal hernia is noted. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. There is moderate sigmoid diverticulosis without diverticulitis The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: A 2.3 cm left adnexal cyst is noted. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Minimal atherosclerotic disease is noted. There is compression of the left common iliac vein by the right common iliac artery at the bifurcation, with the vein measuring 6 mm in AP diameter (image 3:99). There is complete occlusive thrombus of the left common iliac vein, extending down into the left femoral vein. BONES: An 8 mm sclerotic focus is seen in the right iliac bone (image 3:125) and likely represents a benign bone island. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Compression of the left common iliac vein by the right common iliac artery with complete thrombosis of the left common iliac vein extending down into the left femoral vein. 2. Incidental findings of cystic lesions within the tail of the pancreas as well as a 2.3 cm left adnexal cyst. RECOMMENDATION(S): Non urgent MRCP is recommend for further evaluation of the pancreatic tail lesions. Non urgent pelvic ultrasound is recommend for further evaluation of the left adnexal cyst. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 9:09AM, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with subarachnoid hemorrhage. Assess for evolution. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 14.0 s, 15.2 cm; CTDIvol = 46.4 mGy (Head) DLP = 702.4 mGy-cm. 2) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 100.3 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: Outside head CT performed on ___ at 23:22. FINDINGS: A globular focus of subarachnoid blood in a left medial frontal sulcus is unchanged. Small left parafalcine subdural hematoma is also stable. There is no mass effect on the brain parenchyma. No new hemorrhage is identified. There is no evidence for parenchymal edema or loss of gray/ white matter differentiation. The ventricles and sulci are age-appropriate. No fracture is identified. There is minimal mucosal thickening in the frontoethmoidal recesses. Middle ear cavities, pneumatized petrous apices, and the visualized mastoid air cells are well aerated. IMPRESSION: 1. Stable globular focus of subarachnoid hemorrhage in a left medial frontal sulcus. 2. Stable small left parafalcine subdural hematoma without mass effect on the brain parenchyma. Radiology Report INDICATION: IVC filter placement confirmation TECHNIQUE: Fluoroscopic abdominal radiograph. COMPARISON: CT abdomen pelvis dated ___. FINDINGS: Intraoperative insertion of an IVC filter. An IVC filter is in a vertical orientation with its feet at approximately the level of T10. Visualized osseous structures are unremarkable. Radiology Report Study carotid series complete Reason syncope Findings. Duplex evaluation was performed of both carotid arteries. No plaque is identified. On the right velocities are 88/20, 75/20, 57 in the ICA, CCA, ECA respectively. The ratio is 1.2. This is consistent with no stenosis. On the left velocities are 76/13, 71/23, 60 in the ICA, CCA, ECA respectively. The ratio is 1.1. This is consistent with no stenosis. There is antegrade flow in both vertebral arteries. Impression no evidence of stenosis in either carotid artery Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ female status post fall with parafalcine subdural hematoma and subarachnoid hemorrhage. Evaluate for interval change. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 9.0 s, 15.3 cm; CTDIvol = 48.8 mGy (Head) DLP = 746.1 mGy-cm. Total DLP (Head) = 757 mGy-cm. COMPARISON: NECT ___. FINDINGS: No significant change in the left frontal parafalcine subdural hematoma and focus of subarachnoid hemorrhage in the left medial frontal sulcus . There is no mass effect or midline shift. The basal cisterns appear patent. There is no CT evidence of new hemorrhage or infarct. There is mild global cerebral volume loss with appropriate ventricular size. 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. Stable focus of subarachnoid hemorrhage in the left medial frontal sulcus. 2. Stable left parafalcine subdural hematoma. 3. No evidence of mass effect or midline shift, new hemorrhage or acute infarct. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ female status post fall with traumatic subarachnoid hemorrhage 5 days prior study now on therapeutic anticoagulation. Evaluate for interval change in subarachnoid hemorrhage. 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) = 843 mGy-cm. COMPARISON: Noncontrast head CT ___. FINDINGS: Stable left medial frontal sulcus parafalcine subarachnoid hemorrhage. Stable small left parafalcine subdural hematoma. No new hemorrhage identified. No mass effect or midline shift. The ventricles and sulci are normal in size and configuration. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Stable left medial frontal sulcus parafalcine subarachnoid hemorrhage. 2. Stable small left parafalcine subdural hematoma. 3. No evidence of mass effect or midline shift, new hemorrhage or acute infarct. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Syncope, SDH, PE Diagnosed with Syncope and collapse temperature: 98.7 heartrate: 74.0 resprate: 16.0 o2sat: 98.0 sbp: 129.0 dbp: 79.0 level of pain: 0 level of acuity: 2.0
Dear Ms. ___, You were admitted to the Acute Care Trauma service on ___ after a fall. You were found to have a small subarachnoid hemorrhage, bilateral pulmonary emobli and a left femoral leg blood clot. You underwent IVC placement and were anticoagulated. You were additionally found to be in atrial fibrillation and you were treated with multiple agents- you will be discharged home on metoprolol and amiodarone.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___ drainage of abscess History of Present Illness: Mr. ___ is a ___ gentleman with Crohn's disease (complicated by fistulas & abscess in the past) s/p colectomy, as well as DVT on Warfarin for the past 2 months who presented to the ED due to 2 weeks of abdominal pain, fever today and outpt MRI today demonstrating intra-abdominal abscess. . At his baseline he is very functional, maintaining a demanding job, with plans to travel to ___ next week for business. But for the last 2 weeks he has felt stabbing pain to the right of his belly button. At first he thought it was muscle strain from weightlifting. The pain started out mild but is now severe, ___. He has felt a hard lump in the area as well. On the day of presentation, he went to an outpatient GI appointment, where he was refferred for U/S. It was felt that this might represent a spigelian hernia or hematoma in the setting of Warfarin use, but he was also referred for MRI to r/o abscess. The MRI showed 51mm x 60mm x 68mm RLQ abdominal abscess and possible fistulous tract, so he was referred to the ED. . In the ED, initial VS were: pain ___, T 101.1, HR 76, BP 146/73, RR 16, POx 100%RA. Labs were notable for WBC 15.7, ESR 44, CRP 33.1, and INR 4.0. GI consult suggested PPI, Zosyn, and continuing ___ at his current dose. It was felt that the abscess may be amenable to ___ drainage. He received Zosyn 4.5g IV. Also received Tylenol ___ PO and Dilaudid 2mg IV for pain. Was given Vitamin K 10mg IV, Protonix 40g IV, and 1L normal saline. Dr. ___ GI) was called from the ED and requested Medicine admission. On the floor, he feels fine because he just received pain medication. The pain becomes very severe between doses of pain meds. REVIEW OF SYSTEMS: (+) -easy bleeding since starting Warfarin -bloody ostomy output since starting Warfarin -abdominal hernia seems the same as usual (-) Denies night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation, tarry output from ostomy, dysuria, hematuria. Past Medical History: Crohns Disease -history of remote pneumocolonic fistula and pelvic abscesses Nephrolithiasis s/p L ureteropscopy, laser litho on ___ Urethral strictures. Rosacea. Anxiety and depression. Lactose intolerant. ___ Ex-lap/LOA, take down of enterocutaneous fistula w ileocolonic anastomosis ___ I&D of intraabdominal abscess; Abdominal wound exploration; excision of abdominal wall abscess secondary to infected suture; SBR for enterocutaneous fistula ___ Exploratory laparotomy with takedown of fistula ___ Exploratory laparotomy, lysis of adhesion, jejunal stricturoplasty ___ Total proctectomy with end transverse colostomy Social History: ___ Family History: Patient is adopted. Physical Exam: ADMISSION EXAM VS - Temp 98.7F, BP 128/81, HR 85, R 18, O2-sat 97% RA GENERAL - Alert, interactive, well-appearing gentleman in NAD HEENT - EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, JVP non-elevated, no carotid bruits HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no wheezes/rales/ronchi, good air movement, resp unlabored, no accessory muscle use ABDOMEN - nondistended; ventral hernia present (easily reducible); right abdomen with palpable grapefruit-sized mass; tender to palpation left abdomen but no rebound or guarding; no hepatomegaly EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, steady gait . DISCHARGE EXAM VS - T 98.1 BP 97/64 (97/64-123/76), HR 61, R 18, O2-sat 99% RA drain 5 mL over 24 hours GENERAL - Alert, interactive, well-appearing gentleman in NAD HEART - RRR, nl S1-S2, no MRG LUNGS - CTAB ABDOMEN - nondistended; mild TTP at the the drain site EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: ADMISSION LABS ___ 10:19AM BLOOD WBC-15.7*# RBC-5.42 Hgb-14.3 Hct-45.5 MCV-84 MCH-26.3* MCHC-31.4 RDW-14.4 Plt ___ ___ 10:19AM BLOOD Neuts-86.5* Lymphs-7.7* Monos-4.3 Eos-1.2 Baso-0.2 ___ 10:19AM BLOOD ESR-44* ___ 10:19AM BLOOD UreaN-16 Creat-1.1 Na-141 K-3.5 Cl-102 HCO3-31 AnGap-12 ___ 10:19AM BLOOD ALT-36 AST-23 CK(CPK)-85 AlkPhos-58 Amylase-134* TotBili-0.4 DirBili-0.1 IndBili-0.3 ___ 10:19AM BLOOD Albumin-3.5 Calcium-8.4 Iron-24* ___ 08:00PM BLOOD CRP-33.1* ___ 10:19AM BLOOD calTIBC-415 VitB12-GREATER TH Folate-GREATER TH Ferritn-104 TRF-319 ___ 08:18PM BLOOD Lactate-1.7 . DISCHARGE LABS ___ 06:25AM BLOOD WBC-6.0 RBC-5.12 Hgb-13.1* Hct-43.4 MCV-85 MCH-25.5* MCHC-30.1* RDW-14.5 Plt ___ ___ 06:25AM BLOOD ___ PTT-31.0 ___ ___ 06:25AM BLOOD Glucose-80 UreaN-8 Creat-1.2 Na-139 K-4.3 Cl-99 HCO3-32 AnGap-12 ___ 06:25AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.1 . URINE STUDIES ___ 10:30AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 10:30AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ___ 10:30AM URINE RBC-66* WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 ___ 10:30AM URINE CaOxalX-OCC ___ 10:30AM URINE Mucous-RARE . MICROBIOLOGY GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). FLUID CULTURE (Final ___: ESCHERICHIA COLI. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. ESCHERICHIA COLI. SPARSE GROWTH ___ STRAIN. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMPICILLIN------------ <=2 S <=2 S AMPICILLIN/SULBACTAM-- <=2 S <=2 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S ANAEROBIC CULTURE (Preliminary): RESULTS PENDING. . STUDIES US ___ IMPRESSION: Bilobed-shaped intra/ extra abdominal cystic lesion at the level of the lateral border of the right rectus abdominis muscle. This could represent a resolving hematoma/ abscess or a spigelian hernia containing fluid. Given the acuity of onset and skin discoloration reported by the patient, a hematoma is favored. However, the intra-abdominal communication is less typical of a hematoma and abscess or hernia is not excluded. Correlate with MRE performed the same day. . MRE ___ 1. Walled off abscess is identified in the right lower quadrant. The abscess extends into the right abdominal wall. 2. Thickened ileal loops with mucosal hyperenhancement on arterial phase are seen in proximity to the abscess, consistent with active Crohn's disease. 3. Cholelithiasis without signs of cholecystitis. . ___ CT Abdomen Pelvis 1. The previously described abscess in the right lower quadrant has significantly resolved when compared to prior imaging and now measures 1.4 x 2.5 x 3.2 cm with a catheter noted in good position. No fistulous communication is demonstrated between this collection and the adjacent small or large bowel. There is no evidence for recurrent Crohn's disease in the small bowel. 2. Cholelithiasis. Medications on Admission: mercaptopurine 50 mg daily warfarin 2.5mg ___ (since 2 months ago; plans for 6 month treatment) Fish Oil 300 mg-500 mg daily cyanocobalamin 1,000 mcg/mL injection once or twice monthly Multi-Vitamin HP/Minerals daily Folic Acid 1 mg daily fluticasone 50 mcg/actuation Nasal Spray daily Discharge Medications: 1. mercaptopurine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fish Oil 300-500 mg Capsule Sig: One (1) Capsule PO once a day. 3. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One (1) Injection once a month. 4. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 7. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous twice a day. Disp:*28 syringe * Refills:*0* 8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 14 days: do not drink while taking this medication. Disp:*42 Tablet(s)* Refills:*0* 9. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:*28 Tablet(s)* Refills:*0* 10. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every eight (8) hours as needed for pain: do not drive while taking this medication as it can make you tired . Disp:*10 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Abscess Crohns Disease Microscopic hematuria Secondary Diagnosis Nephrolithiasis Urethral strictures. Rosacea. Anxiety depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report REASON FOR THE EXAMINATION: This is a ___ patient with history of Crohn's disease that involves the large and small bowel. The patient is status post multiple resections of the terminal ileum and resection of the rectum. The patient has left colostomy. The patient is now presenting with right-sided pain. The request is to rule out fistula. COMPARISON: Ultrasound examination from ___. CT of the abdomen from ___. 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 intravenous administration of 8 cc of Gadovist. 900 cc of barium sulfate was given orally. In addition, 1 mg of IM glucagon was administered to reduce bowel motion. FINDINGS: A fluid filled multiloculated collection is seen in the right lower quadrant. The collection measures 51 x 60 (12, 28) x 68 mm (1001, 68). The collection extends into the right abdominal wall (12, 16) and shows persistent rim enhancement. The collection is surrounded by multiple thickened ileal loops that shows mucosal hyperenhancement (12, 59 and 12, 57 and 1001, 66). No discrete fistula is seen between the bowel loops and the collection; however, in some regions there is no fat plane between the bowel loops and the collection (1001, 16). Mild-to-moderate fat stranding is seen in proximity to the collection (1002, 61). The patient is status post multiple resections of the terminal ileum and resection of the rectum. Susceptibility artifacts are seen along the proximal colon. Left-sided colostomy is seen. The rest of the small and large bowel shows no mucosal hyperenhancement or thickening of the wall that suggest inflammation. Bilobed structure is seen in segment VI of the liver. The lesion shows high signal intensity on T2-weighted images and shows no enhancement. The lesion measures 9 x 50 mm (11, 23) and is most consistent with simple liver cyst. Otherwise, the liver is normal. There is no intra- or extra-hepatic biliary duct dilatation. Cholelithiasis is seen without signs of cholecystitis. The spleen is within normal limits. Note is made of a small splenule. The pancreas shows normal signal and is within normal limits. The adrenals are unremarkable. Multiple lesions are seen within the kidneys. The lesions show high signal intensity on T2-weighted images and no enhancement post-contrast, consistent with simple cysts. No free fluid or lymphadenopathy are detected. The aorta and its branches are patent and of normal caliber. The portal vein and its branches and the splenic vein are patent and of normal caliber. Normal bone marrow signal is seen. IMPRESSION: 1. Walled off abscess is identified in the right lower quadrant. The abscess extends into the right abdominal wall. 2. Thickened ileal loops with mucosal hyperenhancement on arterial phase are seen in proximity to the abscess, consistent with active Crohn's disease. 3. Cholelithiasis without signs of cholecystitis. These findings were discussed by Dr. ___ Dr. ___ by phone at 4 p.m. ___. Radiology Report STUDY: FOCUSED RIGHT LOWER QUADRANT ABDOMINAL SONOGRAM. INDICATION: Patient with questionable hematoma due to Coumadin in the abdominal wall. COMPARISON: No recent studies are available for comparison. TECHNIQUE: Focus sonographic evaluation of the lower quadrant of the abdomen was performed and reviewed. FINDINGS: In the region of the patient's palpable abnormality and tenderness, there is a 6.8 x 5.9 x 5.1 cm hypoechoic lesion with posterior acoustic enhancement which appears to extend into the subcutaneous muscle plane as well as into the abdominal cavity. There is a dehisence in the anterior abdominal wall seen lateral to the lateral margin of the right rectus abdominis muscle. There are few foci of increased echogenicity within this lesion. There is no definite communication with bowel identified nor was there peristalsis with this lesion. IMPRESSION: Bilobed-shaped intra/ extra abdominal cystic lesion at the level of the lateral border of the right rectus abdominis muscle. This could represent a resolving hematoma/ abscess or a spigelian hernia containing fluid. Given the acuity of onset and skin discoloration reported by the patient, a hematoma is favored. However, the intra-abdominal communication is less typical of a hematoma and abscess or hernia is not excluded. Correlate with MRE performed the same day. Findings were discussed with Dr ___ by Radiology ___ over telephone on ___ at 4: 15 p.m Radiology Report STUDY: CT-guided percutaneous drainage of right lower quadrant abdominal fluid collection. INDICATION: ___ male with history of Crohn's disease complicated by multiple previous fistulas and abscesses, status post colectomy, two weeks of abdominal pain and fever, recent MRI demonstrating intra-abdominal abscess. Request percutaneous drainage. COMPARISON: Previous MR enterography dated ___ and ultrasound abdomen dated ___. OPERATORS: Dr. ___ Dr. ___. Dr. ___ was present for the entire duration of the procedure and personally supervised it. PROCEDURE: After explaining the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was brought to the CT suite and was placed supine on the CT table. A preprocedure timeout was performed using three unique patient identifiers as per standard ___ protocol. Limited preprocedure CT images were obtained through the lower abdomen, which demonstrated irregular 7.2 x 3.7 cm fluid collection in the right lower abdomen. An appropriate skin entry site overlying this fluid collection was marked and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to anesthetize the skin, subcutaneous soft tissues and the anterior abdominal wall musculature. Under CT fluoroscopic guidance, ___ needle was advanced into the fluid collection via an anterior approach. There was immediate return of purulent fluid. A floppy-tipped ___ wire was advanced through the ___ needle into the abscess cavity. The ___ needle was then exchanged for an 8 ___ pigtail drainage catheter. After confirming appropriate positioning, the loop of the pigtail drainage catheter was formed within the abscess cavity. We immediately drained about 75 mL of purulent fluid. Following this, about 35 mL of diluted intravenous contrast was injected through the pigtail drainage catheter into the abscess cavity. There was no communication with the surrounding loops of small bowel. The injected contrast was aspirated back. The drainage catheter was secured to the anterior abdominal wall and was attached to a large suction bulb. The patient tolerated the procedure well without any immediate ___ complications. Moderate sedation was provided by administering divided doses of Versed (1.5 mg) and Fentanyl (150 mcg) throughout the total intraservice time of 30 minutes during which the patient's hemodynamic parameters were continuously monitored. IMPRESSION: Successful CT-guided percutaneous drainage catheter placement into right lower quadrant intra-abdominal abscess. Sample of the aspirate sent for microbiological analysis. Sinogram shows no communication with bowel. Radiology Report CT ABDOMEN AND PELVIS INDICATION: Status post ___ drainage of abdominal abscess. History of Crohn's disease. COMPARISON: MR enterography ___, CT abdomen ___ and CT interventional procedure ___. TECHNIQUE: MDCT axial acquired images from the lung bases to pubic symphysis displayed with 5mm slice thickness withwith oral and IV contrast. Multiplanar 2D and 3D reformations have been provided. FINDINGS: Atelectatic changes noted in the right lower lobe without pleural or pericardial effusion. Normal hepatic contour with a simple hepatic cyst identified within segment VII of the liver measuring 13 mm (series 2a, image 20). The hepatic and portal venous vasculature is patent. There is no intra- or extra-hepatic biliary dilatation and a single gallstone is evident within the gallbladder (series 2a, image 27). Spleen is normal in size with an incidental splenule noted in the left upper quadrant (series 2a, image 23). Pancreas enhances homogeneously. Both adrenal glands are unremarkable. Both kidneys are normal apart from simple renal cysts identified bilaterally. There are no retroperitoneal masses or adenopathy. No abnormally dilated or thickened small or large bowel loop in the visualized upper abdomen. There is no evidence for active Crohn's disease. A neoterminal ileum is noted in the right lower quadrant. Adjacent to this is a pigtail catheter inside a collection which now measures 1.4 x 2.5 x 3.2 cm (previously 5.1 x 6.5 x 7.9 cm) (series 2a, image 63) which is entirely decompressed when compared to prior MR enterography from ___ and the catheter is in good position. There is no fistulous communication demonstrated between this collection and the small or large bowel in the vicinity which are completely opacified with oral contrast. No oral contrast is identified within the collection. CT PELVIS: No pelvic adenopathy or free fluid. Visualized portions of the bladder and prostate gland were unremarkable. There has been a previous proctectomy. There is no free fluid. CT OSSEOUS SKELETON: No osseous destructive lesion. IMPRESSION: 1. The previously described abscess in the right lower quadrant has significantly resolved when compared to prior imaging and now measures 1.4 x 2.5 x 3.2 cm with a catheter noted in good position. No fistulous communication is demonstrated between this collection and the adjacent small or large bowel. There is no evidence for recurrent Crohn's disease in the small bowel. 2. Cholelithiasis. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ABD ABSCESS Diagnosed with PERITONEAL ABSCESS temperature: 101.1 heartrate: 76.0 resprate: 16.0 o2sat: 100.0 sbp: 146.0 dbp: 73.0 level of pain: 10 level of acuity: 3.0
Mr. ___, It was a pleasure participating in your care while you were admitted to ___. As you know you were admitted because you were having abdominal pain. You had a MRI which showed a collection of pus called an abscess. A drain was placed to remove the infected fluid. You were started on antibiotics which you will need to continue for at least 14 more days. You will follow-up with Dr. ___ if you need to continue antibiotics for a longer period of time You were given a medication that reverses the effects of your warfarin so that the drain could be placed. You were started on lovenox in place of the warfarin. You will continue on this medication in the place of the warfarin. You should discuss this further with Dr. ___ at your next appointment. You also had small amount of blood in your urine. You will need to follow up with your PCP about this ___ made the following changes to your medications. 1. START ciprofloxacin 500 mg twice a day 2. START flagyl 500 mg every 8 hours 3. START lovenox 80 mg twice a day 4. STOP Warfarin 5. START oxycodone as needed for pain You should continue to take all other medications as instructed. Please call with any questions or concerns.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: ___ Major Surgical or Invasive Procedure: colonoscopy (___) History of Present Illness: ___ history of atrial fibrillation on Eliquis and hypertension who presents as transfer from ___ with melena. Patient underwent colonoscopy on ___ which was notable for polypectomy x3, 1 site requiring clipping due to oozing. He was then discharged home restarted his Eliquis ___. His bowel movement on ___ was brown but required some straining. His bowel movement on ___ noted was brown-black in color. Since then, he has continued to have dark stools, becoming more black and tarry in nature. He also noted one BM that was very dark with a streak of red in the toilet. Other than the change in color of his stools, he was completely asymptomatic at home. He denies any dizziness, lightheadedness, palpitations, chest pain, shortness of breath, abdominal pain, n/v, or hematemesis. Given the ongoing nature of his dark stools, he called the o/c GI physician at ___ who recommended he present to the ED. He went to ___ and was transferred to ___ for further evaluation. Of note, initial lab work at ___ was notable for Hgb of 14. Of note, the patient reports 30lbs unintentional weight loss over the past year. In the ED: The patient arrived late on ___. His initial hemoglobin was 13.1. KUB was unremarkable. GI was consulted, and the patient was started on IV PPI and bowel prep was initiated for scope on ___. Repeat colonoscopy was notable for cecal site with adherent clot, which was thought to be the source of bleeding. The patient received 3 endoclips to the site and was admitted for further monitoring. Initial vital signs were notable for: Temperature 96.5 heart rate 80 blood pressure 112/70 respiratory rate 16 satting 96% on room air Exam notable for: Gen: well developed male, NAD, talkative HEENT: NC/AT CV: Irregular rhythm, normal rate. No appreciable murmurs. Pulm: CTAB. Nonlabored respirations. Abd: soft, nondistended, nontender to palpation. Rectal: no frank blood. guaiac positive. Ext: no lower extremity edema Labs were notable for: Hemoglobin 13.1 INR 1.4 Studies performed include: -Chest x-ray did not reveal free air -Colonoscopy with cecal site with adherent clot, received clip x3 Patient was given: Moviprep Colchicine metoprolol succinate 25mg lorazepam 0.25 mg PO Zofran 4mg IV febuxostat 80mg PO Consults: GI Upon arrival to the floor, the patient is hungry but feels well. His last bloody BM was while taking prep, which he notes at that time was a very deep blackish red. He has not had any BMs since the colonoscopy. He denies any fevers, chills, abdominal pain, lightheadedness, dizziness, palpitations. REVIEW OF SYSTEMS: Notable for 30 lbs unintentional weight loss over past year. Other per HPI. Otherwise negative. Past Medical History: -COLON POLYP -HYPERTENSION -DIVERTICULOSIS -ATRIAL FIBRILLATION -ADHD -CHOLECYSTECTOMY -HERNIA REPAIR Social History: ___ Family History: No family history of colon cancer or GI malignancy that he is aware of. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== 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: Irregular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: Normal bowels sounds, 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 wnl. No rash. NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. Gait is normal. AOx3. DISCHARGE PHYSICAL EXAM: ======================== VITALS: 24 HR Data (last updated ___ @ 2322) Temp: 98.4 (Tm 98.4), BP: 102/69 (102-120/67-85), HR: 67 (67-72), RR: 18, O2 sat: 98% (97-100), O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. HEENT: PERRLA, MMM. CARDIAC: irregularly irregular. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, 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 wnl. No rash. NEUROLOGIC: A&Ox3, moving all 4 extremities with purpose Pertinent Results: ADMISSION LABS: =============== ___ 11:45PM BLOOD WBC-4.8 RBC-3.86* Hgb-13.1* Hct-39.7* MCV-103* MCH-33.9* MCHC-33.0 RDW-14.3 RDWSD-54.4* Plt ___ ___ 11:45PM BLOOD Neuts-61.8 Lymphs-17.1* Monos-9.8 Eos-9.8* Baso-1.3* Im ___ AbsNeut-2.97 AbsLymp-0.82* AbsMono-0.47 AbsEos-0.47 AbsBaso-0.06 ___ 11:45PM BLOOD ___ PTT-29.6 ___ ___ 11:45PM BLOOD Glucose-94 UreaN-29* Creat-1.2 Na-142 K-4.8 Cl-100 HCO3-29 AnGap-13 ___ 06:50AM BLOOD Calcium-10.4* Phos-3.7 Mg-2.5 EGD REPORT (___) ==================== Impressions: -Cecal EMR site was identified which had a large adherent clot suggestive of recent bleeding. No active bleeding was seen. (Injection, Endoclip). -Ascending colon polypectomy site was visualized with no signs of active bleeding. There was a visible post polypectomy ulcer. (Endoclip). -Moderate diverticulosis of the descending colon and sigmoid colon. -No other sources of bleeding identified. Recommendations: -Cecal EMR site is the most likely source of bleeding. No active bleeding, s/p successful application of 3 hemoclips. -Recommend repeat colonoscopy in 6 months to assess EMR site and polypectomy of previously seen small left sided polyps. -Recommend observation inpatient overnight. If no signs of any more bleeding, may discharge home. -Continue to hold anticoagulation for 48 hours after which it may be resumed. IMAGING: ======== CXR (___) The lungs are well inflated and clear. No focal consolidations. No pulmonary edema. 7 mm nodule projecting over the left lower lung, which should be followed up with a chest CT on a nonemergent basis. Unchanged enlargement of cardiac silhouette. No pleural effusion. No pneumothorax. No pneumoperitoneum. IMPRESSION: 1. No pneumoperitoneum. 2. Cardiomegaly. 3. 7 mm nodule projecting over the left lower lung, which should be followed up with a chest CT on a nonemergent basis. DISCHARGE LABS: =============== ___ 05:35AM BLOOD WBC-4.3 RBC-3.43* Hgb-11.4* Hct-35.5* MCV-104* MCH-33.2* MCHC-32.1 RDW-14.0 RDWSD-53.8* Plt ___ ___ 05:10AM BLOOD ___ PTT-26.3 ___ ___ 05:35AM BLOOD Glucose-101* UreaN-17 Creat-0.9 Na-139 K-4.3 Cl-105 HCO3-26 AnGap-8* ___ 05:10AM BLOOD Calcium-9.5 Phos-2.7 Mg-2.1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Calcium Carbonate 500 mg PO QID:PRN heartburn 3. Colchicine 0.6 mg PO DAILY 4. Famotidine 20 mg PO BID:PRN heartburn 5. Furosemide 40 mg PO QAM 6. Furosemide 20 mg PO QPM 7. LORazepam 0.25 mg PO BID:PRN anxiety 8. Losartan Potassium 100 mg PO QHS 9. MethylPHENIDATE (Ritalin) 10 mg PO BID 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Spironolactone 25 mg PO DAILY 12. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 2. Calcium Carbonate 500 mg PO QID:PRN heartburn 3. Colchicine 0.6 mg PO DAILY 4. Famotidine 20 mg PO BID:PRN heartburn 5. Furosemide 20 mg PO QPM 6. Furosemide 40 mg PO QAM 7. LORazepam 0.25 mg PO BID:PRN anxiety 8. Losartan Potassium 100 mg PO QHS 9. MethylPHENIDATE (Ritalin) 10 mg PO BID 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Spironolactone 25 mg PO DAILY 12. HELD- Apixaban 5 mg PO BID This medication was held. Do not restart Apixaban until the morning of ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== post-polypectomy lower gastrointestinal bleed SECONDARY DIAGNOSES: ==================== atrial fibrillation hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with ongoing melena after recent colonoscopy with biopsies. Needs eval to exclude perforation.// eval of free air under diaphragm TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph dated ___. FINDINGS: The lungs are well inflated and clear. No focal consolidations. No pulmonary edema. 7 mm nodule projecting over the left lower lung, which should be followed up with a chest CT on a nonemergent basis. Unchanged enlargement of cardiac silhouette. No pleural effusion. No pneumothorax. No pneumoperitoneum. IMPRESSION: 1. No pneumoperitoneum. 2. Cardiomegaly. 3. 7 mm nodule projecting over the left lower lung, which should be followed up with a chest CT on a nonemergent basis. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Melena, Transfer Diagnosed with Gastrointestinal hemorrhage, unspecified temperature: 96.5 heartrate: 80.0 resprate: 16.0 o2sat: 96.0 sbp: 112.0 dbp: 70.0 level of pain: 0 level of acuity: 2.0
Dear Mr. ___, It was a pleasure to care for you at the ___ ___. Why did you come to the hospital? -You were having black sticky stools which was concerning for bleeding from your intestines. What did you receive in the hospital? -You underwent a colonoscopy which showed that you had blood clot over the site where they removed a polyp a few weeks ago during a prior colonoscopy. This suggests that you had a recent bleed from this area, though there were no signs of active bleeding seen. You had clips placed over this area to prevent any further bleeding. You were also seen to have an ulcer at another site where you had a polyp remove which is a normal process of healing after a polyp removal; this did not show any signs of bleeding and a clip was placed at that site to prevent any possible future bleeding. -You were monitored for any more signs of bleeding afterwards and we held your blood thinner Eliquis (apixaban) for 48 hours to decrease your risk of rebleeding. -Your blood counts were stable while you were here which was reassuring that you had no more bleeding. -You did not have any bowel movements while here to show that there was no more bleeding but we were reassured by your blood counts. -We felt you were stable after 2 nights of monitoring and discharged you home. What should you do once you leave the hospital? -Please resume your Eliquis on the morning of ___. -Please make sure to get a CT scan of your lungs to work up the lung nodule that we found. -Please monitor your bowel movements at home. It may be normal for you to have a small streaks of black in your first bowel movement from blood that remained in your intestines after the colonoscopy. If you continue to have large black sticky bowel movements or large amounts of blood in your bowel movements - please call your doctor. If you are having any lightheadedness, dizziness, chest pain, trouble breathing or any other symptoms that concern you please go to the nearest emergency room. -Please follow up with your primary care office as scheduled below We wish you the best! Your ___ Care Team
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 bicycle accident Major Surgical or Invasive Procedure: ___: Open reduction, internal fixation, right olecranon using tension band.Irrigation and debridement including skin, subcutaneoustissue, muscle and bone, excisional debridement of hematoma, right elbow. ___: Open reduction, internal fixation of right anterior column acetabular fracture with intercolumnar screws and supra-acetabular screws with minimal invasive exposure History of Present Illness: ___ year female with no PMH presenting to the ED s/p bike accident. Per family, she was riding her bike and hit a stick in the road and fell off her bike, + LOC, no helmet. Per the family, when they went back to see her she was unresponsive at the scene, whole body tremors and "foaming" at the mouth, this episode lasted for approximately 30 seconds, - incontinence. After episode, was confused and within ___ minutes was oriented but drowsy. + nausea, + headache. She complains of right hip and right elbow pain in the trauma bay. Past Medical History: none Social History: ___ Family History: noncontributory Physical Exam: Admission Physical Exam: VS - 98.2 79 104/53 19 100% RA General: alert, in mild discomfort HEENT: R forehead abrasion and hematoma, PERRL, EOMI, Oropharynx WNL Neck: supple. C-collar. CV: RRR, no murmur Lungs: CTAB, normal work of breathing Abdomen: soft, NT, ND GU: +foley Ext: splint to RUE, ttp over R hip Neuro: alert and oriented to self, year, place. CN ___ intact. Moving all extremities. Skin: no rash Discharge Physical Exam: VS: 97.9 F, 62, 107/60, 18, 98% RA N: A&Ox3. PERRL. follows commands. Moves all extremities. Right arm full ROM strength not assessed r/t non weight bearing. CV: RRR, no murmur Lungs: CTAB Abdomen: soft, non-tender, non-distended Ext: warm and dry. no edema Skin: grossly intact. abrasion to right side of face. sutures to right elbow. two sites with single suture to right anterior pelvis. Pertinent Results: ___ 05:25AM BLOOD WBC-5.1 RBC-3.29* Hgb-9.7* Hct-29.1* MCV-88 MCH-29.5 MCHC-33.3 RDW-11.9 RDWSD-38.6 Plt ___ ___ 04:55AM BLOOD WBC-5.0 RBC-3.21* Hgb-9.5* Hct-28.8* MCV-90 MCH-29.6 MCHC-33.0 RDW-12.1 RDWSD-39.7 Plt ___ ___ 04:30AM BLOOD WBC-5.9 RBC-3.05* Hgb-8.9* Hct-27.4* MCV-90 MCH-29.2 MCHC-32.5 RDW-12.2 RDWSD-39.6 Plt ___ ___ 08:42PM BLOOD WBC-8.0# RBC-3.10* Hgb-9.2* Hct-27.9* MCV-90 MCH-29.7 MCHC-33.0 RDW-12.3 RDWSD-40.1 Plt Ct-88* ___ 04:53PM BLOOD WBC-5.1# RBC-3.10* Hgb-9.1* Hct-28.1* MCV-91 MCH-29.4 MCHC-32.4 RDW-12.3 RDWSD-40.4 Plt Ct-81* ___ 11:38PM BLOOD WBC-13.2* RBC-3.58* Hgb-10.5* Hct-31.8* MCV-89 MCH-29.3 MCHC-33.0 RDW-12.1 RDWSD-39.7 Plt ___ ___ 03:45PM BLOOD WBC-10.7* RBC-4.19 Hgb-12.5 Hct-37.2 MCV-89 MCH-29.8 MCHC-33.6 RDW-12.1 RDWSD-38.8 Plt ___ ___ 08:42PM BLOOD Glucose-109* UreaN-8 Creat-0.6 Na-138 K-3.4 Cl-103 HCO3-26 AnGap-12 ___ 04:53PM BLOOD Glucose-89 UreaN-7 Creat-0.5 Na-137 K-3.8 Cl-103 HCO3-22 AnGap-16 ___ 06:37AM BLOOD Glucose-108* UreaN-9 Creat-0.5 Na-135 K-3.7 Cl-103 HCO3-23 AnGap-13 ___ 11:38PM BLOOD Glucose-111* UreaN-15 Creat-0.6 Na-137 K-3.7 Cl-103 HCO3-23 AnGap-15 ___ 12:43AM BLOOD Lactate-1.0 ___ 03:58PM BLOOD Glucose-125* Lactate-3.8* Na-138 K-3.3 Cl-100 Radiology: ___ pelvis: Several fluoroscopic images from the operating room demonstrate placement of 2 screws in the right hemipelvis. Single screw is seen within the right iliac bone and a second screw is seen through the superior pubic rami along the iliopectineal line. This is fixating a minimally displaced acetabular fracture. No hardware related complications are seen. ___ right knee: Small effusion. No acute fracture is seen ___ R Shoulder XRAY: No fracture or dislocation in the right upper humerus, imaged right scapula and distal clavicle and adjacent ribs ___ R Forearm Xray: Acute open displaced fracture of the right olecranon ___ CT C Spine: No cervical spine fracture or malalignment ___ CT Torso: No acute soft tissue or organ injury within the torso. 2. Small amount of free fluid in the pelvis, nonspecific and can be physiologic but correlation with physical exam is suggested. 3. Minimally displaced fracture of the right acetabulum involving the anterior and medial walls with fracture line extending to the right iliac wing. 4. Minimally displaced fracture of the parasymphyseal right pubic bone at the pubic symphysis. 5. 4.9 cm well-circumscribed fat containing lesion at the left adnexa, compatible with a dermoid. ___ Pelvis XRAY: Full extent of the nondisplaced fracture involving the right acetabulum, superior pubic or a mass, and extend into the right iliac wing are shown to better advantage by the torso CT and oblique views of the pelvis obtained today. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H pain RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 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. Milk of Magnesia 30 mL PO Q6H:PRN constipation 4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every three (3) hours Disp #*60 Tablet Refills:*0 5. Polyethylene Glycol 17 g PO DAILY 6. Senna 8.6 mg PO BID:PRN constipation 7. Enoxaparin Sodium 40 mg SC QHS Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg SC at bedtime Disp #*14 Syringe Refills:*1 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Anterior column acetabular fracture, right side Right open olecranon fracture Left subarachnoid hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: Trauma. TECHNIQUE: Single supine view of the chest. COMPARISON: None. FINDINGS: The lungs are clear. There is no focal consolidation. No evidence of pneumothorax on this supine film. The cardiomediastinal silhouette is within normal limits. No visualized fractures. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with +head strike +LOC off bike // acute IC process TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformats were also performed. DOSE: Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: There is artifact from motion and beam hardening centered at the skullbase. Noting this, there is hyperdensity in the region of the left sylvian fissure. It is uncertain if this is artifactual or due to subarachnoid hemorrhage (2:11, 12). There is no mass, midline shift, or acute major vascular territorial infarct. No other evidence of hemorrhage. Gray-white matter differentiation is preserved. Ventricles and sulci and unremarkable. Basilar cisterns are patent. Included paranasal sinuses and mastoids are essentially clear besides partial opacification of the right posterior ethmoids. There is right forehead scalp swelling without underlying fracture. Skull and extracranial soft tissues are otherwise unremarkable. IMPRESSION: Hyperdensity in the region of the left sylvian fissure, potentially artifactual although subarachnoid hemorrhage cannot be excluded. Repeat exam is suggested. No other evidence of acute intracranial hemorrhage. Right frontal scalp swelling without underlying fracture. NOTIFICATION: Findings discussed by Dr. ___ with Dr. ___ at 24:30 on ___ in person at time of discovery. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ year old woman with +head strike +LOC off bike // acute fx/malalign TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Total DLP (Body) = 732 mGy-cm. COMPARISON: None. FINDINGS: Alignment is normal. No fractures are identified.There is no significant canal or foraminal narrowing.There is no prevertebral edema. The thyroid and included lung apices are unremarkable. IMPRESSION: No cervical spine fracture or malalignment. Radiology Report INDICATION: ___ year old woman with fall off bike, evaluate for acute process, difficulty moving legs TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and pelvis following intravenous contrast administration with split bolus technique. IV Contrast: 130 mL Omnipaque. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 433 mGy-cm. COMPARISON: None. FINDINGS: CHEST: HEART AND VASCULATURE: The thoracic aorta is normal in caliber without evidence of acute injury. There is no mediastinal hematoma. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass or hematoma. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal opacification. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesion or laceration. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesion or laceration. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. There is no evidence of mesenteric injury. There is no free fluid or free air in the abdomen. PELVIS: The urinary bladder and distal ureters are unremarkable. There is a small amount of free fluid in the cul-de-sac. REPRODUCTIVE ORGANS: The uterus is unremarkable. At the left adnexa, there is a 4.9 x 4.9 cm well circumscribed predominantly fat containing lesion with some internal soft tissue and calcifications. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma. No atherosclerotic disease is noted. BONES: There is a minimally displaced fracture of the right acetabulum involving the anterior and medial walls extending to the right iliac wing. There is also a minimally displaced fracture of the parasymphyseal right pubic bone. No focal suspicious osseous abnormality. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No acute soft tissue or organ injury within the torso. 2. Small amount of free fluid in the pelvis, nonspecific and can be physiologic but correlation with physical exam is suggested. 3. Minimally displaced fracture of the right acetabulum involving the anterior and medial walls with fracture line extending to the right iliac wing. 4. Minimally displaced fracture of the parasymphyseal right pubic bone at the pubic symphysis. 5. 4.9 cm well-circumscribed fat containing lesion at the left adnexa, compatible with a dermoid. NOTIFICATION: Findings discussed with Dr. ___ the trauma team in person, at 16:30 on ___, 2 minutes following discovery. Finding of free fluid was subsequently discussed by Dr. ___ with Dr. ___ the phone. Radiology Report INDICATION: b24F with right elbow pain and laceration after fall from bicycle // eval for fracture/dislocation TECHNIQUE: Three views of the right elbow. COMPARISON: None. FINDINGS: There is an acute displaced fracture through the olecranon process. The proximal fracture fragment is displaced approximately by 2.8 cm. There is no definite other fracture noting suboptimal views due to patient's injury. There is subcutaneous gas and apparent gas within the joint space as well. IMPRESSION: Acute open displaced fracture of the right olecranon. Radiology Report EXAMINATION: PELVIS (AP ONLY) PORT INDICATION: ___ year old woman with s/p bicycle accident, acetabular fracture on CT in the ED // eval acetabular fracture eval acetabular fracture TECHNIQUE: Frontal view of the pelvis. COMPARISON: Torso CT ___. IMPRESSION: Full extent of the nondisplaced fracture involving the right acetabulum, superior pubic or a mass, and extend into the right iliac wing are shown to better advantage by the torso CT and oblique views of the pelvis obtained today. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman status post bike accident with possible subarachnoid hemorrhage on imaging. Evaluate for interval change. Please perform at 22:00 on ___ TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal, sagittal thin-section bone algorithm images were obtained. DOSE: Total DLP (Head) = 803 mGy-cm. COMPARISON: CT head from ___ at 16:06. FINDINGS: Small amount of subarachnoid hemorrhage along the left temporal lobe is seen (series 2: Image 13). Otherwise, no new intracranial hemorrhage, territorial infarct, mass or edema is seen. The ventricles and sulci are normal in size and configuration. There is no evidence of fracture. Moderate amount of fluid is seen in the right maxillary sinus. The visualized portion of the other paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. Right parietal subgaleal hematoma/swelling is minimally more prominent when compared to prior exam. No skull fractures. IMPRESSION: Interval evolution of left temporal subarachnoid hemorrhage along the sylvian fissure. No definitive new intracranial hemorrhage or infarction. Radiology Report EXAMINATION: ELBOW, AP AND LAT VIEWS IN O.R. RIGHT INDICATION: I D ORIF RIGHT OLECRANON FRACTURE TECHNIQUE: Screening provided in the operating room without a radiologist present. COMPARISON: ___ FINDINGS: Total fluoroscopy time 49.5 seconds. Images demonstrate fixation of olecranon fracture. With pins and cerclage wires. For details of procedure, please consult the procedure report. IMPRESSION: Screening for procedure guidance. Radiology Report EXAMINATION: SHOULDER 1 VIEW RIGHT INDICATION: ORIF RIGHT OLECRANON FX TECHNIQUE: One AP One view of the right shoulder. COMPARISON: Torso CT ___. IMPRESSION: No fracture or dislocation in the right upper humerus, imaged right scapula and distal clavicle and adjacent ribs. Radiology Report EXAMINATION: PELVIS W/JUDET VIEWS (3V) INDICATION: R/O FRACTURE TECHNIQUE: 2 oblique views of the hips. COMPARISON: 2 oblique views of the pelvis are obtained IMPRESSION: Right acetabular fracture extends into the right iliac wing posteriorly to the upper margin of the RPO view. Both femurs are intact. Radiology Report EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT INDICATION: ___ year old woman s/p MVC accident with right knee pain // acute fractures? acute fractures? TECHNIQUE: Three views of the left knee COMPARISON: None available. FINDINGS: Tricompartmental joint spaces are preserved. No acute fracture is seen. No concerning bone lesion. No chondrocalcinosis. No erosion. There is a small effusion. IMPRESSION: Small effusion. No acute fracture is seen. Radiology Report EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT INDICATION: ___ year old woman with Right knee pain // ?fracture ?fracture TECHNIQUE: Three views of the right knee. COMPARISON: None available FINDINGS: No acute fracture is seen. No concerning bone lesion. Joint spaces are preserved. There is a small effusion. Small soft tissue calcification medial subcutaneous tissues. No embedded radiopaque foreign body is seen. IMPRESSION: Small effusion. No acute fracture is seen. Radiology Report INDICATION: Acetabular fracture. ORIF. COMPARISON: Radiographs from ___ IMPRESSION: Several fluoroscopic images from the operating room demonstrate placement of 2 screws in the right hemipelvis. Single screw is seen within the right iliac bone and a second screw is seen through the superior pubic rami along the iliopectineal line. This is fixating a minimally displaced acetabular fracture. No hardware related complications are seen. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: PED STRUCK/HEAD INJURY Diagnosed with Disp fx of olecran pro w/o intartic extn right ulna, init, Unsp fracture of right acetabulum, init for clos fx, Traum subrac hem w LOC of 30 minutes or less, init, Pedl cyc driver inj pick-up truck, pk-up/van in traf, init temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: 10 level of acuity: nan
You were admitted to ___ after a bike accident. Your injuries include a right olecranon fracture, a right acetabular fracture, and a small bleed in your head. You were seen by Neurosurgery who reviewed your imaging. Your repeat head cat scan did not show any progression of the bleeding and your neuro exam has been stable. You do not need to follow-up with Neurosurgery. Orthopedics was consulted and you were taken to the operating room for repair of the olecranon fracture. INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Touch down weight bearing right lower extremity - non-weight bearing right upper extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take as prescribed. - You are being discharged home with Lovenox. You should give yourself one injection per day until follow up with the orthopedic surgery department outpatient. WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. - Splint can be worn for comfort as needed. - Do NOT get splint wet DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: HA/fever/body aches Major Surgical or Invasive Procedure: TEE (___) History of Present Illness: ___ MEDICINE ATTENDING ADMISSION NOTE . Date: ___ Time: 0200 _ ________________________________________________________________ PCP: Dr. ___. _ ________________________________________________________________ HPI: ___ with h/o tobacco use, HTN, COPD, discoid lupus, presents with fevers, lethargy thrombocytopenia. Patient received reclast 5 days ago and corticosteroid injections to LLF and RRF flexor trigger finger on ___. Developed fevers to 100.7 5 days ago after the reclast injection. She also had sx c/w Raynaud's as well. Complains of severe headache, neck pain, back pain, and myalgias for 5 days- worse with walking. Also reports cough with white sputum. Decreased appetite at home but reports no weight loss ? ___ lbs.Denies urinary sympotoms, chest pain, N/V. Conjunctivae became injected with increased drainage in the past week. No sick contacts. HV CXR read: New patchy right perihilar density most consistent with an acute inflammatory and/or infectious infiltrate but follow-up is recommended. In ER: (Triage Vitals:0 98.2 86 148/74 18 99% ) Meds Given: Morphine Sulfate (Syringe) 4mg Syringe [class 2] ___ ___, ___ ___ 18:20 &&Cefepime [___] ___ ___ ___ 20:30 Vancomycin 1g Frozen Bag ___ ___ ___ 20:32 Morphine Sulfate (Syringe) 4mg Syringe [class 2] 1 ___ ___ 20:47 Dexamethasone Sod Phosphate 10mg/mL Vial 4 ___ ___ 21:08 Acyclovir 500 mg in 5% Dextrose 1 from Pharmacy Diagnosis: PNA and ? mennigits [x]CXR: done at ___ [x]speak with hematolgy ___: transfuse platelets, decadron 40mg IV QD x4 days [X]CT abdomen- negative [x]CT head: no ICH While in the ED desated to 90% while sleeping and placed on 2L. Pt being admitted for multiple issues. 1) thrombocytopenia: got transfused, decadron per hematology recs. likely ITP 2) CXR suggest infection, also has syx concerning for meningitis. Will treat for both. Cannot tap ___ platelets Disposition/Pending: admit to medicine, hematology will see in the am Admission Vitals: sleeping 98.5 87 120/76 20 96% on ? 2L . Upon arrival to the floor the above history from the ED is confirmed. PAIN SCALE: ___ neck pain ________________________________________________________________ REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative" CONSTITUTIONAL: [] All Normal [+ ] Fever [ +] Chills [ ] Sweats [ ] Fatigue [ ] Malaise [ +]Anorexia [ ]Night sweats [- ] _____ lbs. weight loss/gain over _____ months Eyes [] All Normal [ ] Blurred vision [ -] Loss of vision [] Diplopia [ ] Photophobia + erythematous injected conjunctivae ENT [ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [- ] Sore throat [] Sinus pain [ ] Epistaxis [ ] Tinnitus [ ] Decreased hearing [ ] Other: RESPIRATORY: [] All Normal [+? ] Shortness of breath- she denies but her sister has noticed some increased sob [ ] Dyspnea on exertion [ ] Can't walk 2 flights [+ ] baseline Cough without clear change but it hurt to cough[ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [+]Pleuritic pain [ ] Other: CARDIAC: [] All Normal [ ?] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ -] Chest Pain [ ] Dyspnea on exertion [ ] Other: GI: [] All Normal [-] Nausea [-] Vomiting [+] Abd pain- b/l with palpation when she arrived in the ED [] Abdominal swelling [ +] Diarrhea- light brown, no blood, not black [ ] Constipation [ ] Hematemesis [ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids [ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux [ ] Other: GU: [X] All Normal [ ] Dysuria [ ] Incontinence or retention [ ] Frequency [ ] Hematuria []Discharge []Menorrhagia SKIN: [] All Normal [ -] Rash [ ] Pruritus MS: [] All Normal [+ ] Joint pain - per HPI [ ] Jt swelling [ ] Back pain [ ] Bony pain NEURO: [] All Normal [+ ] Headache [- ] Visual changes [ ] Sensory change [ ]Confusion [ ]Numbness of extremities [-] dysarthria [ ] Seizures [ -] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo [ ] Headache ENDOCRINE: [X] All Normal [ ] Skin changes [ ] Hair changes [ ] Heat or cold intolerance [ ] loss of energy HEME/LYMPH: [X] All Normal [ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy PSYCH: [X] All Normal [ ] Mood change []Suicidal Ideation [ ] Other: ALLERGY: [- ]Medication allergies [ ] Seasonal allergies []all other systems negative except as noted above Past Medical History: LUNG DISEASE, CHRONIC OBSTRUCTIVE Hypertension Thyroid nodule BENIGN NEOPLASM - PANCREAS- s/p pancreatectomy and splenectomy ??DECLINED - COPD (NOT DX, FOR PROB LIST ONLY) GOITER - NONTOXIC MULTINODULAR TOBACCO DEPENDENCE OSTEOPOROSIS HEARING LOSS, SENSORINEURAL DISCOID LUPUS SCREENING FOR ___ CANCER Lumbar Spinal Stenosis Social History: ___ Family History: She is ___ of 6 siblings and only she and her sister are left. Brother ___ Cancer- ___ lung cancer Father ___ and died of metastatic prostate cancer with asbestos exposure. Mother ___ and asbestos exposure secondary to husband- died at age ___. Sister died of ALS but also had breast and bladder cancer Oldest sister with rheumatoid arthritis and lung cancer. Physical Exam: PHYSICAL EXAM: I3 - PE >8 VITAL SIGNS: GLUCOSE: PAIN SCORE ___. VS T 98.7 P 93 BP 154/84 RR O2Sat on __100% RA__ Gen: Thin female laying bed, NAD. Sister at bedside. Nourishment: Thin, she appears frail, pale and ? chronic vs acute illness Grooming: OK Mentation: alert, speaks in full sentences, looks exhausted. 2. Eyes: [] WNL Injected erythematous conjunctivae b/l 3. ENT [] WNL [+] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm [] Dry [+] Poor dentition [] Thrush [] Swelling [] Exudate 4. Cardiovascular [X] WNL [] Regular [] Tachy [X] S1 [X] S2 [] Systolic Murmur /6, Location: [X] Edema RLE None [] Bruit(s), Location: [X] Edema LLE None [] PMI [] Vascular access [X] Peripheral [] Central site: 5. Respiratory [ ] Decreased BS throughout out. Occasional soft wheezes. She does look as though her breathing is a little labored. 6. Gastrointestinal [ X] 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 [x] WNL [ ] Tone WNL [X ]Upper extremity strength ___ and symmetrical [ ]Other: [ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica [ ] Other: 8. Neurological [X] WNL [X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ] CN II-XII intact [ X] Normal attention [ ] FNF/HTS WNL [] Sensation WNL [ ] Delirious/confused [ ] Asterixis Present/Absent [ ] Position sense WNL [ ] Demented [ ] No pronator drift [] Fluent speech 9. Integument [X] WNL [] Warm [] Dry [] Cyanotic [] Rash: none/diffuse/face/trunk/back/limbs [ ] Cool [] Moist [] Mottled [] Ulcer: None/decubitus/sacral/heel: Right/Left 10. Psychiatric [X] WNL [X] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated [] Pleasant Pertinent Results: ___ 09:05PM PLT COUNT-48*# ___ 06:12PM COMMENTS-GREEN ___ 06:12PM LACTATE-0.9 ___ 04:37PM GLUCOSE-144* UREA N-48* CREAT-1.0 SODIUM-131* POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-23 ANION GAP-13 ___ 04:37PM estGFR-Using this ___ 04:37PM ALT(SGPT)-33 AST(SGOT)-39 ALK PHOS-149* TOT BILI-0.7 ___ 04:37PM LIPASE-50 ___ 04:37PM ALBUMIN-3.6 ___ 04:37PM URINE HOURS-RANDOM ___ 04:37PM URINE GR HOLD-HOLD ___ 04:37PM WBC-9.0 RBC-4.47 HGB-15.6 HCT-45.0 MCV-101* MCH-34.9* MCHC-34.7 RDW-13.7 ___ 04:37PM NEUTS-85* BANDS-2 LYMPHS-7* MONOS-4 EOS-0 BASOS-0 ATYPS-2* ___ MYELOS-0 ___ 04:37PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL TARGET-OCCASIONAL BURR-OCCASIONAL HOW-JOL-OCCASIONAL ___ 04:37PM PLT SMR-RARE PLT COUNT-6* ___ 04:37PM ___ PTT-31.1 ___ ___ 04:37PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04:37PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 04:37PM URINE HYALINE-3* ___ 04:37PM URINE MUCOUS-RARE ------------------ Admission Abdominal CT: No clear CT explanation for patient's abdominal pain. -No bowel obstruction or inflammation -Appendix not visualized though no secondary signs of acute appendicitis -Indeterminate right renal hypodensity - likely a hyperdense cyst. Consider non-emergent renal ultrasound -Severe degenerative changes of the lumbar spine Head CT: no acute intracranial process. ECG: Rate = 91 bpm, incomplete RBBB, TWI in leads V1- V3. . . . TTE (___): No echocardiographic evidence of endocarditis in a high quality study. Normal regional and global biventricular systolic function. Moderate pulmonary hypertension. Mildly dilated right ventricle with preserved systolic function. . TEE (___): Mild aortic and mitral leaflet thickening without discrete valvular pathology or pathologic valvular regurgitation. No evidence of endocarditis. Extensive suimple atheroma in thoracic aorta. . PCXR (___): Right PICC in standard position with distal tip in the mid SVC. No pneumothorax. Previously identified right perihilar opacity is less dense on this study and may represent interval improvement. . . Discharge Labs: ___ 06:32AM BLOOD WBC-16.2* RBC-3.55* Hgb-11.8* Hct-34.6* MCV-97 MCH-33.2* MCHC-34.1 RDW-14.3 Plt ___ ___ 06:32AM BLOOD Glucose-159* UreaN-16 Creat-0.5 Na-134 K-4.5 Cl-98 HCO3-32 AnGap-9 ___ 06:32AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8 . . Microbiology Blood Cx (___) Blood Culture, Routine (Final ___: STREPTOCOCCUS GALLOLYTICUS SSP PASTEURIANUS. FINAL SENSITIVITIES. Sensitivity testing performed by Sensititre. CLINDAMYCIN = <=0.12 MCG/ML. CEFTRIAXONE = 0.125 MCG/ML = S. CEFTRIAXONE Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS GALLOLYTICUS SSP PASTEURIANUS | CLINDAMYCIN----------- S ERYTHROMYCIN----------<=0.25 S PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S Surveillance Blood Cx's: ___ - no growth. ___ - no growth to date, final pending. . . Medications on Admission: Zoledronic Acid-Mannitol&Water (RECLAST) 5 mg/100 mL Intravenous Solution reclast 5mg/100ml infuse as directed Losartan 50 mg Oral tablet Take 1 tablet daily Clobetasol 0.05 % Topical Cream APPLY TO ITCHY RED SPOTS ON THE BODY.NEVER FOR USE ON THE FACE Desonide 0.05 % Topical Cream APPLY AS DIRECTED once to twice daily AS NEEDED Triamcinolone Acetonide 0.1 % Topical Cream apply 2x/day to body rash as needed for itch&redness for up to 2wks.not on face, neck,under arms or breasts or in groin Hydrochlorothiazide 50 mg Oral Tablet take one tablet daily Fluticasone-Salmeterol (ADVAIR DISKUS) 100-50 mcg/dose Inhalation Disk with Device INHALE 1 PUFF TWICE DAILY Potassium Chloride 10 mEq Oral Tablet Extended Release TAKE 4 TABLETS TWICE DAILY Albuterol Sulfate (PROAIR HFA) 90 mcg/Actuation Inhalation HFA Aerosol Inhaler ___ puffs every ___ hours as needed; dispense ProAir if generic inhaler is not available Hydrocortisone Valerate 0.2 % Topical Cream APPLY TWICE DAILY AS DIRECTED TO THE FACE FOR ITCHY RED FLARES ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION use 1 ampule EVERY FOUR TO SIX HOURS AS NEEDED for asthma symptoms FISH OIL 1,000 MG CAP (OMEGA-3 FATTY ACIDS/VITAMIN E) daily VITAMIN D-3 400 UNIT TAB (CHOLECALCIFEROL) 1 by mouth once daily B COMPLEX ___ TAB (VITAMIN B COMPLEX) 1 by mouth once daily VITAMIN C 500 MG TAB (ASCORBIC ACID) 1 by mouth once daily MAGNESIUM OXIDE 250 MG TAB 1 by mouth once daily SELENIMIN 200 MCG TAB (SELENIUM) 1 by mouth once daily LYSINE 500 MG TAB 1 by mouth once daily COENZYME Q10 100 MG CAP (UBIDECARENONE) 1 by mouth once daily PRIMROSE OIL 1,000 MG CAP (EVE PRIM/LINOLEIC/GAMOLENIC AC) taking 1300mg daily ASTRAGALUS ROOT 250 MG CAP taking 500mg/day MILK THISTLE 140 MG CAP taking 70mg/day MULTIVITAMIN CAPSULE PO (MULTIVITAMINS) 1 TABLET DAILY Discharge Medications: 1. CeftriaXONE 2 gm IV Q 12H please continue until ___ for a total of a 2 week course ___ - ___ RX *ceftriaxone 2 gram 2 grams IV every twelve (12) hours Disp #*16 Bag Refills:*0 2. Losartan Potassium 50 mg PO DAILY RX *losartan 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 4. Ascorbic Acid ___ mg PO BID 5. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob 6. Artificial Tears Preserv. Free ___ DROP BOTH EYES HS:PRN dry eyes RX *dextran 70-hypromellose [Artificial Tears] ___ drops in each eye at bedtime Disp #*1 Bottle Refills:*0 7. Calcium Carbonate 500 mg PO QID:PRN heart burn RX *calcium carbonate 200 mg calcium (500 mg) 1 tablet(s) by mouth four times a day Disp #*120 Tablet Refills:*0 8. 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 9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush 10. Reclast *NF* (zoledronic acid-mannitol&water) 5 mg/100 mL Injection q ___ year Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Strep Bovis pneumonia, meningitis and bacteremia hyponatremia hypocalcemia thromobocytopenia Sjogrens sydrome hematuria Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HEAD CT WITHOUT CONTRAST: ___. HISTORY: ___ female with platelet count of 3, fevers and headache. Abdominal pain. TECHNIQUE: Contiguous axial images were obtained from skull base to vertex without intravenous contrast. Coronal and sagittal reformats were reviewed. COMPARISON: None listed. FINDINGS: There is no acute intra-axial or extra-axial hemorrhage, mass, midline shift, or territorial infarct. The ventricles and sulci are symmetric and unremarkable. The gray-white matter differentiation is preserved. Mucous retention cyst is seen in the left maxillary sinus. There is also partial opacification of the bilateral ethmoid air cells and mucosal thickening in the sphenoid sinuses. Mastoid air cells are clear. Skull and extracranial soft tissues are unremarkable. IMPRESSION: No acute intracranial process. Radiology Report HISTORY: ___ female with fevers, thrombocytopenia, and diffuse abdominal pain COMPARISON: None available TECHNIQUE: ___ MDCT-acquired axial images from the lung bases to the pubic symphysis were displayed with 5-mm slice thickness. Intravenous contrast was administered. Coronal and sagittal reformations were prepared. CT ABDOMEN WITH INTRAVENOUS CONTRAST: There is minimal bibasilar atelectasis. No pleural effusion is identified. The imaged cardiac apex is within normal limits. There are multiple too small to characterize hypodensities throughout the liver (2:9, 11, 18, 26), likely small cysts or biliary hamartomas. No suspicious hepatic lesion is identified. The hepatic veins and portal venous system are grossly patent. No intra- or extra-hepatic biliary ductal dilatation is identified. The gallbladder is mildly distended, though without pericholecystic fluid or wall thickening. The spleen is not visualized, likely secondary to prior surgical resection. The pancreatic head, neck, and proximal body appear normal. Surgical clips are seen in the region of the pancreatic tail, likely due to prior distal pancreatectomy (2:20). No pancreatic ductal dilatation is noted. The adrenal glands are symmetric without focal lesion. There is symmetric enhancement and excretion of both kidneys without suspicious focal lesion or hydronephrosis. A 1.3 x 1.6 cm hypodense lesion is identified within the interpolar region of the right kidney with indeterminate attenuation values, likely a hyperdense cyst (2:23). Non-emergent renal ultrasound could be performed for further evaluation. There is no abdominal free fluid or free air. The abdominal aorta and its branch vessels demonstrate moderate atherosclerotic calcifications, though are non-aneurysmal and grossly patent. Stomach and small bowel loops are normal in caliber and configuration without evidence of obstruction or inflammation. The appendix is normal. CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum and colon are normal in caliber and configuration without evidence of obstruction or inflammation. The bladder is distended and appears normal. The uterus and adnexa appear unremarkable. No pelvic free fluid is identified. OSSEOUS STRUCTURES: No bone destructive lesion or acute fracture is identified. There is mild S-shaped scoliosis of the lumbar spine with loss of vertebral body height at multiple levels, most severe at L1 and L2. IMPRESSION: 1. Small subcentimeter hypodensities throughout the liver, likely small cysts, though too small to characterize. 2. 1.6-cm hypodense lesion in the interpolar region of the right kidney, likely a hyperdense parapelvic cyst. Non-emergent renal ultrasound is recommended for further evaluation. 3. Severe degenerative changes of the lumbar spine with loss of height at multiple levels, though no malalignment. Radiology Report CHEST RADIOGRAPH INDICATION: Right perihilar density, mild thrombocytopenia, evaluation for developing pneumonia. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the right perihilar opacity is almost unchanged in extent and appearance. The opacity is rounded and adjacent to the minor fissure. The opacity also cannot completely be differentiated against a structure of the right hilus. The differential diagnosis should not only include pneumonia, but also the possibility of a part solid neoplasm, potentially associated with right hilar adenopathy. This finding should best be confirmed or excluded by CT. At the right lung base, mild peribronchial thickening persists. The left lung is normal. Bilateral apical thickening is symmetrical. The presence of bilateral dorsal minimal pleural effusions cannot be excluded. Borderline size of the cardiac silhouette without evidence of pulmonary edema. Radiology Report INDICATION: New PICC placement. COMPARISON: Comparison is made to radiographs of the chest from ___ and ___. FINDINGS: Frontal radiograph of the chest demonstrates a right subclavian line in standard position with distal tip terminating in the mid SVC. The previously seen right perihilar opacity is less dense on this study and may be resolving, however, it is difficult to compare the current portable AP view with the prior PA and lateral views for subtle changes of this finding. Further imaging of this area with either conventional radiographs or CT is recommended if clinically justified. The cardiomediastinal silhouette is unremarkable. There is no evidence of new focal consolidation, pleural effusion or pulmonary edema. CONCLUSION: Right PICC in standard position with distal tip in the mid SVC. No pneumothorax. Previously identified right perihilar opacity is less dense on this study and may represent interval improvement. The above findings were communicated to IV nurse, ___, via telephone by Dr. ___ at 12:30, at the time of discovery. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: LETHARGY Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, THROMBOCYTOPENIA NOS temperature: 98.2 heartrate: 86.0 resprate: 18.0 o2sat: 99.0 sbp: 148.0 dbp: 74.0 level of pain: 0 level of acuity: 3.0
___ were admitted to ___ with fatigues, myalgias and cough and were found to have pneumonia and likely meningitis with bacteria in your blood. ___ improved with antibitoics. ___ were also found to have a low platelet count, which improved with steroids. ___ will be sent home with IV antibioitcs and will need to complete a 2 week course of IV antibiotics. ___ should follow closely with your outpatient team of doctors. ___ will need an outpt colonoscopy. . ___ underwent a transesophageal echocardiogram, which did not show evidence of infection in your heart valves. . Medications changes-see next page. please take as prescribed / listed. . Please f/u with your doctors as listed below. .
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Ace Inhibitors / lisinopril Attending: ___. Chief Complaint: nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: ERCP ___ History of Present Illness: ___ year old female with nausea, vomiting, abdominal pain for three four days. Symptoms triggered only after eating; patient essentially asymptomatic when not eating. Abdominal pain sharp, epigastric/RUQ, and radiating to back. No fevers or chills. No diarrhea. No chest pain or dyspnea. Seen in local ED two days ago, complaining of back pain, given cyclobenzeprine. Yesterday, during hemodialysis, looked unwell, brought back to local ED with SBP 84 mmHg. Given history, concern for biliary pathology. Labs obtained, T. bili, alkaline phosphatase, and INR elevated. Ultrasound suggestive of common bile duct obstruction. The patient has penicillin allergy, was given levofloxacin (per report, no documentation), vitamin K (per report, no documentation), gentle IV fluid bolus, and transferred to ___ for ERCP. . ___ ED Course (labs, imaging, interventions, consults): - Initial Vitals: 99.4 78 90/43 18 95% 4L Nasal Cannula - guaiac negative . Upon tranfer from ED: Mental Status: alert and oriented x 3, very pleasant Lines & Drains: #22g IV in left DH-after multiple attemps, very poor access. Fluids: NS 500 cc bolus Drips: Received flagyl 500mg IV, and 2 units of FFP Precautions:Universal Belongings: with patient Most Recent Vitals: 98.3 79 92/44 23 99%RA . Upon arrival to floor, patient felt well. Denied abdominal pain, no nausea. No other complaints. . 12 point ROS as noted above, otherwise negative. Past Medical History: -Renal Failure on Dialysis for over ___ years (___) -Type II DM -HTN -protein C deficiency, homosyteinanemia, spontan DVT s/p IVC filter about ___ years ago -AV fistula placement Social History: ___ Family History: No family history of biliary pathology. Physical Exam: VS: 98.4 104/75 HR 80 16 95% 2 liters nasal cannula General: pleaseant female, appears tired, no distress HEENT: mild scleral icterus Cardiac: RRR, normal S1, S2. II/VI SEM at ___ without radiation. No thrills or rubs. Pulm: bibasilar rales Abdomen: obese, soft, non-distended, non-tender Ext: 2+ radial and DP pulses. AV fistula in RUE; failed grafts in LUE. trace bilateral ___ edema Neuro: CNs intact. Strength and sensation grossly intact. Pertinent Results: Abdominal ultrasound (pre-liminary) CBD dilated to 1.4 cm. No intrahepatic bile duct dilatation. Pancreas obscured by overlyign bowel gas. Cholelithiasis without cholecystitis. Numerous shadowing right renal stones. Labs: blood cultures ___ pending WBC-16.1* RBC-3.47* HGB-11.6* HCT-36.2 MCV-105* MCH-33.4* MCHC-31.9 RDW-15.0 NEUTS-89.2* LYMPHS-8.5* MONOS-2.0 EOS-0.2 BASOS-0.1 PLT COUNT-160 LACTATE-2.6* GLUCOSE-148* UREA N-31* CREAT-7.9* SODIUM-132* POTASSIUM-4.8 CHLORIDE-90* TOTAL CO2-25 ANION GAP-22* ALT(SGPT)-66* AST(SGOT)-138* ALK PHOS-251* TOT BILI-7.0* LIPASE-13 ALBUMIN-2.9* ___ PTT-70.5* ___ Medications on Admission: - Coumadin - nifedipine ER 30 mg tablet,24 hr extended release Oral 1 tablet extended release 24hr(s) Once Daily - Lipitor 20 mg tablet Oral 1 tablet(s) Once Daily - pentoxifylline ER 400 mg tablet,extended release Oral 1 tablet extended release(s) Three times daily - allopurinol ___ mg tablet Oral 1 tablet(s) Twice Daily - Humulin N 100 unit/mL Susp, Sub-Q Inj Subcutaneous 1 Suspension(s) unknown times daily - trazodone 50 mg tablet Oral 1 tablet(s) Once Daily, at bedtime - Diovan 80 mg tablet Oral 1 tablet(s) Twice Daily Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Ciprofloxacin HCl 500 mg PO Q24H RX *Cipro 500 mg 1 tablet(s) by mouth once a day Disp #*5 Tablet Refills:*0 3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *Flagyl 500 mg 1 tablet(s) by mouth three times a day Disp #*15 Tablet Refills:*0 4. NIFEdipine *NF* 30 mg Oral daily extended release 5. Pentoxifylline 400 mg PO DAILY extended release 6. Valsartan 80 mg PO BID 7. Allopurinol ___ mg PO EVERY OTHER DAY 8. Atorvastatin 20 mg PO DAILY 9. Glargine 25 Units Bedtime 10. Warfarin 3 mg PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: cholangitis choledocholithiasis esrd protein c deficincy 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 cholangitis, ERCP, pre-operative chest x-ray. COMPARISON: No comparison available at the time of dictation. FINDINGS: The lung volumes are normal. Borderline size of the cardiac silhouette with no evidence of overt pulmonary edema. No pleural effusions, no pneumonia. Normal appearance of the hilar and mediastinal structures. Radiology Report STUDY: MR of the abdomen. INDICATION: ___ female with end-stage renal disease, on hemodialysis, presenting with cholangitis from choledocholithiasis status post ERCP, now with increasing total bilirubin, question choledocholithiasis. COMPARISON: No previous MR examination is available for comparison. Correlation is made to ultrasound abdomen dated ___. TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained on a 1.5 Tesla magnet. IV contrast was not administered for the examination. 2.5 mL of Gadavist was mixed with 75 mL of water and was administered as enteric contrast. FINDINGS: The lung bases are clear. In the liver, there is ill-defined, poorly characterized lesion in segment ___ of the liver measuring 1.6 x 1.3 cm in size, which is hypointense on T1 sequences (series 15, image 13) and hyperintense on the T2 sequences (series 16, image 6). There is no intrahepatic biliary ductal dilatation. Again noted is dilatation of the middle aspect of the common hepatic duct measuring up to 12 mm in size (series 3, image 10). There is anatomic variant with low and medial insertion of the cystic duct (series 3, image 11). There is a large gallstone within the fundus of the gallbladder measuring 1 cm in size. No filling defects are seen in the extrahepatic biliary tree to suggest choledocholithiasis. Evaluation for cholangitis is limited due to lack of IV contrast administration. The adrenal glands and spleen appear within normal limits. In the pancreatic neck, note is made of an 11 x 4 mm T2 hyperintense lesion (series 9, image 18) which likely represents a side branch IPMN versus a pancreatic cyst. Additional smaller similar lesions measuring less than 5 mm in size are seen in the uncinate process (series 9, image 22) and tail of the pancreas (series 9, image 14). The pancreatic duct is nondilated. There are no inflammatory changes about the pancreas. The kidneys appear atrophic and there are multiple small T2 hyperintense lesions in the left kidney, most suggestive of acquired renal cysts. Nonspecific fluid signal intensity is seen around the kidneys bilaterally. There is no upper abdominal lymphadenopathy. No obvious abnormalities are seen in the bowel. Bone marrow signal is within normal limits. IMPRESSION: 1. No MRCP evidence of choledocholithiasis. 2. Low and medial insertion of the cystic duct, anatomic variant. 3. Incompletely characterized focal lesion in segment ___ of the liver, slightly hyperintense on T2-weighted images, and not well evaluated without contrast. Dedicated hepatic imaging or comparison with prior studies suggested for further characterization. Given ESRD/hemodialysis, consideration could be made for multiphasic CT with IV contrast, and coordination with dialysis schedule. 4. Multiple cystic lesions in the pancreas, the largest of which measures about 11 mm in size in the pancreatic neck. A followup MRI could be considered in six months (as clinically indicated) to ensure stability, or comparison to prior studies. MRCP findings were discussed with Dr. ___ by Radiology ___ over phone on ___ at 3:15 p.m. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: CBD OBSTRUCTION/ERCP Diagnosed with CHOLELITH/CHOLEDOCHOLITH, NO CHOLECYS, NO OBS, ABNORMAL COAGULATION PROFILE, ADV EFF ANTICOAGULANTS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN temperature: 99.4 heartrate: 78.0 resprate: 18.0 o2sat: 95.0 sbp: 90.0 dbp: 43.0 level of pain: 0 level of acuity: 3.0
Please call Dr. ___ ___ if you have any of the following: temperature of 101 or greater, chills, nausea, vomiting, abdominal pain, jaundice or diarrhea. -you need to take antibiotics for 5 days (ciprofloxacin and flagyl) -continue a low fat diet -resume Coumadin -resume your outpatient hemodialysis schedule
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Plaquenil Attending: ___ Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo female with history of CAD with previous MI, HTN, and ESRD on peritoneal dialysis presents with 1 day of sharp, right-sided chest pain. Patient reports that pain began last night after she ate watermelon. As she was finishing eating, she developed ___ pain in the Right side of her chest and throughout her abdomen. She notes that she felt gurgling in her stomach and was belching. She had a single episode of diarrhea. Afterward, the pain in her chest persisted. She describes the pain as radiating to her back. No associated Left-sided CP, SOB, jaw pain, diaphoresis. Pain cannot be reproduced with palpation of chest wall. Pain was not relived by BMs or belching. Pain persisted until today, and she called EMS to bring her to the ED. Of note, patient has had a cough over the past few days. Denies fever, chills. Of note, patient did go on a long car ride to and from ___ in ___, but did not notice any leg swelling in that setting. While in ___, she did not some increased ___ leg swelling/pain. No erythema. In the ED, initial vitals were: 98.0; 75; 162/84; 16; 95% RA Labs notable for: 7.8>12.3/37.2<275 K: 5.6 BUN/Cr: 41/7.1 Trop 0.04 UA w/3 WBCs and >600 prot. D-dimer 2571 Imaging notable for: B/L LENIS: IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. CXR IMPRESSION: Bibasilar atelectasis. Patient was given 4mg IV morphine Vitals prior to transfer: 98.1; 73; 147/77; 17; 99% RA On the floor, patient reports continued pain in her chest. Otherwise, she reported feeling well. Past Medical History: H/o myocardial infarction (___) H/o stroke (___) DM (diabetes mellitus), type 2, uncontrolled ESRD - Left UE AVG placed on ___, first HD session on ___ Obesity Hypothyroidism Depression Hypertension, essential Hepatitis Anemia Hypercholesterolemia Gout ?SLE Social History: ___ Family History: Mother died at age ___, and had history of COPD, emphysema, DM, HTN, stroke, hx of MI. Father is deceased, but patient does not know about the cause of his death or any family history on that side. Patient has 4 children. Physical Exam: ON ADMISSION: Vital Signs: 97.7; 171/84; 73; 20; 95 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, midly-distended, bowel sounds present, no organomegaly, no rebound or guarding. Post CCY scar on RUQ. GU: No foley Ext: Warm, well perfused, 1+ pulses, no clubbing, TTP, warmth, erythema, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. ON DISCHARGE: Vitals- 98.7 155/77 84 18 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. chest wall tender on palpation Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, midly-distended, bowel sounds present, no organomegaly, no rebound or guarding. Catheter in place for PD GU: No foley Ext: Warm, well perfused, 2+ peripheral pulses, no clubbing, or edema. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: ON ADMISSION: ___ 05:28PM GLUCOSE-125* UREA N-41* CREAT-7.1*# SODIUM-135 POTASSIUM-5.6* CHLORIDE-97 TOTAL CO2-25 ANION GAP-19 ___ 05:28PM CK(CPK)-205* ___ 05:28PM cTropnT-0.04* ___ 05:28PM CK-MB-2 ___ 05:28PM D-DIMER-2571* ___ 05:28PM WBC-7.8 RBC-3.71* HGB-12.3 HCT-37.2 MCV-100* MCH-33.2* MCHC-33.1 RDW-13.7 RDWSD-50.0* ___ 05:28PM NEUTS-62.4 ___ MONOS-11.1 EOS-4.4 BASOS-0.8 IM ___ AbsNeut-4.84 AbsLymp-1.64 AbsMono-0.86* AbsEos-0.34 AbsBaso-0.06 ___ 05:28PM PLT COUNT-275 ___ 05:18PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 05:18PM URINE RBC-3* WBC-3 BACTERIA-FEW YEAST-NONE EPI-1 ___ 05:28PM BLOOD cTropnT-0.04* ___ 12:10AM BLOOD cTropnT-0.03* ON DISCHARGE: ___ 07:35AM BLOOD WBC-7.5 RBC-3.57* Hgb-11.8 Hct-35.9 MCV-101* MCH-33.1* MCHC-32.9 RDW-13.3 RDWSD-49.1* Plt ___ ___ 07:35AM BLOOD Plt ___ ___ 07:35AM BLOOD Glucose-230* UreaN-41* Creat-6.9* Na-135 K-3.9 Cl-95* HCO3-24 AnGap-20 IMAGING: Chest X-ray (___): Bibasilar atelectasis. Bilateral Lower extremity duplex (___): No evidence of deep venous thrombosis in the right or left lower extremity veins. V/Q scan (___): Low likelihood ratio for acute pulmonary thromboembolism. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. Amitriptyline 10 mg PO QHS 3. Metoprolol Succinate XL 100 mg PO DAILY 4. Glargine 20 Units Breakfast 5. Nephrocaps 1 CAP PO DAILY 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. Allopurinol ___ mg PO DAILY 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Atorvastatin 40 mg PO QPM 10. Levothyroxine Sodium 175 mcg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Vitamin D 4000 UNIT PO DAILY 13. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*50 Tablet Refills:*0 2. Glargine 20 Units Breakfast 3. Allopurinol ___ mg PO DAILY 4. Amitriptyline 10 mg PO QHS 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Levothyroxine Sodium 175 mcg PO DAILY 10. Lisinopril 10 mg PO DAILY 11. Metoprolol Succinate XL 100 mg PO DAILY 12. Nephrocaps 1 CAP PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Vitamin D 4000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY Musculoskeletal chest pain SECONDARY: End Stage Renal Disease Diabetes Mellitus Hypothyroidism Depression Hypertension Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with chest pain. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___ FINDINGS: Mild to moderate enlargement the cardiac silhouette is unchanged. The mediastinal and hilar contours are within limits. The pulmonary vasculature is not engorged. Streaky and linear opacities in both lung bases likely reflect areas of atelectasis. No pleural effusion, focal consolidation or pneumothorax is present. No acute osseous abnormalities detected. IMPRESSION: Bibasilar atelectasis. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ with chest pain, d dimer 2571. // ? 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 AMBULANCE Chief complaint: Chest pain Diagnosed with Chest pain, unspecified temperature: 98.0 heartrate: 75.0 resprate: 16.0 o2sat: 95.0 sbp: 162.0 dbp: 84.0 level of pain: 8 level of acuity: 2.0
Dear Mr. ___, It was a pleasure taking care of you. Why you were here? -You were in the hospital because of chest pain. We ruled out any dangerous conditions including heart attack, a clot in your lung, and infection. We suspect your chest pain is related to muscle strain What did we do? -We gave you Tylenol and your chest pain improved -You got a lung scan, chest xray, ultrasound, and EKG which were all normal What you should do when you go home? -Continue taking Tylenol to relieve your chest pain. -Take your medications and follow up with your primary care doctor ___ wish you the best, Your ___ team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Egg / Flecainide / Synthroid Attending: ___. Chief Complaint: Abdominal distension, diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: ___ female with a history of hypothyroidism, hypertension, atrial fibrillation on Coumadin presenting with 24 hours of abdominal discomfort, diarrhea. Patient reports yesterday morning she began having diarrhea, no bowel movement for 6 hours and then had almost one episode of diarrhea every hour even throughout the night until today. She notes that she may have had around 20 BM in that entire period. Patient reports the diarrhea is watery with no tenesmus, blood or mucus. Patient feels bloated with multiple lot of gas in her abdomen and nauseous as well last night. She attributes these symptoms to a salad that she ate at ___ one day prior to initiation of symptoms. She has had no recent sick contacts. There is no fever, chills, vomiting, flank pain, dysuria or vaginal discharge or bleeding. Pertinent ED course: ED EXAM VS: 98.9, 58, 178/77, 19, 100% on RA. GEN: ___, no apparent distress ENT: Mucous membranes are moist GI: Abdomen is soft, nondistended, nontender to palpation, no flank tenderness. ED LABS: ___ 06:34AM BLOOD WBC:5.4 RBC:3.81* Hgb:11.3 Hct:35.1 MCV:92 MCH:29.7 MCHC:32.2 RDW:12.7 RDWSD:43.0 Plt Ct:161 ___ 06:34AM BLOOD Glucose:110* UreaN:26* Creat:1.0 Na:141 K:3.9 Cl:106 HCO3:19* AnGap:16 ___ 06:34AM BLOOD ALT:61* AST:45* AlkPhos:208* TotBili:0.9 ___ 06:34AM BLOOD Lipase:44 ___ 06:34AM BLOOD Albumin:4.4 ED MICROBIOLOGY: ___ C. Diff PCR: Negative ___ UCx: PENDING ED RADIOLOGY: CT A/P w Contrat 1. ___ small and large bowel without wall thickening or dilatation, which could represent gastroenteritis in appropriate clinical setting. No evidence of colitis or bowel obstruction. 2. Substantial interval growth of a segment VIII hemangioma measuring 12.5 x 12.3 cm causing intrahepatic biliary ductal dilatation, more severe in the right lobe. 3. Additional hepatic hemangiomas are minimally changed in the interval. 4. 1.4 x 1.2 cm indeterminate lesion in the interpolar region of the left kidney, for which dedicated renal ultrasound on a non urgent basis is recommended. ED TREATMENT ___ 06:51 IVF NS Started ___ 07:04 IV Ondansetron 4 mg ___ 08:30 IVF NS 1 mL Stopped (1h ___ ___ 08:30 IVF NS Started 150 mL/hr ___ 11:02 IVF NS Confirmed No Change in Rate, rate continued at 150 mL/hr ___ 15:21 IVF NS Stopped (6h ___ ___ 15:21 IVF NS Started 250 mL/hr ___ 19:35 IVF NS Stopped (4h ___ ___ 19:41 PO/NG Warfarin 3.75 mg Upon arrival to the floor, the patient reports that she is feeling "much better." She notes that her diarrhea has decreased in frequency, with the last BM at 1300 earlier today. It was watery, without blood. She has been able to eat some ___ crackers and drink water since that point without issue. Currently is not experiencing headache, dizziness, chest pains, or shortness of breath. Past Medical History: AFIB HEPATIC ANGIOMA MULTINODULAR GOITER HYPOTHYROIDISM ___ ___'S PRIMARY HYPERPARATHYROIDISM S/P RESECTION OF LLPT ADENOMA ___ VITAMIN D DEFICIENCY Social History: ___ Family History: noncontributory Physical Exam: Admission Exam: ======================= VITALS: 97.9F, 88, 178/82, 16, 98% on RA. GENERAL: Woman laying in bed in NAD, wearing own clothing. EYES: PERRLA, sclera anicteric, EOMI. ENT: Neck supple, oropharynx nonerythematous, MMM. CV: RRR, no m/g/r RESP: CTAB in Anterior and posterior fields with no w/c/r GI: Abdomen soft, ___ with no palpable masses. Gurgling active bowel sounds auscultated. GU: No foley MSK: Moving all four extremities spontaneously, no ___ edema. SKIN: No evidence of excoriations, sores, or wounds. NEURO: AAOx3 Discharge Exam: ======================= VITALS: GENERAL: Woman sitting in bed in NAD, wearing own clothing. EYES: PERRLA, sclera anicteric, EOMI. ENT: Neck supple, oropharynx nonerythematous, MMM. CV: RRR, no m/g/r RESP: CTAB GI: Abdomen soft, ___ MSK: Moving all four extremities spontaneously, no ___ edema. SKIN: No evidence of excoriations, sores, or wounds. NEURO: AAOx3 Pertinent Results: Admission Labs: ========================= ___ 06:34AM BLOOD ___ ___ Plt ___ ___ 06:34AM BLOOD ___ ___ Im ___ ___ ___ 06:34AM BLOOD Plt ___ ___ 06:34AM BLOOD ___ ___ ___ 06:34AM BLOOD ___ ___ 06:34AM BLOOD ___ Discharge Labs: =========================== ___ 06:20AM BLOOD ___ ___ Plt ___ ___ 10:35AM BLOOD ___ ___ ___ 06:20AM BLOOD Plt ___ ___ 06:20AM BLOOD ___ ___ ___ 06:20AM BLOOD ___ LD(LDH)-162 ___ ___ ___ 06:20AM BLOOD ___ Microbiology: ============================= C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference ___. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Imaging: ========================= CT ABD & PELVIS WITH CONTRAST Study Date of ___ 8:59 AM FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: A right hepatic lobe dominant 12.5 x 12.3 cm hypoattenuating lesion with peripheral puddling of contrast is consistent with an hemangioma (Series 2, image 28), which appears to have grown from the previous CT when the hemangioma was visualized in segment VIII and measured approximately 2.3 x 1.9 cm. Adjacent to the dominant hemangioma are 2 similar appearing but smaller hemangiomas, one measuring 4.3 x 3.0 cm in hepatic segment VI (series 2, image 31) and the other one measuring 4.6 x 2.5 cm near the dome of the liver in hepatic segment VIII (Series 2, image 15). When compared to ___, the segment VI hemangioma has decreased in size and the segment VIII hemangioma near the dome of the liver has increased in size. The dominant hemangioma causes compression the central intrahepatic bile ducts mild intrahepatic biliary ductal dilatation, more severe in the right lobe. The hepatic parenchyma is otherwise homogeneous. The gallbladder is unremarkable. No extrahepatic biliary ductal dilatation. 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 a simple cyst arising from the lower pole of the left kidney measuring 2.4 x 2.2 cm (series 2, image 34). Peripelvic cyst measuring 2.5 x 1.5 cm immediately medially is also noted. A 1.4 x 1.2 cm hypoattenuating lesion superior to the 2 cysts at the interpolar region of the left kidney (series 601, image 37) is indeterminate with attenuation values up to 65 ___. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Fluid filled small and large bowel loops are demonstrated without wall thickening or abnormal dilatation. No obstruction. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus contains fibroids. No adnexal masses. 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. Portal and hepatic veins appear patent. Hepatic arteries are patent. BONES: There is no evidence of worrisome osseous lesions or acute fracture. There are mild degenerative changes of the thoracolumbar spine. SOFT TISSUES: There is a small fat containing umbilical hernia. IMPRESSION: 1. RECOMMENDATION(S): Dedicated renal ultrasound on a nonemergent basis. Radiology Report INDICATION: ___ female with abdominal pain, diarrhea, ongoing//rule out colitis or other abdominal pathology TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP = 9.6 mGy-cm. 2) Spiral Acquisition 5.0 s, 54.4 cm; CTDIvol = 10.7 mGy (Body) DLP = 583.1 mGy-cm. Total DLP (Body) = 593 mGy-cm. COMPARISON: CT abdomen pelvis dated ___ and ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: A right hepatic lobe dominant 12.5 x 12.3 cm hypoattenuating lesion with peripheral puddling of contrast is consistent with an hemangioma (Series 2, image 28), which appears to have grown from the previous CT when the hemangioma was visualized in segment VIII and measured approximately 2.3 x 1.9 cm. Adjacent to the dominant hemangioma are 2 similar appearing but smaller hemangiomas, one measuring 4.3 x 3.0 cm in hepatic segment VI (series 2, image 31) and the other one measuring 4.6 x 2.5 cm near the dome of the liver in hepatic segment VIII (Series 2, image 15). When compared to ___, the segment VI hemangioma has decreased in size and the segment VIII hemangioma near the dome of the liver has increased in size. The dominant hemangioma causes compression the central intrahepatic bile ducts mild intrahepatic biliary ductal dilatation, more severe in the right lobe. The hepatic parenchyma is otherwise homogeneous. The gallbladder is unremarkable. No extrahepatic biliary ductal dilatation. 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 a simple cyst arising from the lower pole of the left kidney measuring 2.4 x 2.2 cm (series 2, image 34). Peripelvic cyst measuring 2.5 x 1.5 cm immediately medially is also noted. A 1.4 x 1.2 cm hypoattenuating lesion superior to the 2 cysts at the interpolar region of the left kidney (series 601, image 37) is indeterminate with attenuation values up to 65 ___. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Fluid filled small and large bowel loops are demonstrated without wall thickening or abnormal dilatation. No obstruction. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus contains fibroids. No adnexal masses. 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. Portal and hepatic veins appear patent. Hepatic arteries are patent. BONES: There is no evidence of worrisome osseous lesions or acute fracture. There are mild degenerative changes of the thoracolumbar spine. SOFT TISSUES: There is a small fat containing umbilical hernia. IMPRESSION: 1. RECOMMENDATION(S): Dedicated renal ultrasound on a nonemergent basis. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Diarrhea, Lower abdominal pain Diagnosed with Other specified noninfective gastroenteritis and colitis temperature: 98.9 heartrate: 58.0 resprate: 18.0 o2sat: 100.0 sbp: 178.0 dbp: 77.0 level of pain: 8 level of acuity: 3.0
Dear. Ms. ___, It was a pleasure taking care of ___ during your stay at ___. WHY WAS I HERE? - ___ were having diarrhea and belly pain WHAT WAS DONE WHILE I WAS IN THE HOSPITAL? - ___ were given IV fluids WHAT SHOULD I DO WHEN I GO HOME? - ___ should drink plenty of fluids - ___ can take the medication ondansetron if ___ feel nauseous. - ___ should eat a bland (BRAT) diet for the next day or two - ___ should go to see your PCP - ___ should get your INR checked early next week and fax it over to your doctor! Be well! -Your ___ team
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 Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old male with PMH of laryngeal cancer s/p tracheostomy, DM II, minimal change disease on chronic prednisone and discharge from ___ yesterday for coag-negative staph UTI and bacteremia presenting from home with fevers up to 102 and diffuse weakness. He presented on ___ with 1 week of urinary retention and weakness, was admitted to ___ for septic shock, required vasopressors and stress dose steroids, was on ceftriaxone, cefepime and then vancomycin and nafcillin. ID was consulted and he was discharged on 6 week course of Vancomycin via ___ line for presumed endocarditis, TTE was negative and he was high risk for TEE given his tracheostomy. He reports feeling well when he left, developed loose stools starting last night, had 3 episodes of loose stools that he reports are soft but not watery. His ___ saw him today and he had a fever of 102, felt weak and unable to ambulate normally. ___ was concerned for bleeding and possible erythema at ___ site. Sent to ___ ED, temp 100.6, CXR was initially read as concerning for RLL consolidation, he was given cefepime and continued on vancomycin and admitted. He says he feels weak currently. Has been urinating frequently with small amounts. He reports having back pain over the last few months that is unchanged, had an MRI of lumber spine on ___ showing new L2-L3 disc herniation with central canal stenosis and mass effect on the conus medullaris. Denies headache, SOB, cough, CP, abdominal pain, n/v, dysuria, rash, easy bruising or bleeding. Ten point review of systems otherwise negative. Past Medical History: - Cancer of the larynx s/p tracheostomy - Type II Diabetes with opthalmic complication - Minimal change disease with a relapsing course, usually steroid-responsive, on chronic prednisone. - Essential Benign Hypertension - Hypercholesterolemia - Liver hemangioma - Iron deficiency anemia - Diverticulosis - Pulmonary nodule - Gynecomastia - Hematuria - Low back pain, facet arthropathy - Insomnia - Urinary retention - Spinal stenosis, unspecified site - Pulmonary nodule - Colonic adenoma - Gait abnormality Social History: ___ Family History: He denies a family history of kidney disease. His mother had diabetes. His brother had prostate cancer. No family history of CAD and HTN. Physical Exam: Admission Physical Exam: VS: T 98.5 HR 65 BP 133/70 RR 18 100% RA Gen: NAD, resting comfortably in bed HEENT: EOMI, PERRLA, MMM, OP clear, tracheostomy with speech valve CV: RRR nl s1s2 no m/r/g Resp: CTAB no w/r/r Abd: Soft, NT, ND +BS Ext: no c/c/e, PICC line site with small amount of blood but without erythema, tenderness or drainage Neuro: CN II-XII intact, ___ strength throughout Back: No spinal or paraspinal tenderness discharge: Vitals: 98.9 125/76 p74 RR18 98%ra General: Alert and oriented x 3. NAD. Lungs: CTAB, moving air well and symmetrically HEENT: Laryngectomy site c/d/i, able to speak. PEERL. EOMI CV: rrr no m/r/g Abdomen: bowel sounds present, soft, nt/nd EXT: No edema or cyanosis PICC site RUE without swelling erythema or induration. dressing c/d/i Pertinent Results: ___ 09:40AM GLUCOSE-144* UREA N-11 CREAT-0.9 SODIUM-138 POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14 ___ 09:40AM ALT(SGPT)-64* AST(SGOT)-33 LD(LDH)-284* ALK PHOS-69 TOT BILI-0.6 ___ 09:40AM WBC-7.4# RBC-4.29* HGB-11.2* HCT-36.0* MCV-84 MCH-26.1* MCHC-31.2 RDW-15.8* ___ 09:40AM PLT COUNT-167 ___ 10:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 10:15AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 CXR PA & L ___: IMPRESSION: No acute cardiopulmonary process. DISCHARGE LABS: ___ 05:59AM BLOOD WBC-4.7 RBC-3.90* Hgb-10.2* Hct-32.4* MCV-83 MCH-26.2* MCHC-31.6 RDW-15.0 Plt ___ ___ 05:59AM BLOOD Neuts-62.5 ___ Monos-9.7 Eos-1.2 Baso-0.4 ___ 05:59AM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-139 K-3.7 Cl-104 HCO3-27 AnGap-12 ___ 05:59AM BLOOD ALT-41* AST-21 AlkPhos-53 ___ 11:21PM BLOOD HBsAg-NEGATIVE ___ 11:21PM BLOOD HIV Ab-NEGATIVE ___ 05:59AM BLOOD Vanco-14.1 ___ 11:21PM BLOOD HCV Ab-NEGATIVE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vancomycin 1000 mg IV Q 12H 2. Amlodipine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Lisinopril 10 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID 8. PredniSONE 10 mg PO DAILY 9. Rosuvastatin Calcium 10 mg PO DAILY 10. Tamsulosin 0.4 mg PO HS 11. Vitamin D 1000 UNIT PO DAILY 12. Finasteride 5 mg PO DAILY 13. diclofenac sodium 0.1 % OPHTHALMIC TID 14. Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. Finasteride 5 mg PO DAILY 5. Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Lisinopril 10 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID 9. PredniSONE 10 mg PO DAILY 10. Rosuvastatin Calcium 10 mg PO DAILY 11. Tamsulosin 0.4 mg PO HS 12. Vancomycin 1500 mg IV Q 12H RX *vancomycin 750 mg 1500 mg iv every twelve (12) hours Disp #*126 Vial Refills:*0 13. Vitamin D 1000 UNIT PO DAILY 14. diclofenac sodium 0.1 % OPHTHALMIC TID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Fever Secondary Staph epidermis bacteremia Diabetes Mellitus Minimal change disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST RADIOGRAPH INDICATION: History: ___ with recent urinary infection, with fever // eval pna eval pna TECHNIQUE: PA and lateral views of the chest. COMPARISON: Chest radiographs from ___ and ___. FINDINGS: Lungs are hyperinflated. There is a hazy opacity at the right lung base which appears similar to findings seen on CXR from ___ and likely represents a prominent fat pad as opposed to an area of early pneumonia. A right-sided PICC line terminates at the mid to lower SVC. Calcifications are noted of the aortic arch. The cardiomediastinal and hilar contours are within normal limits. There is no pleural effusion or pneumothorax. Posterior fixation hardware in the lumbar spine is partially visualized. IMPRESSION: No acute cardiopulmonary process. NOTIFICATION: Final report discussed with Dr. ___ by NSR via phone on ___ at 3:35 ___. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Fever Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN temperature: 99.9 heartrate: 95.0 resprate: 18.0 o2sat: 99.0 sbp: 152.0 dbp: 62.0 level of pain: 8 level of acuity: 2.0
Dear Mr. ___, It was ___ caring for you here at ___. You came in because of fevers. We repeated tests to check for infection and you did not have a new infection. Your fevers are resolved and you are ready to go home.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: AMS, suicidal ideation Major Surgical or Invasive Procedure: none History of Present Illness: ___ PMH severe depression NPH s/p shunt placement in ___, myasthenia ___, hypothyroidism, HTN, esophageal cancer in remission, who presents to the emergency department with suicidal ideation and altered mental status. Per nursing home, patient has been noted to have increased agitation over the past month since he joined the nursing home. He has become more resistant to care and restless. For instance, he has developed skin lesions on his elbows because of continue rubbing of his elbow onto the wheelchair arm rest. He has been restrained more frequently due to his gait becoming more ataxic and multiple falls throughout this month. Patient was scheduled for ECT today but did not pursue as per psych recommendations. Patient complains of left sided abdominal pain. He is unable to point to the exact location or give further history. Patient also reports dysuria and that he has become more depressed lately. He frequently makes comments alluding to his wanting to "give up". He endorses SI to both nursing staff, police officer and to ED staff. He is unable to clarify any further but states he wants to hurt himself. Denies any homicidal ideation. He attests to experiencing auditory hallucinations in the past though not recently. He is alert and oriented to self, thinks that he is in "rehab" and believes that the date is ___, though he could name the current president. Otherwise, patient has not experienced any fevers or chills. No chest pain or shortness of breath. Per his HCP (niece), his change in mental status started in ___ months after he had been diagnosed with Myasthenia ___ and put on Prednisone to which he takes to date. On ___, he got a VP shunt placed at ___ due to his normal pressure hydrocephalus, and his HCP said he got better. However, he regressed and became fully incontinent again and having frequent falls. He had his VP shunt adjusted and in ___ he joined the nursing home he currently resides in. Per nursing home, on ___, recent medication changes include: Trazadone PRN 25 mg Q8 to 50 mg Q6, Klonipin from once daily to twice a day (held on ___ for scheduled ECT today), and Ritalin held. His prednisone was tapered in early ___ from 40 mg to 30 mg daily. Nursing home is unsure when patient's prednisone should be tapered off. In addition, patient got a CXR at OSH for concerning cough and was unremarkable, per home nurse. Based on discussion with the ED, it is unclear whether this AMS is just related to his underlying psych issue or if he has a true medical issue. In the ED, initial VS were: 97.8 151/82 85 20 100/RA Labs showed: - WBC 12 CBC otherwise WNL - serum, urine tox negative - LFTs WNL - K 4.5 -> 7.3 (hemolyzed) -> 5.6 - Cr 1.4 - coags WNL - UA w/o e/o UTI - Lactate 1.7 Imaging showed: -CT head: 1. Left frontal convexity mixed density subdural hematoma measuring 4 mm. No midline shift. No other intracranial hemorrhage. 2. Right posterior approach ventriculostomy catheter terminates near midline in frontal horn of left lateral ventricle. No definite findings to suggest hydrocephalus although no priors for direct comparison. 3. Hypodensity involving the left caudate head may represent chronic small vessel ischemic change. MRI would be more sensitive to assess for acute infarct. - CT shunt series: Right-sided VP shunt without radiographic evidence of discontinuity or kink. - CXR: No evidence of pneumonia Patient received: ___ 13:44 IM LORazepam 2 mg ___ ___ 21:29 PO LamoTRIgine 50 mg ___ ___ 21:29 PO/NG Mirtazapine 45 mg ___ ___ 21:29 PO Pyridostigmine Bromide 60 mg ___ ___ 23:01 PO LevETIRAcetam 1000 mg ___ ___ 23:01 IVF NS ___ Started ___ 00:30 IVF NS 1000 mL ___ Stopped (1h ___ Psychiatry was consulted: Diagnostically this patient certainly has severe depression and likely will need ECT treatment in the future, however; his current picture is most concerning for a delirium of unknown cause. Recommend ongoing medical workup for cause of his delirium with medical admission, consulting psych CL for management of his psychiatric condition. A safety assessment cannot be made at this time due to his mental status. Please contact psychiatry in the event that he wishes to leave AMA or is being discharged. Neurosurgery was consulted: Patient seen and examined. He is altered and a poor historian. He is oriented to self, 'rehab', and says ___. He is otherwise nonfocal. He follows commands and has full strength throughout. NCHCT shows left sided SDH with no mass effect. Discussed case with Attending Dr. ___. SDH is likely not the cause of altered mental status. With these facts in mind, neurosurgery recommends consider Medicine workup for other etiologies of altered mental status Transfer VS were: 138/65 72 16 97/RA Past Medical History: Depression Normal pressure hydrocephalus S/P VP shunt Hernia repair hypothyroidism hypertension BPH esophageal cancer ___ now in remission Social History: ___ Family History: Positive for depression. Physical Exam: ADMISSION EXAM =============== VS: 97.6 ___ 18 93 RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD; bony prominence at left clavicle; bony prominence near thyroid gland 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: Alert, oriented to self, thinks he is in "rehab", and believes the month and year is ___, CN's ___ grossly intact, finger to nose to finger, heel to shin, follows commands though unable to follow two commands at once, 4+/5 strength UE and 4+/5 strength in ___ SKIN: warm and well perfused, traumatic ulcers on flexor surfaces of lower legs bilaterally DISCHARGE EXAM =============== VITALS: 97.9 115/73 63 99%Ra GENERAL: NAD, sleeping comfortably and arouses to voice HEENT: MMM. HEART: RRR, S1/S2, no murmurs LUNGS: CTAB, no wheezes, crackles ABDOMEN: soft, nondistended, nontender, normoactive BS EXTREMITIES: no lower extremity edema NEURO: Says "at rehab" and ___. CN II-XII grossly intact. Moves all four extremities. SKIN: warm and well perfused, lots of ecchymoses, dry. ulcerations on LEs covered with gauze PSYCH: Flat affect. Denies SI. Pertinent Results: =============== Admission labs =============== ___ 03:22PM BLOOD WBC-12.0* RBC-4.07* Hgb-14.2 Hct-43.6 MCV-107* MCH-34.9* MCHC-32.6 RDW-15.4 RDWSD-60.9* Plt ___ ___ 03:22PM BLOOD Neuts-93* Bands-1 Lymphs-1* Monos-3* Eos-0 Baso-0 ___ Metas-1* Myelos-1* AbsNeut-11.28* AbsLymp-0.12* AbsMono-0.36 AbsEos-0.00* AbsBaso-0.00* ___ 09:18PM BLOOD ___ PTT-26.7 ___ ___ 03:22PM BLOOD Glucose-114* UreaN-30* Creat-1.4* Na-143 K-4.5 Cl-102 HCO3-28 AnGap-13 ___ 03:22PM BLOOD ALT-25 AST-28 AlkPhos-62 TotBili-0.8 ___ 03:22PM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.4 Mg-2.1 =============== Pertinent labs =============== ___ 08:36AM BLOOD VitB12-652 ___ 08:36AM BLOOD TSH-5.1* ___ 08:36AM BLOOD T4-5.7 ___ 03:22PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03:41PM BLOOD Lactate-1.7 RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. =============== Discharge labs =============== ___ 08:10AM BLOOD WBC-7.7 RBC-4.10* Hgb-14.8 Hct-44.4 MCV-108* MCH-36.1* MCHC-33.3 RDW-16.2* RDWSD-64.7* Plt ___ ___ 08:10AM BLOOD Glucose-89 UreaN-17 Creat-1.1 Na-139 K-5.0 Cl-99 HCO3-28 AnGap-12 ___ 08:10AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.1 =============== Studies =============== CXR (___): IMPRESSION: No acute cardiopulmonary abnormality. Left clavicle fracture is better assessed on the prior dedicated study. EEG (___): IMPRESSION: This is an abnormal awake EEG because of slow posterior dominant rhythm and mild diffuse slowing suggesting a mild encephalopathy. This is a nonspecific finding but can be seen with toxic/metabolic derangements, anoxia, and medication effect. There are no epileptiform features or electrographic seizures. CT head without contrast (___): IMPRESSION: 1. Unchanged small left subdural hematoma, measuring 4 mm. No new or increasing hemorrhage. 2. Unchanged ventricular catheter position. Stable ventricular size. Shoulder x-ray (___): IMPRESSION: Fracture of the mid clavicle of indeterminate age CT head w/o contrast (___): IMPRESSION: 1. Left frontal convexity mixed density subdural hematoma measuring 4 mm. No midline shift. No other intracranial hemorrhage. 2. Right posterior approach ventriculostomy catheter terminates near midline in frontal horn of left lateral ventricle. No definite findings to suggest hydrocephalus although no priors for direct comparison. 3. Hypodensity involving the left caudate head may represent chronic small vessel ischemic change. MRI would be more sensitive to assess for acute infarct. Shunt series (___): IMPRESSION: Right-sided VP shunt without radiographic evidence of discontinuity or kink. CXR (___): IMPRESSION: No evidence of pneumonia =============== Microbiology =============== Urine culture (___): NEGATIVE Blood cultures (___): NEGATIVE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LamoTRIgine 50 mg PO BID 2. Mirtazapine 45 mg PO QHS 3. TraZODone 100 mg PO QHS 4. ClonazePAM 0.5 mg PO BID 5. MethylPHENIDATE (Ritalin) 20 mg PO DAILY 6. DULoxetine 60 mg PO DAILY 7. Acidophilus (Lactobacillus acidophilus) 1 cap oral BID 8. Juven (arginine-glutamine-calcium bmb) ___ gram oral BID 9. Levofloxacin 750 mg PO Q24H 10. Levothyroxine Sodium 112 mcg PO DAILY 11. Liothyronine Sodium 5 mcg PO DAILY 12. GuaiFENesin ER 600 mg PO Q12H 13. Omeprazole 20 mg PO DAILY 14. Polyethylene Glycol 17 g PO DAILY 15. PredniSONE 30 mg PO DAILY 16. Pyridostigmine Bromide 60 mg PO Q8H 17. Senna 17.2 mg PO BID 18. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___) 19. Thiamine 100 mg PO DAILY 20. AzaTHIOprine 150 mg PO DAILY 21. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 22. Vitamin D ___ UNIT PO 1X/WEEK (___) 23. Milk of Magnesia Dose is Unknown PO DAILY Discharge Medications: 1. Calcium Carbonate 1500 mg PO DAILY 2. CloNIDine 0.1 mg PO QHS 3. Docusate Sodium 100 mg PO BID 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Ramelteon 8 mg PO QHS 6. ClonazePAM 0.125 mg PO QAM 7. DULoxetine 40 mg PO DAILY 8. Levothyroxine Sodium 125 mcg PO DAILY 9. Liothyronine Sodium 5 mcg PO DAILY 10. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___) 11. Vitamin D 800 UNIT PO DAILY 12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 13. AzaTHIOprine 150 mg PO DAILY 14. LamoTRIgine 50 mg PO BID 15. Mirtazapine 45 mg PO QHS 16. Omeprazole 20 mg PO DAILY 17. Polyethylene Glycol 17 g PO DAILY 18. PredniSONE 30 mg PO DAILY 19. Pyridostigmine Bromide 60 mg PO Q8H 20. Senna 17.2 mg PO BID 21. Thiamine 100 mg PO DAILY 22. HELD- Acidophilus (Lactobacillus acidophilus) 1 cap oral BID This medication was held. Do not restart Acidophilus until you see your primary care provider 23. HELD- GuaiFENesin ER 600 mg PO Q12H This medication was held. Do not restart GuaiFENesin ER until you see your primary care provider 24. HELD- Juven (arginine-glutamine-calcium bmb) ___ gram oral BID This medication was held. Do not restart Juven until you see your primary care provider ___: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY ======= Toxic metabolic encephalopathy Delirium SECONDARY ========= Depression with suicidal ideations Normal pressure hydrocephalus status-post VP shunt Subdural hematoma Hypothyroidism Hypertension Benign prostatic hypertrophy Left clavicular fracture Myasthenia ___ GERD Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: History: ___ with AMS// eval for PNA TECHNIQUE: Chest AP COMPARISON: Shunt series from ___ at 19:15 FINDINGS: Lungs are moderately well expanded and essentially clear. Linear opacity in the left lower lobe suggests scarring or atelectasis. The cardiomediastinal silhouette and hila are unremarkable. Partially visualized right ventriculoperitoneal shunt noted without kink or discontinuity. No pneumothorax or pleural effusion. IMPRESSION: No evidence of pneumonia Radiology Report INDICATION: ___ year old man with AMS, increased agitation// eval for shunt malfunctioning TECHNIQUE: Shunt series: AP and lateral views of the head and neck, frontal view of the chest and frontal view of the abdomen COMPARISON: None. FINDINGS: Right ventriculoperitoneal shunt from a posterior approach is seen coursing along the right neck, right chest, and coursing into the abdomen to terminate in the left lower quadrant. No shunt discontinuity or kinking is identified. The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac mediastinal silhouettes unremarkable. There is a nonobstructive bowel gas pattern. IMPRESSION: Right-sided VP shunt without radiographic evidence of discontinuity or kink. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with AMS, shunt placement in ___// eval for worsening hydrocephalus 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 9.0 s, 19.2 cm; CTDIvol = 47.1 mGy (Head) DLP = 903.1 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: None available in PACs. FINDINGS: Right posterior approach ventriculostomy catheter terminates near midline the frontal horn of the left lateral ventricle. The ventricles and sulci are normal in size and configuration for age. No priors are available for direct comparison. Periventricular white matter hypodensities are nonspecific may suggest chronic small vessel ischemic changes. Hypodensity involving the left caudate head may be related to chronic small vessel ischemic changes (02:20). Left frontal convexity extra-axial fluid collection with hyperdensity is suggestive of subdural hemorrhage in measures 4 mm maximally. There is evidence of midline shift. The basal cisterns are patent. No other intracranial hemorrhages seen. No acute fracture seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. Left frontal convexity mixed density subdural hematoma measuring 4 mm. No midline shift. No other intracranial hemorrhage. 2. Right posterior approach ventriculostomy catheter terminates near midline in frontal horn of left lateral ventricle. No definite findings to suggest hydrocephalus although no priors for direct comparison. 3. Hypodensity involving the left caudate head may represent chronic small vessel ischemic change. MRI would be more sensitive to assess for acute infarct. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 8:05 pm, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with subdural hematoma. Evaluation for interval change. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.3 mGy-cm. Total DLP (Head) = 934 mGy-cm. COMPARISON: Noncontrast head CT from ___. FINDINGS: The right parietal approach VP shunt catheter terminates in the frontal horn of left lateral ventricle near the septum pellucidum, unchanged. Streak artifact from the related hardware in the scalp slightly limits evaluation of the right posterior fossa and occipital region. The ventricles are stable in size. The small left convexity mixed-density subdural hematoma appears unchanged from prior study, measuring 4 mm in greatest dimension. There is no significant sulcal effacement or shift of midline structures. Basal cisterns are preserved. There is no evidence of new intracranial hemorrhage or acute major vascular infarction. Periventricular, deep, and subcortical white matter hypodensities are grossly unchanged, nonspecific but likely the sequela of chronic small vessel ischemic disease. A small chronic infarct is again seen in the right caudate head.. Mild partial bilateral mastoid air cell opacification is likely secondary to prolonged supine positioning in the inpatient setting. IMPRESSION: 1. Stable small left convexity subdural hematoma, measuring 4 mm. No new hemorrhage. 2. Stable VP shunt catheter position. Stable ventricular size. Radiology Report EXAMINATION: SHOULDER 1 VIEW LEFT INDICATION: ___ year old man with AMS// LEFT SHOULDER XRAY- dislocation? please do portable if possible as pt is agitated and delirious COMPARISON: None FINDINGS: There is no gross evidence of dislocation involving the shoulder on the solitary frontal view. There is a fracture of the midclavicle with approximately 1.5 cm of overlap, age indeterminate. This was likely present on a prior chest x-ray from ___. No older studies are available for comparison. There is no radiopaque foreign body. IMPRESSION: Fracture of the mid clavicle of indeterminate age. NOTIFICATION: The findings were discussed with ___. by ___ ___, M.D. on the telephone on ___ at 6:15 pm, within 10 minutes after discovery of the findings. Radiology Report EXAMINATION: CLAVICLE LEFT INDICATION: ___ year old man with mid-clavicular fracture// left clavicle xray TECHNIQUE: Left clavicle two views COMPARISON: Portable supine left clavicle radiograph from ___ FINDINGS: Again seen is the fracture through the mid left clavicle,. On today's exam, the edges appear corticated. There is full shaft-width inferior displacement of the lateral fragment and approximately 21 mm of overriding. The AC joint remains congruent, with mild degenerative change. Limited assessment of the left shoulder suggests mild glenohumeral joint degenerative change. No widening of the coracoclavicular interval. Probable diffuse osteopenia. At the edge of these films, tubing extending vertically across the right chest is thought to represent a ventriculoperitoneal shunt. IMPRESSION: Fracture of the mid left clavicle again noted, with full shaft width displacement and overriding. Edges appear corticated, suggesting a nonacute injury. No convincing bony bridging identified.. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man s/p fall// Eval for trauma, hematoma TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 7.2 s, 18.2 cm; CTDIvol = 49.6 mGy (Head) DLP = 903.1 mGy-cm. 2) Sequenced Acquisition 1.6 s, 4.1 cm; CTDIvol = 49.6 mGy (Head) DLP = 200.7 mGy-cm. Total DLP (Head) = 1,104 mGy-cm. COMPARISON: CT head ___ FINDINGS: Hyperdense extra-axial fluid collection overlying the left cerebral convexity measures up to 4 mm, and is unchanged in comparison with 12 hours prior. There is no significant shift of the normally midline structures. No new or increasing hemorrhage. No evidence of acute infarct. A right posterior approach ventricular catheter terminates in the frontal horn of the left lateral ventricle near the septum pellucidum, unchanged in position. 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 with the exception of bilateral lens replacements. IMPRESSION: 1. Unchanged small left subdural hematoma, measuring 4 mm. No new or increasing hemorrhage. 2. Unchanged ventricular catheter position. Stable ventricular size. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old man with depression, NPH, and myasthenia ___ with worsening delirium// evaluate for consolidations concerning for PNA TECHNIQUE: Portable frontal view of the chest. COMPARISON: ___. FINDINGS: VP shunt catheter is partially visualized. Heart size is top-normal. There is mild unfolding of the thoracic aorta with mild knob calcifications. Hilar contours are preserved. Lungs are clear. Pleural surfaces are clear without effusion pneumothorax. Left clavicle fracture is better assessed on the recent dedicated study.. IMPRESSION: No acute cardiopulmonary abnormality. Left clavicle fracture is better assessed on the prior dedicated study. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: SI Diagnosed with Altered mental status, unspecified temperature: 97.8 heartrate: 85.0 resprate: 20.0 o2sat: 100.0 sbp: 151.0 dbp: 82.0 level of pain: ua level of acuity: 2.0
Dear Mr. ___, WHY YOU WERE ADMITTED ======================= - You had altered mental status and were not behaving like yourself - You had a small brain bleed likely from falling WHAT WE DID FOR YOU IN THE HOSPITAL ==================================== - We made sure you were not having an infection, which you did not - We checked all your electrolytes, vitamin levels, and thyroid levels which were all normal - We made sure your head bleed remained stable with CT scans - We made sure your VP shunt for your normal pressure hydrocephalus was working properly - We changed your medications to make sure they were not affecting your mental status - You had an EEG study done that showed your mental status was most likely affected by something temporary, most likely the mediations you were taking WHAT YOU SHOULD DO WHEN YOU LEAVE ================================= - You should continue to take your medications as prescribed - You should use a cane/walker to get around to make sure you do not fall It was a pleasure taking care of you! Sincerely, Your ___ Care Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: nuts / indomethacin Attending: ___ ___ Complaint: Transfer from ___ for leg color change, concern for phlegmasia cerulea dolens Major Surgical or Invasive Procedure: None History of Present Illness: ___ h/o cervical cancer s/p treatment, HTN, HLD, bipolar, recent diagnosis of unprovoked LLE DVT treated with hep gtt, and discharged ___ on xarelto, presents as a transfer from ___ ___ for concern for phlegmasia cerulea dolens. Patient reports when her clot was first diagnosed she had soreness in her left leg. This gradually improved with treatment and while she was at home for 1 week. She regularly kept her leg elevated and wrapped. She took the xarelto without issue. She was able to ambulate without cp or SOB. No fevers, chills, n/v/d. She was waiting for stockings to arrive. Day prior to arrival she evaluated her left leg, she noticed a purplish color change as well as swelling. On further questioning she thinks it had been getting more sore over the past two days as well. No numbness or tingling. She went to ___ ___ for eval and then was sent here as no vascular surgery there over the weekend. In the ED, initial vitals were: 99.0 61 144/71 16 99% RA Exam notable for extensive petechial erythema to the left left lower extremity Labs notable for wbc 10.3, h/h normal with MCV 102, bicarb 20 Vascular was consulted and recommended: hep gtt, stop xarelto, no clot retrieval/TPA lysis given age, comorbidities, and clot >10d. Plan to continue to follow. Decision was made to admit for further management. Vitals prior to transfer: 98.6 70 139/78 18 99% RA On the floor, patient denies focal symptoms beyond described above. Leg remains somewhat sore. She is concerned about how her leg will develop without intervention. Past Medical History: h/o cervical cancer, HTN, HLD, reflux hysterectomy, finger surgery, breast biopsy bipolar disorder with depression Social History: ___ Family History: No known family history of blood clots, hypercoagulable disorders, or vascular disease Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vital Signs: 98.1 151 / 77 61 18 95 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, bilateral pulses 2+, LLE edematous compared to right, with erythema and non-blanching petechiae from shin towards groin. Distal pulse intact without cyanosis or mottling. Distal sensation to light touch intact. Neuro: Grossly intact Access: PIV DISCHARGE PHYSICAL EXAM: ======================== Vitals: 98.1F, 122-148/ 68-74, 55-71, 18, 94-96RA, ___ GENERAL: Cheerful and talkative. NAD HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. No conjunctival pallor or injection, sclera anicteric and without injection. Moist mucous membranes, good dentition. Oropharynx is clear. NECK: Thyroid is normal in size and texture, no nodules. No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: Dry non productive cough. Coarse crackles left upper field. Appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. Resonant to percussion. BACK: Skin. no spinous process tenderness. no CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. Tympanic to percussion. No organomegaly. EXTREMITIES: No clubbing, cyanosis. 3+ edema LLE, no sign of atrophy/hypertrophy. Pulses Radial 2+ bilaterally, DP 2+ Right, 1+ left. SKIN: No evidence of ulcers or lesions suspicious for malignancy. Erythematous non blanching petechiae and purpura along LLE from ankle to hip. Distal sensation diminished LLE but intact. NEUROLOGIC: AOx3 CN2-12 intact. ___ strength throughout. ROM LLE decreased w/ swelling. Normal sensation. Ataxia, dysmetria, disdiadochokinesia, Gait deferred. 3+ reflexes bl Biceps. 2+ brachioradialis, triceps, patellar. Pertinent Results: ADMISSION LABS: =============== ___ 12:15AM PLT COUNT-227# ___ 12:15AM NEUTS-66.3 ___ MONOS-6.2 EOS-6.1 BASOS-1.1* IM ___ AbsNeut-6.85* AbsLymp-2.03 AbsMono-0.64 AbsEos-0.63* AbsBaso-0.11* ___ 12:15AM WBC-10.3* RBC-3.81* HGB-12.0 HCT-38.7 MCV-102*# MCH-31.5 MCHC-31.0* RDW-14.0 RDWSD-51.9* ___ 12:15AM estGFR-Using this ___ 12:15AM GLUCOSE-108* UREA N-19 CREAT-1.0 SODIUM-140 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-20* ANION GAP-20 ___ 07:40AM ___ ___ 07:40AM PLT COUNT-265 ___ 07:40AM WBC-9.3 RBC-3.84* HGB-12.4 HCT-37.6 MCV-98 MCH-32.3* MCHC-33.0 RDW-14.4 RDWSD-50.4* ___ 07:40AM CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.3 ___ 07:40AM GLUCOSE-104* UREA N-17 CREAT-1.0 SODIUM-144 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-20 ___ 10:43AM ___ PTT-150* ___ DISCHARGE LABS: =============== ___ 08:25AM BLOOD WBC-8.6 RBC-4.23 Hgb-13.4 Hct-41.5 MCV-98 MCH-31.7 MCHC-32.3 RDW-14.4 RDWSD-51.1* Plt ___ ___ 08:25AM BLOOD Glucose-101* UreaN-13 Creat-0.9 Na-144 K-3.6 Cl-105 HCO3-26 AnGap-17 ___ 08:25AM BLOOD Calcium-9.5 Phos-2.7 Mg-2.3 IMAGING: ======== CTA ABD PELV (___): Extensive filling defect involving the left common iliac vein, external iliac vein down to the left common femoral, deep femoral and superficial femoral veins, with extensive left inguinal and left thigh soft tissue stranding and subcutaneous edema, consistent with deep venous thrombosis. There is also thrombosis of the left internal iliac vein. There is no filling defect seen within the inferior vena cava, right common iliac vein or its principal branches. CXR (___): Lungs are hyperinflated, suggesting COPD. Heart size is at the upper limits of normal or slightly enlarged. No CHF. Minimal subsegmental atelectasis and/or scarring seen at the left lung base. No focal infiltrate or ___ effusion identified. No pneumothorax detected. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Rivaroxaban 15 mg PO BID 2. ALPRAZolam 0.5 mg PO QHS:PRN insomnia 3. Calcium Carbonate 600 mg PO BID 4. Clozapine 37.5 mg PO QHS 5. Docusate Sodium 100 mg PO DAILY 6. Escitalopram Oxalate 20 mg PO DAILY 7. Hydrochlorothiazide 25 mg PO DAILY 8. Latuda (lurasidone) 80 mg oral QHS 9. Lithium Carbonate CR (Eskalith) 450 mg PO QHS 10. Omeprazole 20 mg PO BID 11. Simvastatin 20 mg PO QPM 12. Vitamin D 800 UNIT PO BID 13. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral DAILY 14. L-Methylfolate (levomefolate calcium) 15 mg oral DAILY 15. Acetaminophen 1000 mg PO TID 16. T.E.D. Anti-Embolism Stocking (comp stocking,knee,regular,sml) 2 stockings miscellaneous DAILY Discharge Medications: 1. T.E.D. Anti-Embolism Stocking (comp stocking,knee,regular,sml) 2 stockings miscellaneous DAILY 2. Acetaminophen 1000 mg PO TID 3. ALPRAZolam 0.5 mg PO QHS:PRN insomnia 4. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral DAILY 5. Calcium Carbonate 600 mg PO BID 6. Clozapine 37.5 mg PO QHS 7. Docusate Sodium 100 mg PO DAILY 8. Escitalopram Oxalate 20 mg PO DAILY 9. Hydrochlorothiazide 25 mg PO DAILY 10. L-Methylfolate (levomefolate calcium) 15 mg oral DAILY 11. Latuda (lurasidone) 80 mg oral QHS 12. Lithium Carbonate CR (Eskalith) 450 mg PO QHS Eskalith CR 13. Omeprazole 20 mg PO BID 14. Rivaroxaban 15 mg PO BID 15. Simvastatin 20 mg PO QPM 16. Vitamin D 800 UNIT PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Left lower extremity DVT Secondary DIAGNOSES: ==================== Hypertension GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with cough and swelling in legs // Evaluate for pulmonary edema and pneumonia COMPARISON: None. FINDINGS: Lungs are hyperinflated, suggesting COPD. Heart size is at the upper limits of normal or slightly enlarged. No CHF. Minimal subsegmental atelectasis and/or scarring seen at the left lung base. No focal infiltrate or gross effusion identified. No pneumothorax detected. IMPRESSION: No CHF, focal infiltrate or gross effusion. Probable background COPD. Heart size borderline enlarged. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: L Leg swelling, Transfer Diagnosed with Acute embolism and thrombosis of deep vein of l low extrem temperature: 99.0 heartrate: 61.0 resprate: 16.0 o2sat: 99.0 sbp: 144.0 dbp: 71.0 level of pain: 0 level of acuity: 3.0
Dear Ms. ___, It was a pleasure taking care of you. You were admitted to the ___ because your left leg was swollen, red, and painful despite recently being started on treatment for a clot in that same leg. What did we do for you while you were in the hospital? - We were initially concerned for a complication of a leg clot that causes interruption of the blood flow to the leg. We initially started you on a blood thinner called heparin because we were concerned the Xarelto was not working well for you. You were evaluated by vascular surgery who did not think that this complication was present and who recommended that we continue your Xarelto and make sure that we keep the leg compressed and elevated whenever possible. What should you do after you leave the hospital? You should continue to take your Xarelto twice daily with large meals. You should try to elevate your legs as much as possible and wear your compression stockings. This is the primary treatment for your blood clot. You should follow-up with your primary care physician and vascular surgery within ___ weeks of discharge. We recommend at least ___ year of Xarelto, perhaps even life long therapy. This should be discussed with both your PCP and ___ ___ Expert. Wishing you a speedy recovery, Your ___ Care Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hyperglycemia Major Surgical or Invasive Procedure: None. History of Present Illness: ___ with a recent dx of insulin dependent DM in ___ and severe esophagitis, who presents from his ___ clinic for vomiting and blood sugar control. Patient was at clinic for followup for his recent diagnosis of diabetes and per the physician there he was somnolent and was subsequently sent to this facility for further management. Patient reports that since ___ he has been increasingly weak and has had ___ episodes of vomiting per day since that time. He does state that the vomit has bright red streaks at times, as well as some bilious material. He does endorse mild diffuse abdominal pain that has been constant since that time as well as decrease in PO intake. He denies fevers, chills, diarrhea, cough, chest pain, dysuria, flank pain. He does admit to stopping his sliding-scale insulin on ___ because of how he felt. He has been taking his lantus but has stopped all other medications. He also endorses subjective fevers and chills, and substernal burning chest pain consistent his known esophagitis pain. Hasn't tried anything for the pain. Abdominal pain described as sharp and stabbing without radiation, currently a ___ in severity. In the ED, initial vital signs were: T97.8 ___ BP131/86 RR18 95%. Labs were notable for a Na of 127, glucose 388 (corrected Na 134). Glucose down to 324 after getting 2L NS. Hct was at 33. Received 6 units of humalog at 7 pm. ABG was 7.52/40/70. No AG on Chem7. Urine with Tr Ketones and 1000 glucose. Also received 40 iv pantoprazole and zofran. Received 3rd liter of NS. On the floor, pt endorses above history, and current ___ abdominal pain and nausea. Past Medical History: DM with neuropathy Personality disorder: avoidant? Esophageal reflux Diabetic neuropathy CKD stage 1, microalbuminuria Complaints of total body pain HTN (hypertension) Vomiting- thought ___ gastroparesis Gastric polyp Myopia Constipation Hearing deficit Elevated LFTs Lung nodule Social History: ___ Family History: negative for diabetes Physical Exam: ADMISSION EXAM: ================= Vitals- T 97.9, BP 143/79, HR 96, 98/RA General: Somnolent, NAD HEENT: NCAT Neck: supple CV: RRR, no m/r/g Lungs:CTAB Abdomen: Soft, non-tender, + BS GU: no foley Ext: no c/c/e Neuro: MAE, grossly wnl Skin: no rash MSK: chest pain reproducible on palpation DISCHARGE EXAM: ================= Vitals- 98.6, 135/68 (121-140/68-79), 88 (88-100), 16, 98/RA CBGs: 107->131->153(1H)->249(60L/2H)->125 General: awake, interactive, NAD CV: RRR, no m/r/g Lungs: CTAB, no w/r/r Abdomen: Soft, mild tenderness periumbilical, non-distended, normoactive BS Ext: no c/c/e Pertinent Results: ADMISSION LABS: ================= ___ 02:50PM BLOOD WBC-10.4 RBC-4.03* Hgb-11.1* Hct-33.3* MCV-83 MCH-27.7 MCHC-33.5 RDW-15.4 Plt ___ ___ 02:50PM BLOOD Glucose-388* UreaN-29* Creat-1.0 Na-127* K-3.5 Cl-83* HCO3-31 AnGap-17 ___ 02:50PM BLOOD cTropnT-<0.01 ___ 02:50PM BLOOD Calcium-9.6 Phos-3.8 Mg-2.3 ___ 06:55PM BLOOD %HbA1c-7.2* eAG-160* ___ 02:55PM BLOOD pO2-70* pCO2-40 pH-7.52* calTCO2-34* Base XS-8 ___ 06:55PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG DISCHARGE LABS: ================= ___ 06:00AM BLOOD WBC-6.3 RBC-3.39* Hgb-9.6* Hct-28.5* MCV-84 MCH-28.4 MCHC-33.8 RDW-16.6* Plt ___ ___ 06:00AM BLOOD Glucose-95 UreaN-16 Creat-0.8 Na-133 K-3.8 Cl-97 HCO3-29 AnGap-11 STUDIES: ================= ___ KUB: IMPRESSION: Moderate fecal loading. No evidence of obstruction. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Chlorthalidone 25 mg PO DAILY 2. Sucralfate 1 gm PO TID 3. Metoclopramide 5 mg PO QIDACHS 4. Pregabalin 150 mg PO QID 5. Carbamazepine (Extended-Release) 200 mg PO BID 6. Multivitamins 1 TAB PO DAILY 7. Amitriptyline 100 mg PO HS 8. Glargine 60 Units Bedtime Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin 9. Aspirin 81 mg PO DAILY 10. Glucagon 1 mg IM ONCE prn:hypoglycemia 11. Ranitidine 150 mg PO DAILY 12. Omeprazole 40 mg PO BID Discharge Medications: 1. Amitriptyline 100 mg PO HS 2. Aspirin 81 mg PO DAILY 3. Carbamazepine (Extended-Release) 200 mg PO BID 4. Glucagon 1 mg IM ONCE prn:hypoglycemia 5. Glargine 60 Units Bedtime Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin 6. Metoclopramide 5 mg PO QIDACHS 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 40 mg PO BID 9. Pregabalin 150 mg PO QID 10. Ranitidine 150 mg PO DAILY 11. Sucralfate 1 gm PO TID 12. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 13. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*2 14. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day Disp #*30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Hyperglycemia Hyponatremia Abdominal Pain Secondary: Diabetes mellitus Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPHS HISTORY: Vomiting and hematemesis. COMPARISONS: None. TECHNIQUE: Chest, PA and lateral. FINDINGS: The heart is normal in size. The mediastinal and hilar contours appear within normal limits. There is no pleural effusion or pneumothorax. There is mild elevation of the right hemidiaphragm. Streaky opacities in the right lower lung, probably referring mostly to the right middle lobe, suggest minor scarring. Otherwise, the lungs appear clear. Bony structures are unremarkable. IMPRESSION: No evidence of acute cardiopulmonary disease. Radiology Report INDICATION: Abdominal pain, vomiting, and constipation. Evaluate for obstruction or fecal loading. COMPARISON: None. FINDINGS: There is a moderate quantity of stool throughout the colon. There are no air-filled dilated loops of small bowel or colon. No free air is seen in the abdomen. Mild linear right lower lung atelectasis. IMPRESSION: Moderate fecal loading. No evidence of obstruction. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: N/V, Hyperglycemia Diagnosed with VOMITING temperature: 97.8 heartrate: 106.0 resprate: 18.0 o2sat: 95.0 sbp: 131.0 dbp: 86.0 level of pain: 10 level of acuity: 2.0
Dear Mr. ___, You were admitted to the hospital with nausea and vomiting. Your blood sugars were high since you had not been able to take your insulin. You were treated with intravenous fluids for dehydration. Your blood sugars returned to normal levels once your insulin was restarted. Please take your medications as prescribed and make sure that you are having regular bowel movements. Please follow up with the ___ doctors and your primary care doctors in the next ___ weeks. Take care, ___ medicine team
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, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ year old male with recently diagnosed CLL and warm autoimmune hemolytic anemia presenting from ___ with chest pain, fevers, and anemia. He reports that ___ he was feeling his regular self until he developed diarrhea, nonbloody. He had several episodes ___ and into ___, no sick contacts, no travel, no recent antibiotics, no exotic food. He tried to sleep it off, but ___ night he woke with sharp chest pain. It was non radiating, no nausea, no shortness of breath. The pain was constant, prompting him to go to ___. There, he was febrile to 102, HR 111, BP 95/70 satting 97% on 2L. Trop and EKG were negative, hct was 22 down from baseline of 36, Cr 3.0. Tbili was 2.5. Cdiff and flu negative. Peripheral phenyephrine was started, he was given 4L NS, and given ceftriaxone and vanc prior to transfer. He contineud to have chest pain. On arrival to the ED, initial vitals were T 99.1 HR 111 BP 109/70 RR 16 O2 97% 3LNC. Labs were notable for 18.5>5.4/15.4<289, K 2.6, HCO3 13, BUN 37 Cr 1.7. LDH 314, direct bili 0.6. INR 1.5. He was complaining of chest pain, EKG was without ischemia. He spiked a fever 103.1 and was given tylenol and unasyn. He received 2 units of emergency release PRBC's and crit bumped to 23.4. BMT evaluated him and he was given prednisone 80mg and transferred to the FICU with another unit of blood running. On arrival to the ICU, he continues to have chest pain, now migrated to the right side and worse with palpation. He feels short of breath and had hiccups that have resolved. He has no abd pain, no nausea. He reports no rash, no joint pains. Past Medical History: Warm antibody autoimmune hemolytic anemia Chronic Lymphocytic Leukemia Hypertension Social History: ___ Family History: Mother, Brother, Sister: HTN 3 Children (daughters): all healthy No family history of leukemia or blood disorders Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals: T 99.4 BP 125/82 HR 100 RR 30 O2 88%RA General: Alert, oriented HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: Poor air movement, scattered ronchi, no wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM ======================= Vitals- 98.0-98.5, 122-134/68-90, 88-102, ___, 98-100% on RA. General: Patient laying in bed comfortably in NAD. HEENT: No oropharyngeal lesions. Lungs: Poor inspiratory effort, but clear to auscultation with no wheezes, rales, or rhonchi. CV: Regular rate, regular rhythm, S1 and S2 present, no murmurs. Abdomen: soft, non-tender, non-distended, no rebound or guarding. Normoactive bowel sounds. Ext: No lower extremity swelling. Lines: Temporary IJ removed, site currently dressed, clean, dry, intact. Pertinent Results: ADMISSION LABS ============== ___ 06:58AM BLOOD WBC-18.5*# RBC-1.81*# Hgb-5.4*# Hct-15.4*# MCV-85 MCH-29.8 MCHC-34.9 RDW-16.0* Plt ___ ___ 06:58AM BLOOD Neuts-77.2* ___ Monos-2.8 Eos-0.9 Baso-0.3 ___ 06:58AM BLOOD ___ PTT-34.9 ___ ___ 01:01PM BLOOD Ret Aut-2.0 ___ 06:58AM BLOOD Glucose-82 UreaN-37* Creat-1.7* Na-140 K-2.6* Cl-115* HCO3-13* AnGap-15 ___ 06:58AM BLOOD ALT-15 AST-16 LD(LDH)-314* AlkPhos-53 TotBili-1.4 DirBili-0.6* IndBili-0.8 ___ 06:58AM BLOOD Albumin-2.3* Calcium-6.1* Phos-2.4*# Mg-1.6 ___ 07:04AM BLOOD Lactate-0.7 ___ 06:58AM BLOOD Hapto-153 HEMOLYSIS LABS ============== ___ 01:01PM BLOOD Ret Aut-2.0 ___ 07:25PM BLOOD Ret Aut-1.7 ___ 04:00PM BLOOD Ret Aut-3.1 ___ 03:16AM BLOOD Ret Aut-3.4* ___ 05:50AM BLOOD Ret Aut-4.9* ___ 12:52AM BLOOD Ret Aut-5.7* ___ 12:08AM BLOOD Ret Aut-8.9* ___:04AM BLOOD Ret Man-17.8* ___ 12:00AM BLOOD Ret Man-18.6* ___ 12:02AM BLOOD Ret Man-32.0* ___ 12:27AM BLOOD Ret Man-31.2* ___ 12:05AM BLOOD Ret Aut-23.9* ___ 12:04AM BLOOD Ret Man-22.0* ___ 12:01AM BLOOD Ret Man-20.1* G6PD ==== QG6PD-25.8 DISCHARGE LABS ============== ___ 12:01AM BLOOD WBC-10.8 RBC-1.97* Hgb-7.3* Hct-23.1* MCV-117* MCH-36.9* MCHC-31.5 RDW-23.2* Plt ___ ___ 12:01AM BLOOD Neuts-70.5* ___ Monos-2.5 Eos-0.1 Baso-0.4 ___ 12:01AM BLOOD ___ PTT-35.2 ___ ___ 12:01AM BLOOD Glucose-139* UreaN-21* Creat-1.0 Na-140 K-4.3 Cl-105 HCO3-22 AnGap-17 ___ 12:01AM BLOOD ALT-41* AST-18 LD(LDH)-670* AlkPhos-58 TotBili-0.7 DirBili-0.2 IndBili-0.5 ___ 12:01AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.2 IMAGING ======= ___: CHEST (PORTABLE AP) Compared to the prior study, there is a new right internal jugular central venous line, the tip of which terminates at the cavoatrial junction. There is no evidence of pneumothorax. The lungs are clear but underinflated, accentuating the cardiomediastinal contour. No pleural effusion. ___: BILATERAL LOWER EXTREMITY VEINS FINDINGS: There is normal compressibility, flow and augmentation of the bilateral common femoral, superficial femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. Inguinal lymph nodes are not enlarged. IMPRESSION: No evidence of deep venous thrombosis in the bilateral lower extremity veins. ___: CTA CHEST WITH AND WITHOUT CONTRAST IMPRESSION: 1. Low lung volumes with trace bilateral pleural effusions. 2. Two right upper lobe nodules, the largest which measures 4 x 7mm. This was not seen previously and could be inflammatory or a true nodule and followup chest CT in 3 months is recommended. 3. Prominent bi-axillary nodes as well as right paratracheal node, minimally changed in size when compared to prior examination dated ___ likely secondary to known CLL. 4. No pulmonary embolism. ___: ABDOMINAL SUPINE AND LATERAL DECUBITUS PORTABLE FINDINGS: Minimally dilated loops of small bowel in the right abdomen, measuring up to 3.0 cm in diameter. There are no abnormally dilated loops of large bowel to suggest megacolon. The apparent sigmoid colonic wall thickening is probably due to colonic under-distension. The left lateral decubitus view does not show any evidence of intraperitoneal free air. IMPRESSION: 1. No abnormally dilated loops of colon to suggest megacolon. 2. No pneumoperitoneum. 3. Minimally dilated small bowel loops, measuring up to 3.0cm in diameter. ___: CHEST X-RAY PA AND LATERAL FINDINGS: Cardiac size normal. Mediastinal lymph nodes are better seen in prior CT. The upper lungs are clear. There is no pneumothorax or right pleural effusion. Small left effusion and atelectasis has minimally increased. Right IJ catheter tip is in the lower SVC. The osseous structures are unremarkable IMPRESSION: Minimal increase in size of small left effusion and adjacent atelectasis MICROBIOLOGY ============ ___ 12:40 pm URINE Source: ___. **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). ___ 12:01 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. VIRAL CULTURE ADD-ON PER ___ ___ ___ 1228. Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FoLIC Acid 5 mg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Amlodipine 10 mg PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q8H RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 4. PredniSONE 80 mg PO DAILY RX *prednisone 20 mg 4 tablet(s) by mouth daily Disp #*32 Tablet Refills:*0 5. Amlodipine 10 mg PO DAILY 6. FoLIC Acid 5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= WARM AUTOIMMUNE HEMOLYTIC ANEMIA CHRONIC LYMPHOCYTIC LEUKEMIA DIARRHEA SECONDARY DIAGNOSIS =================== HYPERTENSION Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with central venous line TECHNIQUE: Portable supine chest radiograph COMPARISON: Outside hospital chest radiograph from earlier on the same date FINDINGS: Compared to the prior study, there is a new right internal jugular central venous line, the tip of which terminates at the cavoatrial junction. There is no evidence of pneumothorax. The lungs are clear but underinflated, accentuating the cardiomediastinal contour. No pleural effusion. IMPRESSION: Satisfactory position of right internal jugular central venous line, with the tip at the superior cavoatrial junction. No pneumothorax. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man with chest pain, tachycardia, hypotension, and hypoxia. 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, superficial 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. Inguinal lymph nodes are not enlarged. IMPRESSION: No evidence of deep venous thrombosis in the bilateral lower extremity veins. Radiology Report INDICATION: ___ male with tachycardia, hypoxia, and tachypnea. 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 307 mGy-cm. COMPARISON: Chest CT dated ___. FINDINGS: CT Thorax: The thyroid gland is unremarkable. There are prominent bilateral axillary nodes, previously present and overall unchanged. There is a 1.2 cm right paratracheal lymph node again noted (4:23), previously 1 cm. There is no hilar adenopathy identified. The airways are patent to the subsegmental level. The heart, pericardium and great vessels are within normal limits. There is no pericardial effusion. No esophageal abnormality is identified. Lung windows demonstrate low lung volumes is thought to account for diffuse subtle increase in density throughout both lung fields. Trace bibasilar pleural effusions are noted. Within the right upper lobe, there is a 4 x 7 mm nodule identified (5:61) and inferiorly a 2 mm nodule along the fissure of the middle lobe. Both were not definitively seen on the prior examination. 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 evaluated to the segmental level. There is no filling defect to suggest pulmonary embolism. Osseous structures: No suspicious lytic or blastic lesions are identified. The study is not tailored for intra-abdominal examination, the visualized viscera are unremarkable. IMPRESSION: 1. Low lung volumes with trace bilateral pleural effusions. 2. Two right upper lobe nodules, the largest which measures 4 x 7mm. This was not seen previously and could be inflammatory or a true nodule and followup chest CT in 3 months is recommended. 3. Prominent bi-axillary nodes as well as right paratracheal node, minimally changed in size when compared to prior examination dated ___ likely secondary to known CLL. 4. No pulmonary embolism. NOTIFICATION: Findings and recommendations were discussed with ___, house staff caring for the patient, by Dr. ___ telephone at 11:21, on ___. Radiology Report EXAMINATION: Abdominal radiograph INDICATION: ___ year old man with CLL, leukocytosis, diarrhea, treating empirically for c diff // ?Megacolon, perforation TECHNIQUE: Portable abdominal radiograph COMPARISON: CT abdomen and pelvis ___ FINDINGS: Minimally dilated loops of small bowel in the right abdomen, measuring up to 3.0 cm in diameter. There are no abnormally dilated loops of large bowel to suggest megacolon. The apparent sigmoid colonic wall thickening is probably due to colonic under-distension. The left lateral decubitus view does not show any evidence of intraperitoneal free air. IMPRESSION: 1. No abnormally dilated loops of colon to suggest megacolon. 2. No pneumoperitoneum. 3. Minimally dilated small bowel loops, measuring up to 3.0cm in diameter. NOTIFICATION: Final results were telephoned to Dr. ___ By Dr. ___ on ___ at 3:29PM. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with CLL and autoimmune hemolytic anemia with decreased breath sounds on examination. // Question of bilateral pleural effusions. TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: Cardiac size normal. Mediastinal lymph nodes are better seen in prior CT. The upper lungs are clear. There is no pneumothorax or right pleural effusion. Small left effusion and atelectasis has minimally increased. Right IJ catheter tip is in the lower SVC. The osseous structures are unremarkable IMPRESSION: Minimal increase in size of small left effusion and adjacent atelectasis Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Transfer, Hypotension Diagnosed with HYPOTENSION NOS, CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION, ACQ HEMOLYTIC ANEMIA NOS temperature: 99.1 heartrate: 111.0 resprate: 16.0 o2sat: 97.0 sbp: 109.0 dbp: 70.0 level of pain: 10 level of acuity: 2.0
Dear Mr. ___, You were admitted to ___ after experiencing diarrhea with resultant chest pain and shortness of breath. You were found to have low red blood cell count, known as anemia. This was likely due to destruction of your red blood cells known as hemolysis. You were transfused red blood cells to increase your blood counts. You also received steroids to help stop the destruction of the red blood cells. You also received a medication called rituximab to help control your low blood cells. These helped stabilize your red blood cell counts. By the time of discharge you did not require a transfusion in 6 days. You were discharged on a medication called prednisone. Please take 80 milligrams of prednisone DAILY. You were also started on a medication called acyclovir and a medication called trimethoprim-sulfamethoxazole to help prevent infections. Your lisinopril and hydrochlorothiazide were STOPPED as your blood pressure was well controlled on your other blood pressure medications. Please discuss this medication change with your oncologist. We would like you to follow up in clinic on ___ at 2PM to get a blood check to see what your blood levels are. Also on imaging of your chest, two nodules were noted in your lung. PLEASE FOLLOW-UP WITH A REPEAT CT SCAN OF YOUR CHEST IN 3 MONTHS. If you have any worsening symptoms including shortness of breath, chest pain, lightheadedness, nausea, vomiting, or diarrhea please seek medical assistance at your nearest Emergency Department. It was a pleasure taking care of you during hospitalization! We wish you all the best! Sincerely, Your ___ Care Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lactose / morphine / onions Attending: ___ Chief Complaint: abdominal pain/SOB Major Surgical or Invasive Procedure: none History of Present Illness: ___ male with history of alcoholic cirrhosis, alcohol abuse complicated by withdrawal seizures, asthma with multiple intubations in the past presenting with abdominal pain and SOB. Pt states his symptoms began ___ days ago with abdominal pain and SOB. Abdominal pain radiates to his back and bilateral, associated with nausea and "dry heaves". Also with subjective fevers and chills. No hematemesis, melena, or hematochezia. Unclear if pain worsened with food but pt has only been taking in liquids recently. Uncertain if this feels like prior episodes of pancreatitis. Pt states he also began drinking again several days ago. Pt additionally reports SOB over this time as well with associated dry cough and wheezing. Has not missed any doses of meds but does report not getting methadone for last few days d/t DOE. In the ED, VS: Temp: 99.5 HR: 110 BP: 131/92 Resp: 20 O(2)Sat: ___id not appear to be actively w/d'ing on initial exam. Pulm exam notable for wheezing Labs: AST: 136, ALT: 37, Alk Phos: 982, Tbili: 2.3 (mildly hemolyzed specimen) CXR negative, CT a/p negative for pancreatitis, did show know cirrhosis with splenomegaly and esophageal varices. ___ given several duonebs, methylpred, 1L NS, Zofran, hydromorphone and admitted for management of abdominal pain, EtOH w/d, and asthma exacerbaton ROS: GEN: positive for fevers, chills, negative for weight loss HEENT: denies vision changes, headache CV: denies chest pain, palpitations RESP: see above HPI GI: see above HPI EXT: denies edema NEURO: reports tremors, denies numbness/weakness Rest of 10 point review of systems otherwise negative. Past Medical History: -Immunodeficiency/CMV gastritis -Esophageal candidiasis -Asthma with h/o intubation and difficult extubation -Substance abuse: etoh with h/o withdrawal and DTs -ETOH cirrhosis -Pancreatitis -Adjustment Disorder with Depressed Mood -Gastritis without bleeding due to alcohol and CMV (CMV seen on path report from gastric biopsy ___ -Atopic Dermatitis -Allergic Rhinitis Social History: ___ Family History: Uncle died of EtOH cirrhosis. Multiple family members with asthma including mother and sister. No other known ailments on maternal side, does not know about father's side. Physical Exam: GEN: laying in bed, appears to be in discomfort HEENT: no scleral icterus, no tongue fasciculations CV: RRR, no m/r/g, no JVD RESP: Diffuse wheezing throughout with decreased air movement, no respiratory distress GI: Soft, TTP in RUQ and LUQ, no rebound, mildly distended EXT: no edema, WWP SKIN: No rashes, no jaundice NEURO: AAOx3, conversing normally, mild bilateral hand tremor, no asterixis PSYCH: Normal mood and affect, no e/o visual or auditory hallucinations Pertinent Results: ___ 01:40AM BLOOD WBC-8.3 RBC-4.33* Hgb-12.2* Hct-39.1* MCV-90# MCH-28.2 MCHC-31.2* RDW-16.0* RDWSD-52.0* Plt ___ ___ 01:40AM BLOOD Neuts-66.8 Lymphs-18.0* Monos-11.3 Eos-2.9 Baso-0.5 Im ___ AbsNeut-5.55# AbsLymp-1.49 AbsMono-0.94* AbsEos-0.24 AbsBaso-0.04 ___ 02:12AM BLOOD ___ PTT-35.3 ___ ___ 01:40AM BLOOD Glucose-86 UreaN-7 Creat-0.4* Na-137 K-4.1 Cl-102 HCO3-23 AnGap-16 ___ 01:40AM BLOOD ALT-37 AST-136* AlkPhos-982* TotBili-2.3* ___ 01:40AM BLOOD Lipase-86* ___ 01:40AM BLOOD Albumin-4.0 Calcium-8.7 Phos-2.8 Mg-1.7 EXAMINATION: Chest radiograph. (___) INDICATION: ___ w/wheeze and cough and tactile fevers, please eval for PNA // ___ w/wheeze and cough and tactile fevers, please eval for PNA TECHNIQUE: Single AP view. COMPARISON: CTA chest ___. FINDINGS: Lung volumes are low. Bibasal areas of atelectasis are extensive, in particular in the right lung base Heart size is within normal limits. Lung fields are clear. There is no pneumothorax. IMPRESSION: No acute cardiopulmonary abnormality. EXAMINATION: CT abdomen pelvis. (___) INDICATION: NO_PO contrast; ___ w/cirrhosis, abdominal pain, immunosuppressed with fevers, please eval for intraabdominal abscessNO_PO contrast // ___ w/cirrhosis, abdominal pain, immunosuppressed with fevers, please eval for intraabdominal abscess TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP = 15.6 mGy-cm. 2) Spiral Acquisition 5.0 s, 54.5 cm; CTDIvol = 16.8 mGy (Body) DLP = 914.7 mGy-cm. Total DLP (Body) = 930 mGy-cm. COMPARISON: CT ___ and MRCP ___ FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver has a cirrhotic morphology. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: Mild splenomegaly is unchanged. The attenuation of the spleen is within normal limits. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. Esophageal, splenic and periportal varices are unchanged. BONES: Mild to moderate compression deformities of the T7 and T9 vertebral bodies are unchanged. No evidence of osseous malignancy or infection. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No acute intra-abdominal abnormality. 2. Cirrhotic liver morphology with re-demonstrated mild splenomegaly and varices. No focal hepatic lesions seen. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acamprosate 666 mg PO TID 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea 3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 4. FoLIC Acid 1 mg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Montelukast 10 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Pantoprazole 40 mg PO Q24H 9. Sertraline 100 mg PO DAILY 10. Spironolactone 50 mg PO DAILY 11. Thiamine 100 mg PO DAILY 12. Tiotropium Bromide 1 CAP IH DAILY 13. Vitamin D 1000 UNIT PO DAILY 14. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID 15. melatonin 3 mg oral QHS 16. Symbicort (budesonide-formoterol) ___ inhalation INHALATION BID Discharge Medications: 1. Azithromycin 500 mg PO Q24H RX *azithromycin 500 mg 1 tablet(s) by mouth daily Disp #*1 Tablet Refills:*0 2. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe Duration: 2 Days RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 6 hours as needed for pain Disp #*8 Tablet Refills:*0 3. PredniSONE 50 mg PO DAILY Duration: 1 Day RX *prednisone 50 mg 1 tablet(s) by mouth daily Disp #*1 Tablet Refills:*0 4. Acamprosate 666 mg PO TID 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea 6. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID 7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 8. FoLIC Acid 1 mg PO DAILY 9. Furosemide 40 mg PO DAILY 10. melatonin 3 mg oral QHS 11. Methadone 80 mg PO DAILY 12. Montelukast 10 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Pantoprazole 40 mg PO Q24H 15. Sertraline 100 mg PO DAILY 16. Spironolactone 50 mg PO DAILY 17. Thiamine 100 mg PO DAILY 18. Tiotropium Bromide 1 CAP IH DAILY 19. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Alcohol withdrawal Asthma exacerbation Opiate dependence 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: ___ w/wheeze and cough and tactile fevers, please eval for PNA // ___ w/wheeze and cough and tactile fevers, please eval for PNA TECHNIQUE: Single AP view. COMPARISON: CTA chest ___. FINDINGS: Lung volumes are low. Bibasal areas of atelectasis are extensive, in particular in the right lung base Heart size is within normal limits. Lung fields are clear. There is no pneumothorax. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report EXAMINATION: CT abdomen pelvis. INDICATION: NO_PO contrast; ___ w/cirrhosis, abdominal pain, immunosuppressed with fevers, please eval for intraabdominal abscessNO_PO contrast // ___ w/cirrhosis, abdominal pain, immunosuppressed with fevers, please eval for intraabdominal abscess TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP = 15.6 mGy-cm. 2) Spiral Acquisition 5.0 s, 54.5 cm; CTDIvol = 16.8 mGy (Body) DLP = 914.7 mGy-cm. Total DLP (Body) = 930 mGy-cm. COMPARISON: CT ___ and MRCP ___ FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver has a cirrhotic morphology. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: Mild splenomegaly is unchanged. The attenuation of the spleen is within normal limits. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. Esophageal, splenic and periportal varices are unchanged. BONES: Mild to moderate compression deformities of the T7 and T9 vertebral bodies are unchanged. No evidence of osseous malignancy or infection. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No acute intra-abdominal abnormality. 2. Cirrhotic liver morphology with re-demonstrated mild splenomegaly and varices. No focal hepatic lesions seen. Gender: M Race: HISPANIC/LATINO - GUATEMALAN Arrive by WALK IN Chief complaint: Abd pain, N/V Diagnosed with Unspecified asthma with (acute) exacerbation, Unspecified abdominal pain temperature: 99.5 heartrate: 110.0 resprate: 20.0 o2sat: 96.0 sbp: 131.0 dbp: 92.0 level of pain: 10 level of acuity: 3.0
You came in with abdominal pain. We think that this pain is either from irritation of your stomach or a very mild pancreatitis. We treated you with pain medications which you did not think helped very much and bowel rest for a day. We also did a CT scan of your abdomen which did not show anything concerning. We also treated you for alcohol withdrawal while you were here and continued you on your methadone. We also treated you for an asthma exacerbation and your breathing was much improved by the time you left.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Throat pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of emergency repair acute Type A dissection ___ at ___ (30mm Gelveave graft from STJ - innominate artery) who presents with chest pain and concern for new dissection or aortic clot on CT scan. Patient was in his USOH until ___ when he developed a senstation that his throat was 'bruised' during inspiration. He then developed intermittent left sided chest, axilla, and back pain on ___ at rest. The pain would come and go, and could get up to ___. He notes the chest pain more when laying on his right side and the throat sensation more when he is lying on his back. Due to his symptoms, his PCP told him to proceed to ___, and he went to ___ on ___. There, a CTA showed concern for a Type A aortic dissection of indeterminate age, but no active extravasation. There was also some concern for an aortic clot at some point, although not mentioned in the read. He was then transferred to ___ for further evaluation. In the ___ intial vitals were pain 4, T 98.5, HR 106, BP 123/84, RR 18, O2 92% RA. Initial labs were notabele for WBC 11.1, INR 1.2, and trops negative x1. Remainder of CBC and chem10 were wnl. Cardiac surgery was consulted who felt that this was not an acute issue, but recommended repeat imaging in 48-72 hours. They also recommended against any anticoagulation. Patient was then transferred to cardiology for further management. Vitals on transfer were pain 0, T 97.7, HR 98, BP 130/77, RR 15, O2 94%RA. On the floor patient notes only mild throat discomfort, and denies dysphagia or difficulty breathing. He also notes he will have some chest pain as above when he rolls on his left side. Both of these are significantly improved from earlier in the week. He denies recent fevers or chills. No SOB or cough. No palpitations. No nausea, vomiting or diarrhea. No recent travel and no pain or swelling in his legs. He does note he started taking tiotropium inhaler and atorvastatin on ___ preceeding these symptoms. ROS is otherwise unremarkable. Past Medical History: 1. Type A aortic dissection status post emergent repair at ___ ___ in ___ with a 30 mm Gelweave graft from the sinotubular junction to takeoff of the innominate artery. 2. Dyslipidemia. 3. Hypertension. 4. PFO and atrial septal aneurysm with apparent small stroke by brain MRI. 5. Reported history of cluster headaches, also with complaint of visual auras in the absence of headache. 6. Tobacco use. 7. ?CODP Social History: ___ Family History: -Maternal aunt, ___ who has an ascending aortic aneurysm and is being evaluated at ___ without as yet a clear genetic diagnosis. -Cousin, (son of ___ also had an ascending aortic aneurysm and has been seen at ___. -Father with PE at ___ Physical Exam: ON ADMISSION VS: T 98.1, BP 118/76, HR 89, RR 18, O2 96%RA General: Well appearing pleasant man in NAD HEENT: Anicteric sclerae, PERLL, OP clear Neck: No LAD, JVD not elevated CV: RRR, no MRG Lungs: Nonlabored on RA. Scattered wheeze greatest over RUL Abdomen: Soft, NT, nondistended. No HSM Ext: No unilateral swelling or erythema. No edema Neuro: Appropriate. AAOx3. CNII-XII intact. Moving all extremities equally. ON DISCHARGE VS: T 98.1, BP 118/76, HR 89, RR 18, O2 96%RA General: Well appearing pleasant man in NAD HEENT: Anicteric sclerae, PERLL, OP clear Neck: No LAD, JVD not elevated CV: RRR, no MRG Lungs: Nonlabored on RA. Scattered wheeze greatest over RUL Abdomen: Soft, NT, nondistended. No HSM Ext: No unilateral swelling or erythema. No edema Neuro: Appropriate. AAOx3. CNII-XII intact. Moving all extremities equally. Pertinent Results: ON ADMISSION ___ 06:30PM BLOOD WBC-11.1* RBC-5.27 Hgb-14.1 Hct-42.7 MCV-81* MCH-26.7* MCHC-33.0 RDW-13.1 Plt ___ ___ 06:30PM BLOOD Neuts-62.6 ___ Monos-8.5 Eos-1.5 Baso-0.8 ___ 06:30PM BLOOD ___ PTT-28.9 ___ ___ 06:30PM BLOOD Glucose-94 UreaN-9 Creat-0.9 Na-133 K-3.5 Cl-101 HCO3-23 AnGap-13 ___ 06:30PM BLOOD cTropnT-<0.01 ___ 06:30PM BLOOD Calcium-9.1 Phos-4.0 Mg-2.0 ON DISCHARGE ___ 07:05AM BLOOD WBC-10.4 RBC-4.84 Hgb-13.3* Hct-39.9* MCV-83 MCH-27.5 MCHC-33.3 RDW-12.9 Plt ___ ___ 07:05AM BLOOD Neuts-54.5 ___ Monos-5.6 Eos-3.0 Baso-0.5 ___ 07:05AM BLOOD Glucose-88 UreaN-12 Creat-0.9 Na-138 K-4.4 Cl-104 HCO3-26 AnGap-12 ___ 07:05AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9 ___ 07:10AM BLOOD TSH-3.0 ___ 07:10AM BLOOD T4-8.3 STUDIES: CTA TORSO (___) 1. Apparent discontinuity of the ascending aorta with communication to an adjacent hematoma/fluid collection. Hyperdense areas adjacent to this site raise concern for extravasation of contrast into a contained rupture/pseudoaneurysm. Recommend repeat multiphase chest CTA to assess for active extravasation of contrast into the adjacent mediastinal collections. Comparison with any prior post-operative chest CTs would also be helpful to determine chronicity of findings. 2. 2-cm partially thrombosed aneurysm of the left gastric artery 3. Nonspecific mediastinal and hilar adenopathy which is stable since ___ suggesting a benign etiology. 4. Borderline pelvic lymph nodes of uncertain etiology and chronicity. 5. Stable 3-cm left adrenal adenoma. 6. Ectasia of the right common iliac artery measuring 1.7 cm. 7. Diverticulosis CT NECK (___) 1. No abnormal fluid collection or lymphadenopathy in the neck. 2. Mediastinal fluid collection and aortic dissection remain unchanged since prior study on ___. CTA CHEST (___) Probable thrombosed traumatic pseudoaneurysm medial to the ascending aortic graft. The chronicity of these findings is uncertain, though given probable surrounding granulation tissue, findings are at least subacute or chronic. No acute active extravasation is identified. Comparison with prior post-operative CT examinations would be helpful. Recommend short interval followup CT (~3 months) to assess for stability and to guide any potential further interventional management. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. Losartan Potassium 25 mg PO DAILY 3. Metoprolol Succinate XL 100 mg PO DAILY 4. Atorvastatin 10 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Tiotropium Bromide 1 CAP IH DAILY Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 10 mg PO DAILY 3. Losartan Potassium 25 mg PO DAILY 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Throat pain Hypoxia SECONDARY DIAGNOSIS: Hypertension Hyperlipidemia COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ male with history of type A aortic dissection, status post emergent surgical repair in ___ with a 30-mm Gelweave graft from STJ-innominate artery. Patient now presenting with chest and back pain acutely. Assess for interval change. COMPARISON: CTA of the chest from outside hospital performed on ___ and CTA of the chest and abdomen from outside hospital performed on ___. TECHNIQUE: MDCT axial images of the chest, abdomen and pelvis were obtained with intravenous contrast. Images were acquired in an arterial phase. Coronal and sagittal reformations were prepared. Additionally, 3D reformations were created on a separate workstation and reviewed on the PACS. CT CHEST WITH INTRAVENOUS CONTRAST: The thyroid gland is homogeneous without focal nodule. No supraclavicular or axillary lymphadenopathy is identified. Numerous mediastinal lymph nodes overall appear unchanged compared to most recent prior examination from two days prior and many were present on preoperative chest CT from ___. An anterior mediastinal lymph node at the level of the great vessel takeoff measures 11 x 13 mm as compared to 11 x 10 mm previously (2:38). A probable conglomerate of right hilar lymph nodes measures 17 x 20 mm as compared to 16 x 22 mm on prior examination from ___ (2:56). The etiology is uncertain, though stability over ___ years suggests a non-neoplastic etiology. The heart size is normal, and there is no pericardial effusion. The central pulmonary arteries are patent. The tracheobronchial tree is patent to subsegmental levels without bronchial wall thickening or bronchiectasis. There is extensive centrilobular and paraseptal emphysema predominantly within the lung apices. No suspicious pulmonary nodule or mass is identified. Linear atelectatic scarring is identified within the bilateral lung bases. There is no pleural effusion. CT ABDOMEN WITH INTRAVENOUS CONTRAST: The liver demonstrates homogeneous parenchymal enhancement without suspicious focal lesion. Subcentimeter hypodensities within segment ___ and VI are unchanged compared to prior examination and remain too small to characterize, though may represent small cysts or biliary hamartomas. A simple cyst within segment IVb of the liver measuring 1.8 x 1.4 cm is slightly increased in size since ___. Hepatic veins and portal venous system are grossly patent. No intra- or extra-hepatic biliary ductal dilatation is identified. The gallbladder, spleen, pancreas, and right adrenal gland are normal. A 2.5 x 3.0 cm hypodense lesion within the left adrenal gland is stable compared to prior examination of ___ and had prior attenuation characteristics consistent with an adenoma. The kidneys enhance symmetrically without suspicious focal lesion. There is no hydronephrosis. Incidental note is made of a splenule. Stomach and small bowel loops are normal in caliber and configuration without evidence of obstruction or inflammation. There is no abdominal free fluid or free air. No suspicious mesenteric or retroperitoneal lymphadenopathy is identified. CT PELVIS WITH INTRAVENOUS CONTRAST: There is colonic diverticulosis without signs of acute inflammation or obstruction. The bladder is distended and appears normal. Prostate and seminal vesicles are unremarkable. Subcentimeter pelvic lymph nodes are identified which are of uncertain etiology. A left external iliac lymph node measures 8 x 20 mm (2:236) and a right external iliac lymph node measures 8 x 10 mm (2:239). The stability of these nodes cannot be determined as no prior pelvic imaging is available for comparison. No suspicious inguinal adenopathy is identified. CTA: The patient is status post emergent repair of a type A aortic dissection in ___. The postoperative appearance of the ascending aorta appears similar to recent examination from ___ from outside hospital. The ascending aorta measures 5.2 x 5.2 cm at its maximum diameter, and this is unchanged compared to recent prior examination. However, there appears to be focal discontinuity of the medial aortic wall (2:52) and communication with an adjacent hematoma/fluid collection. Hyperdense material is also identified adjacent to this collection (2:49-54) which raises concern for extravasation of contrast into a pseudoaneurysm. The adjacent collection measures 2.4 x 3.5 cm and is similar in size compared to CT from 2 days prior, though this stability could just reflect a subacute contained rupture. The collection described above appears to be in continuity with a second more superior anterior mediastinal collection (2:43). This collection has a hyperdense rim and is stable in size compared to CT from 2 days prior. Given the clinical history, findings are concerning for subacute contained aortic rupture. Comparison with prior post-operative chest CTs would be helpful to determine the acuity of findings. Recommend follow-up multiphase chest CT to determine if active extravasation is present. A focal dissection flap is seen at the level of the aortic arch with extension into the proximal descending thoracic aorta. The descending thoracic aorta is normal in caliber and widely patent without significant atherosclerotic plaque. The abdominal aorta and branch vessels are non-aneurysmal and grossly patent. No focal dissection is identified. There is minimal atherosclerotic plaque involving the infrarenal abdominal aorta just proximal to the common iliac bifurcation. The right common iliac artery is mildly ectatic measuring 1.7 x 1.4 cm (2:202). Distal flow to the internal-external iliac arteries is preserved. There is variant anatomy at the celiac axis. The common celiac trunk gives rise to the left gastric artery and the splenic artery, and the common hepatic artery arises directly from the aorta (2:133). There is an aneurysm of the left gastric artery arising 2.7 cm from the origin of the aorta. The aneurysm measures 1.2 x 1.3 x 2.2 cm (2:122 and 602B:42). The more inferior portions of the aneurysm are partially thrombosed. There is also a replaced left hepatic artery arising from the left gastric artery. The SMA origin is widely patent. The two right renal and one left renal arteries are widely patent. The ___ is also widely patent. BONES AND SOFT TISSUES: No bone destructive lesion or acute fracture is identified. IMPRESSION: 1. Apparent discontinuity of the ascending aorta with communication to an adjacent hematoma/fluid collection. Hyperdense areas adjacent to this site raise concern for extravasation of contrast into a contained rupture/pseudoaneurysm. Recommend repeat multiphase chest CTA to assess for active extravasation of contrast into the adjacent mediastinal collections. Comparison with any prior post-operative chest CTs would also be helpful to determine chronicity of findings. 2. 2-cm partially thrombosed aneurysm of the left gastric artery 3. Nonspecific mediastinal and hilar adenopathy which is stable since ___ suggesting a benign etiology. 4. Borderline pelvic lymph nodes of uncertain etiology and chronicity. 5. Stable 3-cm left adrenal adenoma. 6. Ectasia of the right common iliac artery measuring 1.7 cm. 7. Diverticulosis Dr. ___ communicated the above findings and recommendations (#1) to Dr. ___ at 4:45 pm on ___ by telephone ___ minutes after discovery. DLP: 1253.56 mGy-cm Radiology Report HISTORY: Patient with throat pain, rule out abscess. COMPARISON: CT chest from ___. TECHNIQUE: Contiguous axial images were obtained through the neck following administration of oral and 50 cc of Omnipaque. Coronal and sagittal reformats were also submitted for review. CTDIvol: 42.44mGy CLP: 629.32 mGy-cm. FINDINGS: There is no abnormal fluid collection in the neck. The mediastinal fluid collection and aortic dissection remain unchanged since ___. Evaluation of the aerodigestive tract demonstrate no exophytic mucosal mass, nor areas of focal mass effect. Evaluation of the cervical lymph chains demonstrate no pathologic lymphadenopathy by imaging criteria. Thyroid gland is normal. The salivary glands are unremarkable in appearance. Neck vessels enhance bilaterally without significant stenosis. IMPRESSION: 1. No abnormal fluid collection or lymphadenopathy in the neck. 2. Mediastinal fluid collection and aortic dissection remain unchanged since prior study on ___. Radiology Report HISTORY: ___ male with history of type A aortic dissection status post emergent surgical repair in ___ with 30 mm Gelweave graft from STJ-innominate artery. Patient now admitted with throat and back pain. Concern on recent CT for aortic pseudoaneurysm adjacent to the graft site. Assess for active extravasation. COMPARISON: CTA of the chest from ___ and CTA of the chest from outside hospital performed on ___. TECHNIQUE: MDCT axial images of the thoracic aorta were obtained with and without intravenous contrast. Initial axial images were acquired in a non-contrast phase followed by arterial, portal venous, and delayed phase imaging. Coronal and sagittal reformations were prepared. CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: A limited scan field of view focused on the ascending aorta, aortic arch, and proximal descending aorta was performed to assess for active extravasation into a mediastinal fluid collection adjacent to a surgically repaired ascending aorta. A previously described fluid collection adjacent to the ascending aortic graft just to the left of midline appears stable in size compared to multiple recent prior examinations. Additionally, the collection is mildly hyperattenuating on non-contrast images and does not demonstrate significant appreciable enhancement (2:38 and 11:38). There are linear septations between the ascending aortic graft and the above described collection, however, there still appears to be a direct communication between the aortic graft and this collection. The slow progressive enhancement of the septations over time is consistent with granulation tissue/fibrinous tissue. No contrast fills the collection on post-contrast images to suggest active extravasation. A slightly more superior anterior mediastinal collection demonstrates progressive rim enhancement, though does not centrally enhance. The stability over time, and lack significant contrast enhancement of these collections, suggests that the process is subacute or chronic. The patient likely had a subacute rupture of the graft at some point and has now developed a contained thrombosed pseudoaneurysm surrounded by granulation tissue. Comparison with prior postoperative CTs would be helpful for further assessment. Scattered mediastinal lymph nodes remain borderline in size and are unchanged compared to most recent prior examination. Central pulmonary arteries are patent. Severe paraseptal and centrilobular emphysema is noted. No bone destructive lesion or acute fracture is identified. Imaged median sternotomy wires appear intact. IMPRESSION: Probable thrombosed traumatic pseudoaneurysm medial to the ascending aortic graft. The chronicity of these findings is uncertain, though given probable surrounding granulation tissue, findings are at least subacute or chronic. No acute active extravasation is identified. Comparison with prior post-operative CT examinations would be helpful. Recommend short interval followup CT (~3 months) to assess for stability and to guide any potential further interventional management. Dr. ___ communicated the above results and recommendations to Dr. ___ at 4:30 pm on ___ by telephone. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: BACK PAIN Diagnosed with THORACIC AORTIC EMBOLISM temperature: 98.5 heartrate: 106.0 resprate: 18.0 o2sat: 92.0 sbp: 123.0 dbp: 84.0 level of pain: 4 level of acuity: 2.0
Dear Mr. ___, It was a pleasure caring for you at ___ ___. As you recall, you were admitted for throat pain. Imaging did not show progression of your previous known dissection. Imaging of your neck did not show anything that may cause throat pain. Please see below for follow up appointments.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Hydrochlorothiazide / Bactrim / Beta-Blockers (Beta-Adrenergic Blocking Agts) / propranolol Attending: ___ Chief Complaint: Chest pain, shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old lady with H/O IDDM, hypertension, CAD s/p MI in ___, seizures, SLE, CKD, and recent discharge for syncope on ___ thought secondary to a seizure presents with chest discomfort, dyspnea on exertion and fatigue today of sudden onset while exerting herself. She denied palpitations but did state that her heart felt like it had slowed down dramatically when this occurred. She states she has never had symptoms like this before, but has had substernal chest pain previously upon awakening in the morning that was relieved with eating a meal. Due to these new symptoms, she went to the ED where she was felt to have sinus bradycardia to the ___ and hypertension. She was recently started on propranolol 10 mg BID by her PCP for essential tremor on ___. Her chest pain resolved by the time she reached the ED, and over the ED course, it was noted that she went from presumed sinus bradycardia to regular rhythm with rates in the ___ but with a prolonged PR interval of ~300 msec. Cardiology was consulted in the ED who felt that her bradycardia was secondary to her newly started propranolol, and recommended admission to ___ for observation. After arrival to the cardiology floor, she has no complaints. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Insulin dependent diabetes (Dr. ___ - CAD (s/p MI ___ - Hypertension - Hypercholesterolemia - SLE (Dr. ___ - ___ arthritis - Osteoporosis - Cervical dysplasia - Bell palsy - Syphilis s/p penicillin Rx - Fibular Fx and Tibial Fx s/p ORIF, ___ Social History: ___ Family History: Mother - DM, CVA. Daughter - DM Physical ___: Admission Physical Exam: General: Elderly ___ woman, alert, oriented, no acute distress, hard of hearing Vitals: T 98.0 BP 190/61 HR 78 RR 18 SaO2 94% on RA HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP ~10 cm, no LAD Lungs: Bilateral bibasilar rales ___ up CV: Regular rate and rhythm, normal S1 + S2; no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. Trace pedal and pretibial edema. Discharge Physical Exam: General: Alert, oriented, no acute distress, hard of hearing Vitals: T 98.4, BP 154/69, HR 53, RR 16, SaO2 95% on RA HEENT: NC/AT. Sclera anicteric Lungs: Minimal rales in the Right base. No wheezes, rhonchi. CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic murmur at LUSB and RUSB; no rubs or gallops Abdomen: soft, non-tender, non-distended, normo-active bowel sounds present Ext: Warm, well perfused, no edema. Pertinent Results: ___ 07:16PM BLOOD WBC-8.8 RBC-3.57* Hgb-10.8* Hct-32.7* MCV-91 MCH-30.2 MCHC-33.0 RDW-14.2 Plt ___ ___ 07:16PM BLOOD Neuts-58.3 ___ Monos-8.5 Eos-2.5 Baso-0.3 ___ 07:16PM BLOOD ___ PTT-31.1 ___ ___ 07:16PM BLOOD Glucose-180* UreaN-40* Creat-1.7* Na-130* K-5.1 Cl-99 HCO3-23 AnGap-13 ___ 07:16PM BLOOD proBNP-1618* ___ 07:00AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2 ___ 07:00AM BLOOD TSH-1.0 DISCHARGE LABS (from day prior to discharge) ___ 07:00AM BLOOD WBC-7.2 RBC-3.63* Hgb-11.1* Hct-32.9* MCV-91 MCH-30.6 MCHC-33.8 RDW-16.4* Plt ___ ___ 06:43AM BLOOD Glucose-72 UreaN-32* Creat-1.2* Na-141 K-5.0 Cl-107 HCO3-29 AnGap-10 ___ 07:16PM BLOOD cTropnT-<0.01 ___ 07:00AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07:00AM BLOOD CK(CPK)-88 URINE STUDIES ___ 11:22PM URINE Color-Straw Appear-Clear Sp ___ ___ 11:22PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR ___ 11:22PM URINE RBC-0 WBC-2 Bacteri-MOD Yeast-NONE Epi-1 TransE-<1 ___ 11:22PM URINE CastHy-15* ___ 12:50AM URINE Hours-RANDOM UreaN-333 Creat-79 Na-12 K-30 Cl-11 ___ 12:50AM URINE Osmolal-223 URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. EKG ___ Ectopic atrial rhythm at a very slow rate. Left ventricular hypertrophy with associated ST-T wave changes, although ischemia or infarction cannot be excluded. Compared to the previous tracing the rate is much slower. ___ ___ EKG ___ Ectopic atrial rhythm at a normal rate with P-R interval prolongation. Left ventricular hypertrophy with strain pattern. Lateral T wave inversions. Non-specific ST segment flattening in the inferolateral leads and non-specific J point elevation in the right precordial leads. Compared to the previous tracing of the prior date the rate is faster and now normal, although still with leftward P wave axis. Left anterior fascicular block and left ventricular hypertrophy with strain and/or ischemia are unchanged. Non-specific repolarization abnormalities are similar. ___ ___ CXR PA/LAT ___ The heart size is at the upper limits of normal, likely exaggerated by AP technique. The mediastinal contours demonstrate a mildly tortuous aorta with calcified atherosclerotic disease of the aortic knob. The lungs again demonstrate a prominent reticular pattern particulary at the bases without clear evidence of new consolidation. There is no large pleural effusion or pneumothorax. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Calcium Carbonate 500 mg PO DAILY 4. DimenhyDRINATE 50 mg PO Q8H:PRN nausea 5. Docusate Sodium 100 mg PO BID 6. Enalapril Maleate 20 mg PO BID 7. LeVETiracetam 750 mg PO BID 8. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain 9. PredniSONE 5 mg PO DAILY 10. Simvastatin 10 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. Furosemide 20 mg PO DAYS (___) 13. Hydroxychloroquine Sulfate 200 mg PO DAILY; One tablet daily alternating with 2 tablets daily. 14. NPH 15 Units Breakfast; NPH 5 Units Dinner Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Calcium Carbonate 500 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Enalapril Maleate 20 mg PO BID 6. Hydroxychloroquine Sulfate 200 mg PO DAILY; One tablet daily alternating with 2 tablets daily. 7. NPH 15 Units Breakfast; NPH 5 Units Dinner 8. LeVETiracetam 750 mg PO BID 9. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain 10. PredniSONE 5 mg PO DAILY 11. Simvastatin 10 mg PO DAILY 12. Vitamin D 1000 UNIT PO DAILY 13. DimenhyDRINATE 50 mg PO Q8H:PRN nausea 14. Furosemide 20 mg PO 3X/WEEK (___) 15. Doxazosin 2 mg PO HS RX *doxazosin [Cardura] 2 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 16. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Ectopioc atrial bradycardia, due to Beta blocker toxicity Chest pain Coronary artery disease Hypertension Shortness of breath Acute on chronic left ventricular diastolic heart failure Acute kidney injury Gastroesophageal reflux disease Tremor Diabetes mellitus Hypothyroidism Systemic lupus erythematosis Rheumatoid arthritis Seizure disorder 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 dyspnea and chest pain. STUDY: AP upright and lateral chest radiographs. COMPARISON: Chest CT from ___ and multiple chest radiographs from ___ to ___. FINDINGS: The heart size is at the upper limits of normal, likely exaggerated by AP technique. The mediastinal contours demonstrate a mildly tortuous aorta with calcified atherosclerotic disease of the aortic knob. The lungs again demonstrate a prominent reticular pattern particulary at the bases without clear evidence of new consolidation. There is no large pleural effusion or pneumothorax. IMPRESSION: Chronic interstitial lung disease, but no definite evidence of pneumonia. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: CHEST PAIN (CARDIAC FEATURES) Diagnosed with CHEST PAIN NOS temperature: 98.5 heartrate: 97.0 resprate: 18.0 o2sat: 94.0 sbp: 132.0 dbp: 54.0 level of pain: 10 level of acuity: 2.0
You were admitted because of chest pain and a slow heart rate. We made sure you did not have a heart attack. Your slow heart rate was likely due to being started on Propranolol. We observed you off the medication and your heart rate resolved. We have listed "beta blockers" as an allergy. Please discuss possible alternative treatments for your tremor with your Primary care doctor. We made the following changes to your home medication list: -STOP Propranolol -START Omeprazole
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: vertebral artery dissection and basilar thrombus Major Surgical or Invasive Procedure: N/A History of Present Illness: The patient is a ___ year-old right-handed man without significant past medical history who presents with right ear ringing and profound dizziness with nausea and vomiting. Patient was in his usual state of health yesterday evening doing his regular gym routine which included weight lifting and elliptical work he felt at his baseline state of health after his workout and went to sleep. He woke up this morning with severe right sided tinnitus profound nausea and vomiting and extreme dizziness without visual changes. He called ___ he was taken to an OSH, where he had CTA which revealed left-sided vertebral artery dissection with basilar thrombus. He was started on a heparin GTT with bolus and transferred to ___ for further care. On neuro ROS, the pt denies headache, loss of vision, diplopia, dysarthria, dysphagia, lightheadedness,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: No significant past medical history Social History: ___ Family History: Noncontributory Physical Exam: Admission Physical Exam: ======================== Physical Exam: Vitals: reviewed in ED dashboard General: Awake, cooperative, in severe distress due to dizziness. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no nuchal rigidity Pulmonary: breathing non labored on room air Cardiac: warm and well perfused Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Awake, alert, oriented to self, place, time and situation. Able to relate 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. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. no evidence of miosis. III, IV, VI: EOMI without nystagmus. Normal saccades. no evidence of ptosis V: Facial sensation intact to light touch. sweating symmetrically throughout face 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 adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 ___ 5 5 5 5 5 R 5 ___ 5 ___ 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, 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 dysmetria on FNF -Gait: deferred due to patient discomfort bc of profound dizziness Discharge Physical Exam: ======================== Vitals: reviewed in metavision General: Awake, cooperative, in no acute distress. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no nuchal rigidity Pulmonary: breathing non labored on room air Cardiac: warm and well perfused Abdomen: soft, NT/ND Extremities: No cyanosis, clubbing or edema bilaterally Skin: no rashes or lesions noted Neurologic: -Mental Status: Awake, alert, oriented to self, place, time. Able to relate history without difficulty. Language is fluent with normal prosody and no paraphasic errors. Able to follow both midline and appendicular commands. -Cranial Nerves: I: Olfaction not tested. II: PERRL 5 to 3mm and brisk. III, IV, VI: EOMI without nystagmus. Normal saccades. No evidence of ptosis. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to conversation IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 ___ 5 5 5 5 5 R 5 ___ 5 ___ 5 5 5 5 5 -Sensory: No deficits to light touch throughout. -DTRs: deferred -___: No intention tremor, No dysmetria on finger nose finger. No ataxia with heel to shin. -Gait: deferred Pertinent Results: ADMISSION LABS: ___ 03:40PM BLOOD WBC-5.6 RBC-4.51* Hgb-13.3* Hct-41.2 MCV-91 MCH-29.5 MCHC-32.3 RDW-11.9 RDWSD-39.3 Plt ___ ___ 03:40PM BLOOD Neuts-74.3* ___ Monos-3.4* Eos-0.0* Baso-0.4 Im ___ AbsNeut-4.18 AbsLymp-1.21 AbsMono-0.19* AbsEos-0.00* AbsBaso-0.02 ___ 03:40PM BLOOD ___ PTT-150* ___ ___ 03:40PM BLOOD Plt ___ ___ 03:40PM BLOOD Glucose-127* UreaN-13 Creat-1.0 Na-140 K-5.7* Cl-107 HCO3-18* AnGap-15 ___ 03:40PM BLOOD ALT-23 AST-49* AlkPhos-61 TotBili-0.4 ___ 03:40PM BLOOD Lipase-19 ___ 03:40PM BLOOD cTropnT-<0.01 ___ 03:40PM BLOOD Albumin-4.4 Calcium-9.1 Phos-3.2 Mg-2.1 Cholest-253* ___ 03:40PM BLOOD %HbA1c-5.0 eAG-97 ___ 03:40PM BLOOD Triglyc-58 HDL-57 CHOL/HD-4.4 LDLcalc-184* ___ 03:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG MRI HEAD W/O CONTRAST: 1. Acute infarcts involving the right greater than left cerebellar hemispheres, most likely resulting from the known basilar artery thrombosis. 2. Loss of flow void is noted in the basilar artery in the same region as demonstrated on CTA from the day prior. However, complete evaluation is not possible as this is a non angiographic examination. INTERVAL/DISCHARGE LABS: ___ 06:25AM BLOOD WBC-3.5* RBC-4.20* Hgb-12.3* Hct-38.6* MCV-92 MCH-29.3 MCHC-31.9* RDW-11.9 RDWSD-39.9 Plt ___ ___ 06:25AM BLOOD ___ PTT-46.0* ___ ___ 08:55AM BLOOD ___ PTT-46.0* ___ ___ 06:12AM BLOOD ___ PTT-51.9* ___ ___ 06:14AM BLOOD ___ PTT-43.2* ___ ___ 03:49PM BLOOD LMWH-0.74 ___ 06:25AM BLOOD Glucose-90 UreaN-12 Creat-0.9 Na-142 K-4.7 Cl-106 HCO3-26 AnGap-10 ___ 06:25AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0 Medications on Admission: None Discharge Medications: 1. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 2. Warfarin 5 mg PO DAILY RX *Coumadin 1 mg 5 tablet(s) by mouth once a day Disp #*150 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: Acute ischemic stroke Vertebral artery dissection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD INDICATION: ___ year old man with vertebral dissection c/b basilar artery thrombus // evaluate thrombus, communicating arteries and vessels, r/o infarct TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON Reference CTA head and neck dated ___. FINDINGS: There are scattered foci of acute infarction in both inferior cerebellar hemispheres, right greater than (4:5). These correspond with increased T2 signal (9:4). No additional infarction is identified. There is no evidence of hemorrhage or mass. Loss of flow void within the basilar artery is noted in a similar location as the thrombus demonstrated on CTA from 1 day prior (9:7). However this is a non angiographic examination and complete evaluation of the basilar artery is not possible. The ventricles and sulci are normal in caliber and configuration. Mild mucosal thickening is noted in the maxillary sinuses and anterior ethmoid air cells. Mastoid air cells and middle ear cavities are clear. The imaged portions of the orbits are unremarkable. IMPRESSION: 1. Acute infarcts involving the right greater than left cerebellar hemispheres, most likely resulting from the known basilar artery thrombosis. 2. Loss of flow void is noted in the basilar artery in the same region as demonstrated on CTA from the day prior. However, complete evaluation is not possible as this is a non angiographic examination. NOTIFICATION: The finding of cerebellar infarction was documented in the clinical notes in OMR at the time of interpretation. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dizziness, Vomiting, Transfer Diagnosed with Dizziness and giddiness temperature: 96.9 heartrate: 80.0 resprate: 16.0 o2sat: 99.0 sbp: 120.0 dbp: 65.0 level of pain: 0 level of acuity: 1.0
Dear Mr. ___, You were hospitalized due to symptoms of dizziness and vomiting resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. We are changing your medications as follows: Start taking warfarin (blood thinner) Start taking atorvastatin (for cholesterol) Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None Past Medical History: DMII, GERD, morbid obesity, depression, LBP, lumbar disk displacement Social History: ___ Family History: NC Physical Exam: Vitals: AVSS, see flowsheets GEN: No distress, pleasant, conversant HEENT: Sclera non-icteric, neck is supple without lymphadenopathy, thyromegaly or JVD HEART: RRR with no murmurs CHEST: No increased work of breathing, clear to auscultation bilaterally, no crackles or wheezes ABDOMEN: Soft, non-tender, no rebound or guarding INCISIONS: Incisions are clean, dry and intact without erythema EXTREMITIES: Warm, well perfused, no edema Pertinent Results: ___ 09:49PM GLUCOSE-140* UREA N-15 CREAT-0.7 SODIUM-140 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-22 ANION GAP-15 ___ 09:49PM ALT(SGPT)-29 AST(SGOT)-22 ALK PHOS-143* TOT BILI-0.3 ___ 09:49PM LIPASE-30 ___ 09:49PM WBC-11.4* RBC-4.05# HGB-11.3# HCT-35.2# MCV-87 MCH-27.9 MCHC-32.1 RDW-14.7 RDWSD-46.9* ___ 08:25AM URINE HOURS-RANDOM ___ 08:25AM URINE UCG-NEGATIVE ___ 08:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.5 LEUK-NEG Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen ___ mg PO Q6H 2. Omeprazole 20 mg PO DAILY 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 4. Ondansetron 4 mg PO Q8H:PRN nausea Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Gabapentin 100 mg PO TID RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day Disp #*30 Capsule Refills:*0 3. Omeprazole 20 mg PO DAILY 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H:PRN Disp #*20 Tablet Refills:*0 6. Polyethylene Glycol 17 g PO DAILY 7. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Post-operative pain, status-post open cholecystectomy 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 s/p cholecystectomy ?biloma on CT// ?fluid pocket, biliary dilation TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT from earlier same day. FINDINGS: LIVER: The liver is diffusely echogenic. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 9 mm. GALLBLADDER: The patient is status post cholecystectomy. There is a 3.8 x 1.6 cm fluid collection within the cholecystectomy bed. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. KIDNEYS: Limited views of the right kidney show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. A fluid collection within the cholecystectomy bed is re-demonstrated, better assessed on prior CT from earlier today. 2. Hepatic steatosis. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, Transfer Diagnosed with Unspecified abdominal pain, Type 2 diabetes mellitus without complications temperature: 97.7 heartrate: 80.0 resprate: 16.0 o2sat: 98.0 sbp: 130.0 dbp: 77.0 level of pain: 0 level of acuity: 3.0
Dear ___, You were recently admitted to ___ ___ pain control and evaluation of your post-operative open cholecyctectomy recovery. We have reviewed your imaging with our surgeons and radiologists several times and believe the fluid collection seen on your outside hospital CT scan is a small fluid collection consistent with normal post-operative changes. At this time, you are ready for discharge and can continue to recover at home. Please follow the instructions below: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Shellfish Attending: ___. Chief Complaint: cough Major Surgical or Invasive Procedure: none History of Present Illness: ___ w/ ESRD ___ HD, HTN, IDDM currently on INH for tx of latent TB, presenting from ___ clinic due to worsening dyspnea along with progressive cough and overall malaise. He first met new PCP ___ ___ at which time he complained of a cough for at least 6 months duration. Prior to that visit, he had a positive PPD and had AFB smears x3 in ___ which were negative. He endorsed 15lb weight loss and hempoptysis. He was referred to ID and saw them on ___ -> initiated on isoniazid +B6 for 9 months for latent TB treatment. Since that time patient denies any interval improvement in symptoms, and rather his cough is maybe worse. Day of arrival he was seen in the ___ clinic where patient noted chest tightness and cough productive of thick yellow sputum. His BP was 198/100 in the clinic, with 92% SaO2. In the ED, initial vitals were 98.6 86 197/97 16 96% RA Labs notable for K 6.0. Patient received levaquin and ceftriaxone Prior to transfer 98.3 82 176/105 14 98% RA On the floor, he denies any fevers or night sweats but notes some chills. He notes minimal increase in peripheral edema. Notes epigastric pain worse with laying flat or food sometimes. Also notes lose stools and nause+emesis that is chronic for about ___ mo. Emesis caused by eating too much food. No pain with food/water. Last significant emesis during ___. Malaise along with current constant cough really bad in last 4 weeks. Wants to try crackers Past Medical History: ESRD on hemodialysis: presumed secondary to diabetes and/or hypertension, HD on MWF; left radiocephalic AVF placed ___, started HD ___ Diabetes ___ type II: diagnosed ___ with associated lower extremity neuropathy Hypertension: diagnosed around ___ Neck pain: C5 radiculopathy on EMG with C4-5 and C5-6 stenosis on the right, followed by Dr. ___ at ___ Shoulder pain: ___ Family History: Father: alive and healthy Mother: diabetes ___ type II One aunt with ESRD on HD Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.0, 190/98, 88, 94%RA General: Coughing during entire exam and causes him discomfort. NAD. AAOx3. HEENT: Moist mucosa, pink conjuctiva, no scleral icterus Neck: Venous pulsation up to mid neck CV: S1/S2 without murmur, rate in the ___, fistual thrill appreciated Lungs: comfortable breathing but coughing significantly non productive Abdomen: Tender mid epigastrium and RUQ GU: no foley Ext: Left fistula with thrill Neuro: CN ___ grossly intact Skin: Dry chronic venous stasis changes of b/l legs. Midline chest scar from younger years well healed DISCHARGE PHYSICAL EXAM: VS: T 98, HR 81, RR 17, BP 193/111, SpO2 94-95% General: Coughing during entire exam. NAD. AAOx3. HEENT: Moist mucosa, pink conjuctiva, no scleral icterus Neck: JVD to mid neck CV: RRR S1/S2 without murmur; hemodialysis in fistula Lungs: CTAB, comfortable breathing but non productive cough Abdomen: obese, nontender, nondistened, w/o appreciable organomegaly GU: no foley Ext: Left fistula with hemodialysis currently; Dry chronic venous stasis changes of b/l legs. Neuro: CN ___ grossly intact Pertinent Results: ADMISSION RESULTS: ------------------ ___ 10:19PM URINE HOURS-RANDOM UREA N-208 CREAT-58 SODIUM-89 POTASSIUM-22 CHLORIDE-50 ___ 10:19PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 10:19PM URINE BLOOD-SM NITRITE-NEG PROTEIN->600 GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5* LEUK-MOD ___ 10:19PM URINE RBC-5* WBC-79* BACTERIA-FEW YEAST-NONE EPI-<1 ___ 06:00PM GLUCOSE-268* UREA N-73* CREAT-18.3*# SODIUM-139 POTASSIUM-6.1* CHLORIDE-96 TOTAL CO2-29 ANION GAP-20 ___ 06:00PM estGFR-Using this ___ 06:00PM CALCIUM-8.3* PHOSPHATE-6.4* MAGNESIUM-2.3 ___ 06:00PM WBC-9.6 RBC-3.82* HGB-10.8* HCT-35.4* MCV-93 MCH-28.3 MCHC-30.5* RDW-13.8 ___ 06:00PM NEUTS-69 BANDS-1 LYMPHS-13* MONOS-11 EOS-6* BASOS-0 ___ MYELOS-0 ___ 06:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 06:00PM PLT SMR-NORMAL PLT COUNT-149* ___ 02:40PM ALT(SGPT)-23 AST(SGOT)-30 ALK PHOS-92 TOT BILI-0.4 ___ 02:40PM WBC-10.7 RBC-4.02* HGB-11.1* HCT-37.7* MCV-94 MCH-27.7 MCHC-29.5* RDW-14.4 PLT COUNT-151 ___ 02:40PM NEUTS-69.5 LYMPHS-16.3* MONOS-11.0 EOS-2.8 BASOS-0.4 PERTINENT RESULTS: ------------------ ___ 07:29AM BLOOD %HbA1c-9.7* eAG-232* ___ 10:19PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 10:19PM URINE Blood-SM Nitrite-NEG Protein->600 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-MOD ___ 10:19PM URINE RBC-5* WBC-79* Bacteri-FEW Yeast-NONE Epi-<1 ___ 10:19PM URINE Hours-RANDOM UreaN-208 Creat-58 Na-89 K-22 Cl-50 DISCHARGE RESULTS: ------------------ ___ 07:29AM BLOOD WBC-8.8 RBC-3.49* Hgb-10.4* Hct-32.5* MCV-93 MCH-29.7 MCHC-31.9 RDW-14.0 Plt ___ ___ 07:29AM BLOOD Plt ___ ___ 07:29AM BLOOD Glucose-307* UreaN-78* Creat-19.2* Na-141 K-6.1* Cl-97 HCO3-29 AnGap-21* ___ 07:29AM BLOOD Calcium-7.9* Phos-7.0* Mg-2.4 MICROBIOLOGY: ------------- ___ BLOOD CX: PENDING ___ URINE LEGIONELLA Ag: NEGATIVE ___ SPUTUM CX: CONTAMINATED ___ STOOL CX: CONSISTENCY NOT ACCEPTABLE FOR BACTERIAL CULTURE ___ VRE SWAB: PENDING IMAGING: -------- ___ PA-LAT FINDINGS: Bilateral hilar opacities, right greater than left, similar compared to the prior study from ___, compatible with moderate pulmonary edema. Moderate cardiomegaly is unchanged. Mild pectus deformity is again noted, likely accentuating the right lower lung opacity. There is no large pleural effusion pneumothorax. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough, SOB 2. Amlodipine 10 mg PO DAILY 3. Atorvastatin 40 mg PO DAILY 4. Nephrocaps 1 CAP PO DAILY 5. Carvedilol 12.5 mg PO BID 6. HydrALAzine 50 mg PO BID 7. Glargine 25 Units Breakfast Humalog 5 Units Breakfast Humalog 5 Units Lunch Humalog 5 Units Dinner 8. Isoniazid ___ mg PO 3X/WEEK (___) 9. Losartan Potassium 50 mg PO BID 10. Omeprazole 10 mg PO DAILY 11. sevelamer CARBONATE 800 mg PO TID W/MEALS 12. Aspirin 81 mg PO DAILY 13. Vitamin D ___ UNIT PO DAILY 14. Ferrous Sulfate 325 mg PO BID 15. Pyridoxine 50 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough, SOB 2. Amlodipine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO DAILY 5. Carvedilol 12.5 mg PO BID 6. Ferrous Sulfate 325 mg PO BID 7. HydrALAzine 50 mg PO BID 8. Glargine 25 Units Breakfast Humalog 5 Units Breakfast Humalog 5 Units Lunch Humalog 5 Units Dinner 9. Isoniazid ___ mg PO 3X/WEEK (___) 10. Losartan Potassium 50 mg PO BID RX *losartan 50 mg 1 tablet(s) by mouth twice a day Disp #*90 Tablet Refills:*0 11. Nephrocaps 1 CAP PO DAILY 12. Omeprazole 10 mg PO DAILY 13. Pyridoxine 50 mg PO DAILY 14. sevelamer CARBONATE 800 mg PO TID W/MEALS 15. Vitamin D ___ UNIT PO DAILY 16. Fluticasone Propionate 110mcg 2 PUFF IH BID Please talk to your primary care doctor if this does not help you RX *fluticasone [Flovent HFA] 110 mcg/actuation 2 puff inhaled twice a day Disp #*1 Inhaler Refills:*0 17. Loratadine 10 mg PO EVERY OTHER DAY RX *loratadine 10 mg 1 tablet(s) by mouth 3 times per week Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: #Chronic cough #Pulmonary edema #End stage renal disease #Hypertensive urgency #Diabetes ___ type 2, poorly controlled #Dyspepsia #SECONDARY DIAGNOSES: #Latent tuberculosis infection #Anemia of chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST RADIOGRAPH ___ INDICATION: ___ year old man with cough, hx of ESRD on HD, some chills // ? infiltrates ? edema TECHNIQUE: Chest PA and lateral COMPARISON: Comparison is made multiple prior studies, including most recent radiographs of the chest from ___, dating back to ___. FINDINGS: Bilateral hilar opacities, right greater than left, similar compared to the prior study from ___, compatible with moderate pulmonary edema. Moderate cardiomegaly is unchanged. Mild pectus deformity is again noted, likely accentuating the right lower lung opacity. There is no large pleural effusion pneumothorax. IMPRESSION: Bilateral hilar opacities likely reflect moderate pulmonary edema. Cardiomegaly is stable. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Cough, ILI Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, CONGESTIVE HEART FAILURE, UNSPEC, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, RENAL DIALYSIS STATUS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN temperature: 98.6 heartrate: 86.0 resprate: 16.0 o2sat: 96.0 sbp: 197.0 dbp: 97.0 level of pain: 0 level of acuity: 3.0
Mr. ___, you were admitted from the ER for workup of your chronic cough. On arrival you had fluid in your lungs called edema. The fluid in your lungs may cause cough. It seems that you usually have too much fluid in your body, which happens when people require dialysis. Please try sticking to a low salt diet (meaning no fast food, chips, crackers, ___ fries). Feeling better in terms of cough after dialysis may mean that your cough is partially caused by fluid in the lungs. We did not think that you had a bacterial pneumonia requiring antibiotics. The most common causes of cough that does not go away after ___ weeks are not infection. They are usually things like asthma, acid reflux, and allergic post-nasal drip. You were already treated with a stomach acid blocker for reflux in the past few weeks without much help. However, you have not had significant treatment for asthma, so we added an inhaled steroid called fluticasone that you should use daily to prevent any asthma symptoms. If this does not work, you should talk to your primary care doctor (___) about stopping it. Additionally, abdominal fullness and poor appetite you described may be due to diabetes. People with poorly controlled diabetes can develop nerve problems like tingling or numbness in the feet. Occasionally, the nerve problems may affect the stomach and intestines. This can cause food not to move through normally and can make you feel sick or full.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: surgical glue Attending: ___. Chief Complaint: Fever and redness around IPG site Major Surgical or Invasive Procedure: Removal of L DBS battery and debridement, removal of L extension cable History of Present Illness: ___ year old female with history of medically refractory torsion dystonia s/p DBS placement in ___ most recently s/p battery change ___ ___. She presents with complaints of increased pain and fever. She was febrile to 101 two nights prior to admission. She initially thought she had the flu, but noticed her IPG site was swollen. She was referred to the ED for evaluation. A collection was tapped in the ED which was concerning for purulent drainage. She was taken to the OR for a wound washout and removal of her stimulator and extension leads to the level of occiput. Past Medical History: DYSTONIA ANAL FISSURE MEDICALLY REFRACTORY TORSION DYSTONIA HYPERTENSION Had mild HTN prior to pregnancy. Was taking labetalol. HTN higher after pregnancy, but not pre-eclampsia. Changed to Norvasc. ___ cardiology Dr. ___ ___ normal INFERTILITY RSI ___. did IVF. Dr. ___. H/O ABNORMAL PAP SMEAR ___ had ASCUS and ? + HPV. 3 Paps since then normal. Social History: ___ Family History: Family Hx: Mother Living ___ HYPERTENSION DIABETES TYPE II ARTHRITIS COLONIC POLYPS ?adenoma BREAST CANCER ___ Father ___ ___ ___ PLACEMENT MITRAL VALVE REPLACEMENT HYPERTENSION DYT1 Had the gene ___ symptoms Sister Living ___ HYPERTENSION Not a DYT1 carrier MGM Deceased ___ COLON CANCER Brother Living ___ ___ CRAMP ___ Brother MGF Deceased ___ MYOCARDIAL INFARCTION PGM Deceased ___ HYPERTENSION STROKE PGF Deceased ___'sMYOCARDIAL INFARCTION Physical Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: ___ bilaterally EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact [ x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip IPQuadHamATEHLGast Wound: Left crani incisions [x]Clean, dry, intact [x]Staples Left chest incision [x]Clean, dry, intact, very mild erythema [x]Staples Chest drain site - removed ___ [x]Clean, dry, intact [x]Staples Pertinent Results: Please see OMR for pertinent results. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ female with dystonia status post better exchange to a here with fevers. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph performed ___ and ___. FINDINGS: Left chest wall stimulator again noted, with leads coursing superiorly and out of view is grossly unchanged compared to prior exam. Lungs are moderately well inflated. Linear bibasilar and retrocardiac opacification likely reflects platelike atelectasis. No focal consolidation is seen to suggest pneumonia. Tiny bilateral pleural effusions are suspected given blunted CP angles on the lateral view. No large pneumothorax. The cardiomediastinal silhouette is otherwise unchanged. IMPRESSION: 1. Tiny bilateral pleural effusions. 2. No focal consolidation to suggest pneumonia. Radiology Report EXAMINATION: SKULL, ___ VIEWS INDICATION: ___ year old woman with bilateral deep brain stimulators, s/p removal pulse generator and lead extensions.// Pulse generators and lead extensions were removed due to concern for infection. Xrays to look for retained lead fragments. Please include lateral of the skull and neck. TECHNIQUE: Frontal and lateral views of the skull COMPARISON: Skull radiographs ___ FINDINGS: On lateral view, 1.5 cm curvilinear density is identified overlying the parietal region. The morphology of this density is similar to the tip of the previous lead that was present in ___ study. Finding is suspicious for retained lead fragment. The finding is not well visualized on frontal view, but likely located on the left side, adjacent to the cranium. Other leads appear unchanged in position. IMPRESSION: 1.5 cm curvilinear density overlying the parietal region is suspicious for retained lead fragment. The finding is not well visualized on frontal view, but likely located in the left parietal region, external to the cranium. NOTIFICATION: The findings were discussed with Dr. ___. by ___ ___, M.D. on the telephone on ___ at 9:39 am, 15 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: ___ year old woman with bilateral deep brain stimulators, s/p removal pulse generator and lead extensions.// Evaluate pulse generator site s/p removal to ensure no retained fragments Evaluate pulse generator site s/p removal to ensure no retained fragments IMPRESSION: Compared to chest radiographs ___ and ___. Left pectoral generator and ascending leads have been removed since ___. Aside from a row of skin staples, there are no visible retained metal fragments. No pneumothorax or pleural effusion. Lungs clear. Heart size normal. Dilated upper lobe vessels suggest mild volume overload. Radiology Report EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK INDICATION: ___ year old woman s/p bilateral DBS, and removal of infected IPH and lead extensions// **Please protocol to include the base of the skull to the upper chest at the level of the generator chest pocket. Evaluate deep brain stimulator leads in head and neck to evaluate post removal TECHNIQUE: Imaging was performed after administration of Omnipaque intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.3 s, 25.7 cm; CTDIvol = 11.3 mGy (Body) DLP = 289.6 mGy-cm. Total DLP (Body) = 290 mGy-cm. COMPARISON: ___ chest radiographs FINDINGS: In the anterior left chest wall, there is a 7.6 x 2.1 x 7.1 cm rim enhancing fluid collection with few locules of subcutaneous emphysema and adjacent fat stranding consistent with abscess. Along the collapse superior portion of the abscess, there is a surgical drain. There are few locules gas in the anterior aspect of the left pectoralis major. Extending superiorly toward the neck,, the deep brain stimulator tract appears collapsed with a single locule of gas in the left supraclavicular region (series 2, image 63). The remainder of the tract demonstrates calcification, but no significant adjacent fat stranding to suggest infection. Cervical lymph nodes are prominent in number and size, measuring up to 1.1 cm at level 2A on the left. Evaluation of the aerodigestive tract demonstrates no mass and no areas of focal mass effect. The salivary glands enhance normally and are without mass or adjacent fat stranding. The thyroid gland appears normal.The neck vessels are patent. The imaged portion of the lung apices are clear and there are no concerning pulmonary nodules. There are no osseous lesions. IMPRESSION: A left chest wall fluid collection/abscess measures up to 7.6 cm. With a surgical drain is located along the collapsed superior portion . No evidence of infection along the stimulator tract in the subcutaneous soft tissues of the neck. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Fever, Wound eval Diagnosed with Fever, unspecified temperature: 98.9 heartrate: 90.0 resprate: 18.0 o2sat: 99.0 sbp: 137.0 dbp: 87.0 level of pain: 6 level of acuity: 3.0
Discharge Instructions Dr. ___ of DBS battery and debridement Activity •You may gradually return to your normal activities, but we recommend you take it easy for the next ___ hours. •Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. •You may take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much too soon. •Do not go swimming or submerge yourself in water for fourteen (14) days after your procedure. •You may use a damp washcloth to remove any dried blood or iodine from your skin but do not get your head wet in the shower until your staples or sutures are removed. •The incision on your chest has absorbable sutures and skin sealant. You may take a shower and get your chest wet after 5 days. Medications •Take any new medications (i.e. pain medications) as directed. •If you were on a medication such as Coumadin (Warfarin), or Plavix (Clopidogrel), or Aspirin, do not take this until cleared by your Neurosurgeon. •Do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. until follow up. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: •Mild tenderness along the incisions. •Soreness in your arms from the intravenous lines. •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site. •Fever greater than 101.5 degrees Fahrenheit •Severe Constipation •Blood in your stool or urine •Nausea and/or vomiting •Extreme sleepiness •Severe headaches not relieved by pain relievers •Seizures •Any new problems with your vision or ability to speak •Weakness or changes in sensation in your face, arms, or leg Follow-up Instructions •You will need to follow-up with Dr. ___ in ___ days from your surgery for a wound check and staple/suture removal. Please call ___ to make this appointment.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: bilateral ureteral stones Major Surgical or Invasive Procedure: Cystoscopy, left ureteroscopy, laser lithotripsy, and bilateral ureteral stent placement. History of Present Illness: This is a ___ year old male presenting with 1 day history of left flank pain and dysuria. Upon further work up, he was found to have a 5 mm left UVJ stone and 1.9 cm proximal right ureteral stone. He has a history of kidney stones in the past which he passed spontaneously. He has never required surgery for stones. He is afebrile and hemodynamically stable. WBC 11. Cr 1.5. U/A negative for infection. Past Medical History: overweight Social History: ___ Family History: No Family History currently on file. Physical Exam: WdWn male, NAD, AVSS Interactive, cooperative Abdomen soft, Nt/Nd, obese Flank pain improved Lower extremities w/out edema or pitting and no report of calf pain Pertinent Results: ___ 06:17AM BLOOD WBC-6.2 RBC-4.87 Hgb-14.8 Hct-44.4 MCV-91 MCH-30.4 MCHC-33.3 RDW-13.0 RDWSD-43.7 Plt ___ ___ 10:50AM BLOOD WBC-8.1 RBC-4.84 Hgb-14.4 Hct-44.3 MCV-92 MCH-29.8 MCHC-32.5 RDW-13.1 RDWSD-44.1 Plt ___ ___ 01:25PM BLOOD WBC-11.1* RBC-5.77 Hgb-17.4 Hct-51.7* MCV-90 MCH-30.2 MCHC-33.7 RDW-13.2 RDWSD-43.4 Plt ___ ___ 01:25PM BLOOD Neuts-77.0* Lymphs-13.1* Monos-8.6 Eos-0.3* Baso-0.5 Im ___ AbsNeut-8.55* AbsLymp-1.45 AbsMono-0.95* AbsEos-0.03* AbsBaso-0.06 ___ 06:17AM BLOOD Glucose-134* UreaN-13 Creat-0.9 Na-143 K-4.3 Cl-106 HCO3-24 AnGap-13 ___ 10:50AM BLOOD Glucose-132* UreaN-16 Creat-1.5* Na-141 K-4.4 Cl-105 HCO3-24 AnGap-12 ___ 09:44PM BLOOD Glucose-151* UreaN-16 Creat-1.7* Na-140 K-5.0 Cl-102 HCO3-21* AnGap-17 ___ 01:25PM BLOOD Glucose-153* UreaN-17 Creat-1.5* Na-139 K-4.9 Cl-101 HCO3-20* AnGap-18 ___ 01:25PM BLOOD ALT-73* AST-36 AlkPhos-72 TotBili-0.5 ___ URINE URINE CULTURE-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD ___ URINE URINE CULTURE-FINAL EMERGENCY WARD Medications on Admission: NONE Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. Docusate Sodium 100 mg PO BID 3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO ONCE prophylaxis RX *nitrofurantoin monohyd/m-cryst 100 mg ONE capsule(s) by mouth once Disp #*2 Capsule Refills:*0 4. Oxybutynin 5 mg PO TID:PRN bladder spasms 5. Senna 8.6 mg PO ONCE Duration: 1 Dose 6. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Bilateral ureterolithiasis. acute kidney injury (creatinine up to 1.7) 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 bilateral nephrolithiasis// evaluate bilateral ureteral stones TECHNIQUE: Multiple supine portable images were obtained. COMPARISON: CT scan dated ___ FINDINGS: There are no abnormally dilated loops of large or small bowel. Residual contrast within the bilateral renal collecting systems from recent IV contrast administration is again noted with bilateral hydronephrosis right greater than left. There is a calcific density overlying the proximal right ureter measuring 19 mm, corresponding to previously seen proximal ureter obstructing stone. Previously seen left distal ureter 5 mm stone is not definitely seen on this exam. IMPRESSION: Residual contrast within the bilateral renal collecting systems with note of bilateral hydronephrosis, right greater than left. Known stone re-demonstrated within the right UPJ. Known left distal ureteral stone not clearly seen. Radiology Report EXAMINATION: Intraoperative fluoroscopy, abdomen. INDICATION: Ureteral stent placement. TECHNIQUE: 7 fluoroscopic spot images of the abdomen were obtained in the operating room without presence of radiologist. DOSE: Fluoroscopy time 19.8 seconds, cumulative dose 14.45 mGy. COMPARISON: CT is available from ___ and abdominal radiographs are available from ___. FINDINGS: These views depict ongoing bilateral ureteral stent placements. On the right, ureteropelvic junction stone is visualized as well as hydronephrosis. IMPRESSION: Ongoing bilateral retrograde ureteral stent placement in the operating room. Please refer to the operative note if needed for further information. Radiology Report EXAMINATION: CTU (ABD/PEL) W/CONTRAST INDICATION: History: ___ with flank pain, elevated Cr// r/o AAA, nephrolithiasis, other abnormalities of GU system 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 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2 mGy-cm. 2) Spiral Acquisition 7.3 s, 57.1 cm; CTDIvol = 27.7 mGy (Body) DLP = 1,580.2 mGy-cm. Total DLP (Body) = 1,581 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Mild bibasilar atelectasis. Otherwise, the visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: Liver is diffusely hypoattenuating relative to the spleen which raises possibility of hepatic steatosis, incompletely assessed on current study. There are areas of focal fatty sparing in the gallbladder fossa. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: There is moderate to severe hydronephrosis in the right kidney secondary to a 1.9 cm obstructing stone in the proximal right ureter (average Hounsfield units 959) (02:48). There is no perinephric abnormality on the right. There is left hydronephrosis secondary to a 5 mm stone is seen in the distal left ureter immediately proximal to the UVJ (2:90). There is mild left perinephric and left periureteral stranding. GASTROINTESTINAL: There is a small hiatal hernia and the distal esophagus is fluid-filled. No bowel obstruction or bowel wall thickening is seen. The appendix is normal. PELVIS: The urinary bladder is unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Moderate to severe right hydronephrosis secondary to 1.9 cm obstructing stone in the proximal right ureter. No definite perinephric abnormality. 2. Mild left hydronephrosis secondary to a 5 mm stone seen in the distal left ureter immediately proximal to the UVJ. Mild left perinephric and left periureteral stranding. 3. Hepatic steatosis. Gender: M Race: OTHER Arrive by WALK IN Chief complaint: Dysuria, L Flank pain Diagnosed with Hydronephrosis with renal and ureteral calculous obstruction temperature: 97.1 heartrate: 96.0 resprate: 20.0 o2sat: 99.0 sbp: 147.0 dbp: 102.0 level of pain: 8 level of acuity: 3.0
-You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent. -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter. This is normal from the stent irritation. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume your pre-admission/home medications EXCEPT as noted. You should ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. -___ ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -You may be given “prescriptions” for a stool softener and/or a gentle laxative. These are over-the-counter medications that may be “health care spending account reimbursable.” -Colace (docusate sodium) may have been prescribed to avoid post-surgical constipation or constipation related to use of narcotic pain medications. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -Senokot (or any gentle laxative) may have been prescribed to further minimize your risk of constipation. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: change in behavior Major Surgical or Invasive Procedure: None History of Present Illness: ___ female professor at ___ with no known psychiatric history who was brought in by NEU security for erratic behavior. History largely taken from psychiatric consult note and ED notes as pt is somnolent and uncooperative with interview upon arrival to floor. Psych consult spoke with close work friend ___ and ___ roommate ___ who both confirmed various details of her history. Pt has had increasing psychosocial stressors at work and in family. Grandmother recently passed. Also had increasing stress at work. . In the ED, initial VS: 97.6 95 129/91 20 100%. During interview with psychiatry, pt became agitated, screaming loudly. She received haldol 5mg x 2 IM and ativan 2mg x 2 IM and placed in 4 point soft restraints. Following administration of haldol and ativan, pt became tachycardic to the 130s. EKG showed sinus tachycardia. HR decreased to 110s after IV fluids but then increased to 160s again. Toxicology consult was obtained; felt that tachycardia could be due to anticholinergic effects of haldol or paradoxical rxn to ativan. Recommended discontinuation of haldol and liberalization of ativan for agitation. . Currently, pt is extremely lethargic and somnolent. Awakens to loud voice and sternal rub but quickly falls back asleep. . REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: none Social History: ___ Family History: Non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: VS - 97.7 118/91 118 18 98%RA GENERAL - Somnolent, awakes to voice but quick to fall asleep HEENT - EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, no JVD HEART - PMI non-displaced, tachycardic, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - awake, A&Ox3, no facial asymmetry, moving all extremities, follows commands when awake . DISCHARGE PHYSICAL EXAM: Vitals: T 97.8 BP 105/78 HR 78 RR 18 O2 Sat 96% RA General: Patient lying in bed, arousable to voice. HEENT: MMM. CV: RRR. No murmurs, rubs, or gallops. LUNGS: Clear to auscultation bilaterally. No crackles or wheezes. Nml work of breathing. No accessory muscle use. ABD: BS+. Soft. NT/ND. EXT: WWP. No clubbing, cyanosis, or edema. 2+ DPs bilaterally. NEURO: Arousable. Oriented to person, place, and time ___ and ___. Pertinent Results: ADMISSION LABS . ___ 06:39PM GLUCOSE-120* UREA N-16 CREAT-1.0 SODIUM-142 POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16 ___ 06:39PM CALCIUM-10.1 PHOSPHATE-3.6 MAGNESIUM-2.3 ___ 06:39PM TSH-1.8 ___ 06:39PM T4-8.8 ___ 06:39PM CORTISOL-25.4* ___ 06:39PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 06:39PM WBC-6.4 RBC-4.49 HGB-14.2 HCT-41.4 MCV-92 MCH-31.6 MCHC-34.4 RDW-12.1 ___ 06:39PM NEUTS-58.2 ___ MONOS-4.2 EOS-0.7 BASOS-1.1 ___ 06:39PM PLT COUNT-277 ___ 06:05PM URINE UCG-NEGATIVE ___ 06:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 06:05PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 06:05PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR ___ 06:05PM URINE RBC-8* WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 RENAL EPI-<1 ___ 06:05PM URINE MUCOUS-RARE . ADMISSION DIAGNOSTICS ECG (___): Sinus tachycardia. . DISCHARGE LABS: ___ 04:30AM BLOOD WBC-6.3 RBC-4.06* Hgb-12.8 Hct-36.3 MCV-89 MCH-31.4 MCHC-35.1* RDW-12.3 Plt ___ ___ 04:30AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-136 K-4.3 Cl-104 HCO3-25 AnGap-11 ___ 04:20AM BLOOD ALT-49* AST-40 LD(LDH)-190 AlkPhos-74 TotBili-0.5 . MICROBIOLOGY: ___ 5:19 am SEROLOGY/BLOOD **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. . ___ 12:44 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . ___ 10:50 am BLOOD CULTURE Blood Culture, Routine (Pending) times 2 . ___ 09:34AM BLOOD HIV Ab-NEGATIVE . OTHER DIAGNOSTICS: ___ 04:20AM BLOOD CERULOPLASMIN-PND ___ 04:20AM BLOOD ___- PND . IMAGING: Head CT: FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. The ventricles and sulci are normal in size and configuration. The basal cisterns are patent. There is preservation of gray-white matter differentiation. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No evidence of acute intracranial process. . Head MRI with and without contrast: FINDINGS: There are several scattered FLAIR hyperintense foci in the cerebral white matter, in the centrum semiovale, subcortical and periventricular white matter, in the frontal and the parietal lobes on both sides and a few in the occipital lobes. However, there is no associated abnormal enhancement in these foci. There is no focus of slow diffusion allowing for artifacts at the tissue interfaces. On the GRE sequence, there is no focus of negative susceptibility. Pituitary gland is mildly prominent with a convex superior border, however, this may be within normal limits for the patient's age. The ventricles and extra-axial CSF spaces are unremarkable. Minimal increase in the FLAIR signal intensity in the right hippocampus is of equivocal significance, superiorly (series 7, image 10) and on post-contrast images relates to enhancment of the adjacent choroid plexus- seen end-on on axial images and better characterized on coronal and sagittal MPRAGE sequences. Major intracranial arterial flow voids are noted. A few retention cysts are noted in the maxillary sinuses, left more than right. IMPRESSION: 1. Several small scattered FLAIR hyperintense foci in the cerebral white matter in the frontal and the parietal lobes predominantly, without associated enhancement. These are nonspecific in appearance and can be seen with small vessel ischemic changes, post-inflammatory sequela, post-infectious sequela,vasculitis type of disorders or less likely demyelinating disease given the appearance and distribution. As no prior studies are available, a followup can be considered in a few weeks or earlier as clinically necessary, to assess stability/progression after correlation clinically and with labs to assess underlying risk factors. 2. No focal abnormal enhancing lesions noted. Medications on Admission: None Discharge Medications: 1. haloperidol 5 mg Tablet Sig: One half Tablet PO twice a day. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Psychosis, NOS Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Acute psychosis of unknown origin, to evaluate for acute process. COMPARISON: CT head done on ___. TECHNIQUE: MR of the head without and with IV contrast. FINDINGS: There are several scattered FLAIR hyperintense foci in the cerebral white matter, in the centrum semiovale, subcortical and periventricular white matter, in the frontal and the parietal lobes on both sides and a few in the occipital lobes. However, there is no associated abnormal enhancement in these foci. There is no focus of slow diffusion allowing for artifacts at the tissue interfaces. On the GRE sequence, there is no focus of negative susceptibility. Pituitary gland is mildly prominent with a convex superior border, however, this may be within normal limits for the patient's age. The ventricles and extra-axial CSF spaces are unremarkable. Minimal increase in the FLAIR signal intensity in the right hippocampus is of equivocal significance, superiorly (series 7, image 10) and on post-contrast images relates to enhancment of the adjacent choroid plexus- seen end-on on axial images and better characterized on coronal and sagittal MPRAGE sequences. Major intracranial arterial flow voids are noted. A few retention cysts are noted in the maxillary sinuses, left more than right. IMPRESSION: 1. Several small scattered FLAIR hyperintense foci in the cerebral white matter in the frontal and the parietal lobes predominantly, without associated enhancement. These are nonspecific in appearance and can be seen with small vessel ischemic changes, post-inflammatory sequela, post-infectious sequela,vasculitis type of disorders or less likely demyelinating disease given the appearance and distribution. As no prior studies are available, a followup can be considered in a few weeks or earlier as clinically necessary, to assess stability/progression after correlation clinically and with labs to assess underlying risk factors. 2. No focal abnormal enhancing lesions noted. Radiology Report INDICATION: Acute mental status change. COMPARISONS: None. 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 infarction. The ventricles and sulci are normal in size and configuration. The basal cisterns are patent. There is preservation of gray-white matter differentiation. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No evidence of acute intracranial process. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by OTHER Chief complaint: DISORGANIZED THINKING Diagnosed with ALTERED MENTAL STATUS , TACHYCARDIA NOS temperature: 97.6 heartrate: 95.0 resprate: 20.0 o2sat: 100.0 sbp: 129.0 dbp: 91.0 level of pain: 0 level of acuity: 2.0
Dear Dr. ___, ___ were admitted for a change in your behavior following the recent death of your grandmother and other stressors in your life. ___ were also managed for an increase in your heart rate following administration of medication. Your heart rate normalized during the admission and was not affected by the haldoperidol that ___ were started on during this admission. ___ were also seen by Psychiatry for evaluation of your behaviour change who recommended that ___ start haloperidol 2.5mg twice daily. Collectively, it was felt that ___ are safe to go home with your mother and with close psychiatric follow-up which as been arranged for ___ by Psychiatry. ___ have an appointment at ___ Partial ___ Program- ___., ___ on ___ at 9am. ___. Take all medications as instructed. Please note the following medication changes: 1. *ADDED* haloperidol 2.5mg twice daily. ___ and your mother agree to return to the emergency deparment or call ___ should your symptoms worsen again or should ___ experience any suicidal or homicidal ideation. Your mother is to remain with ___ after discharge from ___ ___ to monitor your symptoms and assist with getting ___ to your appointments. In addition to your psychiatric follow-up, ___ will need to make a follow-up with Neurology to follow-up MRI findings that the Neurologists did not feel needed to be worked-up acutely during your admission. Call the following number to schedule an appointment for within 2 weeks of discharge date with the first available appointment: ___. ___ also have a follow-up appointment with your primary care physician on ___ at 9AM.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Ataxia and LUE weakness Major Surgical or Invasive Procedure: None this admission History of Present Illness: Ms. ___ is a ___ year old female who is known to the neurosurgery department, a patient of Dr. ___ with a known brainstem cavernous malformation who called the neurosurgery office earlier today with complaints of LUE weakness and ataxia. Patient was instructed to go to the nearest ED, while at OSH ___ negative for acute new hemorrhage. Patient requested transfer to ___ as she is followed closely by Dr. ___. On presentation to the ED neurosurgery was consulted. On exam, patient lying in stretcher in NAD. Patient states that she noticed today her gait was off balance and she was having difficulty writing with her left arm that was getting progressively worse. Patient states that she has an occipital pressure and headache however states this is common for her. She denies visual changes, nausea, vomiting, lightheadedness, dizziness, bowel or bladder complaints or any other complaints. Patient does endorse tingling in her fingertips which she states has been present since prior CVAs. Past Medical History: Brain stem cavernous malformation with hemorrhage ___ Social History: ___ Family History: Noncontributory Physical Exam: ------------- On Admission ------------- PHYSICAL EXAM: T: 98 BP: 104/80 HR: 87 R: 18 O2Sats: 100% Room air Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3-2mm bilaterally EOMs: Intact Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2mm 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 ___ throughout, except for left tricep and finger intrinsics ___ and left Q/H ___. No pronator drift noted. Sensation: Intact to light touch. Coordination: Dysmetria on left, rapid alternating movements slowed. ------------- On Discharge ------------- Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No Tongue Midline: [x]Yes [ ]No Pronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact: [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip ___ IPQuadHamATEHLGast ___ [x]Sensation intact to light touch Pertinent Results: Please see OMR for pertinent lab/imaging studies. Medications on Admission: Oral contraceptive Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever 2. Dexamethasone 1 mg PO AS DIRECTED Duration: 7 Days 4mg q6hr x 8 doses 3mg q6hr x 8 doses 2mg q6hr x 4 doses 2mg q8hr x 3 doses 1mg q8hr x 3 doses RX *dexamethasone 1 mg as directed by mouth as directed Disp #*73 Tablet Refills:*0 3. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Brain stem cavernous malformation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ w/ cavernous malformation complicated by multiple hemorrhages presenting with LUE weakness and gait instability. Question of hemorrhage and evaluate cavernous malformation. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: ___ and ___. FINDINGS: Re-demonstrated is a 1.9 x 1.7 x 1.5 cm mixed T2 hyperintensity medullary lesion with extensive blooming artifact, compatible with known cavernous malformation. The volume of blood within the lesion appears greater than on the recent prior study. The volume of enhancement appears similar to prior. Postcontrast MPRAGE imaging demonstrates a tiny vascular lesion along the superior aspect of the lesion likely representing a small developmental venous anomaly. There is again intrinsic T1 enhancement on postcontrast imaging (series 14, image 4). There is increased T2/FLAIR signal abnormality associated with lesion, increased compared to prior which may represent evolution and increase of blood products. There is no evidence of infarction or of other hemorrhage. The ventricles and sulci are normal in size and configuration. No mass effect or midline shift. IMPRESSION: Medullary lesion is consistent with cavernous malformation with interval increase in T2/FLAIR signal abnormality, likely representing increased evolving blood products. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: L Weakness, Unsteady gait Diagnosed with Weakness, Unsteadiness on feet temperature: 98.0 heartrate: 87.0 resprate: 18.0 o2sat: 100.0 sbp: 104.0 dbp: 80.0 level of pain: 2 level of acuity: 2.0
Discharge Instructions Brain Hemorrhage without Surgery Activity • We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. • You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. • No driving while taking any narcotic or sedating medication. • If you experienced a seizure while admitted, you are NOT allowed to drive by law. • No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications • Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. • You have been prescribed a steroid (dexamethasone) taper. Please take this medication as follows: • 4mg every six (6) hours for two days (8 doses) • 3mg every six (6) hours for two days (8 doses) • 2mg every six (6) hours for one day (4 doses) • 2mg every eight (8) hours for one day (3 doses) • 1mg every eight (8) hours for one day (3 doses) • Then stop. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: • You may have difficulty paying attention, concentrating, and remembering new information. • Emotional and/or behavioral difficulties are common. • Feeling more tired, restlessness, irritability, and mood swings are also common. • Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: • Headache is one of the most common symptom after a brain bleed. • Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. • Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. • There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: • Severe pain, swelling, redness or drainage from the incision site. • Fever greater than 101.5 degrees Fahrenheit • Nausea and/or vomiting • Extreme sleepiness and not being able to stay awake • Severe headaches not relieved by pain relievers • Seizures • Any new problems with your vision or ability to speak • Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: • Sudden numbness or weakness in the face, arm, or leg • Sudden confusion or trouble speaking or understanding • Sudden trouble walking, dizziness, or loss of balance or coordination • Sudden severe headaches with no known reason
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: S/p assault to face Major Surgical or Invasive Procedure: ___ fixation, bilateral mandible fracture History of Present Illness: ___ h/op COPD, alcohol abuse, and ___ transferred from ___ after being brought to their ED with EtOH on board after an assault. He was in some type of altercation and walked into a fire station early AM ___ from which he was brought to an OSH. He was noted to have multiple facial lacerations and ongoing pharyngeal bleeding. A head CT was negative for neural injuries but revealed bilateral mandibular fractures and a nasal fracture. He was intubated for airway protection given that he was bleeding and transferred to ___ for further management. Past Medical History: COPD, EtOH abuse Psych History: PTSD- from childhood abuse Psychiatrist/therapist: multiple in the past. Cannot recall the name of most recent provider, seen 2 months ago at ___ ___. Stopped going because, "I didn't need the medicine." Past med trials of mx antidepressants and antianxiety including Zoloft, Paxil, Xanax and Seroquel. Denies Past Suicide Attempt, SIB. Social History: ___ Family History: Alcoholism on both genetic parents mother and father. Physical Exam: Exam Upon Admission: General: Intubated and sedated, NAD Head is atraumatic, normocephalic Eyes: EOMI, PERRL Face: 4 cm chin laceration, multiple facial abrasions.Bilateral nasal bone swelling. mild lower ___ facial edema, L TMJ very tender Lungs: intubated, CTA b/l CV: Regular rate and rhythm Abdomen: soft, non distended, non tender and no guarding Extr/Back: No deformities Skin: Warm and dry Neuro: Responds appropriately to commands Physical examination upon discharge: vital signs: 97.9, hr=79, bp=127/78, 20, 96% room air General: Dressed in room, NAD HEENT: swollen jaw, suture line under neck with staples, mild erythema mid-staple line CV: ns1, s2, -s3, -s4 LUNGS: clear EXT: no pedal edema bil., no calf tenderness bil NEURO: alert and oriented x 3, speech clear, no tremors ABDOMEN: soft, non-tender EXT: no pedal edema bil., no calf tenderness Pertinent Results: ___ 06:01PM GLUCOSE-74 UREA N-10 CREAT-0.6 SODIUM-143 POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-25 ANION GAP-10 ___ 06:01PM CALCIUM-7.1* PHOSPHATE-2.8 MAGNESIUM-1.3* ___ 06:01PM WBC-7.6 RBC-2.73* HGB-8.8* HCT-27.0* MCV-99* MCH-32.2* MCHC-32.6 RDW-15.8* ___ 06:01PM PLT COUNT-137* ___ 05:21PM TYPE-ART TEMP-37.1 RATES-14/ TIDAL VOL-500 PEEP-5 O2-40 PO2-149* PCO2-50* PH-7.34* TOTAL CO2-28 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED chest x-ray: ___: 1. Study was re-read once outside hospital CT scan was uploaded and apparent mediastinal widening is due to abundant mediastinal fat. 2. Although no fracture or other bone abnormality is seen, conventional chest radiographs are not appropriate for detection or characterization of chest cage lesions. Any focal findings should be clearly marked and imaged with either bone detail views or CT scanning. ___: MRA No evidence of dissection or occlusion involving the head and neck vessels. ___: CT of the sinus: 1. Status post open reduction and internal fixation of multiple anterior mandibular fractures. No evidence of hardware failure. 2. Extensive, acute on chronic, multifocal sinus disease, as above ___: chest x-ray: In comparison with study of ___, the patient has taken a better inspiration. There is now a bibasilar opacification consistent with a combination of atelectatic changes and pleural effusions. Monitoring and support devices are unchanged. Continued enlargement of the cardiac silhouette, but no definite vascular congestion or acute focal pneumonia Medications on Admission: None known Discharge Medications: 1. Acetaminophen (Liquid) 1000 mg PO Q8H RX *acetaminophen 500 mg/5 mL 10 cc by mouth every eight (8) hours Disp ___ Milliliter Refills:*0 2. Bacitracin Ointment 1 Appl TP BID RX *bacitracin zinc [Antibiotic (bacitracin zinc)] 500 unit/gram apply to suture line under chin twice a day Disp #*1 Tube Refills:*0 3. Bisacodyl 10 mg PO DAILY:PRN constipation RX *bisacodyl [Dulcolax (bisacodyl)] 5 mg 1 tablet(s) by mouth once a day Disp #*20 Tablet Refills:*0 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID RX *chlorhexidine gluconate 0.12 % rinse and spit 15 cc twice a day Disp #*420 Milliliter Refills:*0 5. Docusate Sodium (Liquid) 100 mg PO BID RX *docusate sodium 50 mg/5 mL 10 cc by mouth twice a day Disp ___ Milliliter Refills:*1 6. OxycoDONE Liquid ___ mg PO Q3H:PRN Pain RX *oxycodone 5 mg/5 mL ___ cc by mouth every 3 hours Disp #*360 Milliliter Refills:*0 7. Sarna Lotion 1 Appl TP QID:PRN itching 8. Senna 8.6 mg PO BID:PRN constipation 9. Cephalexin 500 mg PO Q6H RX *cephalexin 250 mg/5 mL 10 cc by mouth every six (6) hours Disp #*240 Milliliter Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: S/p assault 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 man + EtOH, found by fireman s/p assault, intubated for airway protection, coughing blood. Assess for pneumothorax, hemothorax TECHNIQUE: Single portable frontal supine chest radiograph. COMPARISON: None. FINDINGS: An endotracheal tube is in appropriate position 4.6 cm above the level of the carina. The lungs are hypoinflated with crowding of vasculature. No pleural effusion or pneumothorax. The mediastinum is mildly widened measuring 8.9 cm however this study was re- read with the outside hospital CT scan up-loaded and the mediastinum is within normal limits. Heart size and hila are unremarkable. No displaced rib fractures. IMPRESSION: 1. Study was re-read once outside hospital CT scan was uploaded and apparent mediastinal widening is due to abundant mediastinal fat. 2. Although no fracture or other bone abnormality is seen, conventional chest radiographs are not appropriate for detection or characterization of chest cage lesions. Any focal findings should be clearly marked and imaged with either bone detail views or CT scanning. Radiology Report EXAMINATION: MRA BRAIN AND NECK INDICATION: ___ year old man with head trauma, C2 fx // vacular injury 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 14 ml of Multihance intravenous contrast. Three dimensional maximum intensity projection and segmented images were generated. This report is based on interpretation of all of these images. COMPARISON: Head CT of ___ FINDINGS: MRA brain: The intracranial vertebral and internal carotid arteries and their major branches appear normal without evidence of stenosis, occlusion, or aneurysm formation. MRA neck: The common, internal and external carotid arteries appear normal. There is no evidence of internal carotid artery stenosis by NASCET criteria. The vertebral arteries are unremarkable. There is no evidence of dissection. The origins of the great vessels, subclavian and vertebral arteries appear normal bilaterally. Known mandibular fracture is better appreciated on the CT of the brain from outside hospital. IMPRESSION: No evidence of dissection or occlusion involving the head and neck vessels. Radiology Report EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST INDICATION: ___ year old man with bilateral mandibular fractures s/p ORIF today, currently nasally intubated // OMFS requesting CT MAXILLOFACIAL ICLUDING MANDIBLE WITHOUT CONTRAST, WITH 3D RECONSTRUCTION TECHNIQUE: Helical axial images were acquired through the facial bones. Bone and soft tissue reconstructed images were generated. Coronal reformatted images were also obtained. DOSE: DLP: 628 mGy-cm CTDI: 26 mGy COMPARISON: None available. FINDINGS: The patient is intubated, and both an endotracheal tube and nasogastric tube are incompletely visualized within the upper oropharynx. There is extensive mucosal thickening involving the bilateral maxillary sinuses, sphenoid sinuses, and frontal sinuses, in addition to the bilateral anterior and posterior ethmoidal air cells. Air-fluid levels are seen within the maxillary sinuses, an secretions are noted throughout the nasopharynx, some of which may be due to the patient's intubated status. The ostiomeatal units are attenuated and obscured on the right and left, respectively, secondary to the extensive mucosal thickening. The nasal septum is deviated towards the right, and there is a comminuted fracture of the nasal bone. Obliquely oriented fractures are noted through the anterior body of the right and left mandible. The patient is status post internal fixation of these fractures, with intact surgical plating and fixation screws extending along the anterior surface of the mandible. There is no evidence of hardware failure. Several tiny foci of gas adjacent to the mandible are likely postoperative in nature. Additional postsurgical changes are noted, including adjacent soft tissue swelling and cutaneous surgical staples. IMPRESSION: 1. Status post open reduction and internal fixation of multiple anterior mandibular fractures. No evidence of hardware failure. 2. Extensive, acute on chronic, multifocal sinus disease, as above. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with mandibular fracture s/p repair and seizures from EtOH withdrawal // ? interval change TECHNIQUE: Single frontal view of the chest COMPARISON: ___ IMPRESSION: Cardiac size is top-normal. Mediastinal contours are unchanged. ET tube is in standard position. NG tube tip is out of view below the diaphragm. There are low lung volumes with bibasilar atelectasis. There is mild vascular congestion. Retrocardiac opacities have increased likely atelectasis. There is no evident pneumothorax. Skin staples and hardware material in the mandible are noted Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with intubated in tsicu, fever // interval change interval change IMPRESSION: In comparison with study of ___, the patient has taken a better inspiration. There is now a bibasilar opacification consistent with a combination of atelectatic changes and pleural effusions. Monitoring and support devices are unchanged. Continued enlargement of the cardiac silhouette, but no definite vascular congestion or acute focal pneumonia. Radiology Report EXAMINATION: PORTABLE ABDOMEN INDICATION: ___ year old man with ngt output >3L yesterday, already 1.8L since midnight,? ileus, ? ngt tip placement. TECHNIQUE: Supine portable abdominal radiograph. COMPARISON: Chest x-ray dated ___. FINDINGS: Bowel gas pattern is nonspecific with air in the small and large bowel. Nasogastric tube is in appropriate position. No free intra-abdominal air. Right basilar atelectasis better assessed on same day chest x-ray. IMPRESSION: 1. Nonspecific bowel-gas pattern. 2. Nasogastric tube in appropriate position. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: ASSAULT Diagnosed with FX SYMPHY MANDIB BDY-OPN, NASAL BONE FX-CLOSED, UNARMED FIGHT OR BRAWL, OPEN WOUND OF JAW temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan
You were admitted to the hospital after you were assaulted in the face. You were taken to the operating room where underwent repair of your jaw. Your vital signs have been stable and you are preparing for discharge with the following instructions: Wound care: Do not disturb or probe the surgical area with any objects. The sutures placed in your mouth are usually the type that self dissolve. If you have any sutures on the skin of your face or neck, your surgeon will remove them on the day of your first follow up appointment. SMOKING is detrimental to healing and will cause complications. Bleeding: Intermittent bleeding or oozing overnight is normal. Placing fresh gauze over the area and biting on the gauze for ___ minutes at a time may control the bleeding. If you had nasal surgery, you may have occasional slow oozing from your nostril for the first ___ days. Bleeding should never be severe. If bleeding persists or is severe or uncontrollable, please call our office immediately. If it is after normal business hours, please come to the emergency room and request that the oral surgery resident on call be paged. ___: Normal healing after oral surgery should be as follows: the first ___ days after surgery, are generally the most uncomfortable and there is usually significant swelling. After the first week, you should be more comfortable. The remainder of your postoperative course should be gradual, steady improvement. If you do not see continued improvement, please call our office. Physical activity: It is recommended that you not perform any strenuous physical activity for a few weeks after surgery. Do not lift any heavy loads and avoid physical sports unless you obtain permission from your surgeon. Swelling & Ice applications: Swelling is often associated with surgery. Swelling can be minimized by using a cold pack, ice bag or a bag of frozen peas wrapped in a towel, with firm application to face and neck areas. This should be applied 20 minutes on and 20 minutes off during the first ___ days after surgery. If you have been given medicine to control the swelling, be sure to take it as directed. Hot applications: Starting on the ___ or ___ day after surgery, you may apply warm compresses to the skin over the areas of swelling (hot water bottle wrapped in a towel, etc), for 20 minutes on and 20 min off to help soothe tender areas and help to decrease swelling and stiffness. Please use caution when applying ice or heat to your face as certain areas may feel numb after surgery and extremes of temperature may cause serious damage. Tooth brushing: Begin your normal oral hygiene the day after surgery. Soreness and swelling may nor permit vigorous brushing, but please make every effort to clean your teeth with the bounds of comfort. Any toothpaste is acceptable. Please remember that your gums may be numb after surgery. To avoid injury to the gums during brushing, use a child size toothbrush and brush in front of a mirror staying only on teeth. Mouth rinses: Keeping your mouth clean after surgery is essential. Use 1 teaspoon of salt dissolved in an 8 ounce glass of warm water and gently rinse with portions of the solution, taking 5 min to use the entire glassful. Repeat as often as you like, but you should do this at least 4 times each day. If your surgeon has prescribed a specific rinse, use as directed. Showering: You may shower ___ days after surgery, but please ask your surgeon about this. If you have any incisions on the skin of your face or body, you should cover them with a water resistant dressing while showering. DO NOT SOAK SURGICAL SITES. This will avoid getting the area excessively wet. As you may physically feel weak after surgery, initially avoid extreme hot or cold showers, as these may cause some patients to pass out. Also it is a good idea to make sure someone is available to assist you in case if you may need help. If you develop the following, please return to the emergency room: *fever *chills *nausea/vomitting *abdominal pain *bleeding from mouth *difficulty breathing
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: stab wounds Major Surgical or Invasive Procedure: None. History of Present Illness: HPI: ___ s/p stab to L flank, R trapezius, and R anteromedial neck w/likely old L carotid dissection found on CTA. Patient's brother stabbed him multiple times. Was intoxicated at the time. No respiratory distress, no difficulty swallowing, conversant, no difficulty speaking. No chest or abdominal pain. Neuro exam intact. No numbness/tingling. Was transferred here from ___ for further evaluation. CT head was negative. CTA neck showed air tracking along the right neck stab wound towards the left side of the neck, ending a few centimeters below the area of the left carotid dissection. The dissection itself is 1cm superior to the carotid bifurcation in the ICA, extending for about 5mm. Patient is asymptomatic, no focal neurologic findings. Does have a history of previous L-sided blunt trauma resulting in a mandibular fracture. Past Medical History: Past Medical History: HTN, anxiety, ?cirrhosis Past Surgical History: RUE fasciotomy, mandibular fixation Social History: ___ Family History: nc Physical Exam: Physical Exam: Vitals: 98.3, 94, 150/89, 16, 100%RA GEN: A&Ox3, NAD NEURO: CN II-XII intact, no focal weakness HEENT: R neck stab wound (not probed on exam) CV: RRR PULM: Clear to auscultation b/l Ext: No ___ edema, ___ warm and well perfused Physical Exam: Vitals: 98.3, 94, 150/89, 16, 100%RA GEN: A&Ox3, NAD NEURO: CN II-XII intact, no focal weakness HEENT: R neck stab wound CV: RRR PULM: Clear to auscultation b/l Ext: No ___ edema, ___ warm and well perfused Pertinent Results: Carotid duplex ___ - IMPRESSION: Bilateral less than 40% carotid stenosis with minimal plaque. There is no evidence of carotid dissection bilaterally in the visualized portion of the carotid arteries. Imaging: CT head neg CT a/p neg, ?hip dislocation CTA neck: Dissection in the left internal carotid artery (2:162) begins approximately 1 cm above the bifurcation of the common carotid artery and extends for approximately ___arotid artery and their major branches appear intact without evidence of active extravasation. No evidence of disruption of the internal jugular veins. Extensive subcutaneous gas tracks along the anterior tissue planes in the neck. The esophagus is filled with air but appear intact. Left clavicle fracture. Medications on Admission: Atenolol, ativan Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet,delayed release (___) by mouth Daily Disp #*30 Tablet Refills:*2 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. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain Duration: 5 Days RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Multiple stab wounds Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CLINICAL INDICATION: Stab wounds to the left neck. COMPARISON: None. FINDINGS: Portable supine frontal view of the chest. The lung volumes are low; however, no opacity, pleural effusion or pneumothorax is seen. The cardiac and mediastinal contours are within normal limits for technique. The left clavicle is fractured and displaced; however, the edges are rounded and ill-defined suggesting that this is chronic. There are degenerative changes in the left glenohumeral joint. No displaced rib fracture is detected on this lung-technique film. IMPRESSION: 1) No acute pulmonary process identified. 2) Ununited left clavicular fracture that is thought to be old. Osteoarthritis in the left glenohumeral joint. Radiology Report STUDY: CTA of the neck. CLINICAL INDICATION: ___ male patient with history of stab wound. COMPARISON: No prior examinations of the neck are available. TECHNIQUE: After the administration of intravenous non-ionic contrast material, axial images were obtained through the neck, sagittal, axial and coronal reformations were reviewed. FINDINGS: There is dissection of the left internal carotid artery with a small pseudoaneurysm (series #2, image #162), the dissection begins approximately at 1 cm above the cervical carotid bifurcation and extends for approximately 5 mm. The common carotid arteries and their major branches appear intact without evidence of active extravasation. There is no evidence of disruption of the internal jugular veins. There is extensive subcutaneous gas tracking along the anterior tissue planes through the neck. The esophagus is filled with air, but appears intact. The left clavicle fracture possibly is chronic in nature, please correlate clinically. IMPRESSION: There is dissection of the left internal carotid artery with a small pseudoaneurysm as described in detail above. Subcutaneus emphysema tracking along the anterior neck tissue plane. Apparently, there is no evidence of active contrast extravasation. These findings were discovered and communicated via phone call to Dr. ___ by Dr. ___ at 5:15 a.m. on ___. Radiology Report CLINICAL INDICATION: Stab wound to neck and back. TECHNIQUE: Multidetector CT scan through the abdomen and pelvis was performed after the administration of Omnipaque intravenous contrast. Coronal and sagittal reformatted images were obtained. DLP: 887.63 mGy-cm. COMPARISON: None. FINDINGS: There is bibasilar atelectasis; otherwise, the lung bases are clear. The heart size is normal. There is no pleural or pericardial effusion. The liver enhances homogeneously without focal lesions or evidence of intrahepatic biliary duct dilation. The portal vein is patent. Prominent celiac lymph nodes are not enlarged by CT size criteria. The gallbladder appears normal. The pancreas is unremarkable. The spleen is enlarged, measuring up to 17 cm. There is minimal fat stranding around the liver. The kidneys enhance homogeneously and excrete contrast bilaterally. Adrenal glands appear normal. Esophageal and periesophageal varices are suggested. The stomach contains a minimal amount of fluid and is otherwise unremarkable. The small and large bowel are unremarkable without evidence of wall thickening or adjacent fat stranding. The appendix is visualized in the right lower quadrant and appears normal. The bladder is partially filled and appears normal. The prostate is unremarkable. There is no free fluid, free air or abnormal lymphadenopathy. The aorta is normal in caliber without evidence of dissection. SUBCUTANEOUS AND OSSEOUS STRUCTURES: No fracture is identified; however, the left hip is externally rotated, although this may be positional. There is subcutaneous air as well as fat stranding and breaks within the skin behind the right abdomen (2:33 and 2:62). No focal hematoma or disruption of the deep fascia is identified. IMPRESSION: 1. No evidence of acute intra-abdominal injury. Findings suggesting superficial right posterior injury. 2. Splenomegaly, mildy prominent celiac lymph nodes, and findings suggesting esophageal varices. No clear morphological changes in the liver; however, findings are concerning for liver disease with portal hypertension. 3. The left hip appears to be externally rotated. This may simply be due to positioning; however, injury is not excluded. Correlation with physical exam findings is recommended. Radiology Report CLINICAL INDICATION: Stab wounds to the left neck. TECHNIQUE: Multidetector CT scan through the head was performed without the administration of IV contrast. Coronal, sagittal and thin-section bone algorithm reconstructed images were obtained. DLP: 1025.72 mGy-cm. CTDI VOLUME: 62.20 mGy. COMPARISON: None. FINDINGS: There is no acute hemorrhage, edema, mass, mass effect, or acute large vascular territorial infarction. The ventricles and sulci are normal in size and configuration. The basal cisterns are patent. Gray-white matter differentiation is preserved. No fracture is identified. The paranasal sinuses and mastoid air cells are clear. The globes are unremarkable. IMPRESSION: No acute intracranial process. Radiology Report STUDY: Carotid series complete. REASON: Left carotid dissection noted on CT. FINDINGS: Duplex was performed of bilateral carotid arteries. Minimal homogeneous plaque is seen in the carotid bifurcations bilaterally. No intimal flap is seen bilaterally. On the right, peak velocities are 108 124 and 101 in the ICA, CCA and ECA. This is consistent with less than 40% stenosis. On the left, peak velocities are 109, 136 and 117 in the ICA, CCA and ECA. This is consistent with less than 40% stenosis. There is antegrade vertebral flow bilaterally. IMPRESSION: Bilateral less than 40% carotid stenosis with minimal plaque. There is no evidence of carotid dissection bilaterally in the visualized portion of the carotid arteries. Gender: M Race: UNKNOWN Arrive by AMBULANCE Chief complaint: STAB TO NECK Diagnosed with OPEN WOUND OF NECK NEC, OPN WND LATERAL ABDOMEN, OPEN WOUND OF BACK, FX CLAVICLE NOS-CLOSED, ASSAULT-CUTTING INSTR, DISSECTION OF CAROTID ARTERY, ALCOHOL ABUSE-UNSPEC temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan
Mr. ___, You were admitted to the ___ Surgery service at ___ after sustaining multiple stab wounds - to the right flank, anterior neck and posterior neck. We obtained several imaging scans including CT of your head and neck, as well as CT with contrast to evaluate the vessels in your head and neck. This scan showed a small dissection in your L internal carotid artery. You were also seen by our colleagues in Vascular Surgery who advised a carotid doppler imaging study to further evaluate the dissection. This study was reassuring; however, you should follow-up with Vascular Surgery in ONE (1) month for a repeat study and clinic visit. Please keep in mind the following instructions: 1) Activity: You may resume all previous activities. You should limit your alcohol intake as this appears to be causing damage to your liver, a condition called alcoholic cirrhosis, which is irreversible and can lead to very serious medical problems including esophageal varices, bleeding and infection. 2) Medications: you may continue all previous medications. However, you should check with your doctor before starting any new medications that may interfere with, or worsen your liver function. 3) Pain: we are providing you with oxycodone, an opiate pain medication. Please wait at least four hours between doses, and do not drive while taking this medication. You should avoid overusing Tylenol (>3 grams/day) since this can affect your liver as well. 4) Food: You may resume your previous diet.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ambien / shellfish derived / nafcillin Attending: ___. Chief Complaint: Weakness, fall, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH of advanced dementia, systolic CHF (EF35%) ___ ischemic CM, s/p bioprothestic MVR, atrial fibrillation on xarelto, h/o VT/VF and AF s/p AVJ ablation s/p BiV ICD, PVD s/p L external iliac to femoral bypass presenting for evaluation of slowly progressive decline in his mental status particularly over the last week. Patient limited historian. Denies pain. Says he's had trouble swallowing. Unsure if any falls. Unable to confirm history personally from family, so mostly derived from ED ___. "Has had decreased p.o. intake over the last 2 days, episode of vomiting today. Per his son was at bedside the patient has had occasional falls, difficulty with ambulation and episodes of emesis over the last 2 days. Of note the patient has had progressive dysphasia and recently had an EGD that confirmed that he did have esophageal hiatal hernia without reflux but with severe ___ esophagitis with ulceration, no evidence of malignancy. GI note from ___: "Patient underwent endoscopy to evaluate dysphagia shows severe ___ esophagitis and some retained food in stomach. will treat with fluconazole for 14 days 200 mg bid" PCP ___ ___: "We will continue to treat his xerosis with a emollient and I discussed skin care including choice of soap. We discussed possible risk factors for his ___ esophagitis. I advised him that the likelihood of chronic viral infection is remote, but he has had multiple blood transfusions in the past. He agrees to HIV, HBV and HCV serology along with a lymphocyte profile." In the ED, initial VS were: 97.8 116/59 66 18 96/RA Orthostatics: 147/72@80 lying -> 136/72@80 sitting -> 127/72@81 standing. Exam notable for: Orientation x1, trace edema bilaterally ECG: Paced, Sgarbossa negative Labs showed: - WBC 4.8 Hb 9.4 Plt 139 - Cr 1.8 Bicarb 19 AG 21 lytes otherwise WNL - INR 2.3 Imaging showed: - CXR: No PNA - CT A/P: 1. No acute findings in the abdomen or pelvis. 2. Large stool ball in the rectum. - CT C-spine: No cervical spine fracture or malalignment - CT head: 1. No acute intracranial abnormality. 2. Large area of encephalomalacia involving the right posterior temporoparietal lobes is unchanged from ___. - XR R elbow: No evidence of fracture or dislocation. No erosions. Patient received: ___ 14:29 IVF NS ___ Started ___ 17:07 IVF NS 500 mL ___ Stopped (2h ___ ___ 17:24 IVF LR ___ Started 100 mL/hr ___ 17:47 IVF LR ___ Confirmed Rate Changed to 50 mL/hr ___ 18:15 PO/NG QUEtiapine Fumarate 25 mg ___ ___ 19:01 PO/NG Rivaroxaban 15 mg ___ ___ 20:23 PO Pravastatin 40 mg ___ ___ 20:23 PO Tamsulosin .4 mg ___ ___ 20:23 PO/NG QUEtiapine Fumarate 75 mg ___ ___ 20:23 PO/NG Senna 8.6 mg ___ ___ 20:23 PO/NG Labetalol 200 mg ___ ___ 20:24 PO/NG Lactulose 30 mL ___ On arrival to the floor, patient is somnolent but responsive. Is limited historian. Reports some abdominal discomfort, unsure when his last bowel movement was. Denies black or bloody stool. REVIEW OF SYSTEMS: As above, limited by patient cooperation. Past Medical History: 1. CARDIAC RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - Systolic Heart failure- (LVEF = 35 %) ___ - CAD s/p CABG in ___ - Mitral Valve replacement due to severe MR in ___ (Bioprosthetic) - Syncopal episode leading to MVA. Suspected to be due to VT/VF s/p dual chamber ICD at ___ in ___. - Atrial fibrillation s/p AV junctional ablation and placement of a biventricular ICD device in ___ 3. OTHER PAST MEDICAL HISTORY - Hypothyroid - Cholelithiasis - Anemia - PVD / Femoral aneurysm - OSA on home CPAP - Depression - Cervical spondylosis - Gout - Sigmoid diverticulitis PAST SURGICAL HISTORY: - EVAR ___ coil embolization ___ - Left external iliac to femoral bifurcation bypass ___. - CABG ___ - MVR ___ Bioprosthetic - B/l cataracts - Dual chamber ICD ___ (___) - Trach/PEG s/p MVC ___, now removed Social History: ___ Family History: father with cardiac disease, specifics unknown Physical Exam: ADMISSION: VS: 97.4 132/74 81 20 99/RA GENERAL: Somnolent, NAD, arousable, dry MMM, limited historian but following commands HEENT: AT/NC, EOMI, PERRL, anicteric sclera, no nystagmus. No oropharyngeal ___ appreciable (exam limited by patient cooperation) NECK: supple, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants alghough some discomfort in lower regions, no rebound/guarding EXTREMITIES: no cyanosis, clubbing; trace edema bl ___ ___: 2+ DP pulses bilaterally NEURO: A&Ox1, moving all 4 extremities with purpose SKIN: scaling ecchymosis over arm, warm and well perfused GU: some BR blood at meatus of penis DISCHARGE: 97.7 146/82 82 16 100 Ra GENERAL: Alert, pleasant, NAD HEENT: anicteric sclera, no thrush HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: Few crackles at left base, no wheezes or rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, no ttp EXTREMITIES: warm, trace edema in ___ bilaterally NEURO: Alert and oriented to self only, moving all 4 extremities with purpose SKIN: scaling ecchymosis and bruising over arm, warm and well perfused Pertinent Results: ADMISSION: ___ 12:50PM BLOOD WBC-4.8 RBC-3.16* Hgb-9.4* Hct-29.0* MCV-92 MCH-29.7 MCHC-32.4 RDW-15.2 RDWSD-51.1* Plt ___ ___ 12:50PM BLOOD Neuts-79.4* Lymphs-8.3* Monos-7.3 Eos-3.3 Baso-1.3* Im ___ AbsNeut-3.81 AbsLymp-0.40* AbsMono-0.35 AbsEos-0.16 AbsBaso-0.06 ___ 12:50PM BLOOD ___ PTT-41.1* ___ ___ 12:50PM BLOOD Glucose-115* UreaN-36* Creat-1.8* Na-142 K-4.1 Cl-102 HCO3-19* AnGap-21* ___ 07:05AM BLOOD TotProt-5.4* Calcium-8.7 Phos-3.7 Mg-1.6 UricAcd-6.7 ___ 12:50PM BLOOD ALT-8 AST-30 LD(LDH)-278* AlkPhos-88 Amylase-31 TotBili-0.9 ___ 12:50PM BLOOD calTIBC-233* Ferritn-316 TRF-179* ___ 07:05AM BLOOD VitB12-421 ___ 01:01PM BLOOD Lactate-1.5 ___ 05:20PM URINE Color-Yellow Appear-Clear Sp ___ ___ 05:20PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 05:20PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 NOTABLE: ___ 07:05AM BLOOD TSH-5.9* ___ 07:05AM BLOOD Free T4-0.9* ___ 12:50PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 07:05AM BLOOD PEP-NO SPECIFI IgG-699* IgA-206 IgM-59 DISCHARGE: ___ 05:30AM BLOOD WBC-3.3* RBC-3.26* Hgb-9.6* Hct-29.7* MCV-91 MCH-29.4 MCHC-32.3 RDW-15.0 RDWSD-50.1* Plt ___ ___ 05:30AM BLOOD Glucose-101* UreaN-14 Creat-1.1 Na-143 K-3.7 Cl-103 HCO3-21* AnGap-19* ___ 05:30AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.7 MICRO: ___ URINE URINE CULTURE-FINAL EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PENDING IMAGING: ___ Elbow X ray: No comparison. Three views of the right elbow are provided. Parts of a venous access device are visualized in the cubital fossa and projecting over the joint. No other soft tissue abnormalities. No evidence of fracture or dislocation. No erosions. ___ CT head without contrast: 1. No acute intracranial abnormality. 2. Large area of encephalomalacia involving the right posterior temporoparietal lobes is unchanged from ___. ___ CT A/P without contrast: 1. No acute findings in the abdomen or pelvis.No acute fracture. 2. Large stool ball in the rectum. ___ CT C spine without contrast: No cervical spine fracture or malalignment. ___ Chest X ray: The cardiomediastinal silhouette remains enlarged, but is not significantly changed. No focal consolidations are seen. There is mild pulmonary vascular congestion without interstitial edema. No pleural effusion or pneumothorax. Again seen is a left chest wall AICD with lead wires terminating in their expected locations Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Labetalol 200 mg PO BID 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. Rivaroxaban 15 mg PO DAILY 5. Pravastatin 40 mg PO QPM 6. Ferrous Sulfate 325 mg PO BID 7. urea 10 % topical TID:PRN 8. Tamsulosin 0.4 mg PO QHS 9. Levothyroxine Sodium 25 mcg PO DAILY 10. QUEtiapine Fumarate 75 mg PO QHS 11. Senna 17.2 mg PO BID 12. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 13. Aqua Care (urea) 10 % topical TID:PRN 14. Bisacodyl ___ID:PRN Constipation - First Line 15. Calcium Carbonate 500 mg PO Q6H:PRN indigestion 16. Docusate Sodium 100 mg PO BID 17. Doxycycline Hyclate 100 mg PO Q12H 18. QUEtiapine Fumarate 25 mg PO QPM Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY 2. Polyethylene Glycol 17 g PO DAILY 3. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 4. Allopurinol ___ mg PO DAILY 5. Aqua Care (urea) 10 % topical TID:PRN 6. Bisacodyl ___ID:PRN Constipation - First Line 7. Calcium Carbonate 500 mg PO Q6H:PRN indigestion 8. Docusate Sodium 100 mg PO BID 9. Doxycycline Hyclate 100 mg PO Q12H 10. Ferrous Sulfate 325 mg PO BID 11. Fluticasone Propionate NASAL 1 SPRY NU DAILY 12. Labetalol 200 mg PO BID 13. Levothyroxine Sodium 25 mcg PO DAILY 14. Pravastatin 40 mg PO QPM 15. Rivaroxaban 15 mg PO DAILY 16. Senna 17.2 mg PO BID 17. Tamsulosin 0.4 mg PO QHS 18. urea 10 % topical TID:PRN Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute metabolic Encephalopathy Constipation Acute kidney injury secondary to Dehydration Chronic Systolic CHF Dementia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) RIGHT INDICATION: History: ___ with right elbow pain status post fall// Evaluate for fracture Evaluate for fracture IMPRESSION: No comparison. Three views of the right elbow are provided. Parts of a venous access device are visualized in the cubital fossa and projecting over the joint. No other soft tissue abnormalities. No evidence of fracture or dislocation. No erosions. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with slowly declining altered mental status in the context of frequent falls and patient on Xarelto// Evaluate for ICH TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP = 829.0 mGy-cm. Total DLP (Head) = 842 mGy-cm. COMPARISON: Outside reference CT head from ___. FINDINGS: There is no evidence of acute infarction,hemorrhage,edema,or mass-effect. Large area of encephalomalacia involving the right posterior temporoparietal lobes is unchanged. There is prominence of the ventricles and sulci suggestive of involutional changes. Extensive subcortical and periventricular white-matter hypodensities are nonspecific, but likely represent sequela of chronic ischemic small vessel disease. There is no evidence of fracture. There is mild mucosal thickening of the ethmoid air cells. The visualized portion of the other paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. 2. Large area of encephalomalacia involving the right posterior temporoparietal lobes is unchanged from ___. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ s/p unwitnessed fall// evaluate for fracture TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.3 s, 20.8 cm; CTDIvol = 22.6 mGy (Body) DLP = 470.0 mGy-cm. Total DLP (Body) = 470 mGy-cm. COMPARISON: CT cervical spine from ___. FINDINGS: Alignment is maintained. No fractures are identified.There is fusion of the posterior aspect of the C4 and C5 vertebral bodies and fusion of the bilateral facet joint. There is no significant canal or foraminal narrowing.There is no prevertebral edema. The thyroid and included lung apices are unremarkable. IMPRESSION: No cervical spine fracture or malalignment. Radiology Report EXAMINATION: CT ABDOMEN PELVIS WITHOUT CONTRAST INDICATION: ___ s/p unwitnessed fall NO_PO contrast// evaluate for fracture TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.5 s, 51.1 cm; CTDIvol = 9.1 mGy (Body) DLP = 465.9 mGy-cm. Total DLP (Body) = 466 mGy-cm. COMPARISON: CT abdomen pelvis from ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. Heart is moderately enlarged. Partially imaged cardiac lead wires are again noted. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains gallstones without wall thickening or evidence of inflammation. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. Bilateral low-density lesions, likely simple renal cysts measure up to 3 cm in the right lower pole. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops demonstrate normal caliber and wall thickness throughout. Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening and fat stranding. The appendix is normal. A large stool ball is noted within the rectum. PELVIS: The urinary bladder is unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is enlarged and the seminal vesicles are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: Patient is post aorta bi-iliac stent graft with extension of graft into the right common iliac artery. Aneurysmal dilatation of the infrarenal abdominal aorta to 3.7 x 3.2 cm is stable (3:279). Moderate atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Rod and screw fixation of the left proximal femur is again noted. SOFT TISSUES: There is a small fat containing left inguinal hernia. The abdominal and pelvic walls are otherwise within normal limits. IMPRESSION: 1. No acute findings in the abdomen or pelvis.No acute fracture. 2. Large stool ball in the rectum. Radiology Report EXAMINATION: CHEST RADIOGRAPHS INDICATION: ___ with weakness and vomiting// eval for pneumonia TECHNIQUE: Chest AP and lateral COMPARISON: Multiple chest radiographs, most recent from ___. FINDINGS: The cardiomediastinal silhouette remains enlarged, but is not significantly changed. No focal consolidations are seen. There is mild pulmonary vascular congestion without interstitial edema. No pleural effusion or pneumothorax. Again seen is a left chest wall AICD with lead wires terminating in their expected locations IMPRESSION: No pneumonia. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: N/V Diagnosed with Acute kidney failure, unspecified temperature: 97.8 heartrate: 66.0 resprate: 18.0 o2sat: 96.0 sbp: 116.0 dbp: 59.0 level of pain: 0 level of acuity: 3.0
Dear Mr. ___, You came to the hospital because you were more confused and having trouble walking. You were also nauseated. You were found to be constipated which was likely causing your confusion and your nausea. You felt better after having a bowel movement. You were also found to have impaired kidney function. Dehydration likely caused your constipation and the problem with your kidneys. Your kidneys got better with fluids. You worked with ___ for your walking and they recommended that you go to rehab to get stronger. It was a pleasure participating in your care. We wish you all the best in the future. Sincerely, Your ___ team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: codeine / Penicillins Attending: ___ Chief Complaint: Chest pain, Shortness of breath Major Surgical or Invasive Procedure: ___ 1. Urgent coronary artery bypass graft x3; left internal mammary artery to left anterior descending artery, and saphenous vein graft to ramus and posterior descending arteries. 2. Mitral valve replacement with a 27 mm ___ mechanical valve. History of Present Illness: Mrs. ___ is ___ ___ yo current smoker who has had minimal past medical care. On ___ she presented to an outside hosptal with intermittent SSCP which was worse with exertion. She presented with hypertension, SBP>200 and frothy pink sputum. She was given lasix and lisinopril. She ruled in for a NSTEMI, and was taken for cardiac cath, report not in chart but per report ___, 100%LCx,90%oRCA, 90%mRCA. Past Medical History: CAD - Mitral Regurgitation - Obesity - Hypertension - Peripheral arterial disease - COPD Social History: ___ Family History: No Premature coronary artery disease Physical Exam: Pulse:60 Resp:18 O2 sat:98% on 2L NC B/P Right:140/78 Left: Height:5'3" Weight 180lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs coarse rhonch bilat with productive cough, no wheezes, no rales Heart: RRR [x] Irregular [] Murmur [x] grade ___ systolic murmur loudest at apex Abdomen: Soft [x] obese,non-distended [x] non-tender [x] bowel sounds +[x] Extremities: Warm [x], well-perfused [x] No Edema [] _____ Varicosities: None x Neuro: Grossly intact [x] Pulses: Femoral Right:2+ Left:2+-cath site w/small ecchymotic area, no hematoma DP Right:dopp Left:dopp ___ Right:dopp Left:dopp Radial Right:1+ Left:1+ Carotid Bruit Right:none Left:none Pertinent Results: Carotid U/S ___: 1. No significant right ICA or CCA stenosis. 2. Approximately 40% left ICA stenosis. . Vein Mapping ___: The greater saphenous veins are patent throughout their entire course, please see digitized images on PACS for formal sequential measurements. . Echo ___: PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. 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. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. MR increased to 3+ will increase in BP vs. ischemia. Due to the eccentric nature of the regurgitant jet (posterior directed), its severity may be significantly underestimated (Coanda effect). The mitral valve tenting height is 13 mm and the tenting area is 1.9 cm2. First POSTBYPASS Period: Biventricular systolic function is preserved. There is a ring annuloplasty in the mitral position. However MR remains moderate in quantity and is still posteriorly directed. Second POSTBYPASS: Biventricular systolic function remains normal. There is a well seated, well functioning bileaflet mechanical valve in the ___ position. MR is present which is normal in quantity and location (washing jets) for this type of prosthesis. TR is mild. The remaining study is unchanged from prebypass. . ___ 08:15AM BLOOD WBC-9.5 RBC-3.16* Hgb-9.3* Hct-28.9* MCV-91 MCH-29.3 MCHC-32.1 RDW-15.6* Plt ___ ___ 08:30AM BLOOD WBC-9.3 RBC-3.34* Hgb-9.6* Hct-30.2* MCV-90 MCH-28.9 MCHC-32.0 RDW-15.9* Plt ___ ___ 08:15AM BLOOD ___ PTT-57.7* ___ ___ 08:30AM BLOOD ___ PTT-58.4* ___ ___ 12:35AM BLOOD ___ PTT-45.3* ___ ___ 01:50PM BLOOD ___ PTT-36.3 ___ ___ 06:40AM BLOOD ___ PTT-34.0 ___ ___ 07:00AM BLOOD ___ PTT-40.1* ___ ___ 04:30AM BLOOD ___ PTT-40.9* ___ ___ 08:50AM BLOOD ___ PTT-38.2* ___ ___ 01:55PM BLOOD ___ PTT-38.7* ___ ___ 12:50PM BLOOD ___ PTT-37.4* ___ ___ 06:00AM BLOOD ___ PTT-72.9* ___ ___ 04:21AM BLOOD ___ PTT-48.0* ___ ___ 08:15AM BLOOD UreaN-22* Creat-0.7 Na-141 K-4.2 Cl-101 ___ 08:30AM BLOOD Glucose-88 UreaN-24* Creat-0.8 Na-139 K-4.1 Cl-102 HCO3-28 AnGap-13 Medications on Admission: Medications at home: 1) fish oil 2) garlic tab Medications on transfer: 1) Lisinopril 5 mg PO Daily 2) Aspirin 325 mg PO Daily 3) Atorvastatin 80 mg PO Daily 4) Plavix 75 mg PO Daily 5) Lovenox 80 mg SC Twice Daily 6) Metoprolol tartrate 25 mg PO Twice Daily 7) Acetaminiphen 650 mg PO Q 4 hours PRN Pain Discharge Medications: 1. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth daily Disp #*30 Tablet Refills:*0 2. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Metoprolol Tartrate 25 mg PO TID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 4. Guaifenesin ___ mL PO Q6H:PRN cough RX *guaifenesin [Adult Tussin Chest Congestion] 100 mg/5 mL ___ liquid(s) by mouth every six (6) hours Disp #*1 Bottle Refills:*0 5. Furosemide 40 mg PO BID Duration: 7 Days RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 6. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days RX *potassium chloride [Klor-Con] 20 mEq 1 packet by mouth twice a day Disp #*14 Packet Refills:*0 7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 8. Ranitidine 150 mg PO BID RX *ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: - Myocardial infarction, coronary artery disease s/p coronary artery bypass graft x 3 - Mitral valve regurgitation s/p Mitral valve replacement - Acute systolic Congestive heart failure Past medical history: - Obesity - Hypertension - Peripheral arterial disease - COPD Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - eschar at inferior pole, no drainage or erythema Leg - healing well, no erythema or drainage. Edema: 1+ Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH INDICATION: Evaluation for CABG. COMPARISON: No comparison available at the time of dictation. FINDINGS: The lung volumes are normal. Moderate cardiomegaly with no evidence suggesting pulmonary edema. Bilateral small pleural effusions, better appreciated on the lateral than on the frontal radiograph. The effusions are accompanied by small areas of atelectasis. No lung nodules or masses. No evidence of pneumonia. Radiology Report CAROTID STUDY HISTORY: Coronary artery disease. FINDINGS: Mild calcific plaque involving the internal carotid arteries bilaterally. Peak systolic velocities on the right are 71, 84, 112, 88, and 139 cm/sec for the proximal, mid, and distal ICA and CCA and ECA, respectively. Similar values on the left are 135, 87, 81, 96, and 162 cm/sec. There is antegrade flow involving both vertebral arteries. The ICA/CCA ratio is 1.2 on the right and 1.4 on the left. IMPRESSION: Findings as stated above which indicate: 1. No significant right ICA or CCA stenosis. 2. Approximately 40% left ICA stenosis. Radiology Report Vein mapping prior to cardiac bypass. FINDINGS: The greater saphenous veins are patent throughout their entire course, please see digitized images on PACS for formal sequential measurements. Radiology Report CHEST RADIOGRAPH HISTORY: Status post CABG and mitral valve replacement. COMPARISONS: ___. TECHNIQUE: Chest, portable AP supine. FINDINGS: The patient is status post interval mitral valve replacement surgery. The patient is intubated. The endotracheal tube terminates about 6 cm above the carina. An orogastric tube passes into the stomach where it loops once, its distal course not visualized. A chest tube projects over the left lower hemithorax. There is apparently at least one mediastinal drain, although not optimally visualized.A Swan-Ganz catheter terminates in the right main pulmonary artery. The mediastinum is similar in configuration with indistinct contours that can be expected immediately following surgery. There is probably a small left basilar pleural effusion as well as minor atelectasis at the left lung base. Trace air is present in the right cardiophrenic angle, also not unanticipated after surgery. IMPRESSION: Anticipated post-operative findings. Radiology Report HISTORY: ___ female with removal of chest tubes. COMPARISON: Chest radiograph dated ___. FINDINGS: Frontal and lateral chest radiograph demonstrate interval removal of endotracheal tube, enteric tube, and Swan Ganz catheter. There is increased right pleural effusion and adjacent atelectasis but improved left atelectasis. Left-sided pleural effusion is similar in appearance. The cardiomediastinal silhouette is stable. No pneumothorax. IMPRESSION: Increased right-sided pleural effusion with adjacent atelectasis. Improved left-sided atelectasis with persistent and unchanged left pleural effusion. Radiology Report PA AND LATERAL CHEST FILM, ___ AT 1530 CLINICAL INDICATION: ___ status post CABG and MVR with persistent productive cough, question pneumonia. Comparison is made to the patient's previous study of ___ at 1443. PA and lateral views of the chest, ___ at 1530 is submitted. IMPRESSION: Stably enlarged cardiac contours status post median sternotomy with mitral valve annular ring and CABG. There is persistent bibasilar patchy opacity with likely associated small effusions. These findings may reflect compressive atelectasis, although aspiration or pneumonia should also be considered. No evidence of pulmonary edema. No pneumothorax. Overall, the appearance is not significantly changed since ___. Radiology Report INDICATION: ___ female status post CABG and mitral valve replacement. Assess for pleural effusions. COMPARISON: Chest radiographs dating back to ___, most recent from ___. PA AND LATERAL CHEST RADIOGRAPHS: Overall aeration of the lungs is unchanged compared to most recent prior from one day prior. There are bibasilar consolidations, left greater than right, likely a combination of atelectasis and pleural fluid. The upper lungs are clear. There is no interstitial edema. No pneumothorax is evident. A radiopaque prosthetic mitral valve is in unchanged expected position. Median sternotomy wires are intact. IMPRESSION: Unchanged probable basilar atelectasis and effusions, moderate on the left and small on the right. Gender: F Race: WHITE Arrive by UNKNOWN Chief complaint: Transfer Diagnosed with SUBENDOCARDIAL INFARCTION, INITIAL EPISODE OF CARE, HYPERCHOLESTEROLEMIA temperature: 97.9 heartrate: 65.0 resprate: 18.0 o2sat: 93.0 sbp: 169.0 dbp: 70.0 level of pain: 0 level of acuity: 2.0
1. Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions 2). Please NO lotions, cream, powder, or ointments to incisions 3). Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4). No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive 5). No lifting more than 10 pounds for 10 weeks Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours**
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right ankle pain Major Surgical or Invasive Procedure: closed reduction under anathesia, right ankle History of Present Illness: HPI: ___ male who presents to the emergency room today for right leg pain. The patient was climbing over a fence last night and had a fall resulting in injury to the right leg. The patient was seen at outside hospital where he was found to have a midshaft fibular fracture and a medial and posterior malleolus fracture. The patient denies any other injury. He says the pain is increasing. He took approximately 3 oxycodone around noon today prior to our evaluation. He denies any numbness or tingling in the foot. PMH: none MED: none ALL: nkda SH: Denies any etoh, tobacco or illicit drug use PE: A&O x 3 Calm in mild discomfort Chest: ctab Abd: soft, non tender RLE skin clean and intact Significant swelling, ecchymosis noted in the distal leg especially around the medial malleolus and into the foot The anterior compartment is somewhat tense, posterior compartment is soft No pain with passive motion of the toes, there is pain with passive dorsi and plantar flexion Saphenous, Sural, Deep peroneal, Superficial peroneal SILT ___ FHS ___ TA Peroneals Fire 1+ ___ and DP pulses LABS: Laboratory data was reviewed and notable for normal coagulation profile, hct 45 IMAGING: Plain films were reviewed and notable for right midshaft fibula fracture, medial and posterior malleolus fracture Past Medical History: none Social History: ___ Family History: n/c Physical Exam: A&O x 3 Calm in mild discomfort Chest: ctab Abd: soft, non tender RLE skin clean and intact Significant swelling, ecchymosis noted in the distal leg especially around the medial malleolus and into the foot The anterior compartment and posterior compartments are soft No pain with passive motion of the toes, passive dorsi and plantar flexion Saphenous, Sural, Deep peroneal, Superficial peroneal SILT ___ FHS ___ TA Peroneals Fire 1+ ___ and DP pulses Pertinent Results: ___ 04:30PM BLOOD Glucose-79 UreaN-12 Creat-1.1 Na-135 K-4.1 Cl-98 HCO3-21* AnGap-20 ___ 04:30PM BLOOD Plt ___ ___ 04:48PM BLOOD ___ PTT-31.0 ___ ___ 04:30PM BLOOD Neuts-75.6* Lymphs-14.8* Monos-6.6 Eos-2.3 Baso-0.7 ___ 04:30PM BLOOD WBC-13.6* RBC-5.21 Hgb-16.0 Hct-45.2 MCV-87 MCH-30.7 MCHC-35.3* RDW-12.9 Plt ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 650 mg PO Q4H 2. Docusate Sodium 100 mg PO BID 3. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*61 Tablet Refills:*0 4. Aspirin 325 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Right ankle 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 fluoroscopic imaging post closed reduction. Two intraoperative fluoroscopic images are compared with prior radiographs performed ___. A minimally displaced medial malleolar fracture is again present with unchanged alignment. There appears to be improved alignment of the ankle mortise with decreased lateral subluxation of the talar dome (difficullt assessment). A minimally displaced posterior malleolar fracture is better visualized on the current study. The imaged portions of the right foot are intact. The distal fibula is intact. Cast material projects over the ankle. IMPRESSION: Minimally displaced bimalleolar fracture with probable improved alignment of the ankle mortise post closed reduction. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: R TIB FIB FRACTURE Diagnosed with FX MEDIAL MALLEOLUS-CLOS, UNSPECIFIED FALL, FX SHAFT FIBULA-CLOSED temperature: 97.6 heartrate: 105.0 resprate: 18.0 o2sat: 97.0 sbp: 156.0 dbp: 94.0 level of pain: 8 level of acuity: 3.0
Activity: -Continue to be non weight bearing on your right leg. -Elevate right leg to reduce swelling and pain. -Do not remove splint. Keep splint dry. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the aspirin 325 every day to prevent blood clots. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___ 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. If you have questions, concerns or experience any of the below danger signs then please call your doctor at ___ or go to your local emergency room.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Nucynta / Hydromet Attending: ___ Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ y/o woman with PMH notable for NASH cirrhosis c/b recurrent admissions for HE and grade 2 varices s/p banding, GAVE s/p APC in ___, HFpEF, HTN, and T2DM, presenting with 3 days of worsening weakness. Per both patient and her husband at bedside, Ms. ___ has been quite weak for sometime now with her chronic medical problems, namely cirrhosis. However, about 3 days ago, her husband noted that she was unable to get up, even with assistance. She began endorsing pain in her bilateral upper thighs long the lateral aspects and almost fell multiple times, including on day of admission due to her weakness. Her husband comments that she may be a little more confused than usual, but has been making about 3 BM's per day. She has been taking her home rifaximin and lactulose as instructed. Otherwise, the patient was sick with a cold about 2 weeks ago, which has resolved. She denies any infectious symptoms of fevers, chills, lingering cough, N/V, abdominal pain, rash, or dysuria/urinary frequency. Her husband does note that her UTI's in the past have been asymptomatic. She also denies any hematochezia, but states that he stool is always dark with iron. Recent medication changes include decrease in her dose of Lasix from 20mg to 10mg PO daily and spironolactone from 50mg to 25mg PO daily about 2 weeks PTA, at instruction of outpatient hepatologist (Dr. ___. She does feel that her legs are swollen, most from her ongoing pyoderma gangrenosum and that her abdomen is slightly more swollen than usual. Denies any shortness of breath or orthopnea. At baseline, she is essentially non-ambulatory, sitting in a sofa most of the day and not walking. This is attributed to chronic fatigue and weakness from her liver disease and chronic pain in her lower extremities due to PG. With regards to mental status, the patient's husband feels that she may be slightly more confused than usual, but they presented to the ED mostly due to worsening of her weakness. In the ED, initial VS were: 98.7 60 163/55 17 99% RA Exam was notable for: -No asterixis -B/l ___ weakness, unable to lift up against gravity -___ strength to upper extremities for muscle bulk, intact cerebellar and sensory function grossly -rectal exam showed guaiac+ dark mucous in vault without frank melena Hepatology was consulted and recommended RUQ ultrasound, Hepatitis A, B, and C serologies, CK, 50g of 25% albumin, lactulose q4h, rifaximin 550 bid, and ___ admission. Work-up was notable for: -Hemolyzed blood sample with K 4.7, Bicarb 14 (without AG), BUN/Cr 35/0.8 (baseline Cr 0.9-1), CK 7758, AST 742, ALT 742, AP 364, Lipase 190, Albumin 3 -Hepatitis serologies pending -Hgb 12, Plt 129 -lactate 1.2 -U/A showing moderate leuks, large blood, negative nitrites, 100 protein, 4 RBC, 17 WBC, few bacteria, albeit with ___ yeast -Ucx and Blood cx x2 sent (pending) Imaging showed: -CXR with no acute cardiopulmonary processes but interval vertebral body ehigh loss at level of T12 -Liver/Gallbladder U/S showing hepatic cirrhosis without focal lesion and patient vasculature without cholelithitasis or acute cholecystitis Patient was given: -500cc IVF -50g of 25% albumin -Ceftriaxone 1g IV x1 -Lactulose 30mg PO x1 On transfer, patient's vitals were 98.2 149/77 78 18 95RA. On the floor, she reports the same history as above and is without acute complaint, endorsing the same b/l leg weakness and pain as well as leg pain overlying sites of pyoderma gangrenosum. Past Medical History: - ___ cirrhosis complicated by hepatic encephalopathy and grade 2 varices s/p banding - HFpEF (LVEF 65%) - Celiac disease - Hypertension - Diabetes mellitus type II complicated by neuropathy - Hyperlipidemia - Pyoderma gangrinosum - Lumbar spondylosis - History of compression fracture - History of bladder surgery - Cough-variant asthma Social History: ___ Family History: No history of liver disease Physical Exam: ADMISSION PHYSICAL EXAM ================= VITALS: 98.2 149/77 78 18 95RA General: chronically ill appearing, malnourished HEENT: temporal wasting appreciated; no scleral icterus; EOMI, PERRL, MMM, tongue midline on protrusion, no appreciable tongue fasciculations Neck: symmetric, supple, brisk carotid upstrokes; no bruits appreciated b/l; JVP appears to be about 8cm with prominent carotid pulsations CV: RRR with ___ mid-systolic murmur, no appreciable radiation to carotids or axilla; no r/g Lungs: CTAB with initial crackles that clear with repeated inspiration; no r/w Abdomen: Soft, mildly distended, mild TTP over RUQ with negative ___ sign; no r/g; GU: no foley Ext: thin, warm well perfused; 1+ pitting edema up to thighs b/l with +erythema and increased warmth surrounding b/l anterior shins, which are bandaged over sites of PG (c/d/I); tenderness to palpation over b/l lateral thighs from hips to knees without tenderness appreciated in hip joints; distal pulses intact Neuro: alert and appropriately interactive on exam; ___ strength in b/l UE; no asterixis appreciated; on strength exam, unable to lift b/l ___ up against gravity; sensation intact and symmetric throughout Skin: b/l PG wounds c/d/i DISCHARGE PHYSICAL EXAM ================= Vitals: 99.1 127/49 75 18 95%RA General: NAD, malnourished HEENT: temporal wasting appreciated; no scleral icterus; EOMI, PERRL, MMM, tongue midline on protrusion, no appreciable tongue fasciculations Neck: symmetric, supple, brisk carotid upstrokes; no bruits appreciated b/l; JVP appears to be about 8cm with prominent carotid pulsations CV: RRR with ___ mid-systolic murmur, no appreciable radiation to carotids or axilla; no r/g Lungs: CTAB, no r/w Abdomen: Soft, mildly distended, NT GU: no foley Ext: thin, warm well perfused; 1+ pitting edema up to thighs b/l with +erythema and increased warmth surrounding b/l anterior shins, which are bandaged over sites of PG (c/d/I); tenderness to palpation over b/l lateral thighs from hips to knees without tenderness appreciated in hip joints; distal pulses intact Neuro: alert and appropriately interactive on exam; ___ strength in b/l UE; no asterixis appreciated; on strength exam, lower extremities ___ in hip flexion, knee flexion, extension, dorsiflexion and plantar flexion; sensation intact and symmetric throughout Skin: b/l PG wounds c/d/I bandaged with mild erythema but not spreading Pertinent Results: ADMISSION LABS =========== ___ 11:45AM BLOOD WBC-7.9 RBC-3.34* Hgb-12.0 Hct-35.2 MCV-105* MCH-35.9* MCHC-34.1 RDW-17.3* RDWSD-66.0* Plt ___ ___ 11:45AM BLOOD Neuts-68.7 Lymphs-12.6* Monos-12.9 Eos-4.3 Baso-0.9 Im ___ AbsNeut-5.45# AbsLymp-1.00* AbsMono-1.02* AbsEos-0.34 AbsBaso-0.07 ___ 11:45AM BLOOD ___ PTT-28.7 ___ ___ 11:45AM BLOOD Glucose-125* UreaN-35* Creat-0.8 Na-139 K-4.7 Cl-112* HCO3-14* AnGap-18 ___ 11:45AM BLOOD ALT-542* AST-742* CK(CPK)-7758* AlkPhos-364* TotBili-0.9 ___ 11:45AM BLOOD Albumin-3.0* Calcium-10.2 Phos-2.2* Mg-2.0 NOTABLE LABS ========= ___ 06:40AM BLOOD Glucose-61* UreaN-22* Creat-0.6 Na-141 K-4.4 Cl-112* HCO3-18* AnGap-15 ___ 06:43AM BLOOD ALT-319* AST-386* CK(CPK)-2207* AlkPhos-285* TotBili-0.9 ___ 06:40AM BLOOD ALT-301* AST-342* CK(CPK)-1856* AlkPhos-276* TotBili-1.2 ___ 07:04AM BLOOD WBC-5.8 RBC-2.53* Hgb-9.1* Hct-26.7* MCV-106* MCH-36.0* MCHC-34.1 RDW-17.6* RDWSD-67.9* Plt ___ ___ 07:04AM BLOOD Glucose-66* UreaN-31* Creat-0.8 Na-149* K-4.5 Cl-122* HCO3-12* AnGap-21* ___ 09:25PM BLOOD ALT-356* AST-481* LD(___)-353* CK(CPK)-3634* AlkPhos-249* TotBili-0.8 ___ 07:04AM BLOOD ALT-333* AST-435* LD(LDH)-334* CK(CPK)-2580* AlkPhos-248* TotBili-0.9 ___ 11:45AM BLOOD HBsAg-Negative HBsAb-Negative HAV Ab-Positive IgM HBc-Negative ___ 09:25PM BLOOD CRP-10.5* ___ 11:45AM BLOOD HCV Ab-Negative ___ 12:07PM BLOOD Lactate-1.2 ___ 09:25PM BLOOD SED RATE-31 MICROBIOLOGY ========== URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 CFU/mL. CIPROFLOXACIN SUSCEPTIBILITY REQUESTED BY ___ ___ (___) @ 1420 ON ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R CIPROFLOXACIN--------- =>8 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- <=1 S VANCOMYCIN------------ =>32 R IMAGING ====== ___ CXR No acute cardiopulmonary process. Interval vertebral body height loss at T12 since ___, to be correlated with physical exam as acuity cannot be determined. ___ ABD ULTRASOUND 1. Hepatic cirrhosis without focal lesion. Patent hepatic vasculature. 2. Cholelithiasis without evidence for acute cholecystitis. DISCHARGE LABS ========== ___ 05:38AM BLOOD WBC-8.7 RBC-2.58* Hgb-9.6* Hct-26.9* MCV-104* MCH-37.2* MCHC-35.7 RDW-17.9* RDWSD-66.8* Plt ___ ___ 05:38AM BLOOD ___ PTT-89.2* ___ ___ 05:38AM BLOOD Glucose-50* UreaN-33* Creat-0.8 Na-140 K-4.3 Cl-110* HCO3-17* AnGap-17 ___ 05:38AM BLOOD ALT-196* AST-156* CK(CPK)-124 AlkPhos-280* TotBili-1.1 ___ 05:38AM BLOOD Calcium-10.3 Phos-3.3 Mg-1.8 ___ 09:25PM BLOOD CRP-10.5* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 10 mg PO DAILY 2. Spironolactone 25 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Omeprazole 20 mg PO DAILY 5. Nadolol 20 mg PO DAILY 6. Sertraline 50 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. Vitamin D ___ UNIT PO DAILY 10. Gabapentin 200 mg PO QHS 11. Alendronate Sodium 70 mg PO QWED 12. Rifaximin 550 mg PO BID 13. Lactulose 30 mL PO TID 14. Glargine 24 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 15. Lidocaine 5% Ointment 1 Appl TP QID:PRN pain Discharge Medications: 1. Doxycycline Hyclate 100 mg PO DAILY Duration: 7 Days End date ___ RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth Daily Disp #*7 Tablet Refills:*0 2. Alendronate Sodium 70 mg PO QWED 3. Aspirin 81 mg PO DAILY 4. Furosemide 10 mg PO DAILY 5. Gabapentin 200 mg PO QHS 6. Glargine 24 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Lactulose 30 mL PO TID 8. Lidocaine 5% Ointment 1 Appl TP QID:PRN pain 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Nadolol 20 mg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Rifaximin 550 mg PO BID 13. Sertraline 50 mg PO DAILY 14. Spironolactone 25 mg PO DAILY 15. Vitamin D ___ UNIT PO DAILY 16. HELD- Atorvastatin 40 mg PO QPM This medication was held. Do not restart Atorvastatin until you talk to your doctor and your blood enzymes return to normal Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: Rhabdomyolysis Urinary tract infection Toxic metabolic encephalopathy Hepatic encephalopathy Secondary Chronic diastolic heart failure Diabetes mellitus Pyoderma gangrenosusm 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 altered mental status // Pneumonia TECHNIQUE: AP and lateral views of the chest. COMPARISON: ___ chest x-ray and ___ torso CT. FINDINGS: The lungs are clear without consolidation, effusion, or edema. Cardiac silhouette is mildly enlarged, unchanged. When compared to ___, there is interval height loss T12. IMPRESSION: No acute cardiopulmonary process. Interval vertebral body height loss at T12 since ___, to be correlated with physical exam as acuity cannot be determined. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ with elevated transaminase, altered mental status // Please eval with dopplers, ? portal vein thrombosis, cholecystitis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdominal ultrasound dated ___. FINDINGS: LIVER: The hepatic parenchyma appears coarsened. The contour of the liver is nodular, consistent with cirrhosis. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. Hepatic arteries and hepatic veins are all patent. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm. GALLBLADDER: Cholelithiasis without gallbladder wall thickening. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 7.8 cm. KIDNEYS: Limited views of the right kidney show no hydronephrosis. Right kidney measures 10.9 cm in sagittal dimension. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Hepatic cirrhosis without focal lesion. Patent hepatic vasculature. 2. Cholelithiasis without evidence for acute cholecystitis. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Weakness, Confusion, Presyncope Diagnosed with Hepatic failure, unspecified without coma, Urinary tract infection, site not specified, Altered mental status, unspecified temperature: 98.7 heartrate: 60.0 resprate: 17.0 o2sat: 99.0 sbp: 163.0 dbp: 55.0 level of pain: 0 level of acuity: 3.0
Dear Miss ___, You were admitted due to weakness and leg pains. From your laboratory results, we concluded you had rhabdomyolysis. This also led to a rise in liver enzymes which is usually expected. You were given fluids to help this resolve. We are unclear what led to this happening; we suspect sitting in one place for days could have caused that or the use of atorvastatin. We reviewed the rest of your medications to ensure you're not on any new other medications which could have caused this. We also treated you for a urinary tract infection which was initially treated with ciprofloxacin but your cultures showed an organism called Enterococcus which was resistant to it, so we switched you to Doxycyline 100mg daily for a 7 day course, last dose on ___. Note that we STOPPED your atorvastatin. Please do not take it until you see your doctor. Please ensure close follow up with your doctors after ___. It was a pleasure being part of your care. Sincerely, Your ___ Liver Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril / Avandia / Glucophage / Lactose / aspirin Attending: ___ Chief Complaint: vaginal bleeding malaise Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ year old woman with history of HTN, DM2, CKDV, gout who presents with 1 day of vaginal bleeding and several weeks of malaise and poor appetite. The vaginal bleeding started this morning. She's never had anything like this since going through menopause. It's small volume, but was concerning enough to her and her family to present to the ED. In terms of her fatigue and poor appetite, it has been occurring over the last several months, and she's been told by her PCP and nephrologist that it's likely secondary to her kidney disease. She notes that she can't taste food very well (not a metallic taste) and therefore doesn't feel like eating and so has been loosing weight. No change in bowel habits. She denies any chest pain, palpitations, shortness of breath, cough, wheeze. She also denies abdominal pain, abdominal distension or bloating. No fevers, chills, or nightsweats. In the ED: - initial vital signs: 98.4 100 169/82 18 99% RA - Exam notable for abdominal distension, guaiac negative stool. Vaginal exam with moderate ___ bloody discharge with some cervical changes, no tenderness to palpation. - Labs were significant for Creatinine 4.3 (baseline 4.1), BUN 74, bicarb 17, Mg 1.1, phos 4.9; mild leukocytosis 10.6, normocytic anemia H/H 8.5/26.2 (baseline 9.4/29.4) , MCV 89, plts 237, normal coags. LFTs with elevated alk phos 124 otherwise within normal limits. - UA showed few bacteria, 24 WBC, large leuks, small blood, 300 protein, negative ketones. - Imaging: Pelvic ultrasound showed: Heterogeneous endometrium with fluid in the endometrial canal. - OBGYN was consulted for vaginal bleeding who recommended outpatient endometrial biopsy for post-menopausal bleeding. - Vitals prior to transfer: 98.5 81 126/68 14 100% RA On arrival to the floor, pt has no complaints. Describes feeling tired, but no other complaints. Past Medical History: CKD HTN DM (sees Podiatry at ___, see ophthalmology at ___) hyperlipidemia obesity History of palpitations Cholecystectomy surgery in ___ Colonoscopy ___ normal: repeat ___ years Social History: ___ Family History: +diabetes, +colon CA, -heart disease, +ovarian CA Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.1 145/79 81 18 100% on RA GEN: NAD, pleasant, surrounded by family, picking at a sandwich HEENT: MMM, anicteric sclera, no conjunctival pallor NECK: Supple without LAD PULM: CTAB COR: RRR, no murmurs ABD: obese, NT, ND, normal BS GYN: deferred, given family members and recent exam in ED EXTREM: Warm, no edema NEURO: CN II-XII grossly intact, upper and lower extremity strength symmetrical and intact, mild short term memory impairment DISCHARGE PHYSICAL EXAM: VS: 98.3 160/81 80 18 100% RA GEN: NAD, pleasant, NAD HEENT: MMM, anicteric sclera, no conjunctival pallor NECK: Supple without LAD PULM: CTAB COR: RRR, no murmurs ABD: obese, NT, ND, normal BS EXTREM: Warm, no edema NEURO: CN II-XII grossly intact, upper and lower extremity strength symmetrical and intact Pertinent Results: ADMISSION LABS: ___ 12:05PM BLOOD WBC-10.6* RBC-2.96* Hgb-8.5*# Hct-26.2*# MCV-89 MCH-28.7 MCHC-32.4 RDW-12.9 RDWSD-41.0 Plt ___ ___ 12:05PM BLOOD Neuts-61.4 ___ Monos-7.0 Eos-4.3 Baso-0.5 Im ___ AbsNeut-6.51* AbsLymp-2.80 AbsMono-0.74 AbsEos-0.46 AbsBaso-0.05 ___ 12:05PM BLOOD Glucose-91 UreaN-74* Creat-4.3*# Na-143 K-4.9 Cl-110* HCO3-17* AnGap-21 ___ 12:05PM BLOOD ALT-14 AST-16 AlkPhos-124* TotBili-0.2 ___ 12:05PM BLOOD Albumin-3.6 Calcium-8.0* Phos-4.9*# Mg-1.1* ___ 12:05PM BLOOD TSH-3.2 DISCHARGE LABS: ___ 07:30AM BLOOD WBC-8.7 RBC-2.83* Hgb-8.3* Hct-25.3* MCV-89 MCH-29.3 MCHC-32.8 RDW-12.9 RDWSD-41.4 Plt ___ ___ 07:30AM BLOOD Glucose-79 UreaN-64* Creat-4.1* Na-144 K-4.7 Cl-111* HCO3-19* AnGap-19 ___ 07:30AM BLOOD ALT-15 AST-19 AlkPhos-121* TotBili-0.2 ___ 07:30AM BLOOD Albumin-3.3* Calcium-7.7* Phos-4.9* Mg-1.0* IMAGING: IMAGING: ___: Pelvic Ultrasound: Preliminary Report Heterogeneous endometrium with fluid in the endometrial canal. Ovaries are not visualized however there are no adnexal masses identified. No free fluid in the pelvis. RECOMMENDATION(S): Endometrial biopsy when clinically appropriate Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vitamin D ___ UNIT PO DAILY 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 3. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM 4. Glargine 19 Units Bedtime Insulin SC Sliding Scale using novolog Insulin 5. Epoetin ___ ___ units SC Q5 WEEKS 6. Atorvastatin 40 mg PO QPM 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Allopurinol ___ mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Amlodipine 5 mg PO DAILY 11. Potassium Chloride 20 mEq PO DAILY 12. GlipiZIDE 10 mg PO BID 13. Acetaminophen 325 mg PO DAILY 14. Torsemide 10 mg PO DAILY Discharge Medications: 1. Acetaminophen 325 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. Amlodipine 5 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM 9. Torsemide 10 mg PO DAILY 10. Vitamin D ___ UNIT PO DAILY 11. Sodium Bicarbonate 650 mg PO BID RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 12. Epoetin ___ ___ units SC Q5 WEEKS 13. GlipiZIDE 10 mg PO BID 14. Potassium Chloride 20 mEq PO DAILY 15. Outpatient Lab Work Please have electrolytes drawn ___ and have then sent to PCP: Dr. ___: ___ Fax: ___ ICD10: CKD N18.5 16. Glargine 19 Units Bedtime Insulin SC Sliding Scale using novolog Insulin Discharge Disposition: Home Discharge Diagnosis: Postmenopausal bleeding Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: PELVIS U.S., TRANSVAGINAL INDICATION: History: ___ with vaginal bleeding/tenderness // acut eprocess TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: Pelvic ultrasound on ___ FINDINGS: The uterus is anteverted and measures 7.3 x 2.7 x 5.4 cm. The endometrial canal is distended with fluid and the split endometrial thickness measures 6 mm. There is no increased vascularity within the surrounding endometrium, no discrete mass identified. The ovaries are not visualized. No adnexal masses are identified. There is no free fluid in the pelvis. IMPRESSION: Heterogeneous, thickened endometrium with fluid in the endometrial canal. Ovaries are not visualized however there are no adnexal masses identified. No free fluid in the pelvis. RECOMMENDATION(S): In this postmenopausal patient with bleeding and thickened heterogeneous appearance of the endometrium, further correlation with endometrial sampling is recommended. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: BLOOD FROM VAGINA Diagnosed with Acute kidney failure, unspecified, Abnormal uterine and vaginal bleeding, unspecified temperature: 98.4 heartrate: 100.0 resprate: 18.0 o2sat: 99.0 sbp: 169.0 dbp: 82.0 level of pain: 0 level of acuity: 3.0
You were admitted for vaginal bleeding and weakness. You had an ultrasound of the uterus which showed thickened endometrium which is abnormal. You should contact gynecology clinic to schedule a biopsy of the endometrium. On admission you felt well and did not have further episodes of heavy bleeding or clots, and your blood counts were stable. You felt at you baseline but were found to have low magnesium and low bicarbonate which were repleted. You should continue the bicarbonate supplement at home and have your labs rechecked on ___.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: iron Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with PMH of afib on coumadin, diastolic heart failure, and known bradycardia (previously considered for pacemaker) who presents from home with AMS and ongoing bradycardia. Pt. has several admissions and evaluations leading up to this presentation that are summarized below: Pt. was recently admitted to ___ from ___ to ___ with cough found to have a COPD exacerbation. Pt. was treated empirically with vanc/cefepime later transitioned to prednisone 40mg ___nd azithromycin 5 day course (day 1 ___. Pt. was also noted to have frequent ventricular ectopy and bradycardia on telemetry (HRs to ___ with coughing episodes). She was noted to be asymptomatic during these episodes, thought to be ___ increased vagal tone ___ to coughing. Hospital course was also complicated by delirium in the setting of baseline dementia. She also was recently seen in the ED following prior admission with lip swelling treated with benadryl, prednisone (4 day course), and H2-blocker with improvement (ED course complicated by SBPs in 200s). She was then seen in ED with episode of chest pain. Pt. had negative troponins with no significant changes seen on EKG. She was noted to have bradycardia on this eval. She had a normal head CT. Per pt's daughter, since time of original ___ admission, pt. has not regained her baseline functioning. She remains weak and was noted to have ongoing cough and ___ production over the most recent several days. She also endorses more confusion in her mother. Other than these symptoms, pt. has not complained of lightheadedness, dizziness, chest pain, SOB, orthopnea, PND, palpitations, N/V/D, abdominal pain, or muscle aches. She does note decreased urinary frequency and some constipation. She also does note ongoing exudative type drainage from her mouth. This began following first ED evaluation for lip swelling. This was in the setting of new changes in vision over the last 2 weeks per the pt. On day of presentation, pt. was noted to be unarousable, sitting at breakfast table unresponsive. Pt's daughter checked vital signs at this time which revealed HR 50-60, BP 140-150/60-70, Sat 98%. Pt. unresponsive episode lasted on the order of approximately 1 hour. She was transferred to the ED via EMS who noted her blood glucose to be at 128. In the ED, initial vitals were 98.3, 120, 121/66, 18, 99% on RA. Pt. was with HRs in ___ following commands, alert, oriented, but drowsy. She was then noted to have symptomatic bradycardia with HRs in ___. EKG at this time revealed afib with delayed ventricular conduction. UA reveals negative leuks, negative nitrites, 30 protein, trace hematuria. Labs notable for bicarb 33, lactate 2.0, WBC 6.8, Hct 44.7. Pt. received atropine with improvement bradycardia. ___ revealed no acute intracranial process. Blood cx. and Urine cx were sent. Pt. was transferred to cardiology for further evaluation. Past Medical History: Afib on coumadin COPD with 2 liters home O2 Heart Failure with Preserved EF Osteoarthritis Right cerebellar infarct found incidentally, never symptomatic ___ disease HTN h/o PE Pulmonary embolism ___ ___reaking her L shoulder Hospitalization at ___ for UTI - Prior UTI with VRE and MRSA Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================= VS: 98.2, 152/85, 66 (___), 22, 100% on RA General: NAD, somnolent but arousable to voice, answers questions appropriately HEENT: NCAT, pupils minimally reactive to light, no evidence of conjunctival inflammation, evidence of superficial oral mucosal and oropharynx ulceration with minimal lower lip swelling Neck: Supple, no LAD, JVP 8cm CV: Irregular, S1/S2, no m/r/g/c Lungs: Poor respiratory effort, limited exam, otherwise CTAB with decreased breath sounds at the bases Abdomen: Soft, NT, ND, +BS, no rebound or guarding GU: Foley in place Ext: WWP, no ___ edema, 2+ DP pulses Neuro: moving all extremities, exam limited by pt's ability to follow commands appropriately, sensation intact light touch all extremities DISCHARGE PHYSICAL EXAMINATION: ================================= VS: 98.1, 145/74, 61 afib, 18, 96% on RA General: NAD, intermittently somnolent but arousable to voice, oriented to person, intermittently to place and time HEENT: NCAT, pupils minimally reactive to light, no evidence of conjunctival inflammation, healing lip and oropharynx ulcerations Neck: Supple, no LAD, JVP 8cm CV: Irregular, Bradycardic, S1/S2, no m/r/g/c Lungs: Poor respiratory effort, limited exam, otherwise CTAB Abdomen: Soft, NT, ND, +BS, no rebound or guarding GU: Foley in place Ext: WWP, no ___ edema, 2+ DP pulses Neuro: moving all extremities, exam limited by pt's ability to follow commands appropriately, sensation intact light touch all extremities Pertinent Results: ADMISSION LABS ================= ___ 11:54AM BLOOD WBC-6.8 RBC-4.29 Hgb-13.6 Hct-44.7 MCV-104* MCH-31.8 MCHC-30.5* RDW-16.0* Plt ___ ___ 11:54AM BLOOD Neuts-82.8* Lymphs-8.9* Monos-5.4 Eos-2.6 Baso-0.3 ___ 06:45AM BLOOD ___ PTT-43.0* ___ ___ 11:54AM BLOOD Glucose-129* UreaN-23* Creat-0.9 Na-133 K-7.8* Cl-96 HCO3-32 AnGap-13 ___ 11:54AM BLOOD ALT-34 AST-108* LD(LDH)-1169* AlkPhos-49 TotBili-0.4 ___ 11:54AM BLOOD Albumin-3.4* ___ 11:59AM BLOOD Glucose-124* Lactate-2.0 Na-140 K-4.2 Cl-93* calHCO3-33* NOTABLE LABS ============= ___ 06:45AM BLOOD WBC-8.7 RBC-4.05* Hgb-12.8 Hct-42.4 MCV-105* MCH-31.7 MCHC-30.2* RDW-16.1* Plt ___ ___ 06:15AM BLOOD WBC-6.0 RBC-3.59* Hgb-11.9* Hct-36.9 MCV-103* MCH-33.3* MCHC-32.4 RDW-15.7* Plt ___ ___ 05:50AM BLOOD WBC-4.8 RBC-3.92* Hgb-12.6 Hct-41.0 MCV-105* MCH-32.2* MCHC-30.7* RDW-16.3* Plt ___ ___ 06:45AM BLOOD ___ PTT-45.9* ___ ___ 06:15AM BLOOD ___ PTT-45.2* ___ ___ 06:45AM BLOOD ___ PTT-45.9* ___ ___ 05:50AM BLOOD ___ PTT-45.6* ___ ___ 06:45AM BLOOD Glucose-76 UreaN-20 Creat-0.9 Na-144 K-3.6 Cl-99 HCO3-38* AnGap-11 ___ 06:15AM BLOOD Glucose-95 UreaN-22* Creat-0.9 Na-143 K-3.8 Cl-103 HCO3-35* AnGap-9 ___ 05:50AM BLOOD Glucose-87 UreaN-14 Creat-0.7 Na-141 K-3.8 Cl-100 HCO3-33* AnGap-12 ___ 06:45AM BLOOD VitB12-1239* Folate-14.8 ___ 06:10AM BLOOD Homocys-13.2 ___ 06:45AM BLOOD TSH-1.9 ___ 05:26AM BLOOD Type-ART pO2-109* pCO2-53* pH-7.40 calTCO2-34* Base XS-6 DISCHARGE LABS ================= ___ 06:10AM BLOOD WBC-4.2 RBC-3.77* Hgb-12.4 Hct-37.4 MCV-99* MCH-32.9* MCHC-33.2 RDW-15.9* Plt ___ ___ 06:10AM BLOOD ___ PTT-43.5* ___ ___ 06:10AM BLOOD Glucose-78 UreaN-13 Creat-0.7 Na-139 K-3.6 Cl-101 HCO3-30 AnGap-12 ___ 06:10AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9 STUDIES =========== ECG (___): Atrial fibrillation with slow ventricular response and a narrow QRS complex. Leftward axis. Non-specific repolarization abnormalities. Compared to the previous tracing of ___ the ventricular response in atrial fibrillation has slowed further. CXR (___): IMPRESSION: No evidence of acute cardiopulmonary disease. CT HEAD (___): IMPRESSION: Stable areas of atrophy, encephalomalacia, and white matter disease. No evidence of acute process. MRA BRAIN AND NECK W/O CONTRAST (___): MR brain: There is no acute infarct or intracerebral hemorrhage. A chronic right cerebellar infarct is again noted. Principal intracranial vascular flowvoids are preserved. No extra-axial blood or fluid collection is present. The ventricles and sulci are prominent, consistent with age related involutional changes. Mild small vessel ischemic disease is seen. No diffusion abnormality is detected. No intracranial mass is identified. MRA brain and neck: MRA is limited due to patient motion. Normal flow is seen in the bilateral ICAs and MCAs, but the peripheral branches of these vessels cannot be evaluated. The distal left vertebral artery is not visualized on this exam and is probably congenitally small. Limited evaluation is performed of the neck vessels with 2D time-of-flight, which demonstrates no high-grade stenosis or occlusion. IMPRESSION: 1. No acute intracranial process. 2. Limited MRA due to patient motion. No high-grade stenosis or occlusion detected. MICRO ======== Blood Cultures: All returned negative Urine Culture ___ and ___: No growth final Radiology Report CHEST RADIOGRAPH HISTORY: Altered mental status. COMPARISONS: ___ and ___. TECHNIQUE: Chest, AP upright portable. FINDINGS: The cardiac, mediastinal and hilar contours appear stable. Lung volumes remain low. Minimal opacification at each lung base suggests minor atelectasis. Otherwise, the lungs appear clear. There are no pleural effusions or pneumothorax. IMPRESSION: No evidence of acute cardiopulmonary disease. Radiology Report HEAD CT HISTORY: Altered mental status. COMPARISONS: ___. TECHNIQUE: Non-contrast head CT. FINDINGS: Areas of volume loss in the brain, most noteworthy along the left frontal and temporal lobes as well as in the right cerebellar hemisphere, appear stable, in addition to more generalized background atrophy. Patchy but substantial areas of white matter hypodensity in the white matter of cerebral hemispheres appear unchanged. The degree of ventricular dilatation appears stable and not probably out of proportion to the extent of generalized atrophy. Volume loss is also striking in the anterior temporal lobes and along the cerebellum. There is no evidence for intracranial hemorrhage. The mastoid air cells appear clear. The visualized paranasal sinuses also appear clear. Cavernous carotid and vertebral artiers calcifications are prominent. There has been no significant change. IMPRESSION: Stable areas of atrophy, encephalomalacia, and white matter disease. No evidence of acute process. Radiology Report EXAMINATION: MRI AND MRA BRAIN AND MRA NECK INDICATION: ___ year old woman with history of past strokes and ___ now admitted with episode of unresponsiveness // new stroke, also looking for evidence of MSA TECHNIQUE: Mr imaging of the brain and MRA imaging of the brain and neck were performed. Sequences include axial FLAIR, axial MRA 3D TOF, sagittal T1, axial T2, axial GRE, axial MRA 2D TOF, and diffusion imaging. . COMPARISON: Comparison is made with CT head from ___ and MR head from ___. FINDINGS: MR brain: There is no acute infarct or intracerebral hemorrhage. A chronic right cerebellar infarct is again noted. Principal intracranial vascular flow voids are preserved. No extra-axial blood or fluid collection is present. The ventricles and sulci are prominent, consistent with age related involutional changes. Mild small vessel ischemic disease is seen. No diffusion abnormality is detected. No intracranial mass is identified. MRA brain and neck: MRA is limited due to patient motion. Normal flow is seen in the bilateral ICAs and MCAs, but the peripheral branches of these vessels cannot be evaluated. The distal left vertebral artery is not visualized on this exam and is probably congenitally small. Limited evaluation is performed of the neck vessels with 2D time-of-flight, which demonstrates no high-grade stenosis or occlusion. IMPRESSION: 1. No acute intracranial process. 2. Limited MRA due to patient motion. No high-grade stenosis or occlusion detected. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Weakness, ALT MS Diagnosed with CARDIAC DYSRHYTHMIAS NEC, ALTERED MENTAL STATUS temperature: 98.3 heartrate: 120.0 resprate: 18.0 o2sat: 99.0 sbp: 121.0 dbp: 66.0 level of pain: 0 level of acuity: 1.0
Ms. ___, It was a pleasure meeting and caring for you during your most recent hospitalization at ___. You were admitted with an episode of unresponsiveness witnessed by your daughter. Once you were admitted, we found that you have a slow heart rate which you told us has been known about for a long time. We asked the cardiologists and the neurologists to evaluate you. The cardiologists did not believe that your slow heart rate was related to your symptoms. Following an extensive evaluation, we felt that your symptoms were probably the result of ongoing confusion known as delirium (a common condition we see in elderly patient's) or possibly due to a condition called ___ Body Dementia. Please continue to follow-up with your outpatient doctors. We wish you a speedy recovery. All the best, Your ___ Care Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Adefovir / sulfamethoxazole-trimethoprim / sotalol / levetiracetam Attending: ___ Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old ___ speaking man with h/o ESRD (on HD ___, ESLD (s/p liver transplant ___, on cyclosporine), Afib (on ASA), T1DM, CAD, recent upper GIB (___) and previous subdural hematoma with neurologic deficits (___), recent admission ___, AMS and petechial rash, found to have sepsis with MRSA bacteremia. The most likely source of the patient's bacteremia was thought to be bacterial seeding through his HD graft during HD. By report from ___ patient has had a "change in mental status, refusing meds, meals, and fluids," for the past several days. On ___ patient pulled out tubing, dialysis session was unable to be finished. He is on cyclosporine for immunosuppression. Blood sugars 200s. Discussed with RN in ___ at ___, states the patient has been refusing any medications, food, has been intermittently agitated while getting IVs and dialysis. He has been very withdrawn and not speaking. Fall last week, fell on backside, no headstrike or LOC. The ED also had a discussion with patient her ___ interpreter, patient endorses depression but denies suicidality. He does state that he does not want an IV or any treatment. The ED also discussed in detail with the patient's son, ___. The patient's son reports that his father has been refusing care but has not been expressing any depression or suicidal thoughts to him. Psych was consulted, felt that patient does not have capacity due to delirium. In the ED, initial vitals: 98.0 60 187/81 16 100% RA - Exam notable for: Dry MM, Abd soft, non-distended, mild epigastric tenderness, no focal neuro deficits. - Labs notable for: h/h 9.1/27.9, plt 72, creat 5.2, BUN 32, bicarb 21, AG 19, lactate 1.0, UA 182 WBC, lg leuks - Imaging notable for: CT head limited study but no obvious bleeding, CXR no acute cardiopulmonary process, moderate compression of a vertebral body at thoracolumbar junction of indeterminate age. - RUQUS also ordered with read pending - Patient given: Lorazepam 2 mg, 1L nS, acetominphen 1 g, Cefepime 2g, Vancomycin 1 g. The patient was seen by psych who felt that due to delirium the patient lacked capacity and HCP should be invoked. - The patient was also seen by hepatology who recommended obtaining RUQUS and admitting to ___. - Vitals prior to transfer: 97.5 54 169/85 18 99%RA Of note, the patient was admitted in ___ to ___ for MRSA bacteremia thought to be due to seeding from HD graft. TTE and TEE were both negative for vegetations. He was continued on vancomyin dosed by level after HD, with a plan to continue through ___ with goal vancomycin level ___. He followed up with OPAT/ ID clinic. On arrival to the floor, pt somnolent, arousable, unable to participate in questions Past Medical History: Afib on aspirin; Coumadin held given ___ CAD: cardiac cath in ___ w/ 40% mid LAD and 40% diagonal stenoses. Circumflex with 40-50% mid stenosis; RCA with mild diffuse disease; 50% PDA stenosis. DM type 1 SDH ___ with severe neurologic deficits (mostly nonverbal) S/p tracheostomy ESRD on HD Hx of liver transplant ___ Hx of seizures S/p inguinal hernia repair (3x Left, 2x Right) Papillary thyroid CA, s/p hemithyroidectomy ___ GERD HTN CVA Social History: ___ Family History: No family history of hepatocellular carcinoma or cirrhosis, diabetes. 4 adult children, all in good health. Brother with cardiac problems Physical Exam: ADMISSION PHYSICAL EXAM ================= Vitals: 97.5 153/82 HR 61 18 99 RA General: somnolent, arousable, unable to follow commands HEENT: Sclera anicteric, dry MM, oropharynx clear, neck supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally in anterolateral lung fields, 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. Abdominal scar noted GU: condom cath in place Ext: Warm, well perfused, no cyanosis or edema. ___ AVG noted Skin: Without rashes or lesions Neuro: +withdrawal to pain, good tone DISCHARGE PHYSICAL EXAM ================= Vitals: 98.5 145/72 54 16 99%RA General: awake, says he feels good this AM HEENT: Sclera anicteric, dry MM, oropharynx clear, neck supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally in anterolateral lung fields, no wheezes, rales, rhonchi CV: RRR, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Abdominal scar noted Ext: no cyanosis or edema. LUE AVG noted Skin: Without rashes or lesions Neuro: moving all extremities symmetrically Pertinent Results: ADMISSION LABS =========== ___ 11:30PM ___ PTT-24.8* ___ ___ 11:30PM NEUTS-64.4 ___ MONOS-7.2 EOS-7.0 BASOS-0.2 IM ___ AbsNeut-2.67 AbsLymp-0.87* AbsMono-0.30 AbsEos-0.29 AbsBaso-0.01 ___ 11:30PM WBC-4.2# RBC-2.93* HGB-9.1* HCT-27.9* MCV-95 MCH-31.1 MCHC-32.6 RDW-15.0 RDWSD-51.7* ___ 11:30PM ALBUMIN-3.4* CALCIUM-8.2* PHOSPHATE-7.0* MAGNESIUM-2.5 ___ 11:30PM LIPASE-10 ___ 11:30PM ALT(SGPT)-7 AST(SGOT)-17 ALK PHOS-58 TOT BILI-0.4 ___ 11:30PM GLUCOSE-125* UREA N-38* CREAT-5.2* SODIUM-136 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-21* ANION GAP-23* ___ 12:09AM LACTATE-1.0 ___ 12:30AM URINE RBC-9* WBC->182* BACTERIA-MOD YEAST-NONE EPI-0 ___ 12:30AM URINE BLOOD-SM NITRITE-NEG PROTEIN-300 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG MICROBIOLOGY: ___ Blood culture --> Negative. URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. Cefepime > 16 MCG/ML sensitivity testing performed by Microscan. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- 32 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING: CXR ___: No acute cardiopulmonary process. Moderate compression of a vertebral body at thoracolumbar junction of indeterminate age, this level was not well seen on prior studies. CT Head ___: 1. Severely motion limited examination. 2. No gross intracranial hemorrhage. CT HEAD WITHOUT CONTRAST ___ Redemonstrated right putaminal and adjacent white matter chronic lacune, unchanged since multiple prior exams. There is no evidence of recent infarction or of hemorrhage. TTE ___ The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal to mid inferior wall, inferolateral wall, and mid to distal anterolateral wall . The remaining segments contract normally (LVEF = 40 %). Doppler parameters are indeterminate for left ventricular diastolic function. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. 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. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild left ventricular cavity dilation with regional systolic dysfunction c/w CAD. Mildly dilated right ventricular cavity size with mild global systolic dysfunction. Moderate mitral regurgitation. Dilated aortic root. Pulmonary hypertension. Compared with the prior study (images reviewed) of ___, pulmonary pressures are higher. DISCHARGE LABS =========================================== ___ 06:30AM BLOOD WBC-2.3* RBC-3.02* Hgb-9.2* Hct-28.4* MCV-94 MCH-30.5 MCHC-32.4 RDW-14.6 RDWSD-49.8* Plt Ct-63* ___ 06:30AM BLOOD ___ PTT-30.1 ___ ___ 06:30AM BLOOD Glucose-99 UreaN-43* Creat-5.1*# Na-135 K-4.7 Cl-93* HCO3-28 AnGap-19 ___ 06:30AM BLOOD ALT-22 AST-15 AlkPhos-69 TotBili-0.5 ___ 06:30AM BLOOD Calcium-9.2 Phos-6.6* Mg-2.7* ___ 10:08AM BLOOD HBsAg-Negative HBsAb-Negative HBcAb-Positive* Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Calcium Acetate 667 mg PO TID W/MEALS 5. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QFRI 6. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H 7. Entecavir 0.5 mg PO 1X/WEEK (___) 8. FoLIC Acid 1 mg PO 3X/WEEK (___) 9. Isosorbide Dinitrate 40 mg PO TID 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 11. LevETIRAcetam 250 mg PO BID 12. Pantoprazole 40 mg PO Q24H 13. Senna 8.6 mg PO QHS 14. Sertraline 25 mg PO DAILY 15. Vitamin D 1200 UNIT PO DAILY 16. sevelamer CARBONATE 800 mg PO TID W/MEALS 17. Levothyroxine Sodium 100 mcg PO DAILY 18. Nitroglycerin Ointment 2% 2 in TP DAILY:PRN SBP>160 19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 20. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 21. Lidocaine 5% Patch 1 PTCH TD QAM 22. Amoxicillin-Clavulanic Acid ___ mg PO Q24H UTI 23. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID 24. Vancomycin 1000 mg IV HD PROTOCOL 25. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 26. Lisinopril 30 mg PO QHS 27. Metoprolol Tartrate 50 mg PO Q6H 28. Glargine 10 Units Bedtime Humalog 3 Units Breakfast Humalog 3 Units Lunch Humalog 3 Units Dinner Discharge Medications: 1. Sulfameth/Trimethoprim SS 1 TAB PO BID last day antibiotic: ___. Glargine 10 Units Bedtime Humalog 3 Units Breakfast Humalog 3 Units Lunch Humalog 3 Units Dinner 3. Senna 8.6 mg PO BID:PRN constipation 4. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 5. Amlodipine 10 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 10 mg PO QPM 8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 9. Calcium Acetate 667 mg PO TID W/MEALS 10. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID 11. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QFRI 12. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H 13. Entecavir 0.5 mg PO 1X/WEEK (___) 14. FoLIC Acid 1 mg PO 3X/WEEK (___) 15. Isosorbide Dinitrate 40 mg PO TID 16. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 17. LevETIRAcetam 250 mg PO BID 18. Levothyroxine Sodium 100 mcg PO DAILY 19. Lidocaine 5% Patch 1 PTCH TD QAM 20. Metoprolol Tartrate 50 mg PO Q6H 21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 22. Pantoprazole 40 mg PO Q24H 23. Sertraline 25 mg PO DAILY 24. sevelamer CARBONATE 800 mg PO TID W/MEALS please use powder formulation 25. Vitamin D 1200 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Toxic metabolic encephalopathy Urinary tract infection Secondary: HBV cirrhosis s/p liver transplant ___ ESRD Hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with generalized abd pain, hx liver transplant // Eval for acute process 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, 18.5 cm; CTDIvol = 48.9 mGy (Head) DLP = 903.1 mGy-cm. 2) Sequenced Acquisition 5.0 s, 10.6 cm; CTDIvol = 47.3 mGy (Head) DLP = 501.7 mGy-cm. Total DLP (Head) = 1,405 mGy-cm. COMPARISON: Noncontrast CT of the head from ___. . FINDINGS: Severely motion limited examination. There is no evidence of hemorrhage or ovaries infarction. Ventricles periventricular white matter hypodensities appear unchanged. Again seen is a right putaminal and adjacent white matter chronic lacune, unchanged since ___ No osseous abnormalities seen. IMPRESSION: 1. Severely motion limited examination. 2. In the left pons without large or recent infarction. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with recent fall, AMS, hx of subdural hematoma // ? ICH TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.8 s, 16.5 cm; CTDIvol = 51.4 mGy (Head) DLP = 848.0 mGy-cm. Total DLP (Head) = 848 mGy-cm. DLP: Acquisition sequence: 1) Sequenced Acquisition 4.8 s, 16.5 cm; CTDIvol = 51.4 mGy (Head) DLP = 848.0 mGy-cm. Total DLP (Head) = 848 mGy-cm. COMPARISON: CT head without contrast ___ FINDINGS: There is no evidence of hemorrhage, edema, or mass. Again seen is a right putaminal and adjacent white matter chronic lacune, unchanged since multiple prior exams. There is no evidence of recent infarct. There is prominence of the ventricles and sulci in an atrophic pattern, unchanged. Ill-defined periventricular and subcortical white matter hypodensities are nonspecific but likely due to the chronic sequela of small-vessel ischemic disease. The basilar cisterns remain patent. Atherosclerotic calcifications are seen in the bilateral carotid siphons. 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. Redemonstrated right putaminal and adjacent white matter chronic lacune, unchanged since multiple prior exams. There is no evidence of recent infarction or of hemorrhage. Gender: M Race: ASIAN - SOUTH EAST ASIAN Arrive by WALK IN Chief complaint: Altered mental status Diagnosed with Urinary tract infection, site not specified, Altered mental status, unspecified temperature: 98.0 heartrate: 60.0 resprate: 16.0 o2sat: 100.0 sbp: 187.0 dbp: 81.0 level of pain: unable level of acuity: 3.0
Dear Mr. ___, It was a pleasure taking care of you during your hospitalization at the ___. You were admitted to ___ because you were more confused than usual. This is likely because you had a urinary tract infection. We gave you antibiotics to treat the infection and your mental status improve back to your regular baseline. You also received dialysis for your kidney disease while you were hospitalized. We had a family meeting with your wife and your son, ___, to discuss the next best step with you. The neurology (brain) doctor, explained that your mental status may not get much better than it is now. We recommend that you follow up with a urologist (urinary tract doctor) to evaluate the cause of your frequent urinary tract infections. We also recommend that you talk to your primary care doctor and liver doctor about whether or not you need a feeding tube for nutrition. If you have fevers, chills, worsening confusion, or any symptoms that concern you, please seek medical attention. We wish you the best of luck in your health. Sincerely, Your ___ care team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Increased oral secretions Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old young woman with a past medical history of cerebral palsy who presents with increased mucous production for the past 2 weeks. She is non-verbal and is accompanied by her father who serves as the historian. She does have oral secretions at baseline, managed successfully as an outpatient with ranitidine. However, over the past two weeks she has had an increase sputum production with a mild cough and associated chest tightness. He has tried over the count expectorants with intermittent improvement throughout the past two weeks. However, the mucous production was more pronounced today, which prompted him to bring his daughter to the ___. There is no associated wheezing or shortness of breath. There is no nausea or vomiting. There are no sick contacts. He notes that she has maintained her appetite and there has been no decreased PO intake at home. No change in urination/color/appearance. There is no history of DVT/PE in the patient or in the family. The patient is wheelchair bound and thus relatively immobile. Initial vitals in the ___ 100.2 130 136/89 25 98% RA EKG revealed sinus tachycardia at 137. Lactate notable for 3.9 and she received 2L IVF. Preliminary read of ___ did not reveal evidence of pneumonia. She received 1g ceftriaxone and a flu swab was sent. On the floor, Vitals were: T99.2 P ___ BP 139/92 R22 O2 sat 98% RA Review of sytems: Obtained via patient's father (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion.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: Anemia Cerebral palsy Constipation Eczema Secondary amenorrhea Social History: ___ Family History: Mother with diabetes Father with hypertension Physical Exam: ON ADMISSION: General: Young woman lying in bed appearing uncomfortable, non-verbal at baseline but groaning, mildly diaphoretic HEENT: Sclera anicteric, MMM, oropharynx clear, increased saliva in oral cavity Neck: supple, JVP not elevated, no LAD Lungs: Exam limited due to limited participation but no clear rhonchi or wheezes CV: Tachycardic, no m/r/g 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, contractures in wrists and arms bilaterally Skin: Mildly diaphoretic Neuro: Non-verbal at baseline ON DISCHARGE: General: Young woman lying in bed appearing comfortable and smiling HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Exam limited due to limited participation but no clear rhonchi or wheezes CV: Tachycardic, no m/r/g 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, contractures in wrists and arms bilaterally Skin: Dry, no lesions or rashes Neuro: Non-verbal at baseline Pertinent Results: ON ADMISSION: ___ 02:00PM BLOOD WBC-9.4 RBC-5.14 Hgb-11.0* Hct-38.0 MCV-74* MCH-21.3* MCHC-28.8* RDW-15.5 Plt ___ ___ 02:00PM BLOOD Neuts-86.0* Lymphs-10.5* Monos-2.2 Eos-1.0 Baso-0.2 ___ 02:00PM BLOOD Glucose-157* UreaN-4* Creat-0.6 Na-137 K-4.8 Cl-100 HCO3-23 AnGap-19 ___ 02:00PM BLOOD Calcium-9.4 Phos-2.5* Mg-2.2 PERTINENT INTERVAL: ___ 02:14PM BLOOD Lactate-3.9* ___ 04:17PM BLOOD Lactate-3.2* ___ 07:16AM BLOOD Lactate-1.0 ___ 10:50AM BLOOD Na-141 K-3.2* Cl-107 ___ 05:20PM BLOOD Na-139 K-3.8 Cl-105 ON DISCHARGE: ___ 06:15AM BLOOD WBC-7.2 RBC-4.18* Hgb-9.2* Hct-30.4* MCV-73* MCH-22.0* MCHC-30.3* RDW-15.2 Plt ___ ___ 05:20PM BLOOD Na-139 K-3.8 Cl-105 IMAGING: ___ Baseline artifact. Sinus tachycardia. Non-specific ST-T wave changes. No previous tracing available for comparison. IntervalsAxes ___ ___ ___ CXR ___ IMPRESSION: Limited examination. No evidence of acute cardiopulmonary process. ___ LENIs IMPRESSION: No evidence of lower extremity deep venous thrombosis in either the right or the left lower extremity. ___ CTA Chest 1. No evidence of pulmonary embolism. 2. Endoluminal filling defects seen within the right lower lobe bronchi, particularly within the posterior and lateral basilar bronchopulmonary segments. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrocortisone Cream 2.5% 1 Appl TP BID PRN pruritis 2. MedroxyPROGESTERone Acetate 10 mg PO DAILY 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation 4. Ranitidine 150 mg PO BID 5. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Hydrocortisone Cream 2.5% 1 Appl TP BID PRN pruritis 2. Polyethylene Glycol 17 g PO DAILY:PRN constipation 3. Ranitidine 150 mg PO BID 4. Vitamin D ___ UNIT PO DAILY 5. Azithromycin 250 mg PO Q24H RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 6. MedroxyPROGESTERone Acetate 10 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Increased oral secretions Endobronchial plugging Tachycardia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report PORTABLE CHEST, ___. HISTORY: ___ female with cough. COMPARISON: None. FINDINGS: Single portable view of the chest. Slight limitation due to shells and cardiac wires overlying the patient's chest. The lungs appear grossly clear. Cardiomediastinal silhouette is normal. No acute osseous abnormalities identified. IMPRESSION: No visualized acute cardiopulmonary process. Radiology Report INDICATION: ___ female with cough and fever. Please perform a lateral view to evaluate for pneumonia. COMPARISON: Frontal chest radiograph performed approximately one hour prior to this exam. TECHNIQUE: A leftward rotated AP view and a lateral view of the chest were obtained. FINDINGS: The frontal view is extremely rotated to the left, with complete projection of the mediastinum over the left lung, which limits assessment. The expanded right lung is unremarkable. Assessment in the lateral view is also limited due to superimposition of the arms, but allowing for technical limitations, there is no spine sign, pleural effusion, or abnormality in the anterior mediastinum. No pneumothorax is identified. Artifacts from external hair devices are again seen. IMPRESSION: Limited examination. No evidence of acute cardiopulmonary process. Radiology Report HISTORY: ___ woman with tachycardia. TECHNIQUE: Grayscale, color Doppler, and spectral analysis of the venous system of both lower extremities was performed. COMPARISON: None available FINDINGS: There is normal compression and augmentation of the common femoral veins, proximal, mid and distal superficial femoral veins as well as the popliteal veins in both lower extremities. The peroneal and posterior tibial veins were visualized in both calves and demonstrate wall to wall flow. There is normal phasicity of the common femoral veins bilaterally. IMPRESSION: No evidence of lower extremity deep venous thrombosis in either the right or the left lower extremity. Radiology Report EXAMINATION: CTA chest INDICATION: ___ year old woman with tachycardia // please assess for PE Additional history acquired that the patient has cerebral palsy and has had significant mucus production. TECHNIQUE: CTA of the chest was performed after the administration of IV contrast. 100 mL of Omnipaque was administered for this examination. DOSE: DLP: 235 mGy-cm. COMPARISON: None. FINDINGS: Examination of the pulmonary arterial tree demonstrates no evidence of pulmonary embolism. Evaluation of the aorta demonstrates no acute aortic abnormality. There is a common trunk of the innominate artery and left common carotid artery ("bovine arch"), normal variant. Examination of soft tissue windows demonstrates no evidence of axillary, mediastinal, or hilar lymphadenopathy. An 8 mm right hilar lymph node is seen (series 3, image 44). There is very minimal soft tissue density seen in the anterior mediastinum, consistent with residual thymic tissue, and probably physiologic in a patient of this age. The heart and pericardium appear grossly unremarkable. Examination of the lung windows demonstrate endoluminal filling defects within the right lower lobe lateral and posterior bronchi. In a patient of this age and given the clinical presentation, this is likely mucus plugging. There is no pulmonary consolidation evident. There is some ground-glass opacity and loss of volume involving the left lower lobe, likely due to chest wall morphology. Maximum intensity projection images of the chest and pulmonary arteries confirm these findings. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Endoluminal filling defects seen within the right lower lobe bronchi, particularly within the posterior and lateral basilar bronchopulmonary segments. NOTIFICATION: The findings regarding endobronchial plugging were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 1:55 ___, 5 minutes after discovery of the findings. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Cough, N/V Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED temperature: 100.2 heartrate: 130.0 resprate: 25.0 o2sat: 98.0 sbp: 136.0 dbp: 89.0 level of pain: 13 level of acuity: 1.0
Dear Ms. ___, You were admitted because you had more oral mucous than you normally do and you were having difficulty with these secretions. Your symptoms may have been due to difficulty swallowing or a pneumonia. We will be sending you home with antibiotics to treat a pneumonia. A scan of your chest revealed that you do have mucous build-up in your lungs. We have arranged for you to receive suctioning at home, which will help with these symptoms. We performed some tests to determine if your symptoms are due to the flu. This test has not yet returned. We will discharge you home with a mask until the tests return. Please wear the mask whenever you are in public until we call you with the results. We were also concerned about your fast heart rate. This may have been, in part, the result of dehydration. However, even though you received a lot of fluids, your heart rate was still quite fast. Sometimes this is due to a clot on your lungs. We performed a scan of your chest which did not reveal a clot, but did reveal a build up of mucous in your lungs. The fast heart rate may be your body's response to this mucous build up. We will manage this with suctioning at home. Please continue to take your antibiotics through ___. Please follow up with the appointments listed below. It was a pleasure to be a part of your care! Happy birthday from your ___ treatment team.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left hip fracture Major Surgical or Invasive Procedure: ___: Left TFN History of Present Illness: HPI: ___ female with coronary artery disease, prior STEMI with stent placement and pacemaker placement for cardiac arrest, aortic stenosis with a mean gradient of 17 mmHg (low gradient) who presents after likely mechanical fall at her living facility. The details surrounding the fall are unclear as the patient has some dementia at baseline. In discussing with her son it is likely that she had a mechanical fall. Workup in the ED has been negative. She is currently endorsing pain in the hip. She is denying pain elsewhere. She lives independently with her husband. She is able to walk around the house without any shortness of breath. Past Medical History: PAST MEDICAL HISTORY: -Anemia -Bilateral carotid bruits -Systolic ejection murmur possibly aortic stenosis -Congestive heart failure -Hyperlipidemia -Hypertension -Hyponatremia -Acute myocardial infarction ___ -Cognitive impairment PAST SURGICAL HISTORY: -Pacemaker placement ___ -Pylonidal cyst -Bilateral cataract surgery -Olecranon left side surgery ___ after being hit by a car Social History: ___ Family History: NC Physical Exam: General: Well-appearing, breathing comfortably Pulm: breathing non-labored Abd: soft, non-tender MSK: Left lower extremity: Fires ___ SILT sural, saphenous, superficial peroneal, deep peroneal and tibial distributions Dorsalis pedis pulse 2+ with distal digits warm and well perfused Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. CARVedilol 6.25 mg PO BID 3. Furosemide 20 mg PO DAILY 4. Losartan Potassium 25 mg PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QPM RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous Nightly Disp #*30 Syringe Refills:*0 5. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5 Days Take for 5 total days (last day ___ RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth Every 12 hours Disp #*6 Capsule Refills:*0 6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours as needed Disp #*15 Tablet Refills:*0 7. Senna 8.6 mg PO BID 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 40 mg PO QPM 10. CARVedilol 6.25 mg PO BID 11. Clopidogrel 75 mg PO DAILY 12. Furosemide 20 mg PO DAILY 13. Losartan Potassium 25 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left intertrochanteric femur fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with fall, left hip pain// eval for fx TECHNIQUE: AP view pelvis and AP and lateral views of the left hip and femur COMPARISON: None. FINDINGS: There is a comminuted left intertrochanteric fracture involving the greater and lesser trochanters, and with varus angulation of the left femoral head. No dislocation is seen. There is no fracture of the more distal left femur. Degenerative changes are seen at the pubic symphysis and sacroiliac joints. Severe degenerative changes are seen at the partially imaged lower lumbar spine. Mild to moderate bilateral hip degenerative changes. Partially imaged knee demonstrates narrowing of the medial joint compartment. No definite suprapatellar joint effusion is seen. There are extensive vascular calcifications. There is likely diffuse calcification of the partially imaged distal aorta and proximal bilateral common iliac arteries. Pelvic phleboliths are seen. IMPRESSION: Comminuted, displaced left intertrochanteric fracture, with varus angulation of the femoral head. No fracture of the more distal left femur. Radiology Report INDICATION: History: ___ with fall, eval for traumatic injury, PNA// eval for traumatic injury, PNA TECHNIQUE: Single AP supine portable view of the chest COMPARISON: None. FINDINGS: Dual lead left-sided pacer device is seen with lead extending the expected positions of the right atrium right ventricle. No focal consolidation, large pleural effusion, or evidence of pneumothorax is seen. Cardiac silhouette size is mildly enlarged. Mediastinal contours are unremarkable. Aortic calcifications are seen. There is no pulmonary edema. No displaced rib fracture is identified. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: HIP UNILAT MIN 2 VIEWS LEFT INDICATION: ORIF LEFT HIP IMPRESSION: Spot images are submitted for documentation of an invasive procedure performed under imaging guidance with no radiologist in attendance. For details of the procedure, please refer to the operative report. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: L Hip pain, s/p Fall Diagnosed with Displaced intertrochanteric fracture of left femur, init, Fall same lev from slip/trip w/o strike against object, init temperature: 96.5 heartrate: 74.0 resprate: 18.0 o2sat: 98.0 sbp: 182.0 dbp: 80.0 level of pain: 5 level of acuity: 3.0
Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Weightbearing as tolerated left lower extremity MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - Splint must be left on until follow up appointment unless otherwise instructed. - Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever ___ 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for any new medications/refills. THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB Physical Therapy: Weightbearing as tolerated left lower extremity No other activity or range of motion restrictions Treatments Frequency: Skin staples or sutures to be removed at 2-week follow-up
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: codeine / Penicillins Attending: ___ Chief Complaint: dysarthria, left facial droop Major Surgical or Invasive Procedure: None History of Present Illness: HPI: The patient is a ___ PMHx L frontal lobe infarct (___), L temporal-parietal grade 2 meningioma s/p resection ___, CAD s/p MI, HFpEF, stage III CKD, PAD, HTN, T2DM on insulin, and atrial fibrillation not on AC (unclear reason) who presents with dysarthria and left facial droop. At baseline, patient lives with her daughter and granddaughter. She requires assistance with ADLs but is able to ambulate independently. On the morning of presentation, pt was at her baseline. Her granddaughter left for work at 10a. Shortly thereafter, after 10:30a, her daughter heard a thud upstairs. Pt reports she was walking out of the bathroom to grab her phone and slipped on a hanger. She denies hitting her head or losing awareness; she landed on her butt. Her daughter helped her to standing position and patient was then able to stand unassisted. Pt's daughter then noted pt was slurring her speech and had a right facial droop so EMS was called. In the ED, patient was a code stroke. NIHSS 2 for dysarthria and left nasolabial fold flattening (right facial droop had resolved at the time of my assessment, confirmed with daughter, and daughter stated that left NLFF was chronic). ___ showed a 1.9 cm extra-axial hyperdense lesion that likely represented a meningioma (vs. bleed) and "mixed sclerotic and lytic lesions by an abnormal soft tissue density primarily located in the anterior portion of the middle cranial fossa extending to the left sphenoid sinus with an intra-orbital component" (chronicity unclear). Due to minimal deficits and possible IPH (although less likely), tPA was deferred. Of note, pt was recently diagnosed with an E. coli UTI and underwent treatment with Cipro 250 mg bid x 5 days. On neurologic review of systems, the patient reports chronic visual and hearing loss bilaterally. Pt denies headache, lightheadedness, or confusion. Denies difficulty with producing or comprehending speech. Denies vertigo, tinnitus, or dysphagia. Denies focal muscle weakness, numbness, parasthesia. Denies loss of sensation. Denies bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient denies fevers, chest pain, palpitations, cough, nausea, vomiting, diarrhea, constipation, abdominal pain, dysuria or rash. 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 PHYSICAL EXAMINATION Vitals: 98.1 77 158/78 16 100% RA General: NAD, resting in bed HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes, sclerae anicteric, R eye is opacified Neck: Supple ___: RRR Pulmonary: CTAB Abdomen: Soft, NT, ND Extremities: Warm, no edema Skin: No rashes or lesions Neurologic Examination: - Mental Status - Awake, alert, oriented to person, place and time. Attention to examiner easily maintained. Able to recall a history, although looks to daughter to answer questions about her medical history. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Content of speech demonstrates intact naming (high and low frequency) and no paraphasias. Normal prosody. No evidence of hemineglect. No left-right agnosia. - Cranial Nerves - L pupil 2->1.5. R eye opacified. Blinks to threat in left eye (right eye blind/opacified). EOMI. V1-V3 without deficits to light touch bilaterally. L NLFF at rest, able to activate. Hearing decreased to finger rub bilaterally. Mild dysarthria. Palate elevation symmetric. Trapezius strength ___ bilaterally. Tongue midline. - Motor - Normal bulk and tone. No drift. No tremor or asterixis. Power intact throughout apart from L deltoid 4+. - Sensory - No deficits to light touch bilaterally. -DTRs: ___ reflexes throughout. Plantar response mute bilaterally. - Coordination - No dysmetria with finger to nose testing bilaterally. - Gait - Deferred. DISCHARGE PHYSICAL EXAM: Vitals: Tm 98.5, HR 66-79, BP 166-177/75-88, 99-98%RA Gen: thin older woman lying in bed, NAD HEENT: NCAT, R eye is opacified with no light perception, no oropharyngeal lesions, moist mucous membranes Neck: Supple ___: RRR Pulmonary: CTAB Abdomen: Soft, NT, ND Extremities: Warm, no edema Skin: No rashes or lesions Neurologic Examination: - Mental Status - Awake, alert, oriented to person, place and time. She smiles frequently and speaks quietly, not fully answering questions at times. Naming impaired (calls key a "baby" and cactus "bunny ears"; able to name glove and feather). In cookie jar picture, identifies woman but does not appreciate two young children; calls the cookie jar "two big eyes". Able to repeat "It's a sunny day in ___. No extinction. No left-right confusion. No acalculia. - Cranial Nerves - L pupil 2->1.5. R eye opacified. Blinks to threat in left eye (right eye blind/opacified). EOMI without nystagmus. Right hemianopia (does not identify fingers in right visual field). V1-V3 without deficits to light touch bilaterally. L NLFF at rest, able to activate, improving. Hearing decreased to finger rub bilaterally. Mild dysarthria. Palate elevation symmetric. Trapezius strength ___ bilaterally. Tongue midline. - Motor - Normal bulk and tone. +Left pronator drift. No tremor or asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 ___ 5 5 R 5 ___ ___ 5 5 ___ 5 5 - Sensory - No deficits to light touch bilaterally. - DTRs: ___ reflexes throughout. Plantar response mute bilaterally. - Coordination - No dysmetria with finger to nose testing with right hand. With left hand, consistently reaches left of target (both nose and hand) with no ataxia or intention tremor. - Gait - Able to ambulate slowly with two-person assistance, shuffling gait Pertinent Results: ___ 10:45AM BLOOD WBC-5.8 RBC-4.29 Hgb-11.8 Hct-35.0 MCV-82 MCH-27.5 MCHC-33.7 RDW-16.0* RDWSD-47.3* Plt ___ ___ 10:45AM BLOOD Neuts-60.8 ___ Monos-6.8 Eos-3.1 Baso-0.7 Im ___ AbsNeut-3.50 AbsLymp-1.63 AbsMono-0.39 AbsEos-0.18 AbsBaso-0.04 ___ 10:45AM BLOOD Glucose-250* UreaN-15 Creat-1.4* Na-132* K-5.1 Cl-98 HCO3-17* AnGap-22* ___ 11:07AM BLOOD Creat-1.9* ___ 10:45AM BLOOD ALT-24 AST-56* AlkPhos-90 TotBili-0.5 ___ 10:45AM BLOOD cTropnT-0.03* ___ 07:50PM BLOOD cTropnT-0.04* ___ 12:50AM BLOOD cTropnT-0.03* ___ 10:45AM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.3 Mg-1.8 ___ 05:25AM BLOOD %HbA1c-8.5* eAG-197* ___ 05:25AM BLOOD Triglyc-80 HDL-56 CHOL/HD-2.5 LDLcalc-66 ___ 05:35AM BLOOD Glucose-119* UreaN-15 Creat-1.2* Na-140 K-3.4 Cl-104 HCO3-24 AnGap-15 IMAGING NCHCT (___): 1. A 1.9 cm extra-axial hyperdense lesion with suggestion of calcifications in the right parietal convexity without hyperostosis of the overlying bone. This may represent a meningioma but cannot definitively exclude extra-axial hemorrhage. 2. Expansion of the sphenoid triangle with mixed sclerotic and lytic lesions by an abnormal soft tissue density primarily located in the anterior portion of the middle cranial fossa extending to the left sphenoid sinus with an intra-orbital component leading to mass effect on the left lateral rectus muscle, retro-orbital fat, and proptosis. These findings may be related to an intraosseous meningioma with soft tissue extension and postoperative changes from prior left pterional craniotomy. MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST (___): 1. Status post left pterional craniotomy for meningioma, with area of enhancement in the left middle cranial fossa as described above, suspicious for recurrence. 2. Redemonstration of calcified right parietal meningioma. 3. Acute infarction within the right frontal temporal lobes and in the left precentral gyrus. 4. Chronic infarction within the right cerebellar hemisphere. No intracranial hemorrhage. 5. Diffuse parenchymal volume loss with nonspecific white matter signal abnormality, likely a sequela of chronic small vessel ischemic disease. 6. Unremarkable MRA head. 7. Difficult to assess right vertebral artery with areas of non enhancement which may be related to atherosclerotic disease. Otherwise, unremarkable MRA neck. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID 4. Furosemide 20 mg PO DAILY 5. Carvedilol 6.25 mg PO BID 6. Januvia (SITagliptin) 100 mg oral DAILY 7. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan) 250-200-40-1 mg-unit-mg-mg oral DAILY 8. Losartan Potassium 50 mg PO DAILY 9. Glargine 15 Units Bedtime 10. Atorvastatin 20 mg PO QPM Discharge Medications: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID 4. Furosemide 20 mg PO DAILY 5. Carvedilol 6.25 mg PO BID 6. Januvia (SITagliptin) 100 mg oral DAILY 7. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan) 250-200-40-1 mg-unit-mg-mg oral DAILY 8. Losartan Potassium 50 mg PO DAILY 9. Apixaban 2.5mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: right MCA stroke 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: ED CODE STROKE ONLY CT INDICATION: ___ with history of meningioma status post resection in ___ in ___ with SLURRED SPEECH, Left facial droop// ICH. 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, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: There is a 1.9 x 1.0 cm extra-axial hyperdense lesion at the right parietal convexity with suggestion of calcifications but no overlying bony changes such as hyperostosis. This may represent a meningioma or extra-axial hemorrhage, correlate with prior imaging or follow-up MR. ___ is status post left pterional craniotomy with encephalomalacia in the left frontal and temporal lobe, potentially related to postsurgical changes for resection of mass lesion. There is expansion of the sphenoid triangle with mixed sclerotic and lucent areas and abnormal soft tissue component extending from the region of the prior surgical bed into the left sphenoid sinus. There is an additional orbital soft tissue component measuring 4.2 x 1.5 cm leading to mass effect on the left lateral rectus muscle and the retro-orbital fat with left proptosis (2; 11). An additional extra-axial component is located in the anterior portion of the middle cranial fossa. These changes may be due to an intraosseous meningioma with postoperative changes, correlate with prior imaging or follow-up with MR evaluation. Hypodensity in the cerebellum on the right is consistent with old infarct. Bilateral scattered basal ganglia hypodensities consistent with old lacunar infarcts. Periventricular and subcortical white matter hypodensities are nonspecific but likely represent sequelae of chronic small vessel disease. There is no midline shift. The ventricles and sulci are normal in size and configuration. The frontal sinuses, maxillary sinuses, ethmoid sinuses and mastoid air cells are clear. Scleral band about the right globe noted. IMPRESSION: 1. A 1.9 cm extra-axial hyperdense lesion with suggestion of calcifications in the right parietal convexity without hyperostosis of the overlying bone. This may represent a meningioma but cannot definitively exclude extra-axial hemorrhage. 2. Expansion of the sphenoid triangle with mixed sclerotic and lytic lesions by an abnormal soft tissue density primarily located in the anterior portion of the middle cranial fossa extending to the left sphenoid sinus with an intra-orbital component leading to mass effect on the left lateral rectus muscle, retro-orbital fat, and proptosis. These findings may be related to an intraosseous meningioma with soft tissue extension and postoperative changes from prior left pterional craniotomy. RECOMMENDATION(S): For both of the above findings, correlate with prior imaging or alternatively follow-up with MR. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with SLURRED SPEECH, Left facial droop// ICH. FRACTURE TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.3 s, 21.0 cm; CTDIvol = 22.6 mGy (Body) DLP = 475.2 mGy-cm. Total DLP (Body) = 475 mGy-cm. COMPARISON: Noncontrast head CT performed on the same day. FINDINGS: There is reversal of cervical lordosis without malalignment. No fractures are identified. Multilevel degenerative changes most severe at C3-C4 through C5-C6 with intervertebral disc height loss, uncovertebral hypertrophy, and facet arthropathy. Superimposed post posterior disc bulges at C3-C4 and C4-C5 lead to at least moderate spinal canal narrowing and presumed spinal cord remodeling. There is no prevertebral edema. Known soft tissue lesion extending into the sphenoid sinus is better seen on head CT performed on same day. A 1.4 cm hypodense right thyroid nodule is identified, no follow-up imaging is needed given size and age. The included lung apices are unremarkable. IMPRESSION: 1. No fracture or malalignment. 2. Degenerative changes with posterior disc bulge at C3-C4 and C4-C5 causing at least moderate spinal canal narrowing and presumed spinal cord remodeling. Radiology Report EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___ INDICATION: ___ year old woman with hx meningioma, new dysarthria, transient R nasal labial fold; also odd lesion in L middle cranial fossa. Evaluate for infarct, also further evaluation of left middle cranial fossa lesion 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 13 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: CT head ___ FINDINGS: MRI BRAIN: Patient is status post left pterional craniotomy for resection of known meningioma. There is a 4.1 cm TV x 5.3 cm AP x 6.8 cm enhancing mass within the left middle cranial fossa corresponding to mixed lytic and sclerotic lesion seen on prior CT. Superiorly, the mass is lateral to the orbit exerting mass effect on the lateral rectus muscle with resulting proptosis. Medially, the mass extends into the left sphenoid sinus with enhancement along the left aspect of the cavernous sinus with preserved flow voids. There is extension through the left pterygopalatine fossa and possibly the sphenoid palatine foramen and likely foramina rotundum. There is enhancement within the left anterior temporal lobe extra-axial space with adjacent cystic encephalomalacia within the left temporal lobe. There is slow diffusion within the right frontal temporal lobes and within the left precentral gyrus. There is no intracranial hemorrhage. There is chronic infarction within the right cerebellum. There is a calcified right parietal extra-axial mass measuring 2.1 cm TV x 1.4 cm AP x 1.6 cm SI. There is diffuse parenchymal volume loss with prominence of the ventricles and sulci. There are nonspecific periventricular and subcortical FLAIR hyperintensity in addition to the pons, likely a sequela of chronic small vessel ischemic disease. There is mild mucosal thickening of bilateral ethmoid and sphenoid air cells. There is right scleral banding. Patient is status post bilateral lens replacement again seen is left orbital proptosis. The dural venous sinuses appear patent on post-contrast MPRAGE images. MRA BRAIN: The intracranial vasculature appears patent without evidence of stenosis, occlusion, or aneurysm. There is a left dominant vertebral artery. MRA NECK: It is difficult to assess enhancement within the right vertebral artery with areas of non enhancement, which may be related to atherosclerotic disease or artifactual related to technique. Within the confines of the study, the bilateral internal and common carotid arteries appear patent without internal carotid artery stenosis by NASCET criteria. The left vertebral artery appears patent. IMPRESSION: 1. Status post left pterional craniotomy for meningioma, with area of enhancement in the left middle cranial fossa as described above, suspicious for recurrence. 2. Redemonstration of calcified right parietal meningioma. 3. Acute infarction within the right frontal temporal lobes and in the left precentral gyrus. 4. Chronic infarction within the right cerebellar hemisphere. No intracranial hemorrhage. 5. Diffuse parenchymal volume loss with nonspecific white matter signal abnormality, likely a sequela of chronic small vessel ischemic disease. 6. Unremarkable MRA head. 7. Difficult to assess right vertebral artery with areas of non enhancement which may be related to atherosclerotic disease. Otherwise, unremarkable MRA neck. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 10:40 am, 2 minutes after discovery of the findings. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by UNKNOWN Chief complaint: Slurred speech Diagnosed with Cerebral infarction, unspecified, Slurred speech temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: Critical level of acuity: 1.0
Dear Ms. ___, You were hospitalized due to symptoms of left facial droop and slurred speech resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: -Hypertension -Hyperlipidemia -Atrial fibrillation -Congestive heart failure -Type 2 Diabetes We are changing your medications as follows: -Apixaban 2.5mg twice daily Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team
Name: ___. Unit ___: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Penicillins / Robitussin A-C / Clindamycin / Lipitor / latex Attending: ___ Chief Complaint: right arm numbness and transient aphasia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with a history of atrial fibrillation on aspirin/amiodarone therapy, hypertension, hyperlipidemia, left sided subclavian steal and a lung nodule who presents to the ED with a brief episode of right arm numbness and impaired speech. On the morning of admission, she had just finished eating breakfast when she went into her room and started folding clothes. She noticed that her right hand felt numb. It was not clumsy at the time and she noted that she was able to fold clothes without difficulty. Shortly thereafter, she noted that the tongue felt like it was pushing upwards on the right side of her mouth. She went to speak to her daughter about this and noted that she simply couldn't get any words out. When finally she could use some words to express herself, her speech was slow, stuttering and slurred. Apparently she was able to write her thoughts down. She had ___ difficulty comprehending commands around her. The numbness went away within 5 minutes but the speech difficulties persisted for about 1 hour. Her daughter now reports that the right side of her face was droopy, but is much improved now. The daughter also confirmed that her mother's speech and fluency was much better than previous. Review of systems is positive for difficulties with left sided thigh pain and some recent issues with neck pain. She has not had nausea, emesis, chest pain, congestion, cough, abdominal pain, dysuria, hematuria. She denied double vision or headache during these symptoms. Past Medical History: - Dyslipidemia - Hypertension - Paroxysmal Atrial Fibrillation, only on aspirin/plavix Was admitted in ___ with AF with RVR. She was briefly on a heparin IV gtt but this was stopped after cardiac enzymes remained flat and normal. She has remained on aspirin. It appears from OMR notes from her PCP that he has had numerous conversations with her about switching to warfarin, but she has declined. - Rheumatic Heart Disease with moderate MR. ___ mitral stenosis seen on echo in ___. - Mild Pulmonary Hypertension - GERD - Urinary urgency - Left Subclavian Stenosis Noted to have asymmetric blood pressures (R>L) in ___ when seeing cardiology, also noted to have a carotid bruit. Carotid U/s followed by MRA ___ identified subclavian steal physiology with retrograde left vertebral artery flow. - History of Cervical Cancer in ___, s/p TAH/BSO - Left thalamic calcification: noted to be possibly "cavernoma" on an MRI in ___ Social History: ___ Family History: Patient's brother passed away from MI at the age of ___. Mother suspected of passing from MI as well. ___ family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM T 98.1, 74, 141/66 (left), 18, 100%. She was awake, alert and was pleasant and cooperative. Neck was supple and with full ROM. Chest was without adventitious sounds and her heart rate was regular. Lungs were clear. Pulses were equal. Abdomen was soft. Lower extremities were warm and well perfused. Neurologically, she was awake, alert and oriented x 3. She could follow simple commands without difficulty. She was attentive to the examiner. She was able to name objects on the ___ card, she could read and had ___ visual neglect. She repeated simple sentences without difficulty, but had trouble with more complicated sentences such as ___ ifs, ands, or buts about it". Language was fluent but her talking speed was slower than usual (per daughter). Speech was slightly dysarthric. Pupils were equal, round and reactive. Eye movements were full and visual fields were full to confrontation. The right NLF was flattened compared with the right. ___ ptosis. Tongue deviated to the right, but palate elevated symmetrically. Facial sensation was intact to light touch and pin bilaterally. Motor examination identified full strength in all major muscle groups without pronator drift or tremors/asterixis. Rapid alternating movements were without asymmetry. Confrontation testing identified ___ strength in all four extremities. Reflexes were 2+ throughout with downgoing toes. Sensory examination identified normal pinprick and light touch throughout. Cortical sensation on both palms was symmetric - she appeared to get only 60-70% accuracy on both palms. She had ___ finger-nose dysmetria or tremor. Gait was normal DISCHARGE EXAM: Normal speech. Nonfocal neurological exam Pertinent Results: Labs: BMP: 139 ___ AGap=18 5.4 23 1.0 (hemolyzed) CBC: 9.2, 42.8, 288 ___: 11.5 PTT: 28.5 INR: 1.1 NCHCT: Hyperdense lesion in the left thalamus, consistent with stable cavernoma MRI/MRA head (___): Age-related involutional and chronic microangiopathic changes without evidence of acute infarct, hemorrhage, or mass effect. Entire left vertebral artery is markedly diminished in caliber with severe stenosis just beyond the origin likely related to atheromatous disease, as well as diminutive right A1 and P1 segments. Echocardiogram (___): The left atrium is elongated. ___ atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF = 65%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and ___ aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. The mitral valve shows characteristic rheumatic deformity. There is ___ mitral valve prolapse. An eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is ___ pericardial effusion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Amiodarone 200 mg PO DAILY 3. Aspirin 81 mg PO DAILY Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: TIA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Slurred speech, right hand numbness. COMPARISON: Head CT ___. TECHNIQUE: Axial MDCT images were obtained through the brain without the administration of IV contrast. Coronal and sagittal reformats were also examined. FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or large vascular territory infarction. The ventricles and sulci are normal in size and configuration for age. Again seen is a left thalamic rounded calcific density, stable compared to prior studies. Bilateral basal ganglia calcifications are also noted. The basal cisterns are patent, and gray white matter differentiation is maintained. No fracture is identified. Atherosclerotic calcifications of the carotid siphons are noted. The mastoid air cells and middle ear cavities are clear. Secretions in the left sphenoid sinus and partial opacification of the right mastoid air cells are present. Note is made of a right lens replacement. Additionally, elongation of the posterior right globe is present, consistent with known staphyloma. IMPRESSION: No acute intracranial process. Radiology Report CHEST RADIOGRAPH INDICATION: History of pulmonary nodules, questionable nodule on radiograph. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is unchanged evidence of a minimal parenchymal opacity, located in the left apex, and very likely the result of overlying vascular and parenchymal structures. The structure has not grown or changed in morphology. No other changes. No pleural effusions. Borderline size of the cardiac silhouette. Tortuosity of the thoracic aorta. Normal hilar and mediastinal structures. Radiology Report HISTORY: ___ year old woman with new right sided weakness and aphasia/dysarthria. TECHNIQUE: Multiplanar multi sequence MR images of the head were performed before and after the administration of intravenous contrast. Non contrast MRA of the head, and pre- and post-contrast MRA of the neck, were obtained. COMPARISON: CT head ___ ; MR head ___. FINDINGS: MR Brain: MRI of the brain demonstrates no evidence of hemorrhage or infarction. There are small scattered T2/FLAIR high signal foci throughout the brain consistent; in light of the patient's age, these are probably sequela of chronic microvascular changes. Gray white matter differentiation is otherwise maintained. Ventricular, cisternal, and sulcal prominence may be a function of age-related parenchymal volume loss. There is a stable coarse calcification within the left thalamus. The paranasal sinuses and mastoid air cells demonstrate normal signal. The right globe lens replacement changes are noted. The sella turcica, craniocervical junction, orbits are otherwise unremarkable. MRA Head: Normal flow signal is noted in the petrous, cavernous, and supraclinoid portions of the internal carotid arteries. The right A1 segment is diminutive likely related to atherosclerosis. The anterior and middle cerebral or vertebral arteries are otherwise unremarkable. The anterior communicating artery region unremarkable. The right P1 segment is hypoplastic. The posterior cerebral arteries and basilar artery are otherwise unremarkable. The superior cerebellar arteries are normal. The right vertebral artery is dominant; the intradural segment of the right vertebral artery appears patent. The left intradural vertebral artery is diminutive likely related to atheromatous disease. The posterior communicating arteries are seen. No arterial other stenosis, saccular aneurysm, or AVM is identified. MRA Neck: There is common origin to the innominate and left common carotid artery, a normal variant. The common, internal, and external carotid arteries demonstrate normal flow signal and enhancement. No stenosis is identified. The origins of the innominate, left common carotid, and left subclavian arteries are normal. The right vertebral artery is unremarkable. The entire left vertebral artery is markedly diminished in caliber just beyond the origin likely related to atheromatous disease. IMPRESSION: Age-related involutional and chronic microangiopathic changes without evidence of acute infarct, hemorrhage, or mass effect. Entire left vertebral artery is markedly diminished in caliber with severe stenosis just beyond the origin likely related to atheromatous disease, as well as diminutive right A1 and P1 segments. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Numbness, Slurred speech Diagnosed with TRANS CEREB ISCHEMIA NOS temperature: 98.1 heartrate: 74.0 resprate: 18.0 o2sat: 100.0 sbp: 141.0 dbp: 66.0 level of pain: 0 level of acuity: 1.0
Dear ___, ___ was a pleasure to take care of you at ___ ___. You were admitted on ___ with a transient episode of right hand numbness that progressed to problems with your speech. The whole event lasted approximately 1 hour. When you arrived, a Code Stroke was called an you were taken urgently for CT which showed ___ new stroke or problems with your blood vessels to account for your symptoms. We also did an MRI which showed ___ stroke or obvious vascular cause of your symptoms. We checked additional laboratory tests to evaluate for increased lipids or diabetes. You do not have diabetes, but you did have elevated cholesterol. We would like to start you on: fish oil and feel strongly that you should start Pradaxa, which you refused at this time but stated you will discuss with your primary care doctor. An ultrasound of your heart was also done which showed normal function. At this time we think your symptoms of a transient ischemic attack or TIA. This is a brief stroke-like event that resolves and causes ___ permanent deficit. You may be at increased risk for future TIAs or stroke and it is important that you come back to the ED if you have new or persistent symptoms. Please remain on the medications listed below and follow up as we have scheduled. Thank you for allowing us to participate in your care.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ w h/o well controlled asthma presenting with 4 day h/o abdominal pain. Patient notes that she developed sharp RUQ/RLQ pain 4 days ago toward the end of her menses. The pain was constant and gradually worsened and spread across her abdomen. Over the same period, she has experienced nausea and constipation with last bowel movement ___ days ago. She reports chills but no fever, denies dysuria, frequency urgency. No recent travel or sick contacts. No h/o abdominal surgery. In the ED, initial VS were 98.7 128 137/85 18 100% RA. Physical exam was significant for diffuse abdominal tenderness, no CMT or adnexal tenderness on bimanual exam and small amount of heme negative brown stool on rectal exam. Labs showed normal CBC with WBC 8.4, lactate 1, ALT 8, AST 13, AP 41, Tbili 0.4, lipase 20, negative UA, negative urine HCG. KUB showed nonspecific bowel gas pattern and CT abd/pelvis showed enhancement in the proximal jejunum folllowed by a segment of mildly dilated bowel, which was fecalized, gastroenteritis vs resolving small bowel obstruction. ACS was consulted and saw no acute need for surgical intervention. Recommended admission for bowel regimen and pain control. The patient was given 4mg IV morphine x 1, 1mg IV hydromorphone x 3 and ondansetron 2mg IV x 2 and transferred to medicine for further management. Past Medical History: Asthma: since childhood, last exacerbation ___ years ago. Never hospitalized or intubated. Social History: ___ Family History: Father had MI age ___, paternal GM died of MI age ___, maternal aunt has breast cancer. No family h/o IBD Physical Exam: ADMISSION: VS - 98.5 115/68 70 18 100% RA 75.5kg GEN - Overweight young female, tearful, oriented HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear NECK - supple, no JVD, no LAD PULM - CTAB, no w/r/r CV - RRR, S1/S2, no m/r/g ABD - soft, ND, hypoactive bowel sounds, diffusely tender to palpation, no guarding or rebound EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally NEURO: CN II-XII intact, motor function grossly normal SKIN: no ulcers or lesions DISCHARGE: VS - Tm 98.7 ___ 100% RA GEN - Overweight young female, NAD HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear NECK - supple, no JVD, no LAD PULM - CTAB, no w/r/r CV - RRR, S1/S2, no m/r/g ABD - soft, ND, hypoactive bowel sounds, diffusely tender to palpation, no guarding or rebound EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally Pertinent Results: ADMISSION LABS: ___ 06:09PM LACTATE-0.6 ___ 01:20PM URINE UCG-NEGATIVE ___ 01:20PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 01:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 01:20PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE EPI-2 ___ 01:01PM LACTATE-1.0 ___ 12:50PM GLUCOSE-88 UREA N-13 CREAT-0.8 SODIUM-138 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-23 ANION GAP-14 ___ 12:50PM ALT(SGPT)-8 AST(SGOT)-13 ALK PHOS-41 TOT BILI-0.4 ___ 12:50PM LIPASE-20 ___ 12:50PM ALBUMIN-4.4 ___ 12:50PM WBC-8.4 RBC-4.14* HGB-13.1 HCT-39.6 MCV-96 MCH-31.5 MCHC-33.0 RDW-13.0 ___ 12:50PM NEUTS-65.3 ___ MONOS-4.1 EOS-0.9 BASOS-0.5 ___ 12:50PM PLT COUNT-324 DISCHARGE LABS: ___ 07:20AM BLOOD WBC-10.2 RBC-4.12* Hgb-12.9 Hct-39.7 MCV-96 MCH-31.4 MCHC-32.6 RDW-13.0 Plt ___ ___ 07:20AM BLOOD Glucose-95 UreaN-10 Creat-0.8 Na-137 K-3.9 Cl-103 HCO3-26 AnGap-12 ___ 07:20AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.0 ___ 07:00AM BLOOD TSH-1.7 IMAGING/STUDIES: KUB ___ FINDINGS: The stomach is non-distended. There are no dilated loops of large or small bowel or air-fluid levels. No free air is seen. Stool and air are seen throughout all portions of the colon, including the rectum. IMPRESSION: Unremarkable bowel gas pattern. CT ABD/PELVIS W/ CONTRAST ___ FINDINGS: ABDOMEN: The visualized lung bases are clear. There are no pleural effusions. The liver is homogeneous in texture with no focal lesions. There is no biliary ductal dilatation. The gallbladder is normal. The spleen, pancreas, and adrenal glands are normal. Multifocal chronic scar formation is seen in the bilateral kidneys. The kidneys are otherwise unremarkable. The stomach is normal in caliber and unremarkable. In the left upper quadrant, a long segment of perhaps mildly thickened enhancing small bowel is followed by a mild dilated and distended segment with fecalization of contents. This is followed by a somewhat gradual transition in caliber to fairly collapsed distal small bowel. There are no findings to suggest internal hernia. There is no mesenteric swelling, twisting, or other changes. There is no retroperitoneal or mesenteric lymphadenopathy. The intra-abdominal aorta and its major branches are normal in appearance. PELVIS: The sigmoid colon and rectum are normal in appearance. The distal ureters and bladder are normal. The uterus is unremarkable. There is no pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for infection or malignancy is seen. IMPRESSION: 1. Slight bowel wall thickening and enhancement in the proximal jejunum followed by a segment of mildly dilated bowel, which is fecalized. This is followed by a non-abrupt transition zone and a region of collapsed small bowel. These findings could be secondary to an inflammatory process such as gastroenteritis or could represent intermittent, partial, or resolving small bowel obstruction, although dilatation is not striking. Correlation with physical findings and clinical presentation are recommended. There are no findings to suggest internal hernia or mesenteric involvement. 2. Multifocal chronic scar formation in the bilateral kidneys. KUB ___ FINDINGS: The bowel gas pattern is unremarkable. There is a gas-filled stomach as well as gas-filled large bowel, however, no evidence of distention. There appears to be less of a fecal load compared to the study from ___. There is no pneumatosis or free air. IMPRESSION: No evidence of obstruction. Decreased interval amount of fecal load compared to the study from ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 2. Polyethylene Glycol 17 g PO DAILY Stop medication if you have loose stools. RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 packet(s) by mouth Daily Disp #*30 Packet Refills:*11 3. Psyllium 1 PKT PO DAILY Hold for loose stools. RX *psyllium 1 packet(s) by mouth Daily Disp #*30 Packet Refills:*11 4. Bisacodyl 10 mg PO/PR DAILY constipation Duration: 2 Weeks RX *bisacodyl 5 mg ___ tablet(s) by mouth or rectum Daily Disp #*60 Tablet Refills:*0 5. Lorazepam 0.5 mg PO BID: PRN anxiety Do not take if sedated or driving. RX *lorazepam 0.5 mg 1 tablet by mouth Twice a day Disp #*10 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Constipation Depressed mood Secondary diagnosis: Asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report RADIOGRAPHS OF THE ABDOMEN HISTORY: Diffuse abdominal pain and peritoneal signs. COMPARISONS: None. TECHNIQUE: Abdomen, three views. FINDINGS: The stomach is non-distended. There are no dilated loops of large or small bowel or air-fluid levels. No free air is seen. Stool and air are seen throughout all portions of the colon, including the rectum. IMPRESSION: Unremarkable bowel gas pattern. Radiology Report HISTORY: ___ female with diffuse peritoneal abdominal pain. TECHNIQUE: MDCT imaging of the abdomen and pelvis with intravenous contrast was performed. Multiplanar reformats were prepared and reviewed. COMPARISON: None. FINDINGS: ABDOMEN: The visualized lung bases are clear. There are no pleural effusions. The liver is homogeneous in texture with no focal lesions. There is no biliary ductal dilatation. The gallbladder is normal. The spleen, pancreas, and adrenal glands are normal. Multifocal chronic scar formation is seen in the bilateral kidneys. The kidneys are otherwise unremarkable. The stomach is normal in caliber and unremarkable. In the left upper quadrant, a long segment of perhaps mildly thickened enhancing small bowel is followed by a mild dilated and distended segment with fecalization of contents. This is followed by a somewhat gradual transition in caliber to fairly collapsed distal small bowel. There are no findings to suggest internal hernia. There is no mesenteric swelling, twisting, or other changes. There is no retroperitoneal or mesenteric lymphadenopathy. The intra-abdominal aorta and its major branches are normal in appearance. PELVIS: The sigmoid colon and rectum are normal in appearance. The distal ureters and bladder are normal. The uterus is unremarkable. There is no pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for infection or malignancy is seen. IMPRESSION: 1. Slight bowel wall thickening and enhancement in the proximal jejunum followed by a segment of mildly dilated bowel, which is fecalized. This is followed by a non-abrupt transition zone and a region of collapsed small bowel. These findings could be secondary to an inflammatory process such as gastroenteritis or could represent intermittent, partial, or resolving small bowel obstruction, although dilatation is not striking. Correlation with physical findings and clinical presentation are recommended. There are no findings to suggest internal hernia or mesenteric involvement. 2. Multifocal chronic scar formation in the bilateral kidneys. Radiology Report INDICATION: ___ female with severe constipation, who presents for evaluation of abdominal pain, question change in fecal load since the initial KUB. COMPARISON: CT abdomen and pelvis from ___. FINDINGS: The bowel gas pattern is unremarkable. There is a gas-filled stomach as well as gas-filled large bowel, however, no evidence of distention. There appears to be less of a fecal load compared to the study from ___. There is no pneumatosis or free air. IMPRESSION: No evidence of obstruction. Decreased interval amount of fecal load compared to the study from ___. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: ABD PAIN Diagnosed with ABDOMINAL PAIN OTHER SPECIED temperature: 98.7 heartrate: 128.0 resprate: 18.0 o2sat: 100.0 sbp: 137.0 dbp: 85.0 level of pain: 8 level of acuity: 3.0
Dear Ms. ___, It was a pleasure participating in your care at ___. You were admitted to the hospital with abdominal pain due to severe constipation. You had a CT scan of your abdomen that showed significant stool, but no other concerning process. You were treated with laxatives and your symptoms improved. You should continue to take laxatives at home as needed and make sure to drink plenty of fluid and include fiber in your diet to prevent this constipation from happening again in the future. You spoke with the nutrition team to help with your diet. Please discuss setting up a nutrition follow up appointment with your doctor. You appear to have a lot of stress in your life which may be contributing to your abdominal pain and constipation. You felt much better after talking to a social worker, so we recommend that you see a social worker or other therapist after returning home. Please follow up as scheduled with your new primary care provider and note the changes to your medications on the next page.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Penicillins / Betoptic S / Alphagan P / Travatan Attending: ___. Chief Complaint: Left hip pain Major Surgical or Invasive Procedure: Left hip hemiartrhoplasty History of Present Illness: The patient is an ___ y/o F with severe Alzheimer's, HTN, osteoarthritis, osteoporosis with one month long history of inability to bear weight on the LLE who presented on ___ after imaging showed femoral neck fracture and is now s/p L hemiarthoplasty, found to have urinary retention and UTI with post op course complicated by anemia. Past Medical History: Alzheimer's disease GERD HTN Anxiety/depression Osteoarthritis Osteoporosis Social History: ___ Family History: Noncontributory Physical Exam: DISCHARGE PHYSICAL EXAM: Gen: Patient is lethargic but arousable, appears comfortable. Unable to participate meaningfully in exam due to baseline mental status Cardio: RRR Resp: breathing unlabored MSK: LLE: Dressing in place over surgical incision, c/d/i, no swelling, induration, erythema around incision site. Foot wwp, moves foot and toes spontaneously. Radiology Report INDICATION: ___ with fall a month ago // fx? TECHNIQUE: AP view of pelvis. AP and lateral views of the proximal distal left femur. COMPARISON: None FINDINGS: There is a left femoral neck fracture with significant impaction. The fracture margins are perhaps minimally smoother than expected for an acute fracture and given trauma 1 month prior this could be compatible with a fracture of this age. Vertically oriented lucency through the proximal right femur may be projectional due to overlying soft tissues. No other fractures identified. Distally the left femur is unremarkable. The pubic symphysis and SI joints are intact. IMPRESSION: Recent impacted left femoral neck fracture which could be from trauma 1 month prior. Vertically-oriented lucency within the proximal right femur may be due to overlying tissues however if patient has symptoms on the right side, consider additional imaging to exclude fracture. Radiology Report EXAMINATION: HIP 1 VIEW INDICATION: LEFT HEMI, FX. IMPRESSION: In comparison with the study of ___, there is now a left hemiarthroplasty in place in the left hip. No evidence of hardware failure complication. Gender: F Race: WHITE - RUSSIAN Arrive by AMBULANCE Chief complaint: L Hip pain Diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL, HYPERTENSION NOS, ALZHEIMER'S DISEASE temperature: 98.6 heartrate: 90.0 resprate: 16.0 o2sat: 100.0 sbp: 136.0 dbp: 81.0 level of pain: 13 level of acuity: 3.0
MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment or by your rehab facility. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: - Out of bed w/ assist - Right lower extremity: Full weight bearing - Left lower extremity: Full weight bearing - Encourage turning, deep breathing and coughing Qhour when awake Physical Therapy: - Activity: Out of bed w/ assist - Right lower extremity: Full weight bearing - Left lower extremity: Full weight bearing - No ROM restrictions - Encourage turning, deep breathing and coughing Qhour when awake. Treatments Frequency: Site: Incision Type: Surgical Dressing: Gauze - dry - Change daily or as needed to keep dry; OK to leave open to air once non-draining.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: admitted with febrile neutropenia Major Surgical or Invasive Procedure: none History of Present Illness: ___ is a ___ year old woman with DLBCL finishing C6 DA-EPOCH-R who is admitted from the ED with febrile neutropenia. Patient speaks ___, and history is taken with the aid of her husband, at bedside. Patient was admitted ___ to ___ for C6 EPOCH, which she tolerated well. However, she reports having significant fatigue and dizziness since discharge. Last week she also developed new body aches and intermittent headaches. She noted a new mouth sore (typical following her chemotherapy) on ___, and by ___ she was having low grade temperatures (but not ___. She was seen in clinic on day of admission where she was noted to be neutropenic and she was started on empiric levofloxacin and also received filgrastim. After returning home she noted a T of 100.8 and she presented to the ED. Patient currently denies headache. No dysphagia or odynophagia. No rhinitis or ST. No CP, SOB or cough. No N/V, but does have poor appetite. No abdominal pain or diarrhea. Nl BM. No rectal pain. No dysuria. No new joint pains or swelling. No sick contacts. In the ED, initial VS were pain 2, T 99.8, HR 101, BP 143/76, RR 20, O2 100%RA. Later spiked T of 102.8. Initial labs notable for Na 134, K 3.8, HCO3 23, Cr 0.5, WBC 0.6 (ANC 90), HCT 22.3, PLT 60, ALT 19, AST 19, ALP 96, TBili 0.4, lactate 2.4, UA negative. CXR showed no acute process. Patient was given 1LNS along with IV vancomycin and cefepime and po APAP. VS Prior to transfer were T 99.7, HR 94, BP 1113/51, RR 16, O2 97%RA. Past Medical History: Hematologic/Oncologic History: - ___: Presents to ___ ED with back pain for 2 weeks. CTA Chest demonstrates paraspinal masses bilaterally at the T3 vertebral level which appear to extend into the neural foramina bilaterally with subtle cortical destruction and mottling of the T3 vertebra, multiple splenic hypodense lesions measuring up to 1.8 cm, and bilateral axillary lymphadenopathy. - ___: CT Abdomen/Pelvis demonstrates multiple hypoenhancing splenic lesions, measuring up to 1.8 cm., multiple enlarged lymph nodes throughout the retroperitoneum, pelvic wall (left external iliac) and mesentery. - ___: MRI whole spine shows a paraspinal mass at T3 with diffuse infiltration of the T3 vertebral body extending into the posterior elements. Of note, the paraspinal mass extends through the bilateral neural foramen and to the epidural space at T3-T4 encroaching on the spinal canal and resulting in moderate to severe spinal canal stenosis, and an enhancing lesion within the L1 vertebral body extending into the posterior elements as well as a smaller focal lesion of the L2 vertebral body suspicious for additional sites of malignancy. - ___ and ___: 3 unsuccessful attempts at lymph node biopsy (2 in the left axilla and 1 in the left pelvis). - ___: Left pelvic lymph node biopsy demonstrates fragments of a lymph node with fibrosis and a T-cell predominant lymphoid population. FISH positive for del(13q). FISH negative for high-grade lymphoma panel. - ___: Paraspinal mass core needle biopsy shows a CD5-positive diffuse large B cell lymphoma. By immunohistochemistry, the cells are immunoreactive for CD20, CD5, BCL-6, BCL-2, and MUM1. CD3 highlighs scattered tumor infiltrating lymphocytes. The Ki-___ proliferation index is high, averaging 90%. CD138 and CD21 are negative. Expression of CD5 may occur ___ in a subset of diffuse large B cell lymphoma or may result from large cell transformation of a low grade B cell lymphoma, such as CLL/SLL (Richter transformation). Cytogenetics are positive for BCL6 rearrangement. FISH is negative for CLL panel, including del(13q). - ___: MRI Brain shows a punctate enhancing focus within the right putamen, which raises suspicion for a metastatic deposit given the patient's known thoracic spine mass. - ___: TTE shows LVEF > 55%. - ___: C1 da-EPOCH-R, dose level 1. - ___: C1 rituximab. - ___: Repeat MRI brain shows stable 2-3 mm enhancing focus in the right putamen, without a correlate on T2 weighted/FLAIR or diffusion-weighted images, with diagnostic considerations including malignancy versus a capillary telangiectasia. - ___: C1 intrathecal methotrexate. CSF analysis with 1 nucleated cell, 65% Lymphs, 35% Monos, protein 40, glucose 85. - ___: Discharged to home. - ___: C2 rituximab. - ___: C2D1 da-EPOCH, dose level 1, uncapped vincristine. - ___: C2 intrathecal methotrexate. No evidence of lymphomatous involvement by flow cytometry. - ___: C3 da-EPOCH-R, dose level 2, uncapped vincristine. - ___: C4 da-EPOCH-R, dose level 2, uncapped vincristine, prednisone decreased to 100 mg daily because of agitation and difficulty sleeping. - ___: Surveillance MRI spine demonstrates partial resolution of multiple vertebral body abnormalities, with no evidence of spinal canal compromise or spinal cord encroachment and complete resolution of the previously noted paraspinal mass - - ___: Surveillance CT torso demonstrates resolution of the paraspinal mass at T3, substantially smaller bilateral axillary lymph nodes, an unchanged 1.2 cm hypoattenutating right thyroid nodule, unchanged bilateral 4 mm right lower lobe pulmonary nodules, resolution of previously noted hypoattenuating splenic nodules, interval decrease in size of the retroperitoneal and pelvic sidewall lymph nodes, and no new enlarging lymph nodes. - ___: C5 da-EPOCH-R, dose level 3, uncapped vincristine. - ___: C6 da-EPOCH-R, dose level 2, uncapped vincristine. Past Medical History: - CD5-positive high-grade diffuse large B cell lymphoma, as above - Chronic hepatitis B, on entecavir - Possible G6PD deficiency, normal testing on ___ - Positive PPD, status-post treatment - Hypertension - Cesarean section Social History: ___ Family History: no known history of cancer. Mother had lower back pain and hip fracture at age ___. Father died in ~___ y.o from unknown cause. Physical Exam: ADMISSION PHYSICAL EXAM: ========================= VS: T 98.8 HR 96 BP 108/69 RR 18 SAT 98% O2 on RA GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses, 2+ DP pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN III-XII intact, motor and sensory function grossly intact SKIN: No significant rashes DISCHARGE PHYSICAL EXAM: ========================= ___ 1252 Temp: 98.4 PO BP: 123/71 HR: 91 RR: 18 O2 sat: 99% O2 delivery: RA GEN: WDWN female in NAD. Lying comfortably in bed. EYES: NC/AT. Sclera anicteric. MMM. Multiple teeth missing, otherwise oropharynx without erythema or exudates. CV: RRR with normal S1 and S2. No murmurs, rubs or gallops. PULM: Normal respiratory effort. CTAB without wheezes, rales or rhonchi. GI: Soft, non-tender/non-distended. Normoactive BS. No masses appreciated. MUSKULOSKELATAL: Warm, well perfused. No ___ edema or erythema. NEURO: Alert and interactive. CN II-XII grossly intact. Moves all extremities. SKIN: No significant rashes Pertinent Results: ADMISSION LABS: ================ ___ 09:35AM BLOOD WBC-0.4* RBC-2.30* Hgb-7.1* Hct-21.5* MCV-94 MCH-30.9 MCHC-33.0 RDW-15.7* RDWSD-54.3* Plt Ct-50* ___ 09:35AM BLOOD Neuts-8* Bands-1 ___ Monos-29* Eos-8* Baso-5* ___ Metas-1* Myelos-0 NRBC-2* AbsNeut-0.04* AbsLymp-0.19* AbsMono-0.12* AbsEos-0.03* AbsBaso-0.02 ___ 09:35AM BLOOD UreaN-5* Creat-0.4 Na-138 K-3.5 Cl-104 HCO3-24 AnGap-10 ___ 09:35AM BLOOD ALT-16 AST-14 LD(LDH)-207 AlkPhos-84 TotBili-0.4 ___ 09:35AM BLOOD TotProt-5.3* Albumin-3.6 Globuln-1.7* Calcium-8.2* Phos-2.8 Mg-1.9 UricAcd-2.4 DISCHARGE LABS: =============== ___ 12:00AM BLOOD WBC-4.2 RBC-2.90* Hgb-8.8* Hct-27.3* MCV-94 MCH-30.3 MCHC-32.2 RDW-18.0* RDWSD-59.4* Plt ___ ___ 12:00AM BLOOD Neuts-58 Bands-1 ___ Monos-10 Eos-2 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-2.48 AbsLymp-1.18* AbsMono-0.42 AbsEos-0.08 AbsBaso-0.00* ___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Burr-OCCASIONAL Tear Dr-OCCASIONAL ___ 12:00AM BLOOD Plt Smr-LOW* Plt ___ ___ 12:00AM BLOOD Glucose-139* UreaN-12 Creat-0.4 Na-135 K-3.7 Cl-98 HCO3-24 AnGap-13 ___ 12:00AM BLOOD ALT-20 AST-28 LD(LDH)-589* AlkPhos-113* TotBili-0.2 ___ 12:00AM BLOOD Albumin-3.8 Calcium-8.5 Phos-3.2 Mg-2.0 MICROBIOLOGY: ============= ___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT ___ Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING ___ URINE URINE CULTURE-FINAL EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PENDING Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. amLODIPine 5 mg PO DAILY 3. Atovaquone Suspension 1500 mg PO DAILY 4. Docusate Sodium 200 mg PO BID 5. Entecavir 0.5 mg PO DAILY 6. LORazepam 0.5 mg PO Q6H:PRN Nausea, anxiety 7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 8. Pantoprazole 40 mg PO Q24H 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Senna 8.6 mg PO BID 11. Filgrastim-sndz 300 mcg SC Q24H 12. Ondansetron 4 mg PO Q8H:PRN Nausea 13. Levofloxacin 750 mg PO Q24H Discharge Medications: 1. Senna 8.6 mg PO BID:PRN constipation 2. Acyclovir 400 mg PO Q8H 3. amLODIPine 5 mg PO DAILY 4. Docusate Sodium 200 mg PO BID 5. Entecavir 0.5 mg PO DAILY 6. LORazepam 0.5 mg PO Q6H:PRN Nausea, anxiety 7. Ondansetron 4 mg PO Q8H:PRN Nausea 8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 9. Pantoprazole 40 mg PO Q24H 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== #Febrile Neutropenia #DLBCL SECONDARY DIAGNOSIS: ===================== #Chronic HBV infection 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 DLBCL and fever// eval for pneumonia TECHNIQUE: Chest: Frontal and Lateral COMPARISON: Chest radiograph ___. FINDINGS: Right chest wall port terminates in the lower SVC.A subtle opacity is seen in the retrocardiac region. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. Projecting over only on the lateral view are radiopaque foreign objects, one of which appears like a nail, is external to the patient as demonstrated by a repeat lateral view. IMPRESSION: Subtle opacity in the retrocardiac region could be seen in the setting of an infectious process. NOTIFICATION: Updated findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 1:45 pm, 10 minutes after discovery of the findings. Gender: F Race: BLACK/CAPE VERDEAN Arrive by WALK IN Chief complaint: Fever Diagnosed with Neutropenia, unspecified, Fever presenting with conditions classified elsewhere temperature: 99.8 heartrate: 101.0 resprate: 20.0 o2sat: 100.0 sbp: 143.0 dbp: 76.0 level of pain: 2 level of acuity: 3.0
Ms. ___, You were admitted due to fever when your blood counts were low. You were placed on IV antibiotics for your fever spikes. No source of infection was found. Your counts recovered and you are feeling better and are ready to be discharged home today. You will follow up in the clinic as stated below. It was a pleasure taking care of you.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: lisinopril Attending: ___ Chief Complaint: Palpitations Major Surgical or Invasive Procedure: ___ Redo Mitral valve replacement with a 29 mm ___ mechanical valve. (Prior mechanical aortic valve) History of Present Illness: ___ male with bicuspid aortic valve stenosis and mitral regurgitation post-tandem surgical mechanical AVR/MVR, complete heart block post-CRTP, valvular cardiomyopathy and recent hospitalization for ICD upgrade after sustained monomorphic VT who presents several hours after last discharge with palpitations. Mr. ___ states that after going home, walking around his house, eating dinner, and taking a shower he became sweaty, pale, and felt that his heart was pounding and had an "unusual rhythm," though he did not check his HR. He then self-medicated with an extra dose of Metoprolol XL 25 mg. He states that after this he felt less sweaty but continued to feel that his heart was beating quickly. In the ED, initial vitals: Afebrile, heart rate 90, BP 148/78 - Exam notable for: GEN: uncomfortable but alert and oriented RESP: lungs clear CV: paced rhythm, no tachycardia ABD: soft, non-tender EXT: warm and well perfused - Labs notable for: TropT 0.02, Cr 1.1, WBC 5.9, UA with small blood, INR 1.6 - Imaging notable for: CXR with - Pt given: No medications - Cardiology consulted and interrogated pacemaker: No evidence of VT. Would still recommend admission for close monitoring, daily EKGs, ambulation tomorrow. Upon arrival to the floor, the patient corroborates the above history. He states that his palpitations have mostly abated and he is reassured being hooked up to monitors, though he states that he "is not leaving the hospital until after [my] surgery". He states that "it does not matter what your textbooks tell you or what the interrogation of my pacemaker shows, I know there is something wrong and I am not leaving until my valve is repaired". He denies current chest pain, palpitations, shortness of breath, diaphoresis, nausea, vomiting, lower extremity swelling. Past Medical History: Cardiac History: -Bicuspid aortic valve, severe aortic stenosis post-aortic valve replacement with a 27 mm ___ mechanical valve (___). -Mitral regurgitation post-repair with radical reconstruction and 30 ___ II ring (___). -Complete heart block post-CRTP (___). -Valvular cardiomyopathy. -Atrial fibrillation. Other PMH: -Hypertension. -Dyslipidemia. -Benign prostatic hypertrophy. -H. pylori gastritis post-quadruple therapy (___). -Shingles. -Herniorrhaphy. Social History: ___ Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: ADMISSION PHYSICAL EXAM ======================= PHYSICAL EXAM: VITALS: Temp 97.7 HR 67 BP 109/64 RR 16 SaO2 99%RA GENERAL: Well appearing man in NAD. AAOx3. HEENT: PERRL, EOMI, MMM. NECK: JVP < 10 cm at 90 degrees. Pacemaker pocket in left chest with clear dressing, no tenderness, no evidence of hematoma. CARDIAC: RRR, S1/prosthetic S2, systolic murmur at base, holosystolic across precordium and most pronounced at apex. LUNGS: CTAB, no crackles/wheezing/rhonchi. ABDOMEN: Soft, non tender, non distended. No palpable hepatosplenomegaly. EXTREMITIES: Warm, well perfused, no ___ edema. R PICC without erythema. SKIN: No visible rashes. NEURO: A&Ox3, motor and sensation grossly intact. DISCHARGE PHYSICAL EXAM ======================= Vital Signs I/O 24 HR Data (last updated ___ @ 1147) Temp: 98.5 (Tm 99.4), BP: 130/87 (117-139/67-87), HR: 80 (66-80), RR: 20 (___), O2 sat: 100% (97-100), O2 delivery: Ra Fluid Balance (last updated ___ @ 1147) Last 8 hours Total cumulative -715ml IN: Total 120ml, PO Amt 120ml OUT: Total 835ml, Urine Amt 835ml Last 24 hours Total cumulative -755ml IN: Total 480ml, PO Amt 480ml OUT: Total 1235ml, Urine Amt 1235ml Physical Examination: General: NAD [x] Neurological: A/O x3 [x] Moves all extremities [x](L)UE weakness and mobilization improving. LLE can lift, boot in place Follows commands [x] Cardiovascular: RRR [x] Respiratory: CTA [x] No resp distress [x] GI/Abdomen: Bowel sounds present [x] Softly distended [x] NT[x] Extremities: Right Upper extremity Warm [x] Edema- Left Upper extremity Warm [x] Edema - Right Lower extremity Warm [x] Edema- Left Lower extremity Warm [x] Edema - Sternal: CDI [x] no erythema or drainage [x] Sternum stable [x] Prevena [] Pertinent Results: ADMISSION LAB RESULTS ====================== ___ 04:56AM BLOOD WBC-4.5 RBC-3.22* Hgb-9.3* Hct-30.1* MCV-94 MCH-28.9 MCHC-30.9* RDW-18.2* RDWSD-56.8* Plt ___ ___ 04:56AM BLOOD ___ PTT-28.9 ___ ___ 04:56AM BLOOD Glucose-91 UreaN-17 Creat-0.9 Na-138 K-4.4 Cl-106 HCO3-24 AnGap-8* ___ 04:56AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9 DISCHARGE LAB RESULTS ======================= ___ 05:20AM BLOOD WBC-7.4 RBC-3.48* Hgb-10.0* Hct-31.9* MCV-92 MCH-28.7 MCHC-31.3* RDW-15.2 RDWSD-50.8* Plt ___ ___ 05:20AM BLOOD ___ ___ 06:30AM BLOOD ___ ___ 04:35AM BLOOD ___ PTT-83.1* ___ ___ 10:57AM BLOOD ___ PTT-49.8* ___ ___ 05:20AM BLOOD Glucose-99 UreaN-14 Creat-1.0 Na-139 K-4.3 Cl-100 HCO3-28 AnGap-11 ___ 02:00AM BLOOD ALT-20 AST-50* LD(LDH)-794* AlkPhos-44 TotBili-1.2 ___ 01:10AM BLOOD cTropnT-0.02* ___ 05:20AM BLOOD Mg-1.9 ___ 01:16PM BLOOD %HbA1c-4.4 eAG-80 IMAGING ======= PA/LAT CXR ___ IMPRESSION: Compared to chest radiographs ___ through ___. Previous pulmonary edema has largely cleared. Right lower lobe shows persistent atelectasis adjacent to moderate right pleural effusion. Severe cardiomegaly unchanged. No pneumothorax. Transvenous right atrial ventricular pacer defibrillator leads and 2 epicardial leads are continuous from the left pectoral generator. . CTA Head/Neck ___ IMPRESSION: 1. No definite evidence for acute large territorial infarct, intracranial hemorrhage or intracranial mass effect noncontrast CT head. 2. Asymmetric hypodensity of the right frontal white matter likely represents sequela of chronic microangiopathy however subtle acute infarct could potentially be obscured. 3. Suboptimal CTA examination secondary to contrast bolus timing. Within this confines: 9 mm left supraclinoid ICA aneurysm with ___s well as a 5 mm right supraclinoid ICA aneurysm. The remainder of the intracranial circulation demonstrates no evidence of high-grade stenosis or occlusion. 4. Unremarkable CTA of the neck within confines of technically suboptimal exam. 5. CT perfusion does not demonstrate CBF less than 30%. 6. Additional findings as described above. . TEE ___ (*preliminary*) Conclusions PRE BYPASS The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is moderately to severely depressed with moderate global hypokinesis and a suggestion of more severe hypokinesis in the mid and distal anterior wall. (LVEF= 30 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The riight ventricle displays severe hypokinesis of the mid and distal free wall. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. A bileaflet aortic valve prosthesis is present. The aortic valve prosthesis leaflets appear to move normally. The transaortic gradient is normal for this prosthesis. There is mild aortic valve stenosis (valve area 1.9cm2) as is expected. Though expected, no aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. A mitral valve annuloplasty ring is present. The annuloplasty ring has dehisced from the anterior mitral annulus. Severe (4+) mitral regurgitation is seen through the middle of the valve as well. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Dr. ___ was notified in person of the results in the operating room at the time of the study. Post Bypass The left ventricu;ar function is 35-40%.The mechanical mitral valve is well seated with no paravalvular leak.The transvalvular gradients peak of 6mm Hg and mean of 3 mmHg The rest of the exam is unchanged. . ___ CXR 1. No focal consolidation or pulmonary edema. 2. Stable moderate cardiomegaly with mild pulmonary vascular congestion, however no overt interstitial edema. . ___ Noncontrast Chest CT IMPRESSION: 1. Fusiform enlargement of the ascending thoracic aorta measuring up to 4.2 cm, with ascending aortic calcifications 2 cm distal to the aortic valvular plane. 2. Multiple bilateral ground-glass pulmonary nodules measuring up to 1.4 cm, which could reflect infection with edema, though could also represent true pulmonary nodules, and short-term follow-up CT is recommended. 3. Mild interstitial edema. 4. Status post AVR and MVR with expected postsurgical changes. RECOMMENDATION(S): 3 month follow-up CT chest is recommended to document stability and/or resolution of multiple bilateral ground-glass pulmonary nodules. Medications on Admission: 1. Furosemide 20 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Losartan Potassium 25 mg PO DAILY 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Warfarin 5 mg PO 6X/WEEK (___) 6. Warfarin 7.5 mg PO 1X/WEEK (___) 7. Warfarin 7.5 mg PO 1X/WEEK (___) Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Amiodarone 400 mg PO BID Duration: 5 Days then decrease to 400mg daily x 5 days, then decrease to 200mg daily continuous 3. Atorvastatin 80 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. GuaiFENesin ER 1200 mg PO Q12H Duration: 4 Days 6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills:*0 7. Metoprolol Tartrate 25 mg PO TID hold if SBP<90 or HR<55 8. Polyethylene Glycol 17 g PO DAILY 9. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days 10. Ramelteon 8 mg PO QHS:PRN sleep Should be given 30 minutes before bedtime 11. Ranitidine 150 mg PO BID 12. Senna 17.2 mg PO DAILY 13. Warfarin 5 mg PO ONCE Duration: 1 Dose please dose daily for INR 2.5-3.5 (Mechanical AVR & MVR/afib/CVA) 14. ___ MD to order daily dose PO DAILY16 please dose daily for INR 2.5-3.5 (Mechanical AVR & MVR/afib/CVA) 15. Aspirin EC 81 mg PO DAILY 16. Furosemide 20 mg PO DAILY Duration: 7 Days 17. HELD- Losartan Potassium 25 mg PO DAILY This medication was held. Do not restart Losartan Potassium until SBP consistently >140 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Redosternotomy s/p Mechanical Mitral Valve Replacement RV lead extractions with upgrade to a CRT-D device on ___ postop ischemic stroke with Left weakness Secondary: aortic stenosis s/p prior Mechanical Aortic Valve Replacement and Mitral valve repair with 30mm ___ II ring and LV epicardial lead placement ___ Complete Heart Block-s/p Permanent PaceMaker ___ hypertension hyperlipidemia BPH Shingles Valvular cardiomyopathy mitral regurgitation Atrial fibrillation H. pylori gastritis post-quadruple therapy (___) Discharge Condition: Alert and oriented x3, non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema-left ___ edema 1+ Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with recent MI and new pacemaker/defibrilator now with palpitations. Evaluation for effusion, cardiomegaly. TECHNIQUE: Chest PA and lateral COMPARISON: Comparison to prior chest radiograph from ___. FINDINGS: Cardiac pacemaker device again projects over the left chest wall, with pacer leads extending into the right atrium and right ventricle. Two myocardial pacer leads remain in stable position. Median sternotomy wires remain intact and well aligned. Cardiac valve prostheses are unchanged. Interval removal of right-sided PICC line. Moderately enlarged cardiac silhouette is stable. Mild pulmonary vascular congestion without overt interstitial edema. Lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. IMPRESSION: 1. No focal consolidation or pulmonary edema. 2. Stable moderate cardiomegaly with mild pulmonary vascular congestion, however no overt interstitial edema. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with S/P MVR// fast track extubation, effusion pneumothx Contact name: ___, Phone: 1 TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: Interval redo median sternotomy and mitral valve replacement. And left chest wall dual lead ICD is present. The tip the Swan-Ganz catheter likely projects over the left lower lobe pulmonary artery. The tip of the endotracheal tube projects over the midthoracic trachea. An enteric tube extends to the stomach. Mediastinal drains and chest tubes are present. There is mild pulmonary edema. No focal consolidation, pleural effusion or pneumothorax identified. Pneumomediastinum is present. The size of the cardiac silhouette is enlarged but unchanged. IMPRESSION: Mild pulmonary edema. The tip of the Swan-Ganz catheter projects over the left lower lobe pulmonary artery. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with MVR// PA line reposition TECHNIQUE: AP portable chest radiograph COMPARISON: ___ IMPRESSION: The tip of the Swan-Ganz catheter has been minimally retracted however still projects over the left pulmonary artery. Mild pulmonary edema. Otherwise no significant interval change. Radiology Report EXAMINATION: CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK INDICATION: ___ year old man s/p redosternotomy with Mech MVR (prior Mech AVR, MVrepair)// eval for bleed, shift, mass TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 903.1 mGy-cm. 2) Sequenced Acquisition 19.2 s, 8.0 cm; CTDIvol = 314.2 mGy (Head) DLP = 2,513.8 mGy-cm. 3) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 27.2 mGy (Head) DLP = 13.6 mGy-cm. 4) Spiral Acquisition 5.6 s, 43.7 cm; CTDIvol = 32.0 mGy (Head) DLP = 1,400.1 mGy-cm. Total DLP (Head) = 4,831 mGy-cm. COMPARISON: Carotid ultrasound of ___. FINDINGS: CT HEAD WITHOUT CONTRAST: Asymmetric hypodensity of the right frontal white matter (series 2, image 21) could represent sequela chronic microangiopathy however subtle underlying acute infarct could potentially be obscured. Otherwise, no other evidence for acute large territory infarct. There is no intra or extra-axial mass effect or acute hemorrhage.. The sulci, ventricles and cisterns are within expected limits for the degree of mild senescent related global cerebral volume loss. There is mild mucosal thickening of the ethmoid air cells and right inferior maxillary sinus. The orbits are unremarkable. The mastoid air cells middle ears are well pneumatized and clear. The patient is intubated. CTA HEAD: The examination is suboptimal secondary to timing of contrast bolus. Within this confine: 1. 6 x 9 mm left supraclinoid internal carotid artery aneurysm with 4 mm neck (603:37). 2. Additional 5 mm aneurysm arising from the right supraclinoid internal carotid artery (601:26). The remainder of the intracranial ICA, ACA, MCA and the posterior circulation are unremarkable within confines of technically suboptimal exam. No other aneurysms are identified. There is no evidence of high-grade stenosis or occlusion. CTA NECK: The examination is suboptimal secondary to timing of contrast bolus. Within this confine: The carotidandvertebral arteries and their major branches appear unremarkable with no evidence of stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. CTP: CBF <30% volume = 0 mL, indicating no infarct core Tmax >6.0s volume = 4 mL, negligible Mismatch volume = 4 mL, negligible Mismatch ratio = negligible mismatch ratio. OTHER: Very minimal by apical pneumothorax. Postsurgical emphysema along the superior mediastinum, anterior chest extending to right lateral neck base is identified. Evaluation of the upper chest and lower neck is suboptimal secondary to the degree of postoperative edema. Within this confines: No evidence of cervical lymphadenopathy by size criteria. The thyroid is unremarkable. The patient is intubated with endotracheal tube terminating above the carina and enteric few terminating beyond the field of view. Allowing for respiratory motion artifact, the visualized lungs are grossly clear. No suspicious osseous abnormality. The patient is status post median sternotomy by paired IMPRESSION: 1. No definite evidence for acute large territorial infarct, intracranial hemorrhage or intracranial mass effect noncontrast CT head. 2. Asymmetric hypodensity of the right frontal white matter likely represents sequela of chronic microangiopathy however subtle acute infarct could potentially be obscured. 3. Suboptimal CTA examination secondary to contrast bolus timing. Within this confines: 9 mm left supraclinoid ICA aneurysm with 4 mm neck as well as a 5 mm right supraclinoid ICA aneurysm. The remainder of the intracranial circulation demonstrates no evidence of high-grade stenosis or occlusion. 4. Unremarkable CTA of the neck within confines of technically suboptimal exam. 5. CT perfusion does not demonstrate CBF less than 30%. 6. Additional findings as described above. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with s/p Redo, MVR, CTs d/c'd// eval for ptx eval for ptx IMPRESSION: Compared to chest radiographs ___ through ___. Dense opacification of the left lower lobe is new, more likely collapse than pneumonia. Moderate pulmonary edema has redistributed, now most pronounced in the dependent right lung. Small pleural effusions are unchanged. Moderate enlargement of cardiac silhouette may have increased, function of lower lung volumes and relative increase in central venous return with the termination of positive pressure ventilation. Sternal wires are intact and aligned. Transvenous right atrial ventricular pacer defibrillator leads and epicardial leads unchanged in their respective positions. Right jugular sheath ends in the mid SVC following removal of the Swan-Ganz catheter. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with POD 5 Redo MVR, PPM// effusion. lead placement effusion. lead placement IMPRESSION: Compared to chest radiographs ___ through ___. Previous pulmonary edema has largely cleared. Right lower lobe shows persistent atelectasis adjacent to moderate right pleural effusion. Severe cardiomegaly unchanged. No pneumothorax. Transvenous right atrial ventricular pacer defibrillator leads and 2 epicardial leads are continuous from the left pectoral generator. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ year old man// increased swelling and coolness of left lower extremity f/o DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: No relevant comparison identified. FINDINGS: Moderate to severe soft tissue swelling is noted over the level of the calf. There is normal compressibility, color flow, and spectral doppler 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: Moderate to severe soft tissue swelling over the left calf. No evidence of deep venous thrombosis in the left lower extremity veins. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Palpitations Diagnosed with Palpitations temperature: 99.4 heartrate: 90.0 resprate: 16.0 o2sat: 97.0 sbp: 148.0 dbp: 78.0 level of pain: 0 level of acuity: 2.0
Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours**
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Demerol / Iodine / Augmentin / adhesive,contrast media demerol Attending: ___ Chief Complaint: Transferred for ___ and anemia. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. ___ is a ___ year old lady with history of CAD s/p CABG *3 ((LIMA-LAD, SVG to OM1, SVG to PDA), cath in ___ w/occluded SVGs x 2, patent LIMA), Type I Diabetes with ESRD s/p renal transplant in ___ on chronic immunosuppressive agents and severe gastroparesis presenting from OSH with elevated Cr and anemia. She had presented to ___ yesterday with decreased urine output x1 week with no urine output for 24 hours and weakness, noted to not be in retention, but with Cr elevated to 3.2 from baseline of 2.3 and HCT of 17 from baseline of 28. She was transfused 2U PRBC but not given IV furosemide according to her husband. ___ was WNL prior to the transfusion. She was transferred to BI for renal evaluation. On arrival to the ED, initial VS were notable for brady to 40-60. Per notes, "seemed intoxicated." Creatinine 2.8. HCT 23.2. Benign exam. US notable for no hydro, high resistive index. Renal fellow felt findings non-specific. Placed foley, not retaining, 100cc/out, UA pending. Trop 0.04. EKG: biphase T waves laterally, sinus brady. Got 1 more unit pRBCs. Admitted to hepatorenal for further management. This morning, she was very lethargic but not confused. She has been this way for one week. She also notes weakness in her arms and jaw, along with pain. This started one week ago. She has no fam hx of neurolgical disorders. Feels that her eyes close by themselves at the end of the evening. Feels that her symptoms worsen in the evening. No dysuria. No cough, no shortness of breath, no chest pain. History also obtained from husband, meds as well. He notes no changes in diuretics except to decrease metolazone from BID to QD one month ago. *** Records also obtained from ___: recent labs and ED evaluation note *** Past Medical History: Diabetes Type 1, s/p renal transplant in ___, with a history of episodes of diabetic ketoacidosis Dyslipidemia Hypertension CAD s/p CABG, in ___ anatomy as follows: LIMA-LAD, SVG to OM1, SVG to PDA. As on ___ cath all vein grafts occluded only LIMA-LAD patent. ejection fraction of 55%. Gastroparesis secondary to DM. Left below the knee amputation in ___. Vascular procedures on the right lower extremity. Heel ulcers due to diabetes, s/p bypass graft surgeries Peripheral neuropathy CVA x2. S/p cholecystectomy S/p cataract surgery Depression. Social History: ___ Family History: Uncle with diabetes Sister died of colon CA Mother died of brain CA Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS - 97.7 - 150/57 - 49 - 20 - 100 on 3L - bg 114 i/o: out 400. Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate but very lethargic. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple. CV: RR ,S1, S2. ___ systolic murmur foley in Chest: diffuse crackles throughout Abd: Soft, NTND. No HSM or tenderness. Transplant on left, no edema/bruising. Ext: S/p left BKA. 1+ pitting edema right leg DISCHARGE PHYSICAL EXAMINATION: VS: 98.1 - 128/44 - 52 - 18 - 100ra - bs 267 i.o 250/500, yest 1080/1450 Wt 47.8kg <-- 48.3kg (from 50.1kg) Gen: WDWN middle aged female in NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple. CV: RR, S1, S2. ___ systolic murmur gu: no foley Chest: diffuse crackles halfway up on posterior lung exam Abd: Soft, NTND. No HSM or tenderness. Transplant on left, no edema/bruising. Ext: S/p left BKA. trace pitting edema right leg SKIN: very dry Pertinent Results: ADMISSION LABS ========== ___ 10:40PM BLOOD WBC-4.2 RBC-2.65* Hgb-7.7* Hct-23.2* MCV-88# MCH-29.2 MCHC-33.3# RDW-13.3 Plt ___ ___ 10:40PM BLOOD Neuts-66 Bands-0 ___ Monos-2 Eos-1 Baso-0 ___ Myelos-0 ___ 10:40PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 10:40PM BLOOD ___ PTT-30.6 ___ ___ 10:40PM BLOOD Glucose-118* UreaN-100* Creat-2.8* Na-136 K-4.9 Cl-101 HCO3-26 AnGap-14 ___ 10:40PM BLOOD ALT-25 AST-20 LD(LDH)-172 CK(CPK)-43 AlkPhos-141* TotBili-0.4 DirBili-0.2 IndBili-0.2 ___ 10:40PM BLOOD Albumin-3.7 ___ 09:00AM BLOOD Calcium-8.3* Phos-4.7* Mg-3.0* ___ 10:50PM BLOOD Glucose-99 Lactate-0.9 TACRO LEVELS ========= ___ 09:00AM BLOOD tacroFK-2.5* ___ 07:15AM BLOOD tacroFK-2.1* ___ 07:32AM BLOOD tacroFK-<2.0 ___ 07:38AM BLOOD tacroFK-2.3* ___ 07:10AM BLOOD tacroFK-4.6* ___ 07:30AM BLOOD tacroFK-6.3 OTHER PERTINENT LABS =============== ___ 07:15AM BLOOD %HbA1c-8.8* eAG-206* ___ 10:40PM BLOOD Hapto-125 ___ 03:15PM BLOOD calTIBC-195* Ferritn-617* TRF-150* ___ 10:40PM BLOOD CK-MB-4 DISCHARGE LABS =========== ___ 07:30AM BLOOD WBC-4.4 RBC-3.14* Hgb-9.3* Hct-27.1* MCV-86 MCH-29.5 MCHC-34.1 RDW-13.3 Plt ___ ___ 07:30AM BLOOD Glucose-105* UreaN-89* Creat-2.3* Na-132* K-4.1 Cl-93* HCO3-30 AnGap-13 ___ 07:30AM BLOOD Mg-2.2 CARDIAC ENZYMES ============ ___ 10:40PM BLOOD cTropnT-0.04* ___ 09:00AM BLOOD cTropnT-0.03* URINE STUDIES ========= ___ 01:45AM URINE Color-Yellow Appear-Clear Sp ___ ___ 01:45AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR ___ 01:45AM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 ___ 02:55PM URINE Color-Straw Appear-Clear Sp ___ ___ 02:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR ___ 02:55PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 MICROBIOLOGY ========== ___ CULTURE-FINAL ___ Culture, Routine-FINAL ___ Culture, Routine-FINAL ___ VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL (negative) ___ CULTURE-FINAL ___ Culture, Routine-FINAL EKG === Sinus bradycardia. Diffuse non-specific ST-T wave abnormalities most pronounced in the anterolateral leads. Compared to the previous tracing of ___ there has been a slowing of the sinus rate and the anterolateral ST-T wave abnormalities are slightly more prominent. ___ ___ EKG ___ ========= Sinus bradycardia. Low limb lead voltage. Delayed precordial R wave transition. Q-T interval prolongation. Compared to the previous tracing of ___ no diagnostic interim change. ___ ___ RENAL ULTRASOUND ============= No hydronephrosis or new echogenicity of the renal transplant. Renal arteries have a tardus parvus waveform, a new finding, and high resistive indices ranging up to 0.9, similar to prior. Diastolic flow is either minimal or reversed. Small amount of ascites. CXR === IMPRESSION: 1. Early cardiac decompensation. 2. Faint right lower lobe opacity could represent either asymmetric edema or pneumonia. 3. Vague nodule in right upper lung, for which CT or repeat chest radiograph after therapy is recommended. CXR === In addition to chronic pulmonary vascular congestion, there is progressive consolidation at the base of the right lung, consistent with pneumonia. Moderate cardiomegaly is longstanding. Tiny right pleural effusion may be present. No pneumothorax. ECHO ==== ResultsMeasurementsNormal Range Left Atrium - Long Axis Dimension:*4.9 cm<= 4.0 cm Left Atrium - Four Chamber Length:5.2 cm<= 5.2 cm Left Atrium - Peak Pulm Vein S:0.6 m/s Left Atrium - Peak Pulm Vein D:0.9 m/s Left Atrium - Peak Pulm Vein A:0.2 m/s< 0.4 m/s Right Atrium - Four Chamber Length:*5.2 cm<= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.9 cm0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.4 cm<= 5.6 cm Left Ventricle - Systolic Dimension: 3.2 cm Left Ventricle - Fractional Shortening: *0.27>= 0.29 Left Ventricle - Ejection Fraction: 50%>= 55% Left Ventricle - Stroke Volume: 94 ml/beat Left Ventricle - Cardiac Output: 4.68 L/min Left Ventricle - Cardiac Index: 2.82>= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': *0.07 m/s> 0.08 m/s Left Ventricle - Septal Peak E': *0.05 m/s> 0.08 m/s Left Ventricle - Ratio E/E': *18< 15 Aorta - Sinus Level:2.8 cm<= 3.6 cm Aorta - Ascending:3.2 cm<= 3.4 cm Aortic Valve - Peak Velocity: 1.6 m/sec<= 2.0 m/sec Aortic Valve - LVOT VTI: 33 Aortic Valve - LVOT diam: 1.9 cm Mitral Valve - E Wave:1.1 m/sec Mitral Valve - A Wave:0.6 m/sec Mitral Valve - E/A ratio:1.83 Mitral Valve - E Wave deceleration time:170 ms140-250 ms TR ___ (+ RA = PASP): *36 mm Hg<= 25 mm Hg Pulmonic Valve - Peak Velocity:1.0 m/sec<= 1.5 m/sec Findings This study was compared to the prior study of ___. LEFT ATRIUM: Mild ___. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D or color Doppler. IVC dilated (>2.1cm) with <50% decrease with sniff (estimated RA pressure (>=15 mmHg). LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV systolic function. Mildly depressed LVEF. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size. RV function depressed. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___ mitral annular calcification. TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PS. Significant PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor suprasternal views. Conclusions The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 50 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Mildly depressed global left ventricular systolic function with increased left ventricular filling pressure. Depressed right ventricular systolic function. Moderate to severe tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of ___, biventricular systolic dysfunction is new. The severity of tricuspid has increased (previously mild). Moderate pulmonary artery systolic hypertension is now seen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) 4. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN neuropathy 5. Glargine 8 Units Breakfast Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Metolazone 2.5 mg PO DAILY 7. Nitroglycerin SL 0.4 mg SL PRN chest pain 8. PredniSONE 3 mg PO DAILY 9. Prochlorperazine 10 mg PO TID 10. Ropinirole 1.5 mg PO QPM 11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 12. Tacrolimus 1 mg PO Q12H 13. Torsemide 100 mg PO BID 14. Aspirin 325 mg PO DAILY 15. Docusate Sodium 100 mg PO BID 16. Citalopram 20 mg PO DAILY 17. Metoprolol Tartrate 25 mg PO BID 18. Mycophenolate Mofetil 500 mg PO BID Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN neuropathy 6. Metolazone 2.5 mg PO DAILY 7. PredniSONE 3 mg PO DAILY 8. Ropinirole 1.5 mg PO QPM 9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 10. Acetaminophen 650 mg PO Q6H:PRN pain 11. Nitroglycerin SL 0.4 mg SL PRN chest pain 12. Prochlorperazine 10 mg PO Q8H:PRN nausea DO NOT TAKE IF NOT NEEDED. 13. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) 14. Metoprolol Tartrate 25 mg PO BID 15. Mycophenolate Mofetil 500 mg PO BID 16. Epoetin Alfa ___ UNIT SC QMOWEFR 17. Citalopram 20 mg PO DAILY 18. Levofloxacin 750 mg PO Q48H Duration: 2 Days RX *levofloxacin 750 mg one tablet(s) by mouth EVERY 2 DAYS Disp #*2 Tablet Refills:*0 19. Glargine 7 Units Breakfast Glargine 8 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 20. Outpatient Lab Work icd-9 996.81: please draw AM tacrolimus level before 8 am an send to Dr. ___ at ___. 21. Torsemide 100 mg PO BID 22. Tacrolimus 1 mg PO Q12H 23. Outpatient Lab Work Please check hematocrit on ___ and send to Dr. ___ ___ at ___. icd-9 996.81. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: CHF exacerbation Acute kidney injury Chronic kidney dysfunction Type 1 Diabetes Anemia 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 PA AND LATERAL CHEST, ___. HISTORY: ___ woman with renal transplant. Volume overload. New fever. IMPRESSION: AP chest compared to ___: In addition to chronic pulmonary vascular congestion, there is progressive consolidation at the base of the right lung, consistent with pneumonia. Moderate cardiomegaly is longstanding. Tiny right pleural effusion may be present. No pneumothorax. Gender: F Race: OTHER Arrive by AMBULANCE Chief complaint: ANEMIC/WEAKNESS Diagnosed with RENAL & URETERAL DIS NOS, ANEMIA NOS, KIDNEY TRANSPLANT STATUS temperature: 97.2 heartrate: 47.0 resprate: nan o2sat: 97.0 sbp: 132.0 dbp: 27.0 level of pain: 5 level of acuity: 2.0
Dear Ms. ___, You were admitted to ___ because of acute kidney dysfunction and anemia (low blood count). You were transfused both at ___, and at ___. Your low blood count was thought to be due to your long term kidney dysfunction. You were started on a new medication to improve your blood counts. We also treated you with IV medication in order to help you lose some of the excess water in your body. You were also seen by a diabetes specialist to help you regulate your blood sugar. It is IMPERATIVE that you quit tobacco. While you were here, some changes were made to your medications, please see the sheet below. Please follow up below.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Right upper lobe lung mass Non-ST elevation MI Anemia Hypotension secondary to dehydration and poor PO intake Hypercalcemia Hypoglycemia DM2 Urinary Retention Major Surgical or Invasive Procedure: Ultrasound guided lung biopsy History of Present Illness: ___ male with DM type II and HTN presenting with hypotension, anemia, LBBB in setting of elevated troponin, and right upper lobe opacity. Pt reports that his biggest underlying complaint for several months has been right shoulder pain for which he has been seeing his PCP. He has undergone steroid injections and physical therapy with minimal relief. He has felt increasing short of breath with physical therapy sessions. He also noted frequent diarrhea, general malaise, and poor appetite for at least 3 weeks. He believes he has had a twenty lb weight loss over the course of several months. He has also had subjective fevers/chills, night sweats, and urinary frequency. He went to see a gastroenterologist on ___ for his diarrhea. There he was noted to be hyoptensive with BPs in systolic ___ and Hct was 21. He was referred to ___ ___. At the ED, guaiac was reportedly negative. He believes he had a colonoscopy in ___ that showed one polyp and has not noticed black or bloody stools. EKG revealed LBBB without any prior for comparison. Calcium was elevated to 11.7 (albumin 2.7). WBC 19.2. Hct 21. Blood sugars ___. Troponin I was elevated to 1.9. Cardiology was consulted who felt that this was likely demand ischemia from anemia. Pt denies chest pain. He also had urinary retention; foley was placed with 1L urine output. He was given aspirin and transfused 1 unit PRBC prior to transfer to ___ ED for further evaluation. At ___ ED, initial vitals were 97 76 104/60 17 100%RA. CXR revealed opacification in right upper lobe. He received levofloxacin 750mg iv for possible CAP. He reports subjective fevers/chills but denies cough. He recently quit smoking in ___ and states that he sometimes has phlegm. Cardiology was again consulted who performed bedside TTE showing symmetric LVH with EF approximately 50% and some suggestion of inferoseptal and inferior wall hypokinesis. Cardiology felt that he likely had stable CAD and diastolic dysfunction and may have developed a demand-related NSTEMI in setting of anemia. He was also noted to have a pericardial effusion with no evidence of tamponade. From here, he was transferred to the medical intensive care unit. In the MICU, he received a CT Chest/Abd/Pelvis which revealed a large mass in the RUL from hilum to chest wall and eroding into the ___ and third ribs, concerning for malignancy. He received another 1 ___ and was transfered to the floor. Past Medical History: hypertension diabetes osteoarthritis neuropathy anemia Social History: ___ Family History: Father: DM, ETOH No family history of malignancy Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 98 106/53 84 16 100%RA General: Alert, oriented, very thin male, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi, decreased breath sounds at right upper lobe Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley draining clear urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact Rectal: Good tone. Guiac negative. Discharge Physical Exam: Vitals: 97.9 100/59 89 18 100 RA FSBG 120-153 General: Alert, oriented, no acute distress, cachetic HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation on right lung, decreased aeration on left lung, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, unds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, significant clubbing, bo cyanosis or edema Neuro: Strength 4+/5 bilateral upper and lower extremities, patellar reflex 2+ bilaterally, sensation intact bilateral lower extremities Pertinent Results: ADMISSION LABS ___ 12:05AM BLOOD WBC-17.1* RBC-2.53* Hgb-7.5* Hct-24.1* MCV-96 MCH-29.6 MCHC-31.0 RDW-13.9 Plt ___ ___ 12:05AM BLOOD Neuts-83.9* Lymphs-10.7* Monos-3.7 Eos-1.4 Baso-0.4 ___ 12:05AM BLOOD ___ PTT-28.0 ___ ___ 12:05AM BLOOD Glucose-74 UreaN-24* Creat-1.0 Na-139 K-3.7 Cl-103 HCO3-26 AnGap-14 ___ 04:55AM BLOOD ALT-8 AST-17 CK(CPK)-20* TotBili-0.6 ___ 04:55AM BLOOD Lipase-8 ___ 12:05AM BLOOD cTropnT-0.85* ___ 04:55AM BLOOD Albumin-3.2* Calcium-11.9* Phos-3.0 Mg-1.9 ___ 12:22AM BLOOD Lactate-1.4 ___ PTH= 6 ___:05AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG IMAGING ___ Portable AP CXR FINDINGS: There is opacification of the right upper lobe with superior deviation of the minor but without rightward mediastinal shift. Two convex contours are seen inferior to this density. No pleural effusion or pneumothorax is detected on this view. Heart size is normal. IMPRESSION: Right upper lobe opacification with abnormal inferior margin and volume loss without mediastinal shift, concerning for space occupying process in the right upper lobe which may involve the mediastinum. Differential diagnosis includes malignancy. CT is recommended for further evaluation. ___ CT Chest/Abd/Pelvis IMPRESSION: 1. Large right upper lobe mass extending from the right hilum to the right chest wall with destructive involvement of the second and third right ribs. The right upper lobe bronchus is completely occluded. 2. 6 mm subpleural nodule in the right lower lobe may represent a satellite lesion. Attention on follow up. 3. Indeterminate left adrenal nodule, incompletely characterized on this study. This may represent a metastatic lesion. If no prior imaging is available characterizing this lesion, this could be further evaluated by adrenal protocol CT or MRI if clinically indicated. 4. No acute process in the abdomen or pelvis to explain patient's chronic diarrhea. 5. 1.8-cm right renal superior pole hypodensity with intermediate density (22HU) could be further evaluated by renal ultrasound. 6. Mild emphysema. Mild pulmonary artery enlargement suggests underlying pulmonary arterial hypertension. 7. Prostatic enlargement with circumferential bladder wall thickening suggests outflow obstruction. 8. No definite evidence of spinal metastases as clinically queried, although MRI is more sensitive. 9. The imaged portion of the right shoulder is unremarkable. Findings discussed with Dr. ___ fellow) by phone at 5:20pm ___. The study and the report were reviewed by the staff radiologist. ___. ___ ___. ___ Transthoracic Echocardiogram Conclusions Focused study (apical views added to prior on call echocardiogram dated ___ Overall left ventricular systolic function is moderately depressed (quantitative biplane LVEF= 35-40 %) secondary to akinesis of the apex, distal anterior septum, distal anterior/inferior wall, and hypokinesis of the mid inferior wall and inferior septum. No masses or thrombi are seen in the left ventricle. The mitral valve leaflets are structurally normal. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Mild-moderate pulmonary artery systolic hypertension. Compared with the prior study dated ___, the LV apex and distal segments of the LV are better visualized with evidence of moderate regional and global systolic dysfunction c/w CAD. Mild-moderate elevation of pulmonary pressures is also appreciated. Electronically signed by ___, MD, Interpreting physician ___ ___ 12:13 DISCHARGE LABS: ___ 06:25AM BLOOD WBC-17.2* RBC-2.87* Hgb-8.5* Hct-27.6* MCV-96 MCH-29.6 MCHC-30.7* RDW-14.3 Plt ___ ___ 06:25AM BLOOD Glucose-132* UreaN-16 Creat-0.8 Na-139 K-3.7 Cl-105 HCO3-26 AnGap-12 ___ 06:25AM BLOOD Albumin-2.5* Calcium-10.2 Phos-2.4* Mg-2.1 ___ 11:12AM BLOOD Albumin-2.9* Calcium-9.8 Phos-2.2* ___ 04:30PM BLOOD PARATHYROID HORMONE RELATED PROTEIN-PND Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. MetFORMIN (Glucophage) 500 mg PO BID 2. Simvastatin 20 mg PO DAILY 3. Enalapril Maleate 10 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Cyanocobalamin 100 mcg PO DAILY 6. Glimepiride 4mg daily Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Metoprolol Tartrate 12.5 mg PO BID hold if SBP < 90 or HR < 60 3. Cyanocobalamin 100 mcg PO DAILY 4. Simvastatin 20 mg PO DAILY 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Tamsulosin 0.4 mg PO HS holf for sbp < 100 7. FoLIC Acid 1 mg PO DAILY 8. Thiamine 100 mg PO DAILY 9. Senna 2 TAB PO BID:PRN constipation 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Docusate Sodium 200 mg PO BID:PRN constipation Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Right upper lobe lung mass Non-ST elevation MI Anemia of Chronic Disease Hypotension secondary to dehydration and poor PO intake Hypercalcemia Hypoglycemia Type-II Diabetes Urinary Retention Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ male with dyspnea. COMPARISON: None available. TECHNIQUE: Single frontal chest radiograph was obtained portably with the patient in an upright position. FINDINGS: There is opacification of the right upper lobe with superior deviation of the minor but without rightward mediastinal shift. Two convex contours are seen inferior to this density. No pleural effusion or pneumothorax is detected on this view. Heart size is normal. IMPRESSION: Right upper lobe opacification with abnormal inferior margin and volume loss without mediastinal shift, concerning for space occupying process in the right upper lobe which may involve the mediastinum. Differential diagnosis includes malignancy. CT is recommended for further evaluation. These findings and recommendations were discussed with Dr. ___ by Dr. ___ by telephone at 1:05 a.m. on ___ at the time of discovery of these findings. Radiology Report CLINICAL HISTORY: ___ man with right upper lobe lung mass with shortness of breath and right shoulder pain and diarrhea. COMPARISON: Chest radiograph ___. TECHNIQUE: MDCT-acquired axial images from the thoracic outlet to the pubic symphysis were displayed with 5-mm slice thickness with oral and 100 mL Omnipaque intravenous contrast. Coronal and sagittal reformats were displayed with 5-mm slice thickness. CT CHEST: No nodules are seen in the thyroid gland. The thoracic aorta is normal in caliber with mild atherosclerotic calcifications. The pulmonary artery is borderline enlarged with the right main pulmonary artery measuring 2.8 cm, which may suggest underlying pulmonary arterial hypertension. Contrast bolus timing is not optimized to evaluate for pulmonary embolism, but there is no large central PE. No pathologically enlarged axillary or mediastinal lymph nodes are identified. No left hilar lymph node enlargement. The heart and pericardium are normal aside from mild coronary artery calcifications. No pleural effusion is seen. Within the right upper lobe, there is an 11.1 x 9.0 x 9.4 cm heterogeneously enhancing mass with central hypodensity, which may represent necrosis. The mass extends from the right superior hilum to the right chest wall with bony destruction of the right second and third ribs. No right infrahilar lymph node enlargement is seen. The right upper lobe bronchus is completely occluded by the mass with occlusion of the right upper lobe pulmonary arteries. The right middle and lower lobe bronchi are patent. Left airways are patent to the subsegmental levels. There is left apical pleural parenchymal scarring. A 6-mm subpleural lesion in the right lower lobe (2:42) is seen. There is mild emphysema bilaterally with mild dependent atelectasis at the left lung base. CT ABDOMEN: The liver is normal without focal liver lesion identified. There is no intra- or extra-hepatic bile duct dilation. The gallbladder is distended without radiopaque stones. The spleen, pancreas, and right adrenal gland are normal. A 1.8 x 2.0 cm left adrenal nodule (35 ___ is incompletely characterized on this single phase study. The kidneys enhance symmetrically and excrete contrast promptly without hydronephrosis. A 1.8-cm hypodensity in the right renal superior pole (2:69) has intermediate density (22HU). A 4.6 x 4.2 cm simple cyst is seen in the left renal inferior pole. The small and large bowel are normal in course and caliber without obstruction. There is no free air. The aorta is of normal caliber throughout with dense atherosclerotic calcifications at its inferior portion extending into the iliac arteries. The main portal vein, splenic vein, and SMV are patent. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are identified. Diffuse mesenteric haziness with subcutaneous edema are likely anasarca. CT PELVIS: The rectum is normal. Diverticula are seen in the sigmoid colon without inflammatory changes. The bladder is partially decompressed with a Foley catheter in place with a thick wall. A bladder diverticulum with air is seen at the right aspect of the bladder (2:120). The prostate is enlarged with protrusion of the median lobe into the bladder base and prostatic calcifications. There is no free fluid and no pelvic or inguinal lymphadenopathy. BONE WINDOWS: Osseous destruction of the right second and third ribs is due to the large right upper lobe cancer. No other lesion suspicious for infection or malignancy is seen. No definite evidence of spinal metastases as clinically queried. The visualized portion of the right shoulder is unremarkable. IMPRESSION: 1. Large right upper lobe mass extending from the right hilum to the right chest wall with destructive involvement of the second and third right ribs. The right upper lobe bronchus is completely occluded. 2. 6 mm subpleural nodule in the right lower lobe may represent a satellite lesion. Attention on follow up. 3. Indeterminate left adrenal nodule, incompletely characterized on this study. This may represent a metastatic lesion. If no prior imaging is available characterizing this lesion, this could be further evaluated by adrenal protocol CT or MRI if clinically indicated. 4. No acute process in the abdomen or pelvis to explain patient's chronic diarrhea. 5. 1.8-cm right renal superior pole hypodensity with intermediate density (22HU) could be further evaluated by renal ultrasound. 6. Mild emphysema. Mild pulmonary artery enlargement suggests underlying pulmonary arterial hypertension. 7. Prostatic enlargement with circumferential bladder wall thickening suggests outflow obstruction. 8. No definite evidence of spinal metastases as clinically queried, although MRI is more sensitive. 9. The imaged portion of the right shoulder is unremarkable. Findings discussed with Dr. ___ fellow) by phone at 5:20pm ___. Radiology Report STUDY: Skeletal survey ___. CLINICAL HISTORY: ___ male with large lung mass, likely malignant. Patient has hypercalcemia and has lytic lesions. FINDINGS: Comparison is made to the CT torso study performed on the same day. LATERAL SKULL: There are no focal lytic or blastic lesions. THORACIC/LUMBAR SPINE: There is increased opacity involving the right upper chest consistent with known large lung lesion. Scalloping of the fourth rib on the right side is likely related to the underlying mass. There are no compression deformities of the thoracic vertebral bodies. The intervertebral disc spaces are preserved. The cervical spine demonstrates degenerative changes with loss of intervertebral disc height and spurring worse at C4-C5. Imaging of the lumbar spine demonstrates five non-rib-bearing lumbar-type vertebral bodies. There is contrast material seen within the colon consistent with the recent CT. No large destructive lesions are seen within the vertebral bodies. There are degenerative changes with loss of intervertebral disc height at L5/S1. PELVIS AND FEMURS: Sacroiliac joints are within normal limits. There are mild-to-moderate degenerative changes of both hip joints with spur in the superolateral acetabula. Vascular calcifications are seen bilaterally. HUMERI: Bilateral humeri demonstrate no focal lytic or blastic lesions. IMPRESSION: 1. No focal lytic bone lesions. 2. Large right upper lobe lung mass, better assess on the prior CT scan. 3. Degenerative changes. Radiology Report ULTRASOUND INTERVENTIONAL PROCEDURE DATED ___ INDICATION: ___ man with right upper lobe mass, anemia, and hypercalcemia. Biopsy of lung mass in the right upper lobe. COMPARISON: Comparison is made to previous CT dated ___. PHYSICIANS: Dr. ___ and Dr. ___ performed the procedure. Dr. ___ attending radiologist, was present throughout the procedure. SEDATION: Moderate sedation was provided by administering divided doses of fentanyl 25 mcg and Versed 0.5 mg throughout the total intraservice time of 20 minutes during which the patient's hemodynamic parameters were continuously monitored. PROCEDURE: Following a detailed discussion of the risks, benefits, and alternatives to the procedure, written informed consent was obtained. The patient was transported to the ultrasound suite and placed in a supine position. Initial preprocedure ultrasound was performed for purposes of lesion localization and skin point localization prior to biopsy. An appropriate skin point was obtained within the right axilla. A preprocedural timeout was performed using unique patient identifiers as per ___ protocol. The skin overlying the right axilla was prepped and draped in usual sterile fashion. Approximately 6 mL of 1% lidocaine was infiltrated into the skin, subcutaneous tissues, and to the lesion for local anesthesia. An 18-gauge core biopsy needle was advanced into the lesion and two 18-gauge core biopsy samples were obtained. On-site cytology confirmed sample adequacy. The patient tolerated the procedure well. There were no immediate complications. The patient was transferred back to the floor in stable condition. POE orders were entered online. IMPRESSION: Technically successful ultrasound-guided right upper lobe lung lesion biopsy with two 18-gauge core biopsy samples obtained. No immediate complications. Samples sent to Pathology for further analysis. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: LOW HCT /ELEVATED TROP Diagnosed with SHORTNESS OF BREATH, ANEMIA NOS, MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE, PNEUMONIA,ORGANISM UNSPECIFIED, DIABETES UNCOMPL ADULT temperature: 97.0 heartrate: 76.0 resprate: 17.0 o2sat: 100.0 sbp: 104.0 dbp: 60.0 level of pain: 0 level of acuity: 2.0
You were admitted because of low blood pressure secondary to dehydration, low blood counts, low blood sugars, high calcium levels in your blood, and damage to your heart from a mild heart attack. During your admission, a large mass in the upper aspect of your right lung was found. Initially, this mass thought to be an infection and you were treated with antibiotics; however, these antibiotics were discontinued after further studies suggested it was not an infection. The mass was biopsied, and the results of the biopsy are pending. To correct your low blood counts, you received a blood transfusion. To correct your low blood pressure, dehydration, and high calcium, you received intravenous fluids. To evaluate your heart, you received a heart ultrasound, which suggests that you may have mild heart failure and that one of your heart valves is permitting backflow. To correct your low blood sugar, you received sugar intravenously. During your hospitalization, urinary retention and difficulty urinating was noted. You received a catheter in your bladder to facilitate urine excretion, and were discharged with this catheter.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: amoxicillin Attending: ___ Chief Complaint: Nausea and abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M w/ hx of T2DM, ESRD s/p cadaveric kidney txp in ___ c/b ACR ___, HTN, hypothyroidism p/w 2 weeks of dull, gnawing LUQ abdominal pain and nausea. He notes that he has lost all appetite and has had very little except crackers and water with his pills over the last two weeks. He has never had anything like this before. He denies hx of gallstones, EtOH use, new medications, OTC supplements. Nothing has made it worse or better but pain has been persistent over the two weeks. He denies vomiting, constipation, black or bloody stools, diarrhea. He denies confusion or change in urination. He initially presented to ___ and was found to have Na 125 creatine 1.5 BUN 16 AST 156 ALT 259, alk phos 93. ___ tried to transfer for ___ but hospital is full so transfered to ___ for futher care. In the ED initial vitals were:99.8 72 146/78 18 98% - Labs were significant for UA with protein/glucose/ketones, K 5.2->4.8, Na 128, Bicarb 19, Cl 96, Cr 1.3, BUN 18, Glu 317, Mg 1.5, ALT 269, AST 155, Lipase 514, AP 100, Tbili 0.4, Alb 4.0, H/H 12.3/36.8, Plt 138 - Patient was given 2L NS, IV ondansetron 4mg, MMF 500mg, tacrolimus 1mg, insulin Vitals prior to transfer were: 99.3 80 168/65 16 99% RA On the floor, patient notes that pain is unchanged over the last several weeks and continues at ___. Review of Systems: As per HPI otherwise negative Past Medical History: ESRD due to diabetes mellitus Hypertension Secondary hyperparathyroidism CAD: negative stress test ___, EF 55% Hematuria, cystoscopy ___ negative Meatal stenosis, s/p dilatation ___ Diverticulosis, by colonoscopy ___ s/p amputation of lt middle toe d/t MRSA osteomyelitis ___ s/p ablation d/t AF on ___ (no episodes since) Social History: ___ Family History: No hx of GI/pancreas issues Physical Exam: Vitals - T: 101.6 BP: 171/67 HR: 80 RR: 20 02 sat: 93%RA Wt 78.5kg FSG 258 GENERAL: Well appearing man lying in bed in NAD HEENT: PERRL, anicteric sclera, pink conjunctiva, dry MM CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: Trace crackles at bases bilaterally, no dullness to percussion, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, mild tenderness to palpation over RUQ and epigastrium, 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, AAOx3, motor and sensory exam grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ___ 08:25PM BLOOD WBC-4.5 RBC-4.05* Hgb-12.3* Hct-36.8* MCV-91 MCH-30.4 MCHC-33.4 RDW-13.4 Plt ___ ___ 08:25PM BLOOD Neuts-58 Bands-1 ___ Monos-6 Eos-0 Baso-0 Atyps-2* ___ Myelos-1* Plasma-1* Other-1* ___ 05:44AM BLOOD ___ PTT-26.2 ___ ___ 08:25PM BLOOD Glucose-317* UreaN-18 Creat-1.3* Na-128* K-5.2* Cl-96 HCO3-19* AnGap-18 ___ 05:44AM BLOOD Glucose-270* UreaN-14 Creat-1.2 Na-129* K-4.4 Cl-97 HCO3-21* AnGap-15 ___ 08:25PM BLOOD ALT-269* AST-155* AlkPhos-100 TotBili-0.4 ___ 05:44AM BLOOD ALT-271* AST-195* AlkPhos-89 TotBili-0.4 ___ 08:25PM BLOOD Lipase-514* ___ 05:44AM BLOOD Lipase-75* ___ 08:25PM BLOOD Albumin-4.0 Calcium-9.0 Phos-3.0 Mg-1.5* ___ 05:44AM BLOOD Hapto-251* ___ 08:25PM BLOOD Triglyc-232* ___ 05:44AM BLOOD Osmolal-277 ___ 08:25PM BLOOD tacroFK-5.0 ___ 06:19AM BLOOD Lactate-1.2 URINE ___ 09:55PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 ___ 09:55PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 09:55PM URINE Color-Yellow Appear-Clear Sp ___ MICRO Blood culture pending at time of discharge x2 Urine culture pending at time of discharge CMV viral load pending at time of discharge IMAGING: CXR IMPRESSION: Blunting of several pleural sulci could be due to small effusions or pleural scarring. There is the suggestion of tiny pleural calcifications along the diaphragmatic surface which, if present, would suggest prior asbestos exposure. Lungs are grossly clear. Nipple shadow should not be mistaken for lung nodules. Cardiomediastinal and hilar silhouettes are normal. Graft ultrasound FINDINGS: The right iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no pelvi-infundibular thickening, and renal sinus fat is normal. There is no hydronephrosis. There is no perinephric fluid collection. The resistive index of intrarenal arteries ranges from 0.66 to 0.73, within the normal range. Acceleration times and peak systolic velocities of the main renal artery are normal. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: Normal renal transplant ultrasound. Right Upper Quadrant Ultrasound FINDINGS: LIVER: The liver echotexture is normal and the contour is smooth. There is no focal liver lesion. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic bile duct dilation. The CBD measures 4 mm. GALLBLADDER: There are no stones. There is no gallbladder wall thickening. PANCREAS: The head and body of the pancreas are normal. The tail was not well seen due to overlying bowel gas. RETROPERITONEUM: The imaged portions of the aorta and IVC are within normal limits. IMPRESSION: Normal right upper quadrant abdominal ultrasound. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Mycophenolate Mofetil 500 mg PO TID 4. Amlodipine 5 mg PO BID 5. Gabapentin 200 mg PO QHS 6. PredniSONE 5 mg PO DAILY 7. Tacrolimus 1 mg PO Q12H 8. Glargine 40 Units Bedtime Insulin SC Sliding Scale using UNK Insulin Discharge Medications: 1. Amlodipine 5 mg PO BID 2. Aspirin 81 mg PO DAILY 3. Gabapentin 200 mg PO QHS 4. Glargine 40 Units Bedtime Insulin SC Sliding Scale using UNK Insulin 5. Levothyroxine Sodium 75 mcg PO DAILY 6. Mycophenolate Mofetil 500 mg PO TID 7. PredniSONE 5 mg PO DAILY 8. Tacrolimus 1 mg PO Q12H 9. Ciprofloxacin 400 mg IV Q12H 10. Ganciclovir 390 mg IV Q12H 11. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 12. Pantoprazole 40 mg IV Q12H Discharge Disposition: Extended Care Discharge Diagnosis: Abdominal pain and fever 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: ___ man status post renal transplant, presenting with elevated LFTs. TECHNIQUE: Grayscale and color Doppler ultrasound examination of the abdomen was performed. COMPARISON: None. FINDINGS: LIVER: The liver echotexture is normal and the contour is smooth. There is no focal liver lesion. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic bile duct dilation. The CBD measures 4 mm. GALLBLADDER: There are no stones. There is no gallbladder wall thickening. PANCREAS: The head and body of the pancreas are normal. The tail was not well seen due to overlying bowel gas. RETROPERITONEUM: The imaged portions of the aorta and IVC are within normal limits. IMPRESSION: Normal right upper quadrant abdominal ultrasound. Radiology Report EXAMINATION: RENAL TRANSPLANT U.S. INDICATION: ___ man status post renal transplantation 10 months ago, presenting with elevated creatinine. TECHNIQUE: Grayscale, color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: None available. FINDINGS: The right iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no pelvi-infundibular thickening, and renal sinus fat is normal. There is no hydronephrosis. There is no perinephric fluid collection. The resistive index of intrarenal arteries ranges from 0.66 to 0.73, within the normal range. Acceleration times and peak systolic velocities of the main renal artery are normal. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: Normal renal transplant ultrasound. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with renal txp now presenting with pancreatitis // Evidence of pleural effusions? Evidence of pleural effusions? COMPARISON: There are no prior chest radiographs available. IMPRESSION: Blunting of several pleural sulci could be due to small effusions or pleural scarring. There is the suggestion of tiny pleural calcifications along the diaphragmatic surface which, if present, would suggest prior asbestos exposure. Lungs are grossly clear. Nipple shadow should not be mistaken for lung nodules. Cardiomediastinal and hilar silhouettes are normal. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abnormal labs Diagnosed with ACUTE PANCREATITIS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, KIDNEY TRANSPLANT STATUS temperature: 99.8 heartrate: 72.0 resprate: 18.0 o2sat: 98.0 sbp: 146.0 dbp: 78.0 level of pain: 2 level of acuity: 2.0
Dear Mr. ___, It was a pleasure participating in your care at ___ ___. You were admitted with abdominal pain and you had a fever. As you know, given your status, we are concerned that you may have a CMV infection. You received a dose of antiviral medication and then were transferred to the ___ for continued care. You received a study to determine if gastroparesis was contributing to your abdominal pain, and the results are not available. We will send you a letter with the results.
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ketorolac / Nalbuphine / Simvastatin / Atorvastatin / Crestor / adhesive tape / Erythromycin Base / Green Pepper / Tizanidine / ceftriaxone Attending: ___ Chief Complaint: fall Major Surgical or Invasive Procedure: None History of Present Illness: Hospital Medicine Admission Note Time patient seen and examined today: 930 AM CC: Left groin and leg pain HPI(4): Ms. ___ is a ___ female with a past medical history of chronic compression fractures presents with left groin and leg pain ___ the setting of increasingly frequent falls. Patient is a vague historian and blends a lot of information, often tangential to old history. However, she is generally oriented and aware of HPI. Husband at bedside provides a more clear history and timeline. Patient has had increasing falls. Her acute pain started about 1 week ago after sliding off the side of her bed. She fell directly on her buttock and fell to the side. She has had other falls and has hit her head. No reports of loss of consciousness. She has no prodrome to these episodes and seems like these are mechanical. She specifically denies acute chest pain, palpitations, shortness of breath, diaphoresis, or abdominal pain. The episode 1 week ago off her bed, she attributes to wearing slippery shorts. Patient is on chronic fentanyl and hydromorphone for back pain, but her pain was so severe she could not ambulate (or move for that matter) and husband brought her to the hospital. Pain has been increasing over the last few days. Patient's pain started as moderate and ___ the left groin. Now she describes it as severe sharp pain, radiating all the way to the foot on the left side. She has some numbness and tingling of the toes on the left. She has chronic intermittent urinary incontinence without change. The patient went to ___ ER and reportedly had imaging done. She reports they sent her home with outpatient follow up with her primary orthopedic surgeon. The patient has chronic intermittent shortness of breath and cough related to tracheobronchomalacia and extensive surgical history. She also endorses recent URI (2 weeks ago) treated with 5 days of levofloxacin. She believes she had a UTI at that time. She endorses recurrent UTI. She states she is completing a complicated vaginal yeast infection with a 3rd dose (of 3) fluconazole tomorrow morning. ROS: Pertinent positives and negatives as noted ___ the HPI. All other systems were reviewed and are negative. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: CHRONIC PANCREATITIS RAPID GASTRIC EMPTYING COMPRESSION FRACTURES GASTROESOPHAGEAL REFLUX DIABETES, TYPE II/HBP HYPERLIPIDEMIA IRON DEFICIENCY ANEMIA SARCOIDOSIS TRACHEOBRONCHOMALACIA UNILATERAL VOCAL CORD PARALYSIS NECK PAIN RECURRENT UTI CAD s/p MI, stent ___ LAD # Tracheobronchomalacia, - s/p TBP with mesh, ___ - s/p cervical tracheoplasty with mesh, ___ - s/p medialization laryngoplasty with GoreTex, left arytenoid adduction, left pharyngoplasty, ___ # Sarcoidosis # Diabetes mellitus # Hypertension # Hyperlipidemia # Pancreatic disease - s/p cholecystectomy, ___ - s/p sphincterotomy, ___ - numerous ERCP # Chronic abdominal/back pain with history of detox # Osteoarthritis # Osteoporosis with compression fractures # Peptic ulcer disease # Gastroesophageal reflux disease # Depression PAST SURGICAL HISTORY: 1. Appendectomy. ___ 2. Right ankle pinning, 1970s 3. Total abdominal hysterectomy, ___ 4. Kyphoplasy, ___ 5. Rib fracture, thought secondary to coughing (___) 6. Inguinal hernia repair 7. Left pharngoplasty, arytenoid adduction, and medialization laryngoplasty (___) Social History: ___ Family History: Father: died of CVA Mother: died of MI/COPD Brother: died of MI (age ___ Physical Exam: ADMISSION EXAMINATION VITALS: ___ 1139 Temp: 97.6 PO BP: 157/63 HR: 63 RR: 18 O2 sat: 95% O2 delivery: RA GENERAL: Alert. ___ no apparent distress at rest, but appears anxious. Moderate painful distress when moving about bed. EYES: Anicteric, pupils equally round and reactive to light. ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate, but ? structural abnormality on left posterior pharynx, no clear mass. Left superior anterior cervical lymph node (patient recalls this to be known lipoma-like growth). CV: Heart regular, no murmur, no JVD. Radial and DP pulses present. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Obese. Abdomen is soft, non-distended, non-tender. Bowel sounds present. GU: No suprapubic tenderness MSK: Neck supple, moves all extremities, strength grossly symmetric bilaterally ___ upper extremities. Left leg limited range of motion and strength due to pain (per patient). SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs (as above), sensation to light touch grossly intact ___ distal feet. PSYCH: pleasant, appropriate affect DISCHARGE EXAM AVSS, NAD RRR CTAB sntnd wwp neg edema A&O grossly, MAEE, no facial droop, abnormal voice per baseline L hip with mild tenderness to movement and particularly with log roll no rash Pertinent Results: ADMISSION RESULTS ___ 12:00AM BLOOD WBC-6.5 RBC-3.99 Hgb-12.1 Hct-37.0 MCV-93 MCH-30.3 MCHC-32.7 RDW-13.3 RDWSD-45.1 Plt ___ ___ 12:00AM BLOOD Glucose-159* UreaN-14 Creat-0.6 Na-131* K-5.7* Cl-93* HCO3-26 AnGap-12 ___ 06:15AM BLOOD Mg-1.5* ___ 08:02AM BLOOD %HbA1c-8.9* eAG-209* ========== PERTINENT INTERVAL RESULTS DATA: ___ L-SPINE W/O CONTRAST 1. Study limited by diffuse osteopenia. 2. Transitional anatomy as described. 3. Within limits of study, no acute fracture or traumatic subluxation is identified. 4. Grossly stable multilevel vertebral augmentation, and a similar distribution to the study of ___, including some epidural cement at L1. 5. T12 and L1 stable chronic compression deformities. 6. Grossly stable multilevel degenerative changes are similar to ___ prior exam, allowing for difference ___ technique. Please note that lumbar spine MRI is more sensitive for the evaluation of vertebral canal neural foraminal narrowing. 7. Additional findings as described. Outside images: ) lower extremity duplex that did not reveal evidence of acute DVT. 2) CT abd/pelvis without major abnormality, specifically no mention of bony abnormality or fracture. They mention nonspecific pulmonary nodules that may need follow up with outpatient pulmonologist. CT CHEST: IMPRESSION: Left ventricular thrombus, chronicity and clear but element of acute etiology cannot be excluded. Echocardiography is recommended. Near field areas ___ the posterior segment of the right upper lobe as well as basal lateral segment of the right lower lobe and posterior segment of the left lower lobe, most likely representing currently air filled bronchiectasis, cystic and less likely cavitated nodules Multiple pre-existing and some new pulmonary nodules ___ conjunction with mediastinal calcified lymphadenopathy might represent either ongoing sarcoidosis or combination of sarcoidosis ___ a typical mycobacteria. Dilated biliary and pancreatic ducts, reason unclear, correlation with MRCP is to be considered. VIDEO SWALLOW IMPRESSION: Penetration with nectar thick liquids and thin liquids. Instance aspiration with thin liquids with sequential swallows. TTE CONCLUSION: The left atrial volume index is normal. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is mild regional left ventricular systolic dysfunction with apical akinesis and severe hypokinesis of the distal septum and anterior walls (see schematic) and preserved/normal contractility of the remaining segments. The apex is aneurysmal with a moderate 1.0cm mobile left ventricular THROMBUS. Overall left ventricular systolic function is normal. The visually estimated left ventricular ejection fraction is 45%. Left ventricular cardiac index is low normal (2.0-2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests a normal left ventricular filling pressure (PCWP less than 12mmHg). Normal right ventricular cavity size with normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is normal. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. The aortic valve leaflets (?#) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are not well seen. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is borderline elevated. There is a trivial pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with apical akinesis/aneurysm and THROMBUS. No valvular pathology or pathologic flow identified. Borderline elevated pulmonary artery systolic pressure. Compared with the prior TTE (images reviewed) of ___ , an apical thrombus is now seen (prior study was without echo contrast) and the estimated pulmonary artery systolic pressure is now lower. CLINICAL IMPLICATIONS: Based on the echocardiographic findings and ___ ACC/AHA recommendations, antibiotic prophylaxis is NOT recommended. ___ 05:00AM BLOOD ___ PTT-91.1* ___ ___ 10:10AM BLOOD ___ PTT-88.0* ___ ___ 08:10AM BLOOD Glucose-108* UreaN-20 Creat-0.5 Na-128* K-4.7 Cl-92* HCO3-26 AnGap-10 ___ 08:10PM BLOOD Glucose-192* UreaN-19 Creat-0.7 Na-128* K-5.0 Cl-93* HCO3-25 AnGap-10 ___ 07:40AM BLOOD Glucose-91 UreaN-20 Creat-0.5 Na-132* K-4.9 Cl-95* HCO3-23 AnGap-14 ___ 09:00AM BLOOD Glucose-152* UreaN-21* Creat-0.5 Na-134* K-4.8 Cl-97 HCO3-24 AnGap-13 ___ 06:50AM BLOOD Glucose-143* UreaN-18 Creat-0.6 Na-133* K-5.4 Cl-98 HCO3-22 AnGap-13 ___ 05:00AM BLOOD Glucose-219* UreaN-19 Creat-0.6 Na-130* K-4.7 Cl-96 HCO3-25 AnGap-9* ___ 05:00AM BLOOD Calcium-9.5 Phos-2.8 Mg-1.5* ___ 08:02AM BLOOD %HbA1c-8.9* eAG-209* ___ 08:10PM BLOOD Osmolal-281 ___ 08:22AM BLOOD PTH-51 ___ 08:24PM BLOOD freeCa-1.28 ___ 01:12AM URINE Osmolal-422 ___ 01:12AM URINE Hours-RANDOM Na-99 ___ 12:29 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 8:36 pm SPUTUM Source: Induced. GRAM STAIN (Final ___: <10 PMNs and <10 epithelial cells/100X field. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. 2+ ___ per 1000X FIELD): BUDDING YEAST. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. FUNGAL CULTURE (Preliminary): ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): ___ 5:07 am SPUTUM Source: Induced. GRAM STAIN (Final ___: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. FUNGAL CULTURE (Preliminary): GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS Specimen is only screened for Cryptococcus species. New specimen is recommended. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): ___ 4:46 pm SPUTUM Source: Induced. GRAM STAIN (Final ___: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. FUNGAL CULTURE (Preliminary): GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS. Specimen is only screened for Cryptococcus species. New specimen is recommended. ACID FAST SMEAR (Preliminary): ACID FAST CULTURE (Preliminary): ========= DISCHARGE RESULTS ___ 07:40AM BLOOD WBC-5.5 RBC-3.96 Hgb-12.0 Hct-37.6 MCV-95 MCH-30.3 MCHC-31.9* RDW-12.8 RDWSD-44.2 Plt ___ ___ 10:10AM BLOOD ___ PTT-88.0* ___ ___ 05:00AM BLOOD Calcium-9.5 Phos-2.8 Mg-1.5* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fenofibrate 145 mg PO DAILY 2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 3. guaiFENesin 600 mg oral BID 4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath 5. Metoclopramide 10 mg PO QIDACHS 6. Nortriptyline 100 mg PO QHS 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Omeprazole 40 mg PO BID 9. Miconazole 2% Cream 1 Appl TP BID 10. Acetaminophen-Caff-Butalbital 1 TAB PO BID 11. diclofenac sodium 1 % TOPICAL Q4H 12. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheezing 13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing 14. amLODIPine 10 mg PO DAILY 15. Aspirin 81 mg PO DAILY 16. Atorvastatin 80 mg PO QPM 17. Cyclobenzaprine 10 mg PO TID:PRN Muscle spasm 18. Fentanyl Patch 37 mcg/h TD Q72H 19. Ferrous Sulfate 325 mg PO DAILY 20. Fluconazole 150 mg PO ONCE 21. Gabapentin 300 mg PO QHS 22. Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 23. LORazepam 0.5 mg PO BID:PRN Anxiety 24. melatonin 10 mg oral QHS:PRN Insomia 25. methylcellulose (laxative) 15 mL oral DAILY:PRN Constipation 26. Metoprolol Succinate XL 25 mg PO QHS 27. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain 28. Ondansetron ODT 4 mg PO BID:PRN Nausea/Vomiting - First Line 29. Pancrelipase 5000 1 CAP PO TID W/MEALS 30. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Moderate 31. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Benzonatate 100 mg PO TID 3. Enoxaparin Sodium 70 mg SC Q12H 4. Magnesium Oxide 400 mg PO TID Duration: 3 Doses 5. Warfarin 5 mg PO DAILY16 6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 7. Glargine 20 Units Bedtime Humalog 3 Units Breakfast Humalog 3 Units Lunch Humalog 3 Units Dinner Insulin SC Sliding Scale using HUM Insulin 8. LORazepam 0.5 mg PO Q8H:PRN Anxiety RX *lorazepam 0.5 mg 1 TAB by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 9. Nortriptyline 75 mg PO QHS RX *nortriptyline 75 mg 1 tab by mouth at bedtime Disp #*30 Capsule Refills:*0 10. Acetaminophen-Caff-Butalbital 1 TAB PO BID RX *butalbital-acetaminophen-caff 50 mg-300 mg-40 mg 1 tab by mouth twice a day Disp #*20 Capsule Refills:*0 11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing 12. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheezing 13. amLODIPine 10 mg PO DAILY 14. Aspirin 81 mg PO DAILY 15. Atorvastatin 80 mg PO QPM 16. Cyclobenzaprine 10 mg PO TID:PRN Muscle spasm 17. diclofenac sodium 1 % TOPICAL Q4H 18. Fenofibrate 145 mg PO DAILY 19. Fentanyl Patch 37 mcg/h TD Q72H RX *fentanyl 37.5 mcg/hour 1 patch q72h Disp #*10 Patch Refills:*0 20. Ferrous Sulfate 325 mg PO DAILY 21. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 22. Gabapentin 300 mg PO QHS 23. guaiFENesin 600 mg oral BID 24. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath 25. melatonin 10 mg oral QHS:PRN Insomia 26. methylcellulose (laxative) 15 mL oral DAILY:PRN Constipation 27. Metoclopramide 10 mg PO QIDACHS 28. Metoprolol Succinate XL 25 mg PO QHS 29. Miconazole 2% Cream 1 Appl TP BID 30. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain 31. Omeprazole 40 mg PO BID 32. Ondansetron ODT 4 mg PO BID:PRN Nausea/Vomiting - First Line 33. Pancrelipase 5000 1 CAP PO TID W/MEALS 34. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pain after fall Hyponatremia Poorly controlled type 2 diabetes mellitus Tracheobronchomalacia Chronic pain Anxiety SIADH Cavitary lesions ___ lung LV aneurysm LV thrombus Discharge Condition: Ambulating with walker Followup Instructions: ___ Radiology Report EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE INDICATION: History: ___ with 2d hx of L leg pain/weakness// Eval for cause of L leg pain/weakness Eval for cause of L leg pain/weakness 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 7.8 s, 30.8 cm; CTDIvol = 31.1 mGy (Body) DLP = 957.7 mGy-cm. Total DLP (Body) = 958 mGy-cm. COMPARISON: Reference lumbar spine dated ___. FINDINGS: For the purposes of numbering, the lowest rib bearing vertebral body was designated the T12 level. Following this convention, the L1 vertebral body demonstrates left sided rudimentary rib (see 02:34), and there is transitional anatomy with partial lumbarization of S1 (602:39). There is levoscoliosis of the lumbar spine. 3 mm retrolisthesis of L1 on L2 is unchanged. The visualized osseous structures are osteopenic.There is no prevertebral soft tissue swelling. No definite acute fractures are identified. Vertebral augmentation cement is re-demonstrated in T12, L1 and L4 in a similar distribution. Height loss of T12 and L1 is similar. Retropulsion of T12 and L1 posterior endplates into the canal, as well as some epidural cement leakage is also unchanged (02:35). There is mild canal narrowing at L1 due to the cement and retropulsion. Allowing for difference in technique, grossly stable multilevel lumbar spondylosis is noted, including loss of intervertebral disc height, vacuum disc phenomena, disc bulges, disc osteophytes, and facet joint hypertrophy. There is at least moderate neural foraminal narrowing on the left at L5-S1 due to osteophytes. Overall, degenerative changes are similar to ___. OTHER: Subpleural fibrotic changes are noted at both lung bases. Bilateral renal cysts are partially imaged. Severe aortoiliac calcification is present. Within the limits of this noncontrast study there is no paravertebral or paraspinal mass identified. IMPRESSION: 1. Study limited by diffuse osteopenia. 2. Transitional anatomy as described. 3. Within limits of study, no acute fracture or traumatic subluxation is identified. 4. Grossly stable multilevel vertebral augmentation, and a similar distribution to the study of ___, including some epidural cement at L1. 5. T12 and L1 stable chronic compression deformities. 6. Grossly stable multilevel degenerative changes are similar to ___ prior exam, allowing for difference in technique. Please note that lumbar spine MRI is more sensitive for the evaluation of vertebral canal neural foraminal narrowing. 7. Additional findings as described. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with TBM, with increased cough// infiltrate? TECHNIQUE: Frontal and lateral view radiographs of the chest. COMPARISON: Chest radiograph ___. IMPRESSION: There is no focal consolidation, pleural effusion or pneumothorax. There is unchanged right basilar fibrosis/scarring. The cardiomediastinal silhouette is stable in appearance. There is a defect in the posterior aspect of the right fourth rib, which may be postsurgical. Kyphoplasty changes are seen in several lower thoracic and lumbar vertebral bodies. Radiology Report EXAMINATION: SECOND OPINION CT ABD/PELVIS INDICATION: ___ year old woman with left hip and left pain, osh pelvic ct// evaluate for fracture TECHNIQUE: Please see a sign report for further details on techniques. DOSE: Found no primary dose record and no dose record stored with the sibling of a split exam. !If this Fluency report was activated before the completion of the dose transmission, please reinsert the token called CT DLP Dose to load new data. COMPARISON: Prior abdominal CT from ___. Trachea CT from ___ FINDINGS: LOWER CHEST: New lung nodules in the middle lobe and left lung base (3:4) measuring respectively 7 and 8 mm. Mild bronchial wall thickening. Several calcified lymph nodes are noted in the mediastinum. There is no evidence of pleural or pericardial effusion. ABDOMEN AND PELVIS: Hepatobiliary: The liver demonstrates homogenous attenuation throughout with nodular contour. There is no evidence of focal lesions. Gas foci are noted within the biliary tree, likely secondary to recent instrumentation. The gallbladder is surgically absent. Pancreas: The pancreas is again noted to be atrophic with no pancreatic duct dilation. 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 normal and symmetric in size with normal nephrogram. There is no evidence of hydronephrosis. Multiple hypodense lesions are seen in both kidneys measuring up to 4.7 cm, representing simple cysts (03:39). There is no perinephric abnormality. Gastrointestinal: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout.The colon and rectum are within normal limits. The appendix is normal. Pelvis: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. Reproductive Organs: The 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. Mild atherosclerotic disease is noted. Bones: There is no evidence of worrisome osseous lesions or acute fracture. Prior vertebroplasty of L4, L1 and T12. Soft Tissues: Diastasis of the rectus muscles. IMPRESSION: 1. New lung nodules measuring up to 8 mm as compared to prior trachea CT from ___. This should be fully assessed by dedicated chest CT. 2. No evidence acute fractures within the visualized skeleton. 3. Redemonstration of an atrophic pancreas, evidence of chronic pancreatitis. 4. Patient is status post cholecystectomy and hysterectomy. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old woman with tracheobronchomalacia, fall, found to have siadh and pulmonary nodules// assess nodules, r/o cancer 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: Pulmonary artery is mildly dilated, 3.3 cm. Aorta is normal in diameter. Coronary calcifications are extensive. There is left ventricular aneurysm containing small, 11 x 8 x 15 mm thrombus, series 5, image 52. It appearance might be concerning for acute on chronic etiology. Multiple calcified mediastinal and noncalcified mediastinal and hilar lymph nodes are unchanged might represent sarcoidosis as previously suggested. Esophagus is patulous, similar or progressed since previous examination. Airways are patent to the subsegmental level bilaterally. Image portion of the upper abdomen demonstrate pneumobilia, unchanged as well as dilatation of the pancreatic duct, series 2, image 55, reason unclear. Previously nodular appearance of the findings in the posterior segment of the right upper lobe now has a air filled appearance and most likely represent a cystic bronchiectasis and substantially less likely large cavitated nodule. The overall ___ are 3 x 2 cm, series 4, image 91. Similar appearance is also noted in the basal lateral segment of the right lower lobe (4:165) and posterior segment of the left lower lobe (4:131), most likely representing similar etiology. Multiple pulmonary nodules are demonstrated scattered throughout the lungs, the majority of them is stable but some are new, series 4, image 165, series 4, image 157.. Multiple liver renal cysts are bilateral. There are no lytic or sclerotic lesions worrisome for infection or neoplasm. The patient is after lower thoracic vertebral plasty IMPRESSION: Left ventricular thrombus, chronicity and clear but element of acute etiology cannot be excluded. Echocardiography is recommended. Near field areas in the posterior segment of the right upper lobe as well as basal lateral segment of the right lower lobe and posterior segment of the left lower lobe, most likely representing currently air filled bronchiectasis, cystic and less likely cavitated nodules Multiple pre-existing and some new pulmonary nodules in conjunction with mediastinal calcified lymphadenopathy might represent either ongoing sarcoidosis or combination of sarcoidosis in a typical mycobacteria. Dilated biliary and pancreatic ducts, reason unclear, correlation with MRCP is to be considered. Radiology Report INDICATION: ___ year old woman with TBM, dysphagia, spinal surgeries, here w worse dysphagia// r/o aspiration TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the Speech-Language Pathologist from the Voice, Speech & Swallowing Service. Multiple consistencies of barium were administered. DOSE: Fluoro time: 5 min. COMPARISON: None FINDINGS: Thin liquid, nectar thick liquid, purees, solid and barium pill with administered in conjunction with speech pathologist. There is complete velopharyngeal closure. There is normal hyolaryngeal excursion. Intermittent penetration is seen with nectar thick liquid and thin liquid with single sips. There was instance aspiration of thin liquids with sequential swallows. A barium tablet was administered and rapidly arrived to the stomach. Of note, the esophagus appears distended by gas. IMPRESSION: Penetration with nectar thick liquids and thin liquids. Instance aspiration with thin liquids with sequential swallows. Please note that a detailed description of dynamic swallowing as well as a summative assessment and recommendations are reported separately in a standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation Services). Gender: F Race: WHITE Arrive by WALK IN Chief complaint: L Leg pain Diagnosed with Radiculopathy, lumbosacral region temperature: 96.3 heartrate: 75.0 resprate: 22.0 o2sat: 96.0 sbp: 140.0 dbp: 76.0 level of pain: 10 level of acuity: 2.0
Dear ___ was a pleasure caring for you. You were hospitalized with leg pain after your fall. There is thankfully no fracture and your pain is slowly improving. ___ addition, you were found to have low sodium due to a condition called "SIADH" or syndrome of inappropriate antidiuretic hormone. SIADH is likely caused by your pain and maybe your lung issues. This improved with fluid restriction, and we recommend you continue to limit yourself to 1.5L of free water daily. This will hopefully be temporary, but your doctors ___ when you can stop restricting. We also found that you had lesions ___ your lungs ("cavitary lesions"), the cause of which is not completely clear but which may be from infection of mycobacteria. Tests are pending and you will follow up with the lung doctors here to decide what if any management will be necessary. We also found you had a clot ___ your heart with an aneurysm ___ the heart. For this we started you on a blood thinner. You are currently taking 2 blood thinners (Lovenox injections and warfarin) until the warfarin kicks ___, after which you will stop taking the Lovenox and just take the warfarin. You will be on the warfarin for at least 3 months and will have follow up with your cardiologist to consider what if any further diagnosis/management will be necessary. We found that you had slight widening of some of the biliary tubes around your liver. This is likely not a problem, but at some point ___ the near future you will need to have a test called an "MRCP". We have informed your doctors about this. We have increased some of your pain and anxiety medications, but as we discussed, these increase your risk of fall and other adverse outcomes, so we recommend you work with your doctors to reduce these sedating medications as soon as able.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___,pcn Attending: ___. Chief Complaint: Head strike with supratherapuetic INR Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx afib, recent small stroke w/ minimal residual deficit who was recently started on coumadin post stroke, transferred from ___ after falling at home with head strike and supratherapeutic INR. A head CT was negative at ___ but due to lack of neurosurgical services, the patient was transferred here. The pt fell about 24 hours ago after getting up to urinate at night. She denies symptoms prior to fall such as dizziness, lightheadedness, vasovagal syptoms, and had no LOC. She fell from standing as she reports tripping due to the thick carpeting in her home, and hitting her right face on carpeted floor. She reports difficulty with her walker as it sticks to the carpet. After falling, she felt fine and reports getting up and going back to bed before being found the subsequent morning by her ___ with a bruise over her right face at which point she presnted to ___. The patient actually reports returning from hospitalization and rehab just a few weeks ago after a "series of small strokes," at which point she was started on warfarin. Up until the event yesterday, she reports doing very well. In the ED intial vitals were Pain 0, T 98.7, HR 53, BP 187/70 RR 13 O2 97% RA. Pt was admitted for observation. Notably, INR was 3.9. On the floor, patient is comfortable and has no complaints. Review of Systems: (+) (-) 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: Afib Anemia Arthritis HLD Colostomy CVA Hypothyroidism Celiac Disease Social History: ___ Family History: Mom- DM Brother- CAD Negative for cancer or CVA Physical Exam: ADMISSION EXAM: Vitals- 98.4 BP 182/66 51 18 99% RA General- Alert, oriented, no acute distress HEENT- Bruise over left forehead/eye, PERRL, EOMI, 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, Harsh systolic murmur heard throughout precordium with minimal radiation to carotids. Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, notable for presence of ostomy bag GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, ___ strength and sensation in tact of upper and lower extremities DISCHARGE EXAM: Vitals- 98.2, 144/67, 54, 16, 100% RA General- Pleasant, sitting up in chair reading, NAD HEENT- Normocephalic. Bruising around right eye from fall. Sclera anicteric, PERRL, EOMI, MMM, oropharynx clear. Neck- supple, JVP not elevated, no carotid bruits Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Bradycardic with regular rhythm, normal S1 + S2, ___ harsh systolic murmur heard best at LUSB and can be heard throughout the precordium. NO rubs or gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Colostomy bag in LLQ with both air and stool in the bag. Stool is brown in color with no e/o frank blood Neuro- A+O x 3 Pertinent Results: ADMISSION LABS: ___ 08:26PM BLOOD WBC-6.0 RBC-3.44* Hgb-9.6* Hct-29.0* MCV-84 MCH-28.0 MCHC-33.2 RDW-13.4 Plt ___ ___ 08:26PM BLOOD Neuts-61.4 ___ Monos-5.8 Eos-2.7 Baso-0.6 ___ 08:26PM BLOOD ___ PTT-39.4* ___ ___ 08:26PM BLOOD Glucose-92 UreaN-26* Creat-1.1 Na-138 K-4.6 Cl-103 HCO3-29 AnGap-11 ___ 08:26PM BLOOD Iron-41 ___ 08:26PM BLOOD calTIBC-280 Ferritn-63 TRF-215 PERTINENT LABS: ___ 05:50AM BLOOD Hgb-9.7* Hct-28.1* ___ 05:15AM BLOOD WBC-6.1 RBC-3.44* Hgb-9.8* Hct-28.9* MCV-84 MCH-28.4 MCHC-33.8 RDW-13.6 Plt ___ ___ 05:50AM BLOOD ___ ___ 05:15AM BLOOD ___ PTT-35.3 ___ ___ 05:50AM BLOOD Ret Aut-1.5 DISCHARGE LABS: ___ 05:15AM BLOOD WBC-5.9 RBC-3.25* Hgb-9.2* Hct-27.3* MCV-84 MCH-28.4 MCHC-33.8 RDW-13.7 Plt ___ ___ 05:15AM BLOOD ___ PTT-35.1 ___ URINE: ___ 09:17PM URINE Color-Straw Appear-Clear Sp ___ ___ 09:17PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM ___ 09:17PM URINE RBC-4* WBC-4 Bacteri-FEW Yeast-NONE Epi-<1 MICRO: None IMAGING: ___ ECG Sinus bradycardia. Left anterior fascicular block. Baseline artifact. Otherwise, within normal limits. No previous tracing available for comparison. ___ CAROTID SERIES COMPLETE Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right there is mild heterogeneous plaque in the ICA. On the left there is mild heterogeneous plaque seen in the ICA. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 45/13, 74/20, 69/15, cm/sec. CCA peak systolic velocity is 83 cm/sec. ECA peak systolic velocity is 106 cm/sec. The ICA/CCA ratio is .89. These findings are consistent with <40% stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 45/9, 67/16, 63/12, cm/sec. CCA peak systolic velocity 62 cm/sec. ECA peak systolic velocity is 102 cm/sec. The ICA/CCA ratio is 1.0. These findings are consistent with <40% stenosis. Right antegrade vertebral artery flow. Left antegrade vertebral artery flow. IMPRESSION: Right ICA<40% stenosis. Left ICA<40% stenosis. ___ ECG Sinus bradycardia. P-R interval prolongation. Left atrial abnormality. Left axis deviation with left anterior fascicular block. Compared to the previous tracing of ___ there is no significant diagnostic change. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 300 mg PO Q2D 2. Levothyroxine Sodium 50 mcg PO DAILY 3. Metoprolol Tartrate 25 mg PO BID 4. Paroxetine 10 mg PO DAILY 5. Simvastatin 40 mg PO DAILY 6. Warfarin 2 mg PO DAILY16 7. Aspirin 325 mg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Paroxetine 10 mg PO DAILY 3. Simvastatin 40 mg PO DAILY 4. Warfarin 1 mg PO DAILY16 RX *warfarin 1 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 5. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 6. Amiodarone 100 mg PO DAILY RX *amiodarone 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 Discharge Disposition: Home With Service Facility: ___ ___: PRIMARY DIAGNOSES: Fall Atrial Fibrillation s/p embolic stroke SECONDARY DIAGNOSES: Hypertension Celiac disease Dyslipidemia Hypothyroidism 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 ___ Department of Radiology Standard Report Carotid US Study: Carotid Series Complete Reason: ___ year old woman with history of A/Fib, and recent small stroke, with a non palpable left carotid pulse. Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right there is mild heterogeneous plaque in the ICA. On the left there is mild heterogeneous plaque seen in the ICA. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 45/13, 74/20, 69/15, cm/sec. CCA peak systolic velocity is 83 cm/sec. ECA peak systolic velocity is 106 cm/sec. The ICA/CCA ratio is .89. These findings are consistent with <40% stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 45/9, 67/16, 63/12, cm/sec. CCA peak systolic velocity 62 cm/sec. ECA peak systolic velocity is 102 cm/sec. The ICA/CCA ratio is 1.0. These findings are consistent with <40% stenosis. Right antegrade vertebral artery flow. Left antegrade vertebral artery flow. Impression: Right ICA<40% stenosis. Left ICA<40% stenosis. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: FALL, HIGH INR Diagnosed with SYNCOPE AND COLLAPSE, HEAD INJURY UNSPECIFIED, UNSPECIFIED FALL, ABNORMAL COAGULATION PROFILE, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT temperature: 98.7 heartrate: 53.0 resprate: 18.0 o2sat: 97.0 sbp: 187.0 dbp: 70.0 level of pain: 0 level of acuity: 3.0
Ms. ___, It was a pleasure taking care of you at the ___ ___. You were transferred to our hospital from ___ because you had a fall while on the blood thinner coumadin. ___ did a CT scan of your head and did not see any evidence of bleeding. They transferred you to ___ for a second opinion and any further management that you would require. You had a carotid ultrasound which showed no significant disease. You were seen by the physical therapists in the hospital who determined that you are safe for discharge home with physical therapy. Please take all your medications as prescribed. We changed or stopped the following medications: Metoprolol: Please stop the metorpolol. Amiodarone: Please continue your amiodarone at 100 mg by mouth daily. Coumadin: Your coumadin was decreased to 1 mg by mouth daily. Lisinopril: Please start 1 tablet by mouth daily for blood pressure control. You will need to make a follow up appointment with your primary care physician ___ 7 days after discharge. You have an appointment with your cardiologist as listed below. It is important that you make/keep these appointments as they might want to make medication changes. You will need to have an INR and renal function checked on ___ and have the results sent to Dr. ___ ___. Thank you for allowing us to participate in your care.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Fall, Left ___ Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year-old male who was dining at his daughter's restaurant on the evening of admission. He had two beers with dinner and then drove home. He was found down at his door step by a friend confused and disoriented. He was brought to the ED by ambulance. Past Medical History: - HLD - Gout - Bilateral knee replacement ___ - Appendectomy Social History: ___ Family History: Father deceased at age ___ from myocardial infarction. Mother deceased age ___ from myocardial infarction. Patient has 5 siblings all of whom have a history of cancer ranging from breast cancer, to pancreatic cancer, lung cancer in the non-Hodgkin lymphoma. Physical Exam: Upon admission: Gen: Slightly uncomfortable laying on his back, asking for pain medications for chest pain HEENT: Abrasions above left eye Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. . Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to self only. Language: Speech fluent with good comprehension Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,4 to 3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. _______________________________ Upon discharge: Awake, alert, oriented to self, date, hospital, ___. Follows commands briskly. Speech fluent. PERRL, EOM-I. Left periorbital ecchymosis. Face symmetric, tongue midline. No drift. Moves all extremities with grossly full strength. Sensation grossly intact to LT throughout. Anterior chest wall pain to palpation on left. Pertinent Results: CT C-Spine - ___: No acute fracture or malalignment involving the cervical spine. CT Chest - ___ 1. Extensive coronary artery calcification and moderate to severe aortic valvular calcifications are present. 2. Nondisplaced left anterior rib fractures involving ribs 5 through 7. There is no pneumothorax. CT Head - ___: 1. Increased left subdural collection with Ventricles remain unchanged . Basal cisterns remain patent. 2. Small foci of subarachnoid hemorrhage involves the posterior left insular region not significantly change relative to prior examination. No new hemorrhage. FAST U/S - ___: No free fluid identified on this limited abdominal ultrasound. Medications on Admission: Simvastatin 20mg daily Vitamin B12-Folic acid Aspirin 81mg daily Citalopram 10mg daily Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Citalopram 10 mg PO DAILY 3. Simvastatin 20 mg PO QPM 4. Cyanocobalamin 50 mcg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. FoLIC Acid 1 mg PO DAILY OTC Medication - Ask your Pharmacist 7. Multivitamins 1 TAB PO DAILY OTC Medication - Ask your Pharmacist 8. Senna 17.2 mg PO HS OTC Medication - Ask your Pharmacist 9. Thiamine 100 mg PO DAILY OTC Medication - Ask your Pharmacist 10. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush 11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills:*0 12. Acetaminophen 325-650 mg PO Q6H:PRN Pain/Fever Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Traumatic Subarachnoid Hemorrhage Chronic Left Subdural Hematoma Rib fractures Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: History: ___ with s/p fall unwitness known SAH from OSH left rib pain // unwitness fall eval for trauma unwitness fall eval for trauma TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 5.6 s, 21.8 cm; CTDIvol = 37.2 mGy (Body) DLP = 811.7 mGy-cm. Total DLP (Body) = 812 mGy-cm. COMPARISON: None available. FINDINGS: There is no fracture or acute malalignment involving the cervical spine. Multilevel degenerative changes are mild to moderate and most severe at the C3-C4 and C5-C6 levels. Minimal central canal narrowing at these levels is noted. There is no abnormal prevertebral soft tissue swelling. Extensive atherosclerotic calcifications involve bilateral carotid bulbs. A small 6 mm hypodensity is present within the left thyroid lobe (3:65). Imaged lung apices demonstrate apical pleural parenchymal scarring involving the left upper lobe. IMPRESSION: No acute fracture or malalignment involving the cervical spine. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ male status post fall. TECHNIQUE: Multi detector CT images through the chest were obtained after the uneventful administration of intravenous contrast in soft tissue and bone algorithm windows. Coronal and sagittal reformations were generated and reviewed. Axial maximal intensity projection images were additionally performed. DOSE: Total DLP (Body) = 601 mGy-cm. COMPARISON: None available. FINDINGS: The imaged thyroid gland is unremarkable in appearance. There is no axillary, supraclavicular, mediastinal, or hilar adenopathy. The ascending aorta is non aneurysmal. The main pulmonary artery is within normal limits in caliber. Extensive coronary artery calcifications predominantly involve the left anterior descending coronary artery. Moderate to severe aortic valvular calcifications are additionally present. Heart is normal in size. There is no pericardial effusion. Coronary artery calcifications involve the lateral aortic arch as well as the descending thoracic aorta. Note is made of a common origin of the right brachiocephalic artery and left common carotid artery. The esophagus is unremarkable. Airways are patent to the subsegmental level. Bibasilar atelectasis is mild. There is no large mass or suspicious pulmonary nodule. Minimal biapical pleural parenchymal scarring is symmetric. A ground-glass opacity within the right upper lobe measures 7 mm (02:19). There is no pleural effusion or pleural abnormality. Although study is not tailored for subdiaphragmatic evaluation, imaged portions demonstrate of the upper stomach demonstrates heterogeneous density layering within the posterior gastric lumen dependently, most likely gastric contents. There is no pneumothorax. There is no focal bony lesion worrisome for malignancy or infection. Nondisplaced left rib fractures involve the ___, ___, and 7th ribs anteriorly. Bones are diffusely demineralized. Minimal rightward convex upper thoracic scoliosis is present. IMPRESSION: 1. Extensive coronary artery calcification and moderate to severe aortic valvular calcifications are present. 2. Nondisplaced left anterior rib fractures involving ribs 5 through 7. There is no pneumothorax. NOTIFICATION: Updated impression regarding rib fractures and impression of likely gastric contents within the stomach discussed with the Dr. ___ telephone at 9:17 am on ___ after attending readout. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with s/p syncope intoxicated // eval for interval change at 0500 TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. COMPARISON: Head CT performed ___ at approximately 20:51 FINDINGS: Relative to prior examination, a left frontal convexity subdural hemorrhage appears to have increased in size measuring 6 mm in maximal thickness previously 4 mm (02:14). This is associated with a a rightward shift of normally midline structures approximately 4 mm. Trace amount of subarachnoid blood is identified involving the left insular region has not progressed (02:16). No new hemorrhage is present. There is no evidence of large acute territorial infarction. Gray-white matter differentiation is preserved. Basal cisterns are patent. Subgaleal hematoma involving the left frontal scalp soft tissues is unchanged. No underlying bony abnormality is present. Soft tissue swelling involves the soft tissues lateral to the left orbit. The globe and orbits bilaterally are otherwise unremarkable. Visualized paranasal sinuses demonstrate minimal mucosal thickening within the ethmoidal air cells. Mastoid air cells and middle ear cavities are clear bilaterally. Atherosclerotic calcifications involving the carotid siphon are moderate to severe. IMPRESSION: 1. Increased left subdural collection with Ventricles remain unchanged . Basal cisterns remain patent. 2. Small foci of subarachnoid hemorrhage involves the posterior left insular region not significantly change relative to prior examination. No new hemorrhage. NOTIFICATION: Findings discussed immediately with Dr. ___ via telephone at 5:30 am on ___ at the time study was reviewed. Radiology Report EXAMINATION: US ABD LIMIT, SINGLE ORGAN INDICATION: ___ year old man status post found down with anterior rib fracture// Trauma survey - rule out blood or free fluid in the abdomen status post fall. TECHNIQUE: Limited grey scale ultrasound images of the 4 quadrants of the abdomen were obtained. COMPARISON: None. FINDINGS: Limited gray scout ultrasound images of the 4 quadrants of the abdomen do not demonstrate a any free fluid or fluid collections. The limited image of the liver is grossly unremarkable. IMPRESSION: No free fluid identified on this limited abdominal ultrasound. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, SAH Diagnosed with Traum subdr hem w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter temperature: 97.7 heartrate: 72.0 resprate: 18.0 o2sat: 97.0 sbp: 160.0 dbp: 82.0 level of pain: 0 level of acuity: 2.0
You suffered a small brain bleed after a fall. This did not require surgery, but you will need follow-up as an outpatient with repeat imaging. Activity - We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. - You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. - No driving while taking any narcotic or sedating medication. - If you experienced a seizure while admitted, you are NOT allowed to drive by law. - No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. - Continue to use your Incentive Spirometer 10x every hour to encourage deep breathing. Medications - You may take your Aspirin 81mg as previously prescribed. Please do NOT take any additional blood thinning medication (Ibuprofen, Plavix, Coumadin) until cleared by your Neurosurgeon. - You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. - You may use Oxycodone for more severe pain as needed. This medication may make you drowsy. Do not drive or drink alcohol while taking this medication. What You ___ Experience: - You may have difficulty paying attention, concentrating, and remembering new information. - Emotional and/or behavioral difficulties are common. - Feeling more tired, restlessness, irritability, and mood swings are also common. - Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: - Headache is one of the most common symptom after a brain bleed. - Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. - Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. - There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: - Fever greater than 101.5 degrees Fahrenheit - Nausea and/or vomiting - Extreme sleepiness and not being able to stay awake - Severe headaches not relieved by pain relievers - Seizures - Any new problems with your vision or ability to speak - Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: - Sudden numbness or weakness in the face, arm, or leg - Sudden confusion or trouble speaking or understanding - Sudden trouble walking, dizziness, or loss of balance or coordination - Sudden severe headaches with no known reason
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath and lower extremity swelling Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. ___ is a ___ with a PMH of CHF (EF 50-55%), severe TR, aortic regurgitation s/p bioprosthetic AVR (___) now s/p TAVR (___), CHB s/p dual chamber PPM (___), pAfib s/p failed DCCV (___) presenting with worsening shortness of breath found to be in ___ exacerbation. Elevated BNP, volume overloaded on exam. Prior hospitalization in ___ for her TAVR with 26 ___ valve via transapical approach was complicated by a tear in the left ventricle and thoracotomy for repair. She also had heart block and was implanted with a ___ pacemaker, Adapta L ADDRL1 with a ___ atrial lead 4076, and a ___ leadventricular 4076 on ___. Last checked by Dr. ___ on ___. She was discharged to rehab on post-operative day ___. Readmit for rapid atrial fibrillation and a dehisced thoracotomy incision. Discharged back to rehab. Since the surgery, has had progressive shortness of breath which is worse when lying down. Associated with bilateral leg swelling. Was seen at ___ ED, diuretics dose was increased and she was discharged. Presented for outpatient echo today and was referred to ED for progressive SOB. In the ED, initial vitals were 97.8 80 126/64 18 100% 3L Nasal Cannula. His labs were notable for WBC 8.4, Hg 10.6, Hct 30.9, Plt 134, BNP notable for HCO3 35. proBNP 5255, lactate 1.1. INR was 2.4. He had a CXR that demonstrated a left pleural effusion and low left lung volume, right lung normal. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, palpitations, syncope or presyncope. Past Medical History: Replacement of ascending aorta and aortic valve using a 23mm aortic valve cryopreserved Homograft with reimplantation of the coronary arteries in ___ @ ___. ___ Left Thoracotomy Wound Dehisence ___ Transcatheter aortic valve replacement with a 26 mm ___ valve via transapical approach. ___ Repair right femoral artery cannulation site ___ - permanent pacemaker ___ Model: ___ Diastolic chronic heart failure Paroxysmal Atrial Fibrillation, failed ___ ___ Hypertension Hyperlipidemia Anxiety/Depression with Panic Attacks Obesity Ectopic Left Kidney Social History: ___ Family History: Mother - myocardial infarction ~___ deceased in early ___ Father - ___ infarction deceased ~___ Physical Exam: ADMISSION VS: Wt=184.2 lbs (182.3 lbs on discharge from previous admission) T=98.3 BP=116/66 HR=83 RR=26 O2 sat=99% 3 L General: Woman sitting in bed, taking breaths every few words HEENT: MMM, PERRL Neck: JVP to earlobe CV: RRR, systolic murmur Lungs: labored breathing with accessory muscle use, crackles at the bases bilaterally, decreased breath sounds at LLL Abdomen: soft, non-tender, +BS GU: foley Ext: warm, well-perfused, 2+ pitting edema to thighs Neuro: A&Ox3, CNII-XII grossly intact Skin: warm, dry, no rashes or lesions PULSES: +2 pulses bilaterally DISCHARGE VS: 97.7-98.4, 119-137/62-67, 78-80, 20, 96-97% RA Wt: 75.3 kg <- 75.3 kg <- 76.7 <- 79.2 kg <- 78 kg <- 79.8 kg <- 79.4 kg <- 81.7 kg (180 lbs) <- 82.4 kg <- 82.2 kg (182.3 lbs on discharge from previous admission, per pt, dry weight is 183 lbs or 83 kg) I/O: ___ General: No acute distress HEENT: MMM Neck: decreased JVP ~1-2 cm above clavicle CV: RRR, ___ systolic murmur Lungs: CTA bilaterally, non-labored breathing Abdomen: soft, non-tender, +BS GU: no foley Ext: warm, well-perfused, trace lower extremity pitting edema on feet Pertinent Results: ___ 01:00PM BLOOD WBC-8.4# RBC-3.54* Hgb-10.6* Hct-30.9* MCV-87 MCH-29.8 MCHC-34.2 RDW-15.7* Plt ___ ___ 01:00PM BLOOD Neuts-82.2* Lymphs-11.1* Monos-5.3 Eos-1.3 Baso-0.1 ___ 01:00PM BLOOD Plt ___ ___ 01:00PM BLOOD Glucose-107* UreaN-16 Creat-0.8 Na-136 K-3.6 Cl-91* HCO3-35* AnGap-14 ___ 01:00PM BLOOD proBNP-5255* ___ 08:30PM BLOOD cTropnT-0.05* ___ 01:00PM BLOOD Calcium-9.0 Phos-3.5 Mg-1.8 ___ 01:17PM BLOOD Lactate-1.1 ___ 04:55AM BLOOD WBC-6.4 RBC-3.55* Hgb-10.6* Hct-31.6* MCV-89 MCH-29.7 MCHC-33.4 RDW-15.4 Plt ___ ___ 09:35AM BLOOD ___ ___ 06:25AM BLOOD Glucose-98 UreaN-21* Creat-0.9 Na-136 K-3.9 Cl-97 HCO3-30 AnGap-13 ___ 06:45AM BLOOD proBNP-320___* ___ 06:25AM BLOOD Calcium-9.5 Phos-4.1 Mg-1.9 Echo ___ IMPRESSION: Suboptimal image quality. A well seated ___ aortic valve was seen with normal gradients and mild to moderate paravalvular aortic regurgitation. At least mild pulmonary systolic arterial hypertension in the setting of severe tricuspid regurgitation. Compared with the prior study (images reviewed) of ___, the image quality was poor on the current study. Only one moderate quality transaortic continuous wave Doppler was obtainable which showed a decrease in aortic transvalvular gradient. The ejection fraction seems slightly less vigorous with beat to beat variation due to atrial fibrillation. The degree of tricuspid regurgitation has increased but was not well visualized on the prior study. EKG ___ Ventriclar pacing with probably underlying atrial fibrillation and occasional intrinsic conduction. Occasional ventricular premature contraction. Compared to the previous tracing of ___ the findings are similar. CXR ___ IMPRESSION: Small left pleural effusion with associated left basilar atelectasis. Mild pulmonary vascular congestion, slightly worse in the interval. CXR ___ IMPRESSION: In comparison with the study ___, there is little overall change in the left pleural effusion with volume loss in the left lower lobe. No evidence of pulmonary vascular congestion. The right lung remains clear. Chest CT ___ IMPRESSION: Nonhemorrhagic left-sided pleural effusion with subsequent left lower lobe atelectasis. Mild mediastinal lymph node enlargement. Moderate cardiomegaly. Moderate coronary calcifications. Status post CABG and aortic valve replacement. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin EC 81 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. diltiazem HCl 60 mg oral QID 4. Docusate Sodium (Liquid) 100 mg PO BID 5. Furosemide 40 mg PO DAILY 6. Metoprolol Tartrate 25 mg PO TID 7. Senna 8.6 mg PO BID:PRN constipation 8. Warfarin 2 mg PO DAILY16 Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Docusate Sodium (Liquid) 100 mg PO BID 4. Senna 8.6 mg PO BID:PRN constipation 5. Furosemide 80 mg PO DAILY RX *furosemide 40 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*3 6. Warfarin 2.5 mg PO DAILY16 RX *warfarin [Coumadin] 1 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*3 7. Outpatient Lab Work Please check INR ___ and call ___ ___ at ___ with results. 8. Metoprolol Succinate XL 75 mg PO DAILY RX *metoprolol succinate 25 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*3 9. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours RX *potassium chloride 10 mEq 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*3 10. Outpatient Lab Work Please draw chem 10 on ___ and call PCP ___ at ___ with the results. 11. Diltiazem Extended-Release 240 mg PO DAILY RX *diltiazem HCl 240 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*3 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Acute on chronic diastolic congestive heart failure exacerbation Left lower lobe pleural effusion Secondary: Atrial fibrillation Aortic stenosis s/p TAVR Aortic regurgitation Complete heart block s/p pacer 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 dyspnea, TAVR TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: The patient is status post median sternotomy and transcatheter aortic valve replacement. Left-sided pacemaker device is re- demonstrated with leads terminating in the right atrium and right ventricle. Heart size remains moderately enlarged. Mediastinal contours are unchanged with diffuse atherosclerotic calcifications again noted. Mild pulmonary vascular congestion is slightly worse in the interval. Small left pleural effusion with associated atelectasis is present. Right lung remains otherwise grossly clear without new focal consolidation present. No pneumothorax is identified. Multilevel moderate degenerative changes are seen in the thoracic spine. Postsurgical changes within the left lower ribs are re- demonstrated with a bridged device again noted. IMPRESSION: Small left pleural effusion with associated left basilar atelectasis. Mild pulmonary vascular congestion, slightly worse in the interval. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with hx recent TAVR complicated by LV tear, now s/p pacemaker for CHB w/ 4+TR and worsening dyspnea on exertion w/ CHF exacerbation. // Eval for left pleural effusion. Eval for left pleural effusion. IMPRESSION: In comparison with the study ___, there is little overall change in the left pleural effusion with volume loss in the left lower lobe. No evidence of pulmonary vascular congestion. The right lung remains clear. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old woman with hx dCHF, recent TAVR, AR, ___ s/p pacer, afib with chf exacerbation and ?left pleural effusion. // ?left pleural effusion, ?persistent CHF exacerbation TECHNIQUE: VOLUMETRIC CT ACQUISITIONS OVER THE ENTIRE THORAX IN INSPIRATION, NO ADMINISTRATION OF CONTRAST MATERIAL, MULTIPLANAR RECONSTRUCTIONS. DOSE: DLP: 552 mGy-cm COMPARISON: No comparison available. FINDINGS: No incidental thyroid findings. No supraclavicular, infraclavicular or axillary lymphadenopathy. Status post sternotomy. Left pectoral pacemaker in situ. Status post aortic valve replacement. Moderate cardiomegaly and calcification of the ascending aorta. Moderate coronary calcifications. Moderate cardiomegaly. Moderate nonhemorrhagic left-sided pleural effusion with subsequent atelectasis of the left lower lobe. Calcifications along the left pericardium. Mild hiatal hernia. No hilar lymphadenopathy. Several borderline to slightly enlarged lymph nodes in the mediastinum (2, 16). No osteolytic lesions at the level of the ribs, the sternum and the vertebral bodies. Mild bilateral apical thickening, symmetrical in distribution. The assessment of the lung parenchyma is limited by severe respiratory motion are defects. Signs of mild chronic interstitial fluid overload. No suspicious masses or nodules. No evidence of diffuse lung disease. The airways are patent. IMPRESSION: Nonhemorrhagic left-sided pleural effusion with subsequent left lower lobe atelectasis. Mild mediastinal lymph node enlargement. Moderate cardiomegaly. Moderate coronary calcifications. Status post CABG and aortic valve replacement. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, PLEURAL EFFUSION NOS temperature: 97.8 heartrate: 80.0 resprate: 18.0 o2sat: 100.0 sbp: 126.0 dbp: 64.0 level of pain: 0 level of acuity: 2.0
Dear Ms. ___, You were admitted to the hospital with difficulty breathing due to fluid in your lungs and excess fluid in your legs. We gave you medication to remove this extra fluid. Your breathing and swelling improved as the fluid was removed and you were able to walk comfortably and no longer needing oxygen. Please remember to continue to limit salt and total fluid intake and to measure your weight every day. It was a pleasure taking care of you. Sincerely, Your ___ Cardiology Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: ciprofloxacin Attending: ___ Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with hx of 7.6cm AAA s/p open repair via midline incision (___) and appendectomy presenting nausea, vomiting and diarrhea. He was in his normal state of health until 2 days ago when he developed these symptoms. He spent most of yesterday with nonbilious vomiting. His nausea/vomiting has improved today but he complains of continued nonbloody diarrhea. Denies abdominal pain, fever, and chills. He was hospitalized for 2 days in ___ for small bowel obstruction, which was managed conservatively on the ACS service. He denies any recent travels or changes in his appetite. CT scan was obtained today which showed evidence of a partial small bowel obstruction. Past Medical History: - CORONARY ARTERY DISEASE: MI ___ - ADULT ONSET DIABETES MELLITUS - BENIGN PROSTATIC HYPERTROPHY s/p turp - COLONIC POLYPS latest colonoscopy in ___ - DIVERTICULOSIS - HYPERLIPIDEMIA - HYPERTENSION - PERIPHERAL VASCULAR DISEASE s/p AAA repair in ___. claudication w/ ___ mile walking, R popliteal obstruction per ___ - POLYMYALGIA RHEUMATICA - S/P APPENDECTOMY - stage IV chronic kidney disease due to underlying hypertensive nephrosclerosis Social History: ___ Family History: Per OMR: CAD in multiple family members- mother and brother both had MI's. Father had cancer. Several family members had diabetes. Physical Exam: Exam on discharge: 98.7 98.7 76 136/58 20 98RA Gen: NAD, A&Ox3 CV: RRR, No M/G/R Abd: Soft, distention improved from admission, no rebound or guarding, no palpable or pulsatile masses, well healed midline incision and inferior right midline incision Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 06:10AM BLOOD WBC-4.5# RBC-2.96* Hgb-9.5* Hct-29.9* MCV-101* MCH-32.1* MCHC-31.8* RDW-13.4 RDWSD-49.1* Plt ___ ___ 02:15AM BLOOD WBC-11.8* RBC-3.68* Hgb-12.0*# Hct-36.8*# MCV-100* MCH-32.6* MCHC-32.6 RDW-13.2 RDWSD-48.6* Plt ___ ___ 06:10AM BLOOD Glucose-82 UreaN-46* Creat-2.4* Na-140 K-4.9 Cl-107 HCO3-27 AnGap-11 ___ 02:15AM BLOOD Glucose-158* UreaN-53* Creat-2.5* Na-139 K-5.0 Cl-105 HCO3-22 AnGap-17 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Metoprolol Succinate XL 12.5 mg PO DAILY 4. Simvastatin 20 mg PO QPM 5. Ropinirole 2 mg PO DAILY 6. Melatin (melatonin) 3 mg oral QPM 7. Aspirin 81 mg PO DAILY 8. Tamsulosin 0.4 mg PO QHS 9. Citalopram 10 mg PO DAILY 10. Calcitriol 0.25 mcg PO DAILY 11. Levothyroxine Sodium 50 mcg PO EVERY OTHER DAY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Simvastatin 20 mg PO QPM 3. Metoprolol Succinate XL 12.5 mg PO DAILY 4. Ropinirole 2 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. Finasteride 5 mg PO DAILY 7. Citalopram 10 mg PO DAILY 8. Calcitriol 0.25 mcg PO DAILY 9. Levothyroxine Sodium 50 mcg PO EVERY OTHER DAY 10. Lisinopril 10 mg PO DAILY 11. Melatin (melatonin) 3 mg oral QPM Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Partial bowel obstruction vs gastroenteritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS W/O CONTRAST INDICATION: +PO contrast; History: ___ with LLQ tenderness+PO contrast // eval for diverticulitis TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.1 s, 56.0 cm; CTDIvol = 16.4 mGy (Body) DLP = 916.6 mGy-cm. Total DLP (Body) = 917 mGy-cm. COMPARISON: CT abdomen pelvis dated ___ FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains gallstones without wall thickening or evidence of inflammation. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are atrophic bilaterally. A hyperdense abnormality is seen in the upper pole of left kidney. It is too small to definitively characterize on this examination. There is no hydronephrosis. There is no nephrolithiasis. Symmetric perinephric stranding is seen. GASTROINTESTINAL: The stomach is unremarkable. Several loops of prominent small bowel are seen in the mid and lower abdomen, reaching up to 2.7 cm, not significantly different from the prior examination. These contain air-fluid levels. Contrast is seen flowing from the more prominent loops into more collapsed loops, making high-grade obstruction unlikely. Scattered colonic diverticular noted without evidence of acute diverticulitis. The rectum is unremarkable. The appendix is not definitively visualized. PELVIS: The urinary bladder is distended. There is no 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: The infrarenal abdominal aorta is ectatic, similar to the prior examination, reaching up to 3 cm in greatest dimension. The thoracic aorta is also mildly ectatic, up to 3.9 cm in greatest dimension. Moderate atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No evidence of diverticulitis. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: n/v/d Diagnosed with Nausea with vomiting, unspecified, Diarrhea, unspecified temperature: 97.1 heartrate: 60.0 resprate: 18.0 o2sat: 100.0 sbp: 110.0 dbp: 71.0 level of pain: 0 level of acuity: 3.0
Weigh yourself every morning, call MD if weight goes up more than 3 lbs. You were admitted to the hospital for a partial small bowel obstruction vs gastroenteritis. You were given bowel rest and intravenous fluids. Your symptoms have subsequently resolved after conservative management. You have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. Furthermore you have not had any diarrhea, bloody bowel movements, and your hematocrit (blood count levels) have been stable. You may return home to finish your recovery. Please monitor your bowel function closely. If you notice that you are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck!
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: sulfamethoxazole / Cipro Attending: ___. Chief Complaint: Palpitations Major Surgical or Invasive Procedure: None ___ cardiac catheterization - normal coronary arteries History of Present Illness: ___ w/ h/o SVT, HTN, HLD, anxiety, CKD, and recent admission for atrial fibrillation / flutter s/p ablation, presents with recurrent palpitations. He was discharged on ___, after undergoing flutter ablation procedure on ___. Earlier today, he developed recurrent palpitations. There was not any associated chest pain, dyspnea, nausea. He does note some diaphoresis, which he attributes to anxiety. He was initially evaluated at an OSH ED, where he was given IV diltiazem x2, w/o improvement in his tachycardia. In our ED, he was persistently tachycardic to ~150. He was evaluated by EP, who recommended holding on further CCB so that patient remains in a-flutter, with plan for repeat EPS/ablation in the AM. On the floor, patient complains only of anxiety. Past Medical History: 1. CARDIAC RISK FACTORS: No HTN, HL, or DM. 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Plastic surgery for eyelids. - Vaginal hysterectomy. She states no cervical cuff is present. - Rotator cuff repair - obesity - obstructive sleep apnea on CPAP - colonic adenoma - anxiety with insomnia Social History: ___ Family History: - Mother: urinary incontinence, dementia, hypertension, aneurysm in the brain, and a history of lung cancer which she survived. - Father is deceased from alcohol abuse. - Daughter (age ___ and son (36) are both living; They both have cerebral palsy, spastic in all four extremities. They are independently living at a domicile near Ms. ___. - Brother: CAD, HLD - Sister: well Physical ___: VS: T=97,8, BP=124/82 HR=81 RR=18 O2 sat= 98 GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with no JVD appreciated. CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ ___ 2+ Left: Carotid 2+ DP 2+ ___ 2+ Pertinent Results: ___ 08:50PM cTropnT-<0.01 ___ 02:41PM ___ PTT-30.7 ___ ___ 02:38PM GLUCOSE-77 UREA N-16 CREAT-0.6 SODIUM-138 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13 ___ 02:38PM GLUCOSE-77 UREA N-16 CREAT-0.6 SODIUM-138 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13 ___ 02:38PM estGFR-Using this ___ 02:38PM cTropnT-<0.01 ___ 02:38PM CALCIUM-9.7 PHOSPHATE-3.8 MAGNESIUM-2.0 ___ 02:38PM WBC-6.1 RBC-4.80 HGB-14.9 HCT-45.0 MCV-94 MCH-31.1 MCHC-33.1 RDW-13.2 ___ 02:38PM NEUTS-67.8 ___ MONOS-4.4 EOS-2.2 BASOS-0.4 ___ 02:38PM PLT COUNT-175 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ibuprofen 600 mg PO Q8H:PRN pain 2. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Ibuprofen 600 mg PO Q8H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Chest pain with positive stress test Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with cp // cp TECHNIQUE: PA and lateral views of the chest. COMPARISON: None. FINDINGS: The lungs are clear without focal consolidation, effusion, or pneumothorax. Cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities identified. Surgical staples project over the neck bilaterally. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Chest pain Diagnosed with CHEST PAIN NOS temperature: 98.1 heartrate: 77.0 resprate: 20.0 o2sat: 100.0 sbp: 126.0 dbp: 105.0 level of pain: 6 level of acuity: 2.0
Dear Ms. ___, Taking care of you at ___ was our pleasure. You came in because you were having chest pain and had findings on your stress test suggesting that your heart was possibly not getting enough blood flow. Because of your ongoing pain, which worsened over the last two days, decision was made to admit you for a cardiac catheterization. The procedure showed normal coronary arteries and no evidence of blockages. Your chest pain is not related to heart disease. Please follow up with your primary care doctor and continue all medications as before. We wish you all the ___. Sincerely, The ___ medical team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing Attending: ___. Chief Complaint: Low backpain and fevers Major Surgical or Invasive Procedure: ___ line placement ___ History of Present Illness: ___ old man with history of DM2, CAD s/p CABG ___, redo in ___, multiple stents, AS s/p core valve ___, and lumbar stenosis s/p L3-L5 laminectomies ___ and L3-L5 fusion ___ admitted from rehab with fevers. Of note, patient recently admitted to ___ ___ for revision of laminectomies and re-exploration in the setting of progressive neurogenic claudication. He had L3-L5 fusion c/b dural tear ___. Hospital course complicated by hypoxemia, angina and ___. He reports that since his discharge he has continued to have baseline low back pain which has not improved. He also reports that prior to discharge he began have loose stools. Her ports frequent bloating and flatulence. He has had 3 BM/day without blood/pus. He notes that the stools are watery. In the ED initial vitals were: 97.9 85 65/36 (repeat was 107/49) 22 96% RA. Labs were significant for WBC 13.6, Cr 2.1 (from 1.2 on recent discharge), lactate 2.3. UA unremarkable. CXR was unremarkable. Blood and urine cultures were drawn. Patient was evaluated by spine who felt medicine admission would be appropriate. EKG showed EKG: left bundle, sinus 85. Patient was given 2L IVF boluses, vancomycin, cefepime, tylenol, oxycodone. Vitals prior to transfer were:4 99.8 100 123/44 20 97% RA On the floor, patient reports mild back pain unchanged from prior discharge. He voices no further concerns. Review of Systems: (+) per HPI (-) night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -CAD -bare metal stent to left circumflex (___) -Multiple coronary angioplasties and stents (?19) -CABG (x3, ___, (SVG-LAD, SVG-RCA/OM) -redo CABG (___), (LIMA-LAD, SVG-RCA, ligation of old SVG RCA) -Left inframammary AV fistula -known aortic stenosis - s/p ___ for AV block -___ - insulin dependent DM - HTN - hyperlipidemia - left internal carotid stenosis (50-69%) - Hodgkin's dz (sp XRT neck, mediastinum) - Lupus anticoagulant (on coumadin-subtherapeutic INR secondary to bleeding) - COPD - asthma - sleep apnea - peptic ulcer disease - papillary thyroid cancer s/p thyroidectomy - BPH - hematuria s/p left ureteropyeloscopy (cytology neg) - spinal stenosis - degenerative joint disease of the hips, knees and shoulders - left shoulder fx/pinning secondary to MVA - right wrist fx secondary to fall - right carpal tunnel surgery - back surgery x 2 (disc fusions) - choleycystectomy - tonsillectomy - appendectomy Social History: ___ Family History: Father deceased, ___, CVA. Mother deceased, age ___ CAD. Sister deceased, age ___, breast Ca. Bother, age ___, A+W. Son,age ___, parkinsons dz. Daughter, A+W. Physical Exam: ADMISSION PHYSICAL EXAM Vitals - Tm 102 T:101.4 BP: 99/50 HR:93 RR:18 02 sat: 96% RA GENERAL: Laying in bed in NAD, pleasant and cooperative HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, patent nares, dry MM, NECK: nontender supple neck, no LAD, no appreciable JVD CARDIAC: RRR, S1/S2, ___ holosystolic murmur, no gallops or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably with good air movement throughout and no use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally BACK: no tenderness along spine GU: Foley in place NEURO: Alert and oriented x 4 (person, place, time and situation). CN II-XII intact, Strength over ___ is diminished 4+/5 due to pain, UE ___ bilaterally and sensation intact to LT bilaterally. SKIN: warm and well perfused, no excoriations or lesions, no rashes, Back surgical site dressing is c/d/i. DISCHARGE PHYSICAL EXAM Vitals- 97.9, 147/62, 89, 18, 99% RA, I/O since MN 440/750 (straight cath), 24HR ___ GENERAL: Laying in bed in NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, patent nares, dry MM, NECK: nontender supple neck, no LAD, no appreciable JVD CARDIAC: RRR, S1/S2, ___ holosystolic murmur, no gallops or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulse in R leg, 1+ DP pulse in L leg BACK: no tenderness along spine GU: Foley in place NEURO: Alert and oriented x 3 (person, place, time). CN II-XII intact. Sensation intact to LT bilaterally throughout MOTOR: BUE grossly ___ throughout. LUE below (improved from yesterday) R L Hip Flexion ___ ___ ___ Ankle Dorsiflexion ___ 4+/___ 4+/5 SKIN: warm and well perfused, no excoriations or lesions, no rashes. No splinter hemorrhages, or painful nodes noted on palms or soles. Back surgical site has dressing soaked with serosanguineous fluid. On removal of dressing, wound clean, staples intact, non-purulent with gray tissue in superior section. Pertinent Results: ADMISSION LABS ___ 09:00PM BLOOD WBC-13.6* RBC-4.38* Hgb-12.8* Hct-40.9 MCV-94 MCH-29.2 MCHC-31.3 RDW-15.9* Plt ___ ___ 09:00PM BLOOD Neuts-90.4* Lymphs-4.2* Monos-4.4 Eos-0.5 Baso-0.4 ___ 09:00PM BLOOD Plt ___ ___ 09:00PM BLOOD Glucose-84 UreaN-49* Creat-2.1* Na-137 K-5.1 Cl-95* HCO3-33* AnGap-14 ___ 09:00PM BLOOD estGFR-Using this ___ 09:00PM BLOOD HoldBLu-HOLD ___ 09:00PM BLOOD LtGrnHD-HOLD ___ 09:07PM BLOOD Lactate-2.3* ___ 06:55AM BLOOD WBC-13.4* RBC-4.09* Hgb-12.0* Hct-37.9* MCV-93 MCH-29.2 MCHC-31.6 RDW-15.7* Plt ___ ___ 06:55AM BLOOD Neuts-94.1* Lymphs-2.6* Monos-2.7 Eos-0.4 Baso-0.2 ___ 06:55AM BLOOD ___ ___ 06:55AM BLOOD Plt ___ ___ 06:55AM BLOOD Glucose-89 UreaN-44* Creat-1.6* Na-142 K-3.8 Cl-101 HCO3-28 AnGap-17 ___ 06:55AM BLOOD ALT-20 AST-26 LD(LDH)-298* AlkPhos-76 TotBili-0.9 ___ 06:55AM BLOOD Albumin-3.0* Calcium-8.1* Phos-3.7 Mg-1.6 ___ 07:22AM BLOOD Lactate-2.0 DISCHARGE LABS ___ 05:35AM BLOOD WBC-6.7 RBC-3.94* Hgb-11.5* Hct-37.4* MCV-95 MCH-29.2 MCHC-30.8* RDW-16.1* Plt ___ ___ 05:35AM BLOOD Plt ___ ___ 05:35AM BLOOD ___ PTT-45.2* ___ ___ 05:35AM BLOOD ___ 05:35AM BLOOD Glucose-63* UreaN-20 Creat-0.9 Na-145 K-3.5 Cl-108 HCO3-29 AnGap-12 ___ 05:35AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.2 Cholest-PND ___ 05:35AM BLOOD Triglyc-PND HDL-PND LDLmeas-PND MICROBIOLOGY ============ ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by ___. ___ 14:12 ___. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. ___ URINE CULTURE: <10,000 organisms/ml. ___ FLUID ASPIRATE FROM WOUND GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ C. DIFFICILE C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ___ - BLOOD CULTURES PENDING RADIOLOGY ========= ___ - EKG Normal sinus rhythm. Left bundle-branch block. No change from the previous tracing dated ___. ___ - CHEST XRAY (PA & LAT) AP AND LATERAL VIEWS OF THE CHEST: Postoperative changes with median sternotomy, mediastinal clips and aortic ___ are again seen. Coronary artery stent is again identified. Left chest wall dual-lead pacing device is unchanged in position. Fracture of the superior most sternal wire is again noted. The lungs are clear without significant effusion, consolidation or edema. No acute osseous abnormality is identified. IMPRESSION: No acute cardiopulmonary process. ___ - EKG Normal sinus rhythm with frequent premature ventricular complexes. Left bundle-branch block. Compared to the previous tracing the ventricular premature complexes are new. ___ - CT C-SPINE W/ CONTRAST No cervical spine fracture or malalignment No fracture or visible fluid collection in the cervical spine ___ - CT T-SPINE W/ CONTRAST 1. No findings in the thoracic spine to explain patient's fever. 2. Old left posterior 3rd rib fracture. ___ - CT L-SPINE W/ CONTRAST 1. Subcutaneous fluid collection at L2-3 and locules of air may be post-operative as discussed above, but correlate with recent procedures. CT has low sensitivity for infection. Within this limitation, there are no findings suggesting infection. 2. Healing fracture of the L3 spinous process. ___ - ECHO No 2D echocardiographic evidence of endocarditis. Moderate regional left ventricular systolic dysfunction c/w CAD. Well seated aortic ___ bioprosthesis with mild posterior paravalvular leak. Mild mitral regurgitation. Moderate pulmonary artery hypertension. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. Avodart (dutasteride) 0.5 mg oral daily 3. Levothyroxine Sodium 175 mcg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Tamsulosin 0.4 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Senna 17.2 mg PO QHS 9. ALPRAZolam 1 mg PO DAILY:PRN anxiety 10. Klor-Con (potassium chloride) ___ meq oral BID 11. Metolazone 2.5 mg PO 2X/WEEK (MO,FR) 12. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 13. Theophylline ER 300 mg PO DAILY 14. Torsemide 60 mg PO EVERY OTHER DAY 15. Torsemide 40 mg PO EVERY OTHER DAY 16. Metoprolol Succinate XL 50 mg PO DAILY 17. NPH 25 Units Breakfast NPH 25 Units Bedtime Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Avodart (dutasteride) 0.5 mg oral daily 3. Docusate Sodium 100 mg PO BID 4. Levothyroxine Sodium 175 mcg PO DAILY 5. Metoprolol Succinate XL 12.5 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Senna 17.2 mg PO QHS 8. Tamsulosin 0.4 mg PO DAILY 9. ALPRAZolam 1 mg PO DAILY:PRN anxiety 10. Klor-Con (potassium chloride) ___ meq oral BID 11. Theophylline ER 300 mg PO DAILY 12. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 13. Lisinopril 5 mg PO DAILY 14. Nafcillin 2 g IV Q4H 15. Warfarin 5 mg PO DAILY16 16. NPH 22 Units Breakfast NPH 22 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 17. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 18. Simvastatin 10 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: MSSA Bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair, requires TLSO brace when out of bed Followup Instructions: ___ Radiology Report CHEST, TWO VIEWS: ___. HISTORY: ___ male with fever, postop. Hypoxia and cough. COMPARISON: ___. FINDINGS: AP AND LATERAL VIEWS OF THE CHEST: Postoperative changes with median sternotomy, mediastinal clips and aortic ___ are again seen. Coronary artery stent is again identified. Left chest wall dual-lead pacing device is unchanged in position. Fracture of the superior most sternal wire is again noted. The lungs are clear without significant effusion, consolidation or edema. No acute osseous abnormality is identified. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT L-SPINE W/ CONTRAST INDICATION: ___ year old man with recent L3-L5 laminectomy, p/w fever, bloody drainage at site, possible new neurologic deficits. Has pacemaker from ___ not MRI compatible. // Is there evidence of infection? epidural abscess? epidural hematoma? TECHNIQUE: CT of the lumbar spine was performed after the administration of intravenous contrast. Sagittal and coronal reconstructions were prepared. DOSE: DLP 1020.40 mGycm; CTDI 31.30mGy COMPARISON: None. FINDINGS: The bones are diffusely demineralized. The patient has had a prior L3-5 laminectomy. There is a 3.1 x 1.6 cm fluid collection in the laminectomy site between the L2 and L3 spinous processes, likely postoperative (501:31). More inferiorly in the surgical bed is a locule of air that is also may be postsurgical (3:65). The volume of air is somewhat more than expected this long after the procedure, unless there has been further manipulation in the surgical site, or a drain was more recently removed. There is a fracture with callus formation of the L3 spinous process (02:48). The vertebral bodies are normal in height and alignment. There are mild disc bulges at L3-4, L4-5, and L5-S1. Obscuration of the epidural fat may simply be post-operative. The thecal sac is thickened and the right neural foraminal fat is not visible at L4-5 and L5-S1. IMPRESSION: 1. Subcutaneous fluid collection at L2-3 and locules of air may be post-operative as discussed above, but correlate with recent procedures. CT has low sensitivity for infection. Within this limitation, there are no findings suggesting infection. 2. Healing fracture of the L3 spinous process. Radiology Report EXAMINATION: CT C-spine with contrast. INDICATION: ___ year old man with recent L3-L5 laminectomy, p/w fever, bloody drainage at site, possible new neurologic deficits. Has pacemaker from ___ not MRI compatible. Planning on 8am CT with pre-medication tonight // Is there evidence of infection? epidural abscess? epidural hematoma? Lumbar laminectomy with fever and drainage at surgical site. New neurologic defects. Patient cannot have an MRI. TECHNIQUE: MDCT data were acquired through the cervical spine with intravenous contrast. Data were reconstructed using bone and soft tissue algorithms and images were displayed in multiple planes. DOSE: DLP: 762.34 mGy-cm CTDIvol: 32.65 mGy COMPARISON: None. FINDINGS: There is no cervical spine fracture or malalignment. Evaluation of the intrathecal structures is limited. Vertebral body and disc heights are preserved at all levels. However, the bones are diffusely demineralized. There is no spinal canal narrowing. Pre and paravertebral soft tissues are normal. Visualized portions of the aerodigestive tract are patent. The visualized lung apices are clear. Note is made of an ossified ligamentum flavum in the upper thoracic spine. Visualized portions of the skull base show no abnormalities. The major cervical neck vessels are patent. A stent is noted within the left internal carotid artery. IMPRESSION: No cervical spine fracture or malalignment NOTIFICATION: No fracture or visible fluid collection in the cervical spine. Radiology Report EXAMINATION: CT T-SPINE W/ CONTRAST INDICATION: ___ year old man with recent L3-L5 laminectomy, p/w fever, bloody drainage at site, possible new neurologic deficits. Has pacemaker from ___ not MRI compatible. Planning on 8am CT with pre-medication tonight // Is there evidence of infection? epidural abscess? epidural hematoma? Recent laminectomy with fever and inability to have an MRI. TECHNIQUE: CT of the thoracic spine was performed after the administration of IV contrast. Sagittal and coronal reconstructions were prepared. DOSE: DLP 1198.94 mGy-cm; CTDI 31.47mGy COMPARISON: None. FINDINGS: The thoracic vertebral bodies are demineralized, but normal in height and alignment. Evaluation of the intrathecal contents is limited with CT. There is an old fracture of the posterior left third rib (2:33). There is no high-grade canal stenosis . The visualized lung fields and soft tissues are noteworthy only for an aortic valve replacement and pacer leads. IMPRESSION: 1. No findings in the thoracic spine to explain patient's fever. 2. Old left posterior 3rd rib fracture. Radiology Report INDICATION: ___ year old man with MSSA bacteremia, needs PICC, bedside PICC RN not successful // please place PICC COMPARISON: None. 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: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Lidocaine. CONTRAST: 0 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 00:22 min, 7 mGy PROCEDURE: 1. Single lumen PICC placement through the basilic vein on the right. PROCEDURE DETAILS: Using sterile technique and local anesthesia, the basilic vein on the right was punctured under direct ultrasound guidance using a micropuncture set. Permanent ultrasound images were obtained before intravenous access, which confirmed vein patency. A peel-away sheath was then placed over a guidewire. The guidewire was then advanced into the superior vena cava using fluoroscopic guidance. A single lumen PIC line measuring 39 cm in length was then placed through the peel-away sheath with its tip positioned in the distal SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. FINDINGS: 1. The accessed vein was patent and compressible. 2. Basilicvein approach single lumen right PICC with tip in the distal SVC. IMPRESSION: Successful placement of a right 39 cm basilic approach single lumen PICC with tip in the distal SVC. The line is ready to use. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Fever Diagnosed with FEVER, UNSPECIFIED temperature: 97.9 heartrate: nan resprate: nan o2sat: nan sbp: 65.0 dbp: 36.0 level of pain: 3 level of acuity: 1.0
Dear Mr ___, Thank you for allowing us to participate in your care. You were admitted on ___ with symptoms of low back pain and fevers. Our tests showed bacteria in your blood and we started you on intravenous antibiotics for it. We continued your home medications, and gave you medications for your back pain as well. You responded well to therapy, and we placed a tube in your arm veins through which you will continue to receive antibiotics for 9 more days for a total of 14 days since you started the antibiotics. Our neurosurgery, and infectious disease teams who also saw and evaluated you while you were admitted recommend that you follow up with them after you're discharged at the appointments scheduled below. Discharge instructions - Continue receiving antibiotics through your PICC line till ___ for a total 2 week course till you see the infectious disease team as scheduled below - Please continue your coumadin on discharge and follow up with your regular ___ clinic - Please care for your PICC line as instructed to minimize infections - Your rehab can help remove the staples in your back on ___, ___ - Please remember to wear the TLSO brace whenever you are out of bed till you see the neurosurgery team as scheduled below - You were started on a small dose of metoprolol and statin to help protect your heart. Please follow up with PCP to further discuss these medication changes - Weigh yourself every morning, call MD if weight goes up more than 3 lbs - Please follow up with our infectious disease and neurosurgery teams as scheduled below
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Concerta / Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending: ___ Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: EGD ___ Diagnostic Paracentesis ___ TIPS ___ History of Present Illness: ___ with history of hepatitis C status post Harvoni, with cirrhosis and varices presenting with palpitations x3 days. The patient reports that 3 days ago he developed palpitations and shortness of breath on exertion. He denies any chest or abdominal pain. Denies any blood in the stool or melena. He felt more short of breath than usual yesterday when walking around. He was seen at ___ ED today, where he was found to have a hematocrit of 18 and a troponin I of 0.___epressions. He was transferred to ___ for further management. He received only partially 1 unit pRBCs upon arrival to ___ ED, so repeat CBC showed Hgb of 5.4. Denies any fevers, chills, cough. In the ED, initial vitals: 98.3 84 117/74 95% RA Rectal exam revealed guaiac positive brown stool. EKG - SR, NA, QTC 500, lateral STD c/w prior from this morning but no earlier prior available. Cardiology was consulted and felt the changes were due to anemia. He received protonix 40mg x1, ceftriaxone 1g, and octreotide gtt. Hepatology was consulted and recommend transfusion and trending CBC. He remained hemodynamically stable but was admitted to MICU for profound anemia, NSTEMI, and possible variceal bleed. On arrival to the MICU, he has no complaints. He reports he was just admitted to the ___ ICU in ___ and required intubation there for CHF exacerbation. His nadolol was stopped due to a "slow heart rate" by his report. He was discharged without any diuretics. Past Medical History: HCV Cirrhosis s/p Harvoni with sustained response complicated by varices and ascites Iron-deficiency anemia Hyperaldosteronism Hypogonadism CVA ___ s/p R craniotomy with L sided weakness CHF (EF 68% on TTE at ___ in ___ Social History: ___ Family History: Younger sister passed away from MI at age ___, another younger sister passed away from ruptured brain aneurysm at ___, two other siblings have peripheral vascular disease. Physical Exam: ============================= PHYSICAL EXAM ON ADMISSION ============================= Vitals: T: Afebrile BP: 134/66 P: 83 R: 18 O2: 98% on 2L NC GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP 11cm, no LAD LUNGS: Bibasilar crackles, no wheezes, rales, rhonchi CV: Regular rate and rhythm, II/VI systolic murmur ABD: soft, non-tender, obese, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, 2+ peripheral edema NEURO: Mild left facial droop, LUE contracted, LLE weaker than RLE (chronic). ============================= PHYSICAL EXAM ON DISCHARGE ============================= VS: T 98 HR ___ BP 110s-140s/40s-60s RR 18 97 RA Weight on discharge: 77.3 General: Sitting up in chair, in no acute distress HEENT: NCAT, sclera anicteric, dry MM CV: RRR, S1 and S2 appreciated, ___ systolic murmur best appreciated at base Lungs: + mildly decreased breath sounds at bases, no wheezes. Abdomen: + BS, distended, non tender, no rebound or guarding GU: No foley Ext: wwp, 1+ left lower extremity edema, trace right Neuro: Alert, oriented, neg asterixis, fluent speech, left sided weakness ___ prior CVA Skin: anicteric, scattered spider angiomas Pertinent Results: ======================== LABS ON ADMISSION ======================== ___ 12:25PM BLOOD WBC-3.7* RBC-2.01*# Hgb-5.4*# Hct-18.4*# MCV-92 MCH-26.9 MCHC-29.3* RDW-17.1* RDWSD-57.6* Plt ___ ___ 12:25PM BLOOD Neuts-61.8 ___ Monos-8.6 Eos-2.7 Baso-0.3 NRBC-0.5* Im ___ AbsNeut-2.29 AbsLymp-0.97* AbsMono-0.32 AbsEos-0.10 AbsBaso-0.01 ___ 12:25PM BLOOD ___ PTT-34.0 ___ ___ 12:25PM BLOOD ___ 12:25PM BLOOD Ret Aut-3.7* Abs Ret-0.08 ___ 12:25PM BLOOD Glucose-94 UreaN-15 Creat-0.9 Na-144 K-3.5 Cl-108 HCO3-25 AnGap-15 ___ 12:25PM BLOOD ALT-26 AST-36 LD(LDH)-165 AlkPhos-172* TotBili-0.5 ___ 10:00PM BLOOD CK(CPK)-38* ___ 12:25PM BLOOD cTropnT-0.14* ___ 10:00PM BLOOD CK-MB-3 cTropnT-0.24* ___ 12:25PM BLOOD Albumin-3.4* Calcium-8.8 Phos-3.8 Mg-1.7 ___ 12:43PM BLOOD Lactate-1.4 ======================== PERTINENT INTERVAL LABS ======================== Cardiac Enzymes ___ 12:25PM BLOOD cTropnT-0.14* ___ 10:00PM BLOOD CK-MB-3 cTropnT-0.24* ___ 02:59AM BLOOD CK-MB-2 cTropnT-0.38* ___ 07:30AM BLOOD CK-MB-2 cTropnT-0.31* proBNP-1873* ___ 03:00PM BLOOD cTropnT-0.32* ___ 06:17AM BLOOD CK-MB-1 cTropnT-0.05* ___ 03:10PM BLOOD CK-MB-<1 cTropnT-0.05* Metabolic ___ 07:45AM BLOOD %HbA1c-4.4* eAG-80* ___ 07:30AM BLOOD Triglyc-121 HDL-44 CHOL/HD-3.4 LDLcalc-82 ___ 03:25AM BLOOD Osmolal-289 Blood Gas ___ 03:09AM BLOOD ___ pH-7.31* Comment-GREEN TOP ___ 07:37AM BLOOD ___ Temp-36.7 pO2-54* pCO2-53* pH-7.31* calTCO2-28 Base XS-0 ___ 03:07PM BLOOD ___ pH-7.34* Ascitic Studies ___ 12:00PM ASCITES WBC-82* RBC-2473* Polys-7* Lymphs-81* Monos-12* ___ 12:00PM ASCITES TotPro-0.9 Glucose-136 Creat-1.3 LD(LDH)-43 Amylase-29 TotBili-0.2 Albumin-0.7 Urine Studies ___ 09:49AM URINE Color-Straw Appear-Clear Sp ___ ___ 09:49AM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 09:49AM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-<1 ___ 09:49AM URINE CastHy-16* ___ 09:49AM URINE Mucous-RARE ___ 09:49AM URINE Hours-RANDOM UreaN-187 Creat-39 Na-33 K-59 Cl-89 ___ 09:49AM URINE Osmolal-297 ___ 09:10AM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:10AM URINE Blood-SM Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR ___ 09:10AM URINE RBC-9* WBC-12* Bacteri-FEW Yeast-NONE Epi-<1 TransE-1 ___ 09:10AM URINE CastHy-1* ___ 09:10AM URINE Mucous-RARE ___ 05:24PM URINE Color-Yellow Appear-Clear Sp ___ ___ 05:24PM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 05:24PM URINE RBC-4* WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 ___ 05:24PM URINE CastHy-12* ======================== LABS ON DISCHARGE ======================== ___ 04:34AM BLOOD WBC-4.3 RBC-2.56* Hgb-7.2* Hct-23.7* MCV-93 MCH-28.1 MCHC-30.4* RDW-16.2* RDWSD-55.0* Plt ___ ___ 06:31AM BLOOD ___ PTT-34.8 ___ ___ 04:34AM BLOOD Glucose-83 UreaN-15 Creat-1.1 Na-139 K-3.8 Cl-103 HCO3-26 AnGap-14 ___ 04:34AM BLOOD ALT-20 AST-53* AlkPhos-257* TotBili-0.3 ___ 04:34AM BLOOD Albumin-3.0* Calcium-8.4 Phos-2.8 Mg-1.9 ======================== MICROBIOLOGY ======================== ___ - Blood Culture x 2 - No growth ___ - Peritoneal Fluid - No growth ___ - Peritoneal Fluid - STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL MORPHOLOGIES. ___ - Urine Culture - No Growth ___ - HCV VL - HCV RNA not detected ___ - Urine Culture STENOTROPHOMONAS MALTOPHILIA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS MALTOPHILIA | TRIMETHOPRIM/SULFA---- <=1 S ======================== ENDOSCOPY ======================== ___ - EGD Findings: Esophagus: Protruding Lesions 3 cords of grade I varices were seen in the esophagus. The varices were not bleeding. Stomach: Mucosa: Granularity, congestion and mosaic appearance of the mucosa were noted in the whole stomach. These findings are compatible with portal hypertensive gastropathy. Protruding Lesions Protruding GOV-1 varices, without stigmata of recent bleeding were seen in the cardia. Protuding GOV-2 varices, with stigmata of recent bleeding were seen in the fundus. Duodenum: Mucosa: Normal mucosa was noted. Impression: Esophageal varices Varices at the cardia Varices at the fundus Granularity, congestion and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy Normal mucosa in the duodenum Otherwise normal EGD to second part of the duodenum ======================== IMAGING/STUDIES ======================== ___ - ECG Sinus rhythm. Non-specific ST segment depressions in the lateral leads may reflect myocardial ischemia. Clinical correlation is suggested. Compared to the previous tracing of ___ ST segment depressions are noted. QTc (___) 462/500 ___ - ECG Sinus rhythm. Left ventricular hypertrophy with secondary repolarization abnormalities. Variation in precordial lead placement, in particular leads V4-V6 which show a less prominent ST-T wave change related to left ventricular hypertrophy. No diagnostic interim change. QTc (___) 467 ___ - RUQ US 1. Patent hepatic vasculature. 2. Cirrhotic liver with moderate ascites, moderate right pleural effusion, andsplenomegaly. No suspicious focal liver lesion. ___ - TTE The left atrium is mildly dilated. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Moderately dilated left ventricle with moderate mitral regurgitation. Mild aortic regurgitation. Moderate pulmonary hypertension ___ - CXR Opacities, which are seen predominantly in the right mid and lower zones and,densely, in the left lower lobe. While this could represent asymmetric pulmonary edema, the possibility of a superimposed infectious consolidation cannot be excluded. Upper zone redistribution on the left is noted. On the right, the vessels areobscured by surrounding opacities. Possible small bilateral pleural effusions. ___ - TTE The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is dilated with normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate (___) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, no change. ___ - CT Abdomen Pelvis W and WO contrast 1. Cirrhosis, splenomegaly, and mild ascites. Esophageal and gastric varices.No suspicious lesion. 2. Cardiomegaly. 3. Bibasilar atelectasis. Moderate right and small left pleural effusions. ___ - KUB 1. Hazy appearance of the abdomen with centrally located air-filled bowel loops suggestive ascites. No evidence of obstruction. 2. Left basilar opacity could represent atelectasis and effusion, however, underlying airspace disease cannot be excluded. 3. Postsurgical changes from prior TIPS, coiling, and IVC filter. 4. Stable cardiomegaly. ___ - RUQ US 1. Evaluation of the TIPS is limited in the postoperative day 2 setting. Color flow is seen in the main and proximal portions of the TIPS, but velocities are 8.04 and 55.6 cm/sec, respectively. The distal TIPS is not evaluated, as it is obscured by shadowing. 2. Small echogenic focus in the posterior right portal vein may indicate a small thrombus (see series 1 a, image 3435). 3. Trace ascites an a small right pleural effusion. RECOMMENDATION(S): Close interval imaging follow-up is recommended. ___ - LLE US No evidence of deep venous thrombosis in the left lower extremity veins. ___ - CXR As compared to ___ chest radiograph, cardiac silhouette has decreased in size and pulmonary edema has nearly resolved. A nonspecific left lower lobe opacity has partially cleared and bilateral pleural effusions have decreased in size. ___ - RUQ US Elevated velocities within the visualized portions of the TIPS. Directionality of flow in the right and left portal veins has changed and is noted to be away from the TIPS. Increased ascites. These findings are concerning for a distal TIPS stenosis. ======================== PROCEDURES ======================== ___ - TIPS 1. Pre-TIPS right atrial pressure of 19 mmHg and portal pressure measurement of 33 mmHg, resulting in portosystemic gradient of 14 mmHg. 2. Pre-TIPS right heart catheterization with cardiac output of 8.4 and pressures as follows: Right atrium 19, right ventricle 24, pulmonary artery 31, pulmonary artery wedge pressure 22. 3. Initial portal venogram demonstrating patent portal vasculature with retrograde filling of the coronary vein, posterior gastric vein, and inferior mesenteric vein. Massive gastroesophageal varices are seen to be supplied by the coronary vein and posterior gastric vein. Portosystemic shunting is noted via inferior phrenic veins and the left gonadal vein. 4. Sclerosis and embolization performed of the posterior gastric vein and coronary vein. 5. Successful creation of an intrahepatic portosystemic shunt using 10 mm x 6 mm x 2 cm Viatorr stent and 12 mm x 4 cm Luminex stent, both underdilated to 7mm. 6. Post-TIPS portal venogram showing significantly decreased filling of gastroesophageal varices with complete cessation of flow in the left gastric vein and near complete cessation of flow in the posterior gastric vein. Patent TIPS stent with wall to wall flow. 7. Post TIPS right atrial pressure of 26 and portal pressure of 32, resulting in a portosystemic gradient of 6 mmHg. 8. Post TIPS right heart catheterization with cardiac output of 10 and pressures as follows: Right atrium 19, right ventricle 30, pulmonary artery35, pulmonary wedge pressure 27 . IMPRESSION: Successful right internal jugular access with transjugular intrahepatic portosystemic shunt placement and variceal sclerosis/embolization with decrease in porto-systemic pressure gradient from 14 mmHg to 6 mmHg. ======================== CYTOLOGY ======================== ___ - Peritoneal Fluid NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, histiocytes, and lymphocytes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. ammonium lactate 12 % topical BID 3. Eplerenone ___ mg PO DAILY 4. Escitalopram Oxalate 20 mg PO DAILY 5. HydrALAZINE 25 mg PO TID 6. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 7. LamoTRIgine 100 mg PO BID 8. Lisinopril 40 mg PO DAILY 9. Modafinil 200 mg PO BID 10. Ranitidine 150 mg PO BID 11. Vitamin D ___ UNIT PO DAILY 12. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. Eplerenone ___ mg PO DAILY 3. Escitalopram Oxalate 20 mg PO DAILY 4. HydrALAZINE 25 mg PO TID 5. LamoTRIgine 100 mg PO BID 6. Lisinopril 10 mg PO DAILY RX *lisinopril 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 7. Modafinil 200 mg PO BID 8. Vitamin D ___ UNIT PO DAILY 9. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet Refills:*0 10. Torsemide 20 mg PO DAILY RX *torsemide 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 11. ammonium lactate 12 % topical BID 12. Multivitamins 1 TAB PO DAILY 13. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 14. Outpatient Lab Work ICD 10 K74.60 ___ Labs: Please obtain Chem 10, LFTS, ___, PTT, CBC and Fax to: PCP ___ ___ (P ___ Liver Center Dr. ___ ___ (P ___ 15. Outpatient Lab Work ICD 10 K74.60 ___ Labs: Please obtain Chem 10, LFTS, ___, PTT, CBC and Fax to: PCP ___ ___ (P ___ Liver Center Dr. ___ ___ (P ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses ===================== Anemia Variceal Bleeding s/p TIPS NSTEMI Acute on chronic diastolic heart failure HCV Cirrhosis Acute kidney injury Sinus bradycardia Secondary Diagnoses ===================== Hypertension Hyperaldosteronism History of CVA c/b seizures Vitamin D deficiency Prolonged QTc 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 HCV cirrhosis, diastolic heart failure, s/p TIPS ___ with abdominal distention // eval for obstruction, ileus, free airplease do portable TECHNIQUE: Upright and supine views of the abdomen. COMPARISON: CT abdomen and pelvis ___ FINDINGS: There is a hazy appearance of the abdomen with bowel loops seen centrally. Air-filled loops of large and small bowel is seen within the mid abdomen. No evidence of obstruction. No free air under the diaphragms. There is stable cardiomegaly. There suggestion of left basilar atelectasis and underlying effusion or consolidation cannot be excluded. There is a right-sided PICC likely terminating in the lower SVC. Partially visualized stent there seen overlying the liver related to prior TIPS procedure. Multiple coils are seen overlying the mid and right upper abdomen. There is an IVC filter seen overlying the spine. No acute osseous abnormality. IMPRESSION: 1. Hazy appearance of the abdomen with centrally located air-filled bowel loops suggestive ascites. No evidence of obstruction. 2. Left basilar opacity could represent atelectasis and effusion, however, underlying airspace disease cannot be excluded. 3. Postsurgical changes from prior TIPS, coiling, and IVC filter. 4. Stable cardiomegaly. Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: ___ year old man with HCV cirrhosis, diastolic heart failure, s/p TIPS ___ with abdominal distention. Eval for TIPS patency, ascites, thrombosis. TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: The liver appears diffusely coarsened and nodular consistent with known cirrhosis. No focal liver lesions are identified. There is trace ascites. A small right pleural effusion is incidentally noted. There is splenomegaly, with the spleen measuring 15.2 cm. There is no intrahepatic biliary dilation. The CHD measures 4 mm. There is sludge in the gallbladder with wall edema, likely due to third spacing in the setting of liver disease. The main portal vein is patent with hepatopetal flow. The TIPS is patent and demonstrates flow in the proximal and midportions, although evaluation is limited in the postop day 2 setting. Portal vein and intra-TIPS velocities are as follows: Main portal vein: 9.16 cm/sec Proximal TIPS: 8.04 cm/sec Mid TIPS: 55.6 cm/sec Distal TIPS: Not evaluated, as it is obscured by shadowing. A small echogenic focus in the posterior right portal vein may indicate a small thrombus (series 1a, image 34-35). Flow within the left portal vein is towards the TIPS shunt. Flow within the right anterior and right posterior 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. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Evaluation of the TIPS is limited in the postoperative day 2 setting. Color flow is seen in the main and proximal portions of the TIPS, but velocities are 8.04 and 55.6 cm/sec, respectively. The distal TIPS is not evaluated, as it is obscured by shadowing. 2. Small echogenic focus in the posterior right portal vein may indicate a small thrombus (see series 1 a, image 3435). 3. Trace ascites an a small right pleural effusion. RECOMMENDATION(S): Close interval imaging follow-up is recommended. NOTIFICATION: The above findings were communicated via telephone by Dr. ___ to Dr. ___ at 09:44 on ___, 5 min after discovery. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ year old man with HCV Cirrhosis, dCHF, L hemiparesis s/p CVA with L lower extremity edema. Eval for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the 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 man with diastolic CHF and SOB with low grade fever // evaluate for pneumonia, effusion, pulmonary edema IMPRESSION: As compared to ___ chest radiograph, cardiac silhouette has decreased in size and pulmonary edema has nearly resolved. A nonspecific left lower lobe opacity has partially cleared and bilateral pleural effusions have decreased in size. Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: ___ year old man with HCV cirrhosis and h/o variceal bleeding, dCHF, s/p TIPS // please evaluate for TIPS patency/measurement of velocities, evidence of thrombusPlease assess all four quadrants as well, evaluation of acsites TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Doppler ultrasound ___, TIPS ___ FINDINGS: LIVER: The hepatic parenchyma is noted to be coarse. The contour of the liver is nodular. There is no focal liver mass. There is mild ascites which is noted to be increased since the prior ultrasound of ___. A right pleural effusion is also incidentally noted. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures for mm. GALLBLADDER: No gallstones are visualized. Mild gallbladder wall edema is noted which can be seen in the setting of third spacing. DOPPLER EXAMINATION: The main portal vein is patent with hepatopetal flow and a velocity of 34 cm/sec. Flow within the right and left portal veins is away from the TIPS. This is a change from the prior ultrasound of ___. The proximal and distal portions of the TIPS appear patent with velocities measuring up to 192 cm/sec. The distal portion of the TIPS cannot be visualized due to persistent air in the new TIPS stent. This limited visualization is likely still reflective of the postoperative setting. Also of note, there is an echogenic line within the mid portion of the TIPS shunt seen on grayscale imaging which is of uncertain significance. IMPRESSION: Elevated velocities within the visualized portions of the TIPS. Directionality of flow in the right and left portal veins has changed and is noted to be away from the TIPS. Increased ascites. These findings are concerning for a distal TIPS stenosis. NOTIFICATION: Findings concerning for TIPS stenosis were discovered at 09:05 on ___ and were conveyed by telephone to Dr. ___ by Dr. ___ approximately 10 min after discovery. Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL PORT INDICATION: ___ male with hep C cirrhosis and possible variceal bleeding, evaluate for portal vein thrombosis or splenic vein thrombosis. TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen was performed. COMPARISON: None appear FINDINGS: Liver: The hepatic parenchyma is coarsened. No focal liver lesions are identified. There is moderate ascites and a moderate right pleural effusion. Bile ducts: There is no intrahepatic biliary ductal dilation. The common hepatic duct is borderline enlarged, measuring 6 to 7 mm. Gallbladder: The gallbladder appears within normal limits, without stones, abnormal wall thickening, or edema. Pancreas: The imaged portion of the pancreas appears within normal limits, with portions of the pancreatic tail obscured by overlying bowel gas. Spleen: The spleen demonstrates normal echotexture, and measures 17.5 cm. Kidneys: The right kidney measures 10.6 cm. The left kidney measures 11.7 cm. No stones, masses, or hydronephrosis are identified in either kidney. Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Main portal vein velocity is 19 cm/sec. Right and left portal veins are patent, with antegrade flow. The main hepatic artery is patent, with appropriate waveform. Right, middle and left hepatic veins are patent, with appropriate waveforms. Splenic vein and superior mesenteric vein are patent, with antegrade flow. IMPRESSION: 1. Patent hepatic vasculature. 2. Cirrhotic liver with moderate ascites, moderate right pleural effusion, and splenomegaly. No suspicious focal liver lesion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with CHF, dyspnea after blood transfusion // Evaluate for edema, worsening pleural effusion COMPARISON: None. FINDINGS: All there is alveolar opacity throughout much of the right lung, most pronounced in the mid and lower zones, with apparent air bronchograms and maturation of a right costophrenic angle and without aeration of right hemidiaphragm and its extreme lateral edge. There is increased retrocardiac density, with obscuration left hemidiaphragm and probable air bronchograms, consistent with left lower lobe collapse and consolidation. There is relative sparing of the left upper and mid zones. Mild upper zone redistribution is noted on the left. IMPRESSION: Opacities, which are seen predominantly in the right mid and lower zones and, densely, in the left lower lobe. While this could represent asymmetric pulmonary edema, the possibility of a superimposed infectious consolidation cannot be excluded. Upper zone redistribution on the left is noted. On the right, the vessels are obscured by surrounding opacities. Possible small bilateral pleural effusions. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with cirrhosis, GI bleed, edema, complaining of chest pain // volume overload COMPARISON: Chest x-ray examination from ___ FINDINGS: Again seen is cardiomegaly as well as prominence of the superior mediastinum. This appears more pronounced than on the prior examination, but is also accentuated by lordotic positioning. There is upper zone redistribution with alveolar opacities at both lung bases, including retrocardiac opacity that obscures the left hemidiaphragm. A tiny left effusion would be difficult to exclude. The degree of opacity at the right base is very slightly improved. IMPRESSION: Cardiomediastinal silhouette appears larger, but is likely accentuated by lordotic positioning. Findings compatible with pulmonary edema, including bibasilar alveolar opacities. Possible minimal interval improvement at the right base. As before, the presence of superimposed infectious consolidation at the lung bases, particularly on the left, would be difficult to exclude. Radiology Report INDICATION: ___ year old man with CHF, new PICC line placement, 40cm right brachial // Evaluate new PICC line TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___ 08:19 FINDINGS: Right PICC terminates in the region of the the cavoatrial junction, possibly overlying the upper right atrium. Bibasilar opacities are similar to before which may reflect atelectasis, however pneumonia is difficult to exclude. There is near complete obscuration of the left hemidiaphragm. Small left pleural effusion is similar to before. There is no large right pleural effusion. There is no pneumothorax. Lung slightly volume is low the film is obtained in lordotic position. The cardiac silhouette is probably enlarged, but somewhat exaggerated by these technical factors. Mildly enlarged cardiac silhouette is exaggerated by the low lung volumes. There is mild upper zone redistribution and mild vascular plethora improved compared with ___. . IMPRESSION: Right PICC terminates in the region of the cavoatrial junction -- please see comment above. No pneumothorax detected. Bibasilar opacities are similar to before which may reflect atelectasis, however pneumonia is difficult to exclude. Radiology Report EXAMINATION: CT abdomen pelvis without and with contrast INDICATION: ___ year old man with HCV cirrhosis with variceal bleed and portal hypertensive gastropathy // Discussed with Dr. ___ requests ___ contrast given renal failure, multiphasic liver for evaluation of varices and porto-mesenteric system, pre-op for TIPS or BRTO TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen and pelvis was done without and with IV contrast. Initially the abdomen was scanned without IV contrast. Subsequently a single bolus of IV contrast was injected and the abdomen and pelvis were scanned in the portal venous phase, followed by a scan of the abdomen in equilibrium (3-min delay) phase. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 2,677 mGy-cm. COMPARISON: Ultrasound ___. FINDINGS: LOWER CHEST: Bibasilar atelectasis. Moderate right and small left pleural effusions. Cardiomegaly. ABDOMEN: HEPATOBILIARY: Nodular liver surface consistent with cirrhosis. No large mass in this single phase study. No ductal dilation. Unremarkable gallbladder. PANCREAS: No discrete lesion or ductal dilation. SPLEEN: 18.5 cm splenomegaly. ADRENALS: Fullness of the left adrenal gland without nodules. Unremarkable right adrenal. URINARY: No nephrolithiasis or hydronephrosis.No discrete lesion. GASTROINTESTINAL: No intestinal obstruction. No pneumoperitoneum. Mild ascites. PELVIS: Unremarkable rectum and seminal vesicles. Prostate hypertrophy. Foley catheter within a decompressed bladder.Small fat and fluid containing left inguinal hernia, indirect. LYMPH NODES: No adenopathy. VASCULAR: Mild arteriosclerosis. Patent aorta and major branches. Patent hepatic vasculature. Accessory segment 6 hepatic vein. Patent splenic vein, SMV and IMV. Prominent IMV. Multiple esophageal, paraesophageal, gastric, and perigastric varices. Submucosal esophageal and gastric varices are noted. No hemodynamically significant splenorenal shunt. Patent IVC and iliac veins. Infrarenal IVC filter in situ; filter legs tips are outside of the IVC, not uncommon. . BONES AND SOFT TISSUES: Moderate anasarca. Right anterior acetabulum bone island. No acute fracture. IMPRESSION: 1. Cirrhosis, splenomegaly, and mild ascites. Esophageal and gastric varices. No suspicious lesion. 2. Cardiomegaly. 3. Bibasilar atelectasis. Moderate right and small left pleural effusions. Radiology Report INDICATION: ___ year old man with recurrent upper GI bleed in the setting of liver cirrhosis. // Please perform TIPS for relief of portal hypertension. COMPARISON: ___ CT abdomen pelvis. TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr. ___, attending radiologist performed the procedure. Dr. ___ personally supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: General anesthesia. MEDICATIONS: 1 g ceftriaxone. CONTRAST: 280 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 61.1 min, 1190 mGy PROCEDURE: 1. Right internal jugular venous access using ultrasound. 2. Pre TIPS right heart catheterization with pressure measurements (per study protocol). 3. Portal venogram (from the proximal splenic vein) with pressure measurements. 4. Venogram of posterior gastric vein. 5. Sclerosis / embolization of posterior gastric vein and gastroesophageal varices using STS foam, ethanol, 8 mm x 3 cm coils (x 4), 8 mm x 5 cm coil (x1), and 12 mm Amplatzer plug. 6. Venogram of coronary vein. 7. Sclerosis / embolization of coronary vein and gastroesophageal varices using ethanol and 10 mm Amplatzer plug. 8. Placement of 10 mm x 6 mm x 2 cm Viatorr stent, followed by 7 mm balloon angioplasty of the stent. 9. Post stenting portal venogram (from the proximal splenic vein) with pressure measurements. 10. Extension of the TIPS stent (towards the hepatic confluence) using 12 mm x 4 cm Luminex stent, followed by 7 mm balloon angioplasty of the stent. 11. Post TIPS right heart catheterization with pressure measurements (per study protocol) 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 and abdomen were 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. Images of ultrasound access were stored on PACS. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. A small incision was made at the needle entry site. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a ___ wire was advanced distally into the IVC. The micropuncture sheath was then removed and a TIPS sheath was advanced over the wire into the right atrium. The wire was removed and a ___ catheter was advanced and used to perform a pre TIPS right heart catheterization per study protocol with pressure measurements obtained of the right atrium, right ventricle, pulmonary artery, and pulmonary artery wedge pressure, as well as cardiac output. Next, the ___ catheter was removed, and the right hepatic vein was selected using a combination of the ___ wire and an MPA catheter. Appropriate position was confirmed with contrast injection and fluoroscopy in AP and lateral views. Following this, the TIPS cannula was advanced over the wire into the right hepatic vein, and the wire was exchanged for ___ needle. Several passes were made with the ___ needle anteriorly to attempt selection of the right portal vein from the right hepatic vein. These were unsuccessful. The TIPS cannula was repositioned into the middle hepatic vein, the angled sheath was turned posteriorly, and the needle was then advanced through liver parenchyma and the needle was withdrawn over its sheath. The sheath was slowly withdrawn while gentle suction was applied. Upon blood return, injection of contrast confirmed intraportal position and a Glidewire was introduced into the catheter to pass into the portal vein. The glidewire were initially passed into the intrahepatic portal veins, but was directed towards the splenic vein using ___ 1 glide cath. The wire was removed and injection of contrast confirmed intra portal position. An Amplatz was advanced into the splenic vein and the TIPS sheath was advanced into the portal vein. A straight flush catheter was advanced into the proximal splenic vein, pressure measurement was obtained, and a portal venogram was performed, findings below. Based on results of this portal venogram, decision was made to perform variceal sclerosis and embolization as well as placement of a TIPS. An angled glidecath was advanced into the posterior gastric vein over a Glidewire. Injection of contrast confirmed position. The glide cath was exchanged over ___ wire for an occlusion balloon, which was inflated in the posterior gastric vein. A venogram was performed of the posterior gastric vein, findings below. Sclerosis of the posterior gastric vein and gastroesophageal varices was performed using 10 cc STS foam (4 cc 3% STS, 2 cc Lipiodol, 4 cc air mixture), which was allowed to indwell for 10 min. Following this, venogram of the posterior gastric vein demonstrated reduced but persistent filling of the gastroesophageal varices. Additional sclerosis was performed using 10 cc STS foam (2:1:3 3% STS : Lipiodol : air). Following this, coil embolization was performed of the posterior gastric vein using four 8 mm x 3 cm Hilal coils and two 8 mm x 5 cm Hilal coil. Upon withdrawal of the occlusion balloon, migration of one of the 8 mm x 5 cm Hilal coils was noted. This coil was successfully retrieved using a 7 ___ Ensnare device. Next, a repeat portal venogram was performed from the proximal splenic vein, demonstrating persistent patency of the posterior gastric vein. The occlusion balloon was readvanced over a wire into the posterior gastric vein and further sclerosis was performed using 10 cc of ethanol, which was allowed to indwell for 10 min. Following this, the occlusion balloon was exchanged for a ___ Fr RDC guidecath, which was advanced over ___ wire into the posterior gastric vein, and embolization was performed of the posterior gastric vein using a 12 mm Amplatzer plug. Next, attention was turned to embolization of the left gastric vein. The ___ wire was advanced into the left gastric vein using the RDC guidecath, which was exchanged for an occlusion balloon. A venogram was performed of the left gastric vein, findings below. The balloon was inflated and sclerosis was performed of the left gastric vein using ethanol. Following this, the occlusion balloon was exchanged for an RDC guidecath and embolization of the left gastric vein was performed using a 10 mm Amplatzer plug. Next, attention was turned to placement of a TIPS stent. An Amplatz wire was advanced into the proximal splenic vein. The TIPS sheath was advanced using its dilator into the main portal vein. A 10 mm x 6 cm x 2 cm Viatorr stent was advanced into appropriate position and deployed. Following stent deployment, the stent was dilated using a 7 mm balloon. The straight flush catheter was advanced over the wire into the proximal splenic vein and the wire was removed. Repeat proximal splenic vein and right atrium pressure measurements were performed. Portal venograms were then performed from the proximal splenic vein and the mid splenic vein, findings below. The TIPS stent was extended towards hepatic confluence using a 12 mm x 4 cm Luminex stent, which was then dilated using a 7 mm balloon. The wire was removed and a Swan-Ganz catheter was advanced and used to perform a post TIPS right heart catheterization per study protocol with pressure measurements obtained of the right atrium, right ventricle, pulmonary artery, and pulmonary artery wedge pressure, as well as cardiac output. The sheath was then removed from the right internal jugular vein site and pressure held for 10 minutes to achieve hemostasis. Sterile dressings were applied. The patient tolerated the procedure well. There were no immediate post-procedure complications. The patient was transferred to the ICU in stable condition. FINDINGS: 1. Pre-TIPS right atrial pressure of 19 mmHg and portal pressure measurement of 33 mmHg, resulting in portosystemic gradient of 14 mmHg. 2. Pre-TIPS right heart catheterization with cardiac output of 8.4 and pressures as follows: Right atrium 19, right ventricle 24, pulmonary artery 31, pulmonary artery wedge pressure 22. 3. Initial portal venogram demonstrating patent portal vasculature with retrograde filling of the coronary vein, posterior gastric vein, and inferior mesenteric vein. Massive gastroesophageal varices are seen to be supplied by the coronary vein and posterior gastric vein. Portosystemic shunting is noted via inferior phrenic veins and the left gonadal vein. 4. Sclerosis and embolization performed of the posterior gastric vein and coronary vein. 5. Successful creation of an intrahepatic portosystemic shunt using 10 mm x 6 mm x 2 cm Viatorr stent and 12 mm x 4 cm Luminex stent, both underdilated to 7 mm. 6. Post-TIPS portal venogram showing significantly decreased filling of gastroesophageal varices with complete cessation of flow in the left gastric vein and near complete cessation of flow in the posterior gastric vein. Patent TIPS stent with wall to wall flow. 7. Post TIPS right atrial pressure of 26 and portal pressure of 32, resulting in a portosystemic gradient of 6 mmHg. 8. Post TIPS right heart catheterization with cardiac output of 10 and pressures as follows: Right atrium 19, right ventricle 30, pulmonary artery 35, pulmonary wedge pressure 27 . IMPRESSION: Successful right internal jugular access with transjugular intrahepatic portosystemic shunt placement and variceal sclerosis/embolization with decrease in porto-systemic pressure gradient from 14 mmHg to 6 mmHg. RECOMMENDATION(S): The patient will need an outpatient TIPS venogram in 1 month to assess for any residual varices and further embolization. Gender: M Race: WHITE Arrive by UNKNOWN Chief complaint: NSTEMI Diagnosed with Gastrointestinal hemorrhage, unspecified, Non-ST elevation (NSTEMI) myocardial infarction, Unspecified cirrhosis of liver temperature: 98.3 heartrate: 84.0 resprate: nan o2sat: 95.0 sbp: 117.0 dbp: 74.0 level of pain: 0 level of acuity: 2.0
Dear Mr. ___, It was a pleasure caring for you during your stay at ___. You were admitted to the hospital with low blood counts. You were found to have evidence of bleeding from your GI tract which is caused by your cirrhosis. You were treated with a procedure called a TIPS which can help lower the pressure in your liver to help prevent further bleeds. Dilated blood vessels in your GI tracts were also fixed by the interventional radiologists. You were restarted on diuretics (water pills) while you were here in the hospital. You should weigh yourself every morning and call your doctor if your weight goes up by more than 3 lbs. It is very important that you follow up with our primary care doctor, the interventional radiologists, liver doctors and ___ ___ after you leave the hospital. You will need to have labs drawn on ___ and every ___ after. Your updated medication list and appointments are listed below. We wish you the best! - Your ___ Care Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ y/o woman with a PMH of CAD (s/p silent MI, c/b LV thrombus on warfarin), splenic infarction, HFrEF (LVEF=35%), COPD, recently discharged from ___ on ___, who re-presents with persistent SOB. She reports at least one week of dyspnea with intermittent wheezing. She was seen at ___ and was thought to have pneumonia, heart failure exacerbation, and COPD exacerbation. She reports that she received three days of steroids and antibiotics at the hospital. She was discharged with a course of steroids, which completed today. She reports that since then, her symptoms have persisted. She reports a cough and feels as though there is phlegm in her chest that she is unable to bring up. She has been taking her Lasix, 20 mg once a day, without missing any doses. She denies fevers but does endorse chills. She reports dyspnea on exertion, without orthopnea or PND. She denies chest pain. She endorses RUQ abdominal pain with one dark bowel movement, without hematochezia. She denies dysuria, hematuria, constipation, or diarrhea. Past Medical History: Depression HL C-section Social History: ___ Family History: Father died of an MI, sister has A-fib. Her mother's siblings had cancers, she is unsure of what kind. Physical Exam: ADMISSION EXAM: =============== Admission Weight: 91.1 kg VS: T 97.6F BP 123/85 mmHg P 85 RR 16 O2 99% RA General: Comfortable, NAD. HEENT: Anicteric sclerae; EOMs intact. MMM, OP clear. Neck: Supple; JVD elevated to midneck at 15 degrees. CV: RRR, soft II/VI systolic murmur best heard over LUSB. No rubs or gallops. Pulm: Diminished airflow throughout with prolonged expiratory phase. No wheezes, rhonchi, or rales. No increased work of breathing. Abd: Soft, mild tenderness to palpation over RUQ and LLQ without rebound or guarding. NABS. Ext: Warm and well-perfused. 2+ DP pulses. Trace edema. Neuro: A&Ox3. CNs II-XII grossly intact. DISCHARGE EXAM: =============== VITALS: Temp: 97.6 BP: 118/79 HR: 71 RR: 18 O2 sat: 93% RA DRY WEIGHT: 95.2kg WEIGHT: 91.1 kg on admission --> 90.5kg --> 90.7kg today GENERAL: Well-appearing woman, sitting comfortably in bed in NAD HEENT: NC/AT, EOMI, anicteric sclera, MMM NECK:: Supple, no appreciable JVD HEAR: RRR, soft II/VI systolic murmur best heard over LUSB, no rubs or gallops. LUNGS: CTAB, no wheezes, rhonchi, or rales. No increased work of breathing. ABDOMEN: Soft, mild tenderness to palpation in RUQ/RLQ, no rebound or guarding, non-distended, active bowel sounds EXTREMITIES: Warm and well-perfused, 2+ DP pulses, no edema NEURO: Alert, oriented, moving all extremities with purpose, no facial asymmetry Pertinent Results: ADMISSION LABS: =============== ___ 08:40AM ___ PTT-40.7* ___ ___ 08:40AM PLT COUNT-433* ___ 08:40AM NEUTS-61.2 ___ MONOS-6.1 EOS-0.9* BASOS-0.2 NUC RBCS-1.4* IM ___ AbsNeut-7.36*# AbsLymp-3.71* AbsMono-0.73 AbsEos-0.11 AbsBaso-0.03 ___ 08:40AM WBC-12.0*# RBC-4.88 HGB-10.9* HCT-34.9 MCV-72* MCH-22.3* MCHC-31.2* RDW-21.6* RDWSD-48.2* ___ 08:40AM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-4.3 MAGNESIUM-1.9 ___ 08:40AM proBNP-3660* ___ 08:40AM cTropnT-<0.01 ___ 08:40AM LIPASE-53 ___ 08:40AM estGFR-Using this ___ 08:40AM estGFR-Using this ___ 08:40AM GLUCOSE-90 UREA N-22* CREAT-1.0 SODIUM-146 POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-21* ANION GAP-15 ___ 10:52AM URINE MUCOUS-OCC* ___ 10:52AM URINE RBC-2 WBC-2 BACTERIA-FEW* YEAST-NONE EPI-1 ___ 10:52AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD* ___ 10:52AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 10:52AM URINE UHOLD-HOLD ___ 10:52AM URINE HOURS-RANDOM ___ 04:09PM calTIBC-360 FERRITIN-166* TRF-277 ___ 04:09PM MAGNESIUM-1.9 IRON-66 ___ 04:09PM CK-MB-3 cTropnT-<0.01 ___ 04:09PM GLUCOSE-115* UREA N-19 CREAT-1.1 SODIUM-147 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-19* ANION GAP-21* DISCHARGE LABS: =============== ___ 07:15AM BLOOD WBC-13.6* RBC-5.43* Hgb-12.1 Hct-38.6 MCV-71* MCH-22.3* MCHC-31.3* RDW-22.5* RDWSD-49.2* Plt ___ ___ 07:15AM BLOOD Plt ___ ___ 07:15AM BLOOD ___ PTT-41.1* ___ ___ 07:15AM BLOOD Glucose-94 UreaN-26* Creat-1.0 Na-141 K-4.3 Cl-105 HCO3-25 AnGap-11 ___ 07:15AM BLOOD ALT-64* AST-24 AlkPhos-96 TotBili-0.4 ___ 07:15AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.3 MICROBIOLOGY: ============= ___ BLOOD CX: Pending ___ URINE CX: Negative IMAGING/DIAGNOSTICS: ==================== ___ CXR: Bilateral hilar engorgement with hazy bilateral diffuse opacities concerning for pulmonary edema. Small bilateral pleural effusions. No definite focal consolidations are seen, however post diuresis views could be obtained as clinically indicated. ___ ECHO: The left atrial volume index is moderately increased. A small secundum atrial septal defect is present. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is moderate regional left ventricular systolic dysfunction with inferior/inferolateral/lateral hypokinesis. The remaining segments contract normally (LVEF = 35-40%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+), posteriorly-directed mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD. Moderate to severe functional mitral regurgitation. Mild aortic regurgitation. Small ASD. Compared with the prior study (images reviewed) of ___, left ventricle has dilated. ASD is seen. The other findings are similar. ___ RUQUS: Gravel-like cholelithiasis without evidence of cholecystitis or biliary dilatation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Lisinopril 5 mg PO DAILY 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 4. Aspirin 81 mg PO DAILY 5. Warfarin 7.5 mg PO 2X/WEEK (MO,FR) 6. Warfarin 5 mg PO 5X/WEEK (___) 7. Furosemide 20 mg PO DAILY 8. Atorvastatin 80 mg PO QPM Discharge Medications: 1. Spironolactone 12.5 mg PO DAILY RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Lisinopril 10 mg PO DAILY RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Warfarin 7.5 mg PO 2X/WEEK (MO,FR) 9. Warfarin 5 mg PO 5X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== - Acute heart failure with reduced ejection fraction - LV thrombus - Cholelithiasis SECONDARY DIAGNOSIS: ==================== - CAD - Tobacco use - COPD - Microcytic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: ___ with cough and shortness of breath. Study performed to evaluate for pneumonia. TECHNIQUE: Chest: Frontal and Lateral COMPARISON: Chest radiograph dated ___. FINDINGS: There is bilateral hilar engorgement with hazy bilateral diffuse opacities concerning for pulmonary edema. Fluid is seen within the horizontal fissure on the right. There are small bilateral pleural effusions. No definite focal consolidations are seen. There is no pneumothorax. Heart size is top-normal. The mediastinal silhouette is unremarkable. Osseous structures are unremarkable. IMPRESSION: Bilateral hilar engorgement with hazy bilateral diffuse opacities concerning for pulmonary edema. Small bilateral pleural effusions. No definite focal consolidations are seen, however post diuresis views could be obtained as clinically indicated. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old woman with HFrEF, now with RUQ pain and mild elevation in LFTs// Gall bladder pathology TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: The report from the CT abdomen and pelvis ___ 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 5 mm. GALLBLADDER: Gravel-like cholelithiasis without gallbladder wall thickening. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 9.1 cm. KIDNEYS: The right kidney measures 10.5 cm. The left kidney measures 11.1 cm. Limited views of the bilateral kidneys show no hydronephrosis. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: Gravel-like cholelithiasis without evidence of cholecystitis or biliary dilatation. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with Heart failure, unspecified, Dyspnea, unspecified temperature: 96.9 heartrate: 86.0 resprate: 18.0 o2sat: 96.0 sbp: 135.0 dbp: 95.0 level of pain: 0 level of acuity: 3.0
Ms. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to ___ because you were feeling fatigued and short of breath when you laid flat on your back. WHAT WAS DONE FOR YOU IN THE HOSPITAL? - You were treated with a medicine called Lasix, which was given to you through your vein to help remove the extra fluid in your body that was making it hard for you to breath. You were then switched to an oral version of Lasix that you should take every day to prevent more fluid from building up. - You were started on a new medicine called spironolactone that will protect your heart. You will take a 12.5mg tablet of this medicine once a day. Your home lisinopril 5mg daily was increased to 10mg daily. - You were having some abdominal pain, so you had an ultrasound of your stomach that showed you had gallstones. There is nothing to do for this right now. WHAT SHOULD YOU DO WHEN YOU GO HOME? - You should continue taking all your medicines, as prescribed. As we discussed, you should consider taking your Lasix pill in the morning so you won't have to get up several times in the middle of the night to urinate. - You should follow up with your primary care doctor and cardiologist. - You should weigh yourself every morning using the same scale and call your cardiologist if your weight increases by more than 3 lbs. in one day or 5lbs. in two days. Your discharge weight is: 199.96 lb. - You should drink less than 2 liters of fluid per day and avoid eating salty foods, such as deli meats and canned soups. You should consume less than 2 grams of salt per day. - You should stop smoking. This is one of the most important things you can do to protect your heart from further damage. It was a pleasure taking care of you, and we wish you all the best! Sincerely, Your ___ Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Quinine Attending: ___. Chief Complaint: weakness, low-grade fever Major Surgical or Invasive Procedure: ___ Laparoscopic to open cholecystectomy History of Present Illness: This patient is a ___ year old male who complains of ___ male who is here for one week of intermittent fatigue, fevers. They had a 20 minute episode of discomfort across the chest that was associated with a fever to 102. The discomfort lasted for about 20 minutes and has not recurred. He denies having any abdominal pain, vomiting, reports no bowel movement for 5 days but is passing gas. Also feels like he has been a little bit unsteady on his feet, contrary to resident note the patient denies any mumbling speech just says his mouth has been dry. Past Medical History: -Diabetes Mellitus -HTN -Prostate cancer s/p radical retropubic prostatectomy -Heart murmur -h/o Irregular HR in ___, seen by dr ___ - notable for episodes on NSVT and ATach; was felt to be at risk for AFib -H/O Mild stress incontinence -Nephrolithiasis -Benign L Renal Mass -Elevated Cholesterol Social History: ___ Family History: father had ___ disease Physical Exam: ON ADMISSION Vitals: T:98.1 BP:112/62 P:84 R:20 O2:96 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: tender to palpation in RUQ, rebound tenderness present, soft, non-distended, Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: No slurred speech. No focal weakness. Wide based, shuffling gait, cerebellar testing (finger to nose and Romberg) normal. ON DISCHARGE ___: vital signs: t=98.2, hr=53, bp=157/83, oxygen saturation 93% room air general: NAD CV: irregular, ns1, s2, -s3, -s4 LUNGS: clear, no adventitious BS bil ABDOMEN: soft, mild tenderness, erythematous staple line, no induration EXT: no ankle edema bil., no calf tenderness bil NEURO: alert and oriented x 3, speech clear, no tremors Pertinent Results: ___ 05:09AM BLOOD WBC-15.2* RBC-4.97 Hgb-13.2* Hct-42.4 MCV-85 MCH-26.6* MCHC-31.2 RDW-13.3 Plt ___ ___ 05:30AM BLOOD WBC-13.9* RBC-4.64 Hgb-12.8* Hct-39.8* MCV-86 MCH-27.5 MCHC-32.1 RDW-13.4 Plt ___ ___ 06:10AM BLOOD WBC-10.5 RBC-4.21* Hgb-11.9* Hct-35.7* MCV-85 MCH-28.2 MCHC-33.3 RDW-13.5 Plt ___ ___ 11:01PM BLOOD WBC-9.8 RBC-4.93 Hgb-13.6* Hct-41.5 MCV-84 MCH-27.5 MCHC-32.7 RDW-13.3 Plt ___ ___ 11:01PM BLOOD Neuts-82.6* Lymphs-7.5* Monos-9.3 Eos-0.5 Baso-0.2 ___ 05:09AM BLOOD Plt ___ ___ 05:09AM BLOOD ___ ___ 07:00AM BLOOD ___ PTT-36.9* ___ ___ 11:01PM BLOOD ___ PTT-42.8* ___ ___ 06:10AM BLOOD Glucose-153* UreaN-12 Creat-1.2 Na-138 K-3.9 Cl-103 HCO3-26 AnGap-13 ___ 07:00AM BLOOD ALT-27 AST-38 AlkPhos-119 TotBili-0.5 ___ 05:30AM BLOOD ALT-29 AST-39 AlkPhos-134* TotBili-0.6 DirBili-0.3 IndBili-0.3 ___ 11:01PM BLOOD ALT-61* AST-63* CK(CPK)-33* AlkPhos-134* TotBili-1.5 ___ 08:45AM BLOOD Lipase-19 ___ 11:01PM BLOOD Lipase-23 ___ 07:35PM BLOOD cTropnT-<0.01 ___ 08:45AM BLOOD cTropnT-<0.01 ___ 11:01PM BLOOD cTropnT-<0.01 ___ 07:00AM BLOOD Albumin-2.9* ___ 06:10AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.2 ___ 11:16PM BLOOD Lactate-1.7 ___: EKG: Atrial fibrillation with moderate ventricular response. Occasionalventricular premature contractions. Left axis deviation. Inferior wall myocardial infarction of indeterminate age. Poor R wave progression. Compared to the previous tracing of ___ atrial fibrillation is new. Premature ventricular contractions are also new. ___: chest x-ray: IMPRESSION: Linear left basal opacities most likely atelectasis. Interval increase in size of cardiac silhouette over the past few days could reflect pericardial effusion. ___: gallbladder scan: Normal morphine sulphate hepatobiliary scan. No evidence of acute cholecystitis ___: liver/gallbladder US: IMPRESSION: 1. Distended gallbladder with mural thickening, sludge and gallstones. There is no apparent pericholecystic fluid or sonographic ___ sign. While mural edema is nonspecific and can also be present with cardiac dysfunction, hypoalbuminemia and hepatic dysfunction, in the appropriate clinical setting, this appearance can also be consistent with acute cholecystitis. HIDA can be obtained for further assessment if indicated. 2. Trace perihepatic free fluid. ___ 9:15 am SWAB ABCESS/RUPTURED GALLBLADDER PERICHOLECYSTIC ABCESS.. GRAM STAIN (Final ___: Reported to and read back by ___, R.___. ON ___ AT 1250. 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final ___: ESCHERICHIA COLI. MODERATE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Rivaroxaban 20 mg PO DAILY 2. MetFORMIN (Glucophage) 425 mg PO BID 3. Simvastatin 20 mg PO DAILY 4. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. MetFORMIN (Glucophage) 425 mg PO BID 3. Rivaroxaban 20 mg PO DAILY 4. Simvastatin 20 mg PO DAILY 5. Acetaminophen ___ mg PO Q8H:PRN pain 6. Amlodipine 10 mg PO DAILY 7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 8. Calcium Carbonate 500 mg PO QID:PRN heart burn 9. Docusate Sodium 100 mg PO BID 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 1 TAB PO BID:PRN constipation 12. Valsartan 40 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: acalculus cholecystitis Secondary diagnosis: A-fib Diabetes Mellitus 2 Coronary artery disease Constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Right upper quadrant pain and fever. Assess for cholecystitis. COMPARISON: ___ MRI abdomen. FINDINGS: The liver is normal in echotexture without focal lesion, intra or extrahepatic biliary ductal dilatation. The common bile duct is normal measuring 4 mm. The main portal vein is patent with hepatopetal flow. The gallbladder is distended with sludge and possible intraluminal non shadowing stones with mural thickening. There is no pericholecystic fluid or sonographic ___ sign to suggest cholecystitis. The pancreas is not well seen due to overlying bowel gas nor is the aorta. The imaged IVC is unremarkable. Trace amount of perihepatic free fluid is noted. IMPRESSION: 1. Distended gallbladder with mural thickening, sludge and gallstones. There is no apparent pericholecystic fluid or sonographic ___ sign. While mural edema is nonspecific and can also be present with cardiac dysfunction, hypoalbuminemia and hepatic dysfunction, in the appropriate clinical setting, this appearance can also be consistent with acute cholecystitis. HIDA can be obtained for further assessment if indicated. 2. Trace perihepatic free fluid. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: GENERALIZED WEAKNESS Diagnosed with FEVER, UNSPECIFIED, OTHER MALAISE AND FATIGUE, CHEST PAIN NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: 98.5 heartrate: 82.0 resprate: 18.0 o2sat: 98.0 sbp: 160.0 dbp: 88.0 level of pain: 2 level of acuity: 2.0
Dear Mr. ___, It was a pleasure taking care of you at ___. You came in with 7 days of constipation, loss of appetite, generalized weakness, cough, and sudden onset of chest pain. While ___ were here, we ran some tests including EKG, Troponins, and chest X-ray in order to investigate cardiac causes of your pain. These tests were all negative. You were found to have some upper right quadrant abdominal pain on exam and some of your liver enzymes associated with gallbladder injury were elevated. We did several studies to investigate this further including an ultrasound and a HIDA scan. The ultrasound showed that the gallbladder was distended, there were gallstones and some biliary sludge present, as well as gallbladder wall thickening. The HIDA scan showed normal empting of the gallbladder. We had the surgical team examine you to determine if emergent surgery was necessary. Because you continued to have an elevated white blood cell count and pain, you were taken to the operating room where you had your gallbladder removed. You are slowly recovering from your surgery and you are preparing for discharge home with the following instructions: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. Don't lift more than ___ lbs for 6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap.) You may start some light exercise when you feel comfortable. You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. You may resume sexual activity unless your doctor has told you otherwise. HOW YOU MAY FEEL: You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: Your incision may be slightly red aroudn the stitches or staples. This is normal. You may gently wash away dried material around your incision. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). It is normal to feel a firm ridge along the incision. This will go away. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing r clothes. If the staining is severe, please call your surgeon. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. Ove the next ___ months, your incision will fade and become less prominent. YOUR BOWELS: Constipation is a common side effect of medicine such as Percocet or codeine. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. After some operations, diarrhea can occur. If you get diarrhea, don't take anti-diarrhea medicines. Drink plenty of fluitds and see if it goes away. If it does not go away, or is severe and you feel ill, please call your surgeon. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. You will receive a prescription from your surgeon for pain medicine to take by mouth. It is important to take this medicine as directied. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. IF you are experiencing no pain, it is okay to skip a dose of pain medicine. Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the folloiwng, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. In some cases you will have a prescription for antibiotics or other medication. If you have any questions about what medicine to take or not to take, please call your surgeon. DANGER SIGNS: Please call your surgeon if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. ___ is a pleasant ___ F with a history of hyperparathyroidism (s/p 3.5 gland parathyroidectomy in 2000s at ___), obesity s/p bariatric surgery presents transferred from ___ for work-up of presumed first seizure. She was in her usual state of good health and was walking her dogs on the beach around 4:30pm on ___. The next thing she remembers is being in the ambulance going to ___. She reports people told her she was confused, but she denies incontinence. She denies having any numbness, tingling, or weakness following the event. She denies any palpitations or chest pain or lightheadedness preceding it. In the ___ ED, vitals were T 98.4 BP 131/62 HR 90 SpO2 99% on RA. FSBG was 78. She was reportedly "witnessed seizuing by bystanders." There, she was given 2mg IV hydromorphone, NaPhosphate 63ml of 0.25mmol/ml solution, IV ondansetron - Labs were notable for phos 0.8, mg 1.6, K 3.2, Cr 0.6, normal LFTs, Calcium 8.8 - CT head was without pathology - CT facial bones showed "Nondisplaced fractures of the right orbital floor. Righ tmaxillary wall fracutres and hematoma within the right maxillary sinus" In The ___ ED initial vitals were: 7 98.7 84 118/50 20 100% 2L NC - Received 2.5mg iv diazepam, IV apap, IV fentanyl, 75mg ketamine, 30mg keterolac - Her mandible was reduced and follow-up CT showed better anatomic location of mandible - OMFS was consulted and recommended supportive care and no surgical intervention - Neurology was consulted and recommended MRI and EEG and no AEDs at this time - Labs significant for negative serum & urine tox screen, normal chem-10 (including Mg and Phos), WBC 6.4, Hgb 11.5, Plt 242 Prior to transfer, vitals were: 5 98.1 70 127/76 16 98% RA Currently, she reports feeling relatively well but endorses mild headache. ROS: Positive for headache and back pain Negative for chest pain, neck pain, photophobia, fever/chills, nausea, vomiting, chest pain, palpitations, numbness/tingling/weakness, dysuria. Past Medical History: - Jaw dislocation * ___ while at dentist, manually reduced - Bariatric surgery: 2000s. Patient does not recall details - Hyperparathyroidism * Removed ___ parathyroid glands - Anxiety - Depression - Chronic low back pain Social History: ___ Family History: - Mother died of astrocytoma at age ___ - Father died of multiple myeloma at age ___ - No history of seizures, sudden cardiac death, or cardiac arrhythmia Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 98.4 BP 132/63 HR 77 RR 12 SpO2 100% on RA GENERAL: Well appearing HEENT: EOMI, PERRLA, jaw wrapped NECK: No JVP. Surgical scar. Thyroid not easily discernible RESP: CTAB CV: RRR, no m/r/g ABD: Surgical scare present, obese, nontender, no masses EXT: WWP, no edema NEURO: CNs2-12 intact, motor function grossly normal, PERRLA, Finger-nose-finger intact, eyes track. No nystagmus appreciated as previously described DISCHARGE PHYSICAL EXAM: PHYSICAL EXAM: VS: T 97.8 BP 154/80 HR 71 RR 18 SpO2 99% on RA GENERAL: Well appearing HEENT: EOMI, PERRLA, jaw wrapped. Ecchymosis below right eye. Swollen right face. Numbness in infra-orbital nerve distribution NECK: No JVP. RESP: CTAB CV: RRR, no m/r/g ABD: Surgical scar present, obese, nontender, no masses EXT: WWP, no edema NEURO: Anesthesia in right V2 infraorbital nerve distribution, otherwise CNs2-12 intact, motor function grossly normal, PERRLA, Finger-nose-finger intact, eyes track. No nystagmus. Pertinent Results: ___ 03:40AM BLOOD WBC-6.4 RBC-4.31 Hgb-11.5* Hct-34.3* MCV-80* MCH-26.7* MCHC-33.5 RDW-14.3 Plt ___ ___ 06:33AM BLOOD WBC-4.5 RBC-4.30 Hgb-11.2* Hct-34.9* MCV-81* MCH-26.2* MCHC-32.2 RDW-14.4 Plt ___ ___ 04:58AM BLOOD WBC-4.7 RBC-4.40 Hgb-11.3* Hct-35.4* MCV-81* MCH-25.7* MCHC-31.9 RDW-14.1 Plt ___ ___ 03:40AM BLOOD Glucose-130* UreaN-12 Creat-0.7 Na-140 K-3.8 Cl-105 HCO3-25 AnGap-14 ___ 06:33AM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-143 K-3.5 Cl-105 HCO3-30 AnGap-12 ___ 04:58AM BLOOD Glucose-82 UreaN-8 Creat-0.7 Na-142 K-4.0 Cl-103 HCO3-31 AnGap-12 ___ 03:40PM BLOOD ALT-11 AST-15 CK(CPK)-120 AlkPhos-75 TotBili-0.4 ___ 03:40AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.8 ___ 03:40PM BLOOD Calcium-9.2 Phos-2.9 Mg-2.0 ___ 08:55PM BLOOD Calcium-8.8 Phos-3.2 Mg-2.5 ___ 06:33AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.4 ___ 04:58AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.9 ___ 03:40PM BLOOD 25VitD-16* ___ 03:40PM BLOOD PTH-49 ___ 03:40PM BLOOD Prolact-13 TSH-0.80 ___ 03:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-29 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 06:00AM URINE Hours-RANDOM UreaN-634 Creat-113 Na-149 K-69 Cl-139 Calcium-14.6 Phos-127.3 Mg-6.7 ___ 12:58PM URINE Hours-RANDOM UreaN-168 Creat-63 Na-65 K-15 Cl-58 Calcium-7.0 Phos-18.2 Mg-4.3 HCO3-8 ___ 06:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG IMAGING ======= MRI BRAIN (___) Axial T2 and MP-RAGE sequences are suboptimal secondary to patient motion. There is no intra or extra-axial mass, acute hemorrhage or infarct. No abnormal enhancement is noted. Sulci, ventricles and cisterns are within expected limits for the patient's age. The dural venous sinuses are patent. The major intracranial flow voids are preserved. Although the subtle abnormalities may not be detected secondary to patient motion artifact, there is no clear evidence of gray matter heterotopia and the bilateral mesial temporal cortices are unremarkable. Air-fluid level is seen in the right maxillary sinus. Partial opacification of the ethmoid air cells is noted. The orbits are unremarkable. The mastoid air cells are essentially clear. IMPRESSION: 1. The examination is suboptimal secondary to patient motion artifact. 2. Allowing for this limitation, there is no evidence of intracranial mass, acute hemorrhage or infarct. 3. No gross evidence of gray matter heterotopia or abnormalities of the mesial temporal cortex. 4. If remains high clinical concern, dedicated seizure protocol MRI with contrast may be performed. 5. Air-fluid level in the right maxillary sinus. This may be seen in acute inflammatory process such as acute sinusitis. Clinical correlation is recommended. CT FACIAL BONES ___ @ ___ - CT head was without pathology - CT facial bones showed "Nondisplaced fractures of the right orbital floor. Right maxillary wall fractures and hematoma within the right maxillary sinus" EEG (___) === ABNORMALITY #1: During hyperventilation mild generalized theta slowing is seen but this resolves within 90 seconds post-HV. BACKGROUND: Waking background is characterized by a 10 Hz posterior dominant rhythm, which attenuates symmetrically with eye opening. HYPERVENTILATION: See Abnormality #1. INTERMITTENT PHOTIC STIMULATION: Stepped photic stimulation is not performed. SLEEP: During drowsiness, the background slows to central theta activity, frontal beta activity becomes more prominent, and the alpha rhythm attenuates and becomes intermittent. There is no evidence of stage 2 sleep. CARDIAC MONITOR: A single EKG channel shows a generally regular rhythm with an average rate of 60-70 bpm. IMPRESSION: This is a mildly abnormal awake and drowsy EEG given mild generalized slowing during hyperventilation, which is a nonspecific finding. There are no epileptiform discharges or electrographic seizures. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Venlafaxine XR 75 mg PO DAILY 2. Escitalopram Oxalate 20 mg PO DAILY 3. Celebrex ___ mg oral DAILY 4. Lorazepam 0.5 mg PO QHS:PRN Insomnia 5. Zolpidem Tartrate 5 mg PO QHS Insomnia 6. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN Pain 7. Fentanyl Patch 50 mcg/h TD Q48H Back pain Discharge Medications: 1. Escitalopram Oxalate 20 mg PO DAILY 2. Fentanyl Patch 50 mcg/h TD Q48H Back pain 3. Lorazepam 0.5 mg PO QHS:PRN Insomnia 4. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN Pain 5. Venlafaxine XR 75 mg PO DAILY 6. Zolpidem Tartrate 5 mg PO QHS Insomnia 7. Vitamin D 1000 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit ___ tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Celecoxib 100 mg ORAL DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - Syncope - Right inferior orbital fracture - Hypophosphatemia - Hypomagnesemia - Hypovitaminosis D Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MANDIBLE (PA, ___ AND ___ OBLS) INDICATION: ___ year old woman with mandible dislocation status post reduction. TECHNIQUE: Frontal and lateral views of the mandible were obtained. COMPARISON: CT from ___ FINDINGS: The mandible appears to be in improved anatomic alignment following reduction. Fractures of the right maxillary sinus are better seen on the dedicated CT. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST INDICATION: ___ woman with family history of astrocytoma, presenting with first seizure. Evaluate for anatomic seizure focus. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 9cc 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: No priors available for comparison on PACS. FINDINGS: Axial T2 and MP-RAGE sequences are suboptimal secondary to patient motion. There is no intra or extra-axial mass, acute hemorrhage or infarct. No abnormal enhancement is noted. Sulci, ventricles and cisterns are within expected limits for the patient's age. The dural venous sinuses are patent. The major intracranial flow voids are preserved. Although the subtle abnormalities may not be detected secondary to patient motion artifact, there is no clear evidence of gray matter heterotopia and the bilateral mesial temporal cortices are unremarkable. Air-fluid level is seen in the right maxillary sinus. Partial opacification of the ethmoid air cells is noted. The orbits are unremarkable. The mastoid air cells are essentially clear. IMPRESSION: 1. The examination is suboptimal secondary to patient motion artifact. 2. Allowing for this limitation, there is no evidence of intracranial mass, acute hemorrhage or infarct. 3. No gross evidence of gray matter heterotopia or abnormalities of the mesial temporal cortex. 4. If remains high clinical concern, dedicated seizure protocol MRI with contrast may be performed. 5. Air-fluid level in the right maxillary sinus. This may be seen in acute inflammatory process such as acute sinusitis. Clinical correlation is recommended. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Seizure, Jaw pain Diagnosed with JAW PAIN temperature: 98.7 heartrate: 84.0 resprate: 20.0 o2sat: 100.0 sbp: 118.0 dbp: 50.0 level of pain: 7 level of acuity: 2.0
Dear ___, ___ was a pleasure taking care of you at ___ ___. You were transferred from ___ due to concern for a seizure. While there, bloodwork showed extremely abnormal electrolytes. While at ___, your electrolytes were normal. An MRI of your brain was normal. The EEG of your brain appeared normal and is in final review at the time of discharge. Nevertheless, please follow-up with your PCP to have repeat bloodwork done to ensure your electrolytes remain normal. Also, please make sure to follow-up with a neurologist as outlined below. Because of the concern for seizure, **you cannot drive for six months.** When yawning or opening your mouth wide, you should brace jaw with hands to avoid another jaw dislocation. You should apply an ice pack to your face as needed to decrease swelling. Regards, Your ___ Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo man with a history of recurrent/advanced ___ s/p chemo/XRT, cardiomyopathy (unclear etiology, maybe from chemo, EF 40%), DVT s/p IVC filter, CVA, COPD, HTN, DM who woke up at 2 AM with chest discomfort that started in abdomen and moved up to his chest. This is associated with shortness of breath and dizziness. The episode lasted about a couple hours and was not relieved with TUMS. Patient reports cough and progressively worsening dyspnea but denies fevers, chills, chest pain, abdominal pain, dysuria, syncope. Patient has history of DVTs and has an IVC filter in place. He takes baby aspirin each day but is not on any other anticoagulation. He otherwise reports good exercise tolerance. Takes daily walks around a park. Denies exertional chest discomfort or shortness of breath. No orthopnea, sleeps on one pillow. No lower extremity edema. No recent changes in weight. In regards to ___, his last cycle of palliative chemo was on ___. According to most recent heme/onc note, he has signs of disease progression and further options are limited and appears that an approach of supportive measures is being initiated. He has a chest CT scheduled for tomorrow. In the ED initial vitals were: 98.2 108 111/66 16 95% RA EKG: read as HR 103, low voltage, CXR- unchanged from prior, BNP 4515 trop- 0.3 guaiac- neg CTA was performed which was negative for PE. Head CT was negative for hemorrhagic mets and he was started on a heparin drip. On arrival to the floor, patient is feeling well with no complaints. He wants to know when he can go home. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: none 3. OTHER PAST MEDICAL HISTORY: - ___, on cycle 14 of pemetrexed. diagnosed ___ with stage IIIB disease. started on etoposide, cisplatin, XRT on ___ -DVT status post filter placement in ___. -Hypertension -Macular degeneration -H/O CVA ___, TIA ___ -COPD -AAA s/p endovascular repair Social History: ___ Family History: No family history of early MI, does have a brother with a "bad heart" that also beats slow Physical Exam: Initial Physical Exam ================ VS: T=98.3 BP=102/64 HR=95 RR=22 O2 sat= 97RA GENERAL: in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 6 cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: inspiratory crackles and wheezes heard in all lung fields, no using as accessory muscles ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No ulcers, scars, or xanthomas. PULSES: 1+ DP pulses b/l Discharge Physical Exam ================ GENERAL: in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 6 cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: inspiratory crackles and wheezes heard in all lung fields, no using as accessory muscles ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No ulcers, scars, or xanthomas. PULSES: 1+ DP pulses b/l Pertinent Results: INITIAL LAB RESULTS =============== ___ 12:07PM BLOOD WBC-9.4 RBC-3.85* Hgb-12.5* Hct-38.4* MCV-100* MCH-32.4* MCHC-32.4 RDW-14.6 Plt ___ ___ 12:07PM BLOOD Glucose-139* UreaN-28* Creat-1.3* Na-143 K-4.4 Cl-105 HCO3-28 AnGap-14 ___ 12:07PM BLOOD CK-MB-12* MB Indx-14.8* proBNP-4515* ___ 12:07PM BLOOD cTropnT-0.35* ___ 07:00PM BLOOD CK-MB-8 cTropnT-0.30* ___ 06:05AM BLOOD CK-MB-5 cTropnT-0.21* ___ 06:05AM BLOOD Calcium-9.6 Phos-2.8 Mg-2.1 IMAGING ================= ___ CXR IMPRESSION: Right hilar mass and paramediastinal post treatment changes are unchanged since ___. A small to moderate subpulmonic right pleural effusion has increased since ___. ___ CTA Chest IMPRESSION: 1. No evidence of pulmonary embolism. 2. Unchanged right hilar and paramediastinal post-treatment changes. 3. Slight interval decrease in size of right upper paratracheal mass compared to the prior study. 4. Mucoid impaction in the left lower lobe airways, with an 8-mm endoluminal filling defect in the left lower lobe bronchus which could be a chronic mucus plug; however, attention on followup imaging is recommended to exclude malignancy. 5. Extensive venous collateralization along the left chest wall and paravertebral regions due to narrowing of the left brachiocephalic vein, advanced since the prior study. 6. 2.8 cm left supraclavicular soft tissue nodule is concerning for metastasis. 7. Stable appearance of aortic arch pseudoaneurysm, as described above. ___ CT Head IMPRESSION: 1. No acute intracranial abnormality. 2. Small metastases are better assessed with MRI. 3. Chronic left basal ganglia infarct is unchanged. ___ Cardiac Echo The estimated right atrial pressure is ___ mmHg. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Images were not amenable to quantitatively assess LV function. Right ventricular function is normal. The aortic valve is not well seen. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a small to moderate sized pericardial effusion (1.1-1.3 cm adjacent to the right heart chambers). There are no echocardiographic signs of tamponade (no chamber collapse, IVC plethora; respiratory inflows not assessed). IMPRESSION: Suboptimal image quality. Estimated LVEF is 50-55%. Valves are suboptimally visualized. A small to moderate sized effusion is seen without echocardiographic evidence of hemdynamic compromise. Compared with the prior study (images reviewed) of ___, tecnically limited images on both exams limits comparison. However, LV function appears better than on prior study. The size of the effusion is not appreciably changed. Discharge Lab Results =============== ___ 09:40AM BLOOD WBC-6.4 RBC-3.99* Hgb-13.3* Hct-39.5* MCV-99* MCH-33.2* MCHC-33.6 RDW-14.8 Plt ___ ___ 09:40AM BLOOD Glucose-100 UreaN-27* Creat-1.3* Na-144 K-4.2 Cl-106 HCO3-31 AnGap-11 ___ 09:40AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 2. Cyanocobalamin 1000 mcg IM/SC EVERY 9 WEEKS 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. FoLIC Acid 1 mg PO DAILY 5. Furosemide 20 mg PO DAILY:PRN swelling 6. Lisinopril 2.5 mg PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Mirtazapine 7.5 mg PO HS 9. Omeprazole 20 mg PO DAILY 10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain 11. Pravastatin 20 mg PO DAILY 12. Prochlorperazine 10 mg PO Q6H:PRN nausea 13. Tiotropium Bromide 1 CAP IH DAILY 14. Aspirin 81 mg PO DAILY 15. garlic 1,000 mg oral daily 16. Balanced Nutritional (food supplement, lactose-free) one can oral TID 17. Ocutabs (vitamin A-vitamin C-vit E-min) 1 tab oral daily Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 2. Aspirin 81 mg PO DAILY 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. FoLIC Acid 1 mg PO DAILY 5. Mirtazapine 7.5 mg PO HS 6. Ocutabs (vitamin A-vitamin C-vit E-min) 1 tab oral daily 7. Omeprazole 20 mg PO DAILY 8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain 9. Prochlorperazine 10 mg PO Q6H:PRN nausea 10. Tiotropium Bromide 1 CAP IH DAILY 11. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 12. Balanced Nutritional (food supplement, lactose-free) 0 can ORAL TID 13. Cyanocobalamin 1000 mcg IM/SC EVERY 9 WEEKS 14. Furosemide 20 mg PO DAILY:PRN swelling 15. garlic 1,000 mg oral daily 16. Metoprolol Succinate XL 25 mg PO DAILY 17. Nitroglycerin SL 0.4 mg SL PRN chest pain 1 tablet under the tongue every five minutes, Maximum of 3 (three) tablets total, for chest pain RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually as needed for chest pain Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: non-ST-elevation myocardial infarction, Non-small cell lung cancer SECONDARY: Chronic systolic heart failure, hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with shortness of breath, intermittent cough // evaluate for pna TECHNIQUE: Frontal and lateral views of the chest. COMPARISON: CT chest ___. FINDINGS: A right hilar mass and right paramediastinal post treatment changes are unchanged since ___. A small to moderate subpulmonic right pleural effusion has increased since ___. The left lung is clear. There is no pneumothorax. The cardiac are normal. There is no free air beneath the right hemidiaphragm. IMPRESSION: Right hilar mass and paramediastinal post treatment changes are unchanged since ___. A small to moderate subpulmonic right pleural effusion has increased since ___. Radiology Report HISTORY: ___ male with chest pain, hypoxia and elevated troponin. Evaluation for pulmonary embolism and right heart strain. Further history denotes the patient has a known history of non-small cell lung cancer, as well as a tender nodule or lymph node above the left clavicle. COMPARISON: Comparison is made to multiple prior studies, including most recent from ___, dating back to ___. TECHNIQUE: Axial MDCT images were obtained through the thorax after the dynamic administration of Omnipaque intravenous contrast material. Reformatted coronal and sagittal images were also reviewed. DLP: 584.9 mGy-cm. FINDINGS: There is no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main and right pulmonary arteries are of normal caliber. There is redemonstration of mural outpouching along the undersurface of the aortic arch (2:54), compatible with known pseudoaneurysm, unchanged since ___. There is no evidence of intramural hematoma or aortic dissection. Extensive collateralization of vessels along the left anterior and posterior chest wall, as well as in the paravertebral regions has progressed since prior studies, likely owing to focal narrowing of the left brachiocephalic vein (2:26), which may be partially occluded, although intravenous contrast is identified throughout its course. A moderate right pleural effusion has increased in size since the prior study, and a small pericardial effusion appears relatively stable. The overall heart size is unchanged. The esophagus is unremarkable. Extensive post-treatment changes along the bilateral paramediastinal regions, particularly in the right upper lobe, at the site of previously treated lung mass appear overall similar in comparison to the prior study. No new pulmonary mass or concerning nodules are identified. Stable scattered pulmonary nodules, some of which are ground-glass, and other solid measure less than 4 mm, and are unchanged compared to the prior study (2:54, 2:39). A right upper paratracheal lymph node measures 2.1 x 2.1 cm, slightly decreased since the prior study when it measured 2.7 x 2.5 cm (2:36). Moderate centrilobular background emphysema is overall unchanged, and areas of mucus plugging in the left lower lobe airways appear similar compared to prior studies. A soft tissue endobronchial nodule in the left lower lobe bronchus (2:84) measures approximately 8 mm, and is similar in appearance compared to numerous prior studies, possibly a mucus plug; however, attention on followup imaging is recommended to exclude endobronchial malignancy. No significant mediastinal or hilar lymphadenopathy is noted. No supraclavicular lymphadenopathy is noted on the right. A 2.8 x 2.0 cm soft tissue nodule in the left supraclavicular fat pad is concerning for metastasis (2:11). Incidental note is made of aberrant right subclavian artery, which is not dilated. A small hiatal hernia is present. Although this study is not designed for evaluation of subdiaphragmatic structures, there is no focal hepatic lesion, and a cystic lesion arising from the superior pole of the left kidney is unchanged. No lytic or blastic lesion suspicious for malignancy is identified. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Unchanged right hilar and paramediastinal post-treatment changes. 3. Slight interval decrease in size of right upper paratracheal mass compared to the prior study. 4. Mucoid impaction in the left lower lobe airways, with an 8-mm endoluminal filling defect in the left lower lobe bronchus which could be a chronic mucus plug; however, attention on followup imaging is recommended to exclude malignancy. 5. Extensive venous collateralization along the left chest wall and paravertebral regions due to narrowing of the left brachiocephalic vein, advanced since the prior study. 6. 2.8 cm left supraclavicular soft tissue nodule is concerning for metastasis. 7. Stable appearance of aortic arch pseudoaneurysm, as described above. Radiology Report HISTORY: ___ man with advanced nonsmall cell lung cancer, presenting with altered mental status. Evaluation for hemorrhagic metastasis, prior to administering heparin. COMPARISON: Comparison is made to MRI of the brain from ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of intravenous contrast. Reformatted coronal, sagittal and thin slice bone images were also reviewed. DLP: 1003.4 mGy-cm. CTDIvol: 53.0 mGy. FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass effect, or large vascular territorial infarction. The ventricles and sulci are unchanged in size or configuration, slightly prominent, in keeping with age-related atrophic changes. Chronic infarct involving the left basal ganglia (3A:13) is unchanged. The gray-white matter differentiation is preserved, and the basal cisterns appear patent. There is no shift of the normally midline structures. The cranial and facial soft tissues are unremarkable. The orbits are normal in appearance. There is no evidence of fracture. Mucosal thickening in the ethmoid air cells is noted, otherwise, the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are grossly clear. IMPRESSION: 1. No acute intracranial abnormality. 2. Small metastases are better assessed with MRI. 3. Chronic left basal ganglia infarct is unchanged. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Chest pain, Dyspnea Diagnosed with RESPIRATORY ABNORM NEC, TACHYCARDIA NOS, HYPOXEMIA temperature: 98.2 heartrate: 108.0 resprate: 16.0 o2sat: 95.0 sbp: 111.0 dbp: 66.0 level of pain: 4 level of acuity: 2.0
Dear Mr. ___, It was a pleasure caring for you at ___ ___. You were admitted for chest pain, and you appeared to have had a small heart attack. An echocardiogram revealed that the muscle function of your heart seems to be stable to prior. We recommend medical management for your heart disease, including a baby aspirin, controlling your blood pressure, and other medication changes as noted below. Please be sure to follow up with a cardiologist, as below. Your CT-scan showed relatively stable tumor, and you should discuss the imaging with your oncologists. Weigh yourself every morning, call MD if weight goes up more than 3 lbs.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: naproxen / ___ pig Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with poorly controlled asthma, bronchiectasis, history of positive PPD and tobacco use presents with shortness of breath. The patient has had a complicated course over the last couple of years with exacerbations requiring frequent steroid tapers, antibiotics and hospital admissions. She has at least two ICU stays with one intubation and one bipap. Over the last few weeks, she reports worsening shortness of breath again. She was prescribed a steroid taper that started around ___. She reports improving on the 40mg dose, but by the time she tapered to 10mg, the symptoms has started again. She increased herself back to 30mg prednisone for 2 days on ___ and ___ but then stopped completely because she was out of medication and did not have any refills. So she has been without steroids since ___. She reports increased dyspnea, especially on exertion. SHe is unable to walk across the room to get to her bathroom. She has chest tightness and wheezing. She has been using her home nebulizers and inhalers with increased frequency, with nebs up to four times a day (previously only once a day), which provide some relief. She denies any fevers or chills. Patient was seen in outpatient ___ clinic and was referred to ___ for respiratory distress. At the outside office, her FEV1 fell to 30% from 90% at baseline. Her work-up through the outpatient clinic has included negative ANCA, but there was still a concern that patient has ANCA-negative ___. She received 125mg IV solumedrol, 2 duonebs and 750mg levaquin. She had a flu swab taken and labs including IgE, ESR, CRP, ANCA were all drawn in clinic, as well as a sputum culture. In the ED intial vitals were: 98.0 95 130/88 30 95% RA - Labs were significant for WBC 11 - Patient was given duonebs, levoflox and methylpred - CT scan showed some improvement from previous scans of tree in ___ pattern Vitals prior to transfer were: 98 77 126/87 18 98% RA Past Medical History: MEDICAL & SURGICAL HISTORY: - Asthma (diagnosed in ___ - Brochiectasis - Pulmonary nodules (detected in ___, follow-up CT in ___ showed no progression) - positive PPD Social History: ___ Family History: FAMILY HISTORY: Grandmother had asthma. Father had ___, HTN, and died of Stomach cancer. Mother had HTN and uterine cancer. Daughter has ___. Physical Exam: PHYSICAL EXAM ON ADMISSION: ============================= Vitals- 98.6 1074/81 93 20 96% RA General- NAD, but becomes dyspneic with speech HEENT- PERRL, no scleral icterus, no OP erythema or exudates Neck- supple, no cervical LAD Lungs- poor air movement bilaterally and diffuse wheezes CV- RRR, no m/r/g Abdomen- soft, NT, ND Ext- no peripheral edema Neuro- nonfocal PHYSICAL EXAM ON DISCHARGE: ============================ Vitals: 98.3 ___ 98% General: Alert, oriented, no acute distress, no conversational dyspnea, can speak in full sentences but coughs with deep breathing on lung exam HEENT: Sclera anicteric, MMM, a few white lesions in the hard palate Neck: supple, JVP not elevated, no LAD Lungs: mild wheezes with good air entry CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes Neuro: non-focal Pertinent Results: LABS ON ADMISSION: ================== ___ 09:35PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 09:35PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR ___ 09:35PM URINE RBC-7* WBC-10* BACTERIA-FEW YEAST-NONE EPI-1 ___ 06:53PM ___ PO2-62* PCO2-40 PH-7.41 TOTAL CO2-26 BASE XS-0 ___ 06:53PM LACTATE-1.8 ___ 06:53PM O2 SAT-90 ___ 06:45PM GLUCOSE-171* UREA N-10 CREAT-0.7 SODIUM-140 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16 ___ 06:45PM WBC-11.8* RBC-5.22 HGB-14.3 HCT-45.0 MCV-86 MCH-27.4 MCHC-31.8 RDW-14.0 ___ 06:45PM NEUTS-92.4* LYMPHS-6.0* MONOS-0.8* EOS-0.4 BASOS-0.5 ___ 06:45PM PLT COUNT-316 PERTINENT LABS: ============== ___ 06:50AM BLOOD ALT-27 AST-21 LD(LDH)-198 AlkPhos-81 TotBili-0.2 ___ 06:50AM BLOOD Albumin-3.9 Calcium-9.3 Phos-3.7 Mg-2.0 ___ 06:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE ___ 06:15AM BLOOD HCG-<5 ___ 06:50AM BLOOD HCV Ab-NEGATIVE LABS ON DISCHARGE: =================== ___ 06:15AM BLOOD WBC-15.1* RBC-4.62 Hgb-12.5 Hct-39.8 MCV-86 MCH-27.1 MCHC-31.5 RDW-14.2 Plt ___ ___ 06:15AM BLOOD Glucose-211* UreaN-20 Creat-0.8 Na-139 K-4.2 Cl-102 HCO3-25 AnGap-16 ___ 06:15AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.3 MICROBIOLOGY: =============== DFA ___: DIRECT INFLUENZA A ANTIGEN TEST (Final ___: Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final ___: Negative for Influenza B. BLOOD CULTURE ___: NO GROWTH. STUDIES: ========= CT CHEST ___: 1. Overall improvement of bronchial wall thickening and mucous plugging. Marginally more prominent ___ opacities in right upper lobe suggestive of small airways disease in light of other findings. 2. Pulmonary nodule in the left lower lobe laterally, similar to prior exam. Recommend follow-up CT chest in one year if she has risk factors. CXR ___: Frontal and lateral views of the chest. Heart size and cardiomediastinal contours are normal. Lungs are clear without focal consolidation, pleural effusion, or pneumothorax. IMPRESSION: No focal consolidation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 3. PredniSONE 10 mg PO DAILY 4. Montelukast Sodium 10 mg PO DAILY 5. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation BID 6. Tiotropium Bromide 1 CAP IH DAILY 7. Omeprazole 40 mg PO DAILY 8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 9. Ipratropium Bromide Neb 1 NEB IH Q6H SOB Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 3. Montelukast Sodium 10 mg PO DAILY 4. Omeprazole 40 mg PO DAILY 5. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 6. Tiotropium Bromide 1 CAP IH DAILY 7. Nystatin Oral Suspension 5 mL PO QID thrush RX *nystatin 100,000 unit/mL 5 cc by mouth four times a day Disp #*1 Bottle Refills:*0 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim 400 mg-80 mg One tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. PredniSONE 60 mg PO DAILY RX *prednisone 10 mg One tablet(s) by mouth daily Disp #*80 Tablet Refills:*0 10. Ipratropium Bromide Neb 1 NEB IH Q6H SOB 11. Azathioprine 50 mg PO DAILY RX *azathioprine 50 mg One tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 12. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation BID Discharge Disposition: Home Discharge Diagnosis: 1. asthma exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Shortness of breath, history of likely and ANCA-negative ___, concerning for infection. TECHNIQUE: MDCT imaging of the chest without intravenous contrast was performed. Multiplanar reformats were prepared and reviewed. COMPARISON: Comparison is made with CT chest from ___. FINDINGS: Overall improvement of bronchial wall thickening and mucous plugging, with ___ opacities marginally more prominent now in the right upper lobe compared to prior. The atelectasis previously seen in the right lung base has improved. A granuloma is seen in the right lung base. A nodule is seen along the major fissure in the right lobe, which appears unchanged from prior exam (4:128). The previously seen nodule in the left lung base is no longer appreciated on this exam. A nodule is seen in the left lower lobe laterally, unchanged from prior exam (4:132). No pathologically enlarged axillary, mediastinal, or hilar lymph nodes are identified. There is no pleural or pericardial effusion. The heart, pericardium, and great vessels are within normal limits. The thyroid gland is unremarkable. This study is not tailored for subdiaphragmatic evaluation, but the visualized intra-abdominal organs are unremarkable. BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for infection or malignancy is seen. IMPRESSION: 1. Overall improvement of bronchial wall thickening and mucous plugging. Marginally more prominent ___ opacities in right upper lobe suggestive of small airways disease in light of other findings. 2. Pulmonary nodule in the left lower lobe laterally, similar to prior exam. Recommend follow-up CT chest in one year if she has risk factors. Updated findings from wet read were communicated to Dr. ___ at 11:05 p.m. on ___ by phone. Radiology Report HISTORY: Asthma vs Churg ___ presenting with shortness of breath. COMPARISON: Multiple prior exams, most recently of ___. FINDINGS: Frontal and lateral views of the chest. Heart size and cardiomediastinal contours are normal. Lungs are clear without focal consolidation, pleural effusion, or pneumothorax. IMPRESSION: No focal consolidation. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: WHEEZING Diagnosed with SHORTNESS OF BREATH temperature: 98.0 heartrate: 95.0 resprate: 30.0 o2sat: 95.0 sbp: 130.0 dbp: 88.0 level of pain: 0 level of acuity: 2.0
Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You presented to us with shortness of breath and worsening of your asthma. We placed you on antibiotics, scheduled nebulizer treatments, and IV steroid. You are being discharged on prednisone, a new medication called azathioprine as recommended by your pulmonologist, and bactrim. We consulted pulmonology who agreed with our plan and made recommendations. Please follow up with your pulmonology, Dr. ___, as scheduled. We also consulted rheumatology to assess for Churg ___ and they believed that your current presentation is unlikely to be due to this illness since you lack many symptoms suggestive of this disease. Please take your medications as instructed. Please attend all your follow up appointments.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ yo man with recently diagnosed metastatic pancreatic cancer c/b biliary obstruction s/p CBD stent ___ and chole tube ___ who is admitted from ED with fever. Patient with recent hospitalizations for recurrent fevers and hx cholecystitis requiring biliary stent w/ revisions and long term abx for meropenem resistant pseudomonal bacteremia (+bile ___, blood and bile ___. Admit ___ for fever and abx changed to ceftolazone/tazobactam, as bile from ___ again + pseudomonas. Readmitted ___ w/ fever. he was found to have RUE DVT. Chole tube and CBD stent in good position w/ no drainable fluid collection. MRCP showed progression of liver mets. There was no other cause of fever found and was attributed to DVT, PICC removed. He was discharged off abx, last ___. chole tube was also capped w/ plan for removal in 4 days. tube removed ___. His partner called to report low grade temp last evening, he was reluctant to present to ED. agreed to not take tylenol in case masking fever. of note his partner check his temp every ___ hours at home. when he check again at 2am was 101. Denies any chills or rigors, pt did not notice fever. He has been having some nights sweats lately but not every night. Pt denies cough, shortness of breath, worsening abdominal pain, diarrhea, dysuria, urethral discharge, headache, sinus congestion or pressure, sore throat, skin lesions, mouth sores. No sick contacts. Ab pain is mainly in epigastric area, not worse w/ eating, no RUQ pain. He does have chronic constipation related to narcotics. Had BM ___ after doing enema at home. Per partner he is sleeping more. Initial VS 03:50 0 99.8 104 124/77 20 94%. Liver U/S did not show intrahepatic bili dilatation In ED was given 4L LR, vancomycin, tobramycin, tylenol, his scheduled lovenox and oxycodone HR imiproved to ___. BP stable 110/80s. Past Medical History: PAST ONCOLOGIC HISTORY: per OMR Pt reports that his symptoms began on ___, at which time he noted nonradiating RUQ pressure when he lay down to sleep. He took tums without relief. RUQ discomfort was intermittent, worse at night, with associated darkening of urine and yellowing of his sclera. He also noted onset of light yellow loose stools on ___. Denies history of similar symptoms. He presented to HIV provider, Dr. ___, at ___ for consideration of ART initiation on ___. Given his RUQ pain and jaundice, LFTs and CT abdomen were ordered, which revealed cholestasis and a pancreatic head mass, with possible pulmonary/pleural and hepatic metastases. In light of these results, urgent ERCP was arranged. CEA 54. Biopsy from ___ ___ile duct stricture showed poorly differentiated carcinoma, consistent with adenocarcinoma of a biliary or pancreatic origin. Also He had a CT chest with contrast at ___ on ___ demonstrated innumerable pleural-based nodules in both lungs measuring up to 9 mm. These are indeterminate and metastases cannot be excluded. Admitted ___ to ___ to ___. CBD stent changed to metal stent on ___. Blood culture with pseudomonas, intermediate resistant to meropenem. Biliary culture with pseudomonas, resistant to meropenem. Infectious disease consulted and he was treated with tobramycin and extended infusion cefepime. MRCP revealed lesions that could be early abscesses vs mets, so he was kept on the beta-lactam, although the pseudomonas had intermediate sensitivity. He had a PICC placed and will continue IV antibiotics for at least 4 weeks and will require eventual reimaging to evaluate for abscesses. MRCP also showed possible partial portal vein thrombosis, however, RUQ doppler showed no thrombosis. Admitted to the ___ from ___ after several days of fever following an ___ procedure on ___. His bile grew out MDR pseudomonas. on ___ he was started on ceftolozane-tazobactam 1.5 gm IV every 8 hr through a ___ line PAST MEDICAL HISTORY: Cholangitis Cholecystitis s/p cholecystostomy placement HIV-1 infection - diagnosed in ___ in setting of other STDs, treatment naive. Last CD4 ___,000 on ___. Eczema Syphilis s/p appendectomy Social History: ___ Family History: Father diagnosed with gastric cancer in his ___. No FH pancreatic cancer. Mother with asthma. Physical Exam: DISCHARGE EXAM General: NAD, thin VITAL SIGNS: 98.1 110/70 95 18 95%RA HEENT: MMM, no OP lesions, no scleral icterus Neck: supple, no JVD Lymph: no cervical, supraclavicular, axillary or inguinal adenopathy CV: RR, NL S1S2 no S3S4 or MRG PULM: CTAB ABD: BS+, soft, NTND, no masses or hepatosplenomegaly, L chole site well healed no erythema or drainge EXT: warm well perfused, no edema SKIN: No rashes or bruising, depigmented plaques over L face/neck and posterior scalp NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face symmetric, no tongue deviation, full hand grip, shoulder shrug and bicep flexion, full toe dorsiflexion and hip flexion against resistance bilateral, sensation intact to light touch, no clonus Pertinent Results: ADMISSION LABS: ___ 04:47AM BLOOD WBC-6.5 RBC-2.61* Hgb-7.2* Hct-22.3* MCV-85 MCH-27.6 MCHC-32.3 RDW-18.2* Plt ___ ___ 04:47AM BLOOD Glucose-110* UreaN-16 Creat-1.5* Na-130* K-4.4 Cl-94* HCO3-25 AnGap-15 ___ 04:47AM BLOOD ALT-49* AST-47* AlkPhos-341* TotBili-0.3 ___ 04:47AM BLOOD Albumin-3.5 Calcium-9.3 Phos-3.4 Mg-1.7 ___ 04:52AM BLOOD Lactate-1.1 DISCHARGE LABS: ___ 06:50AM BLOOD WBC-7.3 RBC-3.24* Hgb-9.3* Hct-27.1* MCV-84 MCH-28.6 MCHC-34.1 RDW-18.4* Plt ___ ___ 06:50AM BLOOD Glucose-95 UreaN-9 Creat-1.2 Na-137 K-3.9 Cl-101 HCO3-26 AnGap-14 ___ 06:50AM BLOOD ALT-37 AST-34 AlkPhos-287* TotBili-0.4 MICRO: blood cultures x 2 ___ - negative to date urine culture negative IMAGING: MRCP ___: IMPRESSION: No significant intraabdominal change status post removal of percutaneous cholecystostomy tube. No evidence of recurrent acute cholecystitis or collection. Pancreatic head tumor with local vascular involvement, and diffuse hepatic and nodal metastases, unchanged from recent priors. Slight increase in bilateral pleural effusions. Subpleural parenchymal nodules are visualized in regions of prior consolidation. These could represent residual consolidation or metastases. RUQ U/S ___ IMPRESSION: 1. No intrahepatic biliary duct dilation. Unchanged appearance of the common bile duct stent, with pneumobilia suggesting the stent is patent. 2. Collapsed gallbladder with wall thickening, which is nonspecific. There is a small amount of curvilinear foci of fluid around the gallbladder but no discrete drainable fluid collection. Residual inflammatory change in this region is not excluded. 3. Pancreatic head mass and liver metastases, which were better characterized on the prior MRI. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 100 mg SC DAILY 2. Acetaminophen 650 mg PO Q6H:PRN fever 3. Docusate Sodium 100 mg PO BID 4. Lorazepam 0.5 mg PO BID:PRN nausea/anxiety 5. Multivitamins 1 TAB PO DAILY 6. Nystatin Oral Suspension 5 mL PO QID 7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 8. Senna 8.6 mg PO BID 9. Temazepam 15 mg PO QHS:PRN sleep 10. Polyethylene Glycol 17 g PO DAILY 11. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Enoxaparin Sodium 100 mg SC DAILY Start: Tomorrow - ___, First Dose: First Routine Administration Time 3. Lorazepam 0.5 mg PO BID:PRN nausea/anxiety 4. Multivitamins 1 TAB PO DAILY 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as needed Disp #*60 Tablet Refills:*0 6. Polyethylene Glycol 17 g PO DAILY 7. Senna 8.6 mg PO BID 8. Temazepam 15 mg PO QHS:PRN sleep 9. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral DAILY 10. Acetaminophen 650 mg PO Q6H:PRN fever 11. Nystatin Oral Suspension 5 mL PO QID Discharge Disposition: Home Discharge Diagnosis: Pancreatic cancer Fever History of biliary obstruction s/p bile duct stenting and percutaneous cholecystostomy tube now removed History of multi-drug resistant pseudomonas Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT INDICATION: Metastatic pancreatic cancer and fever. Assess for biliary dilation. TECHNIQUE: Grey scale and color Doppler ultrasound images of the right upper quadrant were obtained. COMPARISON: T-Tube cholangiogram from ___. MRI of the abdomen and pelvis from ___. Right upper quadrant ultrasound from ___. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits.The contour of the liver is smooth. There are several ill-defined hypoechoic masses in the liver, which are compatible with the known metastases. These are better evaluated on the recent MRI. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. A common bile duct stent is in place, obscuring evaluation of the common bile duct. This is similar to the prior exam. Pneumobilia is present, suggesting the stent is patent. GALLBLADDER: Since the prior exam, the cholecystostomy tube has been removed. The gallbladder appears collapsed and thick walled. There are some curvilinear areas of fluid around the gallbladder, but no discrete drainable fluid collection. PANCREAS: There is an unchanged hypodense mass in the head of the pancreas, better assessed on the prior MRI. There is pancreatic duct dilation. KIDNEYS: Limited views of the right kidney demonstrate no hydronephrosis or large mass. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. Small right basal pleural effusion with mild atelectasis is noted. IMPRESSION: 1. No intrahepatic biliary duct dilation. Unchanged appearance of the common bile duct stent, with pneumobilia suggesting the stent is patent. 2. Collapsed gallbladder with wall thickening, which is nonspecific. There is a small amount of curvilinear foci of fluid around the gallbladder but no discrete drainable fluid collection. Residual inflammatory change in this region is not excluded. 3. Pancreatic head mass and liver metastases, which were better characterized on the prior MRI. Radiology Report INDICATION: Fevers of uncertain etiology. Evaluate for pneumonia. TECHNIQUE: PA and lateral views of the chest. COMPARISON: Chest radiograph from ___. CT of the chest from ___. FINDINGS: The lung volumes are low and linear opacities at the bases most likely represent atelectasis. Otherwise there is little change. There is no focal consolidation to suggest pneumonia. There is no pulmonary edema. The small subpleural nodule seen on the prior CT of the chest are not well visualized on today's exam. There are small bilateral pleural effusions. No pneumothorax is identified. The cardiomediastinal silhouette is normal. A metallic biliary stent is present in the right upper quadrant. IMPRESSION: Small bilateral pleural effusions and bibasilar atelectasis. No definite pneumonia. Radiology Report EXAMINATION: MRCP INDICATION: ___ year old man with hx recurrent MDR pseudomonas, recurrent fever after perc chole tube removal 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 6 cc of Gadavist intravenous contrast. The patient also received oral contrast of 1 cc of Gadavist diluted in 50 cc of water. COMPARISON: The abdominal CT dating ___. MRCP dating ___ and ___. FINDINGS: There is been slight interval increase in size of bilateral pleural effusions, left greater than right. Mild adjacent airspace opacity is noted at both lung bases. There also nodular foci of enhancement previously obscured by airspace opacity such as within the subpleural, anterior right lung base (10:15). These may relate to residual consolidation, although metastases should be considered. Innumerable hepatic lesions are again seen scattered throughout the liver parenchyma. These are T2 hyperintense with indistinct and hazy margins. Each demonstrates markedly restricted diffusion, and T1 hypointensity. Each is hypoenhancing compared with the surrounding parenchyma. During the arterial phase of imaging there is transient parenchymal hyperenhancement of the left lobe, accounted for by asymmetric left portal vein narrowing, unchanged from prior (1403: 73). The gallbladder continues to be decompressed status post recent removal of the percutaneous cholecystostomy tube. There is residual gallbladder wall thickening and mucosal hyperemia. The cystic duct is dilated, similar to prior, appearing truncated at the level of the metallic stent within the common bile duct. Maximum diameter of the cystic duct is 1.2 cm (11:3). There is re- demonstration of a large pancreatic head mass with approximate axial ___ of 2.1 x 3.7 cm. The upstream pancreatic parenchyma is atrophied with main duct dilation to 5 mm. This mass abuts the anterior aspect of the distal common bile duct, which contains a metallic stent. The distal proper hepatic artery and proximal common hepatic artery course along the superior margin of the tumor, and gastroduodenal artery traverses the tumor. There is marked focal narrowing of the portal vein/SMV confluence which appears to remain patent. Lymphadenopathy is seen within the porta hepatis and gastrohepatic ligament, unchanged from prior. The spleen, adrenal glands and kidneys are unremarkable. There is a trace amount of abdominal ascites, not significantly changed from prior Note is made of dilated vessels within the right axilla. Arterial vascular anatomy is notable for a replaced left hepatic artery. No focal osseous lesion of concern is identified. IMPRESSION: No significant intraabdominal change status post removal of percutaneous cholecystostomy tube. No evidence of recurrent acute cholecystitis or collection. Pancreatic head tumor with local vascular involvement, and diffuse hepatic and nodal metastases, unchanged from recent priors. Slight increase in bilateral pleural effusions. Subpleural parenchymal nodules are visualized in regions of prior consolidation. These could represent residual consolidation or metastases. Gender: M Race: BLACK/AFRICAN Arrive by AMBULANCE Chief complaint: Fever Diagnosed with FEVER, UNSPECIFIED, MALIG NEO PANCREAS NOS temperature: 99.8 heartrate: 104.0 resprate: 20.0 o2sat: 94.0 sbp: 124.0 dbp: 77.0 level of pain: 0 level of acuity: 3.0
Mr ___ it was a pleasure caring for you during your stay at ___. You were admitted again with fever. Given your history of multiple pseudomonas infections in the recent past and recent removal of the gallbladder tube you were restarted on IV antibioitcs. However you did not have any fevers here in the hospital and there were no signs of infection on blood cultures, liver ultrasound or liver MRI.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Tylenol Attending: ___. Chief Complaint: Arm pain Major Surgical or Invasive Procedure: POC placement ___ History of Present Illness: ___ is a ___ year old man with recently diagnosed high-grade soft tissue sarcoma of the right upper arm who was transferred to ___ with bleeding from his tumor and plan to urgently initiate radiation treatment. Patient initially presented to ___ in ___ with several months of relatively painless enlarging mass of upper right arm. He underwent US guided biopsy on ___ which confirmed diagnosis of high grade sarcoma. He established in our ___ clinic on ___ with plans for neo-adjuvant radiation therapy followed by limb preserving surgery. However, on ___ he developed spontaneous hemorrhage from his right arm mass. He presented to OSH before transfer to ___. He was initially admitted to the orthopedics service, and there was at least some thought regarding embolization to control the hemorrhage. Fortunately, the bleeding resolved and he remained HDS. He started XRT treatment today and is being transferred to the oncology service. On interview, patients main concern is right arm pain. It has been slowly progressive over the last few months as his tumor has grown, and has now become a constant ___ aching pain with tingling in his right bicep. He gets moderate relief with oxycodone 10mg for about two hours. He was started on oxycontin 10mg q12 hours prior to transfer. He denies fevers or chills. No recent URTI. No headache or visual changes. No dysphagia or odynophagia. No CP, SOB or cough. No N/V/D. Large normal BM this am. Denies hematochezia or melena. No dysuria. He has some mild bilateral leg edema, which he reports is due to missing his home HCTZ. No new rashes. No leg pain. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: Mr. ___ is a ___ man with a history of chronic lower back pain who in ___ fell down the stairs in his house suffering multiple bruises. He did not seek evaluation at the time however several weeks later he noticed a bump appearing in his right arm in the area of the lower biceps muscle which he initially thought was a persistent bruise related to his fall. The mass was painless but uncomfortable with deep palpation, and over the subsequent months grew steadily. The skin over the mass also began to become erythematous prompting him to seek evaluation. MRI of the right arm on ___ showed an enhancing and infiltrative mass measuring up to 10 cm with involvement of the brachioradialis and biceps muscles. There was also noted to be abnormal heterogeneous marrow pattern concerning for involvement of the humerus; however, plain films on ___ showed no evidence of bone erosion or periostitis in the adjacent humerus. Ultrasound-guided core biopsy on ___ showed high-grade pleomorphic sarcoma. CT chest on ___ showed no evidence of pulmonary metastases or enlarged regional lymph nodes. - ___: Established care with ___ Radiation oncology PAST MEDICAL HISTORY: - Anemia - Hypertension - Chronic low back pain Social History: ___ Family History: Mother with cervical cancer. No other known family history of cancer. Physical Exam: PHYSICAL EXAM: ___ 1133 Temp: 99.5 PO BP: 136/82 L Sitting HR: 109 RR: 18 O2 sat: 97% O2 delivery: RA GENERAL: Pleasant, anxious man sitting up in bedside chair in NAD.l EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 1+ radial pulses bilaterally. 1+ peripheral edema in bilateral lower extremities. RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding MUSKULOSKELATAL: Right arm with large subcutaneous swelling over anterior bicep is dressed and wrapped. He has 1+edema distally but intact strength and sensation with equal 1+ radial pulses bilaterally. He has limited ROM in elbow flexion and supination due to the mass with associate pain. Otherwise, prominent subcutaneous fullness over bilateral supraclaviular without frank lymphadenopathy and 1+ edema bilaterally; Normal bulk NEURO: Alert, oriented, CN III-XII intact, motor and sensory function grossly intact SKIN: No significant rashes DISCHARGE PHYSICAL EXAM: ___ 0400 Temp: 99.5 PO BP: 104/66 L Lying HR: 95 RR: 18 O2 sat: 96% O2 delivery: RA GENERAL: Pleasant, man in no distress, standing up at bedside EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 1+ radial pulses bilaterally. trace peripheral edema in bilateral lower extremities. RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding MUSKULOSKELATAL: Right arm with large subcutaneous swelling over anterior bicep with gauze dressing c/d/I. No edema distal to the tumor and he has 1+ radial pulses bilaterally. He has limited ROM in elbow flexion and supination due to the mass with associated pain. Otherwise, subcutaneous fullness over bilateral supraclaviular without frank lymphadenopathy; Normal bulk NEURO: Alert, oriented, motor and sensory function grossly intact. Gait normal SKIN: No significant rashes ACCESS: Right POC dressing c/d/i Pertinent Results: ADMISSION LABS: =============== ___ 10:12PM BLOOD WBC-5.3 RBC-2.85* Hgb-9.8* Hct-31.1* MCV-109* MCH-34.4* MCHC-31.5* RDW-14.6 RDWSD-59.1* Plt ___ ___ 10:12PM BLOOD ___ PTT-31.6 ___ ___ 10:12PM BLOOD Glucose-121* UreaN-3* Creat-0.6 Na-138 K-4.7 Cl-97 HCO3-25 AnGap-16 ___ 09:20AM BLOOD ALT-9 AST-19 LD(LDH)-172 AlkPhos-150* TotBili-0.8 ___ 07:20AM BLOOD Calcium-8.1* Phos-4.0 Mg-1.9 ___ 04:40PM BLOOD calTIBC-321 VitB12-<150* Folate-3 ___ Ferritn-69 TRF-247 ___ 06:55AM BLOOD METHYLMALONIC ACID-PND DISCHARGE LABS: =============== ___ 05:31AM BLOOD WBC-5.6 RBC-2.28* Hgb-7.9* Hct-24.2* MCV-106* MCH-34.6* MCHC-32.6 RDW-15.5 RDWSD-60.2* Plt ___ ___ 06:55AM BLOOD ___ PTT-31.6 ___ ___ 05:31AM BLOOD Glucose-95 UreaN-10 Creat-1.0 Na-137 K-4.4 Cl-96 HCO3-23 AnGap-18 ___ 06:55AM BLOOD ALT-8 AST-18 LD(LDH)-182 AlkPhos-123 TotBili-0.7 ___ 05:31AM BLOOD Calcium-8.1* Phos-6.3* Mg-2.5 IMAGING: ======== ___ Imaging PORT PLACEMENT ___ Successful placement of a double lumen chest power Port-a-cath via the right internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. ___ Imaging MR ARM W&W/O CONTRAST R In the distal right upper extremity, there is a predominantly solid, heterogeneously enhancing mass with mixed cystic components currently measuring 13.1 x 11.3 x 16.4 cm. It is similar in size to the prior CT from 2 days prior. However, there has been marked enlargement in size of the mass since ___ when it measured 10.0 x 6.5 x 9.5 cm. Some of the cystic components demonstrate fluid fluid levels with areas that are T1 hyperintense which is new from the study from ___ likely representing components of hemorrhage within the mass. There is mass effect on the adjacent musculature. However, no significant signal abnormality or enhancement is noted within this musculature to suggest invasion. Nonspecific subcutaneous edema is noted the region of the elbow that is partially visualized ___ Imaging BILAT LOWER EXT VEINS No evidence of deep venous thrombosis in the right or left lower extremity veins. ___ Imaging BILAT UP EXT VEINS US 1. Patent deep veins of the bilateral upper extremities without evidence of deep vein thrombosis identified. 2. Bilateral supraclavicular soft tissue edema without focal abnormalities. ___ Cardiovascular ECHO Normal left ventricular wall thickness, cavity size, and regional/global systolic function. No definite pathologic valvular flow identified. ___ Imaging CTA UPPER EXT W&W/O C & Interval increase in size of a highly vascular right upper arm mass. Multiple presumed necrotic cystic spaces within the mass contain hematocrit levels compatible with prior hemorrhage - one with a couple locules of subcutaneous emphysema suggesting recent laceration/abrasion. No evidence of extravasation of intravascular contrast material. There are preserved muscle and fat planes between the mass and the brachial artery and vein. ___HEST W/CONTRAST - The only suggestion malignancy in the chest is a pair of deep right axillary subcentimeter peripherally enhancing lymph nodes. Alternatively these could be benign. There are no pulmonary nodules or any intrathoracic adenopathy. - Proximal LAD atherosclerotic calcification could be hemodynamically significant. ___ Tissue: SOFT TISSUE, CORE BIOPSY FOR TUMOR High grade pleomorphic sarcoma ___ Imaging HUMERUS (AP & LAT) RIGH - Large soft tissue mass is seen in the lower portion of the right upper arm adjacent to the right humerus. No obvious soft tissue calcification is identified. - No definite bone erosion or periostitis. Although there is a segment of slightly ill-defined cortex along the lateral aspect of the distal left humeral metadiaphysis, this is unlikely to reflect bone erosion by the mass, as there was no direct abutment of the soft tissue mass against humerus in this area on the outside scanned-in MRI from ___. - Otherwise, the right humerus is within normal limits. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO BID 2. OxyCODONE (Immediate Release) 5 mg PO QHS:PRN Pain - Moderate 3. Hydrochlorothiazide 25 mg PO DAILY Discharge Medications: 1. Cyanocobalamin 1000 mcg PO DAILY RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 3. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Ondansetron 8 mg PO Q8H:PRN nausea RX *ondansetron HCl 8 mg 1 tablet(s) by mouth q8 hours Disp #*42 Tablet Refills:*0 6. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H RX *oxycodone 30 mg 1 tablet(s) by mouth q12 hours Disp #*60 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth daily Disp #*24 Packet Refills:*0 8. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #*60 Tablet Refills:*0 9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 10 mg 1 tablet(s) by mouth q4 hours Disp #*84 Tablet Refills:*0 10. Hydrochlorothiazide 25 mg PO DAILY RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 11. Lisinopril 20 mg PO BID RX *lisinopril 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: # High grade sarcoma # Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRI right arm with and without contrast INDICATION: ___ year old man with a right arm soft tissue sarcoma// evaluate tumor progression. Biopsy-proven high-grade pleomorphic sarcoma. TECHNIQUE: Multisequence multiplanar MRI of the right humerus was performed before and after the administration of intravenous gadolinium. COMPARISON: Targeted review of CTA of the right upper extremity dated ___. MRI of the humerus dated ___. FINDINGS: At the level of the distal humeral diaphysis, there is a large heterogeneously enhancing, predominantly solid mass with mixed cystic components currently measuring 13.1 x 11.3 x 16.4 cm. It is similar in size to the recent prior CT. However, there has been marked enlargement in size of the mass since ___ when it measured 10.0 x 6.5 x 9.5 cm. Some of the cystic components demonstrate fluid-fluid levels with areas that are T1 hyperintense which is new since ___ likely representing components of hemorrhage and/or proteinaceous content within the mass. There is mass effect on the adjacent musculature. However, no significant signal abnormality or enhancement is noted within this musculature to suggest invasion. Nonspecific subcutaneous edema is noted the region of the elbow that is partially visualized Evaluation of the bones demonstrates heterogeneous marrow signal that remains higher signal intensity on T1 weighted images when compared to the adjacent skeletal muscle compatible with red marrow changes. IMPRESSION: Since ___, there has been marked increase in size of the large, predominantly solid mass in the anterior soft tissues at the level of the distal humerus compatible biopsy-proven high-grade pleomorphic sarcoma. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man with new diagnosis of sarcoma undergoing XRT. bilateral leg edema// eval DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, 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: BILAT UP EXT VEINS US INDICATION: ___ year old man with new diagnosis of sarcoma in proximal right arm. Needs POC placement with prominence of bilateral supraclavicular areas// Eval soft tissue promienence bilateral supraclaviulcar and evaluate for possible permantent central access options TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral upper extremity veins. Separate grayscale images were obtained of the bilateral supraclavicular soft tissues. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. The bilateral internal jugular and axillary veins are patent, show normal color flow and compressibility. The bilateral brachial, basilic, and cephalic veins are patent, compressible and show normal color flow and augmentation. Imaging of the bilateral supraclavicular soft tissues demonstrates soft tissue edema without focal abnormalities. IMPRESSION: 1. Patent deep veins of the bilateral upper extremities without evidence of deep vein thrombosis identified. 2. Bilateral supraclavicular soft tissue edema without focal abnormalities. Radiology Report INDICATION: ___ year old man with proximal right arm sarcoma. Plan to start Adriamycin chemotherapy.// please place double lumen chest port and leave both accessed. ___ aware. COMPARISON: Chest radiograph from ___. TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___ radiologist performed the procedure. Dr. ___ ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 50 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service time of 55 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 g IV Ancef. CONTRAST: 0 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 2.0 min, 8 mGy PROCEDURE 1. Right internal jugular approach chest double 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 internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short ___ wire was advanced to make appropriate measurements for catheter length. An Amplatz wire was then passed distally into the IVC. Next, attention was turned towards creation of a subcutaneous pocket over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a 4.0 cm transverse incision was made and a subcutaneous pocket was created by using blunt dissection. The double lumen port was then connected to the catheter. The catheter was tunneled from the subcutaneous pocket towards the venotomy site from where it was brought out using a tunneling device. The port was then connected to the catheter and checks were made for any leakage by accessing the diaphragm using a non-coring ___ needle. No leaks were found. The port was then placed in the subcutaneous pocket and secured with ___ prolene sutures on either side. The venotomy tract was dilated using the introducer of the peel-away sheath supplied. Following this, the peel-away sheath was placed over the Amplatz wire through which the port was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The subcutaneous pocket was closed in layers with ___ interrupted and ___ subcuticular continuous Vicryl sutures. Steri-strips were used to close the venotomy incision site. Steri-Strips were applied over the sutures. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The po Rt was accessed using non coring ___ needles and could be aspirated and flushed easily. Sterile dressings were applied. The patient tolerated the procedure well without immediate complication. The port was left accessed as requested. FINDINGS: Patent right internal jugular vein. Final fluoroscopic image showing port with catheter tip terminating in the right atrium. IMPRESSION: Successful placement of a double lumen chest power Port-a-cath via the right internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Arm pain Diagnosed with Malig neoplm of conn and soft tiss of l upr limb, inc shldr temperature: 98.7 heartrate: 101.0 resprate: 15.0 o2sat: 96.0 sbp: 160.0 dbp: 83.0 level of pain: 9 level of acuity: 3.0
Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted with bleeding from your sarcoma. The bleeding stopped and we started you on your radiation treatment, which you tolerated well. We also started you on new pain medications. You also had a port placed to prepare you to start the chemotherapy, along with radiation, to start next ___. Be sure to return to 11 Reismann to be re-admitted early ___ morning before your radiation session. Sincerely, Your ___ Care team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: HIDA scan History of Present Illness: Mr. ___ is a ___ yo M with a h/o HIV (CD4 1270, Viral Load <75 on ___ here with acute onset RUQ abdominal pain with radiation to the epigastrium. Patient states that this 'gnawing' pain woke him out of his sleep at 2am this morning and was constant ___ severity. Tried naproxen with no relief. No alleviating/aggrevating factors. Pain was associated with severe nausea, but no vomitting. Denies recent fevers or illnesses, cp/sob, diarrhea, change in appetite, urinary symptoms. Last BM yesterday morning. No bloody or dark stools. Reports 2 prior episodes of same pain, 3wks ago and 6months ago. Similar in nature, waking him from sleep, but resolved with NSAIDs. Pain episodes are not associated with food. Patient reports HIDA scan in ___ for abdominal pain before initiating HAART therapy and it was unremarkable. Has never had an EGD. In the ED, initial VS were 98.3 85 157/92 18 99% RA. Labs including WBC, chem10, LFTs were wnl. RUQ u/s showed a distended gallbladder without definitive evidence of stones or cholecystitis. However, sonographic ___ was positive. Surgery was consulted and recommended admission to medicine for HIDA scan. Kept NPO and given IVF, 10mg of Morphine and 4mg Zofran. Transfer VS were 98 82 118/78 18 98% RA. On arrival to the floor, patient reports that his pain improved from ___ to ___ after receiving morphine. Denies nausea. ROS otherwise negative as below. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: PAST MEDICAL AND SURGICAL HISTORY: HIV- last CD4 1270, viral load <75 on ___ on HAART Obesity Lumbar disc disease Condyloma acuminata Internal hemorrhoids/Recurrent rectal abscesses Aphthous ulcer H/o syphilis-treated Social History: ___ Family History: No h/o Crohns, IBD in family Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.1 135/79 70 16 98RA pain: ___ General - NAD, AOx3 HEENT - mucuouse membranes moist. no thrush. no tonsillar enlargement. Neck - supple. full ROM. CV - RRR, no m/r/g Lungs - CTAB, no wheezes, rales, or crackles Abdomen - +bowel sounds, soft, non-distended. TTP in RUQ, epigastric and mildly in the LUQ. Mild voluntary guarding. No rebound. No organomegaly. GU - no CVA tenderness. Ext - full ROM of all joints. strength/sensation intact. Neuro - no focal neurologic deficits. Skin - no rashes noted. no edema of the extremities DISCHARGE PHYSICAL EXAM: PHYSICAL EXAM: VS - 98.1 135/79 70 16 98RA pain: ___ General - NAD, AOx3 HEENT - mucuouse membranes moist. no thrush. no tonsillar enlargement. Neck - supple. full ROM. CV - RRR, no m/r/g Lungs - CTAB, no wheezes, rales, or crackles Abdomen - +bowel sounds, soft, non-distended. TTP in RUQ, epigastric and mildly in the LUQ. Mild voluntary guarding. No rebound. No organomegaly. GU - no CVA tenderness. Ext - full ROM of all joints. strength/sensation intact. Neuro - no focal neurologic deficits. Skin - no rashes noted. no edema of the extremities Pertinent Results: Admission labs: ___ 07:00AM BLOOD WBC-5.8 RBC-4.43* Hgb-14.3 Hct-43.2 MCV-98 MCH-32.4* MCHC-33.2 RDW-12.9 Plt ___ ___ 07:00AM BLOOD Neuts-59.0 ___ Monos-7.1 Eos-1.9 Baso-0.8 ___ 07:00AM BLOOD Plt ___ ___ 07:00AM BLOOD ___ PTT-30.8 ___ ___ 07:00AM BLOOD Glucose-109* UreaN-18 Creat-1.1 Na-139 K-4.1 Cl-104 HCO3-27 AnGap-12 ___ 07:00AM BLOOD ALT-27 AST-18 AlkPhos-62 TotBili-0.3 ___ 07:00AM BLOOD Lipase-29 ___ 07:00AM BLOOD Albumin-4.5 Calcium-9.2 Phos-2.6*# Mg-2.0 ___ 07:00AM BLOOD LtGrnHD-HOLD ___ 07:00AM BLOOD GreenHd-HOLD Imaging: ___ HIDA scan: IMPRESSION: 1. No evidence of cholecystitis. 2. Small bowel tracer activity not visualized at 60 minutes. This is likely due to recent morphine administration just prior to the exam, but common bile duct obstruction is not excluded. ___ Gallbladder ultrasound: IMPRESSION: 1. Distended gallbladder with positive sonographic ___ sign, but no definite stones, wall edema, or pericholecystic fluid. Findings were equivocal for acute cholecystitis. HIDA scan may be obtained for further evaluation. 2. Hepatic steatosis. More severe forms of liver disease, including cirrhosis, cannot be excluded. Discharge Labs: ___ 07:10AM BLOOD WBC-5.8 RBC-4.46* Hgb-14.5 Hct-43.4 MCV-97 MCH-32.6* MCHC-33.5 RDW-12.4 Plt ___ ___ 07:10AM BLOOD Plt ___ ___ 07:10AM BLOOD Glucose-91 UreaN-14 Creat-1.2 Na-138 K-4.0 Cl-101 HCO3-30 AnGap-11 ___ 07:10AM BLOOD Albumin-4.3 Calcium-9.2 Phos-3.0 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion (Sustained Release) 300 mg PO QAM 2. Multivitamins 1 TAB PO DAILY 3. Complera (emtricitab-rilpivirine-tenofov) 200-25-300 mg Oral QD Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. BuPROPion (Sustained Release) 300 mg PO QAM 3. Complera (emtricitab-rilpivirine-tenofov) 200-25-300 mg Oral QD 4. Acetaminophen 650 mg PO Q6H:PRN pain 5. Famotidine 20 mg PO Q12H RX *famotidine 20 mg 1 tablet(s) by mouth Twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Right upper quadrant pain. COMPARISON: None. TECHNIQUE: Grayscale and Doppler ultrasound images of the right upper quadrant were obtained. FINDINGS: Increased echogenicity of the liver is consistent with hepatic steatosis. The main portal vein is patent with antegrade flow. There is no intra- or extra-hepatic biliary ductal dilatation. The common bile duct measures 4 mm. The gallbladder is distended without wall edema, pericholecystic fluid or definite stones. The neck of the gallbladder and the pancreas were not well assessed due to overlying bowel gas. Sonographic ___ sign was positive. Limited views of the aorta, IVC, and right kidney are unremarkable. IMPRESSION: 1. Distended gallbladder with positive sonographic ___ sign, but no definite stones, wall edema, or pericholecystic fluid. Findings were equivocal for acute cholecystitis. HIDA scan may be obtained for further evaluation. 2. Hepatic steatosis. More severe forms of liver disease, including cirrhosis, cannot be excluded. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: RUQ PAIN Diagnosed with ABDOMINAL PAIN RUQ, ASYMPTOMATIC HIV INFECTION temperature: nan heartrate: 96.0 resprate: 16.0 o2sat: 100.0 sbp: 155.0 dbp: 97.0 level of pain: 8 level of acuity: 3.0
Dear Mr. ___, It was a pleasure to care for you here at ___. As you know, you were hospitilized for severe abdominal pain. We are unsure of the cause of your abdominal pain. Obstruction of your gallbladder can sometimes cause the type of pain your were having. However, all of your labs were normal and a HIDA scan, which is an imaging test used to look to see if your gallbladder is obstructed, showed no gallbladder obstruction. We also performed an ultrasound of your gallbladder which was equivocal, but HIDA scan is a much better test to look for obstruction of your gallbladder. It is possible that your abdominal pain is being caused by gastritis (inflammation of the stomach) or peptic ulcer disease. We ordered an H. pylori test, which is currently pending, so you will need to contact the hospital in 48 hours for these results. We started you on famotidine, which is a medication that will block acid secretion in your stomach and may help with your symptoms. You are being discharged because you are clinically stable, but you should follow up with your primary care doctor. You should also follow up in the ___ clinic. The information needed in order to make an appointment is included in this document. Please return to the hospital if you are experiencing any symptoms that are concerning, including worsening or persistent abdominal pain, blood in stool or black stool, fevers, chills, nausea/vomiting, or any other symptoms that concern you.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dark stools Major Surgical or Invasive Procedure: ___ EGD ___ EGD History of Present Illness: ___ year old gentleman with history of CAD s/p 4 vessel CABG, dyslipidemia and ?diverticulosis who presented to the ___ dark stools x 2 days and lightheadedness x ___ days. He reported that he initially believed that his dark stools were due to changes in diet (eating brownies). Associated symptoms included appearing pale to his co-workers. This morning he felt dizzy when he woke up and then had a completely black bowel movement. No BRBPR, hematochezia or maroon colored stools. No recent consumption of iron supplements or pepto bismol, however he has taken a full dose aspirin for many years. He went to work as a ___ and felt persisent lightheadness so he called his supervisor and was given a ride to the ED. He presented to the ___ ED where his initial vitals were 97.8 78 141/78 18 100% RA. His hematocrit was 32.3 from a baseline of ~40 (in ___. He stools in the ED were noted to be melanotic and guaiac positive. He was seen by GI who were concerned about a possible upper EGD. GI recommending starting the patient on PPI bolus and PPI gtt. 2 peripheral IVs were placed prior to transfer to Medicine floor. On the floor, he reports some ongoing lightheadness with ambulation. He reports that his last bowel movement was this morning. He continues to deny BRBPR and hematochezia. The patient has no history of upper or lower GIB. He has a questionable h/o diverticulosis -- he reports that he was never told he has diverticulosis by a MD, but believes he may have this because he has a lot of pain with peanut ingestion. Past Medical History: MYOCARDIAL INFARCTION CORONARY ARTERY DISEASE s/p CABG ___ FAMILY PLANNING ANEMIA CORONARY ARTERY BYPASS SURGERY Hypercholesterolemia DIVERTICULOSIS -- unclear if patient carries this diagnosis, he reports that he was never told he has diverticulosis by a physician, but he presumes he has because he has a lot of pain with peanut ingestion. OBESITY UNSPEC Hypertension Social History: ___ Family History: There is no family history of premature coronary artery disease or sudden death. Father had CABG at age ___ Physical Exam: ADMISSION: Vitals: 98.2 72 106/60 16 100% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Well healed mid-line incision; regular rate and rhythm, normal S1 + S2 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 DISCHARGE: Vitals: 97.7 ___ ___ 18 99%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Well healed mid-line incision; regular rate and rhythm, normal S1 + S2 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 MSk: R shoulder joint ROM limited to pain -- cannot abduct beyond 40 degrees; no point tenderness in R shoulder; joint is not warmer compared to L side; no appreciable fluid or effusion Pertinent Results: ADMISSION LABS: ___ 01:00PM BLOOD WBC-9.2 RBC-3.44* Hgb-10.8* Hct-32.1* MCV-94 MCH-31.6 MCHC-33.7 RDW-12.6 Plt ___ ___ 01:00PM BLOOD Neuts-86.6* Lymphs-10.0* Monos-3.0 Eos-0.1 Baso-0.3 ___ 01:00PM BLOOD Glucose-108* UreaN-30* Creat-0.8 Na-137 K-4.8 Cl-104 HCO3-22 AnGap-16 ___ 01:00PM BLOOD Calcium-9.2 Phos-2.8 Mg-1.9 ___ 01:08PM BLOOD Lactate-1.0 DISCHARGE LABS: ___ 05:14PM BLOOD WBC-8.9 RBC-3.13* Hgb-9.8* Hct-28.0* MCV-90 MCH-31.2 MCHC-34.9 RDW-15.6* Plt ___ ___ 06:30AM BLOOD Glucose-102* UreaN-11 Creat-0.7 Na-140 K-3.8 Cl-106 HCO3-27 AnGap-11 ___ 06:30AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0 IMAGING: EGD ___: Impression: -Small hiatal hernia -Erythema and petechiae in the antrum compatible with gastritis -Granularity and erythema in the duodenal bulb compatible with duodenitis -The antrum and duodenal bulb were deformed, likely related to duodenal diverticulum -Diverticula in the proximal bulb and third part of the duodenum -Blood was seen in the duodenum but this was washed away with normal mucosa underneath. No new blood was seen during the procedure. -Otherwise normal EGD to third part of the duodenum Recommendations: -Continue BID PPI: Omeprazole 40mg or equivalent No ulcer was seen. Its possible that a small ulcer in the duodenal sweep was missed as the duodenal diverticula ___ ___ antrum and sweep. However this area was examined multiple times and there was certainly no new bleeding over the procedure. -Source of bleeding may have been from gastritis/duodenitis, now treated with PPI -Possible dieulafoy lesion that was missed because not bleeding. If re-bleeds would repeat endoscopy. EGD ___: Impression: Small hiatal hernia Patchy erythema and edema was seen in the stomach, consistent with gastritis. Patchy erythema, edema, and congestion was seen in the duodenum consistent with duodenitis. Duodenal diverticulum Otherwise normal EGD to third part of the duodenum Recommendations: -Continue BID PPI x 8 week course -Check H pylori Shoulder Film ___: FINDINGS: The AC joint is essentially within normal limits. There is narrowing of the glenohumeral joint, consistent with some degenerative changes. There is a large amount of opacification extending upward from the level of the greater tuberosity. This is most consistent with calcific tendinosis in the rotator cuff. ___ ___: IMPRESSION: No evidence of deep venous thrombosis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. Diltiazem 120 mg PO DAILY 4. Atorvastatin 20 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Atorvastatin 20 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. Diltiazem 120 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 40 mg PO BID RX *omeprazole 40 mg 1 capsule,delayed ___ by mouth every 12 hours Disp #*60 Capsule Refills:*1 6. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth Daily Disp #*30 Tablet Refills:*0 7. Acetaminophen 1000 mg PO Q8H:PRN pain RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as needed for shoulder pain Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Upper gastrointestinal bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ man with gastrointestinal hemorrhage. Evaluate for pneumonia. COMPARISON: Chest radiograph from ___. FINDINGS: The patient is status post median sternotomy with surgical clip seen in the anterior mediastinum. The lungs are clear. The hilar and cardiomediastinal contours are normal. There is no pneumothorax or pleural effusion. Pulmonary vascularity is normal. IMPRESSION: No acute cardiopulmonary process. Radiology Report HISTORY: Right shoulder pain. FINDINGS: The AC joint is essentially within normal limits. There is narrowing of the glenohumeral joint, consistent with some degenerative changes. There is a large amount of opacification extending upward from the level of the greater tuberosity. This is most consistent with calcific tendinosis in the rotator cuff. Radiology Report HISTORY: Left flank pain, evaluate for deep venous thrombosis. COMPARISON: None FINDINGS: The there is normal grayscale and color Doppler appearance, pulsed Doppler waveform, compressibility, and augmentation of the veins of the left lower extremity from the left common femoral vein through the mid calf. No adenopathy or other incidental abnormality identified. IMPRESSION: No evidence of deep venous thrombosis. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: DIZZINESS Diagnosed with GASTROINTEST HEMORR NOS, AORTOCORONARY BYPASS temperature: 97.8 heartrate: 78.0 resprate: 18.0 o2sat: 100.0 sbp: 141.0 dbp: 78.0 level of pain: 3 level of acuity: 2.0
It was a pleasure to participate in your care at ___. You came to the hospital for dark stools and dizziness. We found that your blood counts were low. You were seen by the Gastroenterology Team who elected to do a camera study called an EGD (upper endoscopy). Your study showed old blood in your small bowel but no active bleeding. A repeat EGD should similar results. Your blood counts were monitored after the procedure and remained stable. You developed shoulder pain while in the hospital. We treated your pain with tylenol. Please do NOT take medications like ibuprofen, motrin, or naproxen for your pain, as these medications (NSAIDs) can cause bleeding in your gastrointestinal tract. Please take all medications as prescribed. Please follow up with your primary care physician for further care. You will need to have your blood counts checked soon to make sure that there is no further bleeding. If you get dizzy or lightheaded please call your PCP or go the ED to have your labs rechecked.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Imitrex / shellfish derived Attending: ___. Chief Complaint: Right flank pain / fevers Major Surgical or Invasive Procedure: ___: Placement of an 8 ___ percutaneous right-sided nephrostomy tube. ___: Right ureteroscopy with laser lithotripsy, and placement of double-J stent, and basket extraction of stone. ___: Right nephrostomy catheter left in situ given a small stone in the lower calyx and no passage of contrast beyond the mid ureter. The tube was capped. History of Present Illness: PRIMARY CARE PHYSICIAN: ___ HISTORY OF PRESENT ILLNESS: ___ w/ h/o obstructive nephrolithiasis who is one week post-partum presents with worsening right flank pain and fever that began this morning. Mrs. ___ awoke with ___ right flank pain that radiated through to the back. She states that the pain is similar to kidney stones in the past. At home, she was febrile to 102.4. She describes some nausea without vomiting. She denies any hematochezia, melena, hematuria, or dysuria. Mrs. ___ had 3 kidney stones identified in ___ of this year, for which she recieved lithotrypsy and had a ureteral stent placed. The stent was removed one month later. She was subsequently evaluated with monthly ultrasounds. Most recent U/S from ___ showed worsening right-sided hydronephrosis. Invasive therapy was not pursued at this time since she was relatively asymptomatic and late in pregnancy. She delivered her daughter one week ago via vaginal delivery and had no complications. She also had no complications during her pregnancy. CT of the abdomen in the ED showed severe right hydroureteronephrosis with 3 stones in the right distal ureter, largest measuring 1.1 cm. Given the severity of obstruction and patient's presentation with fevers, urology recommended percutaneous nephrostomy tube w/ ___ for rapid decompression of hydronephrosis. Right perc nephrostomy tube was placed in ___. Shortly after the procedure, patient spiked a fever to 105.5 and became tachycardic to 140s. She was started on ampicillin and ceftriaxone. Shortly thereafter, she defervesced and her tachycardia improved. She was admitted to the MICU for close monitoring. On arrival to the MICU, patient continues to have ___ right flank pain. Overall, feels much better. Denies any recent hematuria/dysuria, diarrhea, nausea/vomiting. REVIEW OF SYSTEMS: (+) Per HPI. 10-point ROS conducted and otherwise negative. Past Medical History: Past medical history: Nephrolithiasis -calcium oxalate stones -s/p lithotripsy and ureteral stent in ___ -recurrent obstructive stones seen on u/s from ___ Past surgical histories: Deviated septum repair MNT both ears. Obstetric History: Three pregnancies, two live births, both vaginal deliveries. Social History: ___ Family History: Denies any family history of significant medical conditions. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.9 88 113/66 98% 2Lnc General: Well appearing in no acute distress HEENT: Moist mucous membranes Neck: JVP non elevated CV: Regular rate and rhythm, normal S1 S2, no murmurs Lungs: Clear to auscultation bilaterally, no wheezes/rales/rhonchi Abdomen: Soft, normoactive bowel sounds, nontender, nondistended, no rebound or guarding. Right percutaneous nephrostomy tube in place draining clear/yellow urine. Mild right CVA tenderness present. GU: no Foley in place Ext: Warm, no peripheral edema peripheral pulses 2+ ___ Neuro: alert and oriented to person, hospital, and date. No focal deficits. Discharge Physical Exam: AVSS Abdomen soft, nt/nd R PCN clamped. Dressing over wound. c/d/i. Ext w/out edema, pitting, calf pain to deep palpation bilateral. Pertinent Results: Admission Labs: ___ 10:45AM BLOOD WBC-10.1 RBC-3.92* Hgb-13.0 Hct-34.4* MCV-88 MCH-33.1* MCHC-37.8* RDW-12.6 Plt ___ ___ 10:45AM BLOOD Neuts-89.8* Lymphs-6.3* Monos-3.3 Eos-0.4 Baso-0.2 ___ 01:08PM BLOOD ___ PTT-31.1 ___ ___ 10:45AM BLOOD Glucose-79 UreaN-23* Creat-1.4* Na-139 K-4.0 Cl-104 HCO3-20* AnGap-19 ___ 10:45AM BLOOD Calcium-8.1* ___ 05:45PM BLOOD Lactate-2.1* Interim Labs: Discharge Labs: Microbiology: ___ MRSA SCREEN-PENDING ___ URINE,KIDNEY FLUID CULTURE-PENDING ___ Blood Culture-PENDING ___ URINE CULTURE-PENDING ___ BLOOD CULTURE-PENDING Imaging: CT abdomen and pelvis ___: 1. Severe right hydroureteronephrosis with 3 stones in the right distal ureter, largest measuring 1.1 cm. 2. New non-obstructive 5-mm left renal calculus. ___ 01:15PM BLOOD WBC-9.8 RBC-4.21 Hgb-13.5 Hct-37.7 MCV-90 MCH-32.1* MCHC-35.9* RDW-13.2 Plt ___ ___ 06:05AM BLOOD WBC-7.8 RBC-3.52* Hgb-11.1* Hct-30.7* MCV-87 MCH-31.5 MCHC-36.2* RDW-12.8 Plt ___ ___ 02:37AM BLOOD WBC-11.9* RBC-3.73* Hgb-12.4 Hct-34.0* MCV-91 MCH-33.1* MCHC-36.5* RDW-13.2 Plt ___ ___ 01:15PM BLOOD Glucose-97 UreaN-16 Creat-0.7 Na-137 K-4.4 Cl-103 HCO3-21* AnGap-17 ___ 06:05AM BLOOD Glucose-117* UreaN-13 Creat-0.9 Na-137 K-3.0* Cl-104 HCO3-20* AnGap-16 ___ 02:37AM BLOOD Glucose-112* UreaN-22* Creat-1.3* Na-140 K-4.3 Cl-110* HCO3-18* AnGap-16 ___ 11:13 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ___ 3:17 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): ___ 4:00 pm URINE,KIDNEY RIGHT KIDNEY. **FINAL REPORT ___ FLUID CULTURE (Final ___: PRESUMPTIVE GARDNERELLA VAGINALIS. >10,000 CFU/ML. ___ 12:00 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ URINE URINE CULTURE-FINAL EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY WARD Medications on Admission: Allergies: Sulfa, Imitrex and shellfish. Medications: Prenatal vitamins and zantac Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Senna 1 TAB PO BID constipation 3. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth Q6hrs Disp #*40 Tablet Refills:*0 4. Cephalexin 500 mg PO Q6H Duration: 5 Days RX *cephalexin [Keflex] 500 mg ONE capsule(s) by mouth four times a day Disp #*20 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: ___: SEVERE RIGHT HYDRONEPHROSIS PREOPERATIVE DIAGNOSIS: Right multiple ureteral stones and right renal calculus, history possible urosepsis. POSTOPERATIVE DIAGNOSIS: Right multiple ureteral stones and right renal calculus, history possible urosepsis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent Followup Instructions: ___ Radiology Report INDICATION: History of nephrolithiasis with right flank pain and fever, please evaluate. COMPARISON: CTU from ___ and renal ultrasound from ___. TECHNIQUE: MDCT images were obtained through the abdomen and pelvis without administration of IV contrast. Multiplanar reformatted images in coronal and sagittal axes were generated and reviewed. FINDINGS: The bases of the lungs are clear. CT ABDOMEN: The evaluation of the intra-abdominal structures is limited by the lack of IV contrast. The liver appears unremarkable without evidence of focal lesions concerning for malignancy. There is no evidence of intrahepatic biliary ductal dilatation. The gallbladder is normal without evidence of wall thickening or stones. The spleen appears homogenous and normal in size. The adrenal glands bilaterally are normal. The pancreas is normal without evidence of focal lesions or peripancreatic stranding. The left kidney contains a new left lower pole caliceal stone measuring 5 mm; however, there is no hydronephrosis. There is severe right kidney hydroureteronephrosis with 3 discrete stones in the right distal ureter. The largest calculus measures 1.1 cm. There is mild right perinephric stranding. The stomach, duodenum and small bowel are unremarkable without evidence of obstruction or wall thickening. The colon is normal. The appendix is visualized and is unremarkable. There is no intra-abdominal free air. No retroperitoneal or mesenteric lymphadenopathy is identified. CT PELVIS: There is an enlarged, post-partum uterus. There is no pelvic or inguinal lymphadenopathy. There is no evidence of pelvic free fluid. OSSEOUS STRUCTURES: No lytic or blastic lesions concerning for malignancy are identified. IMPRESSION: 1. Severe right hydroureteronephrosis with 3 stones in the right distal ureter, largest measuring 1.1 cm. 2. New non-obstructive 5-mm left renal calculus. Radiology Report HISTORY: ___ female with kidney stones and right-sided hydroureteronephrosis. COMPARISON: Same day CT abdomen OPERATORS: Dr. ___ (attending) and Dr. ___ (fellow). The attending was present and supervising throughout the entire procedure. ANESTHESIA: Moderate sedation was provided by administering divided doses of fentanyl and Versed throughout the total intra-service time of 40 min. The patient's hemodynamic parameters were continuously monitored. A total dose of 125 mcg of fentanyl and 2 mg of Versed were used. 1% local lidocaine was also used subcutaneously. FINDINGS: The procedure was discussed in detail with the patient. The risks and benefits were emphasized. Informed written consent was obtained. When the patient arrived in the angiography suite they were placed prone on the procedure table. A pre-procedure ultrasound imaged the kidney and lower costal margin. The region was prepped and draped in usual sterile fashion. A preprocedural time out was performed per ___ protocol. Under sonographic guidance a posterior mid pole calyx was identified within the right kidney. A 21 gauge cook needle was then advanced into the collecting system. Clear urine was obtained. Under fluoroscopic guidance an 0.018 Nitinol wire was advanced into the renal pelvis. The needle was then exchanged for an Accustick system. The wire was removed and clear urine drained from the catheter. A sample was sent to microbiology. A small volume of contrast was administered into the collecting system demonstrating severe right -sided hydronephrosis and a moderately dilated right ureter. A dedicated antegrade nephrostogram was not performed given urosepsis. A ___ wire was advanced through the Accustick sheath and coiled within the renal pelvis. The Accustick sheath was removed and 8 and 9 ___ dilators were used to open the tract over the Amplatz wire. This was followed by successful placement of an 8 ___ nephrostomy tube with the pigtail locked within the renal pelvis. Nephrostogram confirmed the location of the nephrostomy tube. The catheter was secured to the skin using a suture and flexi track. The catheter was placed to external bag drainage and bandaged according to protocol. The patient left the department in stable condition. No complications. IMPRESSION: Severe right sided hydronephrosis. Successful placement of an 8 ___ percutaneous right-sided nephrostomy tube. Radiology Report INDICATION: ___ female with obstructing renal stone status post right nephrostomy placed on ___. Now status post ureteroscopy, laser lithotripsy and nephroureteral stent placement. Nephrostomy removal requested. COMPARISON: ___. PHYSICIAN: Dr. ___ (fellow) and Dr. ___ (attending), present and supervising throughout. FLUOROSCOPY TIME: 2.1 minutes. CONTRAST: 10 mL Optiray 320. PROCEDURE: Right nephrostogram. PROCEDURE DETAIL: After explanation of the procedure, the patient was brought to the angiography suite and placed prone on the imaging table. A preprocedure timeout was performed. The right flank was prepped with chlorhexidine. Initial scout fluoroscopic image demonstrates an indwelling right nephrostomy tube with a slightly tortuous course, a double J stent and a calculus in the lower calyx. Approximately 10 mL of contrast was injected under fluoroscopic visualization via the indwelling nephrostomy catheter. Contrast did not pass beyond the mid ureter. The catheter was flushed and secured to the skin with a 0-silk suture and Stat-Lock device. The patient tolerated the procedure well without immediate complication. IMPRESSION: Right nephrostomy catheter left in situ given a small stone in the lower calyx and no passage of contrast beyond the mid ureter. The tube was capped. Findings and recommendations discussed between Dr. ___ Dr. ___ at the time of the exam on ___. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: R Flank pain Diagnosed with CALCULUS OF KIDNEY temperature: 98.0 heartrate: 99.0 resprate: 18.0 o2sat: 98.0 sbp: 131.0 dbp: 88.0 level of pain: 6 level of acuity: 3.0
-You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent (if there is one). -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume all of your pre-admission medications and review your post-operative course with your PCP. -As advised, review your post operative course and medications with your pediatrician and your OB-GYN. Medications that you have been given may be excreted in your breat milk and this can effect your child. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative, and available over the counter. The generic name is DOCUSATE SODIUM. It is recommended that you use this medication. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks and while nephrostomy is in place. No sports, water-immersion (pool/tub). NEPHROSTOMY TUBE INSTRUCTIONS FOR CARE---FOR ___ & FAMILY: Please leave RIGHT PCN tube capped. If there is increased RIGHT FLANK/BACK pain, the PCN may be uncapped and put to to external gravity drainage. Please monitor and record urine output from the PCN tube. Catheter flushing for troubleshooting only: If there are excessive blood clots or debris or thick urine within the connecting tubing, this can also be flushed as needed to clear from the stopcock into the drainage bag. Change dressing daily. Gently cleanse around the skin entry site of the catheter with povidone iodine or dilute hydrogen peroxide. Dry and apply sterile gauze dressing. Dressing should be changed daily for the first three days and then Q3days and prn saturation. Catheter security: a) Every shift, check to be sure the catheter, the connecting tubing and the drainage bag are securely attached to the patient and are not kinked. b) If the catheter appears to be pulling, please notify Interventional Radiology. c) If the catheter pulls out, please notify Interventional Radiology with in 8 hours. SAVE THE CATHETER for us to inspect. Do not throw it away. Call Angio for ANY catheter related questions or problems. ___ or Fellow/Resident (pager# ___ IF Catheter is attached to drainage bag for external drainage; please measure and record the net output every shift (or more often if the urine output is high).
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: BRBPR Major Surgical or Invasive Procedure: none History of Present Illness: ___ with PMH of multiple sclerosis is presenting with BRBPR. 1 day prior to admission patient passed a normal bowel movement followed by large amount of bright red blood with clots. During this time she had severe abdominal pain. She continued to have BMs that were mostly blood and clots so she came to the ED. The BRBPR started suddenly, she rates it as severe, it is not getting better, it has been going on for 1 day. In the ED: VS: T 97.3, HR 94, BP 114/54, RR 17, 100% RA Labs: WBC 11.8, Hgb 13, plts 265, bicarb 21, Cr 0.9. Imaging: CT abd: colitis involving entire descending colon from the splenic flexure to junction of sigmoid colon. Either infectious or inflammatory in etiology with ischemia not included. Meds: CTX, flagyl, LR 1L, morphine 4mg x2. On hospital floor patient is still having moderate abdominal pain. Last BM was in the ED and was liquid blood. Past Medical History: Multiple Sclerosis Acne Social History: ___ Family History: no family history of IBD. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: Afebrile and vital signs stable GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, moderate tenderness to palpation throughout. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE PHYSICAL EXAM: VITALS: 97.9 PO BP133/78 HR62 RR17 100%RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, no TTP. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: LABS ON ADMISSION: ___ 01:20PM WBC-11.8* RBC-4.46 HGB-13.4 HCT-40.1 MCV-90 MCH-30.0 MCHC-33.4 RDW-13.5 RDWSD-44.3 ___ 01:20PM NEUTS-72.9* LYMPHS-17.5* MONOS-8.5 EOS-0.3* BASOS-0.4 IM ___ AbsNeut-8.58* AbsLymp-2.06 AbsMono-1.00* AbsEos-0.04 AbsBaso-0.05 ___ 01:20PM PLT COUNT-265 ___ 01:20PM ALT(SGPT)-14 AST(SGOT)-33 ALK PHOS-52 TOT BILI-0.9 ___ 01:20PM ALBUMIN-4.4 ___ 01:20PM GLUCOSE-99 UREA N-8 CREAT-0.9 SODIUM-136 POTASSIUM-7.1* CHLORIDE-101 TOTAL CO2-21* ANION GAP-14 ___ 01:58PM URINE COLOR-Straw APPEAR-CLEAR SP ___ ___ 01:58PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NORMAL PH-6.0 LEUK-NEG ___ 01:58PM URINE RBC-4* WBC-4 BACTERIA-NONE YEAST-NONE EPI-1 MICRO: ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; FECAL CULTURE - R/O E.COLI 0157:H7-FINAL INPATIENT (NO GROWTH) ___ URINE URINE CULTURE-FINAL (NO GROWTH) IMAGING: Colitis involving the entire descending colon from the splenic flexure to its junction with the sigmoid colon, either infectious or inflammatory in etiology with ischemia not excluded. No evidence of pneumatosis, free intraperitoneal air, or drainable fluid collection. LABS ON DISCHARGE: ___ 06:22AM BLOOD WBC-6.7 RBC-4.28 Hgb-12.8 Hct-39.1 MCV-91 MCH-29.9 MCHC-32.7 RDW-13.4 RDWSD-45.0 Plt ___ ___ 06:22AM BLOOD Glucose-107* UreaN-7 Creat-0.8 Na-140 K-3.9 Cl-101 HCO3-25 AnGap-14 ___ 06:22AM BLOOD CRP-29.4* ___ 06:22AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vitamin D 1000 UNIT PO DAILY 2. glatiramer 20 mg/mL subcutaneous five days a week 3. Spironolactone 50 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO BID Duration: 7 Days 2. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 3. glatiramer 20 mg/mL subcutaneous five days a week 4. Spironolactone 50 mg PO DAILY 5. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Colitis Multiple sclerosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: NO_PO contrast; History: ___ with 2 days of left lower quadrant pain, multiple episodes of bloody diarrheaNO_PO contrast // Diverticulitis, stricturing, other abnormally? 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 2.0 s, 0.5 cm; CTDIvol = 9.6 mGy (Body) DLP = 4.8 mGy-cm. 2) Spiral Acquisition 5.7 s, 44.6 cm; CTDIvol = 8.6 mGy (Body) DLP = 384.5 mGy-cm. Total DLP (Body) = 389 mGy-cm. COMPARISON: CT abdomen and pelvis ___. FINDINGS: LOWER CHEST: Minimal bibasilar atelectasis. No pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of solid renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. There is diffuse, circumferential wall thickening and adjacent fat stranding of the entire descending colon, extending from the splenic flexure to its junction with the proximal sigmoid colon. No evidence of pneumatosis, free intraperitoneal air, or drainable fluid collection. Appendix is normal. PELVIS: The bladder and distal ureters are unremarkable. Trace pelvic free fluid. REPRODUCTIVE ORGANS: A tampon is in situ. The uterus otherwise appears unremarkable. No adnexal masses. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Tiny, fat containing umbilical hernia. IMPRESSION: Colitis involving the entire descending colon from the splenic flexure to its junction with the sigmoid colon, either infectious or inflammatory in etiology with ischemia not excluded. No evidence of pneumatosis, free intraperitoneal air, or drainable fluid collection. Gender: F Race: ASIAN Arrive by WALK IN Chief complaint: BRBPR Diagnosed with Hemorrhage of anus and rectum temperature: 97.3 heartrate: 94.0 resprate: 17.0 o2sat: 100.0 sbp: 114.0 dbp: 54.0 level of pain: 4 level of acuity: 2.0
Dear Ms. ___, It was a pleasure taking care of you during your hospitalization at ___! Why did you come to the hospital? - Because you were having bloody stools What happened while you were in the hospital? - You were diagnosed with colitis of the left side of your colon. You were treated with antibiotics and improved. - You were tested for common bacteria that cause bloody diarrhea, but tests came back negative. What should you do after you leave the hospital? - Please complete a total of 7d of antibiotic therapy (last day ___ - Follow up with Dr. ___ Dr. ___ as scheduled - Please stick to a bland diet until your diarrhea improves. - If you notice any recurrent bleeding, worsening abdominal pain, intolerance of oral intake, please come back to the ED right away. We wish you the best! Sincerely, Your ___ Care Team
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: ERCP with sphincterotomy History of Present Illness: Ms. ___ is a ___ female with the past medical of cholelithiasis s/p CCY who presents with abdominal pain. Patient notes onset of severe, cramping and pressure-like abdominal pain starting ___. Pain was associated with food, sometimes relieved with belching and defecation. Pain was ___, no associated n/v, diarrhea. Patient does endorse chills. She tried tums and Prilosec for the pain however this did not help. Patient presented to her PCP due to the pain and labs were notable for elevated LFTs. US revealed dilated CBD. Pain became very severe today, prompting patient to come to ED due to concern for recurrent stones. Labs again revealed elevated LFTs, US again with dilated CBD concerning for CBD stone. She was taken for ERCP on afternoon of ___ - sphincterotomy performed, sludge noted but no stones. Post procedure patient has no complaints. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Cholelithiasis s/p CCY Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: Admission exam VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Discharge exam VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, mild TTP in epigastric area. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: Admission labs ___ 11:00AM BLOOD WBC-6.6 RBC-4.68 Hgb-13.6 Hct-41.5 MCV-89 MCH-29.1 MCHC-32.8 RDW-12.4 RDWSD-40.7 Plt ___ ___ 11:00AM BLOOD Glucose-68* UreaN-9 Creat-0.6 Na-138 K-4.1 Cl-98 HCO3-23 AnGap-17* ___ 11:00AM BLOOD ALT-451* AST-251* AlkPhos-241* TotBili-5.1* DirBili-3.9* IndBili-1.2 Discharge labs ___ 06:55AM BLOOD WBC-6.3 RBC-3.89* Hgb-11.5 Hct-34.2 MCV-88 MCH-29.6 MCHC-33.6 RDW-12.3 RDWSD-39.4 Plt ___ ___ 06:55AM BLOOD Glucose-70 UreaN-6 Creat-0.6 Na-141 K-4.3 Cl-104 HCO3-24 AnGap-13 RUQ US ___ IMPRESSION: Intrahepatic and extrahepatic biliary ductal dilation with CBD measuring 12 mm. Findings are concerning for distal CBD obstruction and ERCP is recommended to further assess. ERCP ___ The scout film showed surgical clips in the RUQ. •The major papilla was bulging. •The CBD was successfully cannulated using a Rx sphincterotome preloaded with 0.035in guidewire. •Contrast injection revealed small filling defects in the lower CBD consistent with sludge. The CBD was dilated up to approximately 10mm in diameter. •A biliary sphincterotomy was successfully performed at the 12 o'clock position. There was mild post-sphincterotomy oozing. •Large amounts of dark thick bile was draining from the major papilla after sphincterotomy. •The bile duct was swept multiple times using a biliary balloon catheter. Moderate amount of sludge material was successfully removed. •Occlusion cholangiogram revealed no more filling defects. There was excellent contrast and bile drainage at the end of the procedure. •It was noted that the post-sphincterotomy oozing has stopped by the end of the procedure Medications on Admission: None Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO Q12H Take through morning of ___ RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours Disp #*8 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Elevated liver enzymes Abdominal pain Dilated common bile duct 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: ___ with RUQ pain s/p cholecystectomy, had oSH US that showed ? crytals in CBD// eval CBD TECHNIQUE: Ultrasound. COMPARISON: None. FINDINGS: The liver appears normal in grayscale appearance, size, without focal lesion. Mild intrahepatic biliary ductal dilation is noted with the common bile duct measuring up to 12 mm at the level of the porta hepatis. Difficult to exclude distal CBD obstruction including retained stone. The pancreas is grossly unremarkable. No ascites. Gallbladder surgically absent. Right kidney appears normal in grayscale appearance and size. The spleen is normal in size. Left kidney is also normal in grayscale appearance and size. IMPRESSION: Intrahepatic and extrahepatic biliary ductal dilation with CBD measuring 12 mm. Findings are concerning for distal CBD obstruction and ERCP is recommended to further assess. Gender: F Race: ASIAN - SOUTH EAST ASIAN Arrive by WALK IN Chief complaint: Abd pain, Abnormal labs Diagnosed with Gastrointestinal hemorrhage, unspecified temperature: 98.6 heartrate: 70.0 resprate: 18.0 o2sat: 100.0 sbp: 102.0 dbp: 57.0 level of pain: 8 level of acuity: 3.0
Dear ___ ___ were admitted for abdominal pain and elevated liver enzymes. ___ underwent ERCP with sphincterotomy. No stones were found but sludge was removed. Your liver enzymes improved after the procedure. Your abdominal pain improved and ___ tolerated food. ___ will need to follow up with your PCP next week to check labs again. Thank ___ for allowing us to participate in your care Your ___ team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dyspnea on exertion, hematuria Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMH notable for A fib on coumadin, intermittend hematuria for years presenting with lightheadedness and dyspnea on exertion for three days. Patient has had intermittent hematuria for ___ years with known cystoprostatic bleeding and bladder calculi. Of note he was recently diagnosed with E. coli UTI last week (culture from ___, completed 3-day course of a quinolone this morning. Still intermittent hematuria and rust-colored urine, passing some clots in ED. Denies chest pain/pressure, orthopnea, extremity swelling, fevers/chills, back pain, syncope or presyncope, vertigo, HA, or visual changes. In the ED, initial vital signs were: 98.0 78 123/73 20 100% RA. Labs were notable for Hgb 8.5 down from 13.9 on ___, INR 2.2, BNP 1787 (similar to prior), trop <0.01. Urine: rust-colored with clots, >182 RBC/WBC, nitrite neg, many bacteria. Heme negative on rectal exam. CXR with no acute cardiopulmonary processes. Patient was transfused one unit of pRBCs. Patients urologist was contacted who recommended not puting in a catheter for now as long as patient still voiding, r/o other causes of anemia and await cultures for antibiotics if needed with formal urology consult as inpatient. Patient admitted for transfusion and hematuria. Vitals on transfer: 98.8 62 100/55 16 100% RA. Past Medical History: -Hypertension - Seborrheic keratosis -Atrial fibrillation, rate controlled. -Atrial flutter ablation in ___ with development of atrial fibrillation requiring cardioversions and now permament Afib. -Non-ischemic dilated cardiomyopathy with LVEF ___ in ___, improved to 50% ___ -PPM -Right carotid stenosis, left carotid occlusion s/p CEA ___ --Anticoagulation (Patient adjusts coumadin for hematuria). Social History: ___ Family History: No history of sudden cardiac death, premature coronary disease, or arrhythmias. Physical Exam: ADMISSION: Vitals: 98.2 147/89 80 18 98%RA General: Elderly man laying comfortably in bed w/ no accessory muscle use HEENT: NCAT EOMI MMM. Mild tenderness along right jaw. No palpable tmeporal artery. Neck: Supple, full ROM CV: irregularly irregular rate S1/S2 Lungs: CTAB without w/r/r Abdomen: +BS soft NT/ND well healed midline surgical scar below umbilicus Back: No CVA tenderness, no midline spine tenderness or step offs Ext: No c/c/e Neuro: AAOx3, no gross focal neuro deficits noted Skin: warm and dry DISCHARGE: Vitals: 98.3 114/62 (107-147/57-89) 71 (60-80) 20 99%RA General: Elderly man laying comfortably in bed w/ no accessory muscle use HEENT: NCAT EOMI MMM. Mild tenderness along right jaw. No palpable tmeporal artery. Neck: Supple, full ROM CV: irregularly irregular rate S1/S2 Lungs: CTAB without w/r/r Abdomen: +BS soft NT/ND well healed midline surgical scar below umbilicus Back: No CVA tenderness, no midline spine tenderness or step offs Ext: No c/c/e Neuro: AAOx3, no gross focal neuro deficits noted Skin: warm and dry Pertinent Results: ADMISSION: ___ 01:15PM BLOOD WBC-5.4 RBC-2.75*# Hgb-8.5*# Hct-26.5*# MCV-97 MCH-31.1 MCHC-32.2 RDW-15.9* Plt ___ ___ 01:15PM BLOOD Neuts-74.8* Lymphs-16.6* Monos-6.1 Eos-2.3 Baso-0.2 ___ 01:15PM BLOOD Plt ___ ___ 01:22PM BLOOD ___ PTT-35.4 ___ ___ 01:15PM BLOOD Ret Aut-3.3* ___ 01:15PM BLOOD Glucose-96 UreaN-20 Creat-1.0 Na-138 K-4.8 Cl-105 HCO3-23 AnGap-15 ___ 01:15PM BLOOD cTropnT-<0.01 proBNP-1787* ___ 01:15PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2 Iron-36* ___ 01:15PM BLOOD calTIBC-393 ___ Ferritn-22* TRF-302 DISCHARGE: ___ 09:12AM BLOOD WBC-5.8 RBC-3.31* Hgb-10.1* Hct-31.8* MCV-96 MCH-30.6 MCHC-31.8 RDW-16.9* Plt ___ ___ 11:12AM BLOOD ___ ___ 09:12AM BLOOD Plt ___ ___ 03:44AM BLOOD Glucose-88 UreaN-17 Creat-0.9 Na-139 K-3.9 Cl-107 HCO3-21* AnGap-15 IMAGING: ___ CXR IMPRESSION: No acute cardiopulmonary abnormality. ___ EKG: Ventricularly paced rhythm. Underlying rhythm is atrial fibrillation. Compared to the previous tracing of ___ pacemaker rhythm is new. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Desonide 0.05% Cream 1 Appl TP DAILY 3. Doxazosin 4 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Simvastatin 20 mg PO DAILY 6. Warfarin 2.5 mg PO DAILY16 7. Aspirin 81 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Doxazosin 4 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Simvastatin 20 mg PO DAILY 6. Warfarin 2.5 mg PO DAILY16 7. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Desonide 0.05% Cream 1 Appl TP DAILY 9. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO TID:PRN jaw pain Duration: 7 Days before meals as needed, no driving or operating heavy machinery while taking med RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every eight (8) hours Disp #*21 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: chronic iron deficiency anemia, hematuria 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 atrial fibrillation/pacemaker, now with shortness of breath and lightheadedness. TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: Left-sided AICD/pacemaker device is re- demonstrated with leads in unchanged positions. Mild enlargement of the cardiac silhouette is similar. Mediastinal and hilar contours are unremarkable and unchanged. Pulmonary vasculature is normal. Lungs are clear without focal consolidation. No pleural effusion, pneumothorax, or pulmonary edema is present. Moderate hypertrophic changes seen throughout the thoracic spine IMPRESSION: No acute cardiopulmonary abnormality. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with ANEMIA NOS, HEMATURIA, UNSPECIFIED, CARDIAC PACEMAKER STATUS, LONG TERM USE ANTIGOAGULANT temperature: 98.0 heartrate: 78.0 resprate: 20.0 o2sat: 100.0 sbp: 123.0 dbp: 73.0 level of pain: 0 level of acuity: 2.0
Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted due to shortness of breath. Lab test revealed that you have iron deficiency anemia. The most common cause of which is blood loss. This is most likely due to chronic urinary blood loss however gastrointestinal blood loss is possible as well. You were transfused red blood cells and your numbers were stable after this. Your primary care doctor may want to do a colonoscopy or a bladder test after discharge. You were also evaluated by physical therapy who recommended rehab, which you did not want to do. You will go home with physical therapy instead. You also had some R jaw pain with chewing, most likely from irritation. There were no signs of infection. You were discharged with some pain medications as needed. Please follow up with your PCP and dentist if the pain persists. Thank you, Your ___ Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: GI bleeding Major Surgical or Invasive Procedure: ___: Upper endoscopy History of Present Illness: ___ male with a history of alcohol abuse presenting today for evaluation of an upper GI bleed. He was brought into the outside hospital today at request of his girlfriend as patient looked more lethargic than normal. He also had episodes of coffee-ground emesis earlier today. This was also witnessed while at the outside hospital. Lab tests there were notable for a bilirubin of 6 and platelets of 64. Patient was then transferred here for continuous evaluation of upper GI bleed. Recent sick contact at home with his girlfriend ___ daughter, and URI symptoms since ___ with new cough. On arrival states that he has relapsed into alcohol since last ___. Last drink this AM, drinks ~1 bottle vodka daily. Has no diagnosis of cirrhosis but has been told in the past that his lab tests looking at his liver have been concerning. BP 117/78 at OSH. He was treated with Protonix and IV Rocephin prior to transfer. In ED initial VS: 100.3 125 100/80 24 98% Non-Rebreather , BP eventually as low as 84/45 Labs significant for: ALT 26, AST 56, Tbili 6.2, D bili 3.2 WBC 16.8 (bands 16), HGB 13.6-> 12.9, Plt 53, INR 1.7, BUN 9, Cre 1.1, WBC 16.8. Lactate 7.8, VBG 7.25/48 Serum ETOH 111 Patient was given: Ocrtreotide gtt, Levophed gtt, Zosyn, vanc, Ativan 0.5 IV, 2L NS, 50mg Albumin 25% Imaging notable for: CXR: Large area of right mid to lower lung opacity, concerning for consolidation,possibly due to pneumonia and/or aspiration. Right internal jugular central venous catheter terminates in the mid SVC without evidence of pneumothorax. Left costophrenic angle not well seen, may be due to overlying soft tissue, but a pleural effusion is not excluded. Liver US: Probable cirrhosis with evidence of portal hypertension including hepatofugal portal venous flow and splenomegaly. Gallbladder wall edema is likely third spacing related to primary liver disease. Consults: Liver On arrival to the MICU, patient is alert, somewhat inattentive, reasonable historian. Reports that he came to the hospital because he could not stay conscious and had dark vomiting. He reports a new cough that started 2 days ago. Also reports having blood around his mouth when he wakes up for the last week. Has been drinking on and off for years. Says his boss told him he "looked yellow" starting about a month ago. Denies chest pain, SOB, fever/chills, abdominal pain. Past Medical History: Obesity Alcohol use disorder Social History: ___ Family History: Unknown because adopted Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: Reviewed in metavision GENERAL: Sleepy but arousable, mildly inattentive, Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP difficult to assess due to body habitus LUNGS: Decreased breath sounds diffusely, possible ___/ to body habitus. No respiratory distress. CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Large, 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: Mild jaundice NEURO: AAOX3, grossly intact. Mild asterixis. DISCHARGE PHYSICAL EXAM: ======================== VITALS: 24 HR Data (last updated ___ @ 802) Temp: 98.6 (Tm 99.6), BP: 112/72 (87-116/54-79), HR: 81 (81-91), RR: 20 (___), O2 sat: 93% (90-95), O2 delivery: RA, Wt: 345.46 lb/156.7 kg Fluid Balance (last updated ___ @ 044) Last 8 hours No data found Last 24 hours Total cumulative 1621ml IN: Total 1621ml, PO Amt 1505ml, IV Amt Infused 116ml OUT: Total 0ml, Urine Amt 0ml GENERAL: Sleepy but arousable, Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, PERRLA NECK: supple, JVP difficult to assess due to body habitus LUNGS: Decreased breath sounds diffusely, possible ___/ to body habitus. No respiratory distress. CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Large, 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: Mild jaundice NEURO: AAOX3, grossly intact. No Asterixis or tremor Pertinent Results: =============== ADMISSION LABS =============== ___ 05:00PM BLOOD WBC-16.8* RBC-3.87* Hgb-13.6* Hct-40.9 MCV-106* MCH-35.1* MCHC-33.3 RDW-14.6 RDWSD-57.1* Plt Ct-53* ___ 05:00PM BLOOD Neuts-83* Bands-16* ___ Monos-1* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-16.63* AbsLymp-0.00* AbsMono-0.17* AbsEos-0.00* AbsBaso-0.00* ___ 05:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-2+* Microcy-NORMAL Polychr-NORMAL ___ 05:00PM BLOOD ___ PTT-38.4* ___ ___ 05:00PM BLOOD Plt Smr-VERY LOW* Plt Ct-53* ___ 05:00PM BLOOD Glucose-52* UreaN-9 Creat-1.1 Na-142 K-3.9 Cl-98 HCO3-23 AnGap-21* ___ 05:00PM BLOOD ALT-26 AST-56* AlkPhos-107 TotBili-6.2* DirBili-3.2* IndBili-3.0 ___ 08:15PM BLOOD Lipase-52 ___ 05:00PM BLOOD cTropnT-<0.01 ___ 05:00PM BLOOD Albumin-2.8* ___ 02:05AM BLOOD Calcium-7.3* Phos-4.6* Mg-0.9* ___ 05:00PM BLOOD ASA-NEG ___ Acetmnp-NEG Tricycl-NEG =============== PERTINENT LABS =============== ___ 05:35AM BLOOD AMA-NEGATIVE ___ 05:35AM BLOOD ___ ___ 05:35AM BLOOD IgG-1713* IgA-564* IgM-139 ___ 02:09AM BLOOD HIV Ab-NEG ___ 05:35AM BLOOD tTG-IgA-16 ___ 02:09AM BLOOD HCV Ab-NEG =============== DISCHARGE LABS =============== ___ 06:56AM BLOOD WBC-5.0 RBC-3.06* Hgb-10.9* Hct-33.6* MCV-110* MCH-35.6* MCHC-32.4 RDW-15.6* RDWSD-62.1* Plt Ct-62* ___ 06:56AM BLOOD Plt Ct-62* ___ 06:56AM BLOOD ___ PTT-41.3* ___ ___ 06:56AM BLOOD Glucose-92 UreaN-4* Creat-0.7 Na-139 K-4.5 Cl-100 HCO3-31 AnGap-8* ___ 06:56AM BLOOD ALT-19 AST-37 LD(LDH)-227 AlkPhos-82 TotBili-8.1* ___ 06:56AM BLOOD Albumin-2.1* Calcium-7.7* Phos-3.2 Mg-1.7 ================== STUDIES/PATHOLOGY ================== ___: RUQ US Probable cirrhosis with evidence of portal hypertension including hepatofugal portal venous flow and splenomegaly. Gallbladder wall edema is likely third spacing related to primary liver disease. ___ CXR: Large area of right mid to lower lung opacity, concerning for consolidation, possibly due to pneumonia and/or aspiration. Right internal jugular central venous catheter terminates in the mid SVC without evidence of pneumothorax. Left costophrenic angle not well seen, may be due to overlying soft tissue, but a pleural effusion is not excluded. ___ EGD Mosaic appearance in the stomach body and fundus compatible with portal hypertensive gastropathy No varices Otherwise normal EGD to third part of the duodenum ___: TTE The left atrium is moderately dilated. The right atrium is moderately dilated. No right-to-left flow of intravenous agitated saline injection. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild-moderate pulmonary artery systolic hypertension. There is an anterior fat pad. IMPRESSION: Suboptimal image quality. Mild-moderate pulmonary artery systolic hypertension. Normal biventricular cavity sizes with preserved global biventricular systolic function. No valvular pathology or pathologic flow identified. No right-to-left shunt identified. CLINICAL IMPLICATIONS: Based on ___ AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. ============ MICROBIOLOGY ============ __________________________________________________________ ___ 1:52 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. __________________________________________________________ ___ 3:05 am URINE Source: ___. **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. __________________________________________________________ ___ 11:30 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. __________________________________________________________ ___ 10:05 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine: No growth __________________________________________________________ ___ 9:00 pm BLOOD CULTURE Blood Culture, Routine: No growth Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Lactulose 30 mL PO TID:PRN confusion RX *lactulose 20 gram/30 mL 30 mL by mouth three times a day Disp #*90 Package Refills:*0 3. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 4. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Rifaximin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Septic shock Pneumonia Secondary diagnoses: Obstructive sleep apnea Upper GI bleed Macrocytic anemia Alcoholic hepatitis Alcohol use disorder Coagulopathy Cirrhosis Thrombocytopenia Anisocoria 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 history of alcohol abuse and bilirubin of 6// Evaluate for cirrhosis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The liver is diffusely echogenic. The contour of the liver is probably slightly nodular. There is no focal liver mass. The main portal and right portal veins are patent with hepatofugal (reversed) flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 5 mm. GALLBLADDER: Gallbladder wall edema without cholelithiasis. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 18.0 cm. KIDNEYS: Limited views of the right kidney show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: Probable cirrhosis with evidence of portal hypertension including hepatofugal portal venous flow and splenomegaly. Gallbladder wall edema is likely third spacing related to primary liver disease. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with hypertension now a central line placed// Evaluate central line placement TECHNIQUE: Single frontal view of the chest COMPARISON: None FINDINGS: Right internal jugular central venous catheter terminates in the mid SVC without evidence of pneumothorax. Large area of right mid to lower lung opacity could be due to consolidation due to pneumonia and/or aspiration. The left costophrenic angle is not well seen, which may be due to overlying soft tissue, but a pleural effusion is not excluded. Cardiac silhouette size is top-normal. Mediastinal contours are unremarkable. IMPRESSION: Large area of right mid to lower lung opacity, concerning for consolidation, possibly due to pneumonia and/or aspiration. Right internal jugular central venous catheter terminates in the mid SVC without evidence of pneumothorax. Left costophrenic angle not well seen, may be due to overlying soft tissue, but a pleural effusion is not excluded. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: GI bleed, Transfer Diagnosed with Sepsis, unspecified organism, Granuloma faciale [eosinophilic granuloma of skin], Hypotension, unspecified, Pneumonia, unspecified organism, Alcohol dependence with withdrawal, unspecified, Acute and subacute hepatic failure without coma temperature: 100.3 heartrate: 125.0 resprate: 24.0 o2sat: 98.0 sbp: 100.0 dbp: 80.0 level of pain: 0 level of acuity: 2.0
Dear Mr. ___, Why was I admitted? You were admitted because your blood pressure was low and you were found to have an infection in your lung called pneumonia. We were was also concerned that you had bleeding in your belly. What was done while I was here? You were treated with antibiotics for your pneumonia. We watched your bleeding from your belly very closely and looked down your throat with a camera. You have no active bleeding but are prone to bleeding from your underlying liver disease. Your liver disease is thought to be due to alcohol. You were monitored closely for withdrawal from alcohol and given medication to prevent this. In addition, we discovered that Your oxygen becomes low at night and you are diagnosed with sleep apnea. Therefore, we tried to have you sleep with a CPAP machine. Your oxygen also becomes low when you walk; this is probably due to your resolving pneumonia and your liver disease. What should I do now? You should take your medications as instructed. It is very important that you never drink alcohol again to avoid worsening your liver disease. If you continue to drink alcohol, you will be at very high risk of dying from liver disease or problems caused by liver disease. Make sure you seek support in maintaining sobriety through help from you social workers and doctors. You can try a group like AA if you think it would help you stop drinking. You will be discharged with home oxygen. You can use this when you are walking and your oxygen level becomes low. A nurse ___ come to your home and help to measure your oxygen levels to see how much you need. Because you have sleep apnea, you will need to wear oxygen at night at 4L per minute. You will need to see the sleep medicine doctors after leaving the hospital to get a formal sleep study so that you can obtain a CPAP machine. Once you get a CPAP machine, you must use it every night. You should attend your doctor appointments as below. We wish you the best! -Your ___ Care Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: ___ ___ placed Percutaneous Cholecystostomy ___ Laparoscopic cholecystectomy History of Present Illness: Mr. ___ is a ___ history of chronic pneumobilia of unclear etiology, seizure disorder, GERD, gout, presenting with worsening abdominal pain to ___, found to be febrile with CT A/P showing pneumobilia with cholelithiaisis, RUQUS without definitive evidence of cholecystitis transferred here for ERCP evaluation. Patient states that he has had several months of epigastric and RUQ abdominal pain that is intermittent, worse with PO intake. 2 days prior he had acute worsening epigastric abdominal pain worse at night when lying down. Pain is located on bilateral sides, epigastrium, and back. Associated with several days fevers and chills. Also with nausea and 2 episodes of non-bloody emesis. With very poor PO intake due to pain and nausea over last week. Endorsing dry cough, no diarrhea, no burning on urination or pain on urination. At ___ initial VS 98.2 P 72 BP 160/90 RR 22 O2 99% RA. Found to have WBC 12.6. CT A/P with IV contrast showing mildly dilated and thickening of GB wall with air in GB and biliary tree presumably reflecting prior sphincterotomy present in ___. Had RUQUS showing gallstones, pneumobilia in intrahepatic ducts, cBD, and gall bladder. Was given CTX 1gm, morphine, and protonix and transferred for ERCP evaluation. In the ED, Initial Vitals: T 99 HR 74 BP 154/64 RR 16 O2 98%RA During ED course, was febrile to 103 with worsening tachycardia to 121 and hypotension to 79/49. WBC 4, lactate was 8. Given worsening septic shock with presumed intra-abdominal source was started on vanc/zosyn and got 4L NS. Had R IJ placed and was started on levophed 0.15 prior to transfer to MICU. Had repeat RUQUS showing sonographic findings equivocal for possible cholecystitis. With sludge and gallstones, however with minimal gallbladder wall thickening. ___ reat CT A/P at OSH showing no evidence of perforated duodenal diverticulum. CBD with air however without dilatation no obstructing mass or calculus. Exam: Gen: Comfortable, No Acute Distress HEENT: NC/AT. EOMI. Neck: No swelling. Trachea is midline. No JVD Cor: RRR. No m/r/g. Pulm: CTAB, Nonlabored respirations. Abd: Mild epigastric tenderness. Ext: No edema, cyanosis, or clubbing. Skin: No rashes. No skin breakdown Neuro: AAOx3. Gross sensorimotor intact. Psych: Normal mentation. Heme: No petechia. No ecchymosis. Labs: - WBC 4, Hb 16.5, PLT 146 - Na 139, K 4.6, bicarb 15, BUN 13, Cr 1.1 - Ca 9.4, Mg 2.2, P 4.7 - Lactate 8 --> 6 --> 2.7 - ALT 25, AST 24, ALP 93, T. bili 0.5, lipase 18 Imaging: CXR: No acute intrathoracic abnormality. RUQUS: 1. Sonographic findings are equivocal for possible cholecystitis. The gallbladder is filled with sludge and gallstones, however there is minimal gallbladder wall thickening, and the gallbladder is not distended. Further evaluation with HIDA scan may be performed if clinically indicated. 2. Pneumobilia as seen on recent outside hospital CT abdomen pelvis. CT A/P WO Contrast OSH films: 1. There is no evidence of a perforated duodenal diverticulum. Distortion and hyperenhancement of the wall of a short segment of the duodenum in its second portion in the periampullary region is likely related to chronic ulcer disease or recent passage of sludge/gallstones, especially given the presence of unexplained pneumobilia. 2. Air within the gallbladder and pneumobilia noted. The CBD also demonstrates presence of air within it, however tapers normally towards the ampulla without visualization of an obstructing mass or calculus at the ampulla. 3. No other acute process seen in the abdomen or pelvis to explain patient's symptoms. RECOMMENDATION(S): Additional evaluation for cause of pneumobilia and evaluation of the second portion of the duodenum by ERCP is recommended. Consults: Both ACS and ERCP consulted in ED. Per ERCP, no indication for ERCP at this time. Per ACS, given duodenal ulceration and pnuemobilia, concern for possible duodenal perforation. In discussion with GI, decision initially made to order UGIS. However after further discussion with radiology, OSH CT WO contrast did not show evidence of duodenal ulceration. Decision was made per ACS recommendations ultimately to repeat CT A/P with PO contrast to definitively rule out duodenal perforation given prior CT was without PO contrast. Interventions: ___ 00:58 IVF NS ___ 00:58 IV Morphine Sulfate 4 mg ___ 00:58 IV Ondansetron 4 mg ___ 01:51 IV Piperacillin-Tazobactam ___ 02:15 IV Morphine Sulfate 4 mg ___ 02:15 IV Ondansetron 4 mg ___ 02:15 PO/NG PHENObarbital 64.8 mg ___ 02:15 IVF NS ___ 03:24 IV Vancomycin ___ ___ 04:43 IV Acetaminophen IV 1000 mg ___ 05:32 IV DRIP NORepinephrine ___ 05:41 IVF NS ___ 08:11 PO/NG Allopurinol ___ mg ___ 08:11 PO Omeprazole 20 mg ___ 08:11 PO/NG PHENObarbital 64.8 mg ___ 12:45 IV Piperacillin-Tazobactam ___ 13:06 IV Acetaminophen IV 1000 mg ___ 13:20 IV Piperacillin-Tazobactam 4.5 g ___ 13:47 IVF NS ___ Past Medical History: - PUD - Gout - Seizure disorder - Pneumobilia Social History: ___ Family History: No history of hepatobiliary problems Physical Exam: ADMISSION EXAM VS: Reviewed in metavision GEN: Uncomfortable appearing, grimacing in pain HENNT: HEENT, NC/AT, PERRL, EOMI CV: Regular rate and rhythm, no m/r/g RESP: Lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi GI: Non-distended. Normoactive bowel sounds. Diffusely tender. No rebound or guarding. MSK: 2+ peripheral pulses, no c/c/e NEURO: CN II-XII grossly intact. No focal neurological deficits. DISCHARGE EXAM VS: 24 HR Data (last updated ___ @ 420) Temp: 98.1 (Tm 99.7), BP: 113/77 (102-115/67-77), HR: 102 (99-113), RR: 20 (___), O2 sat: 93% (93-94), O2 delivery: RA General: Lying in bed asleep, in no acute distress CV: Normal rate and rhythm. Normal S1 and S2. No murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally without wheezes, rales, or rhonchi. Abdomen: Mildly distended. Tender to palpation in RUQ and epigastrium without rebound or guarding. Ext: Warm, well perfused. 2+ pulses. No clubbing, cyanosis or edema. MSK: No glenohumeral or AC joint effusions appreciated, nontender to palpation, ROM intact but limited by pain Neuro: AAOx3. Motor and sensory function grossly intact throughout. Pertinent Results: ADMISSION LABS ============== ___ 03:33AM BLOOD WBC-16.7* RBC-3.91* Hgb-11.9* Hct-36.4* MCV-93 MCH-30.4 MCHC-32.7 RDW-14.6 RDWSD-50.0* Plt ___ ___ 01:41AM BLOOD ___ PTT-24.3* ___ ___ 01:15AM BLOOD Glucose-135* UreaN-13 Creat-1.1 Na-139 K-4.6 Cl-97 HCO3-15* AnGap-27* ___ 08:22PM BLOOD ALT-46* AST-48* AlkPhos-59 TotBili-0.8 ___ 01:15AM BLOOD Lipase-18 ___ 03:33AM BLOOD Calcium-7.6* Phos-1.5* Mg-1.8 ___ 01:39AM BLOOD Lactate-8.0* PERTINENT LABS ============== ___ 04:40AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 12:55AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 05:38AM BLOOD Lipase-18 ___ 03:00PM BLOOD VitB12-517 ___ 03:00PM BLOOD TSH-1.8 DISCHARGE LABS ============== ___ 05:12AM BLOOD WBC-7.3 RBC-3.98* Hgb-12.1* Hct-35.5* MCV-89 MCH-30.4 MCHC-34.1 RDW-14.1 RDWSD-46.2 Plt ___ ___ 05:12AM BLOOD Glucose-104* UreaN-13 Creat-0.8 Na-135 K-4.4 Cl-97 HCO3-23 AnGap-15 ___ 05:12AM BLOOD ALT-27 AST-25 LD(LDH)-163 AlkPhos-110 TotBili-0.4 MICROBIOLOGY ============ ___ 1:13 am BLOOD CULTURE Blood Culture, Routine (Preliminary): ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). ___ 10:47 am BILE BILE. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). FLUID CULTURE (Preliminary): GRAM NEGATIVE ROD #1. SPARSE GROWTH. GRAM NEGATIVE ROD #2. SPARSE GROWTH. ANAEROBIC CULTURE (Preliminary): IMAGING ======= CXR ___: No acute intrathoracic abnormality. RUQUS ___: 1. Sonographic findings are equivocal for acute cholecystitis. The gallbladder is only partially distended and filled with sludge and air however with minimal wall thickening without a positive sonographic ___ sign or pericholecystic fluid. Further evaluation with HIDA scan may be performed if clinically indicated. 2. Pneumobilia as seen on recent outside hospital CT abdomen pelvis. CT A/P WC ___ opinion ___: 1. There is no evidence of a perforated duodenal diverticulum. Distortion and hyperenhancement of the wall of a short segment of the duodenum in its second portion in the periampullary region is likely related to chronic ulcer disease or recent passage of sludge/gallstones, especially given the presence of unexplained pneumobilia. 2. Air within the gallbladder and pneumobilia noted. The CBD also demonstrates presence of air within it, however tapers normally towards the ampulla without visualization of an obstructing mass or calculus at the ampulla. 3. No other acute process seen in the abdomen or pelvis to explain patient's symptoms. HIDA ___: Abnormal hepatobiliary scan with non-visualization of the gallbladder including non-visualization after morphine administration. Findings compatible with acute cholecystitis. GB Drainage ___: Successful US-guided placement of ___ pigtail catheter into the gallbladder. Samples was sent for microbiology evaluation. MRCP (MR ABD ___ Date of ___ IMPRESSION: 1. No evidence of a bile leak or biloma. 2. Pneumobilia, without evidence choledocholithiasis. 3. 3.0 x 2.1 cm ill-defined focus of heterogeneous T2 hyperintense signal intensity in the gallbladder fossa with inflammation of the surrounding hepatic parenchyma, likely containing some fluid which may be postsurgical. Superimposed infection/phlegmon cannot be excluded, but there is no drainable collection. 4. Trace right pleural effusion. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. PHENObarbital 64.8 mg PO BID 2. Omeprazole 20 mg PO DAILY 3. Allopurinol ___ mg PO DAILY Discharge Medications: 1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 (One) capsule(s) by mouth every four (4) hours Disp #*18 Capsule Refills:*0 2. Allopurinol ___ mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. PHENObarbital 64.8 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: ================== -Septic Shock -E. Coli Bacteremia -Cholecystitis s/p percutaneous cholecystostomy s/p laparoscopic cholecystectomy SECONDARY DIAGNOSES: ==================== -Chronic Pneumobilia -Herpes re-activation -Gout -GERD -Seizure disorder 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 (PA AND LAT) PORT INDICATION: ___ male with right upper quadrant pain, fever, and cough. Evaluate for pneumonia in the right lower lobe. TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: Lungs are moderately well aerated. No focal consolidation is seen. No large pleural effusion or pneumothorax. The cardiomediastinal silhouette is within normal limits. No free subdiaphragmatic gas or mass effect. IMPRESSION: No acute intrathoracic abnormality. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ with c/f pneumobilia. Evaluate for cholecystitis. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Outside hospital CT abdomen pelvis performed ___. 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. Mild pneumobilia is noted. CHD: 5 mm GALLBLADDER: The gallbladder is filled with sludge and gallstones. There is minimal gallbladder wall thickening and possible focal edema however, the gallbladder is not distended or hydropic in appearance. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 10.0 KIDNEYS: Limited views of the kidneys show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Sonographic findings are equivocal for acute cholecystitis. The gallbladder is only partially distended and filled with sludge and air however with minimal wall thickening without a positive sonographic ___ sign or pericholecystic fluid. Further evaluation with HIDA scan may be performed if clinically indicated. 2. Pneumobilia as seen on recent outside hospital CT abdomen pelvis. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 6:58 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ male with CVL line placement. Evaluate TECHNIQUE: Portable AP chest COMPARISON: Chest radiograph performed 4 hours prior. FINDINGS: Interval placement of a right central venous catheter, with the tip projecting over the mid SVC. Otherwise, the lungs are clear without evidence of focal consolidation. No large pleural effusion or pneumothorax is identified. The cardiomediastinal silhouette is within normal limits. IMPRESSION: 1. Interval placement of a right central venous catheter line which projects over the low SVC. 2. No complications. Radiology Report EXAMINATION: SECOND OPINION CT TORSO INDICATION: History: ___ with ?pnuemobilia on OSH CT A/P, reqesting second read to eval ? duodenal diverticulum that could be inflamed and or perforated// ? duodenal diverticulum that could be inflamed and or perforated 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: DLP: 520 mGy cm COMPARISON: None. FINDINGS: LOWER CHEST: The visualized lung bases are clear. ABDOMEN: GENERAL: There is no intra-abdominal free air or free fluid. HEPATOBILIARY: There is left-sided pneumobilia. The background hepatic parenchyma enhances homogeneously with no focal liver lesions. The gallbladder is distended and demonstrates air-fluid level within it. There is minimal gallbladder wall edema. No radiopaque calculi noted within the gallbladder. No pericholecystic stranding of fat seen.. There is air and fluid within the CHD and CBD. The CBD tapers normally towards the ampulla. No obstructing mass or calculi seen on this exam. PANCREAS: There is homogeneous enhancement of the pancreatic parenchyma without main duct dilation. SPLEEN: No splenomegaly or focal splenic lesions noted.. ADRENALS: There are no adrenal nodules. URINARY: No hydronephrosis or solid enhancing renal masses noted. GASTROINTESTINAL: There is no bowel obstruction. No duodenal diverticulum noted. No evidence of a perforated diverticulum mass suggested on the outside read. There is mild hyper enhancement in the wall of the duodenum, just distal to the bulb (best visualized on the sagittal reformats, series 4, image 45) that may be related to chronic ulcer disease Scattered colonic diverticuli without acute diverticulitis seen. Appendix. LYMPH NODES: There are no enlarged lymph nodes in the abdomen or pelvis.. VASCULAR: Abdominal aorta is normal in caliber. PELVIS: The bladder is moderately distended and appears normal. The prostate is not enlarged. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. IMPRESSION: 1. There is no evidence of a perforated duodenal diverticulum. Distortion and hyperenhancement of the wall of a short segment of the duodenum in its second portion in the periampullary region is likely related to chronic ulcer disease or recent passage of sludge/gallstones, especially given the presence of unexplained pneumobilia. 2. Air within the gallbladder and pneumobilia noted. The CBD also demonstrates presence of air within it, however tapers normally towards the ampulla without visualization of an obstructing mass or calculus at the ampulla. 3. No other acute process seen in the abdomen or pelvis to explain patient's symptoms. RECOMMENDATION(S): Additional evaluation for cause of pneumobilia and evaluation of the second portion of the duodenum by ERCP is recommended. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old man with history of chronic pneumobilia, duodenal ulcers, presenting as a transfer from ___ with worsening abdominal pain, pneumobilia, with septic shock found to have GNR bacteremia likely from biliary source// Please perform CT A/P with PO contrast to eval for extrav and possible duodenal perforation per ACS requesting repeat CT A/P with PO contrast 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: Total DLP (Body) = 577 mGy-cm. COMPARISON: CT abdomen pelvis ___ from outside institution. Similar ultrasound ___. FINDINGS: LOWER CHEST: Partially imaged lung bases demonstrate bibasilar atelectasis. There is no evidence of pleural effusion. There is a trace pericardial effusion within physiologic range. ABDOMEN: HEPATOBILIARY: The liver demonstrates heterogeneous attenuation throughout with regional areas of enhancement at the hepatic dome and surrounding the gallbladder fossa/segment 4 (02:10, 02:19). However, there is no evidence of focal lesions. There is similar extent of left pneumobilia with air tracking into the common bile duct and gallbladder fundus. There is extrahepatic biliary dilatation measuring up to 10 mm. There is layering hyperdense material in the distal CBD consistent with retrograde oral contrast from the duodenum. This suggests a sphincter of Oddi dysfunction/incompetence, possibly due to a recently passed gallstone. No evidence of obstructing mass or calculus at the level of the ampulla. Gallbladder layering sludge is better assessed on ultrasound from same day. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Pneumobilia, extrahepatic biliary dilatation and oral contrast filling the CBD in a retrograde fashion suggests sphincter of Oddi dysfunction/incompetence, possibly due to recently passed gallstone. 2. No evidence of bowel perforation. No free intraperitoneal air. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with history of chronic pnuemobilia presenting with fevers, abdominal pain, found to have GNR bacteremia s/p IVF resuscitation, now with worsening hypoxemia to 2L O2// Eval for underlying etiology of worsening hypoxemia, volume status Eval for underlying etiology of worsening hypoxemia, volume status IMPRESSION: Compared to chest radiographs ___. New ring shadows in the right mid and lower lung zone are due to bronchial wall thickening or extra bronchial cuffing. Differential diagnosis includes early edema or new widespread bronchial inflammation. There are no findings of edema elsewhere or any consolidation in the lungs. Heart size top-normal. No appreciable pleural effusion or pneumothorax. Right jugular line ends in the low SVC, as before. Radiology Report EXAMINATION: Ultrasound-guided percutaneous cholecystostomy tube placement. INDICATION: ___ year old man with chronic pneumobilia, duodenal ulcers complicated by strictures presents with GNR bacteremia and sepsis, HIDA scan consistent with acute cholecystitis.// Drainage COMPARISON: Ultrasound liver dated ___. PROCEDURE: Ultrasound-guided drainage of the gallbladder. OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agree 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 supine position on the US scan table. Limited preprocedure ultrasound was performed to localize the gallbladder demonstrated distended gallbladder containing sludge. Based on the ultrasound findings an appropriate skin entry site percutaneous cholecystostomy was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, ___ Exodus drainage catheter was advanced via trocar technique into the gallbladder. A sample of fluid was aspirated, confirming catheter position within the gallbladder. The pigtail was deployed. The position of the pigtail was confirmed within the gallbladder via ultrasound. Approximately 40 cc of purulent fluid was drained with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to bag. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: Moderate sedation was provided by administering divided doses of 2 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 20 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Preprocedure ultrasound was performed demonstrated a distended gall bladder containing sludge as seen on prior ultrasound ___. IMPRESSION: Successful US-guided placement of ___ pigtail catheter into the gallbladder. Samples was sent for microbiology evaluation. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with perc chole tube in placeme// Concern for ___ perc chole drain being mal positioned causing irritation TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph dated ___ FINDINGS: Sole expanded. Cardiomediastinal silhouette is top normal. Hilar contours are unremarkable. Interval removal of right internal jugular central venous catheter. No pneumothorax or pleural effusion. No pneumonia or pulmonary edema. Pigtail catheter projects over the right upper abdomen. IMPRESSION: Interval removal of right internal jugular central venous catheter with no evidence of pneumothorax. No evidence of pneumonia or pleural effusion. Pigtail catheter projects over the right upper abdomen. Radiology Report EXAMINATION: GI fluoroscopy INDICATION: ___ year old man s/p perc chole with right sided pleuritc pain// repo of perc chole. please page Dr. ___ patient arrives. TECHNIQUE: The percutaneous cholecystostomy tube was examined under fluoroscopic guidance. No intervention was found to be necessary. DOSE: Dose information not available at time of reporting. 2 images were saved. COMPARISON: Correlation with chest radiographs from today. FINDINGS: Apparent redundancy in the cholecystostomy tubing seen on the chest radiographs from today was determined to be outside the patient's skin upon manipulation under fluoroscopy. The tube appears in good position and there is no kinking or redundancy around the diaphragm. No adjustment was made to the tube position and no contrast was injected. There is a moderate amount of bilious fluid in the bag. The patient reports mild discomfort with coughing. IMPRESSION: Cholecystostomy tube is in satisfactory position. Radiology Report EXAMINATION: MRCP INDICATION: ___ year s/p lap chole, POD 2, increased abdominal RUQ pain,// concern for bile leak, retained stone? TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 10 mL Eovist. Oral contrast: Not administered. COMPARISON: CT abdomen and pelvis ___ FINDINGS: Lower Thorax: Limited evaluation of the lung bases shows trace right pleural effusion. There is bibasilar subsegmental atelectasis. Liver: There is no significant drop in signal on opposed phase imaging to suggest hepatic steatosis. No focal hepatic lesions are identified. There is a surgical drain, extending from the right lower abdomen towards the inferior surface of the liver. Biliary: Since the prior CT performed on ___, the patient has undergone interval cholecystectomy. Within the gallbladder fossa, there is an area of heterogeneous signal intensity measuring 3.0 x 2.1 cm (22:24). It is largely hyperintense on T2 weighted imaging. There is no appreciable postcontrast enhancement within this region. Findings are suggestive of a small amount of fluid, with inflammation of the surrounding hepatic parenchyma as evidence by heterogeneous arterial hyperenhancement (14:44). Developing phlegmon/infection cannot be excluded. On the delayed hepatobiliary phase, there is expected excretion through the common bile duct, without evidence of a biliary leak. Filling defect in the anti dependent portion of the CBD is consistent with air (22:28). There is no evidence of choledocholithiasis. CBD measures up to 1 cm, which is not significantly changed from the preoperative study. Pancreas: There is normal intrinsic T1 hyperintense signal throughout the pancreas. No focal parenchymal lesions or ductal dilation. Spleen: Spleen is normal in size, without focal lesions. Adrenal Glands: Normal in size and shape. Kidneys: Kidneys are normal in size and shape. No solid parenchymal lesions are identified. There is no hydronephrosis. Gastrointestinal Tract: Stomach is unremarkable. There is no bowel obstruction or ascites. Lymph Nodes: Retroperitoneal and mesenteric lymph nodes are not enlarged by size criteria. Vasculature: Abdominal aorta is not aneurysmal. Celiac artery, superior mesenteric artery, and bilateral renal arteries are patent. Osseous and Soft Tissue Structures: No worrisome osseous lesions are identified. Soft tissues are unremarkable. IMPRESSION: 1. No evidence of a bile leak or biloma. 2. Pneumobilia, without evidence choledocholithiasis. 3. 3.0 x 2.1 cm ill-defined focus of heterogeneous T2 hyperintense signal intensity in the gallbladder fossa with inflammation of the surrounding hepatic parenchyma, likely containing some fluid which may be postsurgical. Superimposed infection/phlegmon cannot be excluded, but there is no drainable collection. 4. Trace right pleural effusion. Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: Abd pain, Transfer Diagnosed with Sepsis, unspecified organism, Acidosis, Unspecified abdominal pain temperature: 99.0 heartrate: 74.0 resprate: 16.0 o2sat: 98.0 sbp: 154.0 dbp: 64.0 level of pain: sleep level of acuity: 3.0
Dear Mr. ___, It was a pleasure to care for you at the ___ ___. Why did you come to the hospital? - You were brought in to the hospital due to concerns for an abdominal infection. What did you receive in the hospital? - Because of how sick you were and your low blood pressure, we had to admit you to the intensive care unit. There you were found to have cholecystitis, or inflammation of your bladder. On ___, our interventional radiologist placed a tube to help drain your gallbladder. - You then had your gallbladder removed by our surgery team. - In addition, we found an infection in your blood related to your gallbladder, and treated it with antibiotics. - After starting antibiotics, you developed a small herpes outbreak around your lips. We treated this with a anti-viral medication. What should you do once you leave the hospital? - Please continue to take your medications as prescribed. - Please keep all your follow-up appointments We wish you the best! Your ___ Care Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: non functioning J tube and redness at site Major Surgical or Invasive Procedure: ___ Jejunostomy tube replacement History of Present Illness: Ms. ___ is a ___ woman with T3N0M0 poorly differentiated squamous cell carcinoma of the esophagus s/p neoadjuvant chemoradiation therapy followed by minimally invasive esophagectomy with Dr. ___ ___, now with local recurrence/lymph node metastasis undergoing salvage chemoradiation therapy. She underwent a laparoscopic feeding jejunostomy tube placement on ___ with Dr. ___. She tolerated this without complications and went home the same day. She used her J-tube for feeding with no issues last night; she has been cycling her tube feeds. When she showered this morning, she dressed the J-tube site as usual, but noticed that the tube may have appeared loose although all the sutures were in place. She then noted when she tried to flush the tube later on, the water came out through the J-tube site. She then called into the office and was sent to the ED. Of note, she has noticed increasing irritation/redness around the J-tube site, as well as surrounding the sutures. She has not had any temperatures at home, but has felt some chills. She continues with chemoRT and has been tolerating that well with some nausea. She is still able to eat soft foods with careful chewing as she does have some dysphagia, and as previously mentioned, cycles her tube feeds at night. She moves her bowel regularly with the help of miralax. She is scheduled for her next radiation treatment this morning at 8:45AM on ___. Past Medical History: -GERD -Hyperlipidemia -H/o tobacco use -Osteoarthritis -R rotator cuff injury -S/P MIE ___ Social History: ___ Family History: The patient's father died at age ___ from aortic aneurysm; her mother's age is ___ and healthy and was previously treated for breast cancer in her ___ a half brother had lymphoma and a half sister had breast cancer. Physical Exam: T97.5, HR97, BP127/62, RR16, Sat100%RA GENERAL [x] WN/WD [x] NAD [x] AAO [ ] abnormal findings: HEENT [x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric [x] OP/NP mucosa normal [x] Tongue midline [x] Palate symmetric [x] Trachea midline [ ] Abnormal findings: RESPIRATORY [x] CTA/P [x] Excursion normal [x] No fremitus [x] No egophony [x] No spine/CVAT [ ] Abnormal findings: CARDIOVASCULAR [x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema [x] Peripheral pulses nl [x] No abd/carotid bruit [ ] Abnormal findings: GI [x] Soft [] NT [x] ND [x] No mass/HSM [x] No hernia [x] Abnormal findings: tender to palpation around J-tube site GU [x] Deferred [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] Strength intact/symmetric [x] Sensation intact/ symmetric [x] Reflexes nl [x] No facial asymmetry [x] Cognition intact [x] Cranial nerves intact [ ] Abnormal findings: MS [x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl [x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl [x] Nails nl [ ] Abnormal findings: LYMPH NODES [x] Cervical nl [x] Supraclavicular nl [x] Axillary nl [x] Inguinal nl [ ] Abnormal findings: SKIN [] No rashes/lesions/ulcers [] No induration/nodules/tightening [x] Abnormal findings: The skin around the jejunostomy was noted to be erythematous and indurated, without fluctuance. In addition, all of the suture sites were also noted to be erythematous and indurated. Altogether, about a 3cm diameter area around the jejunostomy site was warm, indurated and erythematous. PSYCHIATRIC [x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect [ ] Abnormal findings: Pertinent Results: ___ 01:25AM WBC-6.3 RBC-3.10* HGB-9.0* HCT-28.4* MCV-92 MCH-29.0 MCHC-31.7* RDW-12.9 RDWSD-42.4 ___ 01:25AM NEUTS-85.3* LYMPHS-4.0* MONOS-8.1 EOS-1.7 BASOS-0.3 IM ___ AbsNeut-5.37 AbsLymp-0.25* AbsMono-0.51 AbsEos-0.11 AbsBaso-0.02 ___ 01:25AM PLT COUNT-267 ___ 01:25AM ___ PTT-31.2 ___ ___ 01:25AM GLUCOSE-111* UREA N-9 CREAT-0.4 SODIUM-135 POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-25 ANION GAP-17 ___ Abdomen: Appropriately placed jejunal tube. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q8H:PRN nausea 2. Dexamethasone 8 mg PO DAILY 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. Mirtazapine 30 mg PO QHS 5. Prochlorperazine 10 mg PO Q6H:PRN nausea 6. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough 7. ALPRAZolam 0.5 mg PO Q6H:PRN anxiaty 8. Docusate Sodium 100 mg PO BID 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Atorvastatin 20 mg PO QPM 11. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate 12. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 13. Pantoprazole 40 mg PO Q12H 14. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN wheezing 15. Morphine SR (MS ___ 15 mg PO Q12H Discharge Medications: 1. Sulfameth/Trimethoprim Suspension 20 mL PO BID RX *sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL 20 mls by mouth twice a day Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN wheezing 4. ALPRAZolam 0.5 mg PO Q6H:PRN anxiaty 5. Atorvastatin 20 mg PO QPM 6. Dexamethasone 8 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough 9. Mirtazapine 30 mg PO QHS 10. Morphine SR (MS ___ 15 mg PO Q12H 11. Ondansetron 4 mg PO Q8H:PRN nausea 12. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate 13. Pantoprazole 40 mg PO Q12H 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation 15. Prochlorperazine 10 mg PO Q6H:PRN nausea 16. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: Wound cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: G/GJ/GI TUBE CHECK INDICATION: ___ year old woman with j-tube and concerns for displacement. Evaluate J-tube placement. TECHNIQUE: Supine radiograph were obtained before and after administration of contrast via the G-tube. DOSE: DAP: 2.227 COMPARISON: CT abdomen pelvis of ___. FINDINGS: Initial scout view demonstrates a left-sided to projecting in the region of the left mid abdomen. After administration of contrast through the tube, the jejunum is opacified, indicating appropriate placement of the known J-tube. Bowel loops are not dilated. There is no evidence of free intraperitoneal air on limited supine views. Surgical clips overlie the spine in the midline. Mild lower lumbar degenerative changes are present. IMPRESSION: Appropriately placed jejunal tube. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: gtube eval Diagnosed with Enterostomy infection, Cellulitis of abdominal wall, Form of external stoma cause abn react/compl, w/o misadvnt temperature: 97.5 heartrate: 97.0 resprate: 16.0 o2sat: 100.0 sbp: 127.0 dbp: 62.0 level of pain: 0 level of acuity: 3.0
* You were admitted to the hospital for replacement of your J tube and also for a cellulitis around the tube. You were placed on antibiotics which initially seem to be working. The j tube is not sutured in place but it's taped down securely so that the skin around the tube can heal and you can have it resutured in a day or 2. * You should resume your tube feedings but be very careful not to dislodge the tube. No showers until the tube is sutured in place. For now a sponge bath. * Keep a dry gauze over the insertion site. Dr. ___ see you in clinic tomorrow to look at the site and possibly suture. * Continue the Bactrim for a 10 day course. * If you have any fevers > 101, abd pain, chills or any other symptoms that concern you call Dr. ___ at ___
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: heparin Attending: ___. Chief Complaint: Abdominal aortic aneurysm rupture with hemodynamic instability Major Surgical or Invasive Procedure: ___ INFRARENAL PROXIMAL AORTIC CUFF X 4, OPEN ABDOMEN FOR WASHOUT OF HEMATOMA ___ ABDOMINAL WASHOUT, LOA, ABTHERA PLACEMENT ___ ABDOMINAL WASHOUT, CLOSURE OF ABDOMEN History of Present Illness: HPI: Mr. ___ is a ___, former smoker, with PVD s/p aortobifemoral bypass (___ ___ vs ___ per wife), who presented to the OSH with sudden onset abdominal pain this morning. He underwent a CTA which showed a disrupted proximal anastomosis of the aorto-femoral graft with rupture. Additionally he has a right groin pseudoaneurysm between the right limb of the aort-bifemoral graft with the native artery which appears contained. He was therefore transferred to ___ for further management. On Medflight, he became hypotensive with worsening abdominal distention and was given a total of 4u pRBC and ___ FFP. He was taken directly to the OR for definitive treatment. Past Medical History: PMH: afib, stroke (no neuro deficits ___, PVD, HTN PSH: - aortobifemoral bypass ___ vs ___ - >___nd endovascular procedures including left iliac artery stent, fem-fem bypass, ultimately resulting in R BKA Social History: ___ Family History: FH: unknown Physical Exam: Physical Exam: ON ARRIVAL Vitals: HR 112 BP 135/110 GEN: in acute distress, conversant CV: tachycardic PULM: no respiratory distreess ABD: tense, distended abdomen, tender to palpation Ext: No ___ edema, ___ warm and well perfused Pulses: R: p/d/BKA L: p/d/d/d ON DISCHARGE *************** Pertinent Results: ___ 05:37AM BLOOD WBC-8.7 RBC-3.49* Hgb-9.7* Hct-33.4* MCV-96 MCH-27.8 MCHC-29.0* RDW-21.0* RDWSD-74.2* Plt ___ ___ 05:37AM BLOOD ___ PTT-33.4 ___ ___ 05:37AM BLOOD Glucose-96 UreaN-41* Creat-0.8 Na-138 K-5.0 Cl-97 HCO3-27 AnGap-14 ___ 05:37AM BLOOD Calcium-8.8 Phos-5.6* Mg-2.2 ___ 06:41AM BLOOD calTIBC-332 Ferritn-277 TRF-255 Medications on Admission: Lisinopril Lovastatin Gabapentin Prilosec Warfarin Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN dry eyes 4. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 6. Captopril 37.5 mg PO TID RX *captopril 25 mg 1.5 tablet(s) by mouth three times a day Disp #*135 Tablet Refills:*0 7. CARVedilol 12.5 mg PO BID RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Chlorthalidone 25 mg PO DAILY RX *chlorthalidone 25 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 9. Docusate Sodium (Liquid) 100 mg PO BID 10. Fondaparinux 7.5 mg SC DAILY RX *fondaparinux 7.5 mg/0.6 mL 1 once a day Disp #*30 Syringe Refills:*0 11. Ipratropium-Albuterol Neb 1 NEB NEB Q4H 12. Metoclopramide 10 mg PO Q6H 13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 14. QUEtiapine Fumarate 12.5 mg PO QHS agitation 15. Senna 8.6 mg PO BID 16. Divalproex (DELayed Release) 500 mg PO BID 17. Gabapentin 800 mg PO TID 18. Lovastatin 40 mg oral DAILY 19. Memantine 10 mg PO DAILY ___ 20. Memantine 5 mg PO DAILY AM 21. Omeprazole 20 mg PO DAILY 22. Warfarin 2 mg PO 5X/WEEK (___) 23. Warfarin 4 mg PO 2X/WEEK (___) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Abdominal Aortic Aneurysm Rupture Peripheral Vascular Disease Anemia secondary to rupture requiring transfusion Oliguria Pleural effusions with pulmonary edema requiring diuresis 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 EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ruptured aortobifem now intubated w/ evolving RLL consolidation please eval for change// ___ year old man with ruptured aortobifem now intubated w/ evolving RLL consolidation please eval for change ___ year old man with ruptured aortobifem now intubated w/ evolving RLL consolidation please eval for change IMPRESSION: Comparison to ___. The monitoring and support devices are stable. Moderate cardiomegaly persists. Minimal bilateral pleural effusions. Signs of mild pulmonary edema. No new focal parenchymal changes. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with hypoxemic respiratory failure, two episodes of desaturation this afternoon.// Atelactasis, new consolidation TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___ at 05:37. IMPRESSION: The support lines and tubes are in stable position. Low lung volumes are noted. Small bilateral pleural effusions and bibasilar opacities are unchanged. There is no overt pulmonary edema. The cardiomediastinal silhouette is stable in appearance. No acute osseous abnormalities are identified. Radiology Report EXAMINATION: CHEST (PORTABLE AP) ___ INDICATION: ___ year old man with ruptured aortobifem now intubated w/ evolving RLL consolidation please eval for change// ___ year old man with ruptured aortobifem now intubated w/ evolving RLL consolidation please eval for change ___ year old man with ruptured aortobifem now intubated w/ evolving RLL consolidation please eval for change IMPRESSION: Compared to chest radiographs ___ through ___. Left lower lobe collapse unchanged. Mild pulmonary edema more pronounced in the right lung, moderate right pleural effusion is small left pleural effusion unchanged. No pneumothorax. Heart size normal. Cardiopulmonary support devices in standard placements. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man who presented with ruptured aorta bifem anastomosis s/p proximal aortic cuff x4. Currently intubated.// assess for lung volumes TECHNIQUE: Chest AP film COMPARISON: ___ FINDINGS: In comparison to study completed on ___, there is increased vascular congestion bilaterally. Low lung volumes bilaterally with bilateral atelectasis. Moderate layering pleural effusion on the right and small pleural effusion on the left. Borderline cardiomediastinal silhouette. Trachea is patent, midline. No pneumothorax. ET tube is about 5.6 cm above the carina. Right IJ catheter extends to the upper to mid SVC. Enteric tube is seen extending past the mid-body, tip is out of view. IMPRESSION: Low lung volumes bilaterally, with increased vascular congestion. Moderate pleural effusion on the right and small pleural effusion on the left. Radiology Report EXAMINATION: CHEST (PORTABLE AP) ___ INDICATION: ___ year old man who presented with ruptured proximal anastomosis s/p proximal aortic cuff x4. Currently intubated.// assess lung volumes assess lung volumes IMPRESSION: Compared to chest radiographs ___ through ___. Patient is rotated to his left, obscuring the left lower lobe which is probably still collapsed. Basal atelectasis is also persistent in the right lower lobe, severity indeterminate. The right upper lobe is clear. The heart is not enlarged. There is no pneumothorax. ET tube in standard placement. Transesophageal drainage tube passes into the stomach and out of view. Left jugular line ends in the low SVC. Radiology Report EXAMINATION: CHEST (PORTABLE AP) ___ INDICATION: ___ year old man who presented with ruptured proximal anastomosis s/p proximal aortic cuff x4. Currently intubated.// assess lung volumes assess lung volumes IMPRESSION: Compared to chest radiographs ___ through ___. There is no longer pulmonary edema. Severe left lower lobe atelectasis and small pleural effusions persist. Heart size top-normal. No pneumothorax. Cardiopulmonary support devices in standard placements. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man who presented with ruptured proximal anastomosis s/p proximal aortic cuff x4. Currently intubated.// assess lung volumes IMPRESSION: In comparison with the study of ___, there again are low lung volumes. Monitoring and support devices are stable. Cardiac silhouette is enlarged and there is increased engorgement of ill defined pulmonary vessels consistent with elevated pulmonary venous pressure. Bilateral pleural effusions with compressive atelectasis is seen. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with anastamotic rupture// New Left IJ Central line Contact name: ___, Phone: ___ IMPRESSION: In comparison with the study of 6 hours previously, there has been placement of a left IJ catheter that extends to the lower SVC. No evidence of post procedure pneumothorax. Cardiomediastinal silhouette is less prominent and there is substantial decrease in the bilateral pulmonary opacifications that most likely represented pulmonary edema. There again are bilateral pleural effusions with compressive basilar atelectasis, more prominent on the right. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US LEFT INDICATION: ___ year old man with APLAS, now with LUE swelling and petechial rash// ?LUE DVT TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the left subclavian veins. The left internal jugular, axillary, and brachial veins are patent, show normal color flow, spectral doppler, and compressibility. The left basilic, and cephalic veins are patent, compressible and show normal color flow. There is moderate subcutaneous edema over the dorsum of the hand. IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with hypoxemic respiratory failure// worsening tachypnea TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with small bilateral effusions right greater than left. Cardiomediastinal silhouette is stable. There is mild pulmonary vascular congestion. The ETT, NG tube and left-sided central line are unchanged. No pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) ___ INDICATION: ___ year old man with hypoxic respiratory failure// worsened hypoxemia worsened hypoxemia IMPRESSION: Compared to chest radiographs ___ through ___. Pulmonary vascular congestion persists. Large area of consolidation right lower lobe in smaller regions of peribronchial opacification suggest widespread pneumonia. Heart size normal. Small pleural effusions are likely. No pneumothorax. Cardiopulmonary support devices in standard placements. Radiology Report EXAMINATION: CTA TORSO INDICATION: ___ year old man s/p repair of ruptured aortobifemoral bypass, now with persistent leukocytosis also Hgb drop overnight (unknown source). suspected VAP. Evaluation for bleeding, VAP, abdominal source of leukocytosis/fevers. TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast in the arterial phase. Then, imaging was obtained through the abdomen and pelvis in the portal venous phase. Reformatted coronal and sagittal images through the chest, abdomen, and pelvis, and oblique maximal intensity projection images of the chest were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.7 s, 74.7 cm; CTDIvol = 4.3 mGy (Body) DLP = 317.2 mGy-cm. 2) Spiral Acquisition 5.6 s, 74.7 cm; CTDIvol = 14.9 mGy (Body) DLP = 1,112.0 mGy-cm. 3) Spiral Acquisition 5.6 s, 74.7 cm; CTDIvol = 14.9 mGy (Body) DLP = 1,110.8 mGy-cm. 4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 5) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 13.3 mGy (Body) DLP = 6.6 mGy-cm. Total DLP (Body) = 2,548 mGy-cm. COMPARISON: Comparison to CT abdomen/pelvis performed at outside hospital from ___. FINDINGS: CHEST: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. Moderate atherosclerotic calcification along the aortic arch and descending thoracic aorta. The heart, pericardium, and great vessels are within normal limits. Moderate coronary artery calcifications. No pericardial effusion is seen. Left-sided central venous line with tip extending to the mid SVC. AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is present. A mildly enlarged right hilar lymph node measures 1.3 cm in short axis (301:54), presumably reactive. PLEURAL SPACES: No pneumothorax. Stable small left pleural effusion and new small right pleural effusion, with adjacent compressive atelectasis. LUNGS/AIRWAYS: Focal ground-glass opacities in the right upper lobe (301:34), possibly infectious or asymmetric edema. Mild upper lobe predominant emphysema. Compressive atelectasis at the bilateral lung bases. The airways are patent to the level of the segmental bronchi bilaterally. Patient is intubated with endotracheal tube in appropriate position at the midthoracic trachea. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right adrenal gland is normal in size and shape. The left adrenal gland contains a 1.9 cm nodule (303:125). URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: Enteric tube courses beyond the gastroesophageal junction and into the stomach. The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is 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. A mildly prominent left external iliac lymph node measures 1.3 cm in short axis (303:213), however demonstrates a normal fatty hilum. VASCULAR: Interval repair of a ruptured infrarenal abdominal aortic aneurysm with aortobifemoral graft placement. Expected interval evolution of the large hematoma in the right hemiabdomen, measuring 11.5 x 7.6 x 17.0 cm (303:173, 601:69), which appears to be involuting. No evidence of active extravasation identified. Persistent occlusion of the aortobifemoral bypass is again demonstrated. Persistent occlusion of the fem-fem graft is also noted. There is stable appearance of a chronic bilobed fluid collection in the left inguinal region, measuring 6.0 x 4.8 x 6.8 cm (303:259, 601:74). Stable appearance of a right common femoral pseudoaneurysm measuring approximately 2.2 x 1.8 cm (301:252). BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or acute fracture. Right hip hardware appears intact. Mild multilevel degenerative change of the thoracolumbar spine, including mild wedging of few midthoracic vertebral bodies, unchanged. Postsurgical changes in the anterior abdominal midline, including superficial skin staples. IMPRESSION: 1. Interval repair of a ruptured infrarenal abdominal aortic aneurysm with aortobifemoral graft placement. 2. Expected interval evolution of the large hematoma in the right hemiabdomen, which appears to be involuting and measures up to 17.0 cm. No evidence of active extravasation identified. 3. Stable right common femoral pseudoaneurysm measuring approximately 2.2 x 1.8 cm. 4. Unchanged appearance of a chronic bilobed fluid collection in the left inguinal region, measuring up to 6.8 cm. 5. Nonspecific 1.9 cm left adrenal nodule, indeterminately characterized but most commonly adenoma. A dedicated CT/MRI with adrenal protocol on a nonemergent basis as an outpatient may be performed if needed for better characterization. 6. Focal ground-glass opacities in the right upper lung, possibly representing infection or asymmetric edema. 7. Persistent small left pleural effusion and new small right pleural effusion, with adjacent compressive atelectasis. 8. Mildly enlarged right hilar lymph node measuring 13 mm, presumably reactive. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p ruptured aortic graft w/ concern for fluid overload and possible PNA. Please eval for interval changes// Please eval for interval changes IMPRESSION: In comparison with the study of ___, the monitoring and support devices are unchanged and in satisfactory position. Improved, though still relatively low lung volumes. Cardiomediastinal silhouette is stable and there is indistinctness of engorged pulmonary vessels consistent with the clinical concern for volume overload. Opacification at the left base silhouetting hemidiaphragm is consistent with pleural fluid and volume loss in left lower lobe. Band of atelectasis at the right base is now seen instead of the more amorphous opacification previously noted. Nevertheless, the possibility of superimposed pneumonia would have to be considered in the appropriate clinical setting. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with hypoxemic resp failure// hypoxemia TECHNIQUE: Chest PA and lateral COMPARISON: Multiple prior chest radiographs since ___, most recent ___, and chest CTA from ___. FINDINGS: Right lower lobe band atelectasis is stable. Left basilar opacification silhouetting the hemidiaphragm and suggesting left lower lobe collapse and mild pleural effusion is unchanged, however a superimposed focal consolidation cannot be excluded in the proper clinical setting. Monitoring and support devices are in stable position. IMPRESSION: Right atelectatic band in left lower lobe collapse are unchanged. However, in the appropriate clinical setting, it would be difficult to exclude superimposed consolidation. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with vap// ? vap TECHNIQUE: Chest PA and lateral COMPARISON: Multiple chest radiographs since ___, most recent on ___, and chest CTA from ___. FINDINGS: Right lower lobe band atelectasis is stable. Left basilar opacification silhouetting the hemidiaphragm and suggesting left lower lobe collapse and mild pleural effusion is unchanged, however, a superimposed focal consolidation cannot be excluded in the proper clinical setting. Monitoring and support devices are in stable position. IMPRESSION: Right atelectatic band and left lower lobe collapse are unchanged. However, in the appropriate clinical setting, it would be difficult to exclude superimposed consolidation. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with ruptured aortobifem now intubated and with new CVL// evaluate Contact name: ___: ___ evaluate IMPRESSION: No comparison. The patient is intubated. The tip of the endotracheal tube projects approximately 3 cm above the carinal. The course of the feeding tube is normal. Right internal jugular vein catheter, left internal jugular vein catheter, both in correct position. Lung volumes are low. There is mild cardiomegaly and mild to moderate pulmonary edema, combines to a small left pleural effusion as well as a relatively extensive right basilar atelectasis. No pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with increased O2 requirement, poor left breath sounds// please eval for ?PTX TECHNIQUE: Chest AP film COMPARISON: ___ through ___ FINDINGS: In comparison to the study completed on ___, patient has been extubated. There is a nasogastric tube seen past the midbody, distal tip out of view. Left IJ catheter terminating in the distal SVC. Lower lung volumes today compared to the prior study. Stable cardiomediastinal silhouette. Mildly improved engorgement of pulmonary vascular congestion. Ill-defined opacity seen in the right lower lung that may be represent aspiration/pneumonia in the correct clinical setting. Small to moderate left pleural effusion with volume loss in the left lower lobe. Stable right base atelectasis. No pneumothorax. IMPRESSION: 1. No evidence of pneumothorax. 2. Improved pulmonary vascular congestion. 3. Possible aspiration/pneumonia in the right lower lung in the correct clinical setting. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with VAP// VAP TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Patient is rotated to the right. The left IJ line projects at the junction of the left brachiocephalic and SVC. The NG tubes are unchanged. Lungs are low volume with patchy parenchymal opacity in the right lower lobe and left lower lobe, unchanged. Small bilateral effusions left greater than right are unchanged. No pneumothorax. Mild pulmonary vascular congestion. Radiology Report EXAMINATION: Radiographs with limited views of chest and abdomen. INDICATION: ___ year old man with dobhoff placement// dobhoff placement TECHNIQUE: 4 portable upright images with limited views of the chest and abdomen. COMPARISON: CT scan dated ___, dedicated chest radiograph dated ___. FINDINGS: CHEST: Limited visualization of the chest due to patient being outside the field of view. Right basilar lung opacities previously seen have resolved, there is persistent left basilar opacity and pleural effusion. ABDOMEN: Dobhoff tube is seen coursing through the esophagus, below the diaphragm and eventually coiling in the antrum of the stomach. There is another NG tube also in the stomach.. Central line terminates in the azygos vein. Endotracheal tube terminates 5-6 cm above the carina. IMPRESSION: 1. Dobhoff tube successfully placed in the stomach. 2. Central line terminates in the azygos vein. 3. Interval resolution of right-sided basilar lung opacities, persistence of left-sided basilar opacities and pleural effusion. NOTIFICATION: Findings communicated to ___, MD by ___ ___, MD at 16:33 on ___ 20 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with hypoxemic resp failure// hypoxemia IMPRESSION: In comparison with the study of ___, the monitoring and support devices are stable. Continued low lung volumes with enlargement of the cardiac silhouette and elevation of pulmonary venous pressure. Retrocardiac opacification with obscuration of the hemidiaphragm is consistent with volume loss in left lower lobe and pleural effusion. The opacification at the right base has substantially decreased. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with intubation// intubation IMPRESSION: In comparison with the study of ___, the patient has taken a much better inspiration. The tip of the endotracheal tube is approximately 5 cm above the carina. Other monitoring and support devices are stable. Continued relatively low lung volumes with enlargement of the cardiac silhouette and moderate pulmonary edema. Opacification in the retrocardiac region with obscuration hemidiaphragm is again consistent with volume loss in left lower lobe and pleural effusion. There is an area of increased opacification above the right hemidiaphragmatic contour. This most likely represents merely atelectatic changes. However, in the appropriate clinical setting, superimposed aspiration/pneumonia would have to be considered. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD. INDICATION: ___ year old man with AMS. Evaluation for etiology of AMS. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.3 mGy-cm. Total DLP (Head) = 934 mGy-cm. COMPARISON: No relevant prior imaging for comparison. FINDINGS: There is no evidence of intracranial hemorrhage, acute large territorial infarction, edema,or mass. Extensive encephalomalacia within the posterior right parietal lobe is consistent with prior infarct. Chronic infarction is also noted of the adjacent to the right caudate nucleus. There is prominence of the ventricles and sulci suggestive of involutional changes. Periventricular and subcortical hypodensities are nonspecific, though likely sequela of chronic small vessel ischemic disease. There is no evidence of fracture. Partial opacification of the bilateral ethmoid air cells. Mild mucosal thickening of the bilateral sphenoid sinuses and maxillary sinuses with small amount of layering fluid. Complete opacification of the bilateral mastoid air cells. The middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No evidence of acute intracranial abnormality or hemorrhage. 2. Chronic right caudate nucleus infarct, and chronic posterior right parietal lobe infarct as described above. 3. Moderate paranasal sinus disease with complete opacification of the bilateral mastoid air cells and layering fluid within the bilateral sphenoid sinuses and maxillary sinuses, possibly sequela of intubation. Radiology Report EXAMINATION: BILAT UP EXT VEINS US INDICATION: ___ year old man with pmh significant for anti-phospholipid anitbiody syndrome, hypercoagulable state, PAD s/p R BKA, multiple strokes due to clotting disorder now has LUE swelling, persistent fevers despite extensive infectious work up, concern for venous thrombus.// Please eval for DVT or etiology of upper extremity swelling and persistent fevers. TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral upper extremity veins. COMPARISON: Left upper extremity venous ultrasound from ___ FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. The right internal jugular vein is noncompressible with an intraluminal linear echogenicity, attached to the vessel wall cranially, compatible with an nonocclusive thrombus. Left internal jugular, and bilateral axillary, and brachial veins are patent, show normal color flow, spectral doppler, and compressibility. The bilateral basilic, and cephalic veins are patent, compressible and show normal color flow. IMPRESSION: Nonocclusive venous thrombosis in the right internal jugular vein. Remainder of the right upper extremity veins and left extremity veins are without thrombus. Radiology Report EXAMINATION: GO TO NOTIFICATION CHEST (PORTABLE AP) ___ INDICATION: ___ year old man with intubation// acute process acute process IMPRESSION: Compared to chest radiographs ___ through ___. Although lung volumes are still relatively low, previous left lower lobe atelectasis has improved substantially. Pulmonary edema is mild. Mild cardiomegaly has improved since ___. Small left pleural effusion unchanged. No pneumothorax. No endotracheal tube is seen. Transesophageal drainage tube ends at the thoracic inlet either in the airway or upper esophagus. Transesophageal feeding tube ends in the proximal duodenum. Left jugular line tip in the low SVC. NOTIFICATION: The findings were discussed with ___, RN, by ___, M.D. on the telephone at 12:49, IMMEDIATELY following discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with hypoxemic respiratory failure, now s/p extubation// hypoxemia IMPRESSION: In comparison with the study of ___, there are slightly improved lung volumes. The endotracheal tube is been removed. What appears to of been a transesophageal drainage tube has been removed. The other monitoring and support devices appear stable. Cardiomediastinal silhouette is unchanged. Mild engorgement of ill defined pulmonary vessels is consistent with elevated pulmonary venous pressure. Basilar opacification on the left is consistent with pleural fluid and atelectatic changes. Radiology Report INDICATION: ___ year old man with increased O2 requirements// Eval for pulm edema, effusion COMPARISON: Radiographs from ___ IMPRESSION: There has been improvement of the pulmonary edema. The left IJ central line has been removed. There is a feeding tube with distal tip is below the edge of the film, past the GE junction.. There remains bibasilar opacities at the lung bases, left greater than right. There are no pneumothoraces. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ruptured aortobifem now intubated, please eval for interval change// ___ year old man with ruptured aortobifem now intubated, please eval for interval change ___ year old man with ruptured aortobifem now intubated, please eval for interval change IMPRESSION: Comparison to ___. Stable correct position of the monitoring and support devices. New small to moderate bilateral pleural effusions, with subsequent areas of basilar atelectasis, in addition to the pre-existing right perihilar and basal opacity and consolidation. There also is a new retrocardiac atelectasis. No pulmonary edema. No pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ruptured aortobifem now intubated w/ evolving RLL consolidation please eval for change// ___ year old man with ruptured aortobifem now intubated w/ evolving RLL consolidation please eval for change IMPRESSION: In comparison with the study of ___, there is little change in the monitoring and support devices. The cardiac silhouette is again mildly enlarged with elevated pulmonary venous pressure that appears less prominent than on the prior study. The layering pleural effusions with compressive basilar atelectasis also are less prominent, though much of this could merely reflect a more upright position of the patient. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man post-op vent dependence still with open abdomen. Bronch'd this morning for ?mucus plugging in RLL.// worsening hypoxemia s/p bronch/BAL worsening hypoxemia s/p bronch/BAL IMPRESSION: Comparison to ___. Stable monitoring and support devices. Minimal increase in extent of the moderate right and small left pleural effusion. Stable basal areas of atelectasis. On the current image, signs of mild pulmonary edema present. Mild cardiomegaly persists. No pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ruptured aortobifem now intubated w/ evolving RLL consolidation please eval for change// ___ year old man with ruptured aortobifem now intubated w/ evolving RLL consolidation please eval for change ___ year old man with ruptured aortobifem now intubated w/ evolving RLL consolidation please eval for change IMPRESSION: ET tube tip is 6 cm above the carina. NG tube tip is in the stomach. Right internal jugular line tip is at the level of mid SVC. Heart size and mediastinum are stable. Bibasal consolidations and bilateral pleural effusions are unchanged. There is interval improvement in pulmonary edema with only pulmonary vascular congestion currently present. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with NGT// ? NGT TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___ at 03:59. IMPRESSION: The nasogastric tube terminates in the body of the stomach. The remaining support lines and tubes are in stable position. No other significant interval change compared to study from earlier today. Gender: M Race: UNKNOWN Arrive by HELICOPTER Chief complaint: Transfer Diagnosed with Abdominal aortic aneurysm, without rupture temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan
Mr. ___- It was a pleasure taking care of you at ___ ___. You were admitted to the hospital after transfer from an outside institution for ruptured abdominal aortic aneurysm. You underwent emergent repair which required placement of a graft in you aorta. You also required an incision made into your abdomen to release the blood that collected after the rupture. Please follow the recommendations below to ensure a speedy and uneventful recovery. Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm Repair Discharge Instructions PLEASE NOTE: After endovascular aortic repair (EVAR), it is very important to have regular appointments (every ___ months) for the rest of your life. These appointments will include a CT (“CAT”) scan and/or ultrasound of your graft. If you miss an appointment, please call to reschedule. WHAT TO EXPECT: •Bruising, tenderness, and a sensation of fullness at the groin puncture sites (or incisions) is normal and will go away in one-two weeks CARE OF THE GROIN PUNCTURE SITES: •It is normal to have mild swelling, a small bruise, or small amounts of drainage at the groin puncture sites. In two weeks, you may feel a small, painless, pea sized knot at the puncture sites. This too is normal. Male patients may notice some swelling in the scrotum. The swelling will get better over one-two weeks. •Look at the area daily to see if there are any changes. Be sure to report signs of infection. These include: increasing redness; worsening pain; new or increasing drainage, or drainage that is white, yellow, or green; or fever of 101.5 or more. (If you have taken aspirin, Tylenol, or other fever reducing medicine, wait at least ___ hours after taking it before you check your temperature in order to get an accurate reading.) FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) •If you have sudden, severe bleeding or swelling at either of the groin puncture sites: -Lie down, keep leg straight and apply (or have someone apply) firm pressure to area for ___ minutes with a gauze pad or clean cloth. -Once bleeding has stopped, call your surgeon to report what happened. -If bleeding does not stop, call ___ for transfer to closest Emergency Room. •You may shower 48 hours after surgery. Let the soapy water run over the puncture sites, then rinse and pat dry. Do not rub these sites and do not apply cream, lotion, ointment or powder. •Wear loose-fitting pants and clothing as this will be less irritating to the groin puncture sites. MEDICATIONS •Take aspirin daily. Aspirin helps prevent blood clots that could form in your repaired artery. •It is very important that you never stop taking aspirin or other blood thinning medicines-even for a short while- unless the surgeon who repaired your aneurysm tells you it is okay to stop. Do not stop taking them, even if another doctor or nurse tells you to, without getting an okay from the surgeon who first prescribed them. •You will be given prescriptions for any new medication started during your hospital stay. •Before you go home, your nurse ___ give you information about new medication and will review all the medications you should take at home. Be sure to ask any questions you may have. If something you normally take or may take is not on the list you receive from the nurse, please ask if it is okay to take it. PAIN MANAGEMENT •Most patients do not have much pain following placement of the stent alone. You had an abdominal incision in addition to this, so recovery may take longer. Your puncture sites may be a little sore. This will improve daily. If it is getting worse, please let us know. •You will be given instructions about taking pain medicine if you need it. ACTIVITY •You must limit activity to protect the puncture sites in your groin. For ONE WEEK: -Do not drive -Do not swim, take a tub bath or go in a Jacuzzi or hot tub -Do not lift, push, pull or carry anything heavier than five pounds -Do not do any exercise or activity that causes you to hold your breath or bear down with your abdominal muscles. -Do not resume sexual activity •Discuss with your surgeon when you may return to other regular activities, including work. If needed, we will give you a letter for your workplace. •It is normal to feel weak and tired. This can last six-eight weeks, but should get better day by day. You may want to have help around the house during this time. ___ push yourself too hard during your recovery. Rest when you feel tired. Gradually return to normal activities over the next month. •We encourage you to walk regularly. Walking, especially outdoors in good weather is the best exercise for circulation. Walk short distances at first, even in the house, then do a little more each day. •It is okay to climb stairs. You may need to climb them slowly and pause after every few steps. BOWEL AND BLADDER FUNCTION •You should be able to pass urine without difficulty. Call you doctor if you have any problems urinating, such as burning, pain, bleeding, going too often, or having trouble urinating or starting the flow of urine. Call if you have a decrease in the amount of urine. •You may experience some constipation after surgery because of pain medicine and changes in activity. Increasing fluids and fiber in your diet and staying active can help. To relief constipation, you may talk a mild laxative. Please take to your pharmacist for advice about what to take. SMOKING •If you smoke, it is very important that you STOP. Research shows smoking makes vascular disease worse. This could increase the chance of a blockage in your new graft. Talk to your primary care physician about ways to quit smoking.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / carboplatin Attending: ___. Chief Complaint: C3-C5 Spinal Stenosis s/p Surgical Decompression Major Surgical or Invasive Procedure: C3-6 Laminectomy, C3-7 Posterior Fusion, Autografts/Allografts/Instrumentation on ___ ___ ___ History of Present Illness: Mr. ___ is a ___ year old man with lung ___ on chemo who presents to ED after transfer from ___. Pt had an unwitnessed syncopal episode at 2:30 a.m. Pt's wife states she heard a fall while he was walking to the bathroom and found him after he struck the left anterior aspect of his face on the floor, laying on his bilateral hands. He presented to ___ where he reported B/L hand numbness on radial aspect and pain and L foot numbness s/p fall. At ___ head was negative, and CT Cspine revealed no fracture but narrowing at C3-C5. EKG showed multifocal PVCs. Pt is ambulatory at baseline. Since the fall, he stood to transfer to a wheelchair but has otherwise not walked. He has recently diagnosed afib but is not on Coumadin, takes aspirin 81mg daily. Currently on weekly chemo for lung ___. Previously had two bilateral lower lung resections, unknown when date. Got 5 sessions of pemetrexed ___ to first week of ___. Tumor regressed by only half, then started vinorelbine, had 2 sessions, ___. Admit to medicine for medical clearance/syncope workup, then spine op In the ED, initial VS were temp: 98.4 HR: 100 BP: 128/76 RR: 20O2 SaO2 98%. Exam notable for decreased sensation in bilateral hands and left foot. Alert, oriented x3. Labs showed trop neg, otherwise unremarkable. MRI spine showed significant cervical stenosis at C3-C5. Hand x-ray showed no evidence of fracture. Received morphine, NS. Transfer VS were 98 °F (36.7 °C), Pulse: 87, RR: 19, BP: 107/68, O2 sat: 93. Ortho spine was consulted and the patient will likely have surgery following synocope workup/OR clearance, but no need for urgent surgery. Spine will continue to follow on the floor. Patient OK to eat. Decision was made to admit to medicine for further management. On arrival to the floor, patient denies numbness and tingling currently and his main complaint is bilateral dorsal hand pain to the mid forearm. He denies a history of neuropathy in the past. No CP/SOB/palp. No NV. Past Medical History: COPD HLD Renal ___ (transitional cell carcinoma of the left renal pelvis and a papillary tumor--dx ___ lung ___ (Likely non small cell lung ___. Previously had two bilateral lower lung resections, does not know date. Found to have a new uppe0r lobe lesion in ___. Startd chemo--got 5 qweek sessions of pemetrexed with carboplatin ___ to first week of ___. Was unable to tolerate carboplatin. Tumor regressed by only half, so started on vinorelbine, had 2 sessions, ___ HTN DM C3-C7 Cord Compression post-syncope s/p surgical decompression ___ Social History: ___ Family History: Does not report any family history. Physical Exam: Admission physical exam: VS - 98.2 128/73 94 20 93% on RA General: thin, older gentleman, lying comfortably in bed, with cervical. responding appropriatley to quesitons, aox3. HEENT: mucous membranes dry. Echymosis/hematoma to L orbit. PERRLA. EOMI. Neck: cervical collar CV: regular rate, rhythm. normal s2, s2. could not appreciate murmurs--exam limited by cervical collar extending down. Lungs: clear to auscultation bilaterally Abdomen: soft, nontender, nondistended, +BS GU: deferred Ext: Right axillae with steri strips over a 2cm incision. ___ strength in bilateral hands. Tender to palpation over bilateral hands, wrists- worse in right ___ and ___ digits. No deformity appreciated. No pain with PROM of shoulders, elbows. Pain w/ passive ROM of bilateral wrists/digits. 2+ radial pulses. Small abrasion on left knee, no tenderness in bilateral legs. Painless arom/prom hip, knees and ankles. 1+ ___ and DP pulses. No edema, cyanosis. Warm, well-perfused. Neuro: AOx3. Speech fluent. He has decreased sensation and in fingers of both hands and left foot. Strength normal. He does have slightly decreased motor strength bilateral upper extremities. Skin: bruising around left orbit. no rashes noted. Discharge physical exam: Vitals – 97.9, 90-95, 128-139/75-87, 18, 95% on 2L GENERAL: Lying in bed, NAD, cervical collar in place, A+Ox3 HEENT: Anicteric sclera, pink conjunctiva, patent nares, dry mucous membrances, ecchymosis over left eye NECK: Cervical collar in place, could not evaluate JVD CARDIAC: RRR, no murmurs, gallops, or rubs LUNG: Diffus upper airway noise transmission, intermittent wheeze ABDOMEN: Nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: No cyanosis, clubbing or edema, 2+ DP pulses bilaterally SKIN: warm and well perfused, no excoriations or lesions, no rashes NEURO: Arm flexor/extensors ___ bilaterally, finger flexors/extensors ___ bilaterally, ___ in lower extremities. Sensory intact to light touch bilaterally throughout Pertinent Results: ___ 09:40AM BLOOD WBC-2.8*# RBC-3.36* Hgb-10.8* Hct-34.1* MCV-101* MCH-32.1* MCHC-31.6 RDW-14.1 Plt ___ ___ 09:40AM BLOOD Glucose-178* UreaN-26* Creat-1.0 Na-137 K-4.5 Cl-104 HCO3-25 AnGap-13 ___ 05:40AM BLOOD WBC-4.4 RBC-3.08* Hgb-9.8* Hct-29.6* MCV-96 MCH-31.9 MCHC-33.2 RDW-15.0 Plt ___ ___ 10:32AM BLOOD ___ PTT-28.4 ___ ___ 05:40AM BLOOD Glucose-132* UreaN-12 Creat-0.8 Na-138 K-4.0 Cl-99 HCO3-28 AnGap-15 ___ 05:40AM BLOOD ALT-33 AST-32 LD(LDH)-204 AlkPhos-56 TotBili-0.6 ___ 09:40AM BLOOD cTropnT-<0.01 ___ 05:40AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.2* Mg-1.4* ___ 05:40AM BLOOD VitB12-1680* ___ 05:40AM BLOOD %HbA1c-7.0* eAG-154* ___ 05:40AM BLOOD TSH-2.7 IMAGING: ___ MRI Spine 1. No definite evidence of bony metastatic disease although marrow signal is heterogeneous. 2. Severe changes of cervical spondylosis are seen at C3-4 C5-6 and C6-7 extrinsic indentation and deformity of the spinal cord with subtle increased signal within the spinal cord at C5 and C6 levels indicating cord edema or myelomalacia. 3. Multilevel degenerative changes in the thoracic and lumbar region without spinal stenosis at these levels. No evidence of fracture. 4. Right upper lobe lung mass which can be further evaluated with chest CT. ___ Hand, wrist x-ray: No acute fracture or dislocation in either hand or wrist. ECHOCARDIOGRAM ___ The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. 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 a small circumferential pericardial effusion most prominent around the right ventricle and apex. There are no echocardiographic signs of tamponade. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Small pericardial effusion without evidence for hemodynamic compromise. Mildly dilated ascending aorta. No valvular pathology or pathologic flow identified. No structural cardiac cause of syncope identified. CAROTID ULTRASOUND ___ = Mild heterogenous plaque bilaterally. Flow velocities are indicative of less than 40% stenosis. OPERATIVE REPORT ___. Signed Electronically by ___ on MON ___ 1:57 AM Name: ___ ___ No: ___ Service: Orthopaedic Surgery Date: ___ Date of Birth: ___ Sex: M Surgeon: ___, ___ SERVICE: Orthopedic Surgery. ___ ASSISTANT: ___, MD PREOPERATIVE DIAGNOSES: 1. Cervical stenosis. 2. Cervical spinal cord injury. 3. Myelopathy. POSTOPERATIVE DIAGNOSES: 1. Cervical stenosis. 2. Cervical spinal cord injury. 3. Myelopathy. PROCEDURES PERFORMED: 1. Laminectomy, C3, C4, C5, C6. 2. Posterior fusion, C3-C4, C4-C5, C5-C6, C6-C7. 3. Posterior instrumentation, C3-C7. 4. Autograft, same incision. 5. Allograft. IMPLANTS: 1. Globus Ellipse posterior instrumentation. 2. Corticocancellous allograft. ESTIMATED BLOOD LOSS: 200 cc. SPECIMEN TO PATHOLOGY: None. INDICATIONS: The patient is a ___ man who presented to ___ emergency department after a fall walking to the bathroom. He struck the anterior aspect of his face, and had subsequent tingling in both hands, as well as lower extremity symptoms including difficulty walking. He has found on imaging to have severe spinal cord compression at C3-C4, C4- C5, C5-C6, and C6-C7, including myelomalacia within the spinal cord. Because of the ongoing severe stenosis, the nature of his symptoms, and the severity of the symptoms, he elected to undergo surgical treatment, with the goal of halting the progression of his spinal cord injury and myelopathy. Prior to surgery I explained in detail to the patient the possible risks of surgery which included the risk of nerve injury, persistent and or worsening pain, spinal fluid leak, infection or meningitis, excessive bleeding, paralysis, death, blindness, sexual dysfunction, retrograde ejaculation, blood vessel injury, injury to neighboring organs, need for further surgery, bowel and bladder dysfunction, instability, and autonomic nervous system dysfunction as well as unforeseen medical and surgical complications. An understanding that in general spinal surgery is more predictive in improving extremity discomfort than axial spine pain and arresting the progression of spinal cord dysfunction rather than improving it was stressed. The risks of junctional degeneration, bone graft donor morbidity, the differences in efficacy between local bone graft, autologous iliac crest bone graft and allograft, the FDA status of the instrumentation, the possible need for further surgery, the risk of nonhealing and instrumentation failure, and chronic pain were also explained. The patient was taken to the Operating Room and after identification of the patient and the operative site, administration of antibiotics, and completion of anesthesia, the patient was prepped and draped in the prone position on laminectomy rolls. During this time and the entire operation, care was taken to maintain appropriate perfusion pressures during anesthesia. All bony protuberances and soft tissues were well padded in the standard fashion. Pre- and intra-operatively prophylactic antibiotics were administered according to the appropriate timing schedule. A Foley catheter was placed. Sequential compressive boots were applied and maintained throughout the procedure. A time out was completed before beginning the surgical procedure. Posterior Spinal Exposure: An incision was made in the skin over the intended surgical levels and dissection was carried down through the subcutaneous tissue down to the level of the deep fascia. The deep fascia was divided and elevated off the posterior elements in a subperiosteal manner. An intra-operative radiograph was taken to confirm the appropriate spinal level. Cervical lateral mass screw placement: The anatomic landmarks were identified for lateral mass and pedicular fixation. A pilot hole was initiated in the correct anatomic location with a 2 mm burr. Lateral mass fixation was performed at the C3 to C6 levels. Lateral mass screw trajectory was drilled in an upward and outward direction according to the modified Magerl technique. Each of the holes was tapped if necessary and palpated with a small ball tipped feeler probe to insure proper integrity of the bony tunnel. Pedicle fixation was performed at C7 by directly palpating the borders of the pedicle following a laminoforaminotomy to allow proper placement and trajectory of the pedicle screw. The pedicular holes were tapped if necessary and palpated to ensure integrity of the pedicle screw path. Appropriate length screws were then selected and placed into the properly prepared bone holes. In all cases, satisfactory purchase of the screws was noted. Spinal rods were then contoured and applied to the spinal anchors followed by the appropriate locking vector forces. Intraoperative imaging confirmed the appropriate placement of the spinal anchors and alignment of the spinal fixation. Laminectomy C3, C4, C5, C6: Using sub-periosteal dissection, the laminas of the C3 to C7 vertebrae were exposed. The cervical laminas of C3 to C6 were secured with towel clips for stabilization. The interspinous ligament was carefully removed between the laminectomy levels and the bordering caudal and cranial spinous processes. A high-speed drill was then used to create two lateral gutters at the laminar border. The outer bony cortex and inner cancellous bone was removed down to the level of the inner cortical bone. A small curette and ___ ___ was then used to remove this layer of bone allowing exposure of the ligamentum flavum and dural sac. A ___ ___ rongeur was then used to detach the remaining intervening ligaments. By carefully elevating the lamina through the attached towel clips, the spinous processes and lamina were removed as one unit. A ___ rongeur was then used to widen the laminectomy as necessary. Foraminotomies were next performed at each level of decompression to ensure absence of foraminal compression. Complete hemostasis was obtained in the lateral recesses with bipolar cautery and hemostatic agents. The dura was seen to expand and dural pulsations were evident. Posterolateral fusion C3 to C7 with bone grafting: The remaining posterior elements of the C3 to C7 vertebral bodies were gently decorticarted with a high speed drill to expose bleeding trabecular bone. Autograft prepared from the laminectomy harvest was packed within the decorticated facet joints as well as allograft was packed over the decorticated posterior elements. After the wound was thoroughly irrigated with antibiotic impregnated fluid and all bleeding was stopped, closure was completed with interrupted 0 Vicryl suture ligatures in the fascia, ___ Vicryl suture ligatures in the subcutaneous tissues and a running ___ Monocryl suture ligature in the subcuticular layer. The drain was left in the wound exiting through the wound closure site which was a small Hemovac. All sponge, needle and instrument counts are correct at the end of the case. The patient tolerated the anesthesia and the procedure well and is brought to the postanesthesia care unit in stable condition. ___, MD ___ I was physically present during all critical and key portions of the procedure and immediately available to furnish services during the entire procedure, in compliance with CMS regulations. Dictated By: ___, MD Radiology Report EXAMINATION: MRI CERVICAL SPINE, THORACIC AND LUMBAR SPINES INDICATION: History: ___ with fall on face, BUE tingling, weakness // presence of cord edema, impingement TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the cervical, thoracic and lumbar spine were obtained. COMPARISON: Cervical spine CT EXAMINATION of ___. FINDINGS: There is a right upper lung mass identified. The patient is known to have lung cancer There is heterogeneous bone marrow identified in the cervical, thoracic and lumbar but there are no focal bony abnormalities identified. The T4 vertebra demonstrates mild chronic appearing compression. In the cervical region no evidence of fracture identified. Degenerative changes seen with moderate to severe spinal stenosis at C3-4 level with deformity of the spinal cord. Additionally at the C5-6 there is moderate-to-severe spinal stenosis seen with deformity of the spinal cord. All there is mild to moderate spinal stenosis seen at this C6-7 level. At other levels in the cervical region degenerative changes are identified. At C3-4 C5-6 and C6-7 severe bilateral foraminal narrowing is seen. At the C5-6 and C6-7 levels. There is deformity of the spinal cord. There is subtle increased signal appreciated within the spinal cord which could be secondary to myelomalacia or cord edema. There are no signs of intramedullary hemorrhage is seen. In the thoracic and lumbar region multilevel mild degenerative changes are identified. There is no spinal stenosis seen. At L4-5 mild disc bulging identified with mild narrowing. The remaining spinal cord in the thoracic and upper lumbar region appears normal without extrinsic compression or intrinsic signal abnormalities IMPRESSION: 1. No definite evidence of bony metastatic disease although marrow signal is heterogeneous. 2. Severe changes of cervical spondylosis are seen at C3-4 C5-6 and C6-7 extrinsic indentation and deformity of the spinal cord with subtle increased signal within the spinal cord at C5 and C6 levels indicating cord edema or myelomalacia. 3. Multilevel degenerative changes in the thoracic and lumbar region without spinal stenosis at these levels. No evidence of fracture. 4. Right upper lobe lung mass which can be further evaluated with chest CT. Radiology Report INDICATION: Fall onto hands with bilateral hand numbness and pain TECHNIQUE: Bilateral hands, three views each and bilateral wrists, four views each COMPARISON: None. FINDINGS: Within the left hand and wrist, there is no acute fracture or dislocation identified. A pulse oximeter device slightly obscures assessment of the middle and distal phalanges of the long finger. No concerning lytic or sclerotic osseous abnormalities seen. Minimal degenerative changes are noted within the carpal bones. Within the right hand and wrist, tubing from a intravenous device is seen projecting over the carpal bones. No acute fracture dislocation is seen. Mild degenerative changes are noted at the first CMC joint with osteophytic spurring. No suspicious lytic or sclerotic osseous abnormality is seen. IMPRESSION: No acute fracture or dislocation in either hand or wrist. Radiology Report HISTORY: Cervical fusion. FINDINGS: Images from the operating suite show posterior fusion spanning what appears to be C3 through C7. Further information can be gathered from the operative report. Radiology Report PORTABLE CHEST X-RAY, ___ COMPARISON: ___. FINDINGS: Tip of endotracheal tube terminates 9 cm above the carina and could be advanced approximately 4 to 5 centimeters for standard positioning. Tip of nasogastric tube terminates in proximal stomach with side port above GE junction and could also be advanced. Exam is otherwise remarkable for a large mass-like area of opacification above the right hilum with adjacent surgical sutures, as well as right upper lobe volume loss and asymmetrical right apical thickening. Although similar to recent radiographs, this is a change from baseline radiograph of ___. Surgical sutures are also present in the left mid lung. Further evaluation with dedicated chest CT is suggested when the patient's clinical status permits, in order to assess for possible lung malignancy. Dr. ___ was successfully paged to discuss these findings at 8:15 a.m. on ___ at time of discovery. Radiology Report EXAMINATION: Duplex Doppler evaluation of the extracranial carotid arteries. TECHNIQUE: Grayscale, color and spectral Doppler were used to evaluate the extracranial carotid arteries. HISTORY: ___ male with history of lung cancer and syncope. Request is to evaluate for carotid atherosclerosis. FINDINGS: RIGHT SIDE: There is mild heterogenous plaque involving the right ICA. Peak systolic velocities in the proximal, mid and distal ICA are 68 cm/sec, 62 cm/sec and 54 cm/sec respectively. Peak systolic velocities in the right common and external carotid arteries are 67 cm/sec and 110 cm/sec respectively. Peak systolic antegrade velocities in the right vertebral artery of 62 cm/sec are recorded. This yields a right-sided internal to common carotid ratio of 1.0, predictive of less than 40% stenosis. LEFT SIDE: Again, there is mild heterogenous plaque involving the left internal carotid artery ostium. Peak systolic velocities in the left proximal, mid and distal ICA are 53 cm/sec, 60 cm/sec and 48 cm/sec. Left common and external carotid artery peak systolic velocities of 54 cm/sec and 101 cm/sec are recorded. Again, there is normal antegrade flow in the left vertebral artery with a peak systolic velocity of 79 cm/sec. This yields a left-sided internal to common carotid ratio of 1.1, again predictive of less than 40% stenosis. IMPRESSION: Mild heterogenous plaque bilaterally. Flow velocities are indicative of less than 40% stenosis. Radiology Report INDICATION: ___ year old man with COPD with cough and poor secretion mobilization // ?Aspiration TECHNIQUE: PA and lateral images of the chest. COMPARISON: Comparison made with chest radiographs from ___, and ___ and MR cervical, thoracic, and lumbar spine from ___. FINDINGS: A right-sided central line terminates in the superior cavoatrial junction. The lungs are well expanded. There is a mass in the right upper lobe, partially imaged on recent MR and similar to recent prior radiographs but new since radiographs from ___. There are small bilateral pleural effusions. No definite focal consolidation is seen, however cannot exclude a small opacity in the posterior lungs, which could be obscured by the pleural effusions. There is no pneumothorax. The cardiomediastinal silhouette is unremarkable. A compression deformity is noted in an upper thoracic vertebra. IMPRESSION: 1. No definite focal consolidation, however cannot exclude a small opacity in the posterior lung, which could be obscured by the pleural effusions. 2. Right upper lobe mass, partially imaged on recent MR and similar to recent prior radiographs but new since radiographs from ___. Further evaluation by CT is recommended. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: R/O CORD INJURY Diagnosed with SYNCOPE AND COLLAPSE temperature: 98.4 heartrate: 100.0 resprate: 20.0 o2sat: 98.0 sbp: 128.0 dbp: 76.0 level of pain: 5 level of acuity: 2.0
Dear Mr. ___, It was a pleasure to take care of you at ___ ___. You were admitted because you fainted and broke several bones in your spine, which in turn hurt your spinal cord. Orthopedics performed surgery to stop the bones blocking your spinal cord, you were monitored for improvement, and you were discharged to rehab. Best of luck to you in your future health. Please take all medications as prescribed, attend all physician appointments as scheduled, and call a doctor if you have any questions or concerns.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Macrobid / codeine Attending: ___ Chief Complaint: bil flank tenderness Major Surgical or Invasive Procedure: L PCN exchange (___) History of Present Illness: ___ with lumbar spinal injury with marked b/l ___ weakness, multifactorial CKD stage IV (b/l Cr ~2.1-2.3), obstructive uropathy w/ chronic Foley, L ureteral stricture s/p L PCN, recent admission to ___ ___ for UTI (ESBL E.coli and Stenotrophomas, s/p treatment with Ceftaz/Bactrim) presenting with b/l flank tenderness. Mr. ___ was recently admitted ___ for likely UTI in setting of chills, nausea, and moderate L flank tenderness. UCx grew ESBL E.coli and Stenotrophomonas, for which he was treated with Ceftaz/Bactrim x 10d. Foley was exchanged. In discussion with ___, the decision was made to not exchange his L PCN, as it was draining well. Repeat UCx from ___ again grew ESBL E.coli and Stenotrophomonas, and he was subsequently seen by ID on ___. These organisms were thought to represent colonizers in the absence of fevers/chills/malaise, and he was not treated with additional antibiotics. ID recommended discussing replacement of his L PCN with an internal stent with his outpatient providers. Of note, Mr. ___ was previously followed by ___ urology but is in the process of transitioning his urology care to ___ (he does not appear to have a urologist yet). He has a benign L ureteral stricture, for which his L PCN was placed about a year ago, exchanged q3 months (last about 3 months ago). ___ urology was reportedly unable to pass a ureteral stent anterograde or retrograde. His Foley was placed for BPH/urethral obstruction and is exchanged by his ___ monthly (last about a month ago). Mr. ___ reports that over the last 1.5 weeks he has had worsening L flank pain, with some drainage around the L PCN and malodorous urine. The pain has been getting worse, and yesterday he noticed mild R-sided flank tenderness as well with some nausea and two episodes of NBNB emesis. He endorses chills and fatigue, but denies fevers or rigors. He has chronic lower extremity pain from a prior crush injury, for which he takes oxycontin and oxycodone PRN. His mobility is limited secondary to his injury; he ambulates with a walker with difficulty and has a wheelchair. Transport to and from his home is by ambulance. ED: VS AF, BP 136/65, HR 46, RR 18, 99% RA Exam: Not documented Labs: WBC 9.4, Hgb 11.9, Plt 201, Cr 2.6, Lactate 1.8, UA w/pyuria (see below) Imaging: CT A/P with L PCN in place, no hydro, b/l perinephric stranding, thickened bladder Consults: urology; no recommendations made Interventions: Cefepime 2g x 1, oxycodone 5mg ROS: Denies CP, SOB, cough, abdominal pain, diarrhea/constipation, melena/hematochezia, headaches, new rashes. Past Medical History: # Spinal crush injury -> ___ weakness, mult spinal surgeries. # Hardware L hip, L femur, R ankle, R shoulder # HTN/HLD # Hypothyroidism. # Afib w/junctional bradycardia, on anticoagulation. # CKD stage IV # AIN ___ indomethacin ___ years ago) # IgA nephropathy on low dose prednisone # Obstructive nephropathy, L ureter obstruction - chronic foley (q1 mos), L PCN (q3mo) - ureter brushings, bx (___) neg - urology at ___ reportedly unable to pass ureteral stent # Recurrent UTIs # BPH. # ACD # OSA, on CPAP. # B12 deficiency. # Gout, without recent episodes. Social History: ___ Family History: No family history of kidney disease. Physical Exam: ADMISSION: ---------- 24 HR Data (last updated ___ @ ___) Temp: 98.5 (Tm 98.5), BP: 153/76, HR: 45 (baseline), RR: 18, O2 sat: 98%, O2 delivery: Ra GENERAL: NAD, sitting comfortably in bed EYES: PERRL, anicteric sclerae ENT: OP clear CV: regular, bradycardic, nl S1, S2, no M/R/G, no JVD RESP: CTAB, no crackles, wheezes, or rhonchi GI: obese, + BS, soft, NT, ND, no rebound/guarding, no HSM GU: L PCN in place draining yellow urine without clear purulent drainage; Foley in place draining yellow urine; b/l CVA tenderness SKIN: No rashes or ulcerations noted MSK: Lower extremities warm with trace, non-pitting edema b/l NEURO: AOx3, CN II-XII intact, ___ strength in all extremities, sensation grossly intact throughout, gait testing deferred PSYCH: pleasant, appropriate affect DISCHARGE: ---------- 24 HR Data (last updated ___ @ 1219) Temp: 97.6 (Tm 98.4), BP: 178/81 (130-178/58-81), HR: 44 (37-45), RR: 18 (___), O2 sat: 99% (97-99), O2 delivery: RA GENERAL: NAD, lying comfortably in bed EYES: PERRL, anicteric sclerae ENT: OP clear CV: regular, bradycardic, nl S1, S2, no M/R/G, no JVD RESP: CTAB, no crackles, wheezes, or rhonchi GI: obese, + BS, soft, NT, ND, no rebound/guarding, no HSM GU: L PCN in place draining yellow urine without clear purulent drainage; Foley in place draining yellow urine; no significant L CVA tenderness SKIN: No rashes or ulcerations noted MSK: Lower extremities warm without edema; RUE midline c/d/i NEURO: AOx3, CN II-XII intact, ___ strength in all extremities (limited by pain), sensation grossly intact throughout, gait testing deferred PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION: ---------- ___ 11:40AM BLOOD WBC-9.4 RBC-3.97* Hgb-11.9* Hct-37.7* MCV-95 MCH-30.0 MCHC-31.6* RDW-15.1 RDWSD-52.9* Plt ___ ___ 06:25AM BLOOD ___ ___ 11:40AM BLOOD Glucose-103* UreaN-63* Creat-2.6* Na-138 K-4.9 Cl-100 HCO3-22 AnGap-16 ___ 06:25AM BLOOD Calcium-8.6 Phos-5.0* Mg-2.1 ___ 06:25AM BLOOD CRP-54.9* DISCHARGE: ---------- ___ 06:00AM BLOOD WBC-7.1 RBC-3.46* Hgb-10.2* Hct-33.6* MCV-97 MCH-29.5 MCHC-30.4* RDW-15.1 RDWSD-54.4* Plt ___ ___ 06:00AM BLOOD ___ ___ 06:00AM BLOOD Glucose-104* UreaN-78* Creat-2.3* Na-142 K-5.2 Cl-106 HCO3-19* AnGap-17 ___ 06:00AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.0 UA ___, ___): mod blood, neg nit, lg ___, 600 prot, 70 gluc, 38 RBCs, >182 WBCs, few bact, 0 epis UA ___, PCN): sm blood, neg nit, lg ___, 100 prot, tr gluc, 8 RBCs, 49 WBCs, few bact, 0 epis UCx (___): mixed flora BCx (___): pending x 2 UCx (___): Pseudomonas aeruginosa (>100,000); Corynebacterium (10,000-100,000); not urealyiticum per lab _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 16 I CEFTAZIDIME----------- 32 R CIPROFLOXACIN--------- S GENTAMICIN------------ <=1 S MEROPENEM------------- 4 I PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S IMAGING: ======== EKG (___): Poor baseline, but appears to be a regular rhythm at 46 bpm with no clear P waves and narrow QRS complex; QRS 94, QTC 504 (manual is 495), no clear ischemic changes (similar to ___ Perc nephrostomy (___): FINDINGS: Moderate left hydronephrosis IMPRESSION: Successful exchange of a 8.5 ___ nephrostomy on the left. CT A/p w/o cont (___): 1. Percutaneous nephrostomy tube is seen in the left renal pelvis. 2. Punctate nonobstructing left renal stones. No hydronephrosis. 3. Bilateral perinephric stranding is nonspecific, but can be seen in the setting of infection recommend correlation with urinalysis. 4. Thickened urinary bladder, may be due to underdistention, however recommend correlation with urinalysis. 5. Cholelithiasis without evidence of acute cholecystitis. 6. 1.5 cm cystic lesion in the uncinate process of the pancreas. Recommend nonemergent MRCP if previous workup has not been performed. 7. Small pericardial effusion. RECOMMENDATION(S): 1.5 cm cystic lesion in the uncinate process of the pancreas. Recommend nonemergent MRCP if previous workup has not been performed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. amLODIPine 5 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Cerovite Advanced Formula (multivitamin-iron-folic acid) ___ mg-mcg oral daily 5. Cranberry Concentrate (cranberry conc-ascorbic acid;<br>cranberry extract) 500 mg oral daily 6. Finasteride 5 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Hydrochlorothiazide 25 mg PO DAILY 9. Levothyroxine Sodium 50 mcg PO DAILY 10. PredniSONE 2.5 mg PO DAILY 11. Sertraline 150 mg PO DAILY 12. Cyanocobalamin 500 mcg PO DAILY 13. Vitamin D 1000 UNIT PO DAILY 14. Warfarin 3.75 mg PO DAILY16 15. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 16. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 17. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 18. LORazepam 0.5 mg PO Q6H:PRN anxiety 19. Oxybutynin 5 mg PO BID PRN bladder spasms 20. Epoetin ___ ___ u SC WEEKLY Discharge Medications: 1. Daptomycin 300 mg IV Q24H urinary tract infection Duration: 7 Days RX *daptomycin 350 mg 300 mg IV q24h Disp #*7 Vial Refills:*0 2. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 3. Piperacillin-Tazobactam 4.5 g IV Q12H RX *piperacillin-tazobactam 4.5 gram 4.5 grams IV every 12 hours Disp #*15 Vial Refills:*0 4. amLODIPine 10 mg PO DAILY 5. Warfarin 5 mg PO DAILY16 6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 7. Allopurinol ___ mg PO DAILY 8. Cerovite Advanced Formula (multivitamin-iron-folic acid) ___ mg-mcg oral daily 9. Cranberry Concentrate (cranberry conc-ascorbic acid;<br>cranberry extract) 500 mg oral daily 10. Cyanocobalamin 500 mcg PO DAILY 11. Epoetin ___ ___ u SC WEEKLY 12. Finasteride 5 mg PO DAILY 13. FoLIC Acid 1 mg PO DAILY 14. Hydrochlorothiazide 25 mg PO DAILY 15. Levothyroxine Sodium 50 mcg PO DAILY 16. LORazepam 0.5 mg PO Q6H:PRN anxiety 17. Oxybutynin 5 mg PO BID PRN bladder spasms 18. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 19. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 20. PredniSONE 2.5 mg PO DAILY 21. Sertraline 150 mg PO DAILY 22. Vitamin D 1000 UNIT PO DAILY 23. HELD- Atorvastatin 20 mg PO QPM This medication was held. Do not restart Atorvastatin until you have completed daptomycin Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Pyelonephritis, Catheter associated UTI 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: ___ year old man with h/o chronic L PCN admitted with bil pyelonephritis (L>R)// replacement of L PCN TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 50mcg of fentanyl and 1 mg of midazolam throughout the total intra-service time of 9 during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: CONTRAST: 10 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 0.7 min, 10 mGy PROCEDURE: 1. Left diagnostic nephrostogram. 2. 8.5 ___ nephrostomy exchange. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed lateral decubitus 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. Diluted contrast was injected into the nephrostomy on the left to confirm catheter position. The image was stored on PACS. Local anesthesia was administered with instillation of lidocaine jelly and 1% subcutaneous lidocaine injection. The catheter was cut. A ___ wire was advanced into the left nephrostomy and advanced into the distal ureter. The stay sutures were cut and the catheter was removed over the wire. A new 8.5 ___ nephrostomy was flushed and advanced with its plastic stiffener over the wire into appropriate position. The wire and stiffener were removed and the pigtail was formed. Contrast injection confirmed appropriate positioning. The final image was saved. The catheter was then flushed, stay sutures applied and the catheter was secured with a Stat Lock device and sterile dressings. The nephrostomy was attached to a bag for drainage. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: Moderate left hydronephrosis IMPRESSION: Successful exchange of a 8.5 ___ nephrostomy on the left. Radiology Report EXAMINATION: CT abdomen and pelvis without contrast INDICATION: ___ with L PCN placement? PCN placement ? nephrolithiasis TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered.Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 1,279 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: There is trace dependent atelectasis bilaterally. Otherwise, visualized lung fields are within normal limits. There is a small pericardial effusion. Aortic annulus and coronary artery calcifications are noted. There is no evidence of pleural effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of concerning focal lesions within the limitations of an unenhanced scan. A subcentimeter hypodensities seen in the peripheral right hepatic lobe, likely a hepatic cyst or biliary hamartoma (2; 35). There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains gallstones without wall thickening or evidence of inflammation. PANCREAS: The pancreas is mildly atrophic. A 1.5 x 1.4 cm cystic lesion is seen in the uncinate process and is not fully characterized on this exam (2; 44). 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. There is no evidence of focal renal lesions within the limitations of an unenhanced scan. There is no hydronephrosis. Punctate renal stones are seen in the left kidney. A percutaneous nephrostomy tube is seen within the renal pelvis. There is bilateral perinephric stranding, which extends to surround bilateral proximal ureters. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening and fat stranding. There is distal constipation with perirectal fat stranding. The appendix is normal. Calcified peritoneal mice are seen in the abdomen (2; 67). PELVIS: The urinary bladder wall appears thickened which may be secondary to underdistention. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions. The patient is status post posterior spinal fusion extending from L3-L5. Degenerative changes are seen throughout the thoracolumbar spine. A fixation rod is seen within the left femur stabilizing a femoral neck fracture. A chronic appearing right rib deformity is seen. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Percutaneous nephrostomy tube is seen in the left renal pelvis. 2. Punctate nonobstructing left renal stones. No hydronephrosis. 3. Bilateral perinephric stranding is nonspecific, but can be seen in the setting of infection recommend correlation with urinalysis. 4. Thickened urinary bladder, may be due to underdistention, however recommend correlation with urinalysis. 5. Cholelithiasis without evidence of acute cholecystitis. 6. 1.5 cm cystic lesion in the uncinate process of the pancreas. Recommend nonemergent MRCP if previous workup has not been performed. 7. Small pericardial effusion. RECOMMENDATION(S): 1.5 cm cystic lesion in the uncinate process of the pancreas. Recommend nonemergent MRCP if previous workup has not been performed. Gender: M Race: WHITE - EASTERN EUROPEAN Arrive by AMBULANCE Chief complaint: Dysuria Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic temperature: 97.4 heartrate: 46.0 resprate: 18.0 o2sat: 99.0 sbp: 163.0 dbp: 65.0 level of pain: 7 level of acuity: 3.0
Dear Mr. ___, It was a pleasure to look after you. As you know, you were admitted with flank pain and signs of kidney infection on a CT scan. You were initially placed on intravenous antibiotics; both catheters (foley and nephrostomy tube) were exchanged. Urine cultures grew out a resistant pseudomonas, and for that reason, infectious disease team was consulted and made recommendations regarding changes in the antibiotic. You will be on Daptomycin and Zosyn through ___. Please do not take your atorvastatin until you complete the daptomycin to prevent a possible reaction. Given elevated blood pressures in the hospital, your amlodipine dose was increased to 10mg daily. Please take your medications as prescribed and follow up with your outpatient doctors as below. With best wishes, ___ Medicine
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Percocet / Codeine Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization and deployment of a drug-eluting stent in the high ___ diagonal branch History of Present Illness: ___ with Type 2 diabetes mellitus complicated by neuropathy, prior strokes and ___ transferred from ___ with troponin 0.04, ? evolving ST changes in V2-V3 increasing in the setting of increasing chest pain with concern for NSTEMI. Patient's outside labs were significant for Hct 21, hypokalemia and hypocalcemia. Patient was given ASA and pRBCs and was guaiac negative. Patient is wheelchair bound at baseline with many prior strokes. The patient's most recent coronary angiography was at ___ which was done after a negative ETT. He had only one 50% LAD lesion. Patient presented with intermittent chest pain since the night before Qunicy admission, which became persistent in AM, so he was brought to QH by EMS. There was no report of dyspnea or cough. Initial troponin was 0.048, Ca 5.5, alb 1.9, Hct 21.1. CXR was unremarkable. Per QH notes, he had minimal EKG changes compared with prior and was pain free in their ED. It was decided to transfer the patient to ___ for possible coronary angiography. In the ___ ED, initial VS were pain scale 6 T 97.8 HR 67 BP 138/114 RR 17 SaO2 100%. CXR showed new perihilar fullness with Kerley B lines. Labs were significant for Hct 34 here (was 20 at ___). His troponin-T was 0.08 and he was guaiac negative. He was started on a nitro drip but per ED, was "pain free when no one in room". VS on transfer: T 98.2 HR 73 BP 147/79 RR 16 SaO2 100%. On transfer from ED, patient noted to still have ___ chest pain. Past Medical History: # Diabetes mellitus, type II with Peripheral Neuropathy # Hypertension # Hypercholesterolemia # HCV # Sleep apnea # Erectile dysfunction # Anxiety # Depression # Multiple strokes (4 per fiance) Social History: ___ Family History: # Mother died age ___: No known illnesses # Father die age ___: Possible homicide # 6 Sisters, 3 Brothers: DM2, cancer of unknown primary Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: uncomfortable appearing middle aged ___ man VS: T 98 BP 144/91 HR 77 RR 20 SaO2 98% on 2 Lpm HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM NECK: supple, no LAD LUNGS: anterior lung exam unremarkable HEART: RRR; nl S1-S2; no murmurs, rubs or gallops ABDOMEN: normal bowel sounds, soft, non-tender, non-distended, no rebound or guarding, no masses EXTREMITIES: no edema, 2+ pulses radial and DP NEURO: awake, speech pressured, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric DISCHARGE PHYSICAL EXAM: VS: T 98.0, BP 145/79, HR 63, RR 18, SaO2 99% on RA I/O: 2263/725+ Wt: wt not recorded <-70.5 <-71.8<-72.6 GENERAL: NAD, awake, alert HEENT: NC/AT, sclerae anicteric NECK: supple, no JVD LUNGS: CTAB HEART: RRR, nl S1-S2; no murmurs, rubs or gallops ABDOMEN: normal bowel sounds, soft, non-tender, non-distended, no rebound or guarding, no masses EXTREMITIES: no edema Pertinent Results: ADMISSION LABS: ___ 07:45PM WBC-7.8 RBC-4.03* HGB-11.5* HCT-34.7* MCV-86 MCH-28.7 MCHC-33.2 RDW-14.0 ___ 07:45PM GLUCOSE-113* UREA N-20 CREAT-1.5* SODIUM-139 POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-20* ANION GAP-15 ___ 07:45PM CK-MB-6 cTropnT-0.08* ECG ___ 6:31:04 ___ Normal sinus rhythm. Intra-atrial conduction defect. Diffuse T wave flattening. Since the previous tracing of ___ T waves are slightly more flat. IMAGING STUDIES: - CXR (___) The heart is normal in size. The mediastinal and hilar contours appear within normal limits. There is new perihilar fullness with indistinct pulmonary vascularity and an interstitial abnormality, including ___ B lines at the lung bases, most consistent with mild to moderate pulmonary vascular congestion. No discrete focal opacity is otherwise identified. - Echocardiogram (___) The left atrium is elongated. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild mitral regurgitation with normal valve morphology. Pulmonary artery hypertension. Cardiac catheterization (___): - Hemodynamics: Mild-moderate elevated left-sided filling pressures (LVEDP ___ mmHg) - Coronary angiography: right dominant - LMCA: Large vessel with distal plaque (30%) extending into the LAD origin. - LAD: Mild luminal irregularities. The origin has a 30% lesion (an extension of the distal LM plaque) and the mid segment is tortuous with ___ plaque at the takeoff of the diseased high D1. The high D1 is a large bifurcating vessel (functionally ramus) with 90% ostial lesion. The LAD gives several small distal diagonal branches that are patent. - LCX: Retroflexed with mild luminal irregularities and focal 30% mid vessel lesion. The "high" OM1 a small diameter but bifurcating vessel. The OM2 and OM3 are patent. - RCA: Difficult to engage selectively. Subselective injection with AR1 diagnostic catheter showed a dominant vessel with tortuous mid segment with tubular 50% lesion. - Interventional details - Change for ___ R radial sheath. AC with UFH and several boluses were administered. ___ XB LAD 3.5 guide provided good support throughout the case. Crossed with Prowater with ease and predilated with 2.0x12 mm RX Sprinter balloon. We then decided to pass another wire into the LAD given the presence of disease at the diag takeoff. At this point, a 2.75x12 mm Resolute drug-eluting stent was deployed at 9 ATM with complete balloon expansion. Final angiography showed excellent result with 0% residual stenosis and no angiographically-apparent impingement on the LAD whatsoever. - CT HEAD W/O CONTRAST (___) Small foci of encephalomalacia noted in the right cerebellum, pons and the right basal ganglia indicative of prior infarct. There is no hemorrhage, edema, mass effect or acute large territory infarct. Significant prominence of the ventricles and sulci is suggestive of global atrophy. Periventricular and subcortical white matter hypodensities are compatible with chronic small vessel ischemic disease. The basal cisterns are patent and there is preservation of gray-white matter differentiation. No fracture is identified. The visualized paranasal sinuses, middle ear cavities and mastoid air cells are clear. The globes are intact. Atherosclerotic mural calcifications are noted in the carotid siphons. IMPRESSION: No acute intracranial process. DISCHARGE LABS: ___ 06:00AM BLOOD ___-7.3 RBC-3.90* Hgb-11.0* Hct-33.8* MCV-87 MCH-28.2 MCHC-32.6 RDW-13.6 Plt ___ ___ 06:00AM BLOOD Glucose-96 UreaN-20 Creat-1.8* Na-141 K-3.9 Cl-114* HCO3-20* AnGap-11 ___ 06:00AM BLOOD Calcium-8.3* Phos-4.3 Mg-1.9 ___ 06:00AM BLOOD cTropnT-0.38* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H 2. Amlodipine 10 mg PO DAILY 3. Aspirin 325 mg PO DAILY 4. CloniDINE 0.1 mg PO TID 5. Carvedilol 12.5 mg PO BID 6. Docusate Sodium 100 mg PO BID 7. FoLIC Acid 1 mg PO DAILY 8. Gabapentin 100 mg PO TID 9. HydrALAzine 50 mg PO TID 10. Glargine 23 Units Bedtime novolog 5 Units Breakfast novolog 5 Units Lunch Insulin SC Sliding Scale using Lispro Insulin 11. LeVETiracetam Oral Solution 750 mg PO BID 12. Lisinopril 40 mg PO DAILY 13. Enoxaparin Sodium 40 mg SC DAILY 14. Paroxetine 10 mg PO DAILY 15. Potassium Chloride 10 mEq PO DAILY 16. traZODONE 25 mg PO QAM; Please give at 8am 17. traZODONE 25 mg PO QPM; PLease give at 2pm 18. traZODONE 50 mg PO HS; Please give at 8:30pm 19. Prazosin 1 mg PO BID 20. Ranitidine 150 mg PO BID 21. Simvastatin 80 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H 2. Amlodipine 10 mg PO DAILY 3. Aspirin 325 mg PO DAILY 4. Carvedilol 12.5 mg PO BID 5. CloniDINE 0.1 mg PO TID 6. Docusate Sodium 100 mg PO BID 7. FoLIC Acid 1 mg PO DAILY 8. Gabapentin 100 mg PO TID 9. HydrALAzine 50 mg PO TID 10. LeVETiracetam Oral Solution 750 mg PO BID 11. Lisinopril 40 mg PO DAILY 12. Paroxetine 10 mg PO DAILY 13. Prazosin 1 mg PO BID 14. Ranitidine 150 mg PO BID 15. traZODONE 25 mg PO QAM 16. traZODONE 25 mg PO QPM 17. traZODONE 50 mg PO HS 18. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 19. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 20. Glargine 23 Units Bedtime novolog 5 Units Breakfast novolog 5 Units Lunch Insulin SC Sliding Scale using Lispro Insulin 21. Potassium Chloride 10 mEq PO DAILY 22. Loperamide 4 mg PO QID:PRN diarrhea 23. Psyllium 1 PKT PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Non-ST segment myocardial infarction Secondary: Coronary artery disease Hypertension Diabetes mellitus, type II, with neuropathy Prior cerebrovascular accidents Gastroesophageal reflux disorder Anxiety Depression Seizure disorder Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPHS HISTORY: Chest pain. COMPARISONS: ___. TECHNIQUE: Chest, portable AP upright. FINDINGS: The heart is normal in size. The mediastinal and hilar contours appear within normal limits. There is new perihilar fullness with indistinct pulmonary vascularity and an interstitial abnormality, including ___ B lines at the lung bases, most consistent with mild to moderate pulmonary vascular congestion. No discrete focal opacity is otherwise identified. IMPRESSION: Findings suggesting vascular congestion. Radiology Report HISTORY: Multiple CVAs. Here for NSTEMI with unwitnessed fall last night. TECHNIQUE: Contiguous axial MDCT images were obtained of the head without contrast. Multiplanar reformatted images were generated in the coronal and sagittal planes as well as thin section bone algorithm images. DLP: 891.93 mGy-cm. COMPARISON: MR head ___. FINDINGS: Small foci of encephalomalacia noted in the right cerebellum, pons and the right basal ganglia indicative of prior infarct. There is no hemorrhage, edema, mass effect or acute large territory infarct. Significant prominence of the ventricles and sulci is suggestive of global atrophy. Periventricular and subcortical white matter hypodensities are compatible with chronic small vessel ischemic disease. The basal cisterns are patent and there is preservation of gray-white matter differentiation. No fracture is identified. The visualized paranasal sinuses, middle ear cavities and mastoid air cells are clear. The globes are intact. Atherosclerotic mural calcifications are noted in the carotid siphons. IMPRESSION: No acute intracranial process. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: CP, +NSTEMI Diagnosed with CHEST PAIN NOS temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0
Dear Mr. ___, You were admitted to ___ treatment and work-up of your chest pain. While you were here you were found to have elevated cardiac enzymes and changes in your EKG which were concerning for a type of heart attack called Non-ST segment myocardial infarction (NSTEMI). While you were here you underwent a cardiac cath, which showed that you have a blockage in one of your vessels in your heart. You had a stent placed in this vessel to help open it up. Also, while you were here you had an unwitnessed fall. You had a head CT scan which did not show any acute damage to your head from the fall.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ man with a history of HTN, newly diagnosed with a T9 compression fracture that was biopsied on ___, revealing plasma cell neoplasm CD138+ and kappa LC restricted. He started XRT to T9 on ___, and saw Dr. ___ primary oncologist at ___, where he had a bone marrow on ___ that revealted 10% plasma cells. He was started on Zometa, and referred to ___ for a ___ opinion for systemic treatment. Since his XRT, he has had increasing abdominal pain. He was admitted to Mr. ___ on ___, where EGD revealed mild gastritis and mild edema of the GE junction. He was treated with Dilaudid, and his Fentanyl patch ws increased. He was discharged on ___, and presented for his initial visit with Dr. ___ & Dr. ___ that day. Due to severe stress and pain, he was admitted for further evaluation. In the ED, he continued to have bad epigastric pain. U/S appendix was concerning for appendicitis, and CT abdomen/pelvis showed dilated appendix without surrounding inflammation. General surgery was consulted, and determined there was no role for surgical intervention. Labs showed normal white count, Hgb 13.3, platelets 146. Chem 7 wnl. AST 41, ALT 77, otherwise LFTs also wnl. On arrival to the floor, he reports worsening epigastric pain. Pain is worse after eating, and better after taking pain medications. He had some abdominal pain since starting XRT, but this has intensified over the past 2 weeks, and greatly increased within the past 2 days. He has also had decreased appetite, but denies nausea, vomiting, fevers, chills, or diarrhea. Last bowel movement was 2 days ago. ROS + weight loss 40 lbs since ___ point ROS reviewed in detail and negative except for what is mentioned above in HPI Past Medical History: PAST ONCOLOGIC HISTORY: - ___: biopsy of T9 compresion fracture revealed plasma cell neoplasm CD138+ and kappa LC restricted - ___: started XRT to T9 - ___: bone marrow biopsy showed 10% plasma cells, started on Zometa - ___: initial appointment with Dr. ___ & Dr. ___, admitted to ___ for epigastric pain PAST MEDICAL HISTORY: HTN PAST SURGICAL HISTORY: cholecystectomy ___ years ago Social History: ___ Family History: Brother with type 2 diabetes. maternal ___ cousin: breast cancer. Brother with prostate cancer. Sister with uterine cancer. Physical Exam: ADMISSION PHYSICAL EXAM: ========================= Vitals: Tc 99.2 Tm 99.2 BP 125/65 HR 91 RR 16 SaO2 97% ra General: NAD, Resting in bed comfortably HEENT: MMM, no OP lesions, no cervical/supraclavicular adenopathy CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, mildly distended, epigastric tenderness, no r/g LIMBS: WWP, no ___, no tremors SKIN: No rashes on the extremities NEURO: Grossly normal LABORATORY ANALYSIS: Reviewed in EMR DISCHARGE PHYSICAL EXAM: ========================= Vitals: Tm 99 Tc 97.5 HR 92 BP ___ RR 18 SaO2 98% ra General: NAD, lying down comfortably HEENT: MMM, no OP lesions, no cervical/supraclavicular adenopathy CV: regular rate and rhythm, S1S2 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, mildly distended, mild tenderness on epigastric region SPINE:tender to palpation along T9 dermatome from spine, LIMBS: no lower extremity edema SKIN: No rashes noted NEURO: CN grossly intact. Pertinent Results: ADMISSION LABS: ___ 03:05PM BLOOD WBC-8.3 RBC-4.22* Hgb-13.3* Hct-39.3* MCV-93 MCH-31.5 MCHC-33.8 RDW-13.3 RDWSD-45.2 Plt ___ ___ 03:05PM BLOOD Neuts-74.3* Lymphs-9.5* Monos-13.3* Eos-1.9 Baso-0.5 Im ___ AbsNeut-6.16* AbsLymp-0.79* AbsMono-1.10* AbsEos-0.16 AbsBaso-0.04 ___ 03:05PM BLOOD ___ PTT-34.6 ___ ___ 03:05PM BLOOD UreaN-14 Creat-0.8 Na-138 K-4.8 Cl-102 HCO3-26 AnGap-15 ___ 03:05PM BLOOD estGFR-Using this ___ 03:05PM BLOOD ALT-77* AST-41* LD(LDH)-177 AlkPhos-84 TotBili-0.5 ___ 09:45PM BLOOD Lipase-45 ___ 03:05PM BLOOD TotProt-7.4 Albumin-4.1 Globuln-3.3 Calcium-9.2 Mg-2.4 ___ 03:05PM BLOOD PEP-AWAITING F ___ FreeLam-13.3 Fr K/L-1.41 b2micro-1.6 IgG-1280 IgA-240 IgM-58 IFE-PND ___ 09:50PM BLOOD Lactate-1.0 DISCHARGE LABS: ___ 07:45AM BLOOD WBC-3.8* RBC-3.90* Hgb-12.1* Hct-34.9* MCV-90 MCH-31.0 MCHC-34.7 RDW-12.7 RDWSD-41.9 Plt ___ ___ 07:45AM BLOOD Neuts-61.1 Lymphs-17.6* Monos-15.2* Eos-4.5 Baso-0.8 Im ___ AbsNeut-2.33 AbsLymp-0.67* AbsMono-0.58 AbsEos-0.17 AbsBaso-0.03 ___ 07:45AM BLOOD Plt ___ ___ 07:45AM BLOOD Glucose-103* UreaN-13 Creat-0.7 Na-137 K-4.3 Cl-101 HCO3-28 AnGap-12 ___ 07:45AM BLOOD ALT-50* AST-31 LD(LDH)-131 AlkPhos-92 TotBili-0.4 ___ 07:45AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.3 IMAGING: ___ CT Chest: 1. Nonspecific ill-defined perigastric fat stranding posterior to the left liver lobe at the level of the GE junction appears unchanged from ___. Again, this may reflect gastritis. Proximally the esophagus appears unremarkable. 2. Relative regional hypodensity of the left hepatic lobe is unchanged, and may reflect sequela of prior radiation treatment. Multiple hepatic hypodensities measuring up to 1.3 cm are stable, and likely represents cyst or biliary hamartomas. 3. Vertebral plana of T9 and lytic lesion in the inferior endplate of T8 again seen. ___ MRI T spine: Multiple osseous lesions, likely secondary to multiple myeloma. 2. Pathologic fracture at T9 leading to vertebra plana and associated spinal canal and neural foramen stenosis causing impingement of T10 nerve root. 3. Postradiation changes involving T6- T11 vertebral bodies with fatty infiltration. US APPENDIX ___ Dilated 11 mm, noncompressible appendix in the right lower quadrant. In the correct clinical setting, findings suggest appendicitis. CT ABD/PELVIS ___ 1. Fat stranding at the level of the GE junction likely reflects gastritis seen on the EGD from the outside hospital. This could also be non-specific change from prior radiation therapy. The stomach itself is not well distended, limiting evaluation. 2. The appendix is dilated to 10 mm, although without adjacent fat stranding or fluid collection. Oral contrast fills the cecum, but not the appendix. While outside hospital images are not available for review, based on the outside hospital report, today's appearance of the appendix is presumed to be similar to the scan from 3 days prior. 3. Known multifocal lytic lesions of T8, L4, and the left iliac bone, compatible with known history of multiple myeloma. Near complete collapse of the T9 vertebral body was also identified on the prior study. MRI T-SPINE ___. Multiple osseous lesions, likely secondary to multiple myeloma. 2. Pathologic fracture at T9 leading to vertebra plana and associated spinal canal and neural foramen stenosis causing impingement of T10 nerve root. 3. Postradiation changes involving T6- T11 vertebral bodies with fatty infiltration. CT CHEST ___. Nonspecific ill-defined perigastric fat stranding posterior to the left liver lobe at the level of the GE junction appears unchanged from ___. Again, this may reflect gastritis but appears to be within the radiation treatment field. Proximally the esophagus appears unremarkable. 2. Relative regional hypodensity of the left hepatic lobe is unchanged, and likely reflects sequela of radiation treatment. Multiple hepatic hypodensities measuring up to 1.3 cm are stable, and likely represents cyst or biliary hamartomas. 3. Vertebral plana of T9 and lytic lesion in the inferior endplate of T8 again seen OSH IMAGING CT ABD/PELVIS ___ 1. Apparent appendiceal wall thickening with an appendiceal diameter of up to 8 mm. No evidence of periappendiceal stranding, abscess, or fluid collection. These findings are new when compared to the PET/CT of ___ and could be seen in chronic inflammation of the appendix but equivocal for acute appendicitis. If the patient has continue pain or develops sign of infection, consider a repeat abdominal CT to reassess. 2. Distal and sigmoid colon diverticulosis. No evidence of enteritis or colitis. 3. Multifocal lucent lytic lesions involving T8, T9, L4, and left iliac bone, unchanged from a PET/CT study of ___, ___ PET Impression: Moderately hypermetabolic lytic lesion in the T9 vertebra, known to represent a plasma cell neoplasm. Lucent 1.2 cm lesion in the right L4 vertebral body and a 0.3 cm focus in the left iliac crest are suspicious but do not demonstrate striking hypermetabolism, possibly due to their small size. Mottled, mildly increased hypermetabolism is present in the lumbar vertebrae and in the proximal more so than distal femurs without corresponding lytic lesions is of uncertain significance but could represent low grade disease or hyperplastic marrow. ___ MRI spine: 1) ___ compression fracture of T9. 2) Nondisplaced vertical fracture through the right lamina of T9-T10. 3) Focal ____ at T8-T9 which is superimposed on the posterior buckling of T9. PATHOLOGY: ___. CT guided core bx T9 mass: *** CONSISTENT WITH INVOLVEMENT BY A PLASMA CELL NEOPLASM, CORE BIOPSY REVEALS ABUNDANT PLASMA CELLS STAINING POSITIVELY FOR CD138 AND KAPPA LIGHT-CHAIN RESTRICTED. ___ BONE MARROW ASPIRATE SMEAR PREPARATIONS ARE DILUTE WITH PERIPHERAL BLOOD BUT SHOW MATURING HEMATOPOIETIC ELEMENTS AND SOME SCATTERED PLASMA CELLS. BONE MARROWS CORE BIOPSY AND CLOT SECTIONS (H/E AND PAS): HYPERCELLULAR FOR AGE MARROW,65-75%. PATCHY INFILTRATE OF PLASMA CELLS, SINGLE AND FOCALLY IN CLUSTERS OF UP TO ___ CELLS, ARE ESTIMATED AT APPROXIMATELY 10% CELLULARITY; ATYPICAL NUCLEOLATED FORMS ARE PRESENT (CD138; BIOPSY AND CLOT SECTIONS); BOTH KAPPA AND LAMBDA EXPRESSING PLASMA CELLS ARE PRESENT WITH PREDOMINANCE OF KAPPA POSITIVE CELLS (KAPPA AND LAMBDA). LYMPHOCYTES ARE LESS THAN 5-8% CELLULARITY WITH PREDOMINANCE OF T OVER B CELLS (CD3, CD20). -FLOW CYTOMETRY PROVIDED THE FOLLOWING RESULTS: (SEE ATTACHED REPORT FROM AMERIPATH) THE FINDINGS PROVIDE NO IMMUNOPHENOTYPIC EVIDENCE OF ACUTE LEUKEMIA, A T-CELL OR B-CELL NEOPLASM, OR PLASMA CELL NEOPLASIA. NORMAL KARYOTYPE. -FISH ANALYSIS" NEGATIVE STUDY FOR ALL PROBES EXAMINED. IMPRESSION: - INVOLVEMENT BY A PLASMA CELLS NEOPLASM, PLASMA CELLS APPROXIMATELY 10%, NUCLEOLATED FORMS PRESENT. STUDIES: EGD ___ Dr. ___ at ___ Esophagus: Mild edema at the GE Junction, biopsies obtained. Stomach: Mild gastritis characterized by faint scattered erythema. Duodenum: The duodenum appeared to be normal. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 500 mg PO Q6H:PRN pain 2. Lisinopril 5 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Senna 8.6 mg PO QHS 5. Ranitidine 75 mg PO DAILY 6. Fentanyl Patch 75 mcg/h TD Q72H 7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain 8. Sucralfate 1 gm PO DAILY:PRN pain Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN pain RX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 3. Fentanyl Patch 75 mcg/h TD Q72H RX *fentanyl 75 mcg/hour Apply every 72 hours Disp #*10 Patch Refills:*0 4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every three (3) hours Disp #*90 Tablet Refills:*1 5. Ranitidine 75 mg PO DAILY RX *ranitidine HCl 75 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 6. Senna 8.6 mg PO QHS 7. Amoxicillin 1000 mg PO Q12H Duration: 14 Days RX *amoxicillin 500 mg 2 tablet(s) by mouth every twelve (12) hours Disp #*50 Tablet Refills:*0 8. Clarithromycin 500 mg PO Q12H Duration: 14 Days RX *clarithromycin 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*24 Tablet Refills:*0 9. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #*90 Capsule Refills:*0 10. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Abdominal pain due to T9 Lesion H.pylori/gastritis Multiple myeloma Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ with concern for appy on US, abd pain in RUQ. Evaluate for appendicitis. TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. IV Contrast: 130 mL Omnipaque. Coronal and sagittal reformations were performed and reviewed on PACS. Oral contrast was administered. DOSE: Total DLP (Body) = 671 mGy-cm. COMPARISON: Only the report of the outside hospital CT abdomen pelvis from ___ is available. No images from this study are available for comparison. FINDINGS: LOWER CHEST: There is mild bibasilar dependent atelectasis, but no pleural effusions. ABDOMEN: HEPATOBILIARY: A 1.4 cm and 0.9 cm left hepatic lobe hypodensities were described on the outside hospital as stable, likely hepatic cysts. Multiple other right hepatic lobe subcentimeter hypodensities are too small to characterize, but are also unchanged. Relative regional hypodensity of the left hepatic lobe is likely due to differential perfusion, as described on the prior study. There is no evidence of new focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. A small accessory spleen is identified (2:22). ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: There is nonspecific ill-defined perigastric fat stranding posterior to the left liver lobe at the level of the GE junction (___), which may reflect gastritis seen on EGD from the outside hospital. The stomach itself is not well distended, therefore limiting evaluation. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening and fat stranding. There is appendiceal wall thickening to approximately 1.0 cm (02:59), although without periappendiceal stranding or fluid collection. Oral contrast fills the cecum, but not the appendix. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Prostate is enlarged, with small calcifications, likely due to prior inflammation. 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 AND SOFT TISSUES: Near complete collapse of the T9 vertebral body, as described on the prior study, is identified. Known lytic lesions at the inferior T8 and L4 vertebral bodies, and left iliac bone, are also seen. Retrolisthesis of L5 on S1 is also present, with endplate sclerosis and vacuum disc phenomenon at that level. Small amount of fat seen in the bilateral inguinal canals. IMPRESSION: 1. Fat stranding at the level of the GE junction likely reflects gastritis seen on the EGD from the outside hospital. This could also be non-specific change from prior radiation therapy. The stomach itself is not well distended, limiting evaluation. 2. The appendix is dilated to 10 mm, although without adjacent fat stranding or fluid collection. Oral contrast fills the cecum, but not the appendix. While outside hospital images are not available for review, based on the outside hospital report, today's appearance of the appendix is presumed to be similar to the scan from 3 days prior. 3. Known multifocal lytic lesions of T8, L4, and the left iliac bone, compatible with known history of multiple myeloma. Near complete collapse of the T9 vertebral body was also identified on the prior study. NOTIFICATION: The above findings were communicated in person by Dr. ___ to Dr. ___ resident) at 06:55 on ___. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old man with MM s/p XRT to T9 in ___, p/w 1 week worsening epigastric pain in setting of 2 months epigastric pain // Any changes from MM or radiation to explain acute on chronic epigastric pain? TECHNIQUE: Multidetector helical scanning of the chest was performed without intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images. DOSE: Total DLP (Body) = 205 mGy-cm. COMPARISON: CT abdomen pelvis dated ___. FINDINGS: MEDIASTINUM: The imaged thyroid is normal. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. Partially calcified small mediastinal and hilar lymph nodes are present. The aorta and pulmonary arteries are normal in size. There is a bovine aortic arch (normal variant, common origin of the innominate artery and left common carotid). The heart size is normal and there is no pericardial effusion. PLEURA: There is no pneumothorax. There is no pleural effusion. LUNGS: The airways are patent. There is discoid lingular atelectasis and lingular and mild right middle lobe atelectasis. A punctate pulmonary nodule is seen in the right lower lobe (5:159). BONES: There is vertebral plana of the T9 vertebral body. Unchanged appearance of lytic lesion at the inferior T8 vertebral body. Healed left lateral fifth and sixth rib fractures. UPPER ABDOMEN: This study is not tailored to evaluate the abdomen. Relative regional hypodensity of the left hepatic lobe is unchanged, and likely reflects sequela of radiation treatment. Multiple hepatic hypodensities measuring up to 1.3 cm appear unchanged, and likely represent cysts or biliary hamartomas. Note is made of a small accessory spleen. Nonspecific ill-defined perigastric fat stranding posterior to the left liver lobe at the level of the GE junction appears unchanged from a CT abdomen pelvis dated ___. Proximally the esophagus is unremarkable. IMPRESSION: 1. Nonspecific ill-defined perigastric fat stranding posterior to the left liver lobe at the level of the GE junction appears unchanged from ___. Again, this may reflect gastritis but appears to be within the radiation treatment field. Proximally the esophagus appears unremarkable. 2. Relative regional hypodensity of the left hepatic lobe is unchanged, and likely reflects sequela of radiation treatment. Multiple hepatic hypodensities measuring up to 1.3 cm are stable, and likely represents cyst or biliary hamartomas. 3. Vertebral plana of T9 and lytic lesion in the inferior endplate of T8 again seen. Radiology Report EXAMINATION: MR ___ ANDW/O CONTRAST ___ MR SPINE INDICATION: ___ year old man with newly diagnosed MM, s/p XRT to ___, w/ epigastric pain x 2 months, worsening epigastric pain x 1 week // Any signs of MM or radiation changes that could explain epigastric pain that radiates in T9 distribution? TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. This was followed by sagittal and axial T1 images obtained after the uneventful intravenous administration of 8 mL of Gadavist contrast agent. COMPARISON: CT thoracic spine from ___. CT abdomen and pelvis from ___. FINDINGS: There is vertebra plana at T9, unchanged compared to the prior CT from ___ with associated focal kyphosis of the thoracic spine. This is likely secondary to the vertebral body involvement with multiple myeloma and superimposed pathologic fracture. There is associated retropulsion of the fracture fragments posteriorly into the spinal canal causing severe spinal canal stenosis and indentation of the ventral aspect of the spinal cord as seen on image 7:11. There is associated severe narrowing of the left and moderate narrowing of the right T9-T10 neural foramen with impingement of the T10 nerve roots at this level. No focal cord signal abnormality is however seen. There are multiple other lytic lesions involving the visualized thoracic spine, likely secondary to the involvement by multiple myeloma including a lesion along the inferior end plate of T8, a lesion along the posterior aspect of T1 vertebrae measuring approximately 0.9 x 1.2 cm and a lesion along the superior endplate of T12 vertebrae. There is fatty marrow signal involving T6 to the 11 vertebral bodies, likely postradiation in etiology. No cord signal abnormality is seen. No enhancing epidural soft tissue mass is seen. The remaining thoracic spine appears unremarkable. Neural foramen and spinal canal are patent at all other levels. The visualized retroperitoneal, paraspinal and paravertebral soft tissues appear unremarkable. The visualized lung parenchyma appears clear. IMPRESSION: 1. Multiple osseous lesions, likely secondary to multiple myeloma. 2. Pathologic fracture at T9 leading to vertebra plana and associated spinal canal and neural foramen stenosis causing impingement of T10 nerve root. 3. Postradiation changes involving T6- T11 vertebral bodies with fatty infiltration. Gender: M Race: SOUTH AMERICAN Arrive by AMBULANCE Chief complaint: Abd pain Diagnosed with ABDOMINAL PAIN OTHER SPECIED, NAUSEA temperature: 98.1 heartrate: 88.0 resprate: 22.0 o2sat: 99.0 sbp: 132.0 dbp: 74.0 level of pain: 8 level of acuity: 2.0
Dear Mr. ___, It was a pleasure taking care of you. You were admitted to ___ ___ for evaluation and treatment of abdominal pain. While you were here, we performed imaging of your abdomen and spine. This showed a lesion in the T9 bone, which is likely the cause of your pain. We treated you with pain medicines that help neurologic pain and also medicines that decrease inflammation in your stomach. You were treated with antibiotics to treat an infection in your stomach. Please continue these medications (Pantoprazole 40mg po 2/day, Clarithromycin 500mg 2/day, Amoxicillin 1 g 2/day) until ___. It is very important that you attend follow-up appointments and that you take your medicines as prescribed. We wish you the best in the future. Sincerely, Your ___ Care Team
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: FLANK PAIN, ACUTE KIDNEY INJURY, NEPHROLITHIASIS Major Surgical or Invasive Procedure: Right ureteroscopy with laser lithotripsy and placement of a double-J stent. History of Present Illness: ___ w/ known nephrolithiasis history w/ R flank pain and nausea. He notes stubborn pain over recent days culminating in worsening pain today with some associated nausea. ROS demonstrates dysuria. Vital signs within normal limits; patient well-appearing. PE demonstrates no flank pain b/l; minimal abdominal pain. ___ shows no leukocytosis and creatinine to 1.7 from 1.2 (most recent baseline available in computer. ___ from several days ago shows <10K strep species. CTU shows obstructing right ureteral stone at ___ w/ moderate hydronephrosis and some associated perinephric stranding. Past Medical History: ALLERGIC RHINITIS PROSTATISM SLEEP APNEA SLEEP STUDY-DIAGNOSTIC SCIATICA H/O GASTROESOPHAGEAL REFLUX H/O TENDINITIS NEPHROLITHIASIS INSOMNIA HTN HYPERCHOLESTEROLEMIA TRANSURETHRAL PROSTATECTOMY ___ Social History: No tobacco. Social EtOH, no other illicits. He is married and lives at home with his wife. He works for the ___. Married over ___ years; two children. He has one set of twin girl grandchildren. Nonsmoker, may be has three to four drinks a week, has started doing more regular exercise but actually is incredibly active doing all his own yard work everything from mowing lawn to chopping trees and he reports that he feels very well doing that. He actively wears his seat belt. Marital status: Married, # years: ___ Children: Yes: 2 Lives with: ___ Lives in: House Work: ___ Multiple partners: ___ ___ activity: Past and Present Sexual orientation: Female Sexual Abuse: Denies Domestic violence: Denies Contraception: N/A Tobacco use: Never smoker Alcohol use: Past and Present drinks per week: ___ Recreational drugs Denies Depression: Based on a PHQ-2 evaluation, the patient does not report symptoms of depression Exercise: None Seat belt/vehicle Always restraint use: Family History: Significant for hypertension and a CVA in father. Physical Exam: WDWN, NAD, AVSS Abdomen soft, non-distended Bilateral lower extremities w/out edema, pitting or pain to deep palpation of calves Pertinent Results: ___ 06:45AM BLOOD WBC-6.4 RBC-4.51* Hgb-12.5* Hct-36.9* MCV-82 MCH-27.7 MCHC-33.9 RDW-13.1 Plt ___ ___ 02:30PM BLOOD WBC-8.7 RBC-5.29 Hgb-14.9 Hct-43.7 MCV-83 MCH-28.2 MCHC-34.2 RDW-13.5 Plt ___ ___ 02:30PM BLOOD Neuts-77.6* Lymphs-15.5* Monos-6.0 Eos-0.3 Baso-0.6 ___ 06:45AM BLOOD Glucose-112* UreaN-25* Creat-1.5* Na-140 K-4.5 Cl-107 HCO3-27 AnGap-11 ___ 02:30PM BLOOD Glucose-122* UreaN-28* Creat-1.7* Na-140 K-4.6 Cl-103 HCO3-26 AnGap-16 ___ 02:30PM BLOOD Lactate-1.2 ___ 06:40PM URINE Color-DKAMB Appear-Clear Sp ___ ___ 01:45PM URINE Color-DKAMB Appear-Clear Sp ___ ___ 06:40PM URINE Blood-NEG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-5.5 Leuks-NEG ___ 01:45PM URINE Blood-SM Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG ___ 06:40PM URINE RBC-1 WBC-0 Bacteri-FEW Yeast-NONE Epi-0 ___ 01:45PM URINE RBC-9* WBC-2 Bacteri-FEW Yeast-NONE Epi-<1 ___ 01:45PM URINE CastGr-3* ___ 06:40PM URINE Mucous-OCC ___ 01:45PM URINE Mucous-FEW ___ 2:30 pm BLOOD CULTURE Blood Culture, Routine (Pending): NGTD at time of dictation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Gabapentin 300 mg PO QHS 3. Lorazepam 1 mg PO QHS:PRN insomnia 4. Ranitidine 75 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. pramipexole 0.25 mg oral QHS 7. Aspirin 81 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days RX *ciprofloxacin HCl 500 mg ONE tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 2. Tamsulosin 0.4 mg PO QHS RX *tamsulosin [Flomax] 0.4 mg ONE capsule(s) by mouth Daily Disp #*30 Capsule Refills:*1 3. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth Q6hrs Disp #*30 Tablet Refills:*0 4. Zofran ODT (ondansetron) 4 mg oral Q8hrs prn nausea RX *ondansetron [Zofran ODT] 4 mg ONE tablet(s) by mouth Q8hrs Disp #*21 Tablet Refills:*0 5. Acetaminophen 325-650 mg PO Q6H:PRN Pain 6. Amitriptyline 25 mg PO HS 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 40 mg PO HS 9. Ibuprofen 600 mg PO Q8H:PRN pain RX *ibuprofen 600 mg ONE tablet(s) by mouth Q8hrs Disp #*30 Tablet Refills:*0 10. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 11. Lisinopril 5 mg PO DAILY 12. Lorazepam 1 mg PO QHS:PRN insomnia 13. pramipexole 0.25 mg oral QHS 14. Ranitidine 75 mg PO DAILY 15. Gabapentin 300 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: ACUTE KIDNEY INJURY (creatinine to 1.7) Right ureteral stone with obstruction and hydronephrosis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: NO65M with renal colic similar to prior episodes with bump in creatinine// CTU. Please evaluate for kindey stones TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired without intravenous contrast administration with the patient in prone position. Coronal and sagittal reformations were performed and reviewed on PACS. No oral contrast was administered. DOSE: DLP: 573.47 mGy-cm COMPARISON: Outside hospital CT abdomen ___, CT abdomen pelvis ___.. FINDINGS: LOWER CHEST: Mild atelectatic changes are present at the lung bases anteriorly. A millimetric nodule at the left lung base is stable since ___, as is a punctate nodule at the right lung base. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits, without stones or gallbladder wall thickening. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: There is moderate right hydronephrosis with perinephric stranding. Right hydroureter is also present, with a 5 mm stone at the right UVJ. The left kidney is unremarkable without hydronephrosis or perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Mild fecal loading is present. Sigmoid diverticulosis is present without diverticulitis. Appendix contains air, has normal caliber without evidence of fat stranding. RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden in the abdominal aorta and great abdominal arteries. PELVIS: The urinary bladder is partly distended. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Reproductive organs are within normal limits BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Degenerative changes are noted, most markedly at the anterior superior endplate of L3. Abdominal and pelvic wall is within normal limits. IMPRESSION: 1. 5 mm obstructing stone at the right UVJ with moderate right hydronephrosis and perinephric stranding. 2. Diverticulosis without signs of diverticulitis. Radiology Report EXAMINATION: RETROGRADE UROGRAPHY (FILMS ONLY) IN CYSTO INDICATION: Right ureteral stent placement. FINDINGS: 5 intraoperative images were acquired without a radiologist present. Images show right retrograde urography with placement of a ureteral stent within the nondilated right renal collecting system. Urography demonstrates a filling defect in the mid ureter, potentially a ureteral stone or air bubble. Final image shows a well-formed pigtail of the right renal pelvis, and excludes the bladder pigtail from the field-of-view.. IMPRESSION: Intraoperative images were obtained during right retrograde urography and ureteral stent placement. Please refer to the operative note for details of the procedure. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: R Flank pain Diagnosed with CALCULUS OF KIDNEY temperature: 98.4 heartrate: 74.0 resprate: 18.0 o2sat: 96.0 sbp: 126.0 dbp: 73.0 level of pain: 8 level of acuity: 3.0
-You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent. -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume your pre-admission/home medications EXCEPT as noted. You should ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. HOLD ASPIRIN and aspirin containing products for one week unless otherwise advised. -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -You MAY be discharged home with a medication called PYRIDIUM that will help with the "burning" pain you may experience when voiding. This medication may turn your urine bright orange. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative, and available over the counter. The generic name is DOCUSATE SODIUM. It is recommended that you use this medication. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks and while ___ catheter is in place. IF YOU ARE DISCHARGED HOME WITH A FOLEY CATHETER: -Please refer to the provided nursing instructions and handout on Foley catheter care, waste elimination and leg bag usage. -Your Foley should be secured to the catheter secure on your thigh at ALL times until your follow up with the surgeon. -Follow up in 1 week for wound check and Foley removal. DO NOT have anyone else other than your Surgeon remove your Foley for any reason. -Wear Large Foley bag for majority of time, leg bag is only for short-term when leaving house.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: iodine / metformin / vancomycin / Cephalosporins Attending: ___. Chief Complaint: Hemorrhage from recent infarction Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ R handed gentleman with a past medical history significant for hyperlipidemia, htn, CAD, diabetes mellitus type II, and recently diagnosed R temporo-parietal infarct treated at ___. He presents today as a transfer from ___ after he had an "interval follow up ct scan" to evaluate his stroke which revealed concern for possible hemorrhage prompting transfer to ___. The patient is an extremely poor historian and could not remember when he was admitted but thinks it was "last ___. He states that he was told he had a blood clot leading to a stroke on the R side of his body. Regarding his initial symptoms that prompted evaluation 10-days ago, he states that he remembers feeling like he couldn't coordinate any movements on either side of his body. He called a friend who is in the medical field who thought something was "off" with him and brought him to ___ where he was evaluated. He underwent an MRI on ___ which revealed an acute R temporo-parietal infarct. The rest of his stroke work-up is unknown as patient doesn't remember what tests were done. He was placed on aspirin and Plavix. He reports feeling well a few hours after he was admitted to ___ without any focal weakness, visual loss or field cuts, sensory changes etc. and was symptom-free for the remainder of his hospitalization. He had been taking Plavix alone up until a few months ago but lost his insurance and stopped taking his medications for a short while. The patient has had a stressful summer as he reports recently divorcing from his wife last month. The patient denies having any TIAs or strokes in the past. He denies a history of atrial-fibrillation but states that he went into "cardiac arrest" many years ago and was in the ICU for a prolonged period of time. He does not have further details on this. He was smoking about ___ cigarettes per week until he was admitted for this stroke last week. After discharge, he went to live at his sister's house (___). At baseline, he lives alone (since his divorce). Since discharge the patient reports feeling well. He has not had any headaches, changes or difficulty with speech, no weakness, motor difficulties etc. He has been watching tv and using the computer this week while at his sister's house. He has been taking his medications as prescribed and has not started to smoke again. He does not have any complaints currently. Past Medical History: 1. Recently diagnosed R temporoparietal ischemic infarct: etiology unclear need records 2. HTN 3. HLD 4. Diabetes Mellitus 5. CAD 6. Anxiety 7. Spinal stenosis with chronic pain Social History: ___ Family History: Father had MI at age ___ but died at ___ from dementia. Mother with emphysema and diabetes died a few years ago. No FH of strokes or other neurologic illnesses. Physical Exam: Admission PHYSICAL EXAMINATION Vitals: T 97.9, HR 61, BP 139/69, RR 16 General: odd affect HEENT: NCAT, no oropharyngeal lesions, neck supple Extremities: Warm, no edema Neurologic Examination: - Mental status: Awake, alert, oriented x self,date,location. Poor historian, provides vague details about medical history but able to provide history about his life very well. Attentive, able to name ___ backward without difficulty. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No paraphasias. Mild to moderate dysarthria, speech difficult to understand at times. Normal prosody. No apraxia. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 3->2 brisk on R, 4-->2 on L. VF full to number counting. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. mild tremor with outstretched arms [___] L 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 - Reflexes: [Bic] [Tri] [___] [Quad] [Gastroc] L 2+ 2+ 2+ 2+ 1 R 2+ 2+ 2+ 2+ 1 Plantar response flexor bilaterally - Sensory: No deficits to light touch, pin, or proprioception bilaterally. No extinction to DSS. - Coordination: No dysmetria with finger to nose testing bilaterally. Good speed and intact cadence with rapid alternating movements. - Gait: deferred Discharge PHYSICAL EXAMINATION 24 HR Data (last updated ___ @ 1727) Temp: 97.7 (Tm 98.4), BP: 123/70 (102-145/64-80), HR: 69 (63-97), RR: 16 (___), O2 sat: 91% (91-98), O2 delivery: RA General: NAD, odd affect but very cheerful HEENT: NCAT, no oropharyngeal lesions, neck supple CV: Warm, well-perfused Resp: breathing comfortably on room air Extremities: Warm, no edema Neurologic Examination: - Mental status: Awake, alert, oriented x self, ___, ___. Attentive, able to name ___ backward but went forwards a couple times. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No paraphasias. Mild dysarthria . Normal prosody. No apraxia. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL L 5-4mm, R 4-3mm. VF full to number counting. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. mild tremor with outstretched arms [___] L 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 - Reflexes: [Bic] [Tri] [___] [Quad] [Gastroc] L 2+ 2+ 2+ 2+ 1 R 2+ 2+ 2+ 2+ 1 Plantar response flexor bilaterally - Sensory: No deficits to light touch, pin, or proprioception bilaterally. No extinction to DSS. - Coordination: No dysmetria with finger to nose testing bilaterally. . - Gait: deferred Pertinent Results: ___ 05:35AM BLOOD WBC-12.7* RBC-4.77 Hgb-15.0 Hct-44.8 MCV-94 MCH-31.4 MCHC-33.5 RDW-14.3 RDWSD-48.9* Plt ___ ___ 05:35AM BLOOD Glucose-117* UreaN-43* Creat-1.5* Na-140 K-5.0 Cl-99 HCO3-29 AnGap-12 ___ 08:00AM BLOOD %HbA1c-9.7* eAG-232* ___ 08:00AM BLOOD Triglyc-315* HDL-30* CHOL/HD-6.6 LDLcalc-104 ___ 08:00AM BLOOD TSH-0.79 Medications on Admission: acetaminophen 325 mg capsule oral 2 capsule(s) Every ___ hrs, as needed ___ ___ 21:49) amlodipine 5 mg tablet oral 1 tablet(s) Once Daily ___ ___ 21:49) aspirin 81 mg tablet oral 1 tablet(s) Once Daily ___ ___ 21:49) atorvastatin 80 mg tablet oral 1 tablet(s) Once Daily ___ ___ 21:49) Plavix 75 mg tablet oral 1 tablet(s) Once Daily ___ ___ 21:49) finasteride 5 mg tablet oral 1 tablet(s) Once Daily ___ ___ 21:50) furosemide 20 mg tablet oral 1 tablet(s) Once Daily ___ ___ 21:50) gabapentin 100 mg tablet oral 2 tablet(s) Three times daily ___ ___ 21:50) insulin aspar prt-insulin aspart 100 unit/mL (70-30) subcutaneous soln subcutaneous 1 solution(s) 20 Units SQ twice daily with meals ___ ___ 21:51) metoprolol tartrate 25 mg tablet oral 1 tablet(s) Twice Daily ___ ___ 21:51) mirtazapine 30 mg tablet oral 1 tablet(s) Once Daily ___ ___ 21:51) nicotine 14 mg/24 hr daily transdermal patch transdermal 1 patch 24 hour(s) Once Daily ___ ___ 21:52) nitroglycerin 0.4 mg sublingual tablet sublingual 1 tablet, sublingual(s) q5 min x3 prn for chest pain ___ ___ 21:52) venlafaxine ER 150 mg capsule,extended release 24 hr oral 1 capsule,extended release 24hr(s) Once Daily Discharge Medications: 1. Warfarin 5 mg PO DAILY16 RX *warfarin 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. amLODIPine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Finasteride 5 mg PO DAILY 6. Gabapentin 200 mg PO TID 7. GlipiZIDE XL 10 mg PO DAILY 8. Metoprolol Tartrate 25 mg PO BID 9. Mirtazapine 30 mg PO QHS 10. Nicotine Patch 14 mg TD DAILY 11. Venlafaxine XR 150 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Subacute infarcts due to LV thrombus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with known right parietotemporal infarct diagnosed last week at ___, on interval CT has linear hyperdensity. Question of subarachnoid hemorrhage or laminar necrosis. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 9 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CT head without contrast dated ___ from ___ ___. FINDINGS: Examination is minimally limited by motion artifact. There is an evolving large subacute infarct involving the right parietal lobe, temporal lobe, and posterior insula with extensive gyriform low signal on gradient echo images and gyriform T1 hyperintensity, compatible with hemorrhagic conversion plus/minus pseudolaminar necrosis. There is superimposed gyriform contrast enhancement, as expected in a subacute infarct. Mild partial effacement of the atrium of the right lateral ventricle is similar to ___. No significant shift of midline structures. There is also a smaller area of blood products and T1 hyperintensity in the anterior temporal lobe, with gyriform contrast enhancement, but no evidence for slow diffusion, compatible with hemorrhagic transformation of a subacute infarct which is older than 10 days. Within the posterior inferior right cerebellar hemisphere, there are multiple foci of slow diffusion and patchy contrast enhancement, without evidence for blood products, compatible with subacute infarctions. No significant associated mass effect. There is a punctate focus of slow diffusion with small, but slightly more extensive area of gyriform contrast enhancement in the right posterior frontal lobe, images 6:21 and 13:129, consistent with subacute infarction. Punctate low signal on gradient echo image 10:20 in this area suggest petechial hemorrhage. Nonspecific, non masslike T2 hyperintensity in the bilateral central pons is nonspecific but compatible with sequela of chronic small vessel ischemic disease in this age group. Where not affected by the infarctions, the ventricles and sulci appear age appropriate in size. Basal cisterns are not compressed. Right intracranial vertebral artery flow void is poorly seen, which is likely secondary to its small caliber, as it demonstrates contrast opacification on postcontrast MP RAGE images. The dural venous sinuses are patent on postcontrast MP RAGE images. There is mild mucosal thickening in the right ethmoid and frontal sinuses. IMPRESSION: 1. Large subacute infarct involving the right parietal lobe, temporal lobe, and posterior insula, with hemorrhagic transformation, plus/minus pseudolaminar necrosis. 2. Additional smaller right anterior lobe infarct with hemorrhagic transformation plus/minus pseudolaminar necrosis, also subacute, which appears to be older than 10 days. 3. Patchy small subacute infarctions in the right posterior inferior cerebellar hemisphere. 4. Small focus of cortical subacute infarction in the right posterior frontal lobe. 5. Contrast enhancement associated with above described subacute infarctions is likely physiologic, but follow-up imaging is recommended to ascertain resolution. 6. The above described infarctions of varying ages in multiple vascular territories suggest embolic etiology. RECOMMENDATION(S): Follow up MRI with and without contrast in approximately 6 weeks to confirm expected resolution of contrast enhancement. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: SAH, Transfer Diagnosed with Nontraumatic subarachnoid hemorrhage, unspecified temperature: 97.9 heartrate: 61.0 resprate: 16.0 o2sat: 96.0 sbp: 139.0 dbp: 69.0 level of pain: 0 level of acuity: 2.0
Dear Mr. ___, You were admitted to the hospital because there was concern about possible bleeding in your brain from a recent stroke. You had an MRI which showed multiple recent strokes in different areas of the brain. There was some bleeding and tissue injury due to the recent strokes. You got an echocardiogram which showed you still have a very large clot in the heart, which could break off and cause more strokes. You were continued on aspirin but Plavix (clopidogrel) was stopped. You were started on Coumadin (or warfarin) as a blood thinner, which requires regular blood tests to make sure the levels are not too high or too low. You will follow up with your primary doctor (___) to measure your INR levels and adjust your Coumadin dose. We discussed your condition with your neurologist (Dr. ___ and your primary doctor (___). Follow up with your neurologist in the next ___ weeks. The neurology clinic will call you to set up an appointment. Follow up with your primary doctor (___) this ___ ___. Take your medications as prescribed. Thank you for allowing us to participate in your care. Sincerely, Your ___ Neurology Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Bactrim / Niaspan Extended-Release Attending: ___. Chief Complaint: nausea, vomitting, diarrhea Major Surgical or Invasive Procedure: ___: Successful US-guided aspiration of a superficial right lower quadrant fluid collection History of Present Illness: This patient is a ___ year old female who complains of n/v/d. Hx SBO, s/p recent ventral hernia repair s/p SBO 5d PTA, discharged yesterday, presenting with abdominal pain, nausea, vomiting, and profuse watery diarrhea. She has typically had diarrhea associated with her SBO. No fever/schills. NBNB emesis. Not tolerating po. Decreased flatus. Past Medical History: HTN, HLD PSHx: open CCY, appendectomy, 3 C sections, hysterectomy, ventral hernia repair Allergies: bactrim, niaspan Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION: ___ Temp: 98.6 HR: 90 BP: 133/74 Resp: 16 O(2)Sat: 97 Normal Constitutional: Comfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nondistended, nontender, midline incision c/d/i Extr/Back: No cyanosis, clubbing or edema Skin: No rash Neuro: Speech fluent Psych: Normal mood Physical examination upon diacharge: ___: vital signs: 98.5, hr=75, bp=127/64, rr=18, 96% room air CV: Ns1, s2, -s3, -s4 LUNGS: clear ABDOMEN: soft, scattered mid-abdominal staples, mild separation of skin after few staples removed, wound edges closed with steri-strips EXT: no pedal edema bil., no calf tenderness bil NEURO: alert and oriented x 3 speech clear Pertinent Results: ___ 06:15AM BLOOD WBC-10.1 RBC-3.21* Hgb-11.0* Hct-32.0* MCV-100* MCH-34.2* MCHC-34.3 RDW-12.3 Plt ___ ___ 03:15PM BLOOD WBC-12.0* RBC-3.29* Hgb-11.4* Hct-33.1* MCV-101* MCH-34.7* MCHC-34.5 RDW-12.3 Plt ___ ___ 02:00AM BLOOD WBC-20.2*# RBC-3.82* Hgb-13.5 Hct-37.4 MCV-98 MCH-35.4* MCHC-36.1* RDW-12.3 Plt ___ ___ 02:00AM BLOOD Neuts-84.8* Lymphs-9.8* Monos-4.4 Eos-0.6 Baso-0.4 ___ 06:15AM BLOOD Plt ___ ___ 02:17AM BLOOD ___ PTT-27.2 ___ ___ 06:15AM BLOOD Glucose-96 UreaN-11 Creat-0.7 Na-140 K-4.2 Cl-101 HCO3-29 AnGap-14 ___ 02:00AM BLOOD Glucose-132* UreaN-17 Creat-0.7 Na-136 K-5.5* Cl-97 HCO3-22 AnGap-23* ___ 03:15PM BLOOD ALT-91* AST-61* AlkPhos-231* TotBili-0.6 ___ 02:00AM BLOOD Lipase-194* ___ 06:15AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.9 ___: cat scan abdomen and pelvis: 1. Intra-abdominal fluid collection posterior to the surgical mesh measuring 13.0 x 2.4 cm, concerning for a developing abscess. Markedly edematous, mildly dilated loops small bowel posterior to this collection are probably reactive (vs enteritis or ischemia.) 2. Soft tissue fluid collection within the anterior abdominal wall soft tissues with surrounding stranding, is likely postsurgical although a superimposed infection is not excluded. 3. Fluid-filled large bowel without evidence of thickening. ___: chest x-ray: No radiographic evidence of pneumonia. ___ drainage: ___ Successful US-guided aspiration of a superficial right lower quadrant fluid collection, yielding 50 cc of sanguineous fluid. Samples were sent for microbiology evaluation. Medications on Admission: Meds: lisinopril 10 (or 15, pt unsure)', atorvastatin 80', omeprazole 20'', spironolactone 50''', vitamins Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H last dose ___ RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. Omeprazole 20 mg PO DAILY 5. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: intra-abdominal fluid collection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ with recent surg for vent hernia repair on ___, sbo, with return of symptoms of SBO+PO contrast TECHNIQUE: MDCT images were obtained from the lung bases to the pubic symphysis after the administration of intravenous contrast. Axial images were interpreted in conjunction with coronal and sagittal reformats. Oral contrast was administered. DLP: 943 mGy-cm COMPARISON: Comparison is made to abdomen and pelvic CT from ___. FINDINGS: CHEST: The visualized lung bases are clear. The heart is normal in size and there is no evidence of pericardial effusion. ABDOMEN: The liver enhances homogeneously and is without focal lesions. The portal venous system is patent. Mild intrahepatic biliary ductal dilation is unchanged. The gallbladder is surgically absent.. The spleen and adrenal glands are unremarkable. The pancreas enhances homogenously and is without focal lesions. Focal defects in the cortex of the of right and left kidneys likely from prior scarring. Subcentimeter hypodensity in the left kidney is too small to characterize but likely represents a cyst. There is no hydronephrosis. The ureters are normal in caliber and course to the bladder. Oral contrast extends through the proximal small bowel. The stomach and proximal small bowel are normal in caliber without wall thickening. A mesh from prior ventral hernia repair is seen spanning the midline of the lower abdomen. In the soft tissues anterior to the mesh there is a 8.4 x2.9 x 5.5 cm (transverse by AP by cc) collection with surrounding stranding (series 2:75). There are a few foci of air within the soft tissues. Just posterior to the mesh within the intra-abdominal cavity is an additional fluid collection with a hyperenhancing border crossing the midline and measuring approximately 13.0 x 2.4 cm (transverse by AP). There is no evidence of rim enhancement. Posterior to this collection there are multiple fluid filled loops of edematous and mildly dilated small bowel (series 2, image 76). There is no evidence of intra-abdominal free air. The large bowel is primarily fluid-filled and is without wall thickening. The abdominal aorta and its major branches are patent . The aorta and iliac branches are normal in course and caliber. There is no retroperitoneal or mesenteric lymphadenopathy by CT size criteria. PELVIS: The bladder is well distended and normal. There is no pelvic side-wall or inguinal lymphadenopathy by CT size criteria. No free pelvic fluid is identified. OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. Intra-abdominal fluid collection posterior to the surgical mesh measuring 13.0 x 2.4 cm, concerning for a developing abscess. Markedly edematous, mildly dilated loops small bowel posterior to this collection are probably reactive (vs enteritis or ischemia.) 2. Soft tissue fluid collection within the anterior abdominal wall soft tissues with surrounding stranding, is likely postsurgical although a superimposed infection is not excluded. 3. Fluid-filled large bowel without evidence of thickening. Radiology Report INDICATION: ___ year old woman with N/V and WBC 20 postop day 10 from ventral hernia repair. COMPARISON: None Available. TECHNIQUE Frontal lateral view of the chest. FINDINGS: The cardiomediastinal silhouette is normal. There is no pleural effusion or pneumothorax. There is no focal lung consolidation. No acute osseous abnormality is seen. IMPRESSION: No radiographic evidence of pneumonia. Radiology Report INDICATION: ___ year old woman with SBO w/ fluid collections. COMPARISON: CT abdomen pelvis ___. PROCEDURE: Ultrasound-guided drainage of superficial right lower quadrant collection. OPERATORS: Dr. ___ trainee and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agree 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 supine position on the US scan table. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings an appropriate skin entry site for the drain placement was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, 20G spinal needle was inserted into the collection. Approximately 50 cc of sanguineous fluid was drained, and a sample sent for microbiology evaluation. The needle was withdrawn, and a sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: No sedation was provided. FINDINGS: Limited ultrasound of the right lower quadrants demonstrates a superficial complex fluid collection. IMPRESSION: Successful US-guided aspiration of a superficial right lower quadrant fluid collection, yielding 50 cc of sanguineous fluid. Samples were sent for microbiology evaluation. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: n/v/d Diagnosed with ABDOMINAL PAIN OTHER SPECIED temperature: 98.6 heartrate: 90.0 resprate: 16.0 o2sat: 97.0 sbp: 133.0 dbp: 74.0 level of pain: 7 level of acuity: 3.0
You were readmitted to the hospital on ___ with nausea and vomitting. You were also reported to have an elevated white blood cell count. You underwent a cat scan of the abdomen and you were found to have a fluid collection in the abdominal wall. You were started on intravenous antibiotics. You had the fluid collection drained and no bacteria was reported. Your white blood cell count has normalized and you are preparing for discharge home with the following instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items ___ pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips ___ days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision site
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: bee venom (honey bee) Attending: ___ Chief Complaint: abdominal pain, fevers Major Surgical or Invasive Procedure: diagnostic paracentesis History of Present Illness: ___ with history of cirrhosis secondary to alcoholic liver disease and hep C who presents with worsening ascites and lower extremity swelling. Pt reports that he began having cough with subjective fevers/chills on ___, associated with pain underneath his shoulder blades bilaterally and shortness of breath. His cough was productive of green mucous. Pt reports a Tmax at home of 103.3 on ___. That afternoon, he presented to ___ for a therapeutic tap, where 3 liters of ascitic fluid was reportedly removed. Pt told staff there that he was feeling unwell, but was told that his blood work was normal and he was discharged home. He presented again to the ___ ED on ___ and was reportedly diagnosed wtih pneumonia and started on azithromycin. He reports no improvement since starting on azithro. Since ___, he notes worsening of his lower extremity edema and abdominal distension, associated with diffuse abdominal tenderness. Pt called Dr. ___ for an appointment but stated that he needed to be seen today, so presented to the ED. . Pt was hospitalized ___ for hematemesis with negative EGD. Bleeding was attributed to epistaxis. No evidence of variceal bleed. He was discharged on 7 day course of ciprofloxacin. . ED Course: Initial Vitals 97.7 57 ___ 99% ra. CXR showed stable persistent patchy L basilar opacity wo acute findings. He underwent diagnostic paracentesis which showed WBC 140, RBC 845, tot protein 1.3, gluc 126, 7% PMN. Labs notable for lactate 1.8, wbc 6.8 (wo L shift), Hct 40.7, Plt 70, chem 7 wnl, AST 109, ALT 45, tbili 1.3, alb 2.8. He received ceftriaxone 1g IV to broaden for presumed pna, IV morphine, and zofran. Vitals prior to transfer 97.8 °F (36.6 °C), Pulse: 62, RR: 18, BP: 110/79, O2Sat: 97, O2Flow: ra, Pain: ___. Access: PIV 20g. . On the floor, pt reports feeling improved since getting ceftriaxone in the ED. He states that his leg and abdominal swelling is only mildly increased and his biggest concern has been his cough, nasal congestion and headaches. He also note 1 day of diarrhea and vomitting last ___. Pt reports that he has been compliant with medications, and compliant with a low salt diet. He has been requiring therapeutic taps every 2.5 weeks. Past Medical History: Cirrhosis Hepatitis C Esophageal varices Ascites HTN Myocardial infarction in setting of cocaine use (age ___ b/l hip replacement Social History: ___ Family History: Hypertension; Mother, father and brothers with alcoholism; sister former drug addict, now sober Physical Exam: ADMISSION EXAM: VS: 98.0 122/81 60 22 98% RA ___: Well appearing ___ yo M/F who appears stated age. Comfortable, appropriate and in good humor. HEENT: Sclera anicteric. PERRL, EOMI. NECK: Supple with low JVP CARDIAC: RRR, S1 S2 clear without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: Resp were unlabored, no accessory muscle use, moving air well and symmetrically, upper airway noises transmitted throughout, mildly rhonchous, no crackles, wheezes. ABDOMEN: soft, mild distension, diffusely tender to light touch, worse over spleen and abdominal hernia, splenomegaly. Dullness to percussion over dependent areas but tympanic anteriorly. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. ___ ___ bilaterally to knees. . DISCHARGE EXAM: VS: Tm 98.5 Tc97.9 ___ 20 97/RA I/O: ___ overnight BM x5 ___: Well appearing ___ yo M/F who appears stated age. Comfortable, appropriate and in good humor. HEENT: Sclera anicteric. PERRL, EOMI. NECK: Supple with low JVP CARDIAC: RRR, S1 S2 clear without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: Resp were unlabored, no accessory muscle use, moving air well and symmetrically, upper airway noises transmitted throughout, mildly rhonchous, no crackles, wheezes. ABDOMEN: soft, mild distension, diffusely tender to light touch, worse over spleen and abdominal hernia, splenomegaly. Dullness to percussion over dependent areas but tympanic anteriorly. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. ___ ___ bilaterally to knees. Pertinent Results: ADMISSION LABS: ___ 12:02PM BLOOD WBC-6.8# RBC-4.14* Hgb-13.0* Hct-40.7 MCV-99* MCH-31.4 MCHC-31.9 RDW-17.3* Plt Ct-70* ___ 12:02PM BLOOD Neuts-67.5 ___ Monos-5.3 Eos-2.3 Baso-0.8 ___ 12:02PM BLOOD Glucose-136* UreaN-8 Creat-0.7 Na-133 K-4.1 Cl-100 HCO3-26 AnGap-11 ___ 12:02PM BLOOD ALT-45* AST-109* AlkPhos-91 TotBili-1.3 ___ 12:02PM BLOOD Albumin-2.8* . DISCHARGE LABS: ___ 06:25AM BLOOD WBC-6.8 RBC-4.12* Hgb-12.8* Hct-40.6 MCV-99* MCH-31.2 MCHC-31.6 RDW-17.4* Plt Ct-93* ___ 06:25AM BLOOD ___ PTT-35.7 ___ ___ 06:25AM BLOOD Glucose-116* UreaN-6 Creat-0.6 Na-134 K-4.6 Cl-102 HCO3-25 AnGap-12 ___ 06:25AM BLOOD ALT-45* AST-106* AlkPhos-99 TotBili-1.1 ___ 06:25AM BLOOD Calcium-8.4 Phos-4.2 Mg-1.6 . URINALYSIS/URINE TOX: ___ 05:14PM URINE Color-Yellow Appear-Clear Sp ___ ___ 05:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.5 Leuks-NEG ___ 05:14PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG . DIAGNOSTIC PARACENTESIS: ___ 02:54PM ASCITES WBC-140* RBC-845* Polys-7* Lymphs-32* Monos-4* Mesothe-5* Macroph-52* ___ 02:54PM ASCITES TotPro-1.3 Glucose-126 . MICROBIOLOGY ___ 2:54 pm PERITONEAL FLUID GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): . Blood culture x 2 pending . Urine culture pending . CHEST (PA & LAT) Study Date of ___ FINDINGS: The heart is normal in size. The mediastinal and hilar contours appear within normal limits. There is a persistent patchy left basilar opacity. Given the lack of change, the appearance may be chronic. More generally, there is mild interstitial prominence, perhaps due to slight fluid overload or congestion, but not specific; other possibilities include atypical infection, airway inflammation, or possibly interstitial lung disease. IMPRESSION: Mild suspected background interstitial abnormality and unchanged focal left infrahilar opacity, accordingly suggestive of longer chronicity. Clinical correlation is recommended. If shortness of breath were to continue and the possibility of an underlying interstitial process is of potential clinical concern, dedicated chest CT could be considered. . CT ABD & PELVIS WITH CONTRAST Study Date of ___ CT ABDOMEN: There are no pleural effusions. The lung bases appear clear. The liver is nodular consistent with fibrosis. The caudate and left lateral segments are markedly enlarged. The entire left lobe is shrunken with predominantly central areas of relative hypodensity suggesting fibrosis. Because monophasic technique was used, screening for hepatocellular carcinoma is limited, but there are no suspicious focal lesions identified. The spleen is moderately enlarged, measuring up to 17.3 cm in length. Esophageal, paraesophageal and short gastric varices are apparent. The gallbladder shows mild wall thickening which can be seen in cirrhosis but it does not appear distended. The adrenal glands, pancreas and adrenal glands appear within normal limits. Along the anterior abdominal wall there is a fat-containing paraumbilical hernia with omental contents. Its neck is wide, measuring up to nearly 26 mm in diameter; the sac measures up to 49 mm in diameter. There is congestive change suggested by high attenuation in the fat as well as a small amount of peripheral fluid, which are findings that can be seen with incarceration but which are highly nonspecific particularly in the setting of generalized cirrhosis and ascites with portal hypertension. The stomach, small and large bowel appear within normal limits. The appendix appears normal. CT PELVIS: Moderate-to-large ascites layers in the pelvis. Streak artifact from bilateral hip replacements makes evaluation of lower pelvic structures such as the prostate and seminal vesicles and lower part of the bladder difficult, but no definite abnormality is identified. The bladder is poorly delineated and probably mostly empty. There are patchy vascular calcifications without any aneurysm. There are slightly prominent celiac and periportal lymph nodes but none enlarged by size criteria. The main portal vein and its major branches appear patent, although segmental branches of the portal vein are markedly attenuated in keeping with portal hypertension. BONE WINDOWS: There are no suspicious lytic or blastic lesions. Mild degenerative changes are present along the lower lumbar facets. Patient is status post right hip hemiarthroplasty and left total hip replacement. IMPRESSION: 1. Cirrhosis with findings consistent with portal hypertension including splenomegaly and varices. 2. Moderate-to-large quantity of ascites. 3. Fat-containing ventral hernia with a fairly wide neck. Although there is increased attenuation of fat as well as a small quantity of peripheral fluid, which can be seen with incarceration, findings are highly nonspecific in this setting. Medications on Admission: # nadolol 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). # omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. # sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a day. # hydroxyzine HCl 50 q HS # zinc sulfate 220 mg Tablet Sig: One (1) Tablet PO twice a day. # furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). # spironolactone 150 mg Tablet Sig: One (1) Tablet PO once a day. # ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. # oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. # flovent inhaler 2 puffs BID # flonase daily # vitamin B complex # MVI # Vit D Discharge Medications: 1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 2. nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 10. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). 11. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 12. B complex vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 13. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Please complete 2 more doses, last dose ___. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: abdominal pain SECONDARY: hepatitis C Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPHS HISTORY: Shortness of breath and ascites. 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 persistent patchy left basilar opacity. Given the lack of change, the appearance may be chronic. More generally, there is mild interstitial prominence, perhaps due to slight fluid overload or congestion, but not specific; other possibilities include atypical infection, airway inflammation, or possibly interstitial lung disease. IMPRESSION: Mild suspected background interstitial abnormality and unchanged focal left infrahilar opacity, accordingly suggestive of longer chronicity. Clinical correlation is recommended. If shortness of breath were to continue and the possibility of an underlying interstitial process is of potential clinical concern, dedicated chest CT could be considered. Radiology Report CT OF THE ABDOMEN AND PELVIS HISTORY: Cirrhosis complicated by ascites and varices, presenting with fever and abdominal pain. Question incarcerated hernia or other nidus for infection. COMPARISONS: An ultrasound is available from ___ which showed chronic fibrotic liver disease with ascites and splenomegaly. No prior CT imaging is available. TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained with oral and intravenous contrast. Sagittal and coronal reformations were also performed. Shortly after the study, a preliminary interpretation was provided by Dr. ___: "1. Cirrhosis with splenomegaly to 17.3 cm in portosystemic collaterals, suggesting portal hypertension. Main portal vein, SMV and splenic veins are patent. 2. Moderate large ascites. Superinfection in the ascitic fluid cannot be excluded on this study. No rim-enhancing fluid collection identified. 3. Small ventral hernia with a 2.6-cm neck containing omentum and mesenteric vessels. A small amount of free fluid is seen within it, but is nonspecific in the setting of ascites. It does not contain small or large bowel loops. Correlate clinically. 4. No other infectious nidus seen." FINDINGS: CT ABDOMEN: There are no pleural effusions. The lung bases appear clear. The liver is nodular consistent with fibrosis. The caudate and left lateral segments are markedly enlarged. The entire left lobe is shrunken with predominantly central areas of relative hypodensity suggesting fibrosis. Because monophasic technique was used, screening for hepatocellular carcinoma is limited, but there are no suspicious focal lesions identified. The spleen is moderately enlarged, measuring up to 17.3 cm in length. Esophageal, paraesophageal and short gastric varices are apparent. The gallbladder shows mild wall thickening which can be seen in cirrhosis but it does not appear distended. The adrenal glands, pancreas and adrenal glands appear within normal limits. Along the anterior abdominal wall there is a fat-containing paraumbilical hernia with omental contents. Its neck is wide, measuring up to nearly 26 mm in diameter; the sac measures up to 49 mm in diameter. There is congestive change suggested by high attenuation in the fat as well as a small amount of peripheral fluid, which are findings that can be seen with incarceration but which are highly nonspecific particularly in the setting of generalized cirrhosis and ascites with portal hypertension. The stomach, small and large bowel appear within normal limits. The appendix appears normal. CT PELVIS: Moderate-to-large ascites layers in the pelvis. Streak artifact from bilateral hip replacements makes evaluation of lower pelvic structures such as the prostate and seminal vesicles and lower part of the bladder difficult, but no definite abnormality is identified. The bladder is poorly delineated and probably mostly empty. There are patchy vascular calcifications without any aneurysm. There are slightly prominent celiac and periportal lymph nodes but none enlarged by size criteria. The main portal vein and its major branches appear patent, although segmental branches of the portal vein are markedly attenuated in keeping with portal hypertension. BONE WINDOWS: There are no suspicious lytic or blastic lesions. Mild degenerative changes are present along the lower lumbar facets. Patient is status post right hip hemiarthroplasty and left total hip replacement. IMPRESSION: 1. Cirrhosis with findings consistent with portal hypertension including splenomegaly and varices. 2. Moderate-to-large quantity of ascites. 3. Fat-containing ventral hernia with a fairly wide neck. Although there is increased attenuation of fat as well as a small quantity of peripheral fluid, which can be seen with incarceration, findings are highly nonspecific in this setting. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: LACITIES/EDEMA Diagnosed with OTHER ASCITES, HYPERTENSION NOS, LIVER DISORDER NOS temperature: 97.7 heartrate: 57.0 resprate: 20.0 o2sat: 99.0 sbp: 112.0 dbp: 72.0 level of pain: 6 level of acuity: 3.0
Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted with abdominal pain. You had a CT scan done, which did not show any abnormalities. There was no evidence of infection. Please make the following changes to your medications: # CONTINUE azithromycin 250 mg daily for 2 more days Continue all other medications as prescribed.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / Penicillins / Flagyl Attending: ___. Chief Complaint: headache Major Surgical or Invasive Procedure: Whole brain radiation History of Present Illness: ___ year old female with metastatic lung cancer with progressive brain metastases s/p metastasis resection and craniotomy ___ for brain met felt to be causing intractable nausea/vomiting who started fraction 1 of 5 of whole brain radiation therapy today ___ now presenting with chief complaint of nausea, vomiting and headache. Pt has been admitted previously for nausea/vomiting and right chest/back pain; pain has improved with previous course of chest RT and she is now down to using po dilaudid only once daily. Has also had prior admission before this decrease for opiate related constipation which per pt is no longer an issue. Most recently tapered post-op steroid dose and has been tolerating food and feeling well at home but due to progression ofnumerous brain mets, decision was made to do WBRT rather than cyberknife and she initiated WBRT today (___). She went home after RT, fell asleep and woke up with pounding frontal headache. No visual changes or weakness of any extremity. She also had nausea and 1 episode of nonbloody vomiting. Rad Onc instructed her to take 4mg po dex which she did with some relief but later developed recurrene of nausea and headache and was referred to the ED as she was unable to keep down PO. She also notes that she developed abdominal pain during this time which was mild-moderate and located in the ___ the abdomen; did not appear to be exacerbated by food, and she continues having bowel movements that are formed and nonbloody. She has had no diarrhea and no fevers and no sick contacts. She has had similar pain in the setting of constipation in the past but does not believe she is constipated at this time; last formed bowel movement was fairly soft and was yesterday. ED course: v/s 99.1 115/87 HR ___ RR 18 98% RA. LFTs/lipase unremarkable. CT head noncon read as : Patient is status post right frontal and occipital craniotomy. Relative to CT dated ___, degree of hypodensity surrounding known metastatic lesions particularly within the left frontal lobe and right temporal parietal region are slightly more conspicuous. There is no evidence of hemorrhage or significant mass effect. Pt received 10mg IV dex, 1mg IV dilaudid, 4mg IV Zofran, 1L IVF. Labs otherwise unremarkable. She felt symptomatically improved and was transferred to the floor. At the time of this interview she appears comfortable and conversant and not in extreme pain though endorses ongoing mild gnawing abd pain, denies headache or nausea at this time. Denies cough, sx/signs of bleeding, fever, sick contacts, dysuria. REVIEW OF SYSTEMS: GENERAL: No fever, chills, night sweats, recent weight changes. HEENT: No sores in the mouth, painful swallowing, intolerance to liquids or solids, sinus tenderness, rhinorrhea, or congestion. CARDS: No chest pain, chest pressure, exertional symptoms, or palpitations. PULM: No cough, shortness of breath, hemoptysis, or wheezing. GI: + n/v as sabove but no diarrhea; abd pain as above. No recent change in bowel habits, hematochezia, or melena. GU: No dysuria or change in bladder habits. MSK: No arthritis, arthralgias, myalgias, or bone pain. DERM: Denies rashes, itching, or skin breakdown. NEURO: No headache, visual changes, numbness/tingling, paresthesias, or focal neurologic symptoms. PSYCH: No feelings of depression or anxiety. All other review of systems negative. Past Medical History: PAST ONCOLOGIC HISTORY: -___: presents to ___ with 4 days of L hand weakness after OSH NCHCT demonstrates R frontal lobe lesion with local edema but no midline shift. Keppra and dex loaded (subsequent confirmed seizure activity). Admitted to Neuro ICU. -___: craniotomy w/ tumor resection by Dr. ___: Metastatic adenocarcinoma, lung origin, Positive: TTF-1, CK7, p63 (weak), Negative: Cytokeratin 20, immunoglobin, GCDFP-15 - ___: CT chest showed 1.7 x 1.9 cm solid lesion in the right upper lobe, likely a primary lung tumor. Satellite 2 x 2.3 partially solid lesion suspicious for additional primary malignancy versus organizing pneumonia. Remainder right upper lobe ground-glass opacities are concerning for metastasis There is extensive bilateral hilar and mediastinal lymphadenopathy, also with involvement of the right supraclavicular space. The latter compresses the right internal jugular vein, producing upstream jugular vein thrombosis. Filling defect compatible with thrombus is also in the SVC. -___: vascular surgery consulted for R IJ/subclavian thrombosis as well as submassive PE, initiated on therapeutic lovenox with stable NCHCT on anticoagulation -___: developed seizures, started on Keppra -___: AOx3; motor exam, left upper arm flaccid left leg IP 4+, quad ___, ham ___, at ___, ___ ___, ___ ___, the right arm and leg were full strength. Cipro for UTI. Discharged to rehabilitation in neurological stable condition. -___: 3 sessions CyberKnife OTV -___: Admitted to ___ with high fever and radiologic evidence of RUL PNA, initially treated for HCAP and discharged on levofloxacin we extended to 10 days -___: EGFR wild type, K-Ras wild type, ALK/ROS1 without rearrangement -___: C1D1 carboplatin/pemetrexed -___: Admitted to ___ w/ cavitary lung lesion consistent with abscess, BAL + MRSA, unable to safely drain, discharged on 14 days vanc/aztreonzam w/ ID followup, RUE DVT -___: C2D1 carboplatin/pemetrexed -___: CT chest with substantial involution since ___ in central adenopathy in the mediastinum and right hilus with recovered patency to right upper lobe posterior segmental bronchus and marked decrease in size of postobstructive right upper lobe abscess. Direct tumor extension from the hilus into the right lung has improved, but there is a question of new RLL implant. -___: ID followup, discontinued vanc/aztreonam/clinda and narrowed to PO bactrim -___: C3D1 carboplatin/pemetrexed -___: C4D1 carboplatin/pemetrexed (with fosaprepitant, 1L IVF) -___: C1 pemetrexed maintenance -___: C2 pemetrexed maintenance -___: C3 pemetrexed maintenance HELD -___: RUE ultrasound: On the right there is a large occlusive thrombus in the internal jugular vein that extends partially into the subclavian vein. The axillary, brachial, cephalic, and basilic veins are compressible and demonstrate augmentation. -___: CT venogram (chest): Occlusive thrombus in the right internal jugular vein. Partially occlusive focal thrombus in the superior vena cava. Known right upper lobe mass has slightly increased in size since ___. Necrotic mediastinal lymphadenopathy is relatively stable. This study is not designed to evaluate for extent of disease. A hypodensity in the dome of the liver measuring 13 mm is not fully evaluated on this study. -___: C3 pemetrexed maintenance -___: C4 pemetrexed maintenance -___: CT chest w/ interval progression in the mediastinal lymphadenopathy. There is also possible progression of right upper lobe lesion and right internal jugular and superior vena cava thrombi as well as narrowing up to almost occlusion of the left subclavian vein. Cortical reaction at the lateral aspect of the right tenth rib of uncertain significance. -___: pemetrexed HELD for progression -___: PET/CT FDG avid right upper lobe mass and FDG-avid mediastinal and bilateral hilar lymphadenopathy. FDG avid material in the right internal jugular vein and right brachiocephalic vein is concerning for tumor thrombus. -___: CT chest with continued progression of large scale adenopathy from the supraclavicular regions through all all peritracheal stations of the mediastinum in both hila. The most serious tumor related complications are near occlusion of the superior vena cava, chronic thrombosis of the right internal jugular vein, and recently progressive narrowing of both descending pulmonary arteries, and right main bronchus. No metastatic disease in abd/pelvis. -___: MRI brain with new 4 mm enhancing lesion within the right cerebellar hemisphere concerning for metastatic lesion -___ initiated crizotinib off trial -___ CK to R cerebellar met -___ CT chest with broad response to therapy -___: MRI brain with slight increase edema at resection site, otherwise stable. CT chest with persistent excellent response. -___ admitted with groin hematoma, lovenox temporarily held then restarted at slightly lower dose -___ having orthostatic symptoms, referred to cardiology, she had some transient bradycardia which could be related to crizotinib but was continued on her dose as symptoms were stable -___ saw Dr. ___ in f/u, remained off keppra. Brain MRI showed new R occipital lesion, -___ new R occ lesion treated by Dr. ___ with CK -___ CT showed slight increase in size of her dominant RUL mass, and was noted to have neutropenia attributed to crizotinib, ANC 740. This recovered 1150 by ___ brain MRI stable -___ CT chest: Progressive disease with increase in size of RUL mass from 14x19mm to 26x30mm, increase in size of a RUL nodule, new massive mediastinal LAD and local osteolytic rib lesion - ___ underwent craniotomy and resection for one brain metastasis followed by WBRT initiation on ___ PAST MEDICAL HISTORY: Hypertension Vitamin B12 deficiency Social History: ___ Family History: Her mother died at ___ with dementia and her father died at ___ when the patient was ___ years old. Physical Exam: VITAL SIGNS: 98.9 108/71 71 18 99% RA General: NAD, thin, frail appearing, pale but conversant and energetic conversationalist HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB GI: BS+, soft, NTND, no masses or hepatosplenomegaly. Pt has tenderness to palpation in one area of abdomen to right of center but no RUQ tenderness and appears comfortable despite palpation. No CVA tenderness LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Oriented x3. Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed, no nystagmus; strength is ___ of the proximal and distal upper and lower extremities; reflexes are 2+ of the biceps, triceps, patellar, and Achilles tendons, toes are down bilaterally; gait is normal, coordination is intact. Pertinent Results: ___ 11:20PM BLOOD WBC-4.3 RBC-3.38* Hgb-11.0* Hct-33.5* MCV-99* MCH-32.5* MCHC-32.8 RDW-15.7* RDWSD-57.1* Plt ___ ___ 06:45AM BLOOD WBC-4.6 RBC-3.11* Hgb-10.0* Hct-31.8* MCV-102* MCH-32.2* MCHC-31.4* RDW-15.4 RDWSD-57.8* Plt ___ ___ 11:20PM BLOOD Neuts-74.9* Lymphs-18.3* Monos-5.6 Eos-0.5* Baso-0.5 Im ___ AbsNeut-3.20# AbsLymp-0.78* AbsMono-0.24 AbsEos-0.02* AbsBaso-0.02 ___ 11:20PM BLOOD Glucose-133* UreaN-14 Creat-1.0 Na-135 K-5.4* Cl-101 HCO3-24 AnGap-15 ___ 06:45AM BLOOD Glucose-109* UreaN-17 Creat-1.0 Na-138 K-4.3 Cl-106 HCO3-27 AnGap-9 ___ 11:20PM BLOOD ALT-16 AST-32 AlkPhos-63 TotBili-0.3 ___ 11:20PM URINE Color-Yellow Appear-Clear Sp ___ ___ 11:20PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 11:20PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 ___ 11:20PM URINE CastHy-1* ___ 11:20PM URINE Mucous-RARE CT Head ___ IMPRESSION: 1. Compared to ___, the extent of edema associated with bilateral supratentorial and left cerebellar metastases has increased, statistically likely secondary to radiation therapy. There is only mild new effacement of the atrium of the right lateral ventricle, but no other significant mass effect. 2. No evidence for acute hemorrhage. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ s/p whole brain radiation therapy today for lung metastases, presenting with headache, likely secondary to cerebral edema, please evaluate for acute intracranial process/ hemorrhage, change in brain metastases. 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: CTA head dated ___ as well as MR head dated ___. FINDINGS: Right frontal/parietal and right temporal craniotomies are again seen. There are multiple areas of edema related to the known brain metastases, best seen within the right superior frontal lobe, left inferior frontal lobe, bilateral temporal lobes, right parietal/posterior upper lobes, and the left cerebellar hemisphere. Compared to ___, the extent of edema at the sites has increased. There is new mild mild effacement of the atrium of the right lateral ventricle, but no other significant mass effect, and no shift of midline structures. There is no evidence of acute hemorrhage. Basal cisterns are not compressed. Visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Partially visualized orbits are unremarkable. IMPRESSION: 1. Compared to ___, the extent of edema associated with bilateral supratentorial and left cerebellar metastases has increased, statistically likely secondary to radiation therapy. There is only mild new effacement of the atrium of the right lateral ventricle, but no other significant mass effect. 2. No evidence for acute hemorrhage. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Headache, N/V Diagnosed with Headache temperature: 99.1 heartrate: 86.0 resprate: 18.0 o2sat: 99.0 sbp: 115.0 dbp: 81.0 level of pain: 8 level of acuity: 2.0
You were admitted with headache which was likely due to tapering steroids too quickly after whole brain radiation. Your symptoms improved with steroids. You also experienced some nausea and abdominal fullness that was in part due to steroids. You were started on some medications to help with these symptoms. This is the steroid taper recommended by radiation oncology: Decadron 4mg bid until ___. Then, Decadron 4mg daily for 3 days, then Decadron 2mg daily for 3 days, then Decadron 1mg daily for three days, then stop.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Mango tree bark Attending: ___. Chief Complaint: Altered Mental Status, Hypoxia Major Surgical or Invasive Procedure: Pericardiocentesis Left thoracentesis Abdominal JP drain insertion Intubation, extubation Right IJ line placement, removal History of Present Illness: ___ w/ HLD, HTN, OSA, PNET s/p distal pancreatectomy/splenectomy (___) w/ recent hospitalization (___) w/ abdominal abscess requiring JP drain and PE (warfarin) who p/w hypoxemia and AMS. He went from ___ rehab to ___ on ___ for hypoxia (desatting to ___ and AMS ("baseline confused" to "grossly altered" per records) and was started on NRB. He had purulent drainage from his JP drains and had a CT scan that showed large pericardial effusion. TTE concerning for large effusion. He was transferred to ___ for further management and possible pericardiocentesis. In ED initial VS: T 99.2 HR 117 BP 170/98 RR 28 98% NRB Exam: Somnolent, withdraws to pain Labs: wbc 9.6, hgb 11.2, plt 689, K 6.4 (recheck was 4.1), lactate 1.3, Cr 0.6, INR 2.2, VBG 7.28/80, UA w/ lg leuk, neg nitr, but no bact. Imaging: Bedside US w/ large effusion w/ concern for impending tamponade clinically. Patient was given: Zosyn, calcium gluconate, insulin 10 Imaging notable for: CXR w/ dense L bibasilar opacity likely combination of effusion w/ atelectasis (superimposed infection possible). Englarged cardiac silhouette and pulmonary vascular congestion. EKG w/ AFIB, RBBB (unchanged from prior). Consults: Surgery was consulted and said that patients JP drains are draining purulent fluid, but CT scans are not concerning for repeat abscess. Cardiology was consulted and urgently performed pericardiocentesis in the cath lab w/ 500 serosanguinous, drain placed. Opening pressure 13, closing was 3. Recommended TTE tomorrow pm. VS prior to transfer: T 99.0 HR 121 BP 144/72 RR 26 99% NRB On arrival to the MICU, he is somnolent, but arousable and answers some questions appropriately. His ABG showed ___ w/ K 4.1 and lactate 0.8, he was switched to BiPAP. His mental status did not improve on BiPAP so he was intubated with etomidate without complication. Past Medical History: Past medical history: - Pancreatic neuroendocrine tumor s/p distal pancreatectomy and splenectomy - HTN - hypercholesterolemia - OSA - Hepatic steatosis - Osteoarthritis - Hypogonadism Past surgical history: - ___ lap distal pancreatectomy with splenectomy (___) - Lap chole - Appendectomy - Lumbar disc surgery - thyroid resection - right inguinal herniorrhapy, umbilical herniorrhaphy Social History: ___ Family History: - Father - pancreatic CA, melanoma Physical Exam: ADMISSION PHYSICAL EXAM ======================= VITALS: Afebrile HR 113 BP 137/117 RR 17 93% on ___ GENERAL: Somnolent, but answering some questions appropriately prior to intubation. BiPAP in place. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Decreased breath sounds L > R without rales, rhonchi, wheeze, cough CV: Irregular tachycardia, no m,r,g. Pericardial drain w/ minimal serosanguinous fluid. ABD: 2 JP drains w/ purulent drainage. No erythema around drain site. EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: Warm distal extremities, no erythema or swelling NEURO: CN ___ b/l, ___ strength bilateral wrists, finger grasp, biceps, ankles. DISCHARGE PHYSICAL EXAM ======================= Vitals: 98.0 142/73 81 17 95RA GENERAL - Alert, interactive, NAD HEENT - NC/AT HEART - ___ systolic murmur loudest in LUSB, nl ___, RRR LUNGS - CTAB anteriorly, slightly dull in bases bilaterally ABDOMEN - ___, + bowel sounds, not tender; 3 JP drains in LUQ and left flank draining purulent material EXTREMITIES - WWP, no edema NEURO - Awake, A&Ox3, CNs ___ grossly intact LINES/TUBES: Dobhoff Pertinent Results: ADMISSION LABS ============== ___ 12:30PM BLOOD ___ ___ Plt ___ ___ 12:30PM BLOOD ___ ___ Im ___ ___ ___ 12:30PM BLOOD Plt ___ ___ 02:22PM BLOOD ___ ___ ___ 12:30PM BLOOD ___ ___ ___ 12:30PM BLOOD ___ ___ 12:30PM BLOOD ___ ___ 12:30PM BLOOD cTropnT-<0.01 ___ 12:30PM BLOOD ___ ___ 03:30AM BLOOD ___ ___ 12:45PM BLOOD ___ ___ Base ___ NOTABLE LABS ============ ___ 12:30PM BLOOD ___ ___ 03:30AM BLOOD ___ ___ 05:27PM BLOOD ___ ___ 05:27PM BLOOD RheuFac-<10 ___ ___ 04:23AM BLOOD ___ ___ 05:27PM BLOOD HIV ___ ___ 03:16PM PERICARDIAL FLUID ___ ___ ___ 03:16PM PERICARDIAL FLUID ___ LD(LDH)-924 ___ ___ 05:30PM PLEURAL ___ ___ ___ 05:30PM PLEURAL ___ LD(___)-143 ___ MICRO ===== ___ 3:13 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: Reported to and read back by ___ ___ ___ 350PM. WORK UP PER ___ (___) ___. ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. ENTEROCOCCUS SP.. SPARSE GROWTH. ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH. ___ MORPHOLOGY. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE COMPLEX | ENTEROCOCCUS SP. | | ENTEROBACTER CLOACAE COMPLE | | | AMPICILLIN------------ <=2 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PENICILLIN G---------- 4 S PIPERACILLIN/TAZO----- 8 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S VANCOMYCIN------------ 2 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. IMAGING ======= TTE (___): FOCUSED STUDY/LIMITED VIEWS. The estimated right atrial pressure is at least 15 mmHg. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is a moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of ___, the pericardial effusion is larger. The heart rate is faster and the rhythm appears to be atrial fibrillation . CXR (___): Dense left basilar opacity likely combination of effusion with atelectasis noting superimposed infection would be possible. Enlarged cardiac silhouette potentially due to combination of cardiomegaly and/or pericardial effusion. Pulmonary vascular congestion. Enteric tube off the inferior field of view. TTE (___): The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. Trace 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 a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: 1) Trivial to very small pericardial effusion mostly located of the basal inferolateral wall without signs of tamponade physiology. Compared with the prior study (images reviewed) of ___, the pericardial effusion is much smaller. TTE (___): The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). The right ventricle is mildly dilated with low normal free wall motion. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. A prominent left pleural effusion is present. IMPRESSION: Trivial pericardial effusion. Compared with the prior study (images reviewed) of ___, the findings are similar. CXR (___): IMPRESSION: In comparison with the study of ___, the tip of the right IJ catheter again extends to the level of the carina in the upper to mid SVC. Cardiomediastinal silhouette is stable and there again is mild vascular congestion. Increased opacification at the left base with obscuration of the hemidiaphragm is consistent with pleural fluid and volume loss in the left lower lobe. No evidence of acute focal pneumonia. CXR (___): IMPRESSION: No pneumothorax is identified. Persisting small left pleural effusion with subjacent atelectasis. CT ABD PELVIS (___): IMPRESSION: 1. The 2 more lateral catheters in the left upper abdomen appear in good position. Given the thick consistency of the left upper abdominal collection, up sizing and repositioning the left most lateral drain can be considered. Another potential way of drainage would be through endoscopic placement of a drain through the stomach, for which gastroenterology service consultation would be considered to determine feasibility. 2. The most medial drain can be removed as it does not terminate in any collection. 3. Minimal decrease in size of left upper abdominal gas containing collection. Up sizing the left most lateral catheter can be considered as well as repositioning it more cranially and posteriorly. 4. Decreased size left diaphragmatic crus collections with no drains in place. 5. Decreased left side pleural fluid. DISCHARGE LABS ============== ___ 05:25AM BLOOD ___ ___ Plt ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon 12 6 CAP PO Q8H 2. Diltiazem 30 mg PO Q6H 3. Lantus (insulin glargine) 23 U subcutaneous DAILY 4. HumuLIN R ___ (insulin regular human) 5 U injection Q6H 5. Senna 8.6 mg PO BID:PRN constipation 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 7. ___ Neb 1 NEB NEB Q6H:PRN Shortness of breath 8. Enoxaparin Sodium 100 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 9. Metoprolol Tartrate 50 mg PO Q6H 10. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H 11. Pantoprazole 40 mg PO Q24H 12. Simvastatin 20 mg PO QPM 13. Tamsulosin 0.4 mg PO QHS 14. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 15. LOPERamide 2 mg PO TID:PRN Diarrhea 16. Bisacodyl 10 mg PO DAILY:PRN constipation 17. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 18. Ondansetron 4 mg PO Q8H:PRN nausea 19. ___ MD to order daily dose PO Frequency is Unknown Discharge Medications: 1. insulin syringes (disposable) 1 miscellaneous DAILY RX *insulin syringes (disposable) 1 mL Daily Disp #*1 Package Refills:*0 2. Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Lantus] 100 unit/mL 20 units Before bed Disp #*1 Vial Refills:*0 3. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 4. OneTouch SureSoft Lancing Dev (lancets) 1 miscellaneous DAILY RX *lancets [OneTouch Delica Lancets] 30 gauge Daily Disp #*1 Package Refills:*0 5. OneTouch Ultra Test (blood sugar diagnostic) 1 miscellaneous DAILY RX *blood sugar diagnostic [OneTouch Ultra Test] Daily Disp #*100 Strip Refills:*0 6. OneTouch Ultra2 ___ meter) 1 miscellaneous DAILY RX ___ meter [OneTouch Ultra2] Daily Disp #*1 Kit Refills:*0 7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 9. Bisacodyl 10 mg PO DAILY:PRN constipation 10. Enoxaparin Sodium 100 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 100 mg/mL 100 mg twice a day Disp #*60 Syringe Refills:*0 11. ___ Neb 1 NEB NEB Q6H:PRN Shortness of breath 12. LOPERamide 2 mg PO TID:PRN Diarrhea 13. Ondansetron 4 mg PO Q8H:PRN nausea 14. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 15. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H 16. Pantoprazole 40 mg PO Q24H 17. Senna 8.6 mg PO BID:PRN constipation 18. Simvastatin 20 mg PO QPM 19. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Pancreatic ___ Tumor ___ infection Diabetes mellitus Pericardial effusion Pleural effusion Atrial fibrillation Pulmonary embolism Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Followup Instructions: ___ Radiology Report INDICATION: ___ with ptx// ? acute process TECHNIQUE: Single portable view of the chest. COMPARISON: Chest x-ray from ___. FINDINGS: Enteric tube is seen passing off the inferior field of view. Right PICC is no longer visualized. Moderate to severe cardiac enlargement is noted. Central pulmonary vascular engorgement with indistinct pulmonary vascular markings. There is no pneumothorax. Retrocardiac is likely a combination of effusion with atelectasis and possible consolidation. No large right pleural effusion. Degenerative changes seen at the right shoulder. IMPRESSION: Dense left basilar opacity likely combination of effusion with atelectasis noting superimposed infection would be possible. Enlarged cardiac silhouette potentially due to combination of cardiomegaly and/or pericardial effusion. Pulmonary vascular congestion. Enteric tube off the inferior field of view. Radiology Report INDICATION: ___ year old man with hypoxia s/p intubation// s/p intubation TECHNIQUE: AP portable chest radiograph COMPARISON: ___ IMPRESSION: The tip of the endotracheal tube projects over the mid thoracic trachea. An enteric tube projects over the stomach. There is the tubing catheter which projects over the left hemithorax. There is an unchanged moderate to large left pleural effusion with subjacent atelectasis. The right lung is grossly clear. The size of the cardiac silhouette is enlarged. Radiology Report INDICATION: ___ year old man intubated for hypoxemic respiratory failure.// s/p CVL placement Contact name: ___: ___ TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: An enteric tube courses below the level the diaphragms but beyond the field of view of this radiograph. There is the catheter projecting over the left hemithorax unchanged. The tip of the endotracheal tube projects 1.4 cm above the carina and should be retracted. The tip of the right internal jugular central venous catheter projects over the mid SVC. The size the cardiac silhouette is enlarged but unchanged. Dense retrocardiac opacification likely represents pleural fluid and atelectasis. The right lung is grossly clear. No pneumothorax. IMPRESSION: The tip of the endotracheal tube projects 1.4 cm from the carina and should be retracted by approximately 1 cm. The tip of a new right internal jugular central venous catheter projects at the level of the mid SVC. Unchanged cardiopulmonary findings. Findings were communicated to and acknowledged by the patient's nurse at 22h37 by ___, MD. Radiology Report EXAMINATION: CT-GUIDED DRAINAGE CATHETER PLACEMENT. INDICATION: ___ year old man with H/O abdominal abscess w 2 JP drains. Here for hypoxic respiratory failure and purulent discharge from JP drains. Per surgery, recommend a third JP drain to L upper abdomen- "2 existing percutaneous drains are well located, and there is no undrained fluid adjacent to the pancreatic transection margin. However,there is air and undrained material adjacent to omentum in the left upper quadrant which is not adequately drained by his existing catheters." COMPARISON: CT abdomen/pelvis ___ PROCEDURE: CT-guided drainage catheter biopsy. OPERATORS: Dr. ___ fellow and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the 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 supine position on the CT scan table. Limited preprocedure CT scan was performed to localize the collection. Based on the CT findings an appropriate skin entry site for the drain placement was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was inserted into the collection. A sample of fluid was aspirated, confirming needle position within the collection. 0.038 ___ wire was placed through the needle and needle was removed. This was followed by placement of ___ Exodus pigtail catheter into the collection. The plastic stiffener and the wire were removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via CT fluoroscopy. Approximately 25 cc of greenish thick purulent fluid was aspirated with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to suction bulb. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 11.6 s, 35.6 cm; CTDIvol = 20.9 mGy (Body) DLP = 717.1 mGy-cm. 2) Spiral Acquisition 7.6 s, 23.4 cm; CTDIvol = 19.4 mGy (Body) DLP = 427.5 mGy-cm. 3) Stationary Acquisition 0.4 s, 1.4 cm; CTDIvol = 3.8 mGy (Body) DLP = 5.4 mGy-cm. 4) Stationary Acquisition 5.4 s, 1.4 cm; CTDIvol = 113.3 mGy (Body) DLP = 163.2 mGy-cm. Total DLP (Body) = 1,324 mGy-cm. SEDATION: Moderate sedation and monitoring were provided by the ICU nurse as well as the Radiology nurse. The total intra-service time of 30 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: 1. Left upper quadrant large collection containing gas bubbles. Drainage catheter along the most inferior portion of it. 2. Bilateral small pleural effusions. Trace of pericardial effusion. 3. Esophageal tube in place. Left upper quadrant drainage catheters x2 within additional drainage catheter placed today. 4. Nonobstructing renal calculi. IMPRESSION: Successful CT-guided placement of ___ pigtail catheter into the collection. Samples were sent for microbiology evaluation. Radiology Report INDICATION: ___ year old man with pancreatic tumor s/p distal pancreatectomy/splenectomy, here with hypoxemia/AMS now intubated, found to have R wrist pain and swelling.// effusion? r//o fracture COMPARISON: None IMPRESSION: No acute fractures or dislocations are seen. There are severe degenerative changes the first CMC and triscaphe joints. There is normal osseous mineralization.Chondrocalcinosis is seen. Radiology Report INDICATION: ___ year old man with worsening hypoxia 40% to 100% facetent.// Concern for worsening pulmonary edema vs. aspiration vs. atelectasis COMPARISON: Radiographs from ___ IMPRESSION: Endotracheal tube has been removed. There is a feeding tube and right IJ central line which are in unchanged position. There is cardiomegaly. There is a left retrocardiac opacity. There is mild pulmonary edema, stable. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with hypoxemic respoiratory failure// interval changes IMPRESSION: In comparison with the study of ___, the monitoring and support devices are essentially unchanged, as is the appearance of the heart and lungs. Radiology Report EXAMINATION: Portable chest x-ray INDICATION: ___ year old man s/p panc/splenectomy// R shoulder dislocation TECHNIQUE: Portable chest x-ray COMPARISON: Previous portable chest x-ray from ___ FINDINGS: Monitoring and supporting devices are unchanged. The heart is enlarged. There is increased left retrocardiac density, possibly atelectasis. There is subsegmental atelectasis at the right lung base. There is stable mild pulmonary edema. Degenerative changes are seen in the right shoulder. IMPRESSION: Cardiomegaly. Increased left retrocardiac density. Mild pulmonary edema appear Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ s/p robotic distal panc/splenectomy for PNET, c/b panc fistula s/p ___ drains, bleeding from third order middle colic s/p embol, Afib, PE, now w/ hypercarbic resp failure.// L pleural effusion L pleural effusion IMPRESSION: Right internal jugular line tip is at the level of superior SVC. Heart size and mediastinum are unchanged. There is interval improvement, at least partial of the left retrocardiac atelectasis and more central position of the mediastinum. There is mild vascular congestion but no overt pulmonary edema. No pneumothorax. Radiology Report INDICATION: ___ M status post robotic distal panc/splenectomy for PNET, c/b pancreatic fistula status post ___ drains, bleeding from third order middle colic status post emboli, Afib, PE, now with hypercarbic respiratory failure. Ensure Dobhoff in right position. Thank you TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: CTA chest abdomen pelvis from ___, abdominal radiograph from ___ and ___ FINDINGS: The Dobhoff tube is seen with its tip projecting over the left mid abdomen. This is an expected position if within the duodenum, however cannot exclude that Dobhoff is within the stomach. Dobhoff does appear in similar position compared to CT from ___ in which was seen within the duodenum. 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. There are 3 pigtail drains overlying the left upper quadrant. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Dobhoff tube projecting over the left mid abdomen in expected position. Cannot exclude the Dobhoff is within the gastric lumen, however it appears in similar position to prior CT from ___. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ s/p robotic distal panc/splenectomy for PNET, c/b panc fistula s/p ___ drains, bleeding from third order middle colic s/p embol, Afib, PE, now w/ hypercarbic resp failure.// Ensure central line still in place. Radiology technician aware because already on floor. Thank you IMPRESSION: In comparison with the study of ___, the tip of the right IJ catheter again extends to the level of the carina in the upper to mid SVC. Cardiomediastinal silhouette is stable and there again is mild vascular congestion. Increased opacification at the left base with obscuration of the hemidiaphragm is consistent with pleural fluid and volume loss in the left lower lobe. No evidence of acute focal pneumonia. Radiology Report INDICATION: ___ year old man with effusion s/p ___// PTX TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of a right internal jugular central venous catheter projects over the upper SVC. Multiple drainage catheters project over the left upper quadrant. There is a small left pleural effusion with subjacent atelectasis/consolidation. No pneumothorax is identified. The right lung is clear. The size and appearance of the cardiac silhouette is unchanged. Marked degenerative changes around the right glenohumeral joint. IMPRESSION: No pneumothorax is identified. Persisting small left pleural effusion with subjacent atelectasis. Radiology Report EXAMINATION: CT ABDOMEN/PELVIS WITH CONTRAST. INDICATION: ___ year old man with PNET tumor resection and persistent left upper abdominal infection with 3 JP drains; there is leakage around one of JP sites, looking for drain location with thoughts of possible capsizing. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.4 s, 54.2 cm; CTDIvol = 20.4 mGy (Body) DLP = 1,105.0 mGy-cm. 2) Stationary Acquisition 5.1 s, 0.5 cm; CTDIvol = 27.9 mGy (Body) DLP = 14.0 mGy-cm. Total DLP (Body) = 1,119 mGy-cm. COMPARISON: Multiple prior CTs with the most recent dating ___. FINDINGS: LOWER CHEST: Interval decreased size left-sided pleural effusion. Left basal atelectasis. Trace pericardial effusion. HEPATOBILIARY: Unchanged focal area of enhancement in segment ___, probably hemangioma. Remainder of the liver appears unchanged with scattered cysts. No intrahepatic or extrahepatic bile ductal dilatation. Post cholecystectomy. PANCREAS: Visualized pancreatic head appears unremarkable. Post resection remainder the pancreas. SPLEEN: Post splenectomy. ADRENALS: Adrenals are unremarkable. URINARY:No hydronephrosis. No nephrolithiasis. Under distended urinary bladder with presence of foci of air related to the Foley catheter placed. GASTROINTESTINAL: Esophageal tube terminates within the third part of the duodenum. No dilated loops of small bowel. Scattered colonic diverticulosis without diverticulitis. PERITONEUM: Re-demonstration of moderate-size left upper abdominal collection containing thick material mixed with gas with interval decrease in size measuring 14.4 x 6.8 x 9.3 cm compared to 17.6 x 7 x 11.4 cm. There has been interval placement of a third pigtail catheter. 3 pigtail catheters present in the left upper abdomen: Most central terminates between the liver on the lesser curvature of the stomach (is not located within any collection) can be removed. Lateral to it is a catheter that terminates within the left upper abdominal collection (appears in good position) and the third most lateral catheter, drained the most central collection (posterior to the stomach) and coils into the left upper abdominal collection. The latter 2 catheters are in good position. The third catheter had notable leakage around the tube. This tube can be upsized. Given the thick nature of the material of this collection another consideration would be placing a drainage catheter through the stomach into the collection endoscopically. Posteriorly along the left diaphragmatic crus there is re-demonstration of rim enhancing loculated collections with interval decrease in size measuring 5.2 x 3 cm compared to 7 x 3.9 cm. Very small left lower anterior abdominal wall collection measures 4.6 x 2.3 cm, decreased in size compared to previously. LYMPH NODES: No retroperitoneal adenopathy. Scattered prominent mesenteric lymph nodes. VASCULAR: Markedly atherosclerotic abdominal aorta with normal caliber. Patent intra-abdominal branches. PELVIS: Enlarged prostate. Rectum is unremarkable. BONES:Degenerative changes of the lumbar spine. SOFT TISSUES: Mild subcutaneous edema. Injection granulomas lower abdomen. IMPRESSION: 1. The 2 more lateral catheters in the left upper abdomen appear in good position. Given the thick consistency of the left upper abdominal collection, up sizing and repositioning the left most lateral drain can be considered. Another potential way of drainage would be through endoscopic placement of a drain through the stomach, for which gastroenterology service consultation would be considered to determine feasibility. 2. The most medial drain can be removed as it does not terminate in any collection. 3. Minimal decrease in size of left upper abdominal gas containing collection. Up sizing the left most lateral catheter can be considered as well as repositioning it more cranially and posteriorly. 4. Decreased size left diaphragmatic crus collections with no drains in place. 5. Decreased left side pleural fluid. Radiology Report INDICATION: ___ year old man with 3 JP drains for peripancreatic fluid collections, needs drain upsizing with ___// ___ year old man with 3 JP drains for peripancreatic fluid collections, needs drain upsizing with ___. COMPARISON: CT abdomen dated ___ PROCEDURE: CT-guided drainage of left upper quadrant abscess OPERATORS: Dr. ___, MD, radiology trainee and Dr. ___ ___, MD, attending radiologist. Dr. ___, MD personally supervised the trainee during the key components of the 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 supine position on the CT scan table. Limited preprocedure CT scan was performed to localize the collection. 2- 12 ___ drainage catheters, 1 in the midline and another in the left upper quadrant located adjacent to each other on the skin were identified. The catheter extending from the left of the midline into the fluid collection was cut and a 0.038 ___ wire was placed through this catheter and coiled into the deeper portion of the collection. Another 12 ___ drainage catheter over a plastic stiffener was placed into the deeper portion of this collection over the ___ wire and approximately 30 mL of pus was aspirated. No samples were sent. The plastic stiffener and the wire were removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via CT fluoroscopy. Approximately 30 cc of purulent fluid was aspirated. The catheter was secured by a StatLock. The catheter was attached to bag. Sterile dressing was applied. The midline 12 ___ drainage catheter was not removed as a small amount of purulent discharge was noted in the JP drain connected to this catheter. The procedure was tolerated well, and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 7.1 s, 21.9 cm; CTDIvol = 16.5 mGy (Body) DLP = 340.3 mGy-cm. 2) Stationary Acquisition 2.2 s, 1.4 cm; CTDIvol = 22.6 mGy (Body) DLP = 32.5 mGy-cm. Total DLP (Body) = 383 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 2 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 10 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: The left upper quadrant 12 ___ drainage catheter was exchanged and a similar ___ catheter was repositioned into a deeper portion of the collection and approximately 30 mL of purulent fluid was aspirated. The abscess cavity was irrigated till clear fluid return was noted. The midline drainage catheter was not removed because of persistent purulent fluid within the JP drain connected to this catheter. IMPRESSION: 1. Successful CT-guided repositioning of a 12 ___ pigtail catheter into the left upper quadrant collection. 30 mL of purulent fluid was aspirated. The cavity was irrigated till clear fluid return noted. Postprocedure images demonstrated a small residual collection in the most dependent portion of this collection which as the patient moves around should be drained via the existing position of the pigtail. 2. The midline 12 ___ drainage catheter was not removed as a small amount of purulent fluid was noted within the JP drain connected to this catheter. 3. The patient with stood the procedure well and was transferred back to the floor in a hemodynamically stable condition. Gender: M Race: WHITE Arrive by UNKNOWN Chief complaint: Altered mental status, Hypoxia Diagnosed with Sepsis, unspecified organism temperature: nan heartrate: 100.0 resprate: 28.0 o2sat: 97.0 sbp: 113.0 dbp: 76.0 level of pain: UTA level of acuity: 1.0
Dear ___, You were admitted to the hospital from rehab with confusion. This confusion was due to high levels of carbon dioxide in your blood. You were in the ICU and needed oxygen for a while, but improved by the time you left the hospital. The fluid around your pancreas became infected, and you were treated with strong antibiotics for two weeks. You had an additional drain placed, which helped drain the infected fluid. The will keep these drains until you are seen by the surgeons, flushing them with saline several times a day. You developed fluid around your heart and left lung during this admission. The fluid was drained from both places and did not come back. We did not find that exact cause of this, but it may have been related to the infection in your abdomen. Your diabetes was managed with insulin in the hospital. You are being discharged with diabetes supplies. Please inject 20 units of Lantus every night. Check your blood sugar before you eat/drink each morning and once after you eat/drink in ___. Bring these numbers with you to your PCP and they ___ adjust your insulin. You were started on a different blood thinner, Lovenox, this admission for you ___ and pulmonary embolism. You will inject this medicine twice a day. Surgery ___ with Dr. ___ able to be arranged in the hospital. Please call ___ to set up an appointment time in the next ___ weeks. It was a privilege to care for you in the hospital, and we wish you all the best. Sincerely, Your ___ Health Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aristocort Forte / Lidocaine / Polyethylene Glycol And Derivatives / Novocain Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: ___: Emptying of lap band by bariatric surgery: 1cc removed, emptying the band completely ___: Right heart catheterization History of Present Illness: PCP: ___ HPI: ___ with h/o of lap band in ___, and partial nephrectomy for incidentally discovered renal mass (path: clear cell RCC) in ___ (___) with several recent hospitalizations for PNA who now presents with increased SOB and new acute renal failure. To summarize recent hospitalizations, she reports fevers/chills 1mo prior when she was admitted to OSH and discharged on Levaquin. Her symptoms recurred 3 weeks later when she was admitted to ___ with PNA, felt to be likely aspiration, and treated with IV Abx and discharged on ___ ___, with PICC line to recieve course of Vanc/Zosyn to finish on ___ per OSH records. Boyfriend has been administering infusions at home. Since that time she endorses SOB at baseline (on home 2L O2 since d/c from ___ on ___, no fevers, +fatigue. Endorses moderate fluid intake, denies any changes in bowel habits, urinary frequency, hematuria, or dysuria. Does endorse feeling bloated. She presented to the ___ ED afebrile, labs notable for Cr 2.9 ___ 0.8-1.2). She was seen by bariatric surgery who removed 1cc from lap band, follwed by barium swallow revealing good band position and no leakage, plan for stage 3 bariatric diet and will follow up in 3wk as outpt. CXR at that time revealed lingular and left lower lobe consolidation concerning for PNA (unknown comparison to OSH), and new small left pleural effusion. Subtle righ basal opacity similar to prior. Pt given 1g Vanc and admitted to medicine. She is comfortable, complaining of bloating, but with baseline SOB satting well on 2L O2. Past Medical History: 1. Asthma: on home inhalers. 2. Hypertension 3. Chronic Constipation - controlled with laxatives 4. lap band in ___, lost 55 pounds. Does endorse GERD Sx 5. three shoulder surgeries - last was ___ 6. Robotic partial nephrectomy ___ - clear cell RCC, negative margins. Due for f/u ___ 7. Cardiac stent ___ after angina. Social History: ___ Family History: Mother with unknown kidney problem, DM, HTN Physical Exam: ADMISSION EXAM: Vitals: T: 98 BP: 148/60 P: 60 R: 16 O2: 93% 3L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased BS at LLL 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. Bandaged site in LUQ c/d/i Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE EXAM: Same as above except: Lungs: improved air movement, still mildly decreased breath sounds over L lung base Pertinent Results: ___ 08:50PM GLUCOSE-78 UREA N-15 CREAT-2.9*# SODIUM-138 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-21* ANION GAP-17 ___ 08:50PM WBC-8.5 RBC-3.85* HGB-11.2* HCT-34.9* MCV-91 MCH-29.0 MCHC-32.0 RDW-14.7 ___ 08:50PM NEUTS-70.4* ___ MONOS-6.1 EOS-2.3 BASOS-0.7 ___ 08:50PM PLT COUNT-306 ___ 08:30PM URINE COLOR-Straw APPEAR-Hazy SP ___ ___ 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ Vancomycin trough: 74.8 ___ CXR IMPRESSION: Lingular and left lower lobe consolidation worrisome for pneumonia, new since the prior study. New small left pleural effusion. Subtle right basal opacity similar compared to prior. Recommend followup to resolution. Upper GI IMPRESSION: Normal position of the gastric band with patent stoma. MICRO: ___ UCx negative ___ BCx negative STUDIES/TESTING: ___ ECHO: The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. No late contrast is seen in the left heart (suggesting absence of intrapulmonary shunting). The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension (50mmHg). There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. ___: HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.78 m2 HEMOGLOBIN: 9.9 gms % FICK **PRESSURES RIGHT ATRIUM {a/v/m} ___ RIGHT VENTRICLE {s/ed} ___ PULMONARY ARTERY {s/d/m} ___ PULMONARY WEDGE {a/v/m} ___ **CARDIAC OUTPUT HEART RATE {beats/min} 60 RHYTHM SINUS CARD. OP/IND FICK {l/mn/m2} 3.35 FICK **% SATURATION DATA (FL) RA HIGH 65 PA MAIN 62 AO COMMENTS: 1. Resting hemodynamics revealed elevated left and right-sided pressures. The RA pressure was elevated at 11 mmHg and the PA mean pressure was elevated at 31 mmHg. The wedge pressure was also elevated at 17 mmHg. 2. Oxygen saturations measured in the pulmonary artery and right atrium did not reveal a shunt. FINAL DIAGNOSIS: 1. Elevated right and left sided filling pressures. 2. Moderate to severe pulmonary hypertension. Medications on Admission: 1. Senna 1 TAB PO BID:PRN constipation 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 3. Simvastatin 10 mg PO DAILY 4. Tiotropium Bromide 1 CAP IH DAILY 5. Citalopram 40 mg PO DAILY 6. traZODONE 200 mg PO HS:PRN insomina 7. Omeprazole 40 mg PO DAILY 8. PrimiDONE 50 mg PO BID 9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 10. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation Inhalation daily Discharge Medications: 1. Citalopram 40 mg PO DAILY 2. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 3. PrimiDONE 50 mg PO BID 4. Senna 1 TAB PO BID:PRN constipation 5. Tiotropium Bromide 1 CAP IH DAILY 6. traZODONE 200 mg PO HS:PRN insomina 7. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation INHALATION DAILY 9. Simvastatin 10 mg PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 12. Metoprolol Tartrate 25 mg PO BID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Aspiration PNA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAM: Chest, frontal and lateral views. CLINICAL INFORMATION: ___ female with history of pneumonia with increased shortness of breath. ___. FINDINGS: Frontal and lateral views of the chest were obtained. A right-sided PICC is seen, distal aspect not well appreciated, but likely terminating in the region of the mid-SVC. In the interval since the prior study, there has been development of consolidation in the left lower lobe and extending into the lingula. The blunting of the left costophrenic angle is concerning for a small pleural effusion. Subtle right basal opacity is similar to possibly minimally improved as compared to the prior study. In the interval since the prior study, the hila appears slightly more prominent. Barium is seen in the partially visualized colon in the upper abdomen from recent prior barium study. IMPRESSION: Lingular and left lower lobe consolidation worrisome for pneumonia, new since the prior study. New small left pleural effusion. Subtle right basal opacity similar compared to prior. Recommend followup to resolution. Radiology Report INDICATION: ___ female with laparoscopic gastric band, now with aspiration pneumonia, status post loosening of the band. COMPARISON: ___. TECHNIQUE: Fluoroscopic images of the gastric band were obtained before and after oral administration of thin barium. The ingredients of the thin barium suspension were reviewed and the suspension administered does not contain polyethylene glycol. FINDINGS: Scout image demonstrates residual contrast within the colon. Contrast passes freely through the gastric band without evidence for hold-up, leak, or malpositioning. IMPRESSION: Normal position of the gastric band with patent stoma. Radiology Report COMPUTED TOMOGRAPHY OF THE THORAX. INDICATION: Recurrent pneumonia. COMPARISON: Outside hospital CT from ___. TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration, no administration of intravenous contrast material, multiplanar reconstructions. FINDINGS: The examination is compared to ___. No incidental thyroid findings. A right PICC line is in place. No supraclavicular, infraclavicular, or axillary lymphadenopathy. All mediastinal lymph nodes, most of which have a fatty hilus, are normal in size. The largest mediastinal lymph node is in precarinal location and has a maximum diameter of 9 mm. No enlarged lymph nodes along the aorta and the esophagus. The heart is borderline in size. There are relatively severe coronary calcifications and mild aortic valve calcifications. A small pericardial effusion is present. The large mediastinal vessels have normal diameters, the descending aorta shows moderate calcifications. A small hiatal hernia is present, status post gastric banding. Contrast material in the colon. No other noticeable pathologies in the upper abdomen. Moderate degenerative vertebral disease but no evidence of compression fractures or true lytic lesions. Normal appearance of the sternum. No rib fractures. Evaluation of the lung parenchyma is limited by moderate respiratory motion artifacts. A small left pleural effusion is present, the extent of the effusion is comparable to the previous CT examination. On the right, no pleural effusion is present but bilaterally, minimal pleural irregularities are noted (for example on series 4, image 162 and series 4, image 133). Overall, the lung attenuation continues to be inhomogeneous but overall increased, with minimally increased diameters of the interstitial structures, notably in the lung apices, where minimally thickened interlobular septa increase the visibility of secondary pulmonary lobules (4, 47). The areas of parenchymal abnormalities in the lingula and the left lower lobe are almost unchanged in extent and severity. The areas of abnormality consist of a very mixed pattern, including predominantly peribronchial consolidations, ground-glass opacities, areas of linear atelectasis, and nodular components. The medial aspects of the abnormalities have atelectatic parts, adjacent to the left heart border, leading to mild volume reduction of the left hemithorax. The airways are patent. There is no focal airway narrowing or endobronchial lesion visible. The airways, however, generally show mild irregularities of their walls and mild generalized thickening. Predominating in the right upper lobe, emphysema of moderate extent is seen. Several non-characteristic nodular lesions in the right lung show a tendency to decrease in size as compared to the previous examination (for example on series 4, image 66 and series 4, image 71). The biggest lesion is a 5-mm right upper lobe ground-glass nodule (series 4, 70). Areas of atelectasis at the right lung base are overall unchanged. No other changes are identified. IMPRESSION: Extensive predominantly lingular and left lower lobe parenchymal opacity that suggests chronic infection and is accompanied by a small pleural effusion. No morphological reason for these changes can be identified, notably there is no evidence of focal airway narrowing or airway obstruction. Mild chronic airways disease and moderate right upper lobe predominant pulmonary emphysema, with several mostly ground-glass nodules (the biggest of which measures 5 mm in diameter and is located in the right upper lobe) that should be followed in approximately three months. Unchanged areas of atelectasis at the right lung base. Mild pericardial effusion, moderate-to-severe coronary calcifications. Mild aortic valve calcifications. Right PICC line. No mediastinal adenopathy. Status post gastric banding, mild hiatal hernia. Radiology Report INDICATION: Status post gastric banding with persistent hypoxia and pulmonary infiltrates. Evaluate for upper esophageal aspiration. FINDINGS: A single view of the chest shows a persistent consolidation of the left base, unchanged from the prior radiographs. A linear opacity at the right base is likely atelectasis. With thin barium, multiple swallows were performed. There is a small amount of penetration, best evaluted on the lateral views, but no evidence of aspiration. Esophageal motility is normal. There is no holdup of contrast at the GE junction or the gastric band. Contrast flowed freely into the stomach. IMPRESSION: No evidence of aspiration. Small amount of penetration. Radiology Report INDICATION: ___ female with persistent hypoxia, unable to get V/Q or CT scan for PE. Evaluate for evidence of DVT. COMPARISON: None available. TECHNIQUE: Grayscale, color Doppler, and spectral analysis of the venous systems of both lower extremities was performed. FINDINGS: There is normal compression and augmentation of the common femoral veins, superficial femoral, popliteal, peroneals, and posterior tibial veins bilaterally. There is a normal phasicity of the common femoral veins bilaterally as well. IMPRESSION: No evidence of deep vein thrombosis in either the right or the left lower extremity. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: SHORTNESS OF BREATH Diagnosed with SHORTNESS OF BREATH temperature: nan heartrate: 51.0 resprate: 16.0 o2sat: 100.0 sbp: 146.0 dbp: 60.0 level of pain: 0 level of acuity: 2.0
Dear Ms ___, It was a pleasure taking care of you during your hospitalization at ___. You were admitted because of your shortness of breath and recurrent pneumonia, which we treated with the same antibiotics you had been getting at home. While you were here, the bariatric surgery team was involved and removed fluid from your lap band, which improved your symptoms and will help decrease your risk of other pneumonias. You will remain on a bariatric diet for 3 weeks, when you will follow up with the bariatric team as below. While you were here, we were unable to take you off oxygen without your oxygen levels decreasing. Because of this, we did an ECHO (ultrasound) of your heart which revealed high blood pressure in the arteries in your lungs (pulmonary artery hypertension). You will need to follow up with the lung doctors (___) as below. You then had a right heart catheterization which showed that one of your valves is leaky; you will need to follow up with the heart doctors (___) as below. In terms of your medications: You should CONTINUE taking all your other medications as you had been doing prior to being hospitalized. In terms of your home oxygen, please use your pulse oximeter while you are at home. We would like your pulse oxygen to remain above 92%. While you do not feel short of breath when your oxygen saturation is low, please continue taking your albuterol inhaler as needed and keep your oxygen on.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lactose / morphine Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo male with PMH notable for EtOH dependence, opiate dependence, EtOH cirrhosis (no biopsy) c/b ascites, with recent admission (___) for abdominal pain, transaminitis and pancreatitis, with workup notable for unremarkable RUQ U/S (other than cirrhotic changes), EGD notable for chemical gastropathy w/o PUD/varices, who presents today with increased abdominal pain in the setting of recent 2 week EtOH binge. Patient presented to ED for further evaluation. In ED patient's initial VS 98.0 104 135/79 16 95%RA. Patient had moderate abdominal tenderness on exam. Labs were notable for WBC 5, Hct 40.2, platelet 107, Cr 0.5, ALT 85, AST 246, AP 534, Lipase 154, Tbili 2.1, EtOH 296. Pt reported tactile disturbances and hearing voices consistent with prior withdrawal, denied SI/HI. He was given 4mg IV Morphine x2 and 2mg IV Ativan. Patient was admitted to medicine for further management. VS prior to transfer were 98.1, 88, 135/94, 18, 96%RA. On the floor, patient was sleeping but arousable. Vital signs were 98.1 127/80 79 18 98%RA. Patient reported several days nausea and abdominal pain, occassional vomitting, denied BRBPR, tarry stools. Past Medical History: - EtOH abuse - EtOH Cirrhosis (not biopsy proven) - Gastritis - Asthma (prior intubations) - Opiate dependence on suboxone Social History: ___ Family History: Uncle died of EtOH cirrhosis. No other known family ailments on maternal side, does not know about father's side of family Physical Exam: Admission Exam: Vitals: 98.1 127/80 79 18 98%RA General: Awake, alert, NAD HEENT: MMM, oropharynx clear Lungs: CTAB CV: RRR no m/r/g Abdomen: +BS, soft, diffuse tendering to palpation, non-distended, no rebound tenderness or guarding, no organomegaly Ext: WWP, no edema Psych: patient currently denies hearing voices, does report feeling like animals are crawling on him Discharge Exam: General: Awake, alert, NAD Lungs: CTAB CV: RRR no m/r/g Abdomen: +BS, soft, nontender, non-distended, no rebound tenderness or guarding Ext: WWP, no edema Pertinent Results: Admission Labs: ___ 04:00AM BLOOD WBC-5.0 RBC-4.80 Hgb-12.6* Hct-40.2 MCV-84 MCH-26.3* MCHC-31.5 RDW-18.8* Plt ___ ___ 04:00AM BLOOD Neuts-53.8 ___ Monos-4.7 Eos-5.3* Baso-0.7 ___ 07:35AM BLOOD ___ PTT-42.8* ___ ___ 04:00AM BLOOD Glucose-86 UreaN-6 Creat-0.5 Na-144 K-3.4 Cl-107 HCO3-23 AnGap-17 ___ 04:00AM BLOOD Lipase-154* ___ 04:00AM BLOOD ALT-85* AST-246* AlkPhos-534* TotBili-2.1* ___ 04:00AM BLOOD Albumin-4.5 Calcium-8.7 Phos-3.5 Mg-1.8 ___ 04:00AM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Discharge Labs: ___ 07:10AM BLOOD WBC-3.3*# RBC-4.26* Hgb-11.4* Hct-36.2* MCV-85 MCH-26.8* MCHC-31.5 RDW-18.8* Plt ___ ___ 05:13AM BLOOD ___ PTT-43.5* ___ ___ 06:00AM BLOOD Glucose-104* UreaN-11 Creat-0.6 Na-140 K-4.0 Cl-102 HCO3-27 AnGap-15 ___ 06:00AM BLOOD ALT-54* AST-86* AlkPhos-491* TotBili-2.4* ___ 06:00AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.7 ___ 05:13AM BLOOD HIV Ab-NEGATIVE Urine: ___ 06:40AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG ___ 06:40AM URINE RBC-1 WBC-0 Bacteri-FEW Yeast-NONE Epi-0 ___ 06:40AM URINE CastHy-1* ___ 06:40AM URINE Mucous-OCC Micro: ___ Blood culture x 2: PENDING ___ Abdominal U/S: IMPRESSION: 1. Cirrhosis with secondary findings of portal hypertension including reversal of portal venous flow and recannulization of the umbilical vein, as well as splenomegaly. Trace ascites. 2. Unremarkable gallbladder. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Cetirizine *NF* 10 mg Oral daily 2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 3. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob or wheeze 4. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob or wheeze 2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 3. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Lactulose 30 mL PO DAILY RX *lactulose 20 gram/30 mL 30 ml by mouth daily Disp #*1 Bottle Refills:*0 5. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID 8. Cetirizine *NF* 10 mg Oral daily 9. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Alcohol withdrawal Pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAM: Abdominal ultrasound with liver Doppler. CLINICAL INFORMATION: ___ female with abdominal pain in the setting of recent ETOH binge, found to have transaminitis and elevated lipase, question gallbladder pathology, question size of spleen, question evidence of cirrhosis, question ascites. ___. FINDINGS: Sonographic evaluation of the liver was obtained including color and spectral Doppler analysis. The liver is diffusely echogenic and coarsened in echotexture consistent with cirrhosis, as also seen previously. No intra- or extra-hepatic biliary dilatation is seen. The common bile duct measures 0.5 cm in diameter. The gallbladder is relatively collapsed without evidence of intraluminal stone or sludge. No gallbladder wall thickening is seen. Trace perihepatic fluid is seen. The spleen is enlarged, measuring 17.5 cm in length. No free fluid was seen in the right or left lower quadrants. The pancreas is not well evaluated, partially obscured by overlying bowel gas. No pancreatic ductal dilatation is seen. LIVER DOPPLER: There is reversal of flow in the main portal vein and the right and left portal vein branches. Recanalized umbilical vein is again seen. The right, middle and left hepatic veins are patent. The main hepatic artery is also patent. IMPRESSION: 1. Cirrhosis with secondary findings of portal hypertension including reversal of portal venous flow and recannulization of the umbilical vein, as well as splenomegaly. Trace ascites. 2. Unremarkable gallbladder. Gender: M Race: HISPANIC/LATINO - GUATEMALAN Arrive by WALK IN Chief complaint: SUBSTANCE MISUSE/INTOXICATION Diagnosed with ALTERED MENTAL STATUS , ALCOHOL ABUSE-UNSPEC, ABDOMINAL PAIN LUQ, ACUTE PANCREATITIS temperature: 98.0 heartrate: 104.0 resprate: 16.0 o2sat: 95.0 sbp: 135.0 dbp: 79.0 level of pain: 0 level of acuity: 3.0
Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted with alcohol intoxication and pancreatitis. We gave you IV fluids, pain medicines, vitamins and medicines to help you detox safely. We slowly advanced your diet and you did well. It is important that you refrain from drinking alcohol to prevent this from happening again.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Humira / lisinopril Attending: ___. Chief Complaint: Left Leg Pain Major Surgical or Invasive Procedure: ___ Internal fixation L distal femur. History of Present Illness: ___ female who presents for left leg pain after a fall. She states that she tripped over her sandals today and fell onto her left side. She denies headstrike, LOC, CP, SOB. She feels well overall She has a hx of a remote R TKR ___ yearsr ago at ___) who was admitted this past ___ for repair of a femoral complete stress fracture, thought to be ___ bisphosphonate use. Her procedure was an intramedullary nail fixation Left intertrochanteric hip fracture on ___. Past Medical History: Past Medical History: Hypertension Hyperlipidemia Severe aortic stenosis Morbid obesity GERD Lower back pain Interstitial lung disease Rheumatoid arthritis Osteoporosis Monoclonal gammopathy Asthma Bronchiectasis Left arm fracture Past Surgical History left TKR left foot surgery Social History: ___ Family History: Mother deceased after age ___. Physical Exam: PHYSICAL EXAMINATION in ADM: General: NAD Vitals: T98.2 HR 78 BP 108/92 RR 16 Pox 99 RA LLE: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft compartments. TTP of distal thigh. - Full, painless AROM/PROM of hip and ankle. Limited ROM of knee ___ pain. - ___ fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ ___ pulses, foot warm and well-perfused Cor: RRR Pulm: Non-labored respirations Abd: Soft, nondistended PE in DC: AVSS NAD, A&Ox3 LLE: Incision well approximated. Fires ___. SITLT s/s/dp/sp/tibial distributions. 1+ DP pulse, wwp distally. Pertinent Results: n/p Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Furosemide 30 mg PO DAILY 6. Methotrexate 20 mg IM WEEKLY 7. PredniSONE 5 mg PO DAILY 8. Sertraline 25 mg PO DAILY 9. Orencia (abatacept) 125 mg/mL subcutaneous Weekly Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QPM Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 0.4 ml QPM Disp #*30 Syringe Refills:*0 5. Omeprazole 40 mg PO DAILY 6. OxyCODONE (Immediate Release) 2.5 mg PO TID:PRN Pain - Moderate RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth every four (4) hours Disp #*45 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Senna 8.6 mg PO BID 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 80 mg PO QPM 11. Fluticasone Propionate NASAL 1 SPRY NU DAILY 12. FoLIC Acid 1 mg PO DAILY 13. Furosemide 30 mg PO DAILY 14. Methotrexate 20 mg IM WEEKLY 15. Orencia (abatacept) 125 mg/mL subcutaneous Weekly 16. PredniSONE 5 mg PO DAILY 17. Ramelteon 8 mg PO DAILY:PRN agitation 18. Sertraline 25 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: periprosthetic fracture of L distal femur 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: DX TIB/FIB AND ANKLE/FOOT INDICATION: ___ woman status post fall with left distal femur fracture, tenderness to left ankle and midfoot. Evaluate for fracture TECHNIQUE: Left Tibia-fibula, two views Left ankle, three views Left foot, three views COMPARISON: Knee and tibia fibula radiographs ___ FINDINGS: Left tibia-fibula: There is a partially visualized total knee arthroplasty. No fractures or dislocations. Left ankle: No fractures or dislocations. Ankle mortise is congruent. Left foot: There are degenerative changes throughout midfoot and the first MTP and IP joints. There is prominent calcification along the plantar fascia. The bones are diffusely demineralized. There are vascular calcifications. IMPRESSION: No fracture or dislocation. Radiology Report INDICATION: ___ year old woman with fall, L thigh pain // please evaluate periprostetic fracture of distal femur TECHNIQUE: Axial CT images of the left thigh was obtained without IV contrast. DOSE: No IV contrast administered. COMPARISON: Left femur radiograph dated ___. FINDINGS: There is a comminuted longitudinally oriented fracture of the distal femoral shaft with mild anterior displacement and dorsal angulation of the distal fragment. The fracture extends distally to lie immediately proximal to the lateral proximal edge of the femoral prosthesis component (3:144). The intramedullary rod is intact without displacement or loosening. It courses from posterior to anterior such that the distal tip lies along the anterior portion of the distal femoral medullary cavity. There is a fissure like fenestration in the anterior cortex of the proximal femur (series 3, 47), which could represent a nondisplaced fracture, possibly an insufficiency fracture insufficiency fracture. The previously seen femoral mid diaphyseal insufficiency fracture is healing with bridging callus formation and a less conspicuous fracture line. The left knee total arthroplasty appears intact without hardware loosening or failure. Partially visualized left pelvis shows a small lucency in the anterior acetabulum (04:25) which is unlikely to be a fracture since there is no associated joint effusion or fat fluid level. Degenerative changes of the right hip are noted. There is vacuum phenomenon in the SI joint. The leg muscles are intact with mild diffuse atrophy, not uncommon in someone of this age. There is small joint effusion in the knee. There is mild vascular calcification. The partially visualized pelvis demonstrates diverticulosis without obvious diverticulitis. There is a Foley catheter in the bladder, with a small amount of air in the bladder. The bladder is decompressed. No free pelvic fluid or enlarged left iliac nodes are identified. Scattered vascular calcifications noted. Left buttock and cracked and granuloma noted in the subcutaneous fat. IMPRESSION: 1. Comminuted longitudinally oriented oblique fracture of the distal femoral shaft with mild anterior displacement and dorsal angulation of the distal fragment. 2. Small fissure-like fenestration in the anterior cortex of the proximal femur could represent a nondisplaced incomplete fracture, likely an early insufficiency fracture. 3. Interval healing of the known insufficiency fracture of the mid femoral diaphysis. Faint residual linear lucency is noted. 4. Intact intramedullary rod and total knee arthroplasty. No hardware loosening identified. 5. Linear lucency at the posterior edge of the anterior acetabular column is noted, without other findings to suggest acetabular fracture. Radiology Report EXAMINATION: FEMUR (AP AND LAT) LEFT IN O.R. INDICATION: LEFT FEMUR FX.ORIF TECHNIQUE: Intraoperative fluoroscopy images. COMPARISON: Left femur radiograph dated ___. FINDINGS: 3 intraoperative fluoroscopy images were available for review. Total fluoroscopy time of 94 seconds. The images demonstrate the distal femoral shaft fracture and placement of distal interlocking screws. For additional details, please see operative report. IMPRESSION: As above. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with placement of Right internal jugular central line // placement of Right internal jugular central line Contact name: ___: ___ placement of Right internal jugular central line IMPRESSION: Compared to chest radiographs ___ through ___. New right internal jugular catheter ends in the upper right atrium approximately 2.5 cm below the estimated location of the superior cavoatrial junction. Borderline cardiomegaly. Lungs grossly clear. Pleural effusions small if any. No pneumothorax. Patient has had T AVR. Gender: F Race: BLACK/CARIBBEAN ISLAND Arrive by AMBULANCE Chief complaint: s/p Fall, L Femur fracture Diagnosed with Displaced oblique fracture of shaft of left femur, init, Displaced comminuted fracture of shaft of left femur, init, Fall on same level, unspecified, initial encounter temperature: 98.2 heartrate: 78.0 resprate: 16.0 o2sat: 99.0 sbp: 108.0 dbp: 92.0 level of pain: 8 level of acuity: 2.0
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - touch down weight Bearing in left lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Physical Therapy: TDWB in LLE ROMAT Treatments Frequency: ___ & Rehab
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dark stools, fatigue Major Surgical or Invasive Procedure: EGD (___) Colonoscopy (___) History of Present Illness: ___ with prior history of LIGB with radiation proctitis s/p APC therapy, AVM's, CAD s/p CABG and recent BMS (1 wk ago), prostate cancer s/p RT, bleeding internal hemorrhoids, cirrhosis d/t NAFLD, celiac's disease, pancytopenia, and iron-deficiency anemia (req. iv iron therapy) who presents with fatigue over 5 days. He has had black tarry stools for the past 3 days with some BRBPR today. While unclear, but he was found to have Hct of 29.3 on ___. Baseline Hct around ___. In the ED, labs were significant for WBC3.3, Hct 22 (Hb 7.5), PLT 118. LFTs were only significant for AST 42. He was given 2 large-bore IVs. He was transfused 1U. He was given aspirin and Plavix ___ as well, which was required per Dr. ___. Patient was started on PPI. GI saw the patient in the ED and felt that he was safe to be on the floor. Currently, the patient reports feeling better after the unit of blood. Most of his GI records are at ___. The patient notes use of aspirin and Plavix since his cardiac cath and stent placement 8d ago. Last colonoscopy ___ years ago though unclear on findings. He has a history of Celiac's disease with frqeuent BMs (~4/day though more lately). Patient notes increasing fatigue that has been debilitating. No anxiety, lightheadedness, hematemesis, hematochezia, weight loss, anorexia, change in stool caliber, N/V, or NSAID use. At baseline, the patient has known radiation proctitis and internal hemorrhoids and has intermittent bright red blood per rectum. He has had issues with GI bleeding throughout the years. No fever/chills, nausea/vomiting. ROS: Negative except per HPI. Past Medical History: CAD Hx: CABG in ___ stress nuclear test in ___ showed 1mm ST depression with moderate exertion; echo in ___ shows LVEF>75% PMHx: celiac disease, nonalcoholic cirrhosis; Hx of radiation to prostate ___ years ago Pancytopenia felt secondary to cirrhosis. Cirrhosis caused possibly by nonalcoholic fatty liver associated with sprue. Nontropical sprue, under good control. Radiation proctitis -- received ___ treatment in ___. Status post upper endoscopy in ___ showing small varices. Status post colonoscopy in ___ showing radiation proctitis that was treated with APC and adenomas from the ascending colon that were removed. Status post carcinoma of the prostate treated with radiotherapy. Social History: ___ Family History: Heart disease Physical Exam: Admission Physical Exam: 98.8 120/58 91 20 96/RA GEN: NAD, laying in bed comfortably HEENT: dry oral mucosa, supple neck, no LAD COR: +S1S2, RRR, II/VI holosystolic murmur PULM: CTAB, no c/w/r ___: obese, soft, nontender, nondistended, no ascites or organomegaly appreciated, no caput medusae or spider angiomatas EXT: WWP, 2+ pulses distally Discharge Physical Exam: 98.6 111/51(96-129 / 38-65) 52(52-79) 18 98RA GEN: NAD, laying in bed comfortably HEENT: MMM, supple neck, no LAD COR: +S1S2, RRR, II/VI holosystolic murmur PULM: CTAB, no c/w/r ___: obese, soft, nontender, nondistended, no ascites or organomegaly appreciated, no caput medusae or spider angiomatas EXT: WWP, 2+ pulses distally, tenderness to palpation of left first toe without warmth or erythema, no palmar erythema NEURO: AOx3, alert and appropriate, no asterixis Pertinent Results: Admission Labs: ___ 12:05PM ___ PTT-36.1 ___ ___ 11:00AM GLUCOSE-239* UREA N-49* CREAT-1.2 SODIUM-142 POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-20* ANION GAP-19 ___ 11:00AM estGFR-Using this ___ 11:00AM ALT(SGPT)-28 AST(SGOT)-42* ALK PHOS-70 TOT BILI-0.9 ___ 11:00AM LIPASE-33 ___ 11:00AM cTropnT-<0.01 ___ 11:00AM ALBUMIN-4.1 ___ 11:00AM WBC-3.3* RBC-2.34*# HGB-7.5*# HCT-22.6* MCV-97 MCH-32.1* MCHC-33.1 RDW-15.9* ___ 11:00AM NEUTS-82.1* LYMPHS-12.6* MONOS-4.0 EOS-0.7 BASOS-0.6 ___ 11:00AM PLT COUNT-118* Pertinent Labs: ___ 11:00AM BLOOD WBC-3.3* RBC-2.34*# Hgb-7.5*# Hct-22.6* MCV-97 MCH-32.1* MCHC-33.1 RDW-15.9* Plt ___ ___ 12:47AM BLOOD Hgb-8.0* Hct-22.4* ___ 07:00AM BLOOD WBC-4.5 RBC-3.01*# Hgb-9.6* Hct-28.2*# MCV-94 MCH-32.1* MCHC-34.2 RDW-17.1* Plt ___ ___ 01:25PM BLOOD Hgb-11.3* Hct-32.5* ___ 09:00PM BLOOD Hgb-9.9* Hct-29.1* ___ 06:05AM BLOOD WBC-2.7* RBC-2.87* Hgb-9.1* Hct-26.0* MCV-91 MCH-31.6 MCHC-34.8 RDW-17.6* Plt ___ ___ 02:50PM BLOOD WBC-3.4* RBC-3.46* Hgb-10.9* Hct-31.6* MCV-91 MCH-31.5 MCHC-34.5 RDW-17.6* Plt ___ ___ 07:30AM BLOOD WBC-2.8* RBC-3.25* Hgb-10.2* Hct-29.3* MCV-90 MCH-31.2 MCHC-34.6 RDW-17.6* Plt ___ ___ 07:30AM BLOOD WBC-3.2* RBC-3.14* Hgb-10.3* Hct-28.6* MCV-91 MCH-32.8* MCHC-35.9* RDW-17.7* Plt Ct-94* ___ 05:25PM BLOOD Hgb-10.9* Hct-30.4* ___ 07:30AM BLOOD ___ PTT-36.3 ___ ___ 07:30AM BLOOD ___ PTT-35.4 ___ ___ 07:00AM BLOOD Glucose-132* UreaN-51* Creat-1.3* Na-146* K-3.9 Cl-110* HCO3-21* AnGap-19 ___ 06:05AM BLOOD Glucose-124* UreaN-42* Creat-1.3* Na-144 K-3.8 Cl-109* HCO3-21* AnGap-18 ___ 07:30AM BLOOD Glucose-147* UreaN-35* Creat-1.4* Na-143 K-3.8 Cl-107 HCO3-20* AnGap-20 ___ 07:30AM BLOOD Glucose-153* UreaN-25* Creat-1.3* Na-139 K-4.0 Cl-107 HCO3-22 AnGap-14 Discharge Labs: ___ 07:55AM BLOOD WBC-4.4 RBC-3.68* Hgb-11.9* Hct-34.5* MCV-94 MCH-32.3* MCHC-34.4 RDW-17.8* Plt Ct-93* ___ 07:55AM BLOOD Plt Ct-93* ___ 07:55AM BLOOD Glucose-142* UreaN-19 Creat-1.2 Na-140 K-4.3 Cl-107 HCO3-21* AnGap-16 ___ 07:55AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.1 Pertinent Micro/Path: None Pertinent Imaging: None (except ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Gemfibrozil 600 mg PO BID 3. Isosorbide Mononitrate (Extended Release) 60 mg PO BID 4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 5. Omeprazole 20 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. Cyanocobalamin 500 mcg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -200 unit Oral BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Cyanocobalamin 500 mcg PO DAILY 4. Gemfibrozil 600 mg PO BID 5. Multivitamins 1 TAB PO DAILY 6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 7. Isosorbide Mononitrate (Extended Release) 30 mg PO BID This dose has been decreased. 8. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet,delayed release (___) by mouth twice a day Disp #*60 Tablet Refills:*0 9. Sucralfate 1 gm PO BID RX *sucralfate 1 gram/10 mL 10 mL by mouth twice a day Disp #*60 Unit Refills:*0 10. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -200 unit Oral BID 11. Nadolol 10 mg PO DAILY RX *nadolol 20 mg 0.5 (One half) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Gastrointestinal bleeding Secondary diagnoses: Cirrhosis, Esophageal Varices Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Cirrhosis with massive GI bleed of unknown etiology. Evaluation of the liver vasculature. TECHNIQUE: Grayscale, color, and pulse wave Doppler of the liver. COMPARISON: None. FINDINGS: The liver is coarse and nodular in echotexture, consistent with known cirrhosis. However, no focal liver lesion is identified. The main, left, and right portal veins are patent with hepatopetal flow. The main hepatic artery is patent with sharp systolic upstroke and antegrade diastolic flow. The hepatic veins are patent with antegrade flow and normal waveforms. Several stones are noted in the gallbladder. However, there is no wall thickening or pericholecystic fluid. There is no intra- or extra-hepatic biliary ductal dilatation and the common bile duct measures 4 mm. The spleen is enlarged, measuring 18.9 cm. The visualized pancreas is normal. The tail is not seen, likely due to overlying bowel gas. There is no ascites. IMPRESSION: 1. Cirrhosis. No focal liver lesion. 2. Patent hepatic vasculature. 3. Splenomegaly. 4. No ascites. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: FATIGUE, WEAKNESS Diagnosed with GASTROINTEST HEMORR NOS, ANEMIA NOS temperature: 97.9 heartrate: 74.0 resprate: 16.0 o2sat: 100.0 sbp: 136.0 dbp: 56.0 level of pain: 7 level of acuity: 2.0
Dear Mr. ___, It was a pleasure taking care of you at the ___ ___. You were admitted for your dark stools, fatigue, and anemia due to bleeding in your gastrointestinal tract. We followed your blood counts closely and had the liver doctors ___. As you know, you were at increased risk for bleeding because of the aspirin and Plavix you are taking for your recent stent, which you must continue for the time-being (discuss this with your cardiologist). While here, you had a esophagogastroduodenoscopy (EGD) and colonoscopy to identify sources of bleeding, which did not show any area concerning for acute bleeding though there were large esophageal varices (which is a complication of liver disease). In order to keep your blood counts up, we gave you 6 units of blood. Your blood counts were stable the last 2 days of your hospital stay with non-bloody stools, both of which are reassuring that you are no longer bleeding. Unfortunately you will stay at continued risk of bleeding because of the medications you are taking for your stent, and therefore you must remain cautious for any sources of bleeding. With signs of bleeding or increasing weakness, you should seek medical care.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. ___ is a ___ yo man with a history of CAD, inferior MI in ___ s/p DES to LCx, HTN, HLD, who was recently discharged on ___ with RUL CAP, on a course of levofloxacin, now returning with worsening shortness of breath for 3 days. Since last discharge, he has noted dry cough, but otherwise feeling well until ___ when he had worsening shortness of breath. This occurred usually in the evening, was intermittent, and not associated with activity. On the evening of presentation, he woke up at 4 am short of breath, and had constant dyspnea throughout the day. He reports no ___ swelling and no orthopnea/PND. No chest pain, palpitations, lightheadedness, nausea, sick contacts, recent travel or surgery, fevers/chills, runny nose. On ___, 2 days prior to onset of symptoms, he reports some URI symptoms, including cough and runny nose. Of note, he had recent admission where they found RUL community acquired pneumonia on CTA. During this hospitalization, he had BNP 3884 and loud heart murmur, but TTE showed EF > 60% and no valvular disease. He was discharged on levofloxacin, albuterol prn. Losartan was decreased for ___ to 1.3. In the ED, he experienced new bradycardia and arrhythmia. He experienced HR from ___ to 110s (baseline HR last admission 80-90). Blood pressure was in 150s/60s-100s, and good oxygen saturation on room air. He had taken his home metoprolol at home. Cardiologist was contacted for variable HR, and he was admitted to medicine for further management. REVIEW OF SYSTEMS: All other 10-system review negative except as indicated per HPI. Past Medical History: - HTN - inferior STEMI with LCX occlusion s/p PCI with drug-eluding stent. - history of ischemic colitis - gout - mild cognitive impairment - OSA on CP AP - Hypercholeserolemia - polymyalgia rheumatic (off pred since ___ - benign prostatic hypertrophy - h/o pneumonia - new on this admission: SVT with aberrancy, atrial bigeminy Social History: ___ Family History: No family history of sudden cardiac death or arrhythmia. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.9 141 / 58 58 18 94 RA GENERAL: NAD HEENT: AT/NC, MMM NECK: No JVD HEART: RRR, S1/S2, IV/VI systolic murmur loudest at base LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: NTND, NABS EXTREMITIES: No edema, warm and well perfused PULSES: 2+ DP pulses bilaterally NEURO: No gross motor/coordination abnormalities SKIN: Warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: VS: 97.9 141 / 58 58 18 94 RA GENERAL: NAD HEENT: AT/NC, MMM NECK: No JVD HEART: RRR, S1/S2, IV/VI systolic murmur loudest at base LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: NTND, NABS EXTREMITIES: No edema, warm and well perfused PULSES: 2+ DP pulses bilaterally NEURO: No gross motor/coordination abnormalities SKIN: Warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ================================= ADMISSION/IMPORTANT LABS ================================= ___ 09:11AM BLOOD WBC-7.1 RBC-4.67 Hgb-13.4* Hct-41.8 MCV-90 MCH-28.7 MCHC-32.1 RDW-14.2 RDWSD-46.3 Plt ___ ___ 09:11AM BLOOD Neuts-74.7* Lymphs-14.2* Monos-7.3 Eos-2.8 Baso-0.6 Im ___ AbsNeut-5.30 AbsLymp-1.01* AbsMono-0.52 AbsEos-0.20 AbsBaso-0.04 ___ 09:11AM BLOOD Plt ___ ___ 10:12AM BLOOD ___ PTT-30.7 ___ ___ 09:11AM BLOOD Glucose-111* UreaN-21* Creat-1.2 Na-139 K-4.0 Cl-104 HCO3-23 AnGap-16 ___ 09:11AM BLOOD ALT-16 AST-17 AlkPhos-94 TotBili-1.4 ___ 09:11AM BLOOD proBNP-406* ___ 09:11AM BLOOD cTropnT-<0.01 ___ 01:30PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 09:11AM BLOOD Albumin-3.9 Calcium-9.0 Phos-2.6* Mg-2.2 ___ 09:32AM BLOOD Lactate-1.8 ================================= IMAGING ================================= CXR ___: IMPRESSION: Subtle opacity in the left lower lung is concerning for atelectasis versus an early pneumonia. CXR ___: IMPRESSION: Left lower lobe opacity appears minimally improved from the prior examination however subtle streaky opacities at the base of the left lung still persistent could reflect atelectasis or infection in the appropriate setting. EKG: New bIgeminy from premature atrial contractions @ 88, no ST elevations or depressions. No T wave inversions. TTE ___ (ON PRIOR ADMISSION): The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>65%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. The descending thoracic aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Moderate pulmonary artery systolic hypertension. Dilated thoracic aorta. Mild mitral regurgitation. Mild aortic regurgitation. CLINICAL IMPLICATIONS: The patient has a moderately dilated ascending aorta. Based on ___ ACCF/AHA Thoracic Aortic Guidelines, if not previously known or a change, a follow-up echocardiogram is suggested in 6 months; if previously known and stable, a follow-up echocardiogram is suggested in ___ year. ============================== DISCHARGE LABS ============================== ___ 08:25AM BLOOD WBC-7.7 RBC-4.79 Hgb-13.6* Hct-42.7 MCV-89 MCH-28.4 MCHC-31.9* RDW-14.3 RDWSD-45.6 Plt ___ ___ 08:25AM BLOOD Glucose-140* UreaN-21* Creat-1.3* Na-139 K-4.3 Cl-102 HCO3-25 AnGap-16 ___ 01:30PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 09:11AM BLOOD cTropnT-<0.01 ___ 09:11AM BLOOD proBNP-406* ___ 08:25AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Finasteride 5 mg PO DAILY 5. Losartan Potassium 50 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 8. Tamsulosin 0.4 mg PO QHS 9. Albuterol Inhaler ___ PUFF IH Q4H:PRN Shortness of breath or wheeze Discharge Medications: 1. Losartan Potassium 25 mg PO DAILY RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Albuterol Inhaler ___ PUFF IH Q4H:PRN Shortness of breath or wheeze 4. Allopurinol ___ mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Finasteride 5 mg PO DAILY 8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 9. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Primary --------- - Dyspnea of unknown etiology - SVT with aberrancy Secondary ---------- - Coronary artery disease s/p stent - Recent pneumonia - Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with increased sob, r/o pna COMPARISON: Prior dated ___ FINDINGS: AP portable upright view of the chest. Elevated right hemidiaphragm is unchanged. Subtle opacity in the left lower lobe could represent atelectasis versus early pneumonia. No large effusion is seen. Cardiomediastinal silhouette is grossly unchanged allowing for patient rotation to the right. No large pneumothorax. No overt signs of edema. Bony structures are intact. IMPRESSION: Subtle opacity in the left lower lung is concerning for atelectasis versus an early pneumonia. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ with LLL finding suggesting PNA on portable today TECHNIQUE: Chest PA and lateral COMPARISON: Radiographs from ___ through ___ FINDINGS: The lung volumes are low which accentuates bronchovascular markings. The mediastinal and hilar contours are stable. Subtle opacity within the left lower lobe persists. The right lung appears clear. IMPRESSION: Subtle opacity persists in the left lower lobe concerning for pneumonia. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea, Cough Diagnosed with Weakness temperature: 97.1 heartrate: 40.0 resprate: 18.0 o2sat: 100.0 sbp: 158.0 dbp: 100.0 level of pain: 0 level of acuity: 3.0
Dear Mr. ___, It was a pleasure participating in your care here at ___ ___. You were admitted for shortness of breath WHAT HAPPENED WHILE YOU WERE HERE: - Your shortness of breath resolved without intervention. It did not appear that you had residual pneumonia. - You had a run of fast heartbeat on the heart monitor. We did not see any signs of heart attack on your lab test or EKG. - You had episodes of feeling sweaty, so we kept you an additional night to watch you on the heart monitor. - We increased the dose of your metoprolol, to keep the heart rate down. We also decreased your dose of losartan so that your blood pressure doesn't drop when on the higher dose of metoprolol. WHAT YOU SHOULD DO AFTER YOU LEAVE: - Please follow up with your cardiologist, Dr. ___ the next week. - You will need a repeat ultrasound of your heart in about 2 weeks. - You will receive ___ of hearts monitor in the mail to monitor your heart rate. Please follow the instructions that come with the monitor. If you have questions, call Dr. ___ ___ they ___ be able to assist you with questions. We wish you the best. Sincerely, Your ___ Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: n/v, weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ F h/o subdural hemorrhage on ___ (resolving on interval CT) now p/w worsening n/v, weakness. On ___, pt fell with head strike and CT imaging revealed an 8 mm R subdural hemorrhage w/ 5 mm of leftward shift. Interval CT since that time has shown improvement. Last night the patient woke up with severe headache around 2am, she took APAP but headache did not resolve. By 4am she made the decision to come to the ED. Per report she also vomiting 3x times prior to admission. ROS otherwise negative for changes in vision, tinnitus, neck pain, focal numbness or weakness. Pt had a mild headache in the AM that was frontal, but neither sudden nor maximal in onset. Since the AM, her HA has resolved. Patient is on aspirin (holding since initial fall at the recommendation of her outpatient doctors), but no other anticoagulation. Pt took 4 mg Zofran at home before coming to the ED. In the ED, initial vitals: 98.9 156/65 71 18 99% RA - Labs: CBC 6.4/9.4/29.1/295, Cr 0.6, K 4.1, Lactate 1.7, INR 1.0, UA negative. - CXR showed no acute cardiopulmonary process, CT revealed no new hemorrhage, and there was "increased thickness of the right hemispheric subdural hematoma with increased effacement and mass effect of the right lateral ventricle and worsening midline shift to the left measuring up to 8 mm, previously 4 mm." However, neurosurg saw pt and felt that she was neurologically intact and stable for admission to medicine for optimization of her BP management. - Received: ___ 12:09 IV Ondansetron 4 mg ___ ___ 12:36 IVF NS ___ Started ___ 13:06 IVF NS 500 mL ___ Stopped (___) ___ 16:15 PO Acetaminophen 1000 mg ___ ___ 16:15 IV Labetalol 5 mg ___ Partial Administration ___ 16:23 IV Labetalol 5 mg ___ Partial Administration - In the ED, she received Zofran, tylenol, and labetalol. - Vitals prior to transfer: 72, 123/49, 16, 100%RA Upon arrival to the floor, pt complaining of right sided head pain recurring. She denies vision changes, chest pain, sob, abdominal pain, nausea or vomiting. Her daughter is at the bedside and helps with the history. She adds that her mother is also overall much weaker than prior without clear explantation. Her headaches seem to be coorelated with increases in her blood pressure. She was given a prescription for labetolol 200mg BID after her last hiospitalization. Before she takes this medication her SBP is 170s and after her SBP drops to as low as 80. One episodes resulted in presyncope, requiring then to place her in ___ before she awoke. Daughter is a ___ and is concerned about her blood pressure regimen. Prior to admission for her initial fall she was super active and is the primary caregiver for her husband who has ___. she wants her to be able to return to this baseline. With regards to her other medications, she completed a course of ppx keppra today and has been holding her asa ever since the ___. Past Medical History: Subdural hemorrhage (___) HLD R clavicular fracture (___) Social History: ___ Family History: Non contributory Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals: 98.4 PO 169 / 70 L Sitting 82 20 98 Ra General: Alert, oriented, no acute distress but rubs right temple HEENT: mild healing abrasions on right temple, MMM, OP clear, EOMI, PERRL, neck supple CV: RRR, normal S1 + S2, soft systolic flow murmur Lungs: CTAB, no wheezes/crackles Abdomen: SNTND, +BS, no rebound or guarding GU: No foley Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, gait deferred. DISCHARGE PHYSICAL EXAM ======================== Vitals: 98.0, 134/50, 70, 18, 99% RA General: Alert, awake, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL Lungs: No increased work of breathing; clear to auscultation anteriorly, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops appreciated. Abdomen: soft, non-tender, non-distended Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Face grossly symmetric. Moving all limbs with purpose against gravity. Pertinent Results: ADMISSION LABS ============== ___ 11:54AM BLOOD WBC-6.4 RBC-2.91* Hgb-9.4* Hct-29.1* MCV-100* MCH-32.3* MCHC-32.3 RDW-13.2 RDWSD-48.2* Plt ___ ___ 11:54AM BLOOD Neuts-73.2* Lymphs-16.4* Monos-7.8 Eos-1.3 Baso-0.8 Im ___ AbsNeut-4.68# AbsLymp-1.05* AbsMono-0.50 AbsEos-0.08 AbsBaso-0.05 ___ 11:54AM BLOOD ___ PTT-27.9 ___ ___ 11:54AM BLOOD Plt ___ ___ 11:54AM BLOOD Glucose-126* UreaN-21* Creat-0.6 Na-137 K-4.1 Cl-99 HCO3-26 AnGap-16 ___ 11:54AM BLOOD ALT-16 AST-18 AlkPhos-104 TotBili-0.3 ___ 12:37PM BLOOD Lactate-1.7 IMAGES: ======= CXR (___): No acute cardiopulmonary process CT Head (___): There is increased thickness of the right hemispheric subdural hematoma with increased effacement and mass effect of the right lateral ventricle and worsening midline shift to the left measuring up to 8 mm, previously 4 mm. No new hemorrhage. Continued evolution of the right subdural hematoma with overall decreased density. CTA head and neck (___): 1. Stable bilateral subdural hematomas as described above with stable 7 mm leftward midline shift. 2. No evidence of new hemorrhage or acute territorial infarction. 3. Mild luminal narrowing of the P1 segment of the left posterior cerebral artery. 4. Atherosclerotic vascular calcifications of the bilateral vertebral arteries with mild narrowing of the distal left V4 segment. 5. Atherosclerotic disease at the bilateral carotid bifurcations with approximately ___ right and 50-60% left internal carotid artery stenosis by NASCET criteria. 6. Mild narrowing at the origin of the left vertebral artery. 7. Nonspecific patchy parenchymal opacities within the right upper lung with small adjacent calcific foci measuring 0.8 x 0.8 cm and 1.1 x 0.7 cm. Recommend further evaluation with CT chest. MICRO: ====== Urine culture (___): negative DISCHARGE LABS: =============== ___ 06:15AM BLOOD WBC-5.6 RBC-2.80* Hgb-9.1* Hct-27.8* MCV-99* MCH-32.5* MCHC-32.7 RDW-13.1 RDWSD-46.8* Plt ___ ___ 06:15AM BLOOD Glucose-93 UreaN-17 Creat-0.6 Na-139 K-3.9 Cl-103 HCO3-25 AnGap-16 ___ 06:15AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Labetalol 200 mg PO BID 3. Cyanocobalamin 1000 mcg PO DAILY 4. Acetaminophen 325-650 mg PO Q8H Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram/dose 1 g by mouth daily Refills:*0 3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 4. Labetalol 100 mg PO BID Hold dose if your systolic blood pressure is less than 120. RX *labetalol 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Atorvastatin 40 mg PO QPM 6. Cyanocobalamin 1000 mcg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Subdural hematoma Hypertension Orthostatic Hypotension SECONDARY DIAGNOSIS: ==================== Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with SDH// CXR: eval for pnaCT head: eval for change in ICH TECHNIQUE: AP and lateral views the chest. COMPARISON: Chest x-ray from ___. FINDINGS: Lungs are well inflated. There is biapical scarring. The lungs are clear without focal consolidation. Cardiomediastinal silhouette is stable. Recent right lateral clavicular fracture is again noted. Hypertrophic changes seen in the spine. No interval osseous abnormality. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with SDH// CXR: eval for pnaCT head: eval for change in ICH TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.4 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: CT head ___. FINDINGS: Re-demonstration of subdural hematoma along the right hemispheric convexity, falx, and tentorium with a prepontine component. Interval evolution of subdural blood with overall decreased density, especially along the right frontal convexity. However, there is increased thickness of the subdural bleed measuring up to 8 mm, previously measuring 5 mm over the right frontal lobe. Components of subdural hematoma along the left tentorial leaflet and overlying the cerebellum on the left are unchanged. No new hemorrhage. There is increased midline shift measuring up to 8 mm, previously measuring up to 4 mm. Overall increased mass effect and effacement of the right lateral ventricle. Basal cisterns are patent. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavitiesare essentially clear. The visualized portion of the orbits are unremarkable. IMPRESSION: There is increased thickness of the right hemispheric subdural hematoma with increased effacement and mass effect of the right lateral ventricle and worsening midline shift to the left measuring up to 8 mm, previously 4 mm. No new hemorrhage. Continued evolution of the right subdural hematoma with overall decreased density. NOTIFICATION: The update findings were discussed with Dr. ___. by ___, M.D. on the telephone on ___ at 3:48 pm, 4 minutes after discovery of the findings. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ patient with subdural hematoma. Evaluate for hemorrhage and vascular patency. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP = 829.0 mGy-cm. 2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 3.7 mGy (Head) DLP = 3.7 mGy-cm. 3) Stationary Acquisition 6.5 s, 1.0 cm; CTDIvol = 48.6 mGy (Head) DLP = 48.6 mGy-cm. 4) Spiral Acquisition 10.2 s, 39.2 cm; CTDIvol = 33.6 mGy (Head) DLP = 1,263.2 mGy-cm. Total DLP (Head) = 2,172 mGy-cm. COMPARISON: CT head ___ FINDINGS: CT HEAD WITHOUT CONTRAST: Re-identified is acute on chronic right hemispheric subdural hematoma measuring approximately 9 mm in greatest thickness exerting mass effect on the adjacent brain, resulting in approximately 7 mm leftward midline shift, unchanged from prior examination. The predominantly hypodense component overlies the right frontal lobe. The hyperdense component overlies the right temporal lobe. Hyperdense subdural hematoma extends along the right tentorium (03:16) and posterior interhemispheric falx. Again seen is hyperdensity in the region of the left cerebellar hemisphere (03:13, 12), which may represent additional subdural hematoma, although the possibility of intraparenchymal hemorrhage is difficult to entirely exclude. Otherwise, there is no evidence of new hemorrhage. There is no acute territorial infarction. Extensive atherosclerotic vascular calcifications of the bilateral vertebral arteries are seen. The paranasal sinuses and bilateral mastoid air cells appear clear. There is small amount of cerumen within left external auditory canal. CTA HEAD: There is mild luminal narrowing of P1 segment of the left posterior cerebral artery (7:332, 652:1). There are vascular calcifications of the V4 segments of the bilateral vertebral arteries with mild narrowing of distal V4 segment of the left vertebral artery. Otherwise, the intracranial vasculature appears patent without stenosis, occlusion, or aneurysm. There is hypoplastic A1 segment of the right anterior cerebral artery, likely a congenital variation. There is fetal origin of the right posterior cerebral artery. The dural venous sinuses appear patent. CTA NECK: There is atherosclerotic disease at the bilateral carotid bifurcations and proximal internal carotid arteries resulting in approximately ___ right and 50-60% left internal carotid artery stenosis by NASCET criteria. There is mild narrowing at the origin of the right common carotid artery. The left common carotid artery appears patent. There is mild narrowing at the origin of the left vertebral artery due to vascular calcification. The right vertebral artery appears patent. OTHER: The thyroid gland appears unremarkable. There is subcentimeter mediastinal lymph nodes without evidence of lymphadenopathy per size criteria. There is ectasia of the ascending aorta measuring 3.6 cm. There are multiple calcified right upper lobe pulmonary nodules. There is biapical opacities. Additional parenchymal opacities are seen within the right upper lung (07:53 and 6) with adjacent small calcific foci streak artifact related to dental hardware obscures visualization of adjacent structures. Right lateral clavicular fracture is re-identified. IMPRESSION: 1. Stable bilateral subdural hematomas as described above with stable 7 mm leftward midline shift. 2. No evidence of new hemorrhage or acute territorial infarction. 3. Mild luminal narrowing of the P1 segment of the left posterior cerebral artery. 4. Atherosclerotic vascular calcifications of the bilateral vertebral arteries with mild narrowing of the distal left V4 segment. 5. Atherosclerotic disease at the bilateral carotid bifurcations with approximately ___ right and 50-60% left internal carotid artery stenosis by NASCET criteria. 6. Mild narrowing at the origin of the left vertebral artery. 7. Nonspecific patchy parenchymal opacities within the right upper lung with small adjacent calcific foci measuring 0.8 x 0.8 cm and 1.1 x 0.7 cm. Recommend further evaluation with CT chest. RECOMMENDATION(S): Recommend CT chest to further evaluate nonspecific parenchymal opacities in the right upper lung. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Nausea, Vomiting, Weakness Diagnosed with Nausea with vomiting, unspecified, Nontraumatic acute subdural hemorrhage temperature: 98.9 heartrate: 71.0 resprate: 18.0 o2sat: 99.0 sbp: 156.0 dbp: 65.0 level of pain: 8 level of acuity: 2.0
Dear Ms. ___, It was a pleasure to be part of your care. You were admitted to the hospital because you were having headaches, vomiting and erratic blood pressure at home. We were concerned that your recent brain bleeding having worsened. You received repeat head imaging which was evaluated by neurosurgery and they determined that no intervention was necessary. Your blood pressure remained quite variable during this admission. We adjusted your blood pressure medications to try to maintain your systolic blood pressure between 110 and 160. Please check your blood pressure at home and HOLD your labetalol dose if your systolic blood pressure is <120. If your blood pressure is dropping lower than systolic of 100 at home or rising higher than systolic 160 at home then please call your doctor. If you are falling down at home or your systolic blood pressure is greater than 180 please return to the hospital. Additionally, if your headaches worsen or you develop new weakness or changes in sensation, please seek medical attention immediately. Of note, your headaches or feeling of head "pressure" will take over several weeks to resolve. Please take Tylenol for your headache. Occasional doses of ibuprofen (<400mg) are ok, but this should not be taken daily as it has some risk of bleeding. We wish you the best, Your ___ Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Ibuprofen / Erythromycin Base / Novocain Attending: ___. Chief Complaint: Nausea, vomiting, headache Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old female who was traveling in ___, ___ on ___ at which time she suffered a mechanical fall and fell back and struck her head. A CT was completed in ___, which showed a small parafalcine hematoma, nondisplaced R occipital fracture. An overlying R occipital laceration was sutured with 2 sutures. She was admitted overnight there and discharged the next day after her CT was stable. She remained in ___ for 5 days and c/o of headache, nausea and vomiting but reports slow improvement of her symptoms. She flew from ___ to ___ then drove from ___ to ___. The patient had another episode of emesis this yesterday and went to see her PCP today who recommended that she come to ___ for repeat imaging today. On examination she complains of minor headache and reports feeling nauseous earlier today with some dizziness with changing positions but this has overall improved. In the ED intial vitals were: 98 68 170/70 16 100% ra. Labs were significant for Na to 123. Urine studies were not sent. CT Head showed 3 mm parafalcine subdural hematoma near the vertex. Review of Systems: Otherwise negative in detail Past Medical History: Hypertension, elevated cholesterol, seasonal allergies, osteoarthritis knees, GERD, carpal tunnel syndrome, left rotator cuff tendinitis, constipation. Social History: ___ Family History: Positive for two sisters with postmenopausal breast cancer. Glaucoma father and sister. Brother: status post aortic dissection. Mother and older sister: hypertension, cerebral hemorrhage. Physical Exam: Admission: 97.8 67 158/85 18 100% RA General- NAD HEENT- EOMI, PERRL, dry MM, sutured R occipital lac present Neck- supple Lungs- CTAB CV- RRR, no m/r/g Abdomen- s/nt/nd normoactive BS GU- no foley Ext- no edema Neuro- CN II-XII in tact, ___ strength, no drift, sensation in tact to light touch Discharge: Vitals- 97.8 98.2 174/85 75 20 100% RA General- NAD HEENT- EOMI, PERRL, MMM, R occipital lac present, healing. Neck- supple Lungs- Decreased BS at bilateral lung bases CV- RRR, no m/r/g Abdomen- Soft, NT/ND, NABS Ext- no edema, no skin tenting, nml cap refill Neuro- CN II-XII in tact, strength/sensation grossly nml. A+Ox3. Ambulatory without assistance Pertinent Results: Admission labs: ___ 09:15PM ___ PTT-28.3 ___ ___ 09:15PM PLT COUNT-330 ___ 09:15PM NEUTS-65.1 ___ MONOS-5.7 EOS-3.7 BASOS-0.7 ___ 09:15PM WBC-9.2# RBC-4.45 HGB-13.2 HCT-39.4 MCV-88 MCH-29.6 MCHC-33.4 RDW-12.0 ___ 09:15PM OSMOLAL-255* ___ 09:15PM estGFR-Using this ___ 09:15PM GLUCOSE-106* UREA N-12 CREAT-0.6 SODIUM-123* POTASSIUM-4.2 CHLORIDE-85* TOTAL CO2-22 ANION GAP-20 ___ 05:20AM PLT COUNT-330 ___ 05:20AM WBC-7.4 RBC-4.32 HGB-12.7 HCT-38.3 MCV-89 MCH-29.5 MCHC-33.2 RDW-12.1 ___ 05:20AM CORTISOL-25.6* ___ 05:20AM TSH-3.7 ___ 05:20AM CALCIUM-9.0 PHOSPHATE-3.6 MAGNESIUM-1.9 ___ 05:20AM GLUCOSE-107* UREA N-11 CREAT-0.6 SODIUM-122* POTASSIUM-4.4 CHLORIDE-87* TOTAL CO2-23 ANION GAP-16 ___ 05:38AM URINE MUCOUS-RARE FR FAT-RARE ___ 05:38AM URINE RBC-2 WBC-23* BACTERIA-FEW YEAST-NONE EPI-2 TRANS EPI-<1 ___ 05:38AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG ___ 05:38AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 05:38AM URINE OSMOLAL-674 ___ 05:38AM URINE HOURS-RANDOM UREA N-882 CREAT-151 SODIUM-91 POTASSIUM-99 CHLORIDE-61 ___ 03:31PM SODIUM-126* POTASSIUM-4.0 CHLORIDE-93* ___ 09:10PM SODIUM-126* POTASSIUM-4.2 CHLORIDE-94* Discharge labs: ___ 07:00AM BLOOD WBC-6.8 RBC-4.04* Hgb-12.4 Hct-36.4 MCV-90 MCH-30.7 MCHC-34.1 RDW-12.4 Plt ___ ___ 07:00AM BLOOD Glucose-91 UreaN-10 Creat-0.6 Na-128* K-4.9 Cl-93* HCO3-27 AnGap-13 ___ 07:00AM BLOOD Calcium-9.7 Phos-4.5 Mg-2.2 ___ 08:10PM URINE Hours-RANDOM Na-77 K-34 Cl-93 ___ 08:10PM URINE Osmolal-408 Micro: ___ 5:38 am URINE Site: NOT SPECIFIED CHEM # ___ 12.31. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Radiology: CT head ___: IMPRESSION: Interval decrease in size of the subdural hematoma along the falx when compared to prior. Unchanged nondisplaced posterior right occipital skull fracture. CXR ___: IMPRESSION: PA and lateral chest compared to ___: Heart size top normal, unchanged. Lungs fully expanded and clear. Normal mediastinal and hilar silhouettes and pleural surfaces. CT neck ___: IMPRESSION: 1. Mild-to-moderate degenerative changes involving the cervical spine with no evidence of malalignment or displaced fracture. However, as only two views of the cervical spine were acquired, if the mechanism of injury is concerning for cervical spine fracture, further imaging with a dedicated CT may be helpful. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. azelastine 137 mcg nasal BID 3. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety 4. Atorvastatin 20 mg PO DAILY 5. Omeprazole 40 mg PO BID 6. Calcium Carbonate 500 mg PO DAILY 7. Vitamin D 200 UNIT PO DAILY 8. Aspirin 81 mg PO DAILY 9. Loratadine 10 mg PO DAILY:PRN as needed 10. Levothyroxine Sodium 100 mcg PO DAILY 11. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY 3. Levothyroxine Sodium 100 mcg PO DAILY 4. Omeprazole 40 mg PO BID 5. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety RX *alprazolam 0.25 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 6. azelastine 137 mcg nasal BID 7. Calcium Carbonate 500 mg PO DAILY Do not take with levothyroxine pill 8. Vitamin D 200 UNIT PO DAILY 9. Loratadine 10 mg PO DAILY:PRN as needed 10. Furosemide 20 mg PO DAILY 11. Outpatient Lab Work Please draw chem7 panel. Hyponatremia, 276.1 Dr. ___, Phone: ___ Fax: ___ 12. Lisinopril 40 mg PO DAILY 13. Fluticasone Propionate NASAL 1 SPRY NU DAILY RX *fluticasone 50 mcg 1 spray NU Daily Disp #*1 Bottle Refills:*0 14. Outpatient Physical Therapy Cervical ligament sprain, 847.0 Dr. ___, Phone: ___ Fax: ___ 15. Walker Please allow patient to obtain walker for aid with balance. Cervical ligament sprain, 847.0 Dr. ___, Phone: ___ Fax: ___ Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Hyponatremia, SIADH Subdural hematoma Post-concussive symptoms Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report PA AND LATERAL CHEST ___ HISTORY: A ___ man with SIADH. Assess for infection. IMPRESSION: PA and lateral chest compared to ___: Heart size top normal, unchanged. Lungs fully expanded and clear. Normal mediastinal and hilar silhouettes and pleural surfaces. Radiology Report CERVICAL SPINE SERIES, ___ AT 13:16 CLINICAL INDICATION: ___ with recent fall, question fracture. AP and lateral views of the cervical spine are submitted without comparisons. The prevertebral soft tissues are unremarkable. The C1 through C7 vertebral bodies are visualized and there is no evidence of malalignment. There are mild-moderate degenerative changes in the cervical spine, most marked at the C4/C5 and C6/C7 levels where there is intervertebral disc space narrowing and osteophytes. There are prominent facet degenerative changes of the mid cervical spine as well. Some irregularity of the C2 spinous process is seen but this is felt to be either related to old trauma or represent ligamentous calcification. There is also calcification in the left lateral soft tissues on the frontal projection, which may be carotid in etiology. The visualized lung apices are unremarkable. If the patient has a mechanism where cervical spine fracture is of clinical concern, further imaging with a dedicated cervical spine CT may be helpful. IMPRESSION: 1. Mild-to-moderate degenerative changes involving the cervical spine with no evidence of malalignment or displaced fracture. However, as only two views of the cervical spine were acquired, if the mechanism of injury is concerning for cervical spine fracture, further imaging with a dedicated CT may be helpful. Gender: F Race: ASIAN - ASIAN INDIAN Arrive by AMBULANCE Chief complaint: Headache, Head injury Diagnosed with HYPOSMOLALITY/HYPONATREMIA, CL SKL BASE FX/MENIN HEM, UNSPECIFIED FALL temperature: 98.0 heartrate: 68.0 resprate: 16.0 o2sat: 100.0 sbp: 170.0 dbp: 70.0 level of pain: 0 level of acuity: 3.0
Dear Ms. ___, It was pleasure caring for you at ___. You were admitted with low sodium in your blood, probably related to your head injury and the hydrochlorothiazide you were taking. Your levels trended back to normal with fluid restriction, salt tabs, lasix, and stopping of the hydrochlorothiazide. Do not restart taking your hydrocholorothiazide unless a physician tells you to. Your subdural hematoma was found to be shrinking on CT of your head. Your scalp stitches were removed.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Augmentin / Bactrim / Biaxin / Iodine / Nsaids / Penicillins / IV Dye, Iodine Containing / Symbicort Attending: ___. Chief Complaint: fever, rigors Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx of ESRD, Restrictive Lung Disease and COPD with 3L O2 requirement at baseline, presents from dialysis for fevers and cough. He developed a new cough yesterday night. This morning, he woke with abdominal pain but otherwise felt well. Developed rigors at dialysis. Afterwards, was very weak, somnolent per wife. ___ were called, but wife drove him to ___ as all of his care is here. Currently endorses headache, severe cough, mild dyspnea, periumbilical abdominal pain. No nausea, vomiting, chest pain, diarrhea. On arrival to the floor the patients vitals were 99.1 ___ 93 on 3L NC. The patient was not ___ acute distress and sitting up ___ bed. The patient reports that he feels much better than during his dialysis session. 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 ___ detail. Past Medical History: ESRD (on HD since ___, AVF ___ forearm, ___ CAD status-post MI ___ ___ status-post PTCAx2 at ___, STEMI s/p ___ ___ He is followed by Dr. ___. Type II Diabetes (poorly controlled, complicated by nephropathy and retinopathy and neuropathy, FSBG 180-240 usually) Diastolic Congestive Heart Failure EF>55% ___ ___ Restrictive Lung Disease (after heart attack, sees Dr. ___ ___ on 3L Home O2 at rest/sitting or 4L if exerting himself Obstructive Sleep Apnea on BiPAP ___ @ 6L) Morbid Obesity Neurogenic Bladder with recurrent UTIs and Suprapubic Catheter since ___ (since ___ gave ibuprofen, Kidneys went down and had fluid overload and never regained muscle tone) Hypertension Osteomyelitis status-post right ___ metatarsal amputation Recurrent Clostridium difficile infections Glaucoma Cataract Surgery (bilateral, no glasses, left eye is good) Anxiety GERD Social History: ___ Family History: Unknown biological family history and as patient is adopted and has no siblings. Knows that mother was ___ ___, father was ___, and he was a product of rape Physical Exam: ADMISSION PHYSICAL EXAM: VS - 99.1 ___ 93 on 3L NC GENERAL: chronically ill appearing obese gentleman, tired appearing, oriented x 3 HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, II/VI systolic murmur at LLSB LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no rebound/guarding, no hepatosplenomegaly EXT: 2cm R calcaneus ulcer, clean appearing but malodorous, R leg circumference > L, bilateral 2+ pitting edema and venous stasis changes worse on R PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes GU: suprapubic catheter site clean, non-erythematous, small amount of clear yellow urine ___ bag DISCHARGE PHYSICAL EXAM: Vitals: T:98.1 tm:98.6 HR:68 BP:127/64 RR:20 O2: 97 on3L GENERAL: chronically ill appearing obese gentleman, alert ___ NAD HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, II/VI systolic murmur at LLSB LUNG: CTAB no wheezes, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no rebound/guarding, no hepatosplenomegaly EXT: RLE ulcer with dressing ___ place c/d/i, R leg circumference > L, bilateral 2+ pitting edema and venous stasis changes worse on R NEURO: No focal deficits SKIN: warm and well perfused, no excoriations or lesions, no rashes GU: suprapubic catheter ___ place Pertinent Results: ADMISSION LABS: ================= ___ 06:02PM BLOOD WBC-12.1*# RBC-4.04* Hgb-13.6* Hct-40.6 MCV-101* MCH-33.7* MCHC-33.5 RDW-13.6 RDWSD-49.8* Plt ___ ___ 06:02PM BLOOD Neuts-85.5* Lymphs-7.2* Monos-6.6 Eos-0.0* Baso-0.3 Im ___ AbsNeut-10.31*# AbsLymp-0.87* AbsMono-0.80 AbsEos-0.00* AbsBaso-0.04 ___ 06:02PM BLOOD Glucose-166* UreaN-34* Creat-5.1*# Na-135 K-4.6 Cl-92* HCO3-27 AnGap-21* ___ 06:02PM BLOOD Lipase-18 ___ 06:02PM BLOOD ALT-25 AST-34 AlkPhos-210* TotBili-0.7 ___ 06:02PM BLOOD Albumin-4.5 Calcium-9.9 Phos-4.0 Mg-2.2 ___ 06:37AM BLOOD CRP-71.4* ___ 11:25AM BLOOD SED RATE-22 DISCHARGE LABS: ================= ___ 06:15AM BLOOD WBC-5.4 RBC-3.69* Hgb-12.4* Hct-37.7* MCV-102* MCH-33.6* MCHC-32.9 RDW-13.6 RDWSD-50.9* Plt ___ ___ 06:15AM BLOOD Glucose-114* UreaN-44* Creat-5.8*# Na-140 K-4.2 Cl-97 HCO3-32 AnGap-15 ___ 06:15AM BLOOD Calcium-10.0 Phos-4.9*# Mg-2.3 MICROBIOLOGY: ================= Blood cultures: NGTD Sputum cx: Contaminated with upper respiratory flora RLE Ulcer wound culture: GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS. WOUND CULTURE (Preliminary): MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT ___ this culture. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. MEROPENEM sensitivity testing performed by ___. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. ___ MORPHOLOGY. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CIPROFLOXACIN--------- 2 I =>4 R GENTAMICIN------------ 2 S 4 S MEROPENEM------------- I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S <=1 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. IMAGING: ================= CXR ___ Lung volumes remain low. Cardiac silhouette size is top normal ___ size, unchanged. Mediastinal contour is unremarkable. Crowding of bronchovascular structures is present without overt pulmonary edema. Streaky and patchy bibasilar airspace opacities most likely reflect atelectasis. No focal consolidation, pleural effusion or pneumothorax is present. IMPRESSION: Low lung volumes with bibasilar atelectasis. R Foot xray ___ IMPRESSION: Soft tissue ulcer subjacent to the calcaneus without definite cortical destruction to suggest osteomyelitis. CT A/P W/O contrast ___ IMPRESSION: 1. No acute abdominopelvic pathology. 2. The appendix remains dilated up to 10 mm, unchanged since ___, with no significant surrounding inflammatory changes to suggest acute appendicitis. 3. Severe atherosclerotic disease. Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with history of ESRD, COPD, with 1 day of cough, fevers TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: Chest radiograph ___ FINDINGS: Lung volumes remain low. Cardiac silhouette size is top normal in size, unchanged. Mediastinal contour is unremarkable. Crowding of bronchovascular structures is present without overt pulmonary edema. Streaky and patchy bibasilar airspace opacities most likely reflect atelectasis. No focal consolidation, pleural effusion or pneumothorax is present. IMPRESSION: Low lung volumes with bibasilar atelectasis. Radiology Report INDICATION: History: ___ with history of ESRD, DM II, chronic right calcaneal wound. // Please eval for osteomyelitis TECHNIQUE: Right foot, three views COMPARISON: ___ FINDINGS: The osseous structures are diffusely demineralized. Soft tissue ulcer is noted dorsal to the calcaneus. No cortical destruction is seen to suggest osteomyelitis. Deformity of the calcaneus appears unchanged, likely due to prior fracture. Extensive vascular calcifications are re- demonstrated. No definite acute fracture or dislocation is seen. No subcutaneous gas is noted, however there is diffuse soft tissue swelling about the foot. IMPRESSION: Soft tissue ulcer subjacent to the calcaneus without definite cortical destruction to suggest osteomyelitis. RECOMMENDATION(S): If there is continued clinical concern for osteomyelitis, consider MRI. Radiology Report EXAMINATION: CT abdomen and pelvis without IV contrast. INDICATION: History: ___ with umbilical pain and tenderness, ESRD, IV contrast allergy 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) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 5.4 s, 58.5 cm; CTDIvol = 16.9 mGy (Body) DLP = 988.0 mGy-cm. Total DLP (Body) = 988 mGy-cm. COMPARISON: CT abdomen and pelvis: ___. FINDINGS: LOWER CHEST: Extensive coronary arterial and mitral valvular calcifications are noted. There is no pleural or pericardial effusion. Mild atelectasis is noted in the lung bases (2:6). 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 distended, but otherwise unremarkable. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. There is no evidence of focal renal lesions within the limitations of an unenhanced scan. There is 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. The colon and rectum are within normal limits. The appendix remains dilated up to 10 mm (601 B: 37), unchanged since ___, with no evidence of surrounding inflammatory fat stranding to suggest acute inflammation. PELVIS: A suprapubic catheter is in place within the urinary bladder which is otherwise decompressed. There is no free fluid in the pelvis. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: A fat containing umbilical hernia is noted. Extensive fatty atrophy of the psoas and paraspinal musculature is noted. Anasarca is seen within the lower abdomen and pelvis. IMPRESSION: 1. No acute abdominopelvic pathology. 2. The appendix remains dilated up to 10 mm, unchanged since ___, with no significant surrounding inflammatory changes to suggest acute appendicitis. 3. Severe atherosclerotic disease. NOTIFICATION: The findings were discussed in person by Dr. ___ with Dr. ___ on ___ at 8:10 ___, 5 minutes after discovery of the findings. Gender: M Race: AMERICAN INDIAN/ALASKA NATIVE Arrive by WALK IN Chief complaint: ILI Diagnosed with Fever, unspecified, Syncope and collapse temperature: 100.6 heartrate: 93.0 resprate: 20.0 o2sat: 100.0 sbp: 146.0 dbp: 107.0 level of pain: 2 level of acuity: 2.0
Dear Mr. ___, You came into the hospital because you were having fevers and chills and feeling very tired. We started you on broad spectrum antibiotics. You had multiple tests to look for infection including chest xray, right foot xray, abdominal CT scan, blood and sputum cultures which showed no evidence of infection. We had the podiatry team come evaluate your right lower extremity wound who felt it was not infected and recommended that you follow-up with your podiatrist when you leave the hospital. Your fever was most likely from a viral illness. You improved and your antibiotics were stopped because we couldn't find any source of infection, after which you continued to feel well. You were evaluated by physical therapy who felt you need physical therapy at home to help improve your transfers and safety at home. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. It was a pleasure taking care of you! Your ___ Care Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache, nausea Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female s/p pipeline embolization of left PCA aneurysm on ___ who was transferred from OSH with severe headache and N/V. The patient reports headache began yesterday morning and worsened throughout the day. ___ demonstrated thrombosis of aneurysm. Neurosurgery was consulted for further recommendations and evaluation. On exam the patient denies SOB, CP, visual disturbances. She endorsed photophobia, phonophobia and chills. Past Medical History: Sinus surgery x 3, Knee arthroscopy, Lumpectomy, pipeline embolization of left PCA aneurysm on ___ with Dr. ___ ___ History: ___ Family History: ___ Physical Exam: On Discharge: PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs Full Neck: Supple. Lungs: No resp distress Abd: Soft, NT Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3mm to 2 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Pertinent Results: IMAGING ======= CT HEAD Study Date of ___ Thrombosis of aneurysm MR HEAD W & W/O CONTRAST Study Date of ___ 11:56 ___ IMPRESSION: 1. Pipeline stent embolization of a 1.4 x 1.3 cm left posterior cerebral artery aneurysm demonstrating internal clot and probable peripheral vascular wall enhancement, without definite evidence of residual flow to the aneurysm. Though in stent thrombosis cannot be excluded on the basis of this examination, there is no secondary evidence for in stent thrombosis. No edema is seen around the aneurysm. 2. No hemorrhage, infarct, or enhancing mass. LABS ==== ___ 06:25AM BLOOD WBC-7.0 RBC-3.40* Hgb-9.7* Hct-30.8* MCV-91 MCH-28.5 MCHC-31.5* RDW-12.4 RDWSD-40.9 Plt ___ ___ 05:40AM BLOOD WBC-8.7 RBC-3.45* Hgb-10.1* Hct-30.7* MCV-89 MCH-29.3 MCHC-32.9 RDW-12.5 RDWSD-40.6 Plt ___ ___ 10:10AM BLOOD WBC-8.2 RBC-3.45* Hgb-10.2* Hct-31.1* MCV-90 MCH-29.6 MCHC-32.8 RDW-12.5 RDWSD-41.0 Plt ___ ___ 10:10AM BLOOD Neuts-80.7* Lymphs-14.1* Monos-4.6* Eos-0.1* Baso-0.0 Im ___ AbsNeut-6.64* AbsLymp-1.16* AbsMono-0.38 AbsEos-0.01* AbsBaso-0.00* ___ 06:25AM BLOOD ___ PTT-26.9 ___ ___ 05:40AM BLOOD ___ PTT-28.6 ___ ___ 10:10AM BLOOD ___ PTT-29.3 ___ ___ 06:25AM BLOOD Glucose-114* UreaN-13 Creat-0.8 Na-138 K-4.0 Cl-100 HCO3-25 AnGap-17 ___ 05:40AM BLOOD Glucose-104* UreaN-11 Creat-0.7 Na-134 K-3.8 Cl-99 HCO3-25 AnGap-14 ___ 10:10AM BLOOD Glucose-116* UreaN-12 Creat-0.7 Na-137 K-4.0 Cl-103 HCO3-26 AnGap-12 ___ 06:25AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.1 ___ 05:40AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.0 ___ 10:10AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9 Medications on Admission: Brilinta 90 mg BID, ASA 81 mg qd Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Dexamethasone 3 mg PO EVERY 8 HOURS X 2 DOSES Duration: 2 Doses Take at 6pm and 2am on ___, then discontinue RX *dexamethasone 1 mg 3 tablet(s) by mouth Every 8 hours x 2 doses Disp #*6 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H PRN Disp #*30 Tablet Refills:*0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth Every 4 hours PRN Disp #*30 Tablet Refills:*0 6. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Aspirin 325 mg PO DAILY 8. TiCAGRELOR 90 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: Pipeline embolization of left posterior cerebral artery aneurysm. Assess for stent thrombosis, infarct or edema around aneurysm. TECHNIQUE: Sagittal T1 weighted imaging were performed. After administration of 6 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique as well as sagittal T1. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: Outside hospital MR head ___. CTA head ___. CT head ___. FINDINGS: There is susceptibility artifact from a pipeline stent within left posterior cerebral artery for embolization of a previously noted left PCA aneurysm. There is a 1.4 x 1.3 cm left posterior cerebral artery aneurysm with areas of intrinsic T1 hyperintensity and susceptibility artifact denoting clot formation. Peripheral enhancement around the aneurysm, likely represents vessel wall enhancement. In stent thrombosis cannot be assessed on the included sequences, however enhancement is noted in the P2 segment of the posterior cerebral artery, just distal to the stent. There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. Few, scattered areas of bifrontal subcortical white matter T2/FLAIR hyperintensity are nonspecific, likely representative of chronic small vessel ischemic disease. There is no abnormal enhancement after contrast administration. The dural venous sinuses are patent on MP rage images. The principal intracranial vascular flow voids are preserved. The paranasal sinuses are grossly clear. The orbits are grossly unremarkable. IMPRESSION: 1. Pipeline stent embolization of a 1.4 x 1.3 cm left posterior cerebral artery aneurysm demonstrating internal clot and probable peripheral vascular wall enhancement, without definite evidence of residual flow to the aneurysm. Though in stent thrombosis cannot be excluded on the basis of this examination, there is no secondary evidence for in stent thrombosis. No edema is seen around the aneurysm. 2. No hemorrhage, infarct, or enhancing mass. RECOMMENDATION(S): If dedicated assessment for in stent thrombosis is desired, MRA of the head with and without gadolinium can be obtained, or alternatively CTA of the head. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Headache, Abnormal CT Diagnosed with Headache, Dizziness and giddiness temperature: 98.4 heartrate: 66.0 resprate: 16.0 o2sat: 97.0 sbp: 108.0 dbp: 60.0 level of pain: 10 level of acuity: 3.0
Activity • We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. • You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. • No driving while taking any narcotic or sedating medication. • If you experienced a seizure while admitted, you are NOT allowed to drive by law. • No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications • Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. • You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: • You may have difficulty paying attention, concentrating, and remembering new information. • Emotional and/or behavioral difficulties are common. • Feeling more tired, restlessness, irritability, and mood swings are also common. • Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: • Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. • Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. • There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: • Severe nausea and/or vomiting • Extreme sleepiness and not being able to stay awake • Severe headaches not relieved by pain relievers • Seizures • Any new problems with your vision or ability to speak • Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: • Sudden numbness or weakness in the face, arm, or leg • Sudden confusion or trouble speaking or understanding • Sudden trouble walking, dizziness, or loss of balance or coordination • Sudden severe headaches with no known reason
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: near-syncopal event Major Surgical or Invasive Procedure: none History of Present Illness: ___ male with CLL on ibrutinib, CAD/HLD with NSTEMI in ___, nonischemic cardiomyopathy, CKD stage III, depression, presenting with presyncope and fall with humeral fracture, with elevated troponin in the emergency room. He describes a recent history over about ___ year of postural lightheadedness (says dizziness but clarifies the room is not but that he feels off-balance), and several falls. He reports his last major fall prior to tonight was ___ when he stood up suddenly and was rushing to get the door - fell backwards as soon as he opened it. Have had other falls onto his knees. Reports a negative w/u and had an unremarkable cardiac event monitor around that time. He also had his cath (described below) then. Prior to present admission, he got home and noticed it was quite hot in the house. He disrobed and turned on the AC and was planning to lay down until it had turned on, but was worried he would fall asleep so he stood up suddenly; he felt lightheaded when he got to the cabinet and took the medicine, but as he reached for water he blacked out (but did not lose consciousness) and fell backwards; he was aware of what was happening and did not strike his head but fell on his left arm and immediately noticed it was damaged. He had no chest pain, pressure, palpitations, dyspnea, or other symptoms with the event. When I spoke with patient, he said he did not have LOC. His Flomax was recently increased to BID which he says has helped a lot. He notices his lightheadness only after standing up abruptly. After the fall, he developed left shoulder pain which he says is sharp intermittent and worsened with movement without radiation. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): Dx'd CLL with WBC of 48,000 ___ when he was seen in ___ clinic. He had not had a CBC since ___, at which point his WBC was normal. Differential showed an increase in lymphocytes. Flow cytometry was sent to ___ and returned consistent with CLL. Zap-70 19% Unmutated IgVH Beta-2 10.5 ___ : CT Scans: Cervical, supraclavicular and axillary adenopathy and splenomegaly similar to recent exam. Multiple pulmonary nodules bilaterally several of which are stable; however, a few have marginally increased in size and there is new more focal consolidative changes within the inferior posterior lateral left lower lobe which could be inflammatory but underlying malignancy cannot be excluded and followup is recommended. Trace right pleural fluid. ___: Chest CT - stable pulm nodules. Slight increase in mild adenopathy. Mild splenomegaly (17 CM). ___: FIsh analysis showed 13q- ___: Started Bendamustine alone for rise in wbc to 226K, plt 81K with bulky axillary nodes. LDH normal. Tolerated well. Transient rise in uric acid and creatinine, rx'd allopurinol. ___: Drop in wbc but plts also very low (47K). Tried on decadron 40 mgx4dx2 for possible immune mediated drop. ___: Cycle 2 Bendamustine with split dose Rituxan. WBC 63K, plt 85K., followed by Neulasta. ___: Cycle 3 ___. ___: Cycle 4 ___ - Stopped due to chest pain. PAST MEDICAL HISTORY: -HTN -HLD -Squamous cell skin cancer left ear s/p MOHS ___ -CLL -Depression/Anxiety -CAD -BPH Social History: ___ Family History: - CAD, PVD, CHF, Breast Cancer, Lymphoma. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: left arm in sling 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 PHYSICAL EXAM: VITALS: T98.4, BP 134/66, RR 16, 91%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. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: left arm in sling. non-tender to gentle palpation. slightly weaker grip on L compared to R. 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, grip strength LUE 4+/5, ___ on R, strength ___ in lower extremities bilaterally PSYCH: anxious, circumstantial and occasionally tangential thought process Pertinent Results: LABS ON ADMISSION: ================== ___ 04:20PM WBC-42.7* RBC-3.89* HGB-11.8* HCT-37.4* MCV-96 MCH-30.3 MCHC-31.6* RDW-16.9* RDWSD-58.4* ___ 04:20PM NEUTS-18* BANDS-4 LYMPHS-78* MONOS-0* EOS-0* BASOS-0 AbsNeut-9.39* AbsLymp-33.31* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 04:20PM GLUCOSE-92 UREA N-39* CREAT-1.4* SODIUM-145 POTASSIUM-4.5 CHLORIDE-110* TOTAL CO2-21* ANION GAP-14 ___ 04:20PM CK-MB-20* MB INDX-4.5 cTropnT-0.27* ___ 04:20PM CK(CPK)-444* ___ 08:45PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 08:45PM URINE RBC-11* WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 04:20PM ___ PTT-31.2 ___ ___ 10:15PM TSH-3.3 ___ 10:15PM cTropnT-0.23* ___ 10:15PM ALT(SGPT)-24 AST(SGOT)-30 ALK PHOS-56 TOT BILI-0.6 MICRO: ====== UCx:NEGATIVE IMAGING: ======== ___ Cardiovascular Transthoracic Echo Report CONCLUSION: The left atrial volume index is moderately increased. The right atrium is moderately enlarged. There is normal left ventricular wall thickness with a normal cavity size. There is suboptimal image quality to assess regional left ventricular function. Overall left ventricular systolic function is normal. The visually estimated left ventricular ejection fraction is 60%. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is normal. The aortic valve is not well seen. There is no aortic valve stenosis. There is mild to moderate [___] aortic regurgitation. The mitral valve leaflets are mildly thickened. There is physiologic mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Poor image quality. No obvious structural cardiac cause of syncope identified. ___-SPINE W/O CONTRAST: 1. No acute fracture or traumatic malalignment. 2. Redemonstration of 1.1 cm left thyroid lobe nodule. Please refer to recommendations section below for further instructions. RECOMMENDATION(S): 1.1 cmThyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or ___. ___ Imaging CT HEAD W/O CONTRAST: No acute intracranial process within limitations of this noncontrast study. No evidence of acute intracranial hemorrhage or acute fracture ___ Imaging GLENO-HUMERAL SHOULDER: Acute impacted fracture through the surgical neck of the left humerus. LABS ON DISCHARGE: =================== ___ 06:00AM BLOOD WBC-40.7* RBC-3.25* Hgb-9.8* Hct-33.4* MCV-103* MCH-30.2 MCHC-29.3* RDW-17.2* RDWSD-64.2* Plt Ct-68* ___ 06:00AM BLOOD Glucose-87 UreaN-30* Creat-1.0 Na-143 K-4.4 Cl-112* HCO3-18* AnGap-13 ___ 06:00AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.2 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ibrutinib 280 mg oral DAILY 2. Tamsulosin 0.4 mg PO BID 3. Finasteride 5 mg PO DAILY 4. Zolpidem Tartrate 10 mg PO QHS 5. Fluvoxamine Maleate 100 mg PO QAM 6. Gabapentin 300 mg PO BID 7. Gabapentin 600 mg PO QAM 8. Citalopram 40 mg PO DAILY 9. Pravastatin 20 mg PO QPM 10. Allopurinol ___ mg PO BID 11. Ensure (food supplemt, lactose-reduced) 5 bottle oral DAILY 12. LOPERamide 1 mg PO BID:PRN loose stools 13. Fluvoxamine Maleate 200 mg PO HS Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals [Vitamins and Minerals] 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Tamsulosin 0.4 mg PO DAILY 4. Allopurinol ___ mg PO BID 5. Citalopram 40 mg PO DAILY 6. Ensure (food supplemt, lactose-reduced) 5 bottle oral DAILY 7. Finasteride 5 mg PO DAILY 8. Fluvoxamine Maleate 100 mg PO QAM 9. Fluvoxamine Maleate 200 mg PO HS 10. Gabapentin 300 mg PO BID 11. Gabapentin 600 mg PO QAM 12. ibrutinib 280 mg oral DAILY 13. LOPERamide 1 mg PO BID:PRN loose stools 14. Pravastatin 20 mg PO QPM 15. Zolpidem Tartrate 10 mg PO QHS 16.Outpatient Physical Therapy ICD: ___, I95.1, R26.2 Please provide ___ for gait stability, balance training and humeral fracture 17.Outpatient Occupational Therapy ICD: ___.201A, I95.1, R26.2 Please provide ___ for gait stability, balance training and humeral fracture rehabilitation Discharge Disposition: Home Discharge Diagnosis: PRIMARY Fall Orthostatic hypotension L humerus fracture Urinary retention Hypertension Elevated troponin ___ SECONDARY Chronic lymphocytic leukemia 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 L shoulder deformity s/p fall// ?fx TECHNIQUE: Three views of the left shoulder including a scapular Y-view. COMPARISON: None. FINDINGS: There is an acute impacted fracture through the proximal left humerus at the surgical neck. Distal fracture fragment is displaced slightly anteriorly. Glenohumeral joint remains anatomically aligned. The acromioclavicular joint is within normal limits. Included portion of left hemithorax is grossly unremarkable. IMPRESSION: Acute impacted fracture through the surgical neck of the left humerus. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with thrombocytopenia, fall// eval for bleed, fx 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, 20.8 cm; CTDIvol = 43.5 mGy (Head) DLP = 903.1 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: Noncontrast head CT ___. Sinus CT ___. FINDINGS: There is no evidence of acute large territorial infarction, intracranial hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of age-related cerebral volume loss. Periventricular and subcortical white matter hypodensities are nonspecific, though likely sequelae of chronic small vessel ischemic disease. No acute osseous abnormalities seen. Small mucous retention cyst in the left maxillary sinus. The remaining imaged paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits demonstrate no acute abnormalities. IMPRESSION: No acute intracranial process within limitations of this noncontrast study. No evidence of acute intracranial hemorrhage or acute fracture. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: History: ___ with thrombocytopenia, fall// eval for bleed, fx TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.3 s, 24.8 cm; CTDIvol = 23.1 mGy (Body) DLP = 572.3 mGy-cm. 2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 13.2 mGy (Body) DLP = 26.5 mGy-cm. 3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 13.2 mGy (Body) DLP = 26.5 mGy-cm. Total DLP (Body) = 625 mGy-cm. COMPARISON: CT C-spine ___. FINDINGS: There is minimal retrolisthesis of C4 on C5, unchanged. Otherwise, remaining alignment is normal. No acute fractures are identified.There are multilevel degenerative changes which are mild with intervertebral disc space narrowing, endplate sclerosis and cysts, and osteophyte formation. There is mild central canal narrowing at C4-5 and C5-6 as well as mild bilateral neural foraminal stenosis at C4-5. However, no significant or severe spinal canal or neural foraminal narrowing.There is no prevertebral edema. Again demonstrated, is a 11 mm left isodense inferior thyroid lobe nodule. Otherwise, the remaining thyroid and included lung apices are unremarkable. There are moderate bilateral carotid bulb calcifications, right greater than left. IMPRESSION: 1. No acute fracture or traumatic malalignment. 2. Redemonstration of 1.1 cm left thyroid lobe nodule. Please refer to recommendations section below for further instructions. RECOMMENDATION(S): 1.1 cmThyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or ___. 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. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: L Shoulder injury, s/p Fall Diagnosed with Unsp disp fx of surgical neck of left humerus, init, Other fall on same level, initial encounter temperature: 98.3 heartrate: 98.0 resprate: 18.0 o2sat: 98.0 sbp: 115.0 dbp: 67.0 level of pain: 6 level of acuity: 2.0
Dear Mr. ___, It was a pleasure taking care of you during your hospitalization at ___. You came to the hospital after you had fell and hit your arm. We found that your broke your left shoulder. The orthopedic doctors saw ___ and did not think you need surgery. We found that you were dehydrated, and we gave you fluid to replenish you. We did not give you your Flomax on the first day and then restarted it at a once a day dosing to make sure we prevent any further episodes of dizziness. You were evaluated by physical therapy after your fall, and they felt that over the course of your hospital stay you progressed to where you could go home with physical and occupational therapy services. Please follow up with your primary care doctor who can help ___ on the above issues and continue to work on getting stronger. We wish you the best. Sincerely, Your ___ Care Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Bacitracin / Ciprofloxacin / azithromycin Attending: ___ Chief Complaint: Profound fatigue, shortness of breath and dizziness Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: ___ with a history of b/l breast cancers s/p mastectomies ___, ___, LUL NSCLC (___) s/p lobectomy and RUL NSCLC (___) s/p CK therapy, left atrial clot on ASA, p/w worsening sx of profound fatigue, shortness of breath and dizziness. She is unable to ambulate safely at home due to lightheadedness. The patient contacted her PCP ___ (HCA) on ___ to report hoarseness x 3 weeks without any associated symptoms of URI. At the time she also reported increasing dizziness and a recent fall on ___ at which time she hit her leg and fell on her coccyx. She started using her walker consistently due to dyspnea on exertion. For the last two days she has had worsening dyspnea and increased orthopnea. She has had increased home O2 requirement from 2 to 4 L NC. Her chronic cough is unchanged, non-productive. She denies fever, chills, sweats. She does endorse weight loss of 20 pounds in the last 3 months, possibly partially due to poor appetite. She denies any worsening ___ edema, but does note some unilateral leg tenderness in her left calf. She has had vague chest discomfort with deep inspiration. No hemoptysis. She called her PCP office again today given concern for dyspnea and being unable to ambulate safely at home ___ lightheadedness; she was referred to the ED. Of note, the patient was admitted to this facility in ___ for multi-focal pneumonia. She was initially started on vanco and tigecycline due to an extensive history of reactions to abx including quinolones and penicillins. She was switched to aztreonam and doxy for 10 day course. She was discharged on RA. At that time, a left atrial clot was noted and she was started on Lovenox anti-coagulation. Repeat CTA chest in ___ was negative for PE, thus her Lovenox was stopped. This CT also showed progressive mass-like consolidation around the site of her prior cyberknife procedure as well as new R lung nodules, concerning for infection vs. malignancy. In response to this finding, she was seen in the ___ clinic in late ___ for the first visit since ___. Etiology of the imaging findings was unclear, thus the recommendation at that time was to do follow-up imaging with CT and PET in several months to check for interval change. No immediate treatment recommended. In the ED, initial vitals ___ 98 68 80/44 20 100% 4L NC. Found to have lactate 2.7, CXR showed multifocal PNA. She was started on azithromycin PO and levofloxacin IV, received 2L NS in ED. ___ u/s negative for DVT. On arrival to the floor, pt down to baseline 2L NC and breathing comfortably. Denies worsened SOB or cough from baseline. No current vertigo, although pt says that this was her main concern this morning when she came to the ED. VS were 97.8, 101/40, 68, 20, 98%2L. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, lower extremity edema. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: PAST ONCOLOGIC HISTORY: Regarding her breast cancers, she underwent a right mastectomy in ___ and a left mastectomy in ___, and she had no postmastectomy radiation therapy. After her initial diagnosis of lung cancer in ___, she underwent a left upper lobectomy for stage IA non-small cell carcinoma of the lung; she had no postoperative adjuvant radiation therapy or chemotherapy. - ___: developed cough - ___: CT chest showed a 1.9 x 1.2 cm right upper lobe lung mass, which was suspicious for carcinoma. PET-CT on ___ showed a 1.3 x 1.1 cm right upper lobe lung lesion with an SUV of 11.7; there were no FDG avid mediastinal or hilar lymph nodes, and there were no liver, adrenal, or bone metastases. Ms. ___ was evaluated by Dr. ___ consideration of treatment of what appeared to be a right upper lobe lung cancer. Since she was not a good candidate for surgical treatment (DLCO was 41% of predicted), she underwent CT guided biopsy that showed mucinous lung adenocarcinoma, acinar pattern, moderately differentiated, and subsequently underwent CK radiation to the lesion. - CyberKnife SBRT to the right upper lobe lung adenocarcinoma to a dose of 55 Gy given in five fractions of 11 Gy each completed on ___. - ___ repeat chest CT showed progression of the mass-like consolidation around the fiducial marker and new multiple right lung nodules is either cryptogenic organizing pneumonia (perphaps triggered by radiation therapy) or unusually aggressive recurrent lung cancer. Repeat imaging and PET scanning planned as outpatient with follow-up appt in ___. PAST MEDICAL HISTORY: ANKLE FRACTURE BREAST CANCER CHEST NODULE CORONARY ARTERY DISEASE DEPRESSION HYPERTENSION LUNG CANCER MEMORY DISORDER OSTEOPOROSIS SEIZURE DISORDER SLEEP APNEA SEBORRHEIC DERMATITIS ENCHONDROMA HOME SERVICES LEFT ATRIAL CLOT on Lovenox ___, now on ASA - ___: admission for significant weakness, chest pain, and dyspnea to the point that she could barely walk. CT angiography of the chest on ___ showed multifocal pneumonia in the right lung; there was no pulmonary embolism; there were right hilar lymph nodes up to 2.8 x 2.9 cm, which were felt likely reactive; there was a small left atrial thrombus. Ms. ___ was treated with aztreonam, doxycycline, and Lovenox. Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.8, 101/40, 68, 20, 98%2L GENERAL: NAD, awake and alert HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, MMM NECK: nontender and supple, no LAD, no JVD CARDIAC: RRR, nl S1 S2, no MRG LUNG: Few crackles diffusely, course breath sounds throughout, no wheezes, no accessory muscle use ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or guarding, no HSM EXT: warm and well-perfused, no cyanosis, clubbing or edema NEURO: CN II-XII tested and intact, strength ___ throughout, sensation grossly normal, gait deferred SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: Vitals: T 98.1, HR 77, BP 134/70, RR 20, O2 sat 100% on 2L GENERAL: NAD HEENT: AT/NC, MMM NECK: nontender and supple, no LAD, no JVD CARDIAC: RRR, nl S1 S2, no MRG LUNG: Normal respiratory rate and effort, CTAB, no wheezes ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or guarding EXT: warm and well-perfused, no cyanosis, clubbing or edema NEURO: alert and oriented x3 SKIN: warm and well perfused, dry skin on/around lips, no rashes Pertinent Results: ADMISSION LABS: ============ ___ 12:30PM BLOOD WBC-7.9 RBC-4.77 Hgb-13.0 Hct-38.2 MCV-80* MCH-27.2 MCHC-34.0 RDW-13.6 Plt ___ ___ 12:30PM BLOOD Neuts-72.1* ___ Monos-6.3 Eos-2.8 Baso-0.7 ___ 12:30PM BLOOD Glucose-126* UreaN-21* Creat-0.8 Na-136 K-5.1 Cl-95* HCO3-26 AnGap-20 ___ 12:30PM BLOOD Calcium-9.3 Phos-4.2 Mg-2.1 ___ 06:10AM BLOOD ALT-13 AST-12 AlkPhos-129* TotBili-0.1 ___ 12:40PM BLOOD Lactate-2.7* DISCHARGE LABS: ============ ___ 06:15AM BLOOD WBC-4.9 RBC-3.90* Hgb-10.4* Hct-32.0* MCV-82 MCH-26.7* MCHC-32.6 RDW-15.2 Plt ___ ___ 06:15AM BLOOD Plt ___ ___ 06:15AM BLOOD ___ ___ 06:15AM BLOOD Glucose-111* UreaN-6 Creat-0.5 Na-139 K-4.1 Cl-102 HCO3-29 AnGap-12 ___ 06:15AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1 OTHER PERTINENT LABS: ============ ___ 07:33AM BLOOD ___ PTT-69.1* ___ ___ 05:30AM BLOOD PTT-76.1* ___ 10:00PM BLOOD PTT-73.5* ___ 02:30PM BLOOD PTT-71.0* ___ 06:20AM BLOOD ___ PTT-25.3 ___ ___ 06:23AM BLOOD CK(CPK)-24* ___ 12:00AM BLOOD CK(CPK)-14* ___ 06:10AM BLOOD ALT-13 AST-12 AlkPhos-129* TotBili-0.1 ___ 06:23AM BLOOD CK-MB-1 cTropnT-<0.01 ___ 12:00AM BLOOD CK-MB-1 cTropnT-<0.01 ___ 06:20PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:15AM BLOOD TSH-3.0 ___ 06:15AM BLOOD Free T4-1.1 ___ 06:40AM BLOOD Phenyto-LESS THAN ___ 07:17AM BLOOD Lactate-1.1 IMAGING: ============ CXR ___: FINDINGS: The lungs are hyperinflated, consistent with known emphysema. Opacity is again seen within the right upper lobe compatible with known malignancy with a fiducial marker identified. There is increased opacity adjacent to tumor, most likely representing post-obstructive infection or atelectasis. There is a new patchy opacity in the right lung base, which likely represents infection. Bibasilar atelectasis or scarring is seen. The cardiomediastinal silhouette is unremarkable. Sclerotic lesion in the left humeral head is unchanged from ___, likely representing medullary infarct or enchonroma. A stable bone island is seen in the left glenoid. IMPRESSION: Multifocal pneumonia in the right lung. b/l ___ ultrasound ___: IMPRESSION: No evidence of deep vein thrombosis in the right or left lower extremity. Chest CT ___: IMPRESSION: 1. Significant interval increase in the bulk of the tissue consolidation around the fiducial marker in the right upper lobe, the area of thE patient's radiation-treated malignancy. Innumerable scattered right lung nodules are overall increased in size compared to the prior exam. Many of these nodules have become more confluent into larger nodules. 2. Interval increase in the size of the innumerable left lung nodules concerning for worsening metastatic foci. 3. Interval increase in the diffuse lymphadenopathy. ECHO ___: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No valvular pathology or pathologic flow identified. ompared with the prior study (images reviewed) of ___, the findings are similar. CT Head ___: FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or infarction. No evidence of metastatic disease. Prominent ventricles and sulci most consistent with age related involutional changes. Diffuse ___ ventricular and subcortical white matter hypodensities consistent with small vessel ischemic disease. The basal cisterns appear patent. Visualized major vessels and their branches are patent. Osseous structures are unremarkable. Mild mucosal thickening within the left sphenoid sinus. The remainder of the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No evidence of metastatic disease. CXR ___: FINDINGS: Following the procedure, there is no evidence of pneumothorax. There is some increased opacification in the right mid and upper zone, suggesting some post-procedure hemorrhage. CXR ___: No pneumothorax is detected. Again seen are background COPD, a large mass-like opacity in the right upper zone, and interstitial and more confluent opacities at the bases. No new CHF, effusion or pneumothorax is detected. Note is made of an irregular sclerotic lesion in the left proximal humerus and small rounded sclerotic focus in the left glenoid, not fully evaluated on these views. IMPRESSION: 1. No pneumothorax or acute superimposed pulmonary process detected compared with ___ at 11:59 a.m. 2. Sclerotic densities in the left proximal humerus and left glenoid, not fully evaluated. CTA CHEST ___: FINDINGS: Partially visualized thyroid is normal. There is no axillary lymphadenopathy. Slightly prominent bilateral axillary lymph nodes are unchanged. Subcarinal soft tissue consolidation is seen and there is an increase in compressive attenuation on the adjacent right main bronchus. There are new bilateral small pleural effusions, right greater than left. The consolidation in the right mid lung is increased in size. There are multiple small nodules throughout the right lung, some of which are slightly increased in size compared to prior study, the right middle lobe nodule measures 1.0 cm, increased from prior study when it measured 0.8 cm. Multiple small left pulmonary nodules are grossly unchanged. There is no filling defect in the pulmonary arteries to the subsegmental level. Right hilar lymphadenopathy is unchanged. The aorta is normal in caliber. Limited evaluation of the upper abdominal organs is unremarkable. There is an incidental note of a gastric fundal diverticulum. Bilateral breast implants are seen. Heart size is normal. There is no pericardial effusion. IMPRESSION: 1. Mild increase in size of soft tissue consolidation in the right mid lung. 2. New bilateral small pleural effusions, right greater than left. 3. Multiple pulmonary nodules bilaterally, some of which have slightly increased in size. 4. Subcarinal soft tissue consolidation is seen and there is an increase in attenuation on the adjacent right main bronchus. BRONCHOSCOPY REPORT ___ Impression: Flexible bronchscope passed via LMA and vocal cords with ease. Airways visualized to the subsegmental level. There was diffsue calcification in the airways mainly in the central airways. LUL stump of the previous ___ lobectomy was noticed. Then EBUS scope Otherwise normal to tracheobronchial tree Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Benzonatate 100 mg PO TID:PRN cough 3. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough 4. Omeprazole 20 mg PO BID 5. Ondansetron 4 mg PO Q6H:PRN nausea 6. Phenytoin Sodium Extended 100 mg PO BID 7. QUEtiapine Fumarate 25 mg PO QHS 8. Simvastatin 40 mg PO DAILY 9. Venlafaxine XR 225 mg PO DAILY 10. Aspirin 325 mg PO DAILY 11. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral daily 12. Multivitamins 1 TAB PO DAILY 13. Acetaminophen 325 mg PO Q6H:PRN TMJ pain 14. Lorazepam 0.5 mg PO Q4H:PRN prior to CT Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN TMJ pain 2. Benzonatate 100 mg PO TID:PRN cough 3. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 20 mg PO BID 6. Ondansetron 4 mg PO Q6H:PRN nausea 7. Phenytoin Sodium Extended 100 mg PO BID 8. QUEtiapine Fumarate 25 mg PO QHS 9. Simvastatin 40 mg PO DAILY 10. Venlafaxine XR 225 mg PO DAILY 11. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral daily 12. Meclizine 12.5 mg PO Q8H:PRN dizziness 13. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose 14. Docusate Sodium 100 mg PO BID 15. Lorazepam 0.5 mg PO Q4H:PRN prior to CT 16. Aspirin 81 mg PO DAILY 17. Heparin IV Sliding Scale No Initial Bolus Initial Infusion Rate: 700 units/hr Target PTT: 60 - 100 seconds 18. Ipratropium Bromide Neb 1 NEB IH Q6H 19. Metoprolol Succinate XL 50 mg PO DAILY 20. Warfarin 3 mg PO DAILY16 21. Acetaminophen 1000 mg PO Q8H:PRN Pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: lung cancer Secondary: paroxsysmal atrial fibrillation with rapid ventricular rate, anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report HISTORY: Shortness of breath. COMPARISON: Comparison is made with chest radiographs from ___, ___, an ___. FINDINGS: The lungs are hyperinflated, consistent with known emphysema. Opacity is again seen within the right upper lobe compatible with known malignancy with a fiducial marker identified. There is increased opacity adjacent to tumor, most likely representing post-obstructive infection or atelectasis. There is a new patchy opacity in the right lung base, which likely represents infection. Bibasilar atelectasis or scarring is seen. The cardiomediastinal silhouette is unremarkable. Sclerotic lesion in the left humeral head is unchanged from ___, likely representing medullary infarct or enchonroma. A stable bone island is seen in the left glenoid. IMPRESSION: Multifocal pneumonia in the right lung. Radiology Report HISTORY: Acute dyspnea. TECHNIQUE: Grayscale and color and spectral Doppler evaluation was performed of the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, proximal femoral, mid femoral, distal femoral, and popliteal veins. Normal compressibility is demonstrated in the posterior tibial and peroneal veins bilaterally. There is normal respiratory variation of the common femoral veins bilaterally. IMPRESSION: No evidence of deep vein thrombosis in the right or left lower extremity. Radiology Report INDICATION: History of non-small cell lung cancer, who presents with worsening shortness of breath and fatigue. CT chest in ___ showed progression of mass and new right lung nodules. Please evaluate. COMPARISONS: Chest CTA from ___. TECHNIQUE: ___ MDCT images were obtained through the chest without the administration of IV contrast. Multiplanar reformatted images in coronal and sagittal axes were generated and reviewed. FINDINGS: Thyroid is normal. There is no axillary lymphadenopathy; however, there is a left-sided node which measures 0.6 cm x 1.1 cm, series 2, image 18, overall stable compared to the prior exam. There is a right axillary node measuring 1 cm in short axis, series 2, image 13, which appears overall slightly increased compared to the prior exam. Soft tissue infiltration around the subcarinal region extends superiorly towards the trachea and appears to have slightly increased in size compared to the prior study with the subcarinal portion grossly measuring 2.5 cm x 3.8 cm, series 2, image 30, compared to the prior exam, at which time this measured 1.5 cm x 3.2 cm. There appears to have also been a slight interval increase in the right hilar lymphadenopathy measuring 2.7 cm x 2 cm, series 2, image 28, slightly increased in size compared to the prior exam, at which time this measured 2.3 cm x 1.5 cm. Heart size is normal. There is a small pericardial effusion. Mild coronary and valvular calcifications are identified. The esophagus is normal without evidence of wall thickening or a hiatal hernia. The mass-like consolidation around the fiducial marker in the posterior segment of the right upper lobe abuts the fissure and has overall increased in size compared to the prior exam. Innumerable nodular soft tissue deposits in the right lung have overall increased in size and become more confluent to become larger soft tissue lesions, compared to the prior exam. For example, in the right lower lobe, there is a 2.3 cm x 1.6 cm lesion, series 102, image 172, which has increased in size compared to the prior exam, at which time this measured 1.5 cm x 1.1 cm. In the right lower lobe, there is a second lesion, series 102, image 163, which now measures 2.2 cm x 1.1 cm, increased in size compared to the prior exam, at which time this measured 1.6 cm x 0.8 cm. There is a conglomerate of nodular opacities in the right middle lobe which have fused to become a larger soft tissue mass along the right major fissure measuring up to 3 cm, series 102, image 148. Additional new nodules are seen, for example, in the right upper lobe, there is a pleural-based lesion which measures 0.7 cm x 0.4 cm, series 102, image 95. There is no pleural effusion or pneumothorax. At the left lower lobe, there has also been an interval increase in size of a 5-mm nodule, series 102, image 167, compared to the prior exam, at which time this measured 4 mm. There are nodular opacities in the left lower lobe, series 102, image 126, measuring up to 0.9 cm. There is a soft tissue lesion measuring 0.9 cm x 0.6 cm, series 102, image 162, in the left lower lobe, overall increased in size compared to the prior exam, at which time this measured 0.6 cm x 0.6 cm, series 102, image 163. Severe centrilobular emphysema has an upper lobe predominance bilaterally. The patient is status post bilateral breast implants. This study is not tailored for the evaluation of the subdiaphragmatic structures; however, the imaged portion of the upper abdomen demonstrates no acute abnormalities. A gastric diverticulum is noted, unchanged compared to the prior exam. OSSEOUS STRUCTURES: No suspicious bony lesions are demonstrated. A benign-appearing sclerotic focus in T4 has been stable since at least ___. IMPRESSION: 1. Significant interval increase in the bulk of the tissue consolidation around the fiducial marker in the right upper lobe, the area of the patient's radiation-treated malignancy. Innumerable scattered right lung nodules are overall increased in size compared to the prior exam. Many of these nodules have become more confluent into larger nodules. 2. Interval increase in the size of the innumerable left lung nodules concerning for worsening metastatic foci. 3. Interval increase in the diffuse lymphadenopathy. Findings were placed in the critical results dashboard by Dr. ___ on the day of the exam. Radiology Report HISTORY: ___ female with non-small cell lung cancer presenting with vertigo and lightheadedness. Evaluate for brain metastasis. TECHNIQUE: Contiguous axial multi detector images of the brain were obtained after administration of intravenous contrast. DLP 1040 mGy-cm. CTDI 62 mGy. COMPARISON: None available. FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or infarction. No evidence of metastatic disease. Prominent ventricles and sulci most consistent with age related involutional changes. Diffuse ___ ventricular and subcortical white matter hypodensities consistent with small vessel ischemic disease. The basal cisterns appear patent. Visualized major vessels and their branches are patent. Osseous structures are unremarkable. Mild mucosal thickening within the left sphenoid sinus. The remainder of the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No evidence of metastatic disease. Radiology Report HISTORY: Flexible bronchoscopy. FINDINGS: Images from the procedure are presented. Further information can be gathered from the procedure report. Radiology Report HISTORY: Bronchoscopy, to assess for pneumothorax. FINDINGS: Following the procedure, there is no evidence of pneumothorax. There is some increased opacification in the right mid and upper zone, suggesting some post-procedure hemorrhage. Radiology Report HISTORY: Chest pain, EKG changes, status post bronchoscopy, question pneumothorax, mediastinal changes. CHEST, SINGLE AP PORTABLE VIEW. No pneumothorax is detected. Again seen are background COPD, a large mass-like opacity in the right upper zone, and interstitial and more confluent opacities at the bases. No new CHF, effusion or pneumothorax is detected. Note is made of an irregular sclerotic lesion in the left proximal humerus and small rounded sclerotic focus in the left glenoid, not fully evaluated on these views. IMPRESSION: 1. No pneumothorax or acute superimposed pulmonary process detected compared with ___ at 11:59 a.m. 2. Sclerotic densities in the left proximal humerus and left glenoid, not fully evaluated. Radiology Report INDICATION: Breast cancer and primary lung cancer, now with shortness of breath and chest pain and paroxysmal AFib, with RVR, evaluate for pulmonary embolism. COMPARISON: Chest CT on ___. TECHNIQUE: MDCT images were obtained through the chest with IV contrast. Coronal and sagittal reformations were performed. Right and left MIP reconstructions were performed. FINDINGS: Partially visualized thyroid is normal. There is no axillary lymphadenopathy. Slightly prominent bilateral axillary lymph nodes are unchanged. Subcarinal soft tissue consolidation is seen and there is an increase in compressive attenuation on the adjacent right main bronchus. There are new bilateral small pleural effusions, right greater than left. The consolidation in the right mid lung is increased in size. There are multiple small nodules throughout the right lung, some of which are slightly increased in size compared to prior study, the right middle lobe nodule measures 1.0 cm, increased from prior study when it measured 0.8 cm. Multiple small left pulmonary nodules are grossly unchanged. There is no filling defect in the pulmonary arteries to the subsegmental level. Right hilar lymphadenopathy is unchanged. The aorta is normal in caliber. Limited evaluation of the upper abdominal organs is unremarkable. There is an incidental note of a gastric fundal diverticulum. Bilateral breast implants are seen. Heart size is normal. There is no pericardial effusion. IMPRESSION: 1. Mild increase in size of soft tissue consolidation in the right mid lung. 2. New bilateral small pleural effusions, right greater than left. 3. Multiple pulmonary nodules bilaterally, some of which have slightly increased in size. 4. Subcarinal soft tissue consolidation is seen and there is an increase in attenuation on the adjacent right main bronchus. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dizziness, FTT Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPERTENSION NOS, HX-BRONCHOGENIC MALIGNAN, HX OF BREAST MALIGNANCY temperature: 98.0 heartrate: 68.0 resprate: 20.0 o2sat: 100.0 sbp: 80.0 dbp: 44.0 level of pain: 0 level of acuity: 1.0
Dear Ms. ___, It was a pleasure caring for you at ___ ___. You came to the hospital with shortness of breath, fatigue, and dizziness. We were concerned for pneumonia and treated you with IV antibiotics. A CT of your chest showed no sign of pneumonia, so antibiotics were stopped. You had a bronchoscopy to better understand what is causing your symptoms. The results of these tests will be available by next week. This is likely progression of your underlying lung cancer. During your stay you had difficulty with anxiety. We recommend that you use your medications to help control this problem, which can make your breathing harder. Please discuss your anxiety with your therapist. While you were in the hospital, we noticed several short periods of irregular heartbeat called atrial fibrillation. You were previously on a medication called atenolol which we switched to a similar medication metoprolol, which will better help to control your heart rate. This irregular heartbeat can put you at risk of forming blood clots, which increases your risk of stroke. You had a blood clot in your heart in ___ for which you were treated with Lovenox. To avoid forming similar clots, you decided to start taking a blood thinning medication called coumadin (warfarin). This medication requires regular monitoring that can be done by the Rehab facility. Dr ___ ___ help manage this medication after you leave the facility. Thank you for allowing us to participate in your care.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Mercaptopurine Analogues (Thiopurines) / Remicade / Humira / Cymarin / Dilaudid / Morphine / Erythromycin Base / Halothane / Mercaptopurine / ciprofloxacin / Zofran (as hydrochloride) Attending: ___ Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: ___ Drainage of Peritoneal Cyst History of Present Illness: HISTORY OF PRESENTING ILLNESS: Ms. ___ is a ___ year old woman, with past history of ulcerative colitis s/p colectomy with ileal pouch anal anastomosis, c/b pouchitis (on Vedolizumab, budesonide), primary sclerosing cholangitis, GERD, Bipolar Disorder, and PTSD, who is presenting today for evaluation of abdominal pain. Patient reports that she has been having increased right lower quadrant pain since the end of ___. Patient reports that this has been worsened specifically over the past week, with bloating, flank pain, and breast pain on the right side, as well as nausea/vomiting. She has also been experiencing some increased urinary retention, without dysuria, and has been trying to manage the pain at home. Patient initially thought this was similar to pouchitis that she has had previously, and was hospitalized for this but did not have any relief. Given that the pain was not improving, and patient was having worsening symptoms with inability to tolerate significant PO intake, patient was seen in the ED. Notably, patient has been evaluated about 2 weeks ago by her GYN for peritoneal inclusion cysts, and underwent ultrasound on ___, which was remarkable for continued chronic 11 cm periotoneal inclusion cyst, without significant change, extended into the left hemipelvis and insinuates around the urinary bladder. Patient reports that she has had this drained by ___ in the past to help relieve symptoms. She describes that she feels "full of fluid", no other symptoms. She states that over the past week, she has been not able to tolerate PO intake, feels nauseated most of the day. She has not been able to tolerate PO intake, with pain in the lower quadrant, and she has been vomiting all night. Notably, patient was recently hospitalized from ___. At that time, patient was having BRPBR, nausea, worsening abdominal pain, and concerning for pouchitis. Patient had flex sigmoidoscopy and MRE at that time, and prescribed 10% hydrocortisone into pouch. Patient was continued on home budesonide, added hydrocortisone foam, and vedolizumab and probiotic and home reglan. Since, then patient had her last Vedolizumab infusion on ___. She also was seeing her OB/GYN for fertility in the setting of ovarian cysts and recurrent peritoneal inclusions cysts. At that visit, reviewed complex adnexal cyst potentially representing a hemmhoragic ovarian cyst, and was planning to have repeat ultrasound of the pelvis. She underwent this on ___, and showed a right ovary noted to be surrounded by adhesions and fluid reflecting a peritoneal inclusion cyst, measuring up to 11 cm largest in diameter, and not significantly changed from prior MRI. The right peritoneal inclusion cysts extends into the left hemipelvis and insinuates around the urinary bladder. Patient has also had previous drainages by ___, with prior placement of an US Pigtail catheter in ___, and with peritoneal inclusion cysts she usually has discomfort, urinary retention, loose stools and dyspaurenia. In the ED, initial vitals: 7 99.1 97 124/72 18 100% RA Exam was notable for: Mild distress, trace ___ swelling, + diffuse abdominal pain, + CVAT. - Labs were significant for : Urinalysis: Spec ___ 1038, Epi 10, Many bacteria, WBC 8, Trace leuk, Ketone negative. Sodium 139, K 4.1, Chloride 106, Bicarb 20, BUN 13, Creatinine 0.6. WBC 8.1, Hgb 11.7, Hct 35.8, Platelet 477. PMN 44, L39 INR 1.1. PTT 29.5. - Imaging showed: None obtained. - In the ED, she received: ___ 06:59 IVF NS ___ 06:59 IV Lorazepam 1 mg ___ 06:59 IV Ketorolac 15 mg ___ 09:30 IV Ketorolac 15 mg ___ 09:30 IV Lorazepam 1 mg ___ 09:31 IVF NS 1 mL - Vitals prior to transfer: 98.2 79 108/ 18 98% RA Upon arrival to the floor, patient is now s/p procedure. Past Medical History: - UC s/p total colectomy and ileal pouch-anal anastomosis (___) c/b recurrent pouchitis and intraabdmoinal abscess - PSC - SBO - Vit D deficiency - GERD - Hx of hip bursitis - Depression - Anxiety - Bipolar disorder (per patient) - PTSD - Eating disorder - ___ Total colectomy with ileoanal pouch and diverting ileostomy (c/b sepsis and abscess) - ___ Ileostomy takedown and reversal - Broken ankle surgery - Sinus surgery - Wisdom teeth extraction Social History: ___ Family History: - Father: Living ___. ___ disease, depression, IBS - Mother: ___, arthritis - MGF: HTN - Uncle: ___ Cancer Physical Exam: >> Admission Physical Exam: Vitals: 98.0 PO 100 / 66 L Lying 62 18 99 Ra General: Alert, oriented, no acute distress. Pale, and fatigued. HEENT: Sclera anicteric. MM dry. EOMI. PERRL. Neck supple. CV: RRR, S1, S2. No extra sounds. Lungs: Clear to auscultation bilaterally, no adventitial sounds heard. Abdomen: Soft, mild diffuse tendernesss. No rebound, guarding. negative murphys. Extremities: No ___ edema bilaterally. Sensation intact. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation. . >> Discharge Physical Exam: Vitals: 108 / 67 L Sitting 82 97 RA General: Appears fatigued, uncomfortable. She is conversing well, however appears frustrated with care. HEENT: Mucous membranes mildly dry. Appears mildly pale. Wearing glasses. CV: RRR, S1, S2. No extra sounds heard. Lungs: Diminished at bases, no adventitial sounds heard. Abdomen: Soft, surgical scar on inspection. There is tenderness generalized, without rebound or guarding. Mild distension. +BS Extremities: No ___ Edema bilaterally. Neuro: CN II-XII grossly intact. able to move extremities. Pertinent Results: >> Admission Labs: ___ 02:45AM BLOOD WBC-8.1 RBC-4.21 Hgb-11.7 Hct-35.8 MCV-85 MCH-27.8 MCHC-32.7 RDW-15.3 RDWSD-46.9* Plt ___ ___ 02:45AM BLOOD Glucose-90 UreaN-13 Creat-0.6 Na-139 K-4.1 Cl-106 HCO3-20* AnGap-17 ___ 02:45AM BLOOD Albumin-4.2 Calcium-9.6 Phos-3.6 Mg-2.1 . >> Discharge Labs: ___ 06:10AM BLOOD WBC-7.9 RBC-3.90 Hgb-10.8* Hct-34.4 MCV-88 MCH-27.7 MCHC-31.4* RDW-15.9* RDWSD-50.5* Plt ___ ___ 08:27AM BLOOD Glucose-79 UreaN-16 Creat-0.6 Na-132* K-4.7 Cl-100 HCO3-23 AnGap-14 ___ 08:27AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.1 . >> Pertinent Reports: IMAGING: ___ Imaging PELVIS, NON-OBSTETRIC: 4 cm right adnexal hypoechoic cystic structure, unclear, possibly representing previously drained right lower quadrant cyst. If further delineation is desired, MRI would provide further assessment. Small amount of free fluid may be minimally complex, difficult to discern whether truly free-fluid or if represents previously described residual peritoneal inclusion cyst. ___ Imaging PERC IMAGE GUID FLUID C; The patient was placed in a supine position on the US scan table. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings an appropriate skin entry site for the aspiration was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, a 5 ___ ___ needle was inserted into the cyst. Approximately 150 cc of clear straw-colored fluid was aspirated. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: Moderate sedation was provided by administering divided doses of 3.5 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 43 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Limited postprocedural ultrasound demonstrates near complete resolution of the right lower quadrant cyst. IMPRESSION: Successful US-guided aspiration of a right lower quadrant cyst with 150 cc of clear straw colored fluid removed. ___ Imaging PELVIS, NON-OBSTETRIC: The uterus is anteverted and measures 6.7 x 4.0 x 4.8 cm. The endometrium is homogenous and measures 15 mm. Stable 2.2 cm posterior subserosal fibroid. The left ovary is again surrounded by a small amount of loculated fluid reflecting a peritoneal inclusion cyst, previously drained. The right ovary is also noted to be surrounded by adhesions and fluid reflecting a peritoneal inclusion cyst, measuring up to 11 cm in largest diameter, not significantly changed from prior MRI (up to 11 cm). This right peritoneal inclusion cyst again extends into the left hemipelvis and insinuates around the urinary bladder. The ovaries are otherwise unremarkable. IMPRESSION: No significant change in right peritoneal inclusion cyst extending into the left hemipelvis and measuring up to 11 cm. Fibroid uterus. ___ Imaging MR ENTEROGRAPHY ___: Status post total colectomy with ileal pouch anal anastomosis with mild pouchitis. There is no abscess, fistula, or stricture. There are bilateral fluid-filled tubular structures which likely represent hydrosalpinx. There is also a moderate amount of free-fluid in the pelvis which conforms to the peritoneal reflections, likely due to a peritoneal inclusion cyst. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Budesonide 9 mg PO DAILY 2. Cholestyramine 4 gm PO DAILY 3. ClonazePAM 0.5 mg PO QHS:PRN anxiety 4. Diazepam 10 mg PO QHS anxiety / insomnia 5. Famotidine 20 mg PO BID 6. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN nose 7. HydrOXYzine 100 mg PO QHS 8. LORazepam 0.5 mg PO Q6H:PRN nausea 9. Ursodiol 600 mg PO BID 10. Vitamin D ___ UNIT PO DAILY 11. Hydrocortisone Acetate 10% Foam 1 Appl PR QHS 12. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 13. butalbital-acetaminophen-caff 50-325-40 mg oral Q6H:PRN headache 14. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough 15. Metadate CD (methylphenidate) 20 mg oral QAM 16. Methylphenidate SR 72 mg PO QAM 17. Metoclopramide 5 mg PO Q8H:PRN nausea 18. Multivitamins 1 TAB PO DAILY 19. olopatadine 0.1 % ophthalmic BID 20. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.acidophilus-Bif. animalis;<br>L.rhamn ___ acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 15 billion cell oral DAILY 21. butalbital-acetaminophen-caff 50-300-40 mg oral Q6H:PRN 22. Hyoscyamine 0.125 mg PO TID:PRN spasma Discharge Medications: 1. Oxybutynin 5 mg PO TID RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times daily Disp #*90 Tablet Refills:*0 2. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every 8 hours Disp #*12 Tablet Refills:*0 3. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice daily Disp #*8 Tablet Refills:*0 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 5. Budesonide 9 mg PO DAILY 6. butalbital-acetaminophen-caff 50-325-40 mg oral Q6H:PRN headache 7. butalbital-acetaminophen-caff 50-300-40 mg oral Q6H:PRN headache 8. Cholestyramine 4 gm PO DAILY 9. ClonazePAM 0.5 mg PO QHS:PRN anxiety 10. Diazepam 10 mg PO QHS anxiety / insomnia 11. Famotidine 20 mg PO BID 12. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN nose 13. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough 14. Hydrocortisone Acetate 10% Foam 1 Appl PR QHS 15. HydrOXYzine 100 mg PO QHS 16. Hyoscyamine 0.125 mg PO TID:PRN spasma 17. LORazepam 0.5 mg PO Q6H:PRN nausea RX *lorazepam 0.5 mg 1 tab by mouth every ___ hours Disp #*10 Tablet Refills:*0 18. Metadate CD (methylphenidate) 20 mg oral QAM 19. Methylphenidate SR 72 mg PO QAM 20. Metoclopramide 5 mg PO Q8H:PRN nausea 21. Multivitamins 1 TAB PO DAILY 22. olopatadine 0.1 % ophthalmic BID 23. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.acidophilus-Bif. animalis;<br>L.rhamn ___ acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 15 billion cell oral DAILY 24. Ursodiol 600 mg PO BID 25. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Peritoneal Inclusion Cyst s/p drainage. 2. Cystitis, complicated. SECONDARY DIAGNOSIS: 1. Ulcerative Colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: ULTRASOUND-GUIDED ASPIRATION INDICATION: ___ year old woman with known cyst// Drainage of cyst COMPARISON: Prior ultrasound dated ___ PROCEDURE: Ultrasound-guided drainage of a right lower quadrant cyst. OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agree 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 supine position on the US scan table. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings an appropriate skin entry site for the aspiration was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, a 5 ___ ___ needle was inserted into the cyst. Approximately 150 cc of clear straw-colored fluid was aspirated. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: Moderate sedation was provided by administering divided doses of 3.5 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 43 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Limited postprocedural ultrasound demonstrates near complete resolution of the right lower quadrant cyst. IMPRESSION: Successful US-guided aspiration of a right lower quadrant cyst with 150 cc of clear straw colored fluid removed. Radiology Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ year old woman with history of inclusion peritoneal cyst now s/p drainage.// repeat eval of cyst TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: ___ FINDINGS: The uterus measures 9.1 x 4.0 x 5.0 cm. The endometrium is homogenous and measures 10 mm. In the right adnexa, it potentially internally associated with the right ovary is a 4.0 x 2.2 x 1.5 cm hypoechoic cystic structure. The ovaries are normal in size. Arterial and venous waveforms were demonstrated over both ovaries with pulsed spectral Doppler. Some free fluid is seen, which may be minimally complex; difficult to discern whether truly free-fluid or previously described residual peritoneal inclusion cyst. IMPRESSION: 4 cm right adnexal hypoechoic cystic structure, unclear, possibly representing previously drained right lower quadrant cyst. If further delineation is desired, MRI would provide further assessment. Small amount of free fluid may be minimally complex, difficult to discern whether truly free-fluid or if represents previously described residual peritoneal inclusion cyst. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Right lower quadrant pain temperature: 99.1 heartrate: 97.0 resprate: 18.0 o2sat: 100.0 sbp: 124.0 dbp: 72.0 level of pain: 7 level of acuity: 3.0
Dear Ms. ___, It was a pleasure taking care of you during your hospital stay at ___. You were admitted to the hospital for abdominal pain after a procedure by our interventional radiologists. While here, you underwent drainage of a peritoneal cyst with some fluid removal and started to have relief of your pain. We continued to monitor you until you were able to eat or drink, and your pain was controlled. In addition, you had urinary retention. You were periodically bladder scanned, and your bladder was drained with a straight catheter. We wrote a prescription catheters for you to be able to self-cath at home. Please return to the hospital if you have worsening abdominal pain, fevers, nausea, vomiting, diarrhea, pain with urination, or blood in your urine. Please continue to follow up with your primary care physician and your your specialists upon discharge from the hospital. Take Care, Your ___ Team.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: prostate cancer DVT (LLE) ___ s/p channel TURP hematuria compartment syndrome Cardiac arrest (circulatory arrest) Major Surgical or Invasive Procedure: Date: ___ Surgeon: ___, MD PROCEDURES: Exploratory laparotomy and superior abdominal closure. Date: ___ Surgeon: ___, MD PROCEDURE: Removal of VAC sponge and secondary abdominal closure. Date: ___ Surgeon: ___, MD PROCEDURE: Exploratory laparotomy with complex repair of bladder laceration, temporary abdominal wound closure. PRIOR ADMISSION: Date: ___ Surgeon: ___, MD PROCEDURE: Bipolar transurethral resection of prostate. History of Present Illness: Mr. ___ is an ___ M w/PMHx prostate CA s/p TURP on ___, LLE DVT on Coumadin at home (bridging with Lovenox s/p TURP), presented to the ED on POD#4 with decreased UOP, belly pain, hematuria, and vomiting. The foley was exchanged by urology and CBI was started. Patient went to the floor and became worse- hypotensive to SBP 70's, tachypneic, hypothermic to T ___, and lethargic, with belly looking more distended. He was moved to the FICU with plans to do a stat CT, but pt continued to decompensate- increasingly hypotensive and tachypenic. FAST exam showed free fluid, pt was intubated for stat OR; when resident went to place arterial line, felt the pulse get lost. CPR initiated, multiple rounds of epi, chest compressions continued while bedside ex lap was done. Large amount of blood tinged free fluid from bladder perforation. Was started on Levophed, fentanyl gtt, and sent to OR. ACS team called to assist. In OR, closed bladder injury. Placed suprapubic catheter as well as a foley, irrigating through the SPC and draining out foley. Abdomen was left open. Pt was stabilized post-operatively in the FICU and then transferred to the TICU. Past Medical History: PMH: - Prostate cancer with bone mets - Hypertension - DVT, LLE - urinary retention - arthritis - GERD PSH: ___ Cystoscopy, Bipolar Transurethral Resection of Prostate Social History: ___ Family History: No history of malignancy. Physical Exam: Gen: No acute distress, alert & oriented HEENT: Extraocular movements intact, face symmetric CHEST: Warm and well-perfused BACK: Non-labored breathing, no CVA tenderness bilaterally ABD: Soft, non-tender, mild distention, no guarding or rebound SPT care; waste elimination Wound care/monitoring; staples removed ___ prior to discharge and steristrips applied. EXT: Bilateral lower extremities are warm, dry, well perfused. There is no reported calf pain to deep palpation. No edema or pitting PSY: Appropriately interactive Pertinent Results: ___ 10:40AM BLOOD WBC-10.5* RBC-3.38* Hgb-9.4* Hct-29.0* MCV-86 MCH-27.8 MCHC-32.4 RDW-14.4 RDWSD-44.5 Plt ___ ___ 07:40AM BLOOD WBC-9.0 RBC-2.87* Hgb-7.9*# Hct-24.1* MCV-84 MCH-27.5 MCHC-32.8 RDW-14.4 RDWSD-43.6 Plt ___ ___ 07:40AM BLOOD WBC-8.9 RBC-2.30* Hgb-6.3* Hct-19.7* MCV-86 MCH-27.4 MCHC-32.0 RDW-14.1 RDWSD-43.5 Plt ___ ___ 05:32PM BLOOD WBC-11.0* RBC-2.57* Hgb-7.2* Hct-22.6* MCV-88 MCH-28.0 MCHC-31.9* RDW-15.5 RDWSD-49.7* Plt Ct-93* ___ 01:35PM BLOOD WBC-11.6* RBC-2.44* Hgb-6.5* Hct-20.6* MCV-84 MCH-26.6 MCHC-31.6* RDW-15.1 RDWSD-46.7* Plt ___ ___ 03:28AM BLOOD WBC-15.6*# RBC-2.49*# Hgb-6.7* Hct-20.9*# MCV-84 MCH-26.9 MCHC-32.1 RDW-15.3 RDWSD-46.3 Plt ___ ___ 03:28AM BLOOD Neuts-83.9* Lymphs-9.2* Monos-5.8 Eos-0.0* Baso-0.1 Im ___ AbsNeut-13.14*# AbsLymp-1.44 AbsMono-0.90* AbsEos-0.00* AbsBaso-0.01 ___ 03:10PM BLOOD ___ ___ 10:40AM BLOOD ___ ___ 05:58AM BLOOD ___ PTT-34.2 ___ ___ 02:43PM BLOOD ___ PTT-86.2* ___ ___ 03:28AM BLOOD ___ PTT-32.8 ___ ___ 07:40AM BLOOD Glucose-85 UreaN-16 Creat-1.7* Na-141 K-3.6 Cl-108 HCO3-21* AnGap-16 ___ 07:40AM BLOOD Glucose-91 UreaN-17 Creat-1.8* Na-143 K-3.4 Cl-111* HCO3-21* AnGap-14 ___ 01:35PM BLOOD Glucose-141* UreaN-52* Creat-6.2* Na-134 K-5.3* Cl-100 HCO3-12* AnGap-27* ___ 03:28AM BLOOD Glucose-162* UreaN-46* Creat-5.5*# Na-136 K-4.8 Cl-98 HCO3-16* AnGap-27* ___ 01:30AM BLOOD ALT-725* AST-462* AlkPhos-49 TotBili-0.3 ___ 01:30AM BLOOD ALT-960* AST-967* AlkPhos-45 TotBili-0.4 ___ 03:41PM BLOOD ALT-107* AST-130* AlkPhos-45 TotBili-0.7 ___ 03:41PM BLOOD Lipase-17 ___ 07:40AM BLOOD Calcium-7.5* Mg-1.6 ___ 12:55AM BLOOD Calcium-7.7* Phos-4.2 Mg-1.9 ___ 06:59PM BLOOD Calcium-8.5 Phos-10.2* Mg-2.0 ___ 03:41PM BLOOD Albumin-3.1* ___ 01:35PM BLOOD Mg-2.2 ___ 07:12PM ASCITES Creat-3.5 ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL EMERGENCY WARD Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. amLODIPine 5 mg PO DAILY 3. Warfarin 2.5 mg PO DAILY16 alternate with 5 mg QOD 4. Enoxaparin Sodium 70 mg SC Q24H Start: ___, First Dose: Next Routine Administration Time 5. Famotidine 20 mg PO BID 6. Tamsulosin 0.4 mg PO QHS 7. Cyanocobalamin 1000 mcg PO DAILY 8. Vitamin B Complex 1 CAP PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain or fever 2. Artificial Tear Ointment 1 Appl BOTH EYES PRN eye care 3. Docusate Sodium 100 mg PO BID 4. Senna 8.6 mg PO BID 5. amLODIPine 5 mg PO DAILY 6. Cyanocobalamin 1000 mcg PO DAILY 7. Famotidine 20 mg PO BID 8. Finasteride 5 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H 10. QUEtiapine Fumarate 50 mg PO QHS 11. Tamsulosin 0.4 mg PO QHS 12. Vitamin B Complex 1 CAP PO DAILY 13. Warfarin 2.5 mg PO DAILY16 alternate with 5 mg QOD 14.rolling walker Diagnosis: bladder perforation Prognosis: good ___: 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1) Bladder perforation 2) abdominal compartment syndrome 3) Cardiac Arrest: cardiovascular collapse with return of circulation after CODE 4) Acute kidney injury on chronic kidney disease 5) generalized deconditioning 6) thrombosis, deep vein (pre-existing) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man who had a bladder perf c/b abd compartment syndrome, was coded with chest compressions prior to going to OR, now back in ICU// eval for chest wall fractures TECHNIQUE: Chest single view COMPARISON: ___ 00:56 FINDINGS: Endotracheal tube tip is 2 cm above carina. Enteric tube tip is mid stomach. Postoperative changes upper abdomen. Right IJ central line tip is in mid to low SVC. Opacity right lung apex, with volume loss, scarring, likely atelectasis. Underlying obstruction cannot be excluded. No adjacent rib destruction. Stable right lower lateral rib expansion, adjacent pleural thickening, indeterminate. No new fractures. IMPRESSION: Stable cardiopulmonary findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with open abdomen s/p perf bladder. intubated/sedated// eval for changes, especially RUL TECHNIQUE: Chest single view COMPARISON: ___ 19:27 FINDINGS: Endotracheal tube tip 2.5 cm above carina. Volume loss right lung apex with atelectasis, superior right hilar retraction, stable, most likely from right upper lobe atelectasis. Enteric tube tip well below diaphragm, out of view. Right IJ central line tip in low SVC. Stable right lateral rib lesion. Left lung is clear. No sizable effusion. No pneumothorax. IMPRESSION: Stable exam Radiology Report INDICATION: ___ year old man with open abdomen, intub/sedated// eval for RUL improvement s/p bronch, other changes COMPARISON: Radiographs from ___ IMPRESSION: Support lines and tubes are unchanged in position. Cardiomediastinal silhouette is within normal limits. There is again seen area consolidation and volume loss in the right upper lobe, stable. The rest of lung fields are grossly clear aside for a small right-sided pleural effusion. There are no pneumothoraces. Overall findings are unchanged. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p bedside exlap, intub/sedated// eval for changes eval for changes IMPRESSION: ET tube tip terminates right above the carinal. Right internal jugular line tip terminates at the level of lower SVC. NG tube tip is in the stomach. Heart size and mediastinum are stable. Right apical pleural thickening is unchanged. There is no appreciable pleural effusion. There is no pneumothorax. Radiology Report INDICATION: ___ year old man with RUL collapse on CXR, s/p bronch// interval change s/p bronch, ETT placement COMPARISON: Radiographs from ___ at 05:47. IMPRESSION: Endotracheal tube, feeding tube, and right IJ central line are unchanged position. There remains volume loss and collapse of the right upper lobe similar to prior. The rest of the lung fields are grossly clear. There are no pneumothoraces. There is again seen a known right sixth lateral rib lesion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with perf'd bladder, open abdomen// eval for changes eval for changes IMPRESSION: Comparison to ___. Stable monitoring and support devices. Stable right upper lobe atelectasis and right lateral pleural thickening. Increasing retrocardiac atelectasis. No other changes are seen in the lung parenchyma. Stable borderline size of the heart. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old man with bladder injury// Evaluate kidneys TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None available. FINDINGS: The right kidney measures 9.6 cm and is normal in appearance without hydronephrosis, stones, or mass. Normal cortical echogenicity and corticomedullary differentiation is noted. The left kidney is not seen secondary to extensive overlying bowel gas. The bladder is poorly visualized, and appears collapsed around Foley catheter. IMPRESSION: 1. Normal right renal ultrasound. Nonvisualized left kidney secondary to overlying bowel gas and bedside portable approach. 2. Suboptimal visualization of the urinary bladder, which appears collapsed around Foley catheter. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man w/open abdomen, intub/sedated// eval for changes eval for changes IMPRESSION: Compared to chest radiographs ___ through ___. Right upper lobe has been collapsed since at least ___. Prior radiograph should be obtained to document whether this is a chronic finding or one which requires further investigation with chest CT. Heart size normal. Moderate left lower lobe atelectasis has worsened. Small right pleural effusion is likely. No left pleural effusion or pneumothorax. Cardiopulmonary support devices in standard placements. Radiology Report INDICATION: ___ year old man, inaccurate surgical sponge count. TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: Chest radiograph ___. FINDINGS: There are no abnormally dilated loops of large or small bowel. There is a large amount of stool in the ascending and descending colon. Assessment for free intraperitoneal air is limited on supine radiographs. An enteric catheter side port projects over the proximal gastric body. Multiple staples project over the periphery of the abdomen and pelvis. No evidence of retained sponge. A drain or wound VAC projects over the upper left pelvis. IMPRESSION: No evidence of retained sponge. NOTIFICATION: The findings were discussed with Dr. ___ by ___, M.D. on the telephone on ___ at 4:05 pm, less than 5 minutes after discovery of the findings. and by Dr. ___ with Dr. ___- 10 minutes after observation of these findings Radiology Report EXAMINATION: CR chest INDICATION: ___ year old man with new NGT// NGT placement TECHNIQUE: Portable AP radiograph of the chest was performed COMPARISON: Chest radiograph from earlier today performed at 05:20 FINDINGS: Again seen is a left internal jugular central venous catheter with tip at the cavoatrial junction, and a nasogastric tube coursing into the stomach. There is right upper lobe collapse, stable. The left lung is grossly clear, aside from linear subsegmental atelectasis in the midlung. Blunting of the right costophrenic angle may be secondary to pleural thickening or a small amount of pleural fluid, unchanged. The cardiomediastinal contour remains unchanged. Midline skin staples project over the mid abdomen. IMPRESSION: 1. Nasogastric tube coursing into the stomach. 2. Right upper lobe collapse stable, comparison to priors or investigation with chest CT recommended to exclude central obstruction. Radiology Report INDICATION: ___ year old man with intubation// Interval change TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: There are low bilateral lung volumes. Unchanged right upper lobe collapse. Opacities over the right lung base and right diaphragm may reflect underlying atelectasis and/or consolidation. No new pleural effusion or pneumothorax is identified. Thickening of the right lateral sixth rib is again seen, suspicious for a rib lesion. The size the cardiac silhouette is mildly enlarged but unchanged. Interval removal of the nasogastric tube and right internal jugular central venous line. IMPRESSION: Low bilateral lung volumes and persisting right upper lobe atelectasis. Thickening of the right sixth lateral rib is again seen, suspicious for an underlying rib lesion. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old man with bladder perforation, evaluate for ureteral injury// evaluate for hydro TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: Renal ultrasound from ___ FINDINGS: The right kidney measures 8.8 cm. There is no hydronephrosis or calculi of the right kidney in its limited evaluation secondary to overlying bowel gas. Normal cortical echogenicity and corticomedullary differentiation is seen of the right kidney. The left kidney measures 8.5 cm. There is moderate hydronephrosis, partially seen on prior, not significantly changed. There are no calculi in the left kidney. Normal cortical echogenicity and corticomedullary differentiation is present. A few pararenal cysts are suggested. The urinary bladder is decompressed via Foley catheter. IMPRESSION: Moderate left hydronephrosis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with history of prostate cancer with new CVL// CVL placement? TECHNIQUE: Single frontal view of the chest and bone scan from ___ COMPARISON: None. FINDINGS: A right IJ central venous catheter terminates in the proximal right atrium. There is an opacity in the right upper lobe with elevation of the fissure, consistent with atelectasis. Heart size is mildly enlarged, slightly accentuated by portable supine technique. There is a small right pleural effusion. No pneumothorax. There is again seen thickening and irregularity of the right lateral sixth rib which showed uptake on the prior bone scan. IMPRESSION: -A right IJ central venous catheter terminates in the proximal right atrium. -Small right pleural effusion and right upper lobe atelectasis. -Thickening of the right lateral sixth rib Radiology Report INDICATION: ___ year old man with SOB// lung process causing SOB COMPARISON: Radiographs from ___ and bone scan from ___ IMPRESSION: There is a right IJ central line with the distal lead tip at the cavoatrial junction. There is again seen opacity within the right upper lobe and elevation the minor fissure consistent with atelectasis. Thickening of the right sixth lateral rib is again seen and demonstrated uptake on the prior bone scan suspicious for a rib lesion. Gender: M Race: BLACK/CARIBBEAN ISLAND Arrive by WALK IN Chief complaint: Hematuria, Urinary retention Diagnosed with Hematuria, unspecified temperature: 98.7 heartrate: 121.0 resprate: 24.0 o2sat: 100.0 sbp: 117.0 dbp: 71.0 level of pain: 8 level of acuity: 2.0
-Please also reference the instructions provided by nursing on SUPRAPUBIC TUBE (SPT) catheter care, hygiene and waste elimination. -ALWAYS follow-up with your referring provider ___ your PCP to discuss and review your post-operative course and medications. Any NEW medications should also be reviewed with your pharmacist. -Resume your pre-admission medications except as noted on the medication reconciliation -You may take ibuprofen and the prescribed narcotic together for pain control. FIRST, use Tylenol and Ibuprofen. Add the prescribed narcotic (examples: Oxycodone, Dilaudid, Hydromorphone) for break through pain that is >4 on the pain scale. -The maximum dose of Tylenol (ACETAMINOPHEN) is 3- 4 grams (from ALL sources) PER DAY. -Ibuprofen should always be taken with food. If you develop stomach pain or note black stool, stop the Ibuprofen. Ibuprofen works best when taken “around the clock.” -For your safety and the safety of others; PLEASE DO NOT drive, operate dangerous machinery, or consume alcohol while taking narcotic pain medications. -Do NOT drive while Foley catheter is in place. -AVOID lifting/pushing/pulling items heavier than 10 pounds (or 3 kilos; about a gallon of milk) or participate in high intensity physical activity (which includes intercourse) until you are cleared by your Urologist in follow-up. Generally about FOUR weeks. Light household chores are generally “ok”. Do not vacuum. -No DRIVING until you are cleared by your Urologist -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery -You may be given “prescriptions” for a stool softener ___ a gentle laxative. These are over-the-counter medications that may be “health care spending account reimbursable.” -Colace (docusate sodium) may have been prescribed to avoid post-surgical constipation or constipation related to use of narcotic pain medications. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -Senokot (or any gentle laxative) may have been prescribed to further minimize your risk of constipation. -You may shower as usual but do not immerse in bath/pool while foley in place -Your Foley should be secured to the catheter secure on your thigh at ALL times until your follow up with the surgeon. -DO NOT allow anyone that is outside of the urology team remove your Foley for any reason. -Wear Large Foley bag for majority of time; the leg bag is only for short-term when leaving the house, etc. -___ medical attention for fevers (temp>101.5), worsening pain, drainage or excessive bleeding from incision, chest pain or shortness of breath.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain, diarrhea Major Surgical or Invasive Procedure: Colonoscopy ___ History of Present Illness: ___ hx ___ dz on Remicaide, h/o MV endocarditis, gastritis, s/p cholecystectomy, s/p pancreatic stent & removal ___, presents with abdominal pain. Patient reports that he's been having crampy abdominal pain, diffuse but worst in the RLQ at the site of his ileocolonic resection, with accompanying nausea and loose, nonbloody diarrhea. This is reminiscent of his previous ___ flares. He had a fever to ___s an episode of emesis. There have been no sick contacts, no medication changes, no new or unusual foods, no alcohol intake. He made it through his Remicade treatment in the hope it would help, but his sx were not alleviated and continued to progress after, for which he went to the ED. In the ED, initial vitals were: 99.0 83 142/88 18 98%RA. Labs notable for: No leukocytosis, H/H ___ (at baseline), K 3.5 (Cr 1.0). Lipase 42. Lactate 1.3. CRP 2.2 (WNL). Imaging notable for: Nonspecific bowel gas pattern. Patient given: Morphine 5mg IV x2, Zofran 4mg IV x2, 1L NS. Vitals prior to transfer: 98.0 79 135/86 18 96% RA. On the floor, patient is awoken from sleep to recount the story above, continues to feel unwell with continued abdominal pain, but slightly better than when he came in. Review of systems: (+) Per HPI. Cardiac, respiratory, GU ROS negative. Past Medical History: PAST MEDICAL HISTORY: # ___ disease (dx-ed ___ ileocolonic anastamosis ___ on Remicaide # Mitral Valve Endocarditis ___ port infection, growing S. viridans and ___ in blood s/p tx 6 weeks of IV antibiotics # Cholecystectomy (___) # Appendectomy (___) # Asthma # Migraines --___, takes Tylenol and/or Imitrex for abortive relief # Hypertension # Gastritis Social History: ___ Family History: One sister and cousin with chronic abdominal pain and migraines. # Mother: ___, kidney cancer, kidney stones # Father: ___ cell carcinoma of finger # Brother: ___ disease, migraines # Sisters: 2 healthy sisters, one with migraines and chronic abdominal pain # Paternal Grandfather: ___ disease # Maternal Grandfather: ___ cancer, lymphoma # Paternal Uncle: ___ disease # Paternal Cousin: ___ disease # Maternal Cousin: ___ # ___ Uncle: kidney stones Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.1 133/96 75 18 95%RA General: Young male reclined in bed awoken from sleep, NAD HEENT: NCAT, pupils symmetric, anicteric sclera, clear OP, dry MM Neck: JVP not elevated CV: RRR, no r/g/m Lungs: CTAB Abdomen: Well-healed midline scar, soft, TTP RUQ and RLQ, ND, +BS GU: Deferred Ext: WWP, no edema Neuro: Face symmetric, moving all four limbs on command DISCHARGE PHYSICAL EXAM: Vitals: Tm 98.2 135/85 74 20 98 RA General: NAD, appears stated age, lying in bed HEENT: NCAT, PERRL, EOMI, MMM CV: RRR, nl S1, S2 Lungs: CTAB Abdomen: Midline scar, soft, non-distended, +BS, diffuse abdominal pain most pronounced in RLQ, no g/r/r GU: No foley Ext: pulses 2+ dp b/l, no edema Neuro: CN2-12 intact, moving all extremities Skin: WWP Pertinent Results: ADMISSION LABS: ___ 12:00PM BLOOD WBC-9.6 RBC-4.07* Hgb-12.1* Hct-35.1* MCV-86 MCH-29.6 MCHC-34.3 RDW-14.0 Plt ___ ___ 12:00PM BLOOD Neuts-54.0 ___ Monos-6.0 Eos-1.8 Baso-0.5 ___ 09:55PM BLOOD Glucose-127* UreaN-16 Creat-1.0 Na-139 K-3.5 Cl-102 HCO3-25 AnGap-16 ___ 12:00PM BLOOD ALT-36 AST-27 ___ 09:55PM BLOOD Lipase-42 ___ 09:55PM BLOOD Calcium-8.8 Phos-3.9 Mg-2.1 ___ 12:00PM BLOOD CRP-2.5 ___ 10:04PM BLOOD Lactate-1.3 PERTINENT LABS: ___ 06:09AM BLOOD CRP-2.9 ___ 07:30AM BLOOD CRP-32.8* ___ 08:00AM BLOOD CRP-53.5* ___ 07:50AM BLOOD CRP-28.0* ___ 07:30AM BLOOD Lipase-20 ___ 07:30AM BLOOD ALT-48* AST-30 AlkPhos-77 TotBili-0.8 ___ 08:00AM BLOOD ALT-53* AST-36 AlkPhos-73 TotBili-0.4 ___ 07:50AM BLOOD ALT-52* AST-34 AlkPhos-68 TotBili-0.4 DISCHARGE LABS: ___ 07:50AM BLOOD WBC-7.5 RBC-4.32* Hgb-13.0* Hct-39.2* MCV-91 MCH-30.2 MCHC-33.2 RDW-14.0 Plt ___ ___ 07:50AM BLOOD Glucose-90 UreaN-16 Creat-1.0 Na-140 K-3.7 Cl-104 HCO3-25 AnGap-15 ___ 07:50AM BLOOD ALT-50* AST-37 AlkPhos-61 TotBili-0.2 ___ 07:50AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.1 ___ 07:50AM BLOOD CRP-13.8* IMAGING/REPORTS: - ___ KUB: Nonspecific bowel gas pattern. No evidence of obstruction. - ___ EKG: Sinus rhythm. Normal tracing. No major change from previous tracing. QTc 408 - ___ MRE: Mild proctocolitis extending from the splenic flexure to the rectum. No active inflammation of the small bowel or complication of transmural disease. - ___ CXR: As compared to the previous radiograph, the left PICC line was removed. The lung volumes are low. Normal size of the cardiac silhouette. Normal hilar and mediastinal structures. Mild elongation of the descending aorta. No pneumonia. No pneumothorax, no pleural effusions, no pulmonary edema. - ___ colonoscopy: Impression: No gross endoscopic evidence of inflammation. (biopsy, biopsy, biopsy, biopsy) Fair prep 20 cm into terminal ileum appeared grossly normal Otherwise normal colonoscopy to neo-terminal ileum MICRO: - blood cx ___: negative - blood cx ___: pending - urine cx ___: negative ___ 4:33 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 3. Felodipine 5 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. FoLIC Acid 1 mg PO DAILY 6. Omeprazole 40 mg PO BID 7. Ranitidine 300 mg PO QHS 8. Prochlorperazine 10 mg PO Q8H:PRN nausea 9. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit oral BID 10. Vitamin D 1000 UNIT PO DAILY 11. Infliximab 0 mg IV Q6WEEKS 12. Ondansetron 8 mg PO Q8H:PRN nausea Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 3. Felodipine 5 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. FoLIC Acid 1 mg PO DAILY 6. Ranitidine 300 mg PO QHS 7. Vitamin D 1000 UNIT PO DAILY 8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*7 Tablet Refills:*0 9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*11 Tablet Refills:*0 10. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit oral BID 11. Infliximab 0 mg IV Q6WEEKS 12. Ondansetron 8 mg PO Q8H:PRN nausea 13. Prochlorperazine 10 mg PO Q8H:PRN nausea Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Abdominal pain/diarrhea Secondary diagnosis: ___ disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MR ___ INDICATION: ___ year old man with Crohn's disease TECHNIQUE: T1 and T2-weighted multiplanar images of the abdomen and pelvis were acquired within a 1.5 T magnet, including 3D dynamic sequences performed prior to, during, and following the administration of 0.1 mmol/kg of Gadavist intravenous contrast ( cc). Oral contrast consisted of 900 mL of VoLumen. COMPARISON: Multiple prior abdominal CTs and MRIs dating from ___, the most recent from ___. FINDINGS: MR ENTEROGRAPHY: The patient is status post right hemicolectomy, with ileocolonic anastomosis identified within the right upper quadrant. The remaining small bowel demonstrates normal peristalsis and distensibility throughout. There is no segmental wall thickening, hyperenhancement or edema. No mesenteric fibrofatty proliferation or inflammatory changes noted within the small bowel. The study is not intended to evaluate the colon given lack of a colonic prep. While the colon is incompletely distended, there is mild circumferential wall thickening and mucosal hyperenhancement of the descending colon (05:33), sigmoid and rectum. This does not result in significant surrounding edema or hyperemia. The transverse colon is spared. No extraluminal fluid collection or fistula is identified. MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: Visualized portions of the liver demonstrate normal morphology and enhancement pattern. There is low parenchymal signal on Fiesta sequences suggestive of hepatic steatosis, although confirming and quantifying sequences are not acquired as part of the enterography protocol. There is no focal lesion. The patient is status post cholecystectomy. Intra and extrahepatic biliary tree is unchanged in appearance with mild extrahepatic prominence (common hepatic duct measuring 12 mm). Pancreatic parenchyma maintains normal bulk, intrinsic hyperintense T1 signal and enhancement pattern. There is no ductal abnormality. The spleen and adrenal glands are unremarkable. There are tiny bilateral simple renal cysts, none with concerning features. The largest is noted at the inferior pole of the right kidney with a diameter of 14 mm. There is no lymphadenopathy or ascites. Arterial vascular anatomy is conventional. Venous structures are widely patent. Visualized osseous structures are unremarkable. Note is made of a small fat containing periumbilical hernia. MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST: No free pelvic fluid or lymphadenopathy is noted. The urinary bladder, visualized portion of the prostate gland and seminal vesicles are unremarkable. IMPRESSION: Mild proctocolitis extending from the splenic flexure to the rectum. No active inflammation of the small bowel or complication of transmural disease. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with fevers // eval for intrathoracic process COMPARISON: ___. IMPRESSION: As compared to the previous radiograph, the left PICC line was removed. The lung volumes are low. Normal size of the cardiac silhouette. Normal hilar and mediastinal structures. Mild elongation of the descending aorta. No pneumonia. No pneumothorax, no pleural effusions, no pulmonary edema. Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: Abd pain Diagnosed with ABDOMINAL PAIN OTHER SPECIED temperature: 99.0 heartrate: 83.0 resprate: 18.0 o2sat: 98.0 sbp: 142.0 dbp: 88.0 level of pain: 7 level of acuity: 3.0
Dear Mr. ___, It was a pleasure taking care of you during your stay at ___. You were admitted for abdominal pain and diarrhea. You were found to have a fever and elevation in serum inflammatory markers concerning for infection and/or ___ flare. You were started on antibiotics and your symptoms improved. A colonoscopy showed no sign of active ___. By discharge, you were tolerating a regular diet with improved pain and decreased inflammatory markers. You should continue the antibiotics as prescribed and will be contacted by the ___ department for an outpatient follow-up appointment. Wishing you well, Your ___ Medicine Team
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Back pain, T12 osteomyelitis. Major Surgical or Invasive Procedure: ___: Bilateral psoas muscle abscess drainage ___: Diagnostic Spinal Angiogram ___: Corpectomy T11/12 and PSF T9 to L2, chest tube placement History of Present Illness: ___ year old gentleman with h/o IVDU, recent SBO with ostomy, chronic back pain with multiple disk herniations and recent hx T12 osteomyelitis treated with ___ weeks vancomycin in ___, who is transferred to ___ from ___ with evidence of progression of osteomyelitis with associated with paraspinal abscesses. In ___ s/p surgery for SBO, post-op course was complicated by persistent MRSA bacteremia with a MRSA UTI. TEE and TTE did not show endocarditis. He was treated with IV vancomycin and gradually defervesced. An 8 week course of antibiotics was planned as an inpatient (___ not trusted with patient's history of recent IVDU-last reported IVDU in ___. Patient became frustrated with hospital and left AMA after several weeks. He felt well until ___ when he developed worsening back pain and gradual immobility ___ to pain primarily. At ___ he was found to have destructive T12 osteomyelitis. He was treated with ?8 weeks of IV antibiotics. After his treatment, he returned home but has felt that his back pain and bilat ___ weakness has been progressively worsening. Three days PTA he had CT imaging showing severe T12 degeneration, MRI performed which showed " progression of diskovertebral osteo, complete destruction of T12, retropulsion, kyphotic deformity; LOH @ L1 and T11; epidural collection, likely abscess, resulting in cord compression, ? incr signal at T10-T11, probable bilat focal psoas abscesses and abnormal prevertebral soft tissues; unable to tolerate additional imaging and gad not given/con phase not performed". He was transferred here after discussing with Dr. ___ spine surgeon. Has had some urinary incontinence in recent days but attributed this to being in so much pain he could not get up to go to bathroom. He was given IV vanc at ___ ED, bcx drawn. He had a fluctuating exam with ___ L dorsiflexion, R knee flexion and extension, rectal tone intact. Pt thinks "possible" numbness, has trouble specifying. In the ED, labs were significant for CRP of 256. UA with many bacteria. Spine/Neurosurgery was consulted who felt that he as neurologically intact with full strength and that symptoms were likely from pain. They recommended MRI for possible surgical planning. Multiple trips to MRI were attempted but aborted by pain. Imaging revealed total destruction of T12 with bulging epidural abscess with diskitis. Probably sudural abscess with retrocrural extension. Bilateral opacities in lung (atelectasis). Increased interstial edema. He was given IV dilaudid, klonopin, Ativan, ondansetron. Past Medical History: - T12 destructive osteomyelitis - bilateral psoas abscesses - MRSA bacteremia - IVDU c/b Hepatitis C s/p treatment with Sovaldi - Alcoholism in recovery - Hypertension - Diverticulosis - Anxiety: Has seen psychiatry in the past - Attention deficit, has seen psychiatry in the past - Hyperlipidemia bulging lumbar discs: ___, L5-S1: ___ flaring chronic - Hypothyroidism - Anemia Social History: ___ Family History: Does not know of any medical problems in the family. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: Vitals: T: 98.0 F BP: ___ P: ___ R: 18 O2: 98% 1 L General: Lethargic, conversant, intermittently in pain HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: II/VI systolic murmur strongest at the RUSB Abdomen: soft, TTP around stoma site, good stoma output Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Neuro: small pupils, EOMI, PERRL, intact cranial nerves, good handgrip strength. ___ muscle strength bilaterally in ___, able to lift legs off the bed, no focal motor or sensory deficits. Good rectal tone. PHYSICAL EXAMINATION ON DISCHARGE: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs: Intact Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T IP Q H AT ___ G Sensation: Intact to light touch Pertinent Results: ==ADMISSION LABS== ___ 02:30PM BLOOD WBC-10.9* RBC-4.43* Hgb-10.2*# Hct-31.9*# MCV-72*# MCH-23.0*# MCHC-32.0 RDW-17.1* RDWSD-43.9 Plt ___ ___ 02:30PM BLOOD Neuts-78.6* Lymphs-13.2* Monos-7.0 Eos-0.4* Baso-0.3 Im ___ AbsNeut-8.60* AbsLymp-1.44 AbsMono-0.76 AbsEos-0.04 AbsBaso-0.03 ___ 02:30PM BLOOD ___ PTT-32.1 ___ ___ 02:30PM BLOOD Glucose-99 UreaN-15 Creat-0.6 Na-133 K-3.6 Cl-93* HCO3-28 AnGap-16 ___ 02:30PM BLOOD Calcium-9.2 Phos-2.7 Mg-1.9 ___ 02:30PM BLOOD CRP-256.9* ==INTERIM LABS== ___ 06:05AM BLOOD CRP-173.6* ___ 05:40AM BLOOD HIV Ab-Negative ___ 06:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 06:05 SED RATE Test Result Reference Range/Units SED RATE BY MODIFIED 63 H < OR = 20 mm/h ___ ==DISCHARGE LABS== ==MICRO== ==IMAGING== SPINE CT W/O CONTRAST ___: 1. Osseous destruction and complete collapse of the T12 vertebral body, with bulging soft tissue density material surrounding this area of osseous destruction. The posterior soft tissue at the T12 level is highly concerning for an epidural collection. 2. Additional osseous destructive changes are seen in the inferior endplate of the T11 vertebral body, as well as the superior endplate of the L1 vertebral body. 3. Peripherally enhancing centrally hypodense lobulated collections are seen within the bilateral psoas muscles, centered about T12, extending caudally into the retrocrural space. These collections are consistent with abscesses. 4. Bibasilar consolidations in the lungs may represent atelectasis, however pneumonia cannot be completely excluded. 5. Increased prominence of the interstitial markings in the lung bases is concerning for pulmonary edema. MRI SPINE ___: 1. Discitis/osteomyelitis with abscess formation and resultant near-complete destruction of the T12 vertebral body and adjacent T11-12 and T12-L1 intervertebral discs. 2. Extension of infection posteriorly represents anterior epidural phlegmon. There is resultant compression and cord signal abnormality the extending from T11 to the conus, concerning for new/worsening cord compression. 3. No definite abscess or drainable fluid collection within the epidural space. 4. Extension of infection to involve the prevertebral and bilateral paraspinal musculature from T9-L2/3. In particular, multiloculated psoas abscesses are larger since prior measuring up to 3.6 cm, as above. 5. Possible focus of osteomyelitis in the posterior aspect of the T10 vertebral body, likely secondarily involved via extension from the adjacent paraspinal musculature. The T10-11 intervertebral disc is normal in appearance. PRE-OP CHEST X RAY ___: Cardiomediastinal contours are normal. Nonspecific patchy and linear opacities at the right lung base are probably due to atelectasis although coexisting aspiration or developing infectious pneumonia are possible in the appropriate clinical settings. Known T12 lesion is seen to better detail on ___ dedicated spine MRI study. ==OTHER RESULTS== EKG ___: Sinus rhythm with normal intervals and no diagnostic abnormalities. No previous tracing available for comparison. PSOAS ABSCESS DRAINAGE ___: 32 mm right and 20 mm left psoas fluid collections. The remaining foci of collections were not completely discernible due to lack of contrast and better delineated on previous CT and MRI. Destruction T12 vertebral body with moderate erosions of inferior T12 endplate and superior L1 endplate. Complete drainage of bilateral psoas abscesses yielding purulent fluid. No drainage catheters were left. CXR ___ Cardiomediastinal contours are normal. Nonspecific patchy and linear opacities at the right lung base are probably due to atelectasis although coexisting aspiration or developing infectious pneumonia are possible in the appropriate clinical settings. Known T12 lesion is seen to better detail on ___ dedicated spine MRI study. ___ ___ Complete drainage of bilateral psoas abscesses yielding purulent fluid. No drainage catheters were left. Echo ___ No echocardiographic evidence of endocarditis or pathologic flow. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mildly dilated ascending aorta. The patient has a mildly dilated ascending aorta. Based on ___ ACCF/AHA Thoracic Aortic Guidelines, if not previously known or a change, a follow-up echocardiogram is suggested in ___ year; if previously known and stable, a follow-up echocardiogram is suggested in ___ years. Angio ___ Left T10-L1 segmental artery arteriogram did not show significant supply to spinal cord. Artery of ___ was not visualized in the above segmental vessels. CXR ___: Small left apical pneumothorax CT Cspine w/wo ___: Expected postoperative appearance status post T11/___ corpectomy with extensive posterior spinal fusion. The left pedicle screw at T11 level projects over the left lateral recess. Clinical correlation recommended. There is no evidence of hardware failure and the spinal alignment appears anatomic. However, evaluation of the adjacent soft tissues is severely limited secondary to extensive hardware-related streak artifact. CXR ___ Persistent, small left apical pneumothorax. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 2. ClonazePAM 1 mg PO QID 3. Tamsulosin 0.4 mg PO QHS 4. Acetaminophen 650 mg PO Q6H:PRN pain 5. CloniDINE 0.2 mg PO QHS 6. Amphetamine-Dextroamphetamine 15 mg PO TID:PRN fatigue 7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 8. Senna 8.6 mg PO BID:PRN constipation 9. Docusate Sodium 100 mg PO BID 10. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Amphetamine-Dextroamphetamine 15 mg PO TID 3. ClonazePAM 1 mg PO QID:PRN anxiety 4. OxycoDONE (Immediate Release) 20 mg PO Q4H:PRN pain 5. OxyCODONE SR (OxyconTIN) 40 mg PO Q12H 6. Senna 17.2 mg PO QHS 7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 8. Diazepam 5 mg PO Q8H:PRN muscle spasm 9. Gabapentin 600 mg PO TID 10. Heparin 5000 UNIT SC TID 11. HydrALAzine 10 mg IV Q6H for SBP > 160 12. Omeprazole 40 mg PO BID 13. Simethicone 40-80 mg PO QID:PRN gas 14. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush 15. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 16. Vancomycin 1250 mg IV Q 12H 17. Tamsulosin 0.4 mg PO QHS 18. CloniDINE 0.2 mg PO QHS 19. Docusate Sodium 100 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: T12 osteomyelitis Anemia Acute on chronic pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT L-SPINE W/ CONTRAST INDICATION: ___ with known severe degenereation of ___ osteo, surrounding abscesses // Eval for bony erosion, superior extension of abscesses TECHNIQUE: Non-contrast helical multidetector CT was performed after the intravenous administration of 100 mL of Omnipaque contrast agent. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Total DLP (Body) = 1,190 mGy-cm. COMPARISON: Reference MRI of the lumbar spine dated ___. FINDINGS: There is near complete osseous destruction and complete collapse of the T12 vertebral body as seen on recent MRI from an outside hospital consistent with osteomyelitis. Destructive changes also involve the inferior endplate of T11 and the superior endplate of L1. There is perivertebral soft tissue thickening with discrete rim enhancing fluid collections in the paravertebral space extending inferiorly along the upper portion of the psoas musculature. The largest right-sided collection measures 7.1 x 3 x 2.5 cm. The largest left-sided collection measures 3.4 x 3.5 x 1.5 cm. There is soft tissue thickening along the central spinal canal spanning T11 through L1 which may represent an epidural collection. Due to destructive changes in the T11 through L1 vertebral bodies there is a mild kyphotic angulation centered at this level. There is compressive lower lobe atelectasis in the lower lungs with mild septal thickening which may indicate mild pulmonary edema. Scattered prominent retroperitoneal lymph nodes are likely reactive. The kidneys enhance homogeneously, without hydronephrosis, definite stones, or mass lesions. The adrenal glands are normal in size and shape. Imaged bowel is grossly unremarkable. IMPRESSION: 1. Vertebral osteomyelitis and diskitis at the thoracolumbar junction with complete destruction of the T12 vertebra, also involving the inferior endplate of T11 and the superior endplate of L1. 2. Perivertebral soft tissue thickening with probable epidural abscess. MRI may be performed to further evaluate. 3. Perivertebral abscesses extend into the upper psoas musculature, detailed above. These may be amenable to percutaneous drainage. 4. Opacities in the lower lungs likely represent atelectasis less likely pneumonia. Septal thickening suggests mild interstitial pulmonary edema. NOTIFICATION: Impression was discussed with Dr. ___ by Dr. ___ by phone at 12:30am on ___ approximately 45 minutes after discovery. Radiology Report EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE INDICATION: ___ man with history of MRSA bacteremia, known destructive T12 vertebral body osteomyelitis and psoas muscle abscesses, evaluate for epidural abscess. TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique, followed by axial T2 imaging. This was followed by sagittal and axial T1 images obtained after the uneventful intravenous administration of 6 mL of Gadavist contrast agent. COMPARISON: MRI L-spine ___. FINDINGS: The T12 vertebral body demonstrates near complete destruction and collapse. Intrinsically T1 isointense and heterogeneous, mixed T2 hypo- and hyperintense material occupies much of the T11- L1 interval, replacing the normal T12 vertebral body and T11-T12 and T12-L1 intervertebral discs, and demonstrates heterogeneous enhancement following contrast administration (series 16, image 7 and 8). There are areas of non-enhancement internally, compatible with mixed phlegmon and multifocal abscesses, the largest of which measures 4.3 x 2.1 x 1.7 cm (TV by CC by AP). A T1 and T2 hypointense, nonenhancing focus posteriorly likely represents residual necrotic T12 vertebral body (series 3, image 8). There is bulging of the enhancing material posteriorly into the anterior epidural space; in particular, an irregular enhancing soft tissue collection posteriorly, anterior to the spinal cord within the epidural space, measures 6.7 cm in craniocaudal extent, concerning for anterior epidural phlegmon. A tiny focus of non enhancement internally is millimetric in size, possibly a developing focus of abscess, but there is no drainable fluid collection. There is resultant mass effect on the spinal cord (see series 16, image 8 and series 7, image 31), with worsening heterogeneous T2 cord signal abnormality extending from T11 to the conus medullaris, concerning for new/worsening cord compression. Again seen is involvement/extension of infection into the bilateral paraspinal and psoas musculature. In particular, T2 hyperintense collections within the psoas muscles are larger, currently measuring 3.3 x 2.5 cm on the right (series 7, image 35, previously 2.5 x 1.6 cm on ___ and 3.6 x 1.6 cm on the left (series 7, image 37, previously 1.8 x 1.7 cm). These appear continuous with the adjacent process centered on the T12 vertebral body, and likely reflect extension of infection and resultant psoas muscle abscesses. Overall, the extent of paraspinal musculature involvement extends from T9 to L2/3. A focus of intrinsically T1 hypointense, T2 hyperintense and enhancement of the posterior T10 vertebral body, without signal abnormality of the intervening T10-11 intervertebral disc, may represent secondary osteomyelitis of the posterior T10 vertebral body via extension from paraspinal musculature. The remaining thoracolumbar vertebral bodies demonstrate normal alignment. There are minimal multilevel posterior disc bulges within the lumbar spine without resultant spinal canal or neural foraminal narrowing. The remaining thoracolumbar intervertebral discs demonstrate normal signal intensity. IMPRESSION: 1. Discitis/osteomyelitis with abscess formation and resultant near-complete destruction of the T12 vertebral body and adjacent T11-12 and T12-L1 intervertebral discs. 2. Extension of infection posteriorly represents anterior epidural phlegmon. There is resultant compression and cord signal abnormality the extending from T11 to the conus, concerning for new/worsening cord compression. 3. No definite abscess or drainable fluid collection within the epidural space. 4. Extension of infection to involve the prevertebral and bilateral paraspinal musculature from T9-L2/3. In particular, multiloculated psoas abscesses are larger since prior measuring up to 3.6 cm, as above. 5. Possible focus of osteomyelitis in the posterior aspect of the T10 vertebral body, likely secondarily involved via extension from the adjacent paraspinal musculature. The T10-11 intervertebral disc is normal in appearance. Radiology Report EXAMINATION: CHEST (PRE-OP AP ONLY) INDICATION: ___ year old man with h/o MRSA bacteremia, known destructive T12 osteo, psoas abscesses // pre-op Surg: ___ (epidural abscess removal) COMPARISON: No prior chest radiographs IMPRESSION: Cardiomediastinal contours are normal. Nonspecific patchy and linear opacities at the right lung base are probably due to atelectasis although coexisting aspiration or developing infectious pneumonia are possible in the appropriate clinical settings. Known T12 lesion is seen to better detail on ___ dedicated spine MRI study. Radiology Report EXAMINATION: CT-guided drainage. INDICATION: ___ year old man with known osteomyelitis, destroyed T12, with b/l psoas abscesses R>L // pls drain psoas abscesses COMPARISON: CT spine ___ PROCEDURE: CT-guided drainage of bilateral psoas muscle collection. OPERATORS: Dr. ___ radiology fellow, Dr. ___ resident ___ Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the 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 CT scan was performed to localize the collection. Based on the CT findings an appropriate skin entry site for drainage was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was inserted into the right collection . A sample of fluid was aspirated, confirming needle position within the collection. 0.038 ___ wire was placed through the needle and needle was removed. This was followed by placement of ___ pigtail catheter into the collection. The stiffener and the wire were removed. The position of the pigtail was confirmed within the collection via CT fluoroscopy. 30 cc of purulent material was aspirated. When there was no further return, the catheter was removed. Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was inserted into the left collection . A sample of fluid was aspirated, confirming needle position within the collection. 0.038 ___ wire was placed through the needle and needle was removed. This was followed by placement of ___ pigtail catheter into the collection. The stiffener and the wire were removed. The position of the pigtail was confirmed within the collection via CT fluoroscopy. 3 cc of purulent material was aspirated. When there was no further return, the catheter was removed. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 4.9 s, 15.0 cm; CTDIvol = 6.7 mGy (Body) DLP = 92.0 mGy-cm. 4) Stationary Acquisition 6.1 s, 0.5 cm; CTDIvol = 49.5 mGy (Body) DLP = 24.8 mGy-cm. Total DLP (Body) = 129 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 3.5 mg Versed and 175 mcg fentanyl throughout the total intra-service time of 35 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: 32 mm right and 20 mm left psoas fluid collections. The remaining foci of collections were not completely discernible due to lack of contrast and better delineated on previous CT and MRI. Destruction T12 vertebral body with moderate erosions of inferior T12 endplate and superior L1 endplate. IMPRESSION: Complete drainage of bilateral psoas abscesses yielding purulent fluid. No drainage catheters were left. Radiology Report CLINICAL HISTORY ___ year old man with T12 osteomyelitis, scheduled for T11-T12 corpectomy and fusion ___. // Pre-operative embolization in preparation for ___ sx with Dr. ___. EXAMINATION: Left T10 segmental artery arteriogram. Left T11 segmental artery arteriogram. Left T12 segmental artery arteriogram. Left L1 segmental artery arteriogram. Right T11 segmental artery arteriogram. Right L1 segmental artery arteriogram. Right common femoral artery arteriogram and Angio-Seal closure of right common femoral artery puncture site with 6 ___ Angio-Seal. ANESTHESIA: ANESTHESIA: MAC. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. TECHNIQUE: OPERATORS: Dr. ___ MD, PROCEDURE: The patient was brought to the angiography suite. IV sedation was given. Both groins were prepped and draped in a sterile fashion. Access was gained to the femoral artery using a Seldinger technique and a 5 vascular sheath was placed in the right common femoral artery. The above-mentioned spinal arteries were catheterized and AP filming was performed. This demonstrated that the artery of ___ did not originate from these vessels. FINDINGS: Left T10 segmental artery arteriogram does not show any evidence of significant supply to the spinal cord. Left T11 segmental artery arteriogram does not show any evidence of significant supply to the spinal cord. Left T12 segmental artery arteriogram does not show any evidence of significant supply to the spinal cord Left L1 segmental artery arteriogram does not show any evidence of significant supply to the spinal cord . Right T11 segmental artery arteriogram does not show any evidence of significant supply to the spinal cord . Right L1 segmental artery arteriogram does not show any evidence of significant supply to the spinal cord. Right common femoral artery arteriogram shows widely patent right common femoral artery. IMPRESSION: Artery of ___ was not visualized in the above segmental vessels Radiology Report EXAMINATION: CT T-SPINE W/O CONTRAST Q321 CT SPINE INDICATION: ___ year old man with osteomylytis. Preop. 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) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 9.8 s, 38.5 cm; CTDIvol = 31.4 mGy (Body) DLP = 1,208.3 mGy-cm. Total DLP (Body) = 1,208 mGy-cm. COMPARISON: MR thoracic spine ___, CT interventional procedure ___ FINDINGS: There are 12 rib-bearing vertebrae. T12 vertebral body is nearly completely destroyed, as seen previously. Small posterior remnant of T12 vertebral body is sclerotic, with sclerosis extending into the bilateral pedicles. There is destruction of the T11 inferior endplate and L1 superior endplate with irregular sclerotic margins. There is a kyphotic angulation centered at T12. The prior MRI better demonstrates the abscess spanning the T11-T12 disc, T12 vertebral body remnant, and T12-L1 disc. The prior MRI also better demonstrates the epidural phlegmon centered at T12 with associated spinal canal narrowing. T1 through T10 vertebrae demonstrate normal vertebral body heights without evidence for osseous destruction. Of note, T10 vertebral body demonstrated in a area of marrow edema on the recent MRI. Images through the lower cervical spine demonstrate right greater than left central disc osteophyte complex causing moderate spinal canal stenosis at C6-7, with left greater than right neural foraminal narrowing due to uncovertebral osteophytes at C6-7 right C7-T1 neural foramen is mildly narrowed by facet arthropathy. Small Schmorl's nodes are present at multiple mid and lower thoracic levels. Significant decrease in size of the multiloculated right psoas fluid collection now measuring 1.5 x 1.1 cm (previously 1.9 x 1.4 cm) along its largest component. Left psoas fluid collection also appears decreased. However, these are not fully evaluated in the absence of intravenous contrast. Left para-aortic lymphadenopathy is adequately reassessed compared to ___ contrast enhanced lumbar spine CT. Paratracheal lymph nodes measure up to 1.0 cm in short axis diameter on the left. Subcarinal lymph nodes measure up to 1.0 cm in short axis diameter. There are small bilateral pleural effusions, partially visualized, with adjacent dependent atelectasis. IMPRESSION: 1. Near complete destruction of T12 vertebral body is again demonstrated, with a small sclerotic posterior vertebral body remnant and sclerosis extending into bilateral pedicles. Destruction of the T11 inferior endplate and L1 superior endplate is also again seen, marginated by irregular sclerosis. Unchanged kyphotic angulation centered at T12. 2. Abscess involving the T11-12 and T12-L1 disc spaces was better demonstrated on the ___ MRI. 3. Epidural phlegmon centered at T12 with associated spinal canal narrowing were also better demonstrated on the ___ MRI. 4. Previously noted bilateral psoas collections appear improved, but are not fully visualized and and not adequately evaluated in the absence of intravenous contrast. Left para-aortic lymphadenopathy is also not adequately reassessed. 5. Borderline enlarged paratracheal and subcarinal lymph and small bilateral pleural effusions may be reactive. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 10:22 AM, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PRE-OP PA AND LAT) INDICATION: ___ year old man with osteomyelitis // preop Surg: ___ (T12 corpectomy) OSTEOMYELITIS IMPRESSION: In comparison with the study of ___, there has been some decrease in the opacification at the right base, most likely due to atelectasis. No evidence of acute pneumonia or vascular congestion. Severe changes in the lower lobe thoracic region are consistent with known osteomyelitis. Radiology Report EXAMINATION: Intra op fluoroscopic images INDICATION: T12 and T11 corpectomy and placement of inter vertebral bio mechanical device TECHNIQUE: Fluoroscopic study COMPARISON: CT of the spine from ___ FINDINGS: 31 intraoperative images were acquired without a radiologist present. Images show corpectomy of lower thoracic vertebra and placement of expandable cage. Suboptimal evaluation of thoracic spine. Fluoroscopic time is 41 seconds. IMPRESSION: Intraoperative images during corpectomy of thoracic spine and placement of a biomechanical device. Please refer to the operative note for details of the procedure. Radiology Report EXAMINATION: Intra op fluoroscopy INDICATION: Posterior T9 through L2 fusion TECHNIQUE: Fluoroscopic images in the OR COMPARISON: CT from ___ FINDINGS: 7 intraoperative images were acquired showingan expandable cage, pedicle screws and posterior vertical rods spanning at least 6 vertebrae which include lower thoracic and upper lumbar spine. Fluoroscopic time is 1 minutes and 17 seconds. IMPRESSION: Intraoperative images were obtained during posterior fusion of lower thoracic and upper lumbar spine. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man chest tube placement for anterior spinal fusion. // chest tube placement/?pneumothorax chest tube placement/?pneumothorax COMPARISON: ___ IMPRESSION: Heart size and mediastinum are stable. Lungs are essentially clear with bibasal atelectasis. Left chest tube is in place. No pneumothorax is seen. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with chest tube // r/o effusion, please perform at 1000 on ___ r/o effusion, please perform at 1000 on ___ COMPARISON: ___ IMPRESSION: Heart size and mediastinum are stable. Left chest tube is in place. Small left apical pneumothorax is present, not seen on previous examination. . No pleural effusion is noted. Right basal atelectasis is minimal. Radiology Report EXAMINATION: AP and lateral chest radiographs INDICATION: ___ year old man s/p L chest tube after T11-T12 corpectomy and multi-level fusion. // Chest tube pulled at 1400. Please perform x-ray to assess for pneumothorax around 1600 today. TECHNIQUE: Chest AP and lateral COMPARISON: Portable chest radiograph dated ___ at 10:02 FINDINGS: In comparison to the chest radiograph obtained 6 hours prior, there has been interval removal of the left-sided chest tube with no change in the small left apical pneumothorax. A small amount of subcutaneous emphysema is unchanged. Heart size, mediastinal silhouette, and right basilar atelectasis are unchanged. IMPRESSION: Interval removal of a left-sided chest tube with no change in the small left apical pneumothorax. Radiology Report EXAMINATION: CT T-SPINE W/O CONTRAST Q321 CT SPINE INDICATION: ___ year old man with s/p Corpectomy T11/12 and PSF T9 to L2. Please evaluate fusion // ___ year old man with s/p Corpectomy T11/12 and PSF T9 to L2. Please evaluate fusion ___ year old man with s/p Corpectomy T11/12 and PSF T9 to L2. Please evaluate fusion 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) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Spiral Acquisition 25.7 s, 39.3 cm; CTDIvol = 21.1 mGy (Body) DLP = 801.5 mGy-cm. Total DLP (Body) = 818 mGy-cm. COMPARISON: CT T-spine dated ___. FINDINGS: There has been interval corpectomy of the T11 and T12 vertebral bodies, with posterior spinal fusion extending from the level of T9-L2. There is no evidence of hardware fracture or periprosthetic lucency to to suggest hardware loosening. A vertebral body spacer now replaces the T11 and T12 vertebrae. Overall, alignment appears grossly anatomic. A central depression involving the superior endplate of the L1 vertebral body is unchanged. Expected postoperative changes are noted, including subcutaneous edema multiple foci of air within the pararenal/retroperitoneal space, and numerous surgical clips. A surgical drain terminates at the level of L1-L2. Evaluation of the surrounding soft tissues and spinal canal is limited secondary to extensive streak artifact. Limited assessment of the lung bases demonstrates bibasilar consolidations most compatible with atelectasis. IMPRESSION: Expected postoperative appearance status post ___ corpectomy with extensive posterior spinal fusion. The left pedicle screw at T11 level projects over the left lateral recess. Clinical correlation recommended. There is no evidence of hardware failure and the spinal alignment appears anatomic. However, evaluation of the adjacent soft tissues is severely limited secondary to extensive hardware-related streak artifact. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with chest tube d/c'd ___ // Evaluate for PTX TECHNIQUE: AP and lateral views of the chest were obtained. COMPARISON: ___ FINDINGS: The cardiomediastinal silhouette and pulmonary vasculature are unremarkable and unchanged since most recent examination. The lungs are clear aside from bibasilar atelectasis. Again noted is a small left apical pneumothorax. Minimal subcutaneous emphysema is noted. The stomach is distended. IMPRESSION: Persistent, small left apical pneumothorax. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with 45cm right PICC. ___ ___ // 45cm right PICC. ___ ___ Contact name: ___: ___ right PICC. ___ ___ IMPRESSION: New right-sided PICC line. The course of the line is unremarkable, the tip of the line. Projects over the cavoatrial junction. No complications, notably no pneumothorax. The stomach remains overinflated. And could be decompressed by insertion of a nasogastric tube. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Back pain, Leg weakness Diagnosed with Osteomyelitis of vertebra, thoracic region temperature: 98.5 heartrate: 75.0 resprate: 18.0 o2sat: 100.0 sbp: 139.0 dbp: 91.0 level of pain: 9 level of acuity: 2.0
Discharge Instructions Spinal Fusion Surgery •Your dressing may come off on the second day after surgery. •Your incision is closed with staples or sutures. You will need suture/staple removal. •Do not apply any lotions or creams to the site. •Please keep your incision dry until removal of your staples. •Please avoid swimming for two weeks after staple removal. •Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity •You must wear your brace at all times when out of bed. You may apply your brace sitting at the edge of the bed. You do not need to sleep with it on. •We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. •You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. •No driving while taking any narcotic or sedating medication. •No contact sports until cleared by your neurosurgeon. •Do NOT smoke. Smoking can affect your healing and fusion. Medications •Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. •Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc… until cleared by your neurosurgeon. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. •It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site. •Fever greater than 101.5 degrees Fahrenheit •New weakness or changes in sensation in your arms or legs.
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: Minocycline / Tetracycline Attending: ___ Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: ___ left thoracentesis History of Present Illness: ___ yo male s/p CABGx3 (LIMA-ALD, SVG-OM, SVG-Ramus) on ___. Overall he tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He developed slow afib post-operatively but lopressor was initially held due to continued hypotension. On POD#2, he received 2 units of PRBC for a hematocrit of 17. Stat bedside echo was unremarkable. Plavix was resumed for his history of DES placed in ___. He transferred to the telemetry floor for further recovery. He was started on coumadin for persistent atrial fibrillation. He continued to have paroxysmal atrial fibrillation and Amiodarone was initiated. His Hct remained low but stable. He was discharged to home on ___. He was doing well initially except for some persistent SOB with minimal exertion and stairs. Over the past few nights, he experienced PND, awakening several times per night. Otherwise he has felt well - no CP, palitations, pain well controlled. He presented to PCP for ___ routine follow up and was unable to lie flat for an exam. His PCP sent him to the ED for further evaluation. Past Medical History: Past Medical History: MI ___, angioplasty 6 months later DMII dyslipidemia Hypertension BPH Past Surgical History: herniorrhaphy Past Cardiac Procedures: angioplasty ___ DES to Cx ___ Social History: ___ Family History: Family History: Premature coronary artery disease Father MI < ___ [] Mother < ___ [] Father died in his ___, had MI in late ___ Physical Exam: T 98.8 Pulse:72 Resp:18 O2 sat: 95-96% RA B/P Right: 123/60 Left: Height: 5'7" Weight: 176 (reported) General: AAO x 3 in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [] Decreased left base Heart: RRR [] Irregular [x] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema trace Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ ___ Right:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right:none Left:none Pertinent Results: ___ 05:25AM BLOOD WBC-10.9 RBC-3.68* Hgb-10.4* Hct-33.5* MCV-91 MCH-28.4 MCHC-31.2 RDW-15.0 Plt ___ ___ 05:25AM BLOOD ___ PTT-30.9 ___ ___ 05:25AM BLOOD Glucose-145* UreaN-26* Creat-1.3* Na-133 K-4.4 Cl-97 HCO3-26 AnGap-14 ___ 12:16AM BLOOD ALT-19 AST-19 LD(LDH)-258* AlkPhos-69 Amylase-61 TotBili-0.5 ___ ___ M ___ ___ Radiology Report CHEST (PORTABLE AP) Study Date of ___ 12:15 ___ ___ CSURG FA6A ___ 12:15 ___ CHEST (PORTABLE AP) Clip # ___ Reason: eval effusion post thoracentesis Final Report CHEST RADIOGRAPH HISTORY: ___ man status post CABG. Evaluate for effusion after thoracentesis. An AP portable upright chest radiograph shows significant diminution in what was previously a large left pleural effusion. There is now only some haziness in the left costophrenic and cardiophrenic angles and residual overlying plate-like subsegmental atelectasis. No pneumothorax. Intact sternal wires are seen in this patient status post CABG. CONCLUSION: Notable decrease in left pleural effusion with residual overlying subsegmental atelectasis at the left base. Medications on Admission: 1. Aspirin EC 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Rosuvastatin Calcium 10 mg PO DAILY 4. Tamsulosin 0.4 mg PO HS 5. Glucovance *NF* (glyBURIDE-metformin) 1.25-250 ORAL BID 6. Amiodarone 400 mg PO BID ___ bid x 1 week, then 400mg daily x 1 week, then 200mg daily 7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain 8. Metoprolol Tartrate 12.5 mg PO BID 9. Vitamin D 1000 UNIT PO DAILY 10. Furosemide 20 mg PO DAILY Duration: 5 Days 11. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days 12. Ranitidine 150 mg PO BID 13. Warfarin 5 mg PO DAILY16 dose to change daily for goal INR ___, Dx: AFib, Dr. ___ to manage - Pt has been alternating 5 mg and 2.5 mg Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Amiodarone 200 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Metoprolol Tartrate 12.5 mg PO BID 5. Tamsulosin 0.4 mg PO HS 6. Rosuvastatin Calcium 10 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY 8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain 9. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 10. Furosemide 40 mg PO BID Duration: 7 Days 11. Potassium Chloride 20 mEq PO BID Duration: 7 Days 12. Omeprazole 20 mg PO QOD 13. Clopidogrel 75 mg PO DAILY 14. GlyBURIDE 2.5 mg PO BID 15. MetFORMIN (Glucophage) 500 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: s/p Left thoracentesis ___ s/p Urgent coronary artery bypass graft x3: ___ Left internal mammary artery to left anterior descending artery and saphenous vein graft to distal circumflex and ramus arteries Past Medical History: MI ___, angioplasty 6 months later DMII dyslipidemia Hypertension BPH Past Surgical History: herniorrhaphy Past Cardiac Procedures: angioplasty ___ DES to Cx ___ Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Followup Instructions: ___ Radiology Report HISTORY: Shortness of breath status post CABG. TECHNIQUE: PA and lateral views of the chest. COMPARISON: ___. FINDINGS: The patient is status post median sternotomy and CABG. There has been interval increase in size of the left pleural effusion which is now large, and obscures assessment of the cardiac silhouette size. No pulmonary vascular congestion is identified, and there is mild rightward shift of mediastinal structures. The mediastinum is not widened. Left basilar compressive atelectasis is demonstrated. Right lung is clear. Trace right pleural effusion is slightly smaller compared to the prior study. No pneumothorax is identified. No acute osseous abnormalities are seen. IMPRESSION: Increased size of left pleural effusion which is now large with associated left basilar atelectasis. Trace right pleural effusion. Radiology Report EXAM: Chest frontal and lateral views. CLINICAL INFORMATION: CABG. Check left effusion. ___. FINDINGS: Frontal and lateral views of the chest were obtained. There is persistent large left pleural effusion with associated atelectasis, stable in appearance as compared to the prior study. There is very slight rightward shift of the cardiac silhouette, stable. There is slight blunting of the posterior right costophrenic angle which may be due to a trace right pleural effusion. No focal consolidation is seen in the right lung. There is no pneumothorax. The cardiac and mediastinal contours are stable, although not well evaluated given the large left pleural effusion. IMPRESSION: Stable large left pleural effusion with overlying atelectasis. Possible trace right pleural effusion. Radiology Report CHEST RADIOGRAPH HISTORY: ___ man status post CABG. Evaluate for effusion after thoracentesis. An AP portable upright chest radiograph shows significant diminution in what was previously a large left pleural effusion. There is now only some haziness in the left costophrenic and cardiophrenic angles and residual overlying plate-like subsegmental atelectasis. No pneumothorax. Intact sternal wires are seen in this patient status post CABG. CONCLUSION: Notable decrease in left pleural effusion with residual overlying subsegmental atelectasis at the left base. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: DYSPNEA Diagnosed with SHORTNESS OF BREATH, HYPERTENSION NOS, DIABETES UNCOMPL ADULT temperature: 98.8 heartrate: 72.0 resprate: 18.0 o2sat: 95.0 sbp: 123.0 dbp: 60.0 level of pain: 0 level of acuity: 2.0
Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours**
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: Liver disease Biloma Hyperkalemia Hyponatremia Major Surgical or Invasive Procedure: ___: 1. Cholangiogram through existing right percutaneous transhepatic biliary drainage access. 2. Exchange of the existing right percutaneous transhepatic biliary drainage catheter with a new 10 ___ anchor catheter. 3. Sinogram through existing left drain 4. Exchange of left drain to a 10 ___ APD L . ___ 1. Scout radiograph image of the indwelling drains 2. Antegrade cholangiogram through the indwelling anchor drain. 3. Drain check injection through the existing percutaneous drain in the hepatic collection 4. Over the wire Pull-back cholangiogram via the right PTBD 5. Balloon angioplasty of the hepaticojejunostomy using a 6 mm Conquest balloon 6. Post HJ plasty antegrade cholangiogram 7. New right 10 ___ biliary internal-external drainage catheter. History of Present Illness: Mr. ___ is a ___ year old male well known to the Transplant Surgery service who underwent a DDLT in ___ for HCV cirrhosis and HCC and has a had a prolonged postoperative course complicated by hepatic artery thrombosis with hepatic lobe necrosis, early mild to moderate cellular rejection, infected biloma with recurrent bacteremia, multiple intraabdominal collections, several ___ interventions, and a right iliacus hematoma causing RLE compression paralysis, resolved with ___ drainage and multiple hospitalization. He was most recently admitted ___ for failure to thrive and acute SDH after several falls at home. He was also noted to have increased fluid collections and underwent ___ drainage exchange of existing left hepatic lobe drain with ___ APDL. He was continued on pre-admission Daptomycin and Cefepime. Today, he presented to for scheduled CT scan to evaluate his known collections. At the appointment his Cr was elevated to 7.3. He was sent to the ED for hyperkalemia management. His repeat K was decreased to 6.9 upon presentation. In the ED renal transplant was consulted and they recommend he receive calcium gluconate, insulin/dextrose, sodium bicarb, and 20 IV Lasix. His repeat K was 6.4, however he had not the sodium bicarb and lasix at this point. He is receiving sodium bicarb (150 in D5W) and 20 lasix then we will plan to repeat again once he has received these medications. He reports eating a diet rich in tomatoes/red sauce and potatoes over the last few days. He continues to have some output from his known abscess cavity, requiring emptying his bag approximately every other day. He reports he had been working with ___ at rehab but it continues to weakness and pain in his RLE which he developed after he developed a right iliacus hematoma. He denies any other symptoms including fevers, chills, cough, or urinary symptoms. Past Medical History: PMH: HCV cirrhosis (c/b portal HTN with grade II/III varies), HCC (s/p RFA ___, TIPS & revisions, emboldened of coronary v.), insulin-dependent DM, esophageal vatical bleed, pancreatitis, non-occlusive splenic vein thrombosis, thrombocytopenia, hypersplenism, diverticulitis, colonic polyps PSH: ddLT w RnYHJ (___) c/b HAT, multiple ___ drainage procedures, TIPS procedure ___, extension ___, revision ___, embolization of coronary vein supplying esophageal & gastric varices Social History: ___ Family History: Mother died of breast cancer. Father died at age ___. He has a healthy daughter and healthy siblings. Physical Exam: Exam on Admission: Vitals: 98.0, 80, 118/93, 18, 100% RA Gen: cachectic, no acute distress Head: NC/AT, well healed scar right temporal region, mild temporal wasting CV: regular rate and rhythm Pulm: breathing comfortably on room air Abd: Soft, nondistended, nontender, incisional scars well healed, R ___ drain with minimal bilious output, PTBD capped Ext: warm and well perfused, no edema Psych: appropriate affect . Exam at Discharge: 24 HR Data (last updated ___ @ 019) Temp: 98.6 (Tm 99.4), BP: 114/68 (101-114/65-70), HR: 83 (79-88), RR: 18 (___), O2 sat: 94% (94-98), O2 delivery: Ra, Wt: 152.7 lb/69.26 kg Fluid Balance (last updated ___ @ 2142) Last 8 hours Total cumulative -35ml IN: Total 0ml OUT: Total 35ml, Urine Amt 0ml, PTBD 35ml Last 24 hours Total cumulative 711ml IN: Total 1341ml, PO Amt 1140ml, IV Amt Infused 201ml OUT: Total 630ml, Urine Amt 500ml, PTBD 130ml, abscess drain 0ml GENERAL: [x]NAD [x]A/O x 3 CARDIAC: [x]RRR LUNGS: [x]no respiratory distress ABDOMEN: [x]soft [x]Nontender [x]nondistended Abdomen: R PTBD with bilious output, L drain with scant bilious output EXTREMITIES: [x]no CCE Able to move R leg against gravity, strength reduced compared to Left Pertinent Results: Labs on Admission: ___ WBC-4.8 RBC-4.29* Hgb-11.3* Hct-37.4* MCV-87 MCH-26.3 MCHC-30.2* RDW-15.5 RDWSD-49.5* Plt ___ PTT-32.6 ___ Glucose-171* UreaN-58* Creat-1.3* Na-132* K-7.3* Cl-105 HCO3-15* AnGap-12 ___ 09:35AM K-7.4* ALT-172* AST-73* AlkPhos-1138* TotBili-0.5 Albumin-4.1 Calcium-10.6* Phos-4.0 Mg-1.7 tacroFK-9.2 . Labs at Discharge: ___ CMV VL-NOT DETECT WBC-3.4* RBC-3.54* Hgb-9.1* Hct-29.8* MCV-84 MCH-25.7* MCHC-30.5* RDW-15.9* RDWSD-48.3* Plt Ct-97* Glucose-142* UreaN-21* Creat-0.6 Na-130* K-4.8 Cl-94* HCO3-24 AnGap-12 ALT-75* AST-30 AlkPhos-1028* TotBili-0.7 Calcium-9.6 Phos-2.9 Mg-1.7 tacroFK-3.6* . ___ BLOOD IMMUKNOW-PND . ___ 8:00 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. . ___ 4:40 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Benzonatate 100 mg PO BID:PRN cough 2. CefePIME 2 g IV Q12H 3. Daptomycin 800 mg IV Q24H 4. Dronabinol 2.5 mg PO BID 5. Fluconazole 400 mg PO Q24H 6. Gabapentin 300 mg PO TID 7. NovoLOG U-100 Insulin aspart (insulin aspart U-100) 0 units subcutaneous TID W/MEALS 8. Lantus U-100 Insulin (insulin glargine) 30 units subcutaneous QHS 9. Levothyroxine Sodium 25 mcg PO DAILY 10. Multivitamins W/minerals 1 TAB PO DAILY 11. Lidocaine 5% Patch 1 PTCH TD QAM 12. Pantoprazole 40 mg PO Q12H 13. PredniSONE 5 mg PO DAILY 14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 15. Ursodiol 300 mg PO BID 16. TraMADol 50 mg PO Q8H:PRN Pain - Moderate 17. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 18. Aspirin 81 mg PO DAILY 19. Psyllium Powder 1 PKT PO BID:PRN constipation 20. Tacrolimus 1 mg PO Q12H Discharge Medications: 1. Dapsone 100 mg PO DAILY 2. Aspart 12 Units Breakfast Aspart 12 Units Lunch Aspart 12 Units Dinner Levemir 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 3. Gabapentin 400 mg PO TID 4. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 5. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever Maximum 4 of the 500 mg tablets daily 6. Aspirin 81 mg PO DAILY 7. Benzonatate 100 mg PO BID:PRN cough 8. CefePIME 2 g IV Q12H RX *cefepime 100 gram 2 g IV twice a day Disp #*60 Intravenous Bag Refills:*1 9. Daptomycin 800 mg IV Q24H RX *daptomycin 500 mg 800 mg IV once a day Disp #*30 Intravenous Bag Refills:*1 10. Dronabinol 2.5 mg PO BID 11. Fluconazole 400 mg PO Q24H 12. Levothyroxine Sodium 25 mcg PO DAILY 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Pantoprazole 40 mg PO Q12H 15. PredniSONE 5 mg PO DAILY 16. Psyllium Powder 1 PKT PO BID:PRN constipation 17. Tacrolimus 1 mg PO Q12H 18. Ursodiol 300 mg PO BID 19.Right ___ Brace S74.10XA supply one, wear when out of bed Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hyperkalemia History of liver transplant DM h/o right iliacus hematoma with right femoral nerve compression Right leg numbness/pain/weakness Neutropenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (___ and ___ brace) Followup Instructions: ___ Radiology Report EXAMINATION: CT ABDOMEN W/CONTRAST INDICATION: Please eval for abscess for improvement to help with antibiotic management,. // Please eval for improvement of hepatic abscess. TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen following intravenous contrast administration. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.8 s, 37.2 cm; CTDIvol = 11.1 mGy (Body) DLP = 411.9 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 30.1 mGy (Body) DLP = 15.0 mGy-cm. Total DLP (Body) = 429 mGy-cm. COMPARISON: Prior CT dated ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: Patient is status post deceased liver transplant with Roux-en-Y hepaticojejunostomy. There has been stenting of the proper hepatic artery. Again seen are 2 percutaneous biliary drains in unchanged position. Fluid surrounding drains has nearly completely resolved. There is unchanged intrahepatic biliary dilatation. Previously seen cluster of hypodensities in segment 8 now visualized as a single hypoattenuating lesion measuring 9 x 11 mm, decreased in size compared to prior. There has also been interval decrease in size with resolution of internal gas of a hypoattenuating lesion within segment 6 measuring 2.0 x 2.8 cm (previously measured 2.7 x 2.3 cm). PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: There is splenomegaly. There are multiple wedge-shaped hypodense lesions which represent sequelae of prior infarcts. There has been interval decrease in size of a previously drained fluid collection at the left inferior aspect of the spleen measuring 5.7 x 1.6 x 2.0 cm (previously measured 8.6 x 3.1 x 8 cm). More centrally located fluid collection now spans up to 6.2 cm. Spleen is enlarged measuring 16.9 cm. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of solid renal lesions or hydronephrosis. Large left lower pole simple cyst measures 3.9 x 4.1 cm. GASTROINTESTINAL: The stomach is unremarkable. Visualized small and large bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES: Degenerative changes are seen in the lumbar spine. There is an unchanged wedge compression deformity of L1 vertebra SOFT TISSUES: There is subcutaneous air in the anterior abdominal soft tissue possibly due to recent injection. IMPRESSION: 1. There has been near resolution of fluid surrounding 2 percutaneous drains near the gallbladder fossa. 2. Interval decrease in size of hypoattenuating lesions in segment 8 and segment 6 of the liver. The lesion in segment 6 has also had interval resolution of internal gas. 3. Trace fluid remains near previously drained fluid collection adjacent to the lateral inferior spleen. 4. There has been decrease in size of more centrally located fluid collection in the spleen. 5. No new O focal fluid collections. 6. Unchanged splenomegaly. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with OSH placed PICC // please comment on position TECHNIQUE: AP chest x-ray COMPARISON: AP chest x-ray dated ___ FINDINGS: Lungs are well expanded and clear. Cardiomediastinal and silhouette are normal. No pneumothorax or pleural effusion. The right PICC line terminates within the upper SVC. Acute osseous abnormalities. Perihepatic drains and prior embolization coils partially project over the abdomen. IMPRESSION: The right PICC line terminates within the upper SVC. Radiology Report INDICATION: ___ year old man with h/o DDLT w RNY HJ c/b HAT, infected biloma, VRE bacteremia splenic bleed s/p perc embo of PSA. Recent cholangiogram with 6mm balloon dilatation. Patient presents for cholangiogram // routine follow up cholangiogram COMPARISON: Multiple prior examinations and CT TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 50mcg of fentanyl and 1 mg of midazolam throughout the total intra-service time of 9 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: CONTRAST: 10 ml of OPTIRAY contrast FLUOROSCOPY TIME AND DOSE: 2 min, 6 mGy PROCEDURE: 1. Cholangiogram through existing right percutaneous transhepatic biliary drainage access. 2. Exchange of the existing right percutaneous transhepatic biliary drainage catheter with a new 10 ___ anchor catheter. 3. Sinogram through existing left drain 4. Exchange of left drain to a 10 ___ APD L 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 tubes were injected. The ___ BD catheter was cut and ___ wire introduced into the bowel. Then, a sheath was placed in a cholangiogram performed. This demonstrated brisk flow of contrast into the hepaticojejunostomy. Again this was performed different angulations, but again brisk pearl was noted. There was no hang-up of contrast. Therefore the decision was made to leave an anchor drain. The sheath was removed and a 10 ___ anchor drain was placed. The anchor was formed in the drain secured to the skin with a suture and StatLock. The sinogram through the existing left-sided drain demonstrated a small residual cavity but communication with the biliary tree. This 12 ___ drain was downsized to a 10 ___ drain. This drain was secured to the skin with 0 silk sutures and a StatLock. This drain was attached to a bag. FINDINGS: Brisk flow of contrast through the hepaticojejunostomy with no holdup. Anchor drain placed. Down size of left hepatic drain given CT findings in sinogram findings from today. IMPRESSION: Drain exchanges as above. Radiology Report INDICATION: ___ year old man s/p DDLT w RNY HJ c/b HAT, infected biloma, VRE bacteremia. with pericatheter leakage following recent drain downsize // ___ year old man s/p DDLT w RNY HJ c/b HAT, infected biloma, VRE bacteremia. with pericatheter leakage following recent drain downsize COMPARISON: Biliary drain check-and change dated ___ TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr. ___ fellow performed the procedure. The attending(s) personally supervised the trainee during any key components of the procedure where applicable and reviewed and agrees with the findings as reported below. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 100mcg of fentanyl and 2 mg of midazolam throughout the total intra-service time of 55 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 g IV ceftriaxone pre-procedure CONTRAST: 20 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 12.4 minute, 198 mGy PROCEDURE: 1. Scout radiograph image of the indwelling drains 2. Antegrade cholangiogram through the indwelling anchor drain. 3. Drain check injection through the existing percutaneous drain in the hepatic collection 4. Over the wire Pull-back cholangiogram via the right PTBD 5. Balloon angioplasty of the hepaticojejunostomy using a 6 mm Conquest balloon 6. Post HJ plasty antegrade cholangiogram 7. New right 10 ___ biliary internal-external drainage catheter. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The right/mid abdomen was prepped and draped in the usual sterile fashion. Initial scout images showed biliary drain in the appropriate position. Both drains were injected with dilute contrast. The images were stored on PACS. Following the subcutaneous injection of 1% lidocaine and instillation of lidocaine jelly into the skin site, the right catheter was cut and an Amplatz wire was advanced through the catheter into the jejunum. Antegrade and pull back cholangiogram was then performed with findings as outlined below. Cholangioplasty was performed at multiple stations across the hepaticojejunostomy in the region of the narrowing using 6 x 4 Conquest balloons. The balloon and sheath were then removed over the wire and a 10 ___ percutaneous trans hepatic biliary drainage catheter was advanced into the jejunum. Side holes were positioned above and below the level of the stenosis to facilitate internal drainage. The wire and inner stiffener were removed, the catheter was flushed, the loop was formed, the catheter was attached to a bag and sterile dressings were applied. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Scout radiograph demonstrated the existing drains to be in stable position. 2. Injection through the existing hepatic collection drain demonstrated opacification of the biliary system, suggestive of a communication. 3. Over the wire antegrade and pull-back right cholangiograms demonstrated narrowing at the region of the hepaticojejunostomy. 4. Antegrade cholangiogram through the right biliary access from showed external leakage of contrast around the perihepatic drain. 5. Successful plasty using a 6 mm Conquest balloon at the region of the hepaticojejunostomy. 6. Successful exchange of the existing right external biliary drain to a 10 ___ internal-external biliary drain. IMPRESSION: Technically successful plasty in the region of the hepaticojejunostomy. Successful exchange of existing percutaneous transhepatic biliary anchor drain with new 10 ___ internal-external biliary drainage catheters. Gender: M Race: WHITE - BRAZILIAN Arrive by OTHER Chief complaint: Hyperkalemia Diagnosed with Hypokalemia, Type 2 diabetes mellitus without complications temperature: 98.0 heartrate: 80.0 resprate: 18.0 o2sat: 100.0 sbp: 118.0 dbp: 93.0 level of pain: 5 level of acuity: 2.0
Care Group ___ for IV Antibiotics . Please call the transplant clinic at ___ for fever of 101 or greater, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, liver drain and biliary drain sites have redness, drainage or bleeding, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, weight gain of 3 pounds in a day or any other concerning symptoms. . Bring list of current medications to every clinic visit. . You will need to have labwork drawn on ___ then twice weekly as arranged by the transplant clinic. Usually ___ and ___ . *** On the days you have your labs drawn, do not take your Tacrolimus until your labs are drawn. Bring your Tacrolimus with you so you may take your medication as soon as your labwork has been drawn. . Follow your medication card, keep it updated with any dosage changes, and always bring your card with you to any clinic or hospital visits. . Patient may shower with assist. Do not allow drain bag to hang freely. Keep biliary drain (PTBD)open. Change gauze dressing daily and as needed. Make sure to pin your drain to prevent accidently pulling out . Flush the PTBD drain with 5cc STERILE saline-FORWARD flush ONLY 3 times a day. DO NOT ASPIRATE/PULL back. . Continue IV antibiotics via the PICC line as ordered. No end date is established for the antibiotics. PICC line care per protocol . No tub baths or swimming . Avoid direct sun exposure. Wear protective clothing and a hat, and always wear sunscreen with SPF 30 or higher when you go outdoors. . Report consistently elevated blood sugars or blood pressure values above 160 or less than 110 systolic to the transplant clinic . Do not increase, decrease, stop or start medications without checking with the transplant coordinator at ___.